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Abstract The increasing prevalence of heart failure (HF) in ageing populations drives demand for echocardiography (echo). There is a worldwide shortage of trained sonographers and long waiting times for expert echo. We hypothesised that artificial intelligence (AI)-enhanced point-of-care echo can enable HF screening by novices. The primary endpoint was the accuracy of AI-enhanced novice pathway in detecting reduced LV ejection fraction (LVEF)

Abstract Background Increasing patient loads, healthcare inflation and ageing population have put pressure on the healthcare system. Artificial intelligence and machine learning innovations can aid in task shifting to help healthcare systems remain efficient and cost effective. To gain an understanding of patients’ acceptance toward such task shifting with the aid of AI, this study adapted the Unified Theory of Acceptance and Use of Technology 2 (UTAUT2), looking at performance and effort expectancy, facilitating conditions, social influence, hedonic motivation and behavioural intention. Methods This was a cross-sectional study which took place between September 2021 to June 2022 at the National Heart Centre, Singapore. One hundred patients, aged ≥ 21 years with at least one heart failure symptom (pedal oedema, New York Heart Association II-III effort limitation, orthopnoea, breathlessness), who presented to the cardiac imaging laboratory for physician-ordered clinical echocardiogram, underwent both echocardiogram by skilled sonographers and the experience of echocardiogram by a novice guided by AI technologies. They were then given a survey which looked at the above-mentioned constructs using the UTAUT2 framework. Results Significant, direct, and positive effects of all constructs on the behavioral intention of accepting the AI-novice combination were found. Facilitating conditions, hedonic motivation and performance expectancy were the top 3 constructs. The analysis of the moderating variables, age, gender and education levels, found no impact on behavioral intention. Conclusions These results are important for stakeholders and changemakers such as policymakers, governments, physicians, and insurance companies, as they design adoption strategies to ensure successful patient engagement by focusing on factors affecting the facilitating conditions, hedonic motivation and performance expectancy for AI technologies used in healthcare task shifting.

Scoliosis, characterized by spine deformity, is most common in adolescent idiopathic scoliosis (AIS). Manual Cobb angle measurement limitations underscore the need for automated tools. This study employed a vertebral landmark extraction method and Feedforward Neural Network (FNN) to predict scoliosis progression in 79 AIS patients. The novel intervertebral angles matrix format showcased results. The mean absolute error for the intervertebral angle progression was 1.5 degrees, while the Pearson correlation of the predicted Cobb angles was 0.86. The accuracy in classifying Cobb angles (45°) was 0.85, with 0.65 sensitivity and 0.91 specificity. The FNN demonstrated superior accuracy, sensitivity, and specificity, aiding in tailored treatments for potential scoliosis progression. Addressing FNNs’ over-fitting issue through strategies like “dropout” or regularization could further enhance their performance. This study presents a promising step towards automated scoliosis diagnosis and prognosis.

IntroductionAdolescent idiopathic scoliosis (AIS) is characterized by deranged bone and muscle qualities, which are important prognostic factors for curve progression. This retrospective case–control study aims to investigate whether the baseline muscle parameters, in addition to the bone parameters, could predict curve progression in AIS.MethodsThe study included a cohort of 126 female patients diagnosed with AIS who were between the ages of 12 and 14 years old at their initial clinical visit. These patients were longitudinally followed up every 6 months (average 4.08 years) until they reached skeletal maturity. The records of these patients were thoroughly reviewed as part of the study. The participants were categorized into two sub-groups: the progressive AIS group (increase in Cobb angle of ≥6°) and the stable AIS group (increase in Cobb angle

Abstract Background Three‐dimensional (3D) ultrasonography is nonionizing and has been demonstrated to be a reliable tool for scoliosis assessment, including coronal and sagittal curvatures. It shows a great potential for axial vertebral rotation (AVR) evaluation, yet its validity and reliability need to be further demonstrated. Materials and Methods Twenty patients with adolescent idiopathic scoliosis (AIS) (coronal Cobb: 26.6 ± 9.1°) received 3D ultrasound scan for twice, 10 were scanned by the same operator, and the other 10 by different operators. EOS Bi‐planar x‐rays and 3D scan were conducted on another 29 patients on the same day. Two experienced 3D ultrasonographic researchers, with different experiences on AVR measurement, evaluated the 3D ultrasonographic AVR of the 29 patients (55 curves; coronal Cobb angle: 26.9 ± 11.3°). The gold standard AVR was determined from the 3D reconstruction of coronal and sagittal EOS radiographs. Intra‐class correlation coefficients (ICCs), mean absolute difference (MAD), standard error measurements (SEM), and Bland–Altman's bias were reported to evaluate the intra‐operator and inter‐operator/rater reliabilities of 3D ultrasonography. The reliability of 3D ultrasonographic AVR measurements was further validated using inter‐method with that of EOS. Results ICCs for intra‐operator and inter‐operator/rater reliability assessment were all greater than 0.95. MAD, SEM, and bias for the 3D ultrasonographic AVRs were no more than 2.2°, 2.0°, and 0.5°, respectively. AVRs between both modalities were strongly correlated (R2 = 0.901) and not significantly different (p = 0.205). Bland–Altman plot also shows that the bias was less than 1°, with no proportional bias between the difference and mean of expected and radiographic Cobb angles. Conclusion This study demonstrates that 3D ultrasonography is valid and reliable to evaluate AVR in AIS patients. 3D ultrasonography can be a potential tool for screening and following up subjects with AIS and evaluating the effectiveness of nonsurgical treatments.

Introduction: Bracing is one of the first-line treatment for early-onset idiopathic scoliosis (EOIS) to control curves from progression. This study aimed to explore the determinants that govern bracing effectiveness in EOIS. Methods: One hundred and eleven patients with EOIS (mean age of 8.6 ± 1.25 at diagnosis) received bracing treatment and had a final follow-up beyond skeletal maturity were identified from records between 1988 and 2021. Demographic data and clinical features of spinal curvature were obtained for correlation analyses to determine the associations between curve outcomes and clinical features. Results: Most patients were female (85.6%) and had a major curve on the left side (67%). The mean baseline Cobb angle of major curves was 21.73 ± 7.92°, with a mean Cobb angle progression of 18.05 ± 19.11°. The average bracing duration was 5.3 ± 1.9 years. Only 26 (23.4%) of them underwent surgery. The final Cobb angle and curve progression at the final follow-up with a Cobb angle of ≥50° were positively correlated with the initial Cobb angle (r = 0.206 and r = 0.313, respectively) and negatively correlated with maturity parameters. The lumbar curve type was found to correlate with a smaller final Cobb angle. Conclusions: The majority of patients had a final Cobb angle < 50°, which was considered a successful bracing outcome. The final Cobb angle correlated with the initial Cobb angle and curve types observed in EOIS.

Background: Osteoporosis is a major causative factor of the global burden of disease and disability, characterized by low bone mineral density (BMD) and high risks of fracture. We aimed to identify putative causal proteins and druggable targets of osteoporosis.Methods: This study utilized the largest GWAS summary statistics on plasma proteins and estimated heel BMD (eBMD) to identify causal proteins of osteoporosis by mendelian randomization (MR) analysis. Different GWAS datasets were used to validate the results. Multiple sensitivity analyses were conducted to evaluate the robustness of primary MR findings. We have also performed an enrichment analysis for the identified causal proteins and evaluated their druggability.Results: After Bonferroni correction, 67 proteins were identified to be causally associated with estimated BMD (eBMD) (p < 4 × 10−5). We further replicated 38 of the 67 proteins to be associated with total body BMD, lumbar spine BMD, femoral neck BMD as well as fractures, such as RSPO3, IDUA, SMOC2, and LRP4. The findings were supported by sensitivity analyses. Enrichment analysis identified multiple Gene Ontology items, including collagen-containing extracellular matrix (GO:0062023, p = 1.6 × 10−10), collagen binding (GO:0005518, p = 8.6 × 10−5), and extracellular matrix structural constituent (GO:0005201, p = 2.7 × 10−5).Conclusion: The study identified novel putative causal proteins for osteoporosis which may serve as potential early screening biomarkers and druggable targets. Furthermore, the role of plasma proteins involved in collagen binding and extracellular matrix in the development of osteoporosis was highlighted. Further studies are warranted to validate our findings and investigate the underlying mechanism.

Abstract Background Our previous studies found disproportionate anteroposterior vertebral size is associated with severity of the scoliotic curves in adolescent idiopathic scoliosis (AIS) patients. Subsequent studies showed wedging of vertebral bodies (VB) had less contribution than intervertebral discs (IVD) to the anterior–posterior vertebral column length discrepancy in severe-AIS. However, the exact morphological changes of IVD were not clearly defined. This study aimed to evaluate the morphological and pathological changes of IVD and VB in AIS girls and healthy female controls. Methods This study included 33 age-matched female controls and 76 AIS girls with a right-sided thoracic curvature. Wedge angle, height ratio and distance ratio of VB and IVD were measured on the best midline coronal and sagittal planes from reformatted MRI spine. Volumes of VB, IVD and nucleus pulposus (NP) were also evaluated on volumetric images. One-way ANOVA with Bonferroni correction and Pearson correlation tests were used. Results There was significant difference in wedge angle and height ratio of VB and IVD between AIS and controls. In severe-AIS, the position of NP was significantly shifted to the convexity when compared with non-severe AIS and controls. Whereas, the volume of IVD and NP in severe-AIS was found to be significantly smaller. In addition, Cobb angle was significantly correlated with wedge angle and height ratio, and inversely correlated with the volume of NP. Conclusions In addition to wedging of VB and IVD, there was significantly reduced volume of IVD and NP in AIS patients with severe curve, insinuating the mechanical effect of scoliosis leads to a compression on both IVD and NP before significant disc desiccation occurs. We postulate that the compression of IVD and NP can contribute to curve progression in severe-AIS, these patients are more prone to disc degeneration in adulthood if no operative treatment is offered. Further longitudinal study on these parameters is still warranted.

Abstract Bone densitometry revealed low bone mass in patients with adolescent idiopathic scoliosis (AIS) and its prognostic potential to predict curve progression. Recent studies showed differential circulating miRNAs in AIS but their diagnostic potential and links to low bone mass have not been well-documented. The present study aimed to compare miRNA profiles in bone tissues collected from AIS and non-scoliotic subjects, and to explore if the selected miRNA candidates could be useful diagnostic biomarkers for AIS. Microarray analysis identified miR-96-5p being the most upregulated among the candidates. miR-96-5p level was measured in plasma samples from 100 AIS and 52 healthy girls. Our results showed significantly higher plasma levels of miR-96-5p in AIS girls with an area under the curve (AUC) of 0.671 for diagnostic accuracy. A model that was composed of plasma miR-96-5p and patient-specific parameters (age, body weight and years since menarche) gave rise to an improved AUC of 0.752. Ingenuity Pathway Analysis (IPA) indicated functional links between bone metabolic pathways and miR-96-5p. In conclusion, differentially expressed miRNAs in AIS bone and plasma samples represented a new source of disease biomarkers and players in AIS etiopathogenesis, which required further validation study involving AIS patients of both genders with long-term follow-up.

Insufficient sleep contributes negatively to child developmental processes and neurocognitive abilities, which argues the need for implementing interventions to promote sleep health in children. In this study, we evaluated the effectiveness of a multimodal and multilevel school-based sleep education program in primary school children using a cluster randomized controlled design. Twelve schools were randomly assigned to either the sleep education or nonactive control groups. The sleep education group included a town hall seminar, small class teaching, leaflets, brochures, and a painting competition for children. Parents and teachers were invited to participate in a one-off sleep health workshop. Parental/caregiver-reported questionnaires were collected at baseline and 1-month follow-up. A total of 3769 children were included in the final analysis. There were no significant improvements observed in the sleep-wake patterns, daytime functioning, and insomnia symptoms between the two groups at follow-up, whereas the intervention group had significantly improved parental sleep knowledge than the controls (paternal: adjusted mean difference: 0.95 [95% confidence interval (CI): 0.18 to 1.71]; maternal: adjusted mean difference: 0.87 [95% CI: 0.17 to 1.57]). In addition, children receiving the intervention had a lower persistence rate of excessive beverage intake (adjusted odds ratio: 0.49 [95% CI: 0.33 to 0.73]), and experienced greater reductions in conduct problems (adjusted mean difference: 0.12 [95% CI: 0.01 to 0.24]) compared with the controls at 1-month of follow-up. Moreover, a marginally significant reduction for emotional problems in the intervention group was also observed (adjusted mean difference: 0.16 [95% CI: −0.00 to 0.32]). These findings demonstrated that school-based sleep education was effective in enhancing parental sleep knowledge and improving behavioral outcomes in children, but not sufficient in altering the children’s sleep-wake patterns and sleep problems.

Abstract Introduction Diabetes and bone health are closely related. We examined the incidence and risk factors of hip fractures in Chinese patients with type 2 diabetes (T2D). Materials and Methods In this prospective cohort, we consecutively enrolled 22,325 adults with T2D above the age of 40 years in the Hong Kong Diabetes Register between 1994 and 2015 with crude hip fracture incidence rate censored in 2017. Results At baseline, the mean age of this cohort was 60.9 ± 10.5 years (mean duration of diabetes 6 years, 52.4% male). During a mean ± standard deviation (SD) follow‐up period of 8.7 ± 5.2 years with 193,553 person‐years, 603 patients were hospitalized due to hip fractures with an incidence (95% confidence interval, CI) of 315.1 (290.4–341.3) per 100,000 person‐years. On multivariable analysis with competing death risk adjusted, the independent hazard ratios (95% CI) for hip fractures in T2D were 2.01 (1.61–2.51) for female sex, 1.08 (1.07–1.09) for age, 0.93 (0.90–0.95) for body mass index, 1.52 (1.25–1.85) for albuminuria and 1.12 (1.02–1.23) for low density lipoprotein‐cholesterol. In men, the 30‐day, 1‐year and 5‐year post‐hip fracture mortality rate (95% CI) were 5.8 (2.4–9.1) %, 29.2 (22.3–35.5) % and 65.9 (57.3–72.8) % respectively. The corresponding rates in women were 3.4 (1.6–5.1) %, 18.6 (14.7–22.4) %, and 46.8 (40.9–52.1) %. Conclusions Southern Chinese patients with T2D have a high risk of hip fracture associated with suboptimal cardiometabolic‐renal risk factors and a high post‐fracture mortality rate. The effects of improving modifiable risk factors on bone health warrants further evaluation.

Background & Objective: The application of ultrasound imaging for spine evaluation could minimize radiation exposure for patients with adolescence idiopathic scoliosis (AIS). A customized three-dimensional (3D) ultrasound imaging system has been demonstrated to provide reliable and valid coronal curvature measurements. However, these measurements were using the spinous processes as anatomical reference, leading to a predictable underestimation of the traditionally used Cobb angles. An alternative 3D ultrasound image reconstruction method was applied to create coronal images with more lateral features for angle measurement. The objective of this study was to test the reliability and the validity of this angle, the ultrasound curve angle (UCA), and compare the UCA with the Cobb angles on X-ray images of patients with AIS. Materials and methods: This study was divided into: 1) Investigation of intra- and inter-reliability between two raters for measuring the UCA and two operators for acquiring ultrasound images; 2) Investigation of the validity between the radiographic Cobb angle and the UCA. Fifty patients and 164 patients with AIS, were included in the two stages, respectively. Patients underwent bi-planar X-ray and 3D ultrasound scanning on the same day. The proposed UCA was used to measure the coronal curvature from the ultrasound coronal images, which were formed using a newly customized volume projection imaging (VPI) method. The intra-rater/operator and inter-rater and operator reliability of the UCA were tested by intra-class correlation coefficient (ICC) (3,1) and (2,1), respectively. The validity of UCA measurements as compared to radiographic Cobb angles was tested by inter-method ICC (2,1), mean absolute difference (MAD), standard error of measurement (SEM), Pearson correlation coefficient and Bland–Altman statistics. The level of significance was set as 0.05. Results: Excellent intra-rater and intra-operator (ICC (3,1)≥0.973) and excellent inter-rater and inter-operator reliability (ICC (2,1)≥0.925) for UCA measurement, with overall MAD and SEM no more than 3.5° and 1.7° were demonstrated for both main thoracic and (thoraco)lumbar curvatures. Very good correlations were observed between UCA and Cobb angle for main thoracic (R2=0.893) and (thoraco)lumbar (R2=0.884) curves. The mean (SD) measurements in terms of radiographic Cobb and UCA were 27.2 ​± ​11.6° and 26.3 ​± ​11.4° for main thoracic curves; and 26.2 ​± ​11.4° and 24.8 ​± ​9.7° for (thoraco)lumbar curve respectively. One hundred sixty-four subjects (33 male and 131 female subjects; 11–18 years of age, mean of 15.1 ​± ​1.9 years) were included for the validity session. Excellent inter-method variations (ICC (2,K) ≥0.933) with overall MAD and SEM no more than 3.0° and 1.5° were demonstrated for both main thoracic and (thoraco)lumbar curvatures. In addition, Bland–Altman plots demonstrated an acceptable agreement between ultrasound and radiographic Cobb measurements. Conclusion: In this study, very good correlations and agreement were demonstrated between the ultrasound and X-ray measurements of the scoliotic curvature. Judging from the promising results of this study, patients with AIS with different severity of curves can be evaluated and monitored by ultrasound imaging, reducing the usage of radiation during follow-ups. This method could also be used for scoliosis screening.The Translational potential of this article: Ultrasound curve angle (UCA) obtained from 3D ultrasound imaging system can provide reliable and valid evaluation on coronal curvature for patients with AIS, without the need of radiation.

Introduction: A total of 0.1–0.8% of AIS patients progress to severe stages without clear mechanisms, and AIS girls are more prone to curve progression than boys. Recent studies suggest that AIS girls have systemic and persistent low bone-mineral density (BMD), which has been shown to be a significant prognostic factor of curve progression in AIS. The present study aimed to (a) investigate the prevalence of low BMD in patients with severe AIS and (b) assess the sexual dimorphism and independent risk factors of low BMD in severe AIS patients. Materials and Methods: A total of 798 patients (140 boys vs. 658 girls) with AIS who reached surgical threshold (Cobb ≥ 40°) were recruited. BMD were assessed using BMD Z-scores from dual-energy X-ray absorptiometry (DXA). Demographic, clinical, and laboratory values of the subjects were collected from their medical records. Logistic regression analysis was performed to identify independent risk factors of low BMD. Results: The overall prevalence of BMD Z-score ≤ −2 and ≤ −1 were 8.1% and 37.5%, respectively. AIS boys had significantly lower BMD Z-scores (−1.2 ± 0.96 vs. −0.57 ± 0.92) and higher prevalence of low BMD (Z-score ≤ −2: 22.1% vs. 5.2%, p < 0.001; Z-score ≤ −1: 59.3% vs. 32.8%, p < 0.001) than girls. Sex, BMI, serum alkaline phosphatase, and potassium were independent factors of low BMD in the severe AIS patients. Conclusions: The present large cohort of surgical AIS patients revealed that low BMD is more prevalent and severe in boys than in girls with severe curves. Low BMD may serve as a more valuable predictive factor for curve progression to the surgical threshold in boys than girls with AIS.

Abstract This study aimed to characterize global sagittal alignment in adolescent idiopathic scoliosis (AIS) with normal kyphosis (NTK, kyphosis > 10°) and with thoracic hypokyphosis (THK, kyphosis 21). Biplanar radiographies were acquired at baseline, immediate post-operatively, 1-year and 2-year follow-up, and 3D reconstruction of the spine and pelvis was performed. NTK and THK showed different global sagittal alignment, as well as differences compared to controls. AIS with THK at baseline had higher SVA/SFD (2.0 ± 2.9 vs − 0.4 ± 1.9; P

Background: Glomerulonephritis (GN) is a leading cause of kidney failure and accounts for 20% of incident cases of end-stage kidney disease (ESKD) in Canada annually. Reversal of kidney injury and prevention of progression to kidney failure is possible; however, limited knowledge of underlying disease mechanisms and lack of noninvasive biomarkers and therapeutic targets are major barriers to successful therapeutic intervention. Multicenter approaches that link longitudinal clinical and outcomes data with serial biologic specimen collection would help bridge this gap. Objective: To establish a national, patient-centered, multidimensional web-based clinical database and federated virtual biobank to conduct human-based molecular and clinical research in GN in Canada. Design: Multicenter, prospective observational registry, starting in 2019. Setting: Nine participating Canadian tertiary care centers. Patients: Adult patients with a histopathologic pattern of injury consistent with IgA nephropathy, focal and segmental glomerulosclerosis, minimal change disease, membranous nephropathy, C3 glomerulopathy, and membranoproliferative GN recruited within 24 months of biopsy. Measurements: Initial visits include detailed clinical, histopathological, and laboratory data collection, blood, urine, and tonsil swab biospecimen collection, and a self-administered quality of life questionnaire. Follow-up clinical and laboratory data collection, biospecimen collection, and questionnaires are obtained every 6 months thereafter. Methods: Patients receive care as defined by their physician, with study visits scheduled every 6 months. Patients are followed until death, dialysis, transplantation, or withdrawal from the study. Key outcomes include a composite of ESKD or a 40% decline in estimated glomerular filtration rate (eGFR) at 2 years, rate of kidney function decline, and remission of proteinuria. Clinical and molecular phenotypical data will be analyzed by GN subtype to identify disease predictors and discover therapeutic targets. Limitations: Given the relative rarity of individual glomerular diseases, one of the major challenges is patient recruitment. Initial registry studies may be underpowered to detect small differences in clinically meaningful outcomes such as ESKD or death due to small sample sizes and short duration of follow-up in the initial 2-year phase of the study. Conclusions: The Canadian Glomerulonephritis Registry (CGNR) supports national collaborative efforts to study glomerular disease patients and their outcomes. Trial registration: NCT03460054.

IgA nephropathy (IgAN) is a leading cause of kidney failure, yet little is known about the immunopathogenesis of this disease. IgAN is characterized by deposition of IgA in the kidney glomeruli, but the source and stimulus for IgA production are not known. Clinical and experimental data suggest a role for aberrant immune responses to mucosal microbiota in IgAN, and in some countries with high disease prevalence, tonsillectomy is regarded as standard-of-care therapy. To evaluate the relationship between microbiota and mucosal immune responses, we characterized the tonsil microbiota in patients with IgAN versus nonrelated household-matched control group participants and identified increased carriage of the genus Neisseria and elevated Neisseria-targeted serum IgA in IgAN patients. We reverse-translated these findings in experimental IgAN driven by BAFF overexpression in BAFF-transgenic mice rendered susceptible to Neisseria infection by introduction of a humanized CEACAM-1 transgene (B × hC-Tg). Colonization of B × hC-Tg mice with Neisseria yielded augmented levels of systemic Neisseria-specific IgA. Using a custom ELISPOT assay, we discovered anti-Neisseria–specific IgA-secreting cells within the kidneys of these mice. These findings suggest a role for cytokine-driven aberrant mucosal immune responses to oropharyngeal pathobionts, such as Neisseria, in the immunopathogenesis of IgAN. Furthermore, in the presence of excess BAFF, pathobiont-specific IgA can be produced in situ within the kidney.

Abstract Aims The Kansas City Cardiomyopathy Questionnaire (KCCQ) is a widely used patient‐reported outcome measure in heart failure (HF). The KCCQ was validated in patients with HF with reduced ejection fraction (HFrEF), leaving knowledge gaps regarding its applicability in HF with preserved ejection fraction (HFpEF). This study addresses the psychometric properties of internal consistency and reliability, construct, and known‐group validity of KCCQ in both HFrEF and HFpEF. We aimed to evaluate the psychometric properties of the KCCQ and their prognostic significance in HFpEF and HFrEF, within a large prospective multinational HF cohort. Methods and results We examined the 23‐item KCCQ in the prospective multinational ASIAN‐HF study [4470 HFrEF (ejection fraction

This review aimed to systematically review and meta-analyze the effects of interventions in improving bracing compliance among adolescent idiopathic scoliosis (AIS) patients. Eight databases were searched from their inception to April 2022. The eligibility criteria included controlled studies that used any type of intervention to enhance bracing compliance in braced AIS patients. Two researchers independently screened articles and extracted data based on the PICO (participant, intervention, comparator, and outcome) framework. Quality appraisal of included studies was performed using GRADE (overall assessment), and the risk of bias was assessed with Cochrane RoB Tool 2 for randomized controlled trials (RCT) and ROBINS-I for non-RCT studies. The primary outcome was bracing compliance and secondary outcomes included Cobb Angle and measurements for quality of life. Six eligible studies involving 523 participants were included. All studies were evaluated as low or very low quality with a high risk of bias. Four types of interventions were identified, including sensor monitoring (n = 2, RCTs), auto-adjusted brace (n = 1, RCT), more intensive or collaborated medical care (n = 2), and psychosocial intervention (n = 1). A meta-analysis of 215 patients from the three RCTs suggested that the compliance-enhancing intervention group had 2.92 more bracing hours per day than the usual care control (95%CI [1.12, 4.72], P = 0.001). In subgroup analysis, sensor monitoring significantly improved bracing wearing quantity compared to usual care (3.47 hours/day, 95%CI [1.48, 5.47], P = 0.001), while other aforementioned interventions did not show a significant superiority. Compliance-enhancing interventions may be favorable in preventing curve progression and promoting quality of life, but the improvements cannot be clarified according to limited evidence. In conclusion, although the results of this study suggested that sensor monitoring may be the most promising approach, limited high-quality evidence precludes reliable conclusions. Future well-designed RCTs are required to confirm the actual benefit of compliance-improving interventions in clinical practice.

Abstract Background Although computed tomography (CT) is commonly used to diagnose the scoliotic spine in patients with adolescent idiopathic scoliosis (AIS) preoperatively, it is limited by the high radiation and prone scanning position. Recently, a new biplanar stereoradiography (EOS) was used to image the scoliotic spine in an upright posture with significantly less radiation in non-severe AIS subjects. However, its reliability to assess preoperative AIS patients remains unreported. Hence, the purpose of this study is to compare the scoliotic curvature between prone (CT) and upright positions (EOS) in preoperative AIS patients. Methods Thirty-three pre-operative AIS patients (mean age:18.4 ± 4.2) were recruited. EOS was used to scan the whole thoracic spine at upright position. Whereas on the same day, a conventional CT scan was used to evaluate the spine in prone position. The three-dimensional reconstruction of EOS and CT of the spine were then generated. Using previous validated techniques, multiple scoliotic parameters in both modalities were determined. The agreement between the two modalities was compared using the Bland-Altman test, whereas the correlation was assessed by the intraclass correlation coefficient (ICC). Results The mean ICC (prone and upright) of intra-rater/inter-rater reliabilities for the measured parameters were 0.985,0.961/0.969,0.903, respectively. Thoracic Cobb angles, intervertebral wedging and lumbar lordosis correlated significantly between upright EOS imaging radiographs (62.9 ± 9.3°,6.4 ± 2.9° and 48.8 ± 12.4°) and prone CT (47.3 ± 10.0°,5.8 ± 2.7° and 27.9 ± 11.4°; P

Abstract We report a rare case of aggressive plasmablastic lymphoma with an initial presentation of dermatomyositis. The challenges associated with the diagnosis and treatment approach are also highlighted in this case report.

Abstract Background Air pollution has a significant health impact. Most data originate from temperate regions. We aim to study the health impact of air pollution, particularly among the elderly, in a tropical region. Methods A daily time-series analysis was performed to estimate excess risk (ER) of various air pollutants on daily death counts amongst the general population in Singapore from 2001 to 2013. Air pollutants included particulate matters smaller than 10 μm, and 2.5 μm (PM10, PM2.5), carbon monoxide (CO), nitrogen dioxide (NO2), ozone (O3) and sulphur dioxide (SO2). The studied outcomes were non-accidental and cardiovascular mortality. Single-day lag and distributed lag models were studied and adjusted for confounders. Results In single-day lag models, a 10 μg/m3 increase in particulate matter was associated with significant increases in non-accidental (PM10 ER: 0.627%; 95% confidence interval (CI): 0.260–0.995% and PM2.5 ER: 0.660%; 95% CI: 0.204–1.118%) and cardiovascular mortality (PM10 ER: 0.897; 95% CI: 0.283–1.516 and PM2.5 ER: 0.883%; 95% CI: 0.121–1.621%). This was significant in the elderly ≥ 65 years but not in those

Background: In adolescent idiopathic scoliosis (AIS), the continuous search for effective prognostication of significant curve progression at the initial clinical consultation to inform decision for timely treatment and to avoid unnecessary overtreatment remains a big challenge as evidence of the multifactorial etiopathogenic nature is increasingly reported. This study aimed to formulate a composite model composed of clinical parameters and circulating markers in the prediction of curve progression. Method: This is a two-phase study consisting of an exploration cohort (120 AIS, mean Cobb angle of 25°± 8.5 at their first clinical visit) and a validation cohort (51 AIS, mean Cobb angle of 23° ± 5.0° at the first visit). Patients with AIS were followed-up for a minimum of six years to formulate a composite model for prediction. At the first visit, clinical parameters were collected from routine clinical practice, and circulating markers were assayed from blood. Finding: We constructed the composite predictive model for curve progression to severe Cobb angle > 40° with a high HR of 27.9 (95% CI of 6.55 to 119.16). The area under curve of the composite model is higher than that of individual parameters used in current clinical practice. The model was validated by an independent cohort and achieved a sensitivity of 72.7% and a specificity of 90%. Interpretation: This is the first study proposing and validating a prognostic composite model consisting of clinical and circulating parameters which could quantitatively evaluate the probability of curve progression to a severe curvature in AIS at the initial consultation. Further validation in clinic will facilitate application of composite model in assisting objective clinical decision. Keywords: Scoliosis, Adolescent, Clinical study, Hong Kong

This report is of a proximal femoral unicameral bone cyst in a patient presented at 3 years. Intra-lesional steroid injection was used to treat this large active lesion. The response to treatment was monitored with the use of dual-energy X-ray absorptiometry (DXA) scan as an indirect method of monitoring the activity of the bone cyst. The patient had developed stress fracture during the course of treatment which had remodelled fully after successful treatment with multiple injections; at 12-year follow-up, the patient reached skeletal maturity. The affected femur had remodelled back to normal radiological appearance without avascular necrosis. This has demonstrated that steroid injection is a safe and effective procedure to achieve regression of a large active bone cyst in the proximal femur. It is a minimal invasive procedure resulting in no scar. DXA scan is a useful method combining clinical assessment to monitor status of the bone cyst to allow timing of injection. 中文摘要: 本報告為3歲患者的股骨近端骨囊腫，以用病灶內類固醇注射來治療這個巨大的活性病灶。 使用雙能X射線吸收測定法 (DXA) 掃描作為間接方法監測骨囊腫活性對治療的反應。 患者在治療過程中出現了應力性骨折，經多次注射成功治療後已完全改型，隨訪12年，患者達到骨骼成熟。 受影響的股骨已經重新恢復正常的放射學外觀及沒有缺血性壞死。 這證明了類固醇注射是一種安全有效的方法，以實現股骨近端巨大活躍骨囊腫的消退。 這是微創手術，沒有疤痕。 DXA掃描結合臨床評估以監測骨囊腫狀態是有效的方法以允許注射時機。 Keywords: DXA, steroid injection, Unicameral Bone Cyst

We aim to study the outcome of soft tissue releases by tendon elongations and osteotomies in fixed joint contractures by clinical examination and patient self-reported assessment on 20 patients (14 males and 6 females) with spastic diplegic cerebral palsy treated with single-event multilevel surgery (SEMLS) between 2000 and 2012. A questionnaire was used to collect information on problems encountered before and after surgery and decision on surgery. Comparing patients with Gross Motor Function Classification System class I/II, (N = 8), III (N = 8) and IV/V , patients of classes IV/V showed much slower mean recovery time than I/II group (14.00 vs. 4.38 months, p

Previous studies have reported abnormal muscle morphology and functions in patients with adolescent idiopathic scoliosis (AIS). To answer whether such abnormalities could be reflected in their circulation and their clinical implication for predicting curve progression to the surgical threshold, this preliminary study explored the presence of baseline muscle-related proteins and their association with curve progression. Plasma samples were collected at the first clinical visit for AIS, with patients divided into non-progressive or progressive groups (N = four and four) according to their Cobb angle in six-year follow-ups, with age- and sex-matched healthy subjects (N = 50). Then, the samples were subjected to isobaric tags for relative and absolute quantitation (iTRAQ) for global comparison of untargeted protein expression. Seventy-one differentially expressed proteins (DEPs) were found elevated in progressive AIS. Functional analysis showed that 18 of these are expressed in muscles and play an essential role in muscle activities. Among the muscle-related DEPs, α-actin had the highest fold change in progressive/non-progressive groups. This preliminary study firstly suggested higher circulating levels of muscle structural proteins in progressive AIS, indicating the likelihood of structural damage at the microscopic level and its association with progression to the surgical threshold. Further studies with larger sample sizes are warranted to validate these novel candidates for early diagnosis and predicting progression.

Objectives: We aimed to explore the potential mediating effects of neuroticism, depressive and anxiety symptoms, and somatic symptoms in the relationship between insomnia and health-related quality of life (HRQoL). Methods: This was a cross-sectional family study, which recruited a total of 297 adolescents (eighty insomniacs as determined by clinical interview) and 318 parents (93 insomniacs). HRQoL was measured by short form-36 (SF-36) health survey. A series of questionnaires were employed to measure insomnia severity, neuroticism personality, and depressive, anxiety and somatic symptoms. Results: Participants with insomnia had lower HRQoL than those without insomnia (71.9 vs. 77.1, P < 0.001). Insomnia severity (as measured byInsomnia Severity Index) was significantly associated with HRQoL (correlation coefficient = −0.451, P < 0.001). A total of 53% of the variance of SF-36 could be explained by the mediation model, which showed that a large proportion of the variances in the association between insomnia severity and HRQoL was mediated by depressive symptoms, somatic symptoms, and neuroticism personality trait. Conclusions: The close associations between insomnia severity and impaired HRQoL are largely mediated by psychological symptomatology and personality dimension. Further prospective study is warranted to investigate the long-term impact of insomnia symptoms on HRQoL and the roles of mood and somatic symptoms.