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BACKGROUND: Knee alignment affects the development and surgical treatment of knee osteoarthritis. Automating femorotibial angle (FTA) and hip-knee-ankle angle (HKA) measurement from radiographs could improve reliability and save time. Further, if HKA could be predicted from knee-only radiographs then radiation exposure could be reduced and the need for specialist equipment and personnel avoided. The aim of this research was to assess if deep learning methods could predict FTA and HKA angle from posteroanterior (PA) knee radiographs. METHODS: Convolutional neural networks with densely connected final layers were trained to analyse PA knee radiographs from the Osteoarthritis Initiative (OAI) database. The FTA dataset with 6149 radiographs and HKA dataset with 2351 radiographs were split into training, validation, and test datasets in a 70:15:15 ratio. Separate models were developed for the prediction of FTA and HKA and their accuracy was quantified using mean squared error as loss function. Heat maps were used to identify the anatomical features within each image that most contributed to the predicted angles. RESULTS: High accuracy was achieved for both FTA (mean absolute error 0.8°) and HKA (mean absolute error 1.7°). Heat maps for both models were concentrated on the knee anatomy and could prove a valuable tool for assessing prediction reliability in clinical application. CONCLUSION: Deep learning techniques enable fast, reliable and accurate predictions of both FTA and HKA from plain knee radiographs and could lead to cost savings for healthcare providers and reduced radiation exposure for patients.

Degenerative rotator cuff tears and osteoarthritis (OA) are associated with differences in coronal plane scapular morphology, with particular focus on the effect of the critical shoulder angle (CSA) on shoulder biomechanics. The effect, if any, of axial plane scapular morphology is less well established. We have noticed wide disparity of axial coracoid tip position in relation to the face of the glenoid and sought to investigate the significance of this through measurement of the critical coracoid process angle (CCPA), which incorporates coracoid tip position and glenoid version.CCPA, CSA, and glenoid retroversion were measured by three independent reviewers from the cross-sectional two-dimensional computed tomography (CT) and magnetic resonance imaging of 160 patients in four equal and matched case-control groups: (1) a control group of patients with a radiologically normal shoulder and no history of shoulder symptoms who had a CT thorax for another reason, (2) patients with primary OA with Walch type-A glenoid wear pattern on CT scan, (3) patients with type-B glenoid primary OA, and (4) patients with magnetic resonance imaging-proven atraumatic tears of the posterosuperior rotator cuff.Interobserver agreement was excellent for all measured parameters. The median CCPA was significantly lower in the type-B OA group (9.3˚) than that in controls (18.7˚), but not significantly different in the other study groups. There was a trend toward greater glenoid retroversion in the type-B OA group, but receiver operating characteristic curve analysis demonstrated the CCPA to be by far the most powerful discriminator for type-B OA. The optimal cutoff value was calculated for the CCPA at 14.3˚ with a sensitivity of 93% and specificity of 90% for type-B OA. Compared with controls, the CSA was significantly higher in the rotator cuff tear group and lower in both OA groups, but did not differentiate between type-A and type-B OA.Combined with a lower CSA, a lower CCPA (14.3˚) is strongly predictive of type-B glenoid OA. The authors propose a simple model of pectoralis major biomechanics to explain the effect of this axial plane anatomical variation, which requires further investigation.

Robot-assisted radical prostatectomy has become the standard of care for the removal of localized prostate cancer. Positive outcomes depend upon the precise removal of the prostate and associated tissue without damage to nearby structures. This process can be aided by fluorescence-guided surgery to enhance the visual contrast between different structures. Here the authors have conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify ten investigations into the use of fluorescence-guided surgery in robot-assisted radical prostatectomy. These studies used fluorescent tracers to identify structures, including the prostate, neurovascular bundle and lymph nodes. These studies demonstrate the safe and effective use of fluorescence-guided surgery in robot-assisted radical prostatectomy and pave the way for further developments in this field.

Knee alignment affects the development and surgical treatment of knee osteoarthritis. This research aimed to improve its automatic measurement from posteroanterior (PA) knee radiographs by using convolutional neural networks. Radiographs from the Osteoarthritis Initiative with corresponding femorotibial angle (FTA, N = 6149) and hip-knee-ankle angle (HKA, N = 2351) measurements, were split into training, validation, and test datasets in a 70:15:15 ratio. Separate models were developed for the prediction of FTA and HKA and their accuracy quantified. Heat maps were then used to identify the anatomical features within each image that most contributed to the predicted angles. High accuracy was achieved for FTA (mean absolute error 0.8°), and better than state-of-the-art accuracy was achieved for HKA (mean absolute error 1.7°). Heat maps for both models were concentrated on the knee anatomy and could prove a valuable tool for assessing prediction reliability in clinical application. Deep learning techniques enable fast, reliable and accurate predictions of both FTA and HKA from plain knee radiographs and could lead to cost savings for healthcare providers and reduced radiation exposure for patients.

BACKGROUND Perianal fistulae are either primary (idiopathic) or secondary [commonly associated with Crohn’s disease, (CD)]. It is assumed, although not proven, that the pathophysiology differs. AIM To systematically compare the clinical phenotypes, cytokine and phosphoprotein profiles of idiopathic and CD-related perianal fistulae. METHODS Sixty-one patients undergoing surgery for perianal fistula were prospectively recruited (48 idiopathic, 13 CD) into a cohort study. Clinical data, including the Perineal Disease Activity Index (PDAI) and EQ-5D-5L were collected. Biopsies of the fistula tract, granulation tissue, internal opening mucosa and rectal mucosa were obtained at surgery. Concentrations of 30 cytokines and 39 phosphoproteins were measured in each biopsy using a magnetic bead multiplexing instrument and a chemiluminescent antibody array respectively. Over 12000 clinical and 23500 laboratory measurements were made. RESULTS The PDAI was significantly higher (indicating more active disease) in the CD group with a mean difference of 2.40 (95%CI: 0.52-4.28, P = 0.01). Complex pathoanatomy was more prevalent in the CD group, namely more multiple fistulae, supralevator extensions, collections and rectal thickening. The IL-12p70 concentration at the internal opening specimen site was significantly higher (median difference 19.7 pg/mL, 99%CI: 0.2-40.4, P = 0.008) and the IL-1RA/IL-1β ratio was significantly lower in the CD group at the internal opening specimen site (median difference 15.0, 99%CI = 0.4-50.5, P = 0.008). However in the remaining 27 cytokines and all 39 of the phosphoproteins across the four biopsy sites, no significant differences were found between the groups. CONCLUSION CD-related perianal fistulae are more clinically severe and anatomically complex than idiopathic perianal fistulae. However, overall there are no major differences in cytokine and phosphoprotein profiles.

Hip resurfacing arthroplasty (HRA) is an alternative to total hip arthroplasty (THA) in younger patients with good bone quality who wish to return to high levels of activity. Usage of HRA has declined due to implant-specific complications—metal debris and periarticular soft tissue damage, implant loosening, and femoral neck fracture. These were most common with implants which have now been withdrawn, but fears remain. HRA is more technically challenging than THA, but revision rates for patients operated at specialist centres are equivalent. Gait and biomechanical studies suggest that HRA better restores normal function compared to THA, and registry-based studies suggest a lower mortality. However, randomised clinical trials have not shown superiority using conventional patient-reported outcome measures. As the clinical indications are dependent on patient demands, and more active patients are more likely to wear out artificial joints, it is difficult to robustly compare HRA and THA. Today, safe HRA implants inserted by experienced surgeons in active, male patients seem to deliver the most predictable outcomes, high performance and longevity.

The number of patients with knee osteoarthritis, the proportion that is obese and the number undergoing unicompartmental knee arthroplasty (UKA) are all increasing. The primary aim of this systematic review was to determine the effects of obesity on outcomes in UKA. A systematic review was performed using PRISMA guidelines and the primary outcome was revision rate per 100 observed component years, with a BMI of ≥ 30 used to define obesity. The MINORS criteria and OCEBM criteria were used to assess risk of bias and level of evidence, respectively. 9 studies were included in the analysis. In total there were 4621 knees that underwent UKA. The mean age in included studies was reported to be 63 years (mean range 59.5–72 years old)) and range of follow up was 2–18 years. Four studies were OCEBM level 2b and the average MINORS score was 13. The mean revision rate in obese patients (BMI > 30) was 0.33% pa (95% CI − 3.16 to 2.5) higher than in non-obese patients, however this was not statistically significant (p = 0.82). This meta-analysis concludes that there is no significant difference in outcomes between obese and non-obese patients undergoing UKA. There is currently no evidence that obesity should be considered a definite contraindication to UKA. Further studies are needed to increase the numbers in meta-analysis to explore activity levels, surgeon’s operative data, implant design and perioperative complications and revision in more depth.Level of evidence Level III.

A 30-year-old man with a history of severe right iliac fossa pain was referred to the surgical emergency unit. His symptoms began 3 days prior as mild, non-specific abdominal pain which progressively localised to the right iliac fossa and worsened in severity. Investigations were suggestive of acute appendicitis, and therefore a laparoscopic appendicectomy was planned. Laparoscopy revealed a thickened, necrotic appendix with a mass at the base of the appendix, in keeping with the appearance of an appendiceal malignancy. Subsequently a right hemicolectomy was performed. Histology revealed active chronic inflammation and granulomas highly suggestive of appendiceal Crohn’s disease. Since, the patient has made a good recovery and presently shows no further signs of Crohn’s disease. This case is demonstrative of one of many rare findings on histological examination of the appendix. It emphasises the need for a wide differential when investigating right iliac fossa pain.

Objectives The objectives of this review are to determine the level of evidence for the management of OCF, compare outcomes of different immobilisation, and to review the prognosis. Patients and methods A literature search was conducted using 3 databases (MEDLINE, PubMed and EMBASE). All papers between 1940 and July 2017 were screened using PRISMA guidelines. Inclusion criteria were patients with a confirmed diagnosis of occipital condyle fracture(s) on CT managed with any form of immobilisation with no age restriction. Primary outcome was clinical improvement in symptoms or Neck Disability Index. MINORS and OCEBM level was assigned to each study. Results 25 studies met the inclusion criteria. Most studies used a single form of C-spine immobilisation support (58%) with a semi rigid collar and halo device being the most common. From these studies, the average length of time for immobilisation was 11.7 weeks, 9 weeks and 8.3 weeks for halo, semi-rigid and rigid cervical collars respectively. Neuro deficit was found in 20.3% of patients. OCEBM level of evidence and MINORS score was low. Conclusion Management of OCF is associated with low level of evidence. Further studies are needed to determine optimal management of these under-diagnosed fractures.

This review gives a practical guide to the investigation and management of osteoporotic vertebral compression fractures. With an ageing population, the burden of disease and health system costs attributable to this common injury continue to rise. This article outlines the epidemiology, clinical and radiological assessment of vertebral compression fractures, and key decisions that must be made in their management. It reviews the indications and evidence for conservative vs operative treatment, discusses the rationale for vertebroplasty, kyphoplasty and spinal stabilization, and looks at outcomes in this vulnerable patient population. It also reviews key evidence underlying decision making including National Institute for Health and Care Excellence guidelines.

Near-peer assisted learning (NPAL) is an increasingly important tool in medical education; however, although numerous published papers discuss its merits, the evidence on the effectiveness and student perception of NPAL is limited. We describe a novel near-peer question writing and teaching programme to assess whether it improves the confidence of first-year medical students for their first In-Course Assessment (ICA) in medical school. The evidence on the effectiveness and student perception of NPAL is limited METHODS: A team of medical students designed a question development procedure and a structured teaching programme. A total of 280 first-year medical students were invited to appraise the questions. A questionnaire assessing confidence and student perception was sent to participants at different time points leading up to and after their first ICA at the medical school. Statistical analysis was performed using spss 20.One hundred and seventy one students attempted the questions. Students felt more confident with short-answer questions (SAQs; 95% CI 1.5-2.0, p 0.05) and multiple-choice questions (MCQs; 95% CI 1.0-1.5, p 0.05), as assessed using the Wilcoxon signed-rank test. Overall, students were satisfied with the NPAL questions and teaching programme following their university examinations (p 0.01).The NPAL project highlighted a trend towards improving students' confidence. Furthermore, the question writing and teaching programme can be used as a guide to confidently hold teaching sessions in the future. The NPAL project further reinforces existing published papers that have shown NPAL to be a powerful adjunct to existing undergraduate medical education.

Objective To provide a review of emerging knowledge from genomics and related basic science, preclinical, and clinical precision medicine studies in head and neck squamous cell carcinoma (HNSCC). Data Sources The Cancer Genome Atlas Network (TCGA) publications, PubMed-based literature review, and ClinicalTrials.gov. Review Methods TCGA publications, PubMed, and ClinicalTrials.gov were queried for genomics and related basic science, preclinical, and developmental clinical precision medicine studies in HNSCC. Results TCGA reported comprehensive genomic analyses of 279 HNSCC, defining the landscape and frequency of chromosomal copy number alterations, mutations, and expressed genes that contribute to pathogenesis, prognosis, and resistance to therapy. This provides a road map for basic science and preclinical studies to identify key pathways in cancer and cells of the tumor microenvironment affected by these alterations, and candidate targets for new small molecule and biologic therapies. Conclusion Recurrent chromosomal abnormalities, mutations, and expression of genes affecting HNSCC subsets are associated with differences in prognosis, and define molecules, pathways, and deregulated immune responses as candidates for therapy. Activity of molecularly targeted agents appears to be enhanced by rational combinations of these agents and standard therapies targeting the complex alterations that affect multiple pathways and mechanisms in HNSCC. Level of Evidence N/A

INTRODUCTION AND OBJECTIVES:With infection rates and quinolone resistance increasing, we require straightforward alternatives to transrectal biopsy. TP biopsy has historically been more expensive t...

Management of thoracolumbar fractures remains controversial in the literature. The primary aims of this study were to assess different levels of fixation with respect to radiological outcomes in terms of fracture reduction and future loss of correction.This is a single center, retrospective study. Fifty-five patients presenting with thoracolumbar fractures between January 2012 and December 2015 were analyzed in the study. The levels of fixation were divided in 3 groups: 1 vertebra above and 1 below the fracture (1/1), 2 above and 2 below (2/2), and 2 above and 1 below (2/1).The most common mechanism was high fall injury, and the most common vertebra L1. Burst fractures were the ones with the highest incidence. The 2/2 fixation achieved the best reduction of the fracture, but with no statistical significance. The correction is maintained better by the 2/2 fixation, but there is no statistical difference compared to the other fixations. Insertion of screws at the fracture level did not improve outcomes.The data of this study identified a trend toward better radiological outcomes for fracture reduction and maintenance of the correction in the 2/2 fixations. However, these results are not statistically significant. Future multicenter prospective clinical trials are needed in order to agree on the ideal management and method of fixation for thoracolumbar fractures.

Spinal cord injury leads to major neurological impairment for which there is currently no effective treatment. Recent clinical trials have demonstrated the efficacy of Fortasyn® Connect in Alzheimer's disease. Fortasyn® Connect is a specific multi-nutrient combination containing DHA, EPA, choline, uridine monophosphate, phospholipids, and various vitamins. We examined the effect of Fortasyn® Connect in a rat compression model of spinal cord injury. For 4 or 9 weeks following the injury, rats were fed either a control diet or a diet enriched with low, medium, or high doses of Fortasyn® Connect. The medium-dose Fortasyn® Connect-enriched diet showed significant efficacy in locomotor recovery after 9 weeks of supplementation, along with protection of spinal cord tissue (increased neuronal and oligodendrocyte survival, decreased microglial activation, and preserved axonal integrity). Rats fed the high-dose Fortasyn® Connect-enriched diet for 4 weeks showed a much greater enhancement of locomotor recovery, with a faster onset, than rats fed the medium dose. Bladder function recovered quicker in these rats than in rats fed the control diet. Their spinal cord tissues showed a smaller lesion, reduced neuronal and oligodendrocyte loss, decreased neuroinflammatory response, reduced astrocytosis and levels of inhibitory chondroitin sulphate proteoglycans, and better preservation of serotonergic axons than those of rats fed the control diet. These results suggest that this multi-nutrient preparation has a marked therapeutic potential in spinal cord injury, and raise the possibility that this original approach could be used to support spinal cord injured patients.

Objective Otolaryngology is a highly technical and demanding specialty and the requirements for surgical trainees to acquire proficiency remains challenging. Simulation has been purported to be an effective tool in assisting with this. The aim of this systematic review is to identify the available otolaryngology simulators, their status of validation, and evaluation the level of evidence behind each training model and thereby establish a level of recommendation. Design PubMed, ERIC, and Google Scholar databases were searched for articles that described otolaryngology simulators or training models between 1980 and April 2016. Any validation studies for simulators were also retrieved. Titles and abstracts were screened for relevance using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Level of evidence (LoE) and Level of recommendation (LoR) was awarded to each study and model, respectively. Results A total of 70 studies were identified describing 64 simulators. Out of these, at least 54 simulators had 1 validation study. Simulators for the ear and temporal bone surgery were the most common ( n = 32), followed by laryngeal and throat ( n = 20) and endoscopic sinus surgery ( n = 12). Face validity was evaluated by 29 studies, 20 attempted to show construct, 20 assessed content, 20 transfer, and only 2 assessed concurrent validity. Of the validation assessments, 2 were classified as Level 1b, 10 Level 2a, and 48 Level 2b. No simulators received the highest LoR, but 8 simulators received a LoR of 2. Conclusions Despite the lack of evidence in outcome studies and limited number of high-validity otolaryngology simulators, the role of simulation continues to grow across surgical specialties Hence, it is imperative that the simulators are of high validity and construct for trainees to practice and rehearse surgical skills to develop confidence.

Introduction Management of thoracolumbar fractures remains controversial in the literature. The primary aims of this study were to assess different levels of fixation with respect to radiological outcomes in terms of fracture reduction and future loss of correction. Methods This is a single center, retrospective study. Fifty-five patients presenting with thoracolumbar fractures between January 2012 and December 2015 were analyzed in the study. The levels of fixation were divided in 3 groups, 1 vertebra above and 1 below the fracture (1/1), 2 above and 2 below (2/2), and 2 above and 1 below (2/1). Results The most common mechanism was high fall injury and the most common vertebra L1. Burst fractures were the ones with the highest incidence. The 2/2 fixation achieved the best reduction of the fracture but with no statistical significance. The correction is maintained better by the 2/2 fixation but there is no statistical difference compared to the other fixations. Insertion of screws at the fracture level did not improve outcomes. Conclusion The data of this study identified a trend towards better radiological outcomes for fracture reduction and maintenance of the correction in the 2/2 fixations. However these results are not statistically significant. Future multicenter prospective clinical trials are needed in order to agree on the ideal management and method of fixation for thoracolumbar fractures.