Normal Clinical Examination Research Articles

Orthopedic and ultrasound assessment of hip stability of newborns referred by pediatricians with suspected Developmental Dysplasia.

to evaluate newborns with suspected hip instability, referred by pediatricians to a tertiary orthopedic service. newborns from a public university maternity hospital, with suspected instability or risk factors for hip dysplasia, were referred to the Department of Orthopedics and Anesthesiology, Ribeirão Preto/SP, where we evaluated them clinically and through ultrasound examinations of the hips. Once we found dysplasia, we initiated treatment, and in cases in which there was only hip immaturity and normal clinical examination, we performed clinical and ultrasound observation and review at two or three months of age. we examined 448 newborns, with female predominance and average age at first evaluation of 27 days. The main cause of referral was pelvic presentation at delivery. In 8% there was a positive Ortolani sign and in 12.5%,. At orthopedic examination, 405 (90.5%) patients were normal, 8.5% had hip click and 1.1% had positive Ortolani test. At ultrasound, 368 (89.5%) had immaturity, 26 (6.3%) had moderate dysplasia and in 17 (4.1%) patients the hips were frankly dysplastic. All cases with positive Ortolani sign showed dysplasia at ultrasound. there was an excess diagnosis of hip instability in the pediatrician evaluation, which, however, allowed the patient a second assessment, in a more specialized environment and with more technological resources.

Interocular Asymmetry of Minimum Rim Width and Retinal Nerve Fiber Layer Thickness in Healthy Brazilian Individuals

To determine interocular differences in Bruch's membrane opening minimum rim width (BMO-MRW) and retinal nerve fiber layer thickness (RNFLT) in healthy Brazilian individuals. Both eyes of 220 healthy individuals were included in this observational, cross-sectional study. All individuals had normal clinical examination and visual fields. Global and sectorial interocular BMO-MRW and RNFLT differences, acquired and regionalized relative to the fovea to BMO center (FoBMO) axis, were calculated. The effect of age, axial length, and BMO area asymmetry on the parameters' asymmetry was evaluated. The 95th limits for interocular BMO-MRW and RNFLT global differences were 49 and 9 μm, respectively. BMO-MRW asymmetry was negatively correlated (β=-33.87 μm/mm, R=0.06, P<0.001), whereas RNFLT asymmetry was positively correlated (β= 6.13 μm/mm, R=0.09, P<0.001) with BMO area asymmetry. Neither BMO-MRW nor RNFLT asymmetries were correlated with axial length asymmetry (β=-16.90 μm/mm, R=0.00, P=0.15; β=-1.18 μm/mm, R=0.00, P=0.52, respectively). Similarly, BMO-MRW and RNFLT asymmetries were not correlated with age (β=0.17 μm/y, R=0.01, P=0.22; β=0.0 μm/y, R=0.00, P=0.19, respectively). Our results suggest that global BMO-MRW and RNFLT interocular differences exceeding 49 and 9 μm, respectively, may indicate statistically abnormal asymmetry, which may suggest early structural damage. Asymmetry in BMO area should be accounted for when considering interocular asymmetry in BMO-MRW and RNFLT.

Revisiting Early Stages of Chronic Myeloid Leukemia (CML): Evidence That Leukemic Progenitors Appear First in Peripheral Blood during Molecular Recurrence

The use of tyrosine kinase inhibitors (TKI) has dramatically changed the natural history and the prognosis of CML with a major improvement of survival in patients responding to therapy. However, tyrosine kinase inhibitor (TKI) discontinuation trials in patients with deep molecular responses (DMR), show that 50-60% of patients will have a molecular recurrence requiring to resume the TKI therapy. The great majority of these relapses occur during the first 6 months of TKI discontinuation. Although the sustained persistence of leukemic stem cells (LSC) is clearly the cause of the recurrent disease, cellular dynamics of these early relapses and the pattern of cells giving rise to them are not determined. We had the opportunity to study this pattern in 4 patients (pts) who presented molecular recurrence after Imatinib mesylate (IM) discontinuation (n= 3) or on TKI therapy with Dasatinib (n= 1) after obtaining a deep molecular response de grade MR 4.5. The total duration of TKI therapy before TKI discontinuation was 14 years (UPN1), 15 years (UPN2) and 30 months (UPN3). All three pts (Aged 47, 66, 87 respectively) had CML-CP treated with IM 400 mg as a first line therapy with induction of DMR in all three. The duration of DMR (MR4.5- was for 6, 5 and 2 years for UPN1, 2 and 3 respectively. The reasons for TKI discontinuation were the TKI-discontinuation protocol in French observatory (UPN1, UPN2) and suspicion of interstitial pneumonia (UPN3). The patient UPN4 was on Dasatinib as a second line therapy and in DMR for 3 years. At the time of detection of molecular recurrence, all 4 pts had normal clinical examination with normal complete blood counts (CBC) with no evidence of circulating immature blood cells. After IM-discontinuation, molecular relapses occurred at 2 months (BCR-ABL IS 27%) 3 months (BCR-ABL IS transcript level at 13.1%) and at 9 months (BCR-ABL IS transcript level at 2.7%.) in patients UPN1, 2 and 3 respectively. In UPN 4, the molecular recurrence (BCR-ABL IS transcript 10%) was documented at + 4 months. In all 4 patients, colony forming cell (CFC) assays were performed from the same blood samples in which the molecular recurrence was documented. At day + 14, clonogenic cells (CFU-GM, BFU-E, CFU-Mixed) were plucked and BCR-ABL expression in each individual or pooled (2-4) CFC was determined. For 5.104PBMC plated in methycellulose assays in culture, the mean numbers of CFC obtained varied between 12 and 29 CFC / dish. Despite the normal CBC, the presence of BCR-ABL-expressing CFC in blood was demonstrated in all 4 pts. In UPN1, all CFC (20/20) obtained from peripheral blood were positive for BCR-ABL with a heterogeneous expression amongst CFC (BCR-ABL /ABL ratio range 2- 25%, mean 33%). Interestingly in this patient, CFC and LTC-IC assays performed in a bone marrow aspirate prior to IM discontinuation showed no evidence of BCR-ABL-expressing progenitors, suggesting a rapid and massive expansion of a dormant LSC clone migrating to blood at the time of molecular relapse. In pt UPN2, 9 individual CFC were found to express BCR-ABL with a significant heterogeneity (BCR-ABL/ABL ratio 0.2% - 56% , mean = 15 %). In Pt UPN3, with the lowest levels of BCR-ABL during molecular relapse, 4/73 CFC expressed BCR-ABL. All three pts had a favorable response after resuming Imatinib (UPN1, 2, 3) or after switching therapy to Bosutinib (UPN4). On UPN4, 2 pools of 4 CFC/20 expressed BCR-ABL. In two pts with 100% clonogenic relapse (UPN 1 and UPN2) the estimated circulating leukemic CFC numbers were 607 / ml and 468 / ml of blood respectively, in the presence of normal appearing CBC. In UPN 3 and 4, with approximately 10% of CFC being BCR-ABL +, these numbers were estimated to be 507 and 45 per ml of blood, respectively. Thus, the study of these four patients demonstrates that circulating leukemic CFC are the first detectable abnormal cellular components during molecular recurrence and that the clonogenic relapse in peripheral blood precedes myeloid expansion. These results show also for the first time to our knowledge, that leukemic CFC egress from bone marrow to peripheral blood is an early event during early stages of CML and the CFC expansion takes place not only in bone marrow but also in peripheral blood. Besides shedding light into the pathophysiology of CML, these findings could be of major interest to predict relapse parameters and could lead to the design of novel biological follow-up protocols after TKI discontinuation. DisclosuresNo relevant conflicts of interest to declare.

Evaluation of toxic retinopathy caused by antimalarial medications with spectral domain optical coherence tomography.

To investigate the frequency of toxic retinopathy in patients with lupus erythematosus and rheumatoid arthritis with long-term use of chloroquine diphosphate or hydroxychloroquine through spectral domain optical coherence tomography and the outcomes of ophthalmological exams (visual acuity - Snellen's table, color vision test - Ishihara's table, fundoscopy, and retinography - red-free). A cross-sectional study was carried out involving the ophthalmologic evaluation of patients using regular chloroquine diphosphate or hydroxychloroquine for a period of 1 year or longer. The patients completed a questionnaire on their opinions and treatment regularity. The same patients underwent ophthalmologic examination and spectral domain optical coherence tomography. The prevalence of toxic retinopathy caused by antimalarials was 4.15% (9 of 217 patients), 7.4% (4 of 54 patients) following chloroquine diphosphate usage, and 0.82% (1 of 121 patients) following hydroxychloroquine usage. Only patients with advanced stage maculopathy presented abnormalities during the ophthalmologic exam: the color vision test was altered in 11.1%, and visual acuity and fundoscopy were altered in 33.3%. Identification of early toxic retinopathy, detected in six patients, was possible using spectral domain optical coherence tomography. The mean duration of antimalarial drug usage among patients with toxic retinopathy was 10.4 years. Only 31% of the patients reported some symptoms during treatment, and although 24% were afraid to use the medication, they did so as prescribed. Use of spectral domain optical coherence tomography was essential for the diagnosis of early-stage antimalarial toxic retinopathy in patients with the following characteristics: asymptomatic, antimalarial use 7 days a week for a period of more than 5 years, and normal clinical ophthalmologic examination.

Hand injury without any deficit: Is systematic surgical exploration justified?

Out of 100,000 inhabitants, 700 to 4000 suffer a hand wound each year. Numerous hand wounds that may not have a clinically evaluated deficit, actually have damage to a major structure after surgical exploration in the operating room (OR). The aim of our study was to evaluate the incidence of major structure damage within a population of patients presenting a hand wound with no deficit on the clinical examination. Every patient older than 12 years, consulting for a wound deeper than the dermis with no clinical signs of major structure damage underwent surgical treatment and exploration of the wound under regional anesthesia in the OR. After each surgery, the surgeon filled out an anonymous study form describing the wound characteristics and the potential findings of major structure damage. Of the 145 wounds with normal clinical examination, we found that 58.6% had a major structure damaged. Given that damage to any major structure in the hand can lead to functional sequela, and the fact that a well-conducted clinical examination by a qualified hand surgeon is not sufficient to eliminate major structure damage, we recommend systematic surgical exploration of hand wounds, even when no clinical deficit is evident. Level of evidence III.Type of sudy: diagnostic study.

Detection of Minimal Hepatic Encephalopathy in Iranian Patients with Cirrhosis.

BACKGROUND Minimal hepatic encephalopathy (MHE) is the mildest type of hepatic encephalopathy in patients with cirrhosis. Patients with MHE have normal clinical and physical examination but they show some neurocognitive dysfunctions that affect their quality of life negatively. The aim of the current study is to diagnose MHE in patients with cirrhosis and its associated factors. METHODS This is a cross-sectional study on 120 known cases of cirrhosis referred to hospitals affiliated to Isfahan University of Medical Sciences during 2014-17. The patients’ cirrhosis severity was evaluated using laboratory tests and physical examinations based on MELD (Model for End-stage Liver Disease) and Child-Pugh criteria. The patients’ demographics were filled in a checklist. All included patients with cirrhosis were asked to respond to the questions of Psychometric Hepatic Encephalopathy Score (PHES) test. RESULTS Mean age of the patients was 51.2 ± 9.7 years. 62 (51.7%) patients were men and 58 (48.3%) patients were women. The mean score of the patients based on MELD criteria was 14.03 ± 6.09. 26.7% of the patients presented MHE. Mean age of the patients with MHE was statistically less than the patients without MHE (p value < 0.001). Mean score of MELD criteria among the patients with diagnosis of MHE was significantly higher than the other group (p value < 0.001). The patients’ Child class was statistically associated with MHE (p value < 0.001). Men were significantly more affected than women (p value = 0.03). CONCLUSION MHE was associated with MELD score and Child class of the patients with cirrhosis. The noticeable point was reversible association of age with MHE. Further studies are recommended.

Value of Physical Examination in the Diagnosis of Developmental Hip Dislocation in Preterm Infants

Background: Developmental dislocation of the hip joint is among joint abnormalities and lack of its early diagnosis leads to irreversible complications and disabilities. Methods: The current cross sectional study was conducted on 210 eighteen - month - old premature infants. Premature infants at term gestational age were examined by a neonatologist and underwent a sonographic scanning by a skilled radiologist. The results of the physical examination and ultrasound reports were collected and analyzed. Results: In the clinical assessment, hip joint examination was diagnosed abnormal in 22 cases (10.4%) and joint dislocation was diagnosed by ultrasonographic examination in 17 patients (8.1%). In one high - risk case, despite normal clinical examination (0.48%), the dislocation was diagnosed by ultrasonographic evaluation. There was a significant relationship between hip dislocation rate, and reduced mean gestational age and birth weight (P 0.05). In diagnosis of joint dislocation, clinical examination (the results of the Ortolani and the Barlow tests) had sensitivity of 94% and specificity of 97% compared with sonography; the positive and negative predictive values were 73% and 99%, respectively. Conclusions: Clinical examination has high sensitivity and specificity for early diagnosis of developmental hip dislocation. If there are risk factors, ultrasonographic scanning is recommended despite normal physical examination, and ultrasound is not necessary in case of normal physical examination and the absence of risk factors.

An audit of referral time frames for ultrasound screening of developmental hip dysplasia in neonates with a normal antenatal clinical examination

AbstractIntroductionUltrasound has an established role in the detection of developmental dysplasia of the hip (DDH). Lack of uniformity in the appropriate age to perform studies in at‐risk children with a normal clinical examination at birth exists. Opening a new tertiary paediatric hospital saw a variety of referral time frames for initial screening ultrasound for DDH.MethodsLiterature review and retrospective clinical audit were undertaken. DDH ultrasounds of babies with the following criteria were reviewed: normal clinical examination and one or more risk factors. Patients were followed up via their electronic medical record.ResultsThere were 187 eligible patients: 124 (66.3%) had normal initial scans while 63 (33.7%) were recommended to have a follow‐up scan. Most subnormal results (Graf 2A or lower, laxity and/or less than 50% femoral head coverage) (n = 59, 93.7%) were scanned before 6 weeks of age, only four (6.3%) presented at 5 weeks after birth or later.DiscussionThis study identified a potential for reduction in follow‐up studies through delayed initial ultrasound, improving from 4 to 6 weeks of age, without adverse outcomes. Early screening ultrasounds may result in overdiagnosis of DDH during the maturation process of the neonatal acetabulum, potentially causing anxiety and unnecessary follow‐up.

The cervical spine can be cleared without MRI after blunt trauma:A retrospective review of a single level 1 trauma center experience over 8 years

BackgroundThe newest CT scanners provide resolution comparable to MRIs leading many to question when and whether cervical spine MRIs are warranted. MethodsAn 8 year retrospective review identified 241 patients who underwent CT scan and MRI of the cervical spine. The initial clinical examination, cervical spine CT scan, and cervical spine MRI were compared to identify cervical spine injuries that would have been missed had the MRI not been performed. ResultsThe CT scans were normal in 153 patients, and abnormal in 88. Of the 88 abnormal CT scans, the MRIs were abnormal in 65, and normal in the other 23. The indications for MRI in patients with normal CT scans were neck pain, an abnormal neurologic examination, and/or altered mental status. Of the 13 patients with abnormal MRIs, none were pain free with a normal clinical examination. ConclusionIn the absence of focal signs of neurologic injury, the cervical spine can be cleared without a clinical exam or MRI if the cervical CT scan does not demonstrate injury or abnormality.

Late-Presenting Developmental Dysplasia of the Hip

Research Article| March 01 2018 Late-Presenting Developmental Dysplasia of the Hip AAP Grand Rounds (2018) 39 (3): 31. https://doi.org/10.1542/gr.39-3-31 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Late-Presenting Developmental Dysplasia of the Hip. AAP Grand Rounds March 2018; 39 (3): 31. https://doi.org/10.1542/gr.39-3-31 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: developmental hip dysplasia, hip abduction, leg length inequality, live birth Source: Talbot C, Adam J, Paton R. Late presentation of developmental dysplasia of the hip: a 15-year observational study. Bone Joint J. 2017; 99-B(9): 1250– 1255; doi: https://doi.org/10.1302/0301-620X.99B9.BJJ-2016-1325.R1Google Scholar Investigators from multiple institutions in the United Kingdom conducted an observational cohort study to assess the incidence and characteristics of late-presenting irreducible developmental dysplasia of the hip (DDH). All infants referred to a regional pediatric orthopedic clinic from 1997–2011 with DDH were included. This was the referral clinic for all infants identified by the regional DDH screening program, a program that required a clinical hip exam for all infants within 48 hours of birth and referral within 1–2 weeks for those with clinical hip instability (ie, positive Ortolani or Barlow maneuvers) and 6–9 weeks for those without hip instability but with DDH risk factors present (ie, breech birth and/or family history). All referred infants had risk factors confirmed, hips reexamined, and hip ultrasound performed. Irreducible DDH was diagnosed by ultrasound, and late-presenting DDH was defined as the diagnosis after 3 months of age or having a delayed review or investigation as part of the regional screening program. Investigators calculated the incidence of late-presenting irreducible DDH as the ratio of cases over the number of live births in the region during the study period. The clinical characteristics of infants with late-presenting irreducible DDH were described. There were 64,670 live births and 18 infants with late-presenting irreducible DDH over the study period, resulting in an incidence of 0.48 per 1,000 live births. Each of the 18 infants had a normal clinical examination at birth and no recorded abnormality at 6–8 weeks of age. Two infants were late-presenting because of delayed review despite having DDH risk factors (both had missed appointments). An additional 3 infants had a positive family history (2 parents did not know their family history prior to referral to the orthopedic clinic, and the other was never asked about their family history at the 48-hour exam). The most common reasons for referral for infants who were diagnosed with late-presenting irreducible DDH were leg length discrepancy and limited hip abduction. The investigators conclude that despite universal DDH screening, late-presenting irreducible DDH still occurs and can present as leg length discrepancy and limited hip abduction. Dr Hennrikus has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Early diagnosis and treatment of DDH is important to provide the optimal clinical outcome.1 The incidence of DDH varies depending on the criteria used for diagnosis, the population studied, and the method of screening2 ; the incidence is approximately 1 in 1,000 live births.2 Important risk factors for DDH include breech position, female gender, being first born, and a positive family history. Breech presentation is the most important single risk factor.3 Screening for DDH is important because the condition is initially occult, is easier to treat... You do not currently have access to this content.

Late presentation of developmental dysplasia of the hip : a 15-year observational study.

Despite the presence of screening programmes, infants continue to present with late developmental dysplasia of the hip (DDH), the impact of which is significant. The aim of this study was to assess infants with late presenting dislocation of the hip despite universal clinical neonatal and selective ultrasound screening. Between 01 January 1997 to 31 December 2011, a prospective, longitudinal study was undertaken of a cohort of 64 670 live births. Late presenting dislocation was defined as presentation after three months of age. Diagnosis was confirmed by ultrasound and plain radiography. Patient demographics, referral type, reason for referral, risk factors (breech presentation/strong family history) and clinical and radiological findings were recorded. There were 31 infants with an irreducible dislocation of the hip, an incidence of 0.48 (95% confidence interval (CI) 0.34 to 0.68) per 1000 live births. Of these, 18 (0.28 (95% CI 0.17 to 0.44) per 1000 live births; 58%) presented late. All infants had a documented normal newborn clinical examination and no abnormality reported in the six to eight week check. Of the 18 late presenting cases 72% (n = 13) had no risk factors: 16 were referred by GPs and two were late due to administrative issues (missed appointments). The mean time to diagnosis was 62.4 weeks (19 to 84). Despite universal clinical neonatal and selective ultrasound screening, late cases of irreducible hip dislocation still occur. We recommend an update of the national screening programme for DDH, a review of training and education of healthcare professionals involved in the physical examination of neonates and infants, and the addition of a further assessment after the six to eight week check. Cite this article: Bone Joint J 2017;99-B:1250-5.

Does Late Hip Dysplasia Occur After Normal Ultrasound Screening in Breech Babies?

Recent literature has raised concern regarding the occurrence of late dysplasia after normal screening in breech babies. One paper states a late dysplasia incidence of 29%. This finding is in contrast with other published work, which suggests breech presentation is predictive of spontaneous stabilization of the unstable neonatal hip. We decided to identify the rate of late dysplasia after normal screening in our patient cohort and also to investigate the use of a prophylactic abduction diaper. During the study period of December 2012 to June 2014, breech babies referred to the screening program at our institution were identified. Ninety babies were prospectively enrolled into the study and randomized to either the observational arm or prophylactic treatment with the Healthy Hip Diaper (HALO, Minnetonka, MN). All babies had a normal initial clinical examination and ultrasound. Regular follow-up including clinical and ultrasound examination was undertaken culminating in pelvic x-rays performed at 13±1 months. A total of 63% of patients elected against their randomization to prophylactic treatment, 28% opted for prophylactic treatment against their randomization to observation only, meaning a total of 40% of babies proceeded against their initial randomization. In total, 75% of recruited babies completed follow-up. Dysplasia was defined as an acetabular index >2 SD from the mean sex, age, and side-specific values. The overall rate of radiographic dysplasia at 13 months was 7.4%. The rate was 5% in those using a Healthy Hip Diaper and 8.3% in those under observation only. This was not a statistically significant difference. Two patients required operative intervention, one requiring capsulorraphy with acetabuloplasty, the other requiring an arthrogram. Overall compliance with the abduction diaper was low. We conclude that late radiographic dysplasia does occur after normal clinical and ultrasound screening in breech babies, although not to the same extent as recently published data. We cannot recommend prophylactic abduction devices for breech babies who have a normal hip ultrasound at 6 weeks of age. Consideration must be given to further clinical and radiographic follow-up for hip dysplasia when the risk factor of breech presentation is present. Level II-prospective comparative trial.

Incidence of acetabular dysplasia in breech infants following initially normal ultrasound: the effect of variable diagnostic criteria.

PurposeThis study aimed to determine the incidence of acetabular dysplasia at six months of age in patients with breech presentation and previously normal hip ultrasounds, reporting primary radiographic measurements to allow for comparison with other patient cohorts.MethodsA retrospective analysis of breech infants with initially normal clinical examinations and hip ultrasounds was performed to determine the rate of subsequent acetabular dysplasia and to characterise the distribution of acetabular index (AI). At approximately six months of age, AI was measured bilaterally on anteroposterior (AP) pelvic radiographs and reported using descriptive statistics.ResultsA total of 94 hips in 47 breech infants were eligible for analysis. All infants demonstrated normal ultrasound findings at a mean age of 6.9 ± 1.7 weeks and returned for follow-up at a mean age of 6.4 ± 0.5 months. On AP pelvic radiographs, mean right hip AI was 25.0°, with an interquartile range (IQR) (25th -75th percentile) of 23° to 27° and mean left hip AI was 25.5°, with an IQR of 22° to 28°. If one applies a single commonly used threshold value for defining dysplasia (AI ≥ 30°), 10/94 hips (10.6%) meet diagnostic criteria. Alternatively, strict adherence to previously established normative AI values stratified by gender and laterality results in 4/94 hips (4.3%) qualifying as significantly dysplastic.ConclusionsThe proportion of breech infants who, despite normal initial ultrasound findings, were diagnosed with dysplasia at six months supports observation of breech-born patients beyond six weeks. Reliance on different threshold values for diagnosing acetabular dysplasia can lead to discrepancies in incidence rates.

Successful Pavlik Harness Treatment for Developmental Dysplasia of the Hip and Normal X-Ray at the Age of 2 Years: Is a Longer Follow-up Necessary?

Management of developmental dysplasia of the hip (DDH) with a Pavlik harness is a well-known treatment.Follow-up until skeletal maturity is recommended as long-term studies mention late sequelae.The purpose of this study was to determine whether such a follow-up is necessary in patients treated successfully under a strict protocol. A retrospective review of a consecutive series of normal infants treated for DDH between January 1995 and July 2004 was undertaken.Only normal infants with frankly pathologic hips treated successfully with a Pavlik harness were included, and with a normal anteroposterior (AP) pelvis x-ray at the age of 2 years.All infants with any type of neurological disease, syndrome, other form of treatment for DDH, and failure of the Pavlik harness were excluded.At the last follow-up, a clinical examination and a standing AP pelvis x-ray were performed. A total of 109 hips in 83 children were available for review. The mean follow-up was of 10 years and 2 months. All 109 hips had a normal clinical examination and a normal AP pelvis x-ray: a mean center-edge angle (CEA) of 29.5 degrees, SD±4.1 degrees, a mean acetabular index (AI) of 1457±3.74 degrees, a mean Sharp's angle of 41.92±3.42 degrees, a Seringe-Severin score of IA, a normal teardrop figure, no signs of avascular necrosis, and Moses circles <2. This study strongly suggests that in a selected group of patients treated for DDH with a Pavlik harness, under a strict protocol, and a normal x-ray at 2 years of age, a long-term follow-up is not necessary. Level III-therapeutic.

Postoperative Swallowing Assessment After Lung Transplantation

Dysphagia, aspiration, and potential pneumonia represent a major source of morbidity in patients undergoing lung transplantation. Conditions that potentiate dysphagia and aspiration include frailty and prolonged intubation. Our group of speech-language pathologists has been actively involved in performance of a bedside evaluation of swallowing, and instrumental evaluation of swallowing with modified barium swallow, and postoperative management in patients undergoing lung transplantation. All lung transplant patients from April 2009 to September 2012 were evaluated retrospectively. A clinical bedside examination was performed by the speech-language pathology team, followed by a modified barium swallow or fiberoptic endoscopic evaluation of swallowing. A total of 321 patients were referred for evaluation. Twenty-four patients were unable to complete the evaluation. Clinical signs of aspiration were apparent in 160 patients (54%). Deep laryngeal penetration or aspiration were identified in 198 (67%) patients during instrumental testing. A group of 81 patients (27%) had an entirely normal clinical examination, but were found to have either deep penetration or aspiration. The majority of patients aspirate after lung transplantation. Clinical bedside examination is not sensitive enough and will fail to identify patients with silent aspiration. A standard of practice following lung transplantation has been established that helpsavoid postoperative aspiration associated with complications.

Antenatal prognostic factor of fetal echogenic bowel

ObjectiveThe aim of this study was to identify antenatal prognostic factors of neonatal outcomes in cases of fetal echogenic bowel (FEB). Study designA retrospective study in three tertiary referral centers including fetal echogenic bowel over a 10-year period (from January 2003 to December 2013). The echogenicity of the fetal bowel was graded from 1 to 3, according to Slotnick's definition. Associated echographic findings such as bowel dilations, gallbladder abnormalities, calcifications, extra-abdominal abnormalities, intrauterine growth restriction (IUGR) and a decrease in amniotic fluid volume, if present were also recorded. This was followed by the FEB's sonographic evolution. The sonographic evolution was considered favorable if it was stable or decreasing and unfavorable if the echogenicity of the bowel increased or if additional sonographic findings appeared. Neonates had a pediatric examination in the delivery room and upon discharge from the maternity hospital. An outcome was considered good in the case of on-term delivery of a newborn with normal clinical examination and meconium elimination. ResultsComplete pregnancy outcome data were available for 409 pregnancies. 338 newborns had uneventful outcomes (82.6%). Antenatal exploration diagnosed 4 cases of aneuploidy (1 case of trisomy 13, 1 case of trisomy 18 and 2 cases of triploidies), 16 cases of congenital infections, 9 cases of cystic fibrosis and 11 cases of bowel abnormalities. After a multivariate analysis, we discovered the sonographic grade of the echogenic bowel was not a prognostic factor of neonatal outcome. The isolated fetal echogenic bowel had a 6.6-fold increase chance of uneventful outcomes (adjusted odd ratio (aOR) 6.6, 95% CI 3–14.4). Notably, favorable sonographic evolution (aOR 8.1, 95% CI 4.1–16) and late gestational age at the time of the diagnosis (aOR 1.17, 95% CI 1.07–1.27) are independent, good prognostic factors of good neonatal outcomes. None of the 180 fetuses with isolated fetal echogenic bowel and favorable sonographic evolution had adverse outcomes. Among these, 4 cases (0.98%) of aneuploïdy, 17 cases (4.2%) of congenital infections and 9 cases (2.2%) of cystic fibroses were also diagnosed. No cases of Down syndrome (DS) were reported. ConclusionOur study shows that the grade should not be considered a prognostic factor of neonatal outcomes. Our data suggests the need to reevaluate the concept of systematic amniocentesis. Sonographic evolution of fetal bowel is an independent, strong prognostic factor for good neonatal outcomes. It also better defines the FEB prognostic.

The value of routine screening mammography in women aged 35–39 years in a symptomatic breast unit

To determine the breast cancer detection rate at routine bilateral screening mammography in women aged 35-39 years attending a symptomatic breast clinic, in women of population-risk profile with a normal clinical examination. A retrospective analysis of all mammograms performed on patients aged 35-39 years at St James's Hospital from 2011-2015 was carried out. Patients with moderate or high familial risk of breast cancer, personal breast cancer history or chest radiation, males, general practitioner (GP) and internal hospital referrals, and those with abnormal clinical examinations were excluded. Included women had "normal", "benign", or undocumented examination findings. Results of imaging, including ultrasound and histopathological results, were recorded. Information was extracted from the hospital's electronic record systems. Of 4,087 patients aged 35-39 who had bilateral mammograms from 2011-2015, 2,148 patients were excluded from analysis. Of 1,939 included women, four (0.21%) were diagnosed with breast cancer confirmed at histology based on mammographic findings: two invasive ductal carcinoma (8 and 2mm) and two ductal carcinoma in situ (DCIS; 4.5mm high-grade DCIS and 2mm low-grade DCIS). Other histological findings included two B3, 46B2, and three B1 lesions. Overall, 115 biopsies were performed in this cohort; 55 (47.8%) were attributable to mammographic screening, producing a biopsy rate of 2.8% due to mammography alone. Per 1,000 women screened, 2.1 cases of cancer were detected. This figure would be below accepted international thresholds to undertake screening mammography and raises radiation protection issues. Additionally, a large number of benign biopsies were undertaken, with likely resultant psychological impact. Further studies could inform national guidance.

Usefulness of trans-thoracic echocardiography (TTE) in patients with acute ischaemic strokes and normal clinical cardiac examination

Introduction: Stroke is one of the leading causes of disability and mortality in Sri Lanka. Cardiac sources of embolism account for 15 - 30% of ischaemic strokes. For optimal treatment aiming at secondary prevention it is crucial to identify the source of the embolism.We aimed to assess the influence of routine echocardiography in the management of patients with ischaemic strokes who have no evidence of cardiac abnormality on routine medical history, physical examination or 12-lead ECG. Methods: Transthoracic echocardiography (TTE) was performed in patients admitted to Professorial Medical Unit, Teaching Hospital Karapitiya with an acute ischaemic stroke and normal clinical cardiac evaluation including a 12-lead ECG. The echo findings were categorized as therapeutically significant or insignificant by the cardiologist who performed the echo and the treating physician. Results: Of the 110 patients with acute ischaemic stroke with normal clinical cardiac evaluation, 14.5% had therapeutically significant echo findings; left ventricular systolic dysfunction with ejection fraction Conclusions: In this study, TTE revealed cardiac abnormalities that need specific treatment in 16 (14.5%) patients with acute ischaemic stroke with normal clinical cardiac evaluation. TTE should be considered an essential test in the evaluation of all ischaemic stroke patients regardless of the clinical findings.

Outcome of Acute Myeloid Leukemia in Children and Young Adults Treated with an Uniform Protocol in Casablanca, Morocco

Introduction :With the improvement in the risk assessment, therapeutic advances and supportive care, about 50% of children and young adults with newly diagnosed acute myeloid leukemia(AML) can be cured in high income countries. However similar survival advantages are not seen in patients from low or middle income countries.In Morocco, the main causes of poor outcome in patients with AML are delayed diagnosis, early (before the start of treatment) and induction death, induction failure and therapy abandonment. In 2011, the National AML-MA-2011 protocol was developed to treat AML patients according to international standards and has focused on improving particularly supportive care, prevention and management of infection, transfusion support, implementation of hand hygiene, and education of patients, families and nurses. The goals of the AML-MA-2011 protocol were to obtain of favorable risk AML more than 70% complete remission rate, less than 10% on therapy mortality and event free survival (EFS) (4 years) of 40%.Aim of this study : To evaluate and compare treatment outcomes (Complete remission rate, overall survival [OS] and EFS) of children (≤ 15 yrs.) and adolescents and young adults (AYA) (15-30 yrs) diagnosed with de novo AML and treated at a single center on AML-MA 2011Patients and methods : From January 2011 to December 2015, eligible patient (age ≤ 30 yrs) with de novo AMLwere enrolled ona uniform treatment protocol. Patients with secondary AML, Down syndrome, those with acute promyelocytic leukemia or organ dysfunctions were excluded.The diagnosis was confirmed according to the FAB classification using WHO criteria, At diagnosis BM MPO staining, immunophenotyping and lumbrteritisar puncture were performed. Karyotype was performed on marrow sample (with minimum 20 metaphases analyzed) using R banding technique. Patients with hyperleukocytosis (WBC≥ 50G/L) received as a pre-phase 4 days of hydroxyurea to 50mg/kg/day then 2 inductions and 2 consolidations. The two courses of induction associated cytarabine (100mg/m² q 12h for 10 days), Daunorubicin (50 mg/m² on days 2, 4, 6 for the first course, and on days 1, 3, 5 for the second course) and etoposide (100mg/m² for 5 days for the second course of induction). The consolidation included Cytarabine (3g/m²q 12h days1-3 for first and second course) plus Daunorubicin (30mg/m² on days 3, 4 at the first consolidation). L-Asparaginase 6000UI/m² on day 4 was give at second consolidation. All patients received CNS prophylaxis. Patients with CNS disease received addutional intrathecal.The supportive care consisted of blood product transfusion, antibiotic and antifungal, and patient and family education by hygien team.Complete remission (CR) was defined as normal clinical examination, no evidence of chloroma, peripheral counts recovery (ANC ≥ 1.0 G/L ; platelets ≥ 75 G/L without transfusion) and end of induction II bone marrow showed normal hematopoietic elements and <5% blasts.Résultats :During the study period a total of 155 patients were enrolled, 41 were < 15 yrs (22 boys ; median age 7.8 yrs.). Of the 114 AYA enrolled, 48 were women and the median age was 23 yrs. In children median hemoglobin was 6.75g/dl and platelet 39.5G/L, 15/41 (36.6%) had AML2 and 36/41 (87.8%) had immunophenotyping. Among young adults 32/114 (28.1%) were hyperleucocytosis, 7.38g/dl and 52.81G/L were median hemoglobin and platelets respectively, 31/114 (29.8%) had AML1 and 89/114 (78.1%) had immunophenotyping. Cytogenetics was performed 90.2% of children and 95.6% of AYA. The median delay from diagnosis to treatment was 11.5 days in children and 29.9 days. Complete remission after two inductions was achieved in 28/41 (68.3%) children and 71/114 (62.3%) adults. The number of failure was 21 in age groups which 4 (9.8%) on children and 17 (14.9%) in young adults. The number of deaths in children is 9 (22%) of which 3 occurred in the first 15 days of induction and 6 from the 15th to 42nd day. AYA 26 (22.8%) deaths had been seen by registered including 5 in the first 15 days and 21 after. The causes of death were dominated by infections including 4 cases in children and 10 adults followed hemorrhage 3 cases among children and 10 adults. Leukostasis cases were recorded in 2 children 6 and young adults.Analysis of the results is summarized in the table.Conclusion : The therapeutic results of the protocol AML-MA 2011 were similar in both year groups, but are far from the goals of treatment. DisclosuresNo relevant conflicts of interest to declare.

Correlating clinical and radiological assessment of joints in haemophilia: results of a cross sectional study.

This study was undertaken to determine the correlation between the radiological changes in haemophilic arthropathy [X-ray, Ultrasound (US) and MRI] and clinical assessment as determined by the Hemophilia Joint Health Score (HJHS); and to document the US and MRI changes in joints that appear normal on plain X-ray and clinical evaluation. Of 55 study joints (22 knees and 33 ankles) in 51 patients with haemophilia/von Willebrand disease, with a median age of 15 years (range: 5-17) were assessed using X-rays (Pettersson score) and clinical examination (HJHS) at two centres (Toronto, Canada; Vellore, India). MRI and ultrasonographic scoring was done through a consensus assessment by imagers at both centres using the IPSG MRI and US scores. The HJHS had a good correlation with the Pettersson score (rs = 0.66). Though the HJHS had moderate correlation with the osteochondral component of the MRI and US scores (rs 0.51, 0.45 respectively), its correlation with the soft tissue component was poor (rs 0.19; 0.26 respectively). Of the 18 joints with a Pettersson score of zero, 88.9% had changes that were detected clinically by the HJHS. Osteochondral abnormalities were identified in 38.9% of these joints by the MRI, while US images of the same joints were deemed abnormal in 83.3% by the current criteria. US identified haemosiderin and other soft tissue changes in all of the joints, while the same changes were noted in 94.4% of these joints on MRI. There were four joints with a HJHS of zero, all of which had soft tissue changes on MRI (score 1-7) and US (score 2-7). Osteochondral changes were detected in three of these joints by US and in 2 by MRI. There were four joints with an MRI score of 0-1 that had significant US scores (3-5) and HJHS scores (0-6). US and MRI are able to identify pathological changes in joints with normal X-ray imaging and clinical examination. However, further studies are required to be able to differentiate early abnormalities from normal. Clinical (HJHS) and radiological assessment (US/MRI) provide complimentary information and should be considered conjointly in the assessment of early joint arthropathy.