Retrospective Chart Research Articles

Add-on perceptual learning on refractive amblyopia in children.

To evaluate the visual outcomes of standard amblyopic treatment add-on training via perceptual learning in refractive amblyopic children and to identify the risk factors for treatment failure. Retrospective charts were reviewed in children with refractive amblyopia who received standard treatment and add-on Cambridge Visual Stimulator (CAM) training. The add-on CAM group that was enrolled had worn full-corrected glasses for at least 2mo before training. A control group received only the standard treatment. Treatment success was defined as best-corrected visual acuity (BCVA) ≥20/25. The age, sex, initial BCVA, refractive errors, sessions and duration of training, and final BCVA were recorded. A total of 209 children (129 children in add-on CAM group and 80 children in control group) were enrolled. Seventy-six percent of unilateral and 87% of bilateral amblyopic children achieved treatment success. In children with unilateral or bilateral moderate amblyopia, the duration to reach BCVA ≥20/25 was significantly shorter in add-on CAM group than in control group. Poor initial BCVA (P<0.001) and high astigmatism (P=0.007) were risk factors for treatment failure after add-on CAM training. Age, sex, and types of refractive error were not associated with treatment success. Add-on CAM training is an effective strategy for visual improvement and can shorten the treatment course when the effect of standard treatment is limited in amblyopic children.

Increasing the Knee Arc of Motion in Patients With Arthrogryposis: Minimum 2-year Follow-up.

Surgery for knee flexion contractures in patients with arthrogryposis multiplex congenital (AMC) have achieved extension to redirect the arc of motion and improve ambulation but has not demonstrated maintained increases in total range of motion (ROM). This study aimed to review the clinical outcomes of combined posterior knee release, proximal femoral shortening, and nerve decompression in patients with arthrogryposis. A retrospective chart and radiographic review were performed on patients with AMC who underwent treatment for knee flexion deformities ≥30 degrees. ROM, ambulation status, and orthotic use were reviewed and analyzed. Complications were recorded. Twenty-nine patients with 51 knees and a mean age of 5.7 years were included. The mean follow-up was 36.9 months. The mean ROM increased from 49 to 80 degrees between pre-op and latest follow-up (P<0.0001). The mean final follow-up flexion deformity was 10 degrees (P<0.0001). Preoperative ROM was moderately correlated with final ROM (rs=0.51). The percentage of ambulatory patients improved from 39% to 93%. Five limbs experienced a fracture either intraoperatively or postoperatively, and 5 limbs required a return trip to the operating room. Improved ambulation and knee ROM can be maintained in patients with AMC at a minimum 2-year follow-up. Prospective investigation and longer follow-up are required to validate these findings. Level IV-therapeutic.

Does participation in a court-based trauma-focused evaluation program influence permanency outcomes for children involved in the child welfare system?

BackgroundChildren involved in the child welfare system, especially those in out-of-home care, experience high rates of mental health symptoms. Mental health symptoms have been linked to worse permanency outcomes in this population. ObjectiveThe present study aimed to evaluate whether children who received a trauma-focused evaluation, compared to children who received usual care, experienced differential permanency outcomes, as well as other court-related outcomes (e.g., legal system involvement). Participants and settingOne-hundred and twenty-five children (58% female, Mage = 10.61) from a family court in the Northeastern United States participated in a trauma-focused evaluation program. MethodsData for the current study were collected via a retrospective chart. Participants were recruited at a family court of a Northeastern state. Between-groups differences on court-related outcomes were assessed using logistic regression and Kaplan Meier estimates. FindingsThere were no significant differences between children who received the trauma-focused evaluation program versus usual care in the likelihood for guardianship changes, termination of parental rights, new child welfare petitions or new juvenile legal petitions. The groups significantly differed in the likelihood of case closure; children who received the trauma-focused evaluation program were more likely to experience case closure compared to children who received usual care. Additionally, on average, children who received the trauma-focused evaluation program achieved case closure almost 8 months sooner. ConclusionsThe findings suggest that initiatives aimed at identifying mental health concerns and linking children placed in out-of-home to relevant mental health services care can have a significant and positive impact on permanency outcomes.

Role of unilateral partial facet joint preservation in postero-lateral approach lumbar interbody fusion for patients with degenerative lumbar spinal stenosis presenting bilateral lower limb symptoms: a retrospective study

BackgroundPosterolateral decompression and fusion with internal fixation is a commonly used surgical approach for treating degenerative lumbar spinal stenosis (DLSS). This study aims to evaluate the impact of preserving a portion of the unilateral facet joint during decompression on surgical outcomes and long-term recovery in patients.MethodsThis study analyzed 73 patients with DLSS accompanied by bilateral lower limb neurological symptoms who underwent single-level L4/5 posterolateral decompression and fusion surgery from January 2022 to March 2023. Patients were categorized into two groups based on the type of surgery received: Group A comprised 31 patients who underwent neural decompression without facet joint preservation, while Group B consisted of 42 patients who underwent neural decompression with preservation of partial facet joints on one side. Regular follow-up evaluations were conducted, including clinical and radiological assessments immediately postoperatively, and at 3 and 12 months thereafter. Key patient information was documented through retrospective chart reviews.ResultsMost patients in both groups experienced favorable surgical outcomes. However, four cases encountered complications. Notably, during follow-up, Group B demonstrated superior 1-year postoperative interbody fusion outcomes (P < 0.05), along with a trend towards less interbody cage subsidence and slower postoperative intervertebral disc height loss. Additionally, Group B showed significantly reduced postoperative hospital stay (P < 0.05).ConclusionUnder strict adherence to surgical indications, the posterior lateral lumbar fusion surgery, which preserves partial facet joint unilaterally during neural decompression, can offer greater benefits to patients.

Comparative analysis of molecular and histological glioblastomas: insights into prognostic variance.

Whether molecular glioblastomas (GBMs) identify with a similar dismal prognosis as a "classical" histological GBM is controversial. This study aimed to compare the clinical, molecular, imaging, surgical factors, and prognosis between molecular GBMs and histological GBMs. Retrospective chart and imaging review was performed in 983 IDH-wildtype GBM patients (52 molecular GBMs and 931 histological GBMs) from a single institution between 2005 and 2023. Propensity score-matched analysis was additionally performed to adjust for differences in baseline variables between molecular GBMs and histological GBMs. Molecular GBM patients were substantially younger (58.1 vs. 62.4, P = 0.014) with higher rate of TERTp mutation (84.6% vs. 50.3%, P < 0.001) compared with histological GBM patients. Imaging showed higher incidence of gliomatosis cerebri pattern (32.7% vs. 9.2%, P < 0.001) in molecular GBM compared with histological GBM, which resulted in lesser extent of resection (P < 0.001) in these patients. The survival was significantly better in molecular GBM compared to histological GBM (median OS 30.2 vs. 18.4 months, P = 0.001). The superior outcome was confirmed in propensity score analyses by matching histological GBM to molecular GBM (P < 0.001). There are distinct clinical, molecular, and imaging differences between molecular GBMs and histological GBMs. Our results suggest that molecular GBMs have a more favorable prognosis than histological GBMs.

Revisiting gliomatosis cerebri in adult-type diffuse gliomas: a comprehensive imaging, genomic and clinical analysis

Although gliomatosis cerebri (GC) has been removed as an independent tumor type from the WHO classification, its extensive infiltrative pattern may harbor a unique biological behavior. However, the clinical implication of GC in the context of the 2021 WHO classification is yet to be unveiled. This study investigated the incidence, clinicopathologic and imaging correlations, and prognostic implications of GC in adult-type diffuse glioma patients. Retrospective chart and imaging review of 1,211 adult-type diffuse glioma patients from a single institution between 2005 and 2021 was performed. Among 1,211 adult-type diffuse glioma patients, there were 99 (8.2%) patients with GC. The proportion of molecular types significantly differed between patients with and without GC (P = 0.017); IDH-wildtype glioblastoma was more common (77.8% vs. 66.5%), while IDH-mutant astrocytoma (16.2% vs. 16.9%) and oligodendroglioma (6.1% vs. 16.5%) were less common in patients with GC than in those without GC. The presence of contrast enhancement, necrosis, cystic change, hemorrhage, and GC type 2 were independent risk factors for predicting IDH mutation status in GC patients. GC remained as an independent prognostic factor (HR = 1.25, P = 0.031) in IDH-wildtype glioblastoma patients on multivariable analysis, along with clinical, molecular, and surgical factors. Overall, our data suggests that although no longer included as a distinct pathological entity in the WHO classification, recognition of GC may be crucial considering its clinical significance. There is a relatively high incidence of GC in adult-type diffuse gliomas, with different proportion according to molecular types between patients with and without GC. Imaging may preoperatively predict the molecular type in GC patients and may assist clinical decision-making. The prognostic role of GC promotes its recognition in clinical settings.

Revisiting oligodendroglioma grading in the 2021 WHO classification: calcification and larger contrast-enhancing tumor volume may predict higher oligodendroglioma grade.

To investigate whether qualitative and quantitative imaging phenotypes can predict the grade of oligodendroglioma. Retrospective chart and imaging reviews were conducted on 180 adults with oligodendroglioma (IDH-mutant and 1p/19q codeleted) between 2005 and 2021. Qualitative imaging characteristics including tumor location, calcification, gliomatosis cerebri, cystic change, necrosis, and infiltrative pattern were analyzed. Quantitative imaging assessment was performed from the tumor mask via automatic segmentation to calculate total, contrast-enhancing (CE), non-enhancing (NE), and necrotic tumor volumes. Logistic analyses were conducted to determine predictors of oligodendroglioma grade. This study included 180 patients (84 [46.7%] with grade 2 and 96 [53.3%] with grade 3 oligodendrogliomas), with a median age of 42 years (range 23-76 years), comprising 91 females and 89 males. On univariable analysis, calcification (odds ratio [OR] = 6.00, P < 0.001), necrosis (OR = 21.84, P = 0.003), presence of CE tumor (OR = 7.86, P < 0.001), larger total (OR = 1.01, P < 0.001), larger CE (OR = 2.22, P = 0.010), and larger NE (OR = 1.01, P < 0.001) tumor volumes were predictors of grade 3 oligodendroglioma. On multivariable analysis, calcification (OR = 3.79, P < 0.001) and larger CE tumor volume (OR = 2.70, P = 0.043) remained as independent predictors of grade 3 oligodendroglioma. The multivariable model exhibited an AUC, accuracy, sensitivity, specificity of 0.78 (95% confidence interval 0.72-0.84), 72.8%, 79.2%, 69.1%, respectively. Presence of calcification and larger CE tumor volume may serve as useful imaging biomarkers for prediction of oligodendroglioma grade. Assessment of intratumoral calcification and CE tumor volume may facilitate accurate preoperative estimation of oligodendroglioma grade. Presence of intratumoral calcification and larger contrast-enhancing tumor volume were the significant predictors of higher grade oligodendroglioma based on the 2021 WHO classification.

Identification of prognostic imaging biomarkers in H3 K27-altered diffuse midline gliomas in adults: impact of tumor oxygenation imaging biomarkers on survival.

To investigate prognostic markers for H3 K27-altered diffuse midline gliomas (DMGs) in adults with clinical, qualitative and quantitative imaging phenotypes, including tumor oxygenation characteristics. Retrospective chart and imaging reviews were conducted on 32 adults with H3 K27-altered DMGs between 2017 and 2023. Clinical and qualitative imaging characteristics were analyzed. Quantitative imaging assessment was performed from the tumor mask via automatic segmentation to calculate normalized cerebral blood volume (nCBV), capillary transit time heterogeneity (CTH), oxygen extraction fraction (OEF), relative cerebral metabolic rate of oxygen (rCMRO2), and mean ADC values. Leptomeningeal metastases (LM) was diagnosed with imaging. Cox analyses were conducted to determine predictors of overall survival (OS) in entire patients and a subgroup of patients with contrast-enhancing (CE) tumor. The median patient age was 40.5 years (range 19.9-75.7), with an OS of 30.3 months (interquartile range 11.3-32.3). In entire patients, the presence of LM was the only independent predictor of OS (hazard ratio [HR] = 6.01, P = 0.009). In the subgroup of 23 (71.9%) patients with CE tumors, rCMRO2 of CE tumor (HR = 1.08, P = 0.019) and the presence of LM (HR = 5.92, P = 0.043) were independent predictors of OS. The presence of LM was independently associated with poor prognosis in adult patients with H3 K27-altered DMG. In patients with CE tumors, higher rCMRO2 of CE tumor, which may reflect higher metabolic activity in the tumor oxygenation microenvironment, may be a useful imaging biomarker to predict poor prognosis.

The impact of statin therapy on the healing of diabetic foot ulcers: a case–control series

BackgroundDiabetic foot ulcers (DFU) are a costly complication of diabetes mellitus (DM), with significant implications for the patient and the healthcare professionals that treat them. The primary objective of this study was to evaluate if there were improved healing rates in patients with a DFU that were taking a statin medication compared to those patients with a DFU who were not taking a statin medication. Secondary outcomes assessed were correlations with wound healing or statin use on data obtained from retrospective chart review.MethodsA case–control series was performed to obtain appropriate demographic information, comorbid conditions, laboratory values, and physical examination findings. From the time of presentation with DFU, these patients were followed for 12 weeks to evaluate for healing. Healing was defined as full epithelialization of the DFU with no further drainage. Wound healing and statin use correlation testing was then done for collected variables and each cohort. Chi square and Pearson correlation were then performed to identify any significant correlations. All p-values were two-sided, and findings were considered statistically significant at p < 0.05.ResultsOur study identified 109 patients, 75 patients with a DFU on statin medication and 34 patients with a DFU not on statin medication. The statin cohort was more likely to be older, less than 5-year duration of diabetes, have more comorbidities, decreased low-density lipoprotein (LDL) cholesterol, and decreased total cholesterol (p < 0.05). Among those patients taking a statin medication, 48.0% (36/75) healed their DFU within 12 weeks. Among those patients not taking a statin medication, 44.1% (15/34) healed their DFU within 12 weeks. No correlation was noted between wound healing and statin use (p = 0.7). For wound healing, a negative correlation was noted for prior minor amputations (p < 0.05). For statin use, correlations were noted for age, duration of DM, LDL cholesterol level, total cholesterol level, HTN, CAD, and HLD (p < 0.05).ConclusionsStatin medication use did not influence DFU healing rates between cohorts. There was a correlation noted between wound healing and prior minor amputations and between statin use and age, duration of DM, LDL cholesterol, total cholesterol, HTN, CAD and HLD. Additionally, we observed no correlation between DFU healing rates and use of a statin medication.

Surgical Technique For Chronic Symptomatic Peroneal Sheath Pain in Young Patients

To present the clinical and radiographic data, emphasize our surgical technique and how it was used, and the outcome measures in a case series of patients with chronic symptomatic peroneal sheath pain. A retrospective chart and radiograph review was conducted involving 36 adolescent patients (ages 8 to 20 y) treated surgically for chronic symptomatic peroneal sheath pain from 2010 to 2020. Findings that include chief complaint, magnetic resonance imaging findings, and surgical measures were documented. The patients’ postoperative and clinic visit notes were analyzed and outcome scores (FAOS Foot &amp; Ankle Survey, AOFAS Ankle-Hindfoot Scale, and Kaikkonen Functional Scale) were calculated to determine the long-term results of the procedure. In our case series of 36 patients undergoing surgical treatment for chronic symptomatic peroneal sheath pain the procedures performed were as follows: 35 peroneal sheath repairs (97.22%), 34 ankle arthroscopies (94.44%), 27 resections of anomalous peroneus brevis muscle belly (75.00%), 2 resections of accessory peroneus quartus muscle (5.56%), 7 partial synovectomies (19.44%), 29 debridements (80.56%), and 6 Brostrom repairs (16.67%). magnetic resonance imaging findings showed 50% of our patient population had low-lying peroneus brevis muscles, and on examination during surgery, 61.11% of peroneus brevis muscles extended past the fibular tip. The average time in the cast post-operatively was 4.33 weeks. The average time from surgery to return to activity was 9.03 weeks. Twenty-two of the 36 patients (61.11%) were athletes and 100% were able to return to their sport. Outcome scores were retrospectively determined to be 99.27 for the FAOS Foot and Ankle Survey, 98.72 for the AOFAS Ankle-Hindfoot Scale, and 99.31 for the Kaikkonen Functional Scale. Complications were minimal and included 1 postoperative infection, 3 cast impingements, and 2 reported instances of post-operative pain. In our retrospective case series of 36 patients, the outcomes of surgical intervention for peroneal tendon pathology unresponsive to nonsurgical management in pediatric patients were evaluated. Our surgical method utilizes debridement, synovectomy, excision of low lying peroneus brevis muscle belly, excision of peroneus quartus if present, repair of split-tears of the tendons, and repair of the peroneal tendon sheath using “pants over vest” sutures to tighten the sheath. Our chart review shows all 36 patients were satisfied with the outcome, demonstrated improvement in relevant patient-reported outcome measures, and would elect to undergo the procedure again. Therefore, the novel surgical techniques outlined in this study appear to be viable options to treat chronic symptomatic peroneal tendon sheath pain resistant to conservative methods. Level of Evidence: Retrospective Case Series, Level IV.

Revisiting prognostic factors of gliomatosis cerebri in adult-type diffuse gliomas.

There is lack of comprehensive analysis evaluating the impact of clinical, molecular, imaging, and surgical data on survival of patients with gliomatosis cerebri (GC). This study aimed to investigate prognostic factors of GC in adult-type diffuse glioma patients. Retrospective chart and imaging review was performed in 99 GC patients from adult-type diffuse glioma (among 1,211 patients; 6 oligodendroglioma, 16 IDH-mutant astrocytoma, and 77 IDH-wildtype glioblastoma) from a single institution between 2005 and 2021. Predictors of overall survival (OS) of entire patients and IDH-wildtype glioblastoma patients were determined. The median OS was 16.7months (95% confidence interval [CI] 14.2-22.2) in entire patients and 14.3months (95% CI 12.2-61.9) in IDH-wildtype glioblastoma patients. In entire patients, KPS (hazard ratio [HR] = 0.98, P = 0.004), no 1p/19q codeletion (HR = 10.75, P = 0.019), MGMTp methylation (HR = 0.54, P = 0.028), and hemorrhage (HR = 3.45, P = 0.001) were independent prognostic factors on multivariable analysis. In IDH-wildtype glioblastoma patients, KPS (HR = 2.24, P = 0.075) was the only independent prognostic factor on multivariable analysis. In subgroup of IDH-wildtype glioblastoma with CE tumors, total resection of CE tumor did not remain as a significant prognostic factor (HR = 1.13, P = 0.685). The prognosis of GC patients is determined by its underlying molecular type and patient performance status. Compared with diffuse glioma without GC, aggressive surgery of CE tumor in GC patients does not improve survival.

Is human height based on a Lucas sequence relationship between the foot height, tibial length, femur length and upper body length?

This is a retrospective chart and radiographic review of 145 patients who underwent full-body EOS imaging; 109 males and 36 females. The mean ages of the female and male subsets are 28.8 (SD = 11.6) years and 29.5 (SD = 11.8) years, respectively. The sum of the foot height (Ft) and the tibial length (T) for each subject was compared to their femur length (Fe). Subsequently, the sum of the tibial (T) and femoral lengths (Fe) were compared to their respective upper body lengths (UB), as measured from the tops of the femoral heads. A linear regression test was performed to determine whether a Lucas sequence-based relationship exists between Ft + T and Fe, and between T + Fe and UB. The regression for the relationship between Ft + T and Fe for the entire cohort (R = 0.82, R2 = 0.70), the female subset (R = 0.94, R2 = 0.88) and the male subset (R = 0.75, R2 = 0.57), all demonstrated a strong positive correlation between Ft + T and Fe and showed that Ft + T is a likely predictor of Fe. The regression test for the entire cohort demonstrated a moderately positive correlation between T + Fe and UB (R = 0.41, R2 = 0.17, F(1, 145) = 29.42, p = 2.4E-07). A stronger correlation was found for the relationship between T + Fe and UB (R = 0.57, R2 = 0.32, F(1,35) = 16.64, p = 2.5E-05) for the female subset relative to the male subset (R = 0.20, R2 = 0.038, F(1, 35) = 4.37, p = 0.04). There appears to be a Lucas sequence relationship between the lengths of the foot height, tibial length, femoral length and upper body length, which together make up standing height. This mathematical proportion relationship is stronger in females than males.

Prognostic Significance of Central Skull Base Remodeling in Chiari II Malformation.

Outward convexity of the basiocciput and posterior atlanto-occipital membrane are common in patients with Chiari II malformation associated with an open neural tube defect. We aimed to determine if the severity of these findings correlated with the need for future hydrocephalus treatment. A retrospective chart and imaging review identified patients who underwent open neural tube defect repair at a quaternary care pediatric hospital from July 2014 through September 2022. Patients were classified by the need for hydrocephalus treatment and whether they received prenatal or postnatal neural tube defect repair. Measurements of imaging parameters related to posterior fossa maldevelopment and skull base remodeling were performed. Compared with 65 patients who did not require hydrocephalus treatment, 74 patients who required treatment demonstrated statistically significantly greater mean basiocciput convexity (P < .001). While the mean basiocciput length in the hydrocephalus treatment group was smaller (P < .001), the ratio of basiocciput convexity to length was larger (P < .001). Notably, 100% of patients with a basiocciput convexity of ≥4 mm required hydrocephalus treatment. The mean posterior atlanto-occipital membrane convexity was significantly greater for patients who required hydrocephalus treatment in the postnatal group (P = .02), but not the prenatal group (P = .09). Pediatric patients with Chiari II malformation who ultimately required surgical hydrocephalus treatment had greater outward convexity of the basiocciput but had greater posterior atlanto-occipital membrane outward convexity only if the repair was performed postnatally. Together these measurements may be useful in predicting the need for hydrocephalus treatment.

Cochlear Implantation in Charcot-Marie-Tooth Patients: Speech Perception and Quality of Life.

There is a limited understanding of the impact of cochlear implantation (CI) in patients with Charcot-Marie-Tooth disease (CMT), given the scarcity of reported cases. We aim to evaluate the audiological outcomes and quality of life (QoL) after CI in CMT. Multi-institutional, university-affiliated, tertiary-referral centers, retrospective chart review.Our cohort includes 5 patients with CMT. Patients' charts were reviewed for demographic characteristics, operation notes, and pre- and post-implantation audiology evaluation. Patients completed the Cochlear Implant Quality of Life-10 (CIQOL-10) Global questionnaire. Pre-implantation, the mean pure tone average was 84.1 ± 7.2 dB, and the mean word recognition score was 2.4% in the implanted ear. AzBio sentence test was performed in quiet, revealing a mean of 4 ± 1.4% in the implanted ear. Post-implantation, PTA results were all within the mild hearing loss range (mean 33.0 ± 5.9 dB). Post-CI, AZ-Bio test results were 5%, 65%, and 74% (for 3 patients), and HINT scores were 55% and 58% (for 2 patients). The mean score of the CIQOL-10 questionnaire was 42.7 ± 10.47 (range 1-100). Patients were most satisfied with their ability to listen to the television or radio, have conversations in a quiet environment, and feel comfortable being themselves. To the best of our knowledge, this is the most extensive series of CI in CMT-associated sensorineural hearing loss and auditory neuropathy. Our cohort suggests that CI is a safe and reliable method for hearing rehabilitation that can achieve good speech performance and improve QoL in CMT patients.

Ophthalmic and Neuroimaging Associations In Optic Nerve Hypoplasia/Septo-Optic-Pituitary Dysplasia.

Optic nerve hypoplasia (ONH) and septo-optic-pituitary dysplasia (SOD) are neurodevelopmental disorders associated with congenital visual impairment. Our aim was to investigate associations between several ophthalmic and neuroimaging features in patients with ONH/SOD. A retrospective chart and neuroimaging review was performed in patients with ONH/SOD. Ophthalmic signs (e.g., monocular best-corrected visual acuity [BCVA], nystagmus, and strabismus) and neuroimaging data were extracted and their associations were investigated. There were 128 patients (70 males) with ONH/SOD who had neuroimaging. Their mean age at the end of the study was 13.2 (SD: 7.5) years. Ophthalmic data were available on 102 patients (58 males). BCVA varied from normal to no light perception. There were statistically significant associations between: (A) Reduced optic nerve or chiasm size on neuroimaging and more severely impaired BCVA and (B) laterality of the reduced optic nerve or chiasm size on neuroimaging and laterality of: (1) The eye with reduced BCVA, (2) small optic disc size, and (3) RAPD, if present (p ≤ 0.0002 each). The presence of symmetrically small optic nerves on MRI was significantly more common in patients with nystagmus than when nystagmus was absent (N = 96, 75% vs. 38.6%, p < 0.0001). The presence of neuronal migration disorders, their type and laterality were not associated with BCVA and laterality of the reduced BCVA. The functional and structural associations in ONH are consistent with the impaired visual function that results from the hypoplastic anterior visual pathways. However, these associations were not perfectly concordant making prediction of adult BCVA challenging in these patients.

Surgical strategies in the management of atlantoaxial dislocation in Down syndrome.

To study the clinicoradiological features and treatment outcomes of atlantoaxial dislocation (AAD) in Down syndrome. Retrospective case series. A retrospective chart and radiology review of 9 Down syndrome patients with AAD managed at our center from 2007 to 2018. Chi-squared/Fisher's exact test. There were 4 males and 5 females (n = 9). The median age was 14 years (interquartile range [IQR]: 7-15.5). 77.7% (7/9) of patients had severe spasticity (Nurick Grades 4 and 5). The median duration of symptoms was 9 months (IQR: 5-39). The AAD was reducible in all (n = 9) cases. Eight (88.8%) patients had os odontoideum. The mean atlantodental interval (ADI) was 8.5 mm (±2.9). T2W cord hyperintensity was seen in 66.6% (6/9). Posterior C1-2 transarticular fixation was done in 8 and occipitocervical fusion in 1 patient. Follow-up of more than 6 months (7-57 months) was available in 8/9 (88.9%) patients. There was a significant improvement in spasticity (n = 8, mean Nurick Grade 1.7 (±1.1), P = 0.003). Follow-up radiographs (n = 8) showed good reduction and fusion. A preoperative bedbound patient with poor respiratory reserve expired at 10 months following surgery. There were no other complications. Posterior surgical approach for AAD in Down syndrome resulted in good alignment and fusion, with excellent clinical improvement. Patients with elevated PCO2 are poor surgical candidates and require home ventilation facility.

Predictors of Breast Cancer Outcome in a Cohort of Women Seeking Care at a Safety Net Hospital

ObjectiveThis study aimed to identify predictors associated with lower mortality in a population of women diagnosed and treated for breast cancer at a safety net hospital. MethodsFrom 2008-2014, 1,115 patients were treated for breast cancer at our academic safety net hospital. 208 were excluded due to diagnosis at an outside facility, and the remaining 907 (81%) formed the study cohort. Retrospective charts and imaging reviews looked at race, ethnicity, insurance status, social determinants of health, screening utilization, treatment regimen, and 7-13-year follow-up care, including the cause of death. Multivariable logistic regression modeling assessed mortality, and adjusted odds ratios (aOR) with 95% confidence intervals (CI) were computed. ResultsOf the 907 women, the mean age was 59 years (inter-quartile range 50-68 years), with 40% White, 46% Black, 4% Asian, and 10% Other. Increasing age (aOR=1.03, p=0.001) and more advanced stage at diagnosis (aOR=6.37, p<0.0001) were associated with increased mortality. There was no significant difference in mortality based on race or ethnicity (p>0.05). Of 494 with screening prior to diagnosis, longer screening time was observed for patients with advanced stage (median 521 days) vs. early stage (median 404 days), p=0.0004. Patients with Medicaid, insurance not specified, and no insurance were less likely to undergo screening before diagnosis than privately insured (all p<0.05). Shorter screening time was associated with lower all-cause mortality (aOR=0.57, 95% CI=0.36-0.89, p=0.013). DiscussionIn a safety net population, a more advanced stage at diagnosis was associated with higher mortality and lower odds of undergoing screening mammography in the two years prior to a breast cancer diagnosis. Early screening was associated with lower mortality. Finally, given no racial or ethnic differences in mortality, the safety net infrastructure at our institution effectively provides equitable cancer care once a cancer is confirmed.

The Effect of Fracture Type on Restoration of Radiographic Parameters and Early Loss of Reduction in Surgical Treated Distal Radius Fractures

Purpose: Early loss of reduction remains a challenging complication in distal radius fracture management. There are limited data on factors that correlate with early loss of reduction. The Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification has become a popular way of evaluating complex fracture patterns. This study aims to determine the impact of fracture pattern, as determined by the AO classification, on restoration of intraoperative parameters, early loss of reduction, and time to fracture union in operatively treated distal radius fractures. Methods: Following IRB approval, adult patients with surgically treated acute distal radius fractures at a single level I institution were identified. Retrospective chart and radiographic review were used to obtain AO classification, postoperative radiographic parameters, early loss of reduction, time to fracture union, as well as any complications. Results: 422 patients with operatively treated distal radius fractures were included in this study. Across fracture patterns, there were no significant differences in restoration of radial height or inclination. Higher severity fracture classifications had decreased restoration of volar tilt. Overall, simple fractures (A2, C1) and partial articular fractures (B1, B2, B3) had higher rates of satisfactory alignment restoration compared to comminuted fractures (A3, C2, C3). Although there were differences in restoration of radiographic parameters, fracture type did not correlate with loss of reduction within 30 days. C type fractures correlated with increased weeks to radiographic healing. Conclusions: This study establishes that distal radius fracture pattern, as determined by the AO classification, has a significant impact on intraoperative restoration of parameters but does not correlate with early loss of reduction. Furthermore, more difficult fracture patterns may have a longer time to fracture union, but fracture type does not appear to have an effect on postoperative complications.

Pharyngeal flap outcomes for velopharyngeal insufficiency: Evaluation of speech, obstructive sleep apnea, and velopharyngeal anatomy

The purpose of this study was to evaluate the speech outcomes, reveal postoperative rates of obstructive sleep apnea, and characterize changes in the pharyngeal flap and velopharyngeal anatomy following pharyngeal flap surgery for velopharyngeal insufficiency. A retrospective chart was reviewed for patients with clefts who underwent pharyngeal flap surgery between November 2020 and November 2021. The data collected included age, gender, cleft palate type, age at pharyngeal flap surgery, postoperative complications, age and type of primary palatoplasty, preoperative and postoperative speech assessments, magnetic resonance imaging findings, and obstructive sleep apnea outcomes. The authors included 72 nonsyndromic patients who underwent pharyngeal flap surgery following cleft palate repair. The mean age at pharyngeal flap surgery was 10.6 ± 6.2 years. There was a significant improvement in the Pittsburgh Weighted Speech Score Hypernasality Component and the nasalance scores of oral syllables (p < 0.001). The obstructive sleep apnea rate after pharyngeal flap surgery was 6.9%. Compared to preoperatively, the velar angle was more acute (p < 0.001), the velar length was longer (p < 0.001), the distance of the velum tip to the posterior pharyngeal wall was shorter (p < 0.001), the size of velopharyngeal gap was narrower (p < 0.001), and the pharyngeal flap atrophied (p < 0.001) at 6 months postoperatively. The pharyngeal flap improved speech outcomes in patients with velopharyngeal insufficiency with a relatively low incidence of obstructive sleep apnea (6.9%). The velum is positioned more superiorly and posteriorly, and the size of the velopharyngeal gap is substantially reduced after pharyngeal flap surgery. In addition, the pharyngeal flap partially atrophied over time.

Dosimetric Risk Estimation of Chest Wall Pain Following 5-Fraction Lung Stereotactic Body Radiotherapy

Development of chest wall pain (CWP) following lung stereotactic body radiotherapy (SBRT) is a known toxicity, particularly for peripheral lesions. While CW V30 has been most consistently associated with development of post-SBRT CWP, existing series included heterogeneous dose-fractionation regimens, most commonly 48-54 Gy in 3-4 fractions. The present study aims to identify clinical and dosimetric variables associated with development of CWP among patients treated with 5 fraction lung SBRT. Intradepartmental quality assurance database of SBRT patients was queried to identify lung targets treated to a minimum of 45 Gy in 5 fractions. Retrospective chart and plan reviews were performed on these cases to collect patient, tumor, and treatment-related data, selecting for patients with peripheral lesions (any histology), and recording presence or absence of CWP during or following SBRT. Patients with less than 6 months of post-SBRT clinical follow-up were excluded. The CW was defined as a 2 cm expansion of the ipsilateral lung (inclusive of intercostal musculature, ribs, and superficial soft tissue). Logistic regression analyses were performed on continuous and nominal data to determine statistically significant (p<0.05) correlations between clinical (age, gender, known osteopenia/osteoporosis, diabetes, prior thoracic radiotherapy, lesion distance to CW), treatment (interval of SBRT delivery, dose prescribed), and dosimetric (Dose to 0.1/1/5/10cc; V30, V40) factors with CWP. Between February 2011 and January 2022, 93 patients were identified for inclusion in the present analysis, treated to 100 total lesions in 99 courses of treatment. Median patient age was 75 years (range 34-90), 48 (52%) were female, and 29 (of 99 treatment courses; 29%) had received prior thoracic radiotherapy. Median SBRT dose was 50 Gy (45-60), delivered over a median of 9 days (4-18). At a median post-SBRT follow-up of 21 months, 11 patients developed CWP at a median of 9 months post-SBRT (0-32). Statistically significant correlations were identified between CWP and known pre-existing osteopenia or osteoporosis, target distance to CW, and CW D0.1cc, D1cc, D5cc, and D10cc, but not CW V30 or V40. Crude risk of CWP for selected clinically practical dose-volume thresholds are presented in Table 1: CONCLUSION: For patients treated with lung SBRT in 5 fractions, dose to CW volume thresholds appears to correlate more closely than V30 or V40 for CWP estimation. Further investigation and validation of optimal CW volume thresholds, as well as integration of pre-existing condition clinical factors in risk estimation, appears warranted.