Effect of simultaneous bilateral surgery or simultaneous arthroscopic ankle lateral ligament repair in hindfoot endoscopic surgery for posterior ankle impingement syndrome in athletes

BACKGROUND

Posterior ankle impingement syndrome (PAIS) is sometimes complicated by bilateral cases and lateral ankle ligament injuries. Reports on bilateral surgery for PAIS and simultaneous surgery for lateral ankle ligament injury are scarce in the literature.

METHODS

We present a 2-year follow-up of 76 athletic patients who underwent endoscopic hindfoot surgery for PAIS. Patients were divided into those who underwent unilateral or simultaneous bilateral surgery and PAIS surgery alone or simultaneous bilateral PAIS surgery without arthroscopic ankle lateral ligament repair.

RESULTS

All patients returned to full athletic activities postoperatively. There was no difference in all subscales of the SAFE-Q score between groups except for mean days after surgery for full return to athletic activities.

CONCLUSION

Simultaneous bilateral surgery and simultaneous arthroscopic lateral ankle ligament repair had no negative effect on subjective clinical evaluation 2 years after surgery in hindfoot endoscopic surgery for PAIS.

LEVEL OF EVIDENCE

III, retrospective case-control study.

Arthroscopic Modified Lasso-Loop Stitch Technique for Chronic Lateral Ankle Instability in Skeletally Immature vs Mature Patients

BACKGROUND

In recent years, arthroscopic lateral ankle ligament repair has become increasingly popular. However, reports on the clinical outcomes of arthroscopic ankle stabilization for skeletally immature patients remain scarce. This study investigated the clinical outcomes of arthroscopic lateral ankle ligaments repair in skeletally immature patients compared to skeletally mature patients.

METHODS

Our retrospective analysis compared skeletally immature patients and skeletally mature adults who underwent arthroscopic repair of the ankle lateral ligaments with a modified lasso-loop stitch using a suture anchor. Skeletal immaturity was defined as patients whose epiphyseal line of the distal fibula remained open on plain radiography. Clinical outcomes were evaluated using the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) at 2 years after surgery. The time to postoperative walking, jogging, and return to full sports activities were also evaluated.

RESULTS

Sixty-four skeletally immature patients (IM group) and 103 skeletally mature adults (M group) were included. No significant differences were observed during both walking and jogging after surgery between the groups; however, return to full athletic activities was significantly earlier in IM group (P = .05). The mean scores in all SAFE-Q subscales significantly improved in both groups after surgery (P < .001). There were also no statistically significant differences between the groups in the mean postoperative SAFE-Q scores for all subscales. All patients in the IM group returned to playing sports at their preinjury levels postoperatively.

CONCLUSION

We found that skeletally immature patients with chronic lateral ankle instability had generally similar responses to arthroscopic lateral ankle as skeletally mature adult patients at minimally 2 years' follow-up with a high rate of successful return to sport.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Second Data Release from the European Pulsar Timing Array: Challenging the Ultralight Dark Matter Paradigm

Pulsar Timing Array experiments probe the presence of possible scalar or pseudoscalar ultralight dark matter particles through decade-long timing of an ensemble of galactic millisecond radio pulsars. With the second data release of the European Pulsar Timing Array, we focus on the most robust scenario, in which dark matter interacts only gravitationally with ordinary baryonic matter. Our results show that ultralight particles with masses 10^{-24.0}  eV≲m≲10^{-23.3}  eV cannot constitute 100% of the measured local dark matter density, but can have at most local density ρ≲0.3  GeV/cm^{3}.

Spatially Resolved Whole Transcriptome Analysis of Histologically-Characterized Tissue Microarray of Patient-Matched Primary and Recurrent Glioblastomas to Identify Underlying Mechanisms of Treatment Resistance

PURPOSE/OBJECTIVE(S)

Glioblastoma multiforme (GBM) is a lethal CNS malignancy. Radiation therapy increases overall survival, but tumors often recur in high-radiation dose regions. Additionally, recent investigations have underscored the importance of intra-tumoral heterogeneity as a driver of GBM biology. The purpose of this investigation is to characterize transcriptome differences in primary and recurrent GBM patient clinical samples using a digital spatial profiling approach to better appreciate treatment resistance mechanisms.

MATERIALS/METHODS

To address the lack of understanding of molecular mechanisms of resistance in GBM, patient-matched primary and recurrent GBM pathological specimens were identified within the brain tissue biorepository and tissue cores were selected for generation of a tissue microarray (TMA). Hematoxylin and eosin staining with histomorphological (cellular tumor, pseudopalisading necrosis, invasive edge, and perivascular inflammation) scoring were performed in a blinded fashion for every core. This array was then molecularly characterized using digital spatial profiling of the transcriptome. Quality assurance including filtering of lowly expressed genes followed by downstream analyses of the data were performed using the manufacturer's recommended methods within their Bioconductor library. Gene Set Enrichment Analysis (GSEA) was then performed on the ranked gene lists.

RESULTS

After recommended filtering, 6171 genes and 248 regions of interest remained for downstream analysis representing 22 unique patients across four different tumor histomorphological types. Significance testing revealed 679 genes that were differentially expressed between primary and recurrent tumor samples (at FDR<1%). On GSEA analysis, the chromosomal positional locus that contains genes most strongly up-regulated is 12q14, a locus that was previously identified as genomically amplified in multiple patient-derived xenograft lines after radiation selection. Additionally, recurrent tumors display a transcriptional profile more similar to the mesenchymal subtype, whereas primary tumors have a more classical transcriptional phenotype. The epithelial-to-mesenchymal transition pathway is particularly strongly up-regulated in recurrent tumors.

CONCLUSION

Recurrent selection at previously identified genomic loci and molecular pathways underscores a possible conserved set of pathways for treatment resistance. This analysis has yielded a set of gene and molecular pathways that will guide future work in our lab targeting treatment resistance using novel therapeutics and radiation techniques in GBM. Future directions include assessing the feasibility of mapping these clinical samples onto our previously generated panel of comprehensively characterized patient-derived xenograft lines.

Comparison of trans-radial access and femoral access in cardiogenic shock patient who had undergone primary percutaneous coronary intervention from SMART RESCUE trial

Introduction

Throughout the years of percutaneous coronary intervention (PCI), the debate regarding access route, whether it being trasns-radial or femoral, is an ongoing agenda yet to be solved. Recent guidelines suggest trans-radial approach as an option to be considered in acute coronary syndrome (ACS). However, data on cardiogenic shock patients undergoing PCI is relatively sparse.

Purpose

Compare the clinical implication of trans-radial and femoral approach in cardiogenic shock patients who had undergone PCI.

Method

Cardiogenic shock patients who had undergone PCI from January 2014 to December of 2018 were enrolled. Patients were divided according to their access route respectfully. Primary outcome was composite endpoints including all-cause death, re-admission due to heart failure, myocardial infarction (MI) and cerebrovascular accident.

Result

A total of 694 (572 via femoral approach, 122 via radial approach) cardiogenic shock patients who received PCI were enrolled. Mean age femoral and radial groups was 66.59±12.51 and 66.66±12.8 respectfully. Disease severity was higher for femoral patients compared to radial patients as represented by their LM involvement, mechanical organ support (extracorporeal membrane oxygenation, continuous renal replacement therapy, mechanical ventilation), left ventricular ejection fraction (LVEF) and vasoactive inotropic score. Cox regression analysis after adjusting for conventional risk factors showed that femoral route was a poor prognosticator with respect to composite endpoints (HR=2.059, 95% CI 1.249–3.397, p value = 0.005). Radial approach patients had higher survival probability compared to femoral approach patients (Figure 1).

Conclusion

Radial approach in cardiogenic shock patients who are in need for PCI with relatively less severe clinical condition could be a reasonable option for access route.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Inha University Hospital

Guiding Chemically Synthesized Peptide Drug Lead Optimization by Derisking Mast Cell Degranulation-Related Toxicities of a NaV1.7 Peptide Inhibitor

Studies have shown that some peptides and small molecules can induce non IgE-mediated anaphylactoid reactions through mast cell activation. Upon activation, mast cells degranulate and release vasoactive and proinflammatory mediators, from cytoplasmic granules into the extracellular environment which can induce a cascade of severe adverse reactions. This study describes a lead optimization strategy to select NaV1.7 inhibitor peptides that minimize acute mast cell degranulation (MCD) toxicities. Various in vitro, in vivo, and PKPD models were used to screen candidates and guide peptide chemical modifications to mitigate this risk. Anesthetized rats dosed with peptides demonstrated treatment-related decreases in blood pressure and increases in plasma histamine concentrations which were reversible with a mast cell stabilizer, supporting the MCD mechanism. In vitro testing in rat mast cells with NaV1.7 peptides demonstrated a concentration-dependent increase in histamine. Pharmacodynamic modeling facilitated establishing an in vitro to in vivo correlation for histamine as a biomarker for blood pressure decline via the MCD mechanism. These models enabled assessment of structure-activity relationship (SAR) to identify substructures that contribute to peptide-mediated MCD. Peptides with hydrophobic and cationic characteristics were determined to have an elevated risk for MCD, which could be reduced or avoided by incorporating anionic residues into the protoxin II scaffold. Our analyses support that in vitro MCD assessment in combination with PKPD modeling can guide SAR to improve peptide lead optimization and ensure an acceptable early in vivo tolerability profile with reduced resources, cycle time, and animal use.

Organizing a Successful Practice and Considering Tax and Estate Planning

To care for your family and to do "good" for your alma mater, religious organization, and the other charities you love, you need to do "well," which is to build a successful practice. To achieve a successful practice, following the principles of the dozen A's is helpful: Ability, Availability, Amicability, Approachable, Attuned, Aware, Attentive to patients, Attentive to others, Attentive to details, Apology (ability to apologize and accept apology gracefully), Assimilate, Affordable. Another way to put it is "skills to treat, heart to care at a sensible price."

Superior mesenteric artery syndrome: A rare complication of scoliosis corrective surgery

Superior mesenteric artery (SMA) syndrome is a rare but serious complication following scoliosis surgery. Early diagnosis and management are key factors for successful conservative treatment to avoid the need for emergency laparotomies which causes higher morbidity or even mortality. We report two adolescent idiopathic scoliosis patients with Cobb angle of 49° and 132°, respectively, and low body mass index who presented with SMA syndrome following posterior spinal fusion from T2 to L3 and were treated successfully with conservative management. Abdominal radiographs showed distended gastric shadow. Computed tomography angiography of the abdomen showed decreased aortomesenteric angle and SMA-aorta distance. Both patients were treated successfully with conservative treatment which included three principles: gastric decompression with nasogastric tube, correction of electrolytes imbalance, and nutritional support with low volume, high calorie nutritional supplement. Both patients were started with small but frequent meals. Surgeries were not required in both cases. Early diagnosis and management are the key factors to successful treatment in SMA syndrome. Patients with SMA can be treated successfully with conservative treatment comprising of nasogastric decompression, electrolyte correction, and nutritional support with small but frequent meals.

Micro-electromechanical-system-tuned resonant filters spanning the 8-12 µm band

The spectral band covering ∼8-12µm is atmospherically transparent and therefore important for terrestrial imaging, day/night situational awareness systems, and spectroscopic applications. There is a dearth of tunable filters spanning the band. Here, we propose and demonstrate a new, to the best of our knowledge, tunable-filter method engaging the fundamental physics of the guided-mode resonance (GMR) effect realized with a non-periodic lattice. The polarization-dependent filter is fashioned with a one-dimensional Ge grating on a ZnSe substrate and interrogated with a ∼1.5mm Gaussian beam to show clear transmittance nulls. To expand the tuning range, the device parameters are optimized for sequential operation in TM and TE polarization states. The theoretical model exhibits a tunable range exceeding 4 µm, thus covering the band fully. In the experiment, a prototype device exhibits a spectral range of 8.6-10.0 µm in TM and 9.9-11.7 µm in TE polarization or >3µm total. With additional efforts in fabrication, we expect to achieve the full range.

No pulsed radio emission during a bursting phase of a Galactic magnetar

Fast radio bursts (FRBs) are millisecond-duration radio transients of unknown physical origin observed at extragalactic distances^1-3. It has long been speculated that magnetars are the engine powering repeating bursts from FRB sources^4-13, but no convincing evidence has been collected so far¹⁴. Recently, the Galactic magnetar SRG 1935+2154 entered an active phase by emitting intense soft γ-ray bursts¹⁵. One FRB-like event with two peaks (FRB 200428) and a luminosity slightly lower than the faintest extragalactic FRBs was detected from the source, in association with a soft γ-ray/hard-X-ray flare^18-21. Here we report an eight-hour targeted radio observational campaign comprising four sessions and assisted by multi-wavelength (optical and hard-X-ray) data. During the third session, 29 soft-γ-ray repeater (SGR) bursts were detected in γ-ray energies. Throughout the observing period, we detected no single dispersed pulsed emission coincident with the arrivals of SGR bursts, but unfortunately we were not observing when the FRB was detected. The non-detection places a fluence upper limit that is eight orders of magnitude lower than the fluence of FRB 200428. Our results suggest that FRB-SGR burst associations are rare. FRBs may be highly relativistic and geometrically beamed, or FRB-like events associated with SGR bursts may have narrow spectra and characteristic frequencies outside the observed band. It is also possible that the physical conditions required to achieve coherent radiation in SGR bursts are difficult to satisfy, and that only under extreme conditions could an FRB be associated with an SGR burst.

Unpolarized resonant notch filters for the 8-12 µm spectral region

The long-wave infrared (LWIR) spectral region spanning ∼8-12µm is useful for many scientific and industrial applications. As traditional multilayer film components are not straightforwardly realized at these bands, we provide design, fabrication, and testing of polarization independent bandstop filters based on the guided-mode resonance (GMR) effect. Focusing on the zero-contrast grating architecture, we successfully fabricate prototype filters in the Ge-on-ZnSe materials system. Applying mask-based photolithography and dry etching, photoresist patterns form the desired Ge grating structures. The resulting devices exhibit clean transmittance nulls and acceptably high sidebands. Moreover, we verify polarization independent notch filtering by assembling two identical GMR filters with gratings oriented orthogonally. This approach to realize effective GMR elements will be useful for various fields including photonic and optoelectronic devices operating in the LWIR region.

Role of a modified ultrafast MRI brain protocol in clinical paediatric neuroimaging

AIM

To establish a role for modified ultrafast magnetic resonance imaging (MRI) of the brain in clinical paediatric patients based on clinically acceptable image quality and diagnostic accuracy.

MATERIALS AND METHODS

A prospective study was conducted with institutional review board approval on an ultrafast MRI brain protocol consisting of sagittal T1-weighted, axial T2-weighted, axial fluid-attenuated inversion recovery (FLAIR), axial diffusion-weighted imaging (DWI), and axial T2∗-weighted sequences. Preliminary investigations revealed that the default ultrafast T2-weighted sequence was prone to pulsation artefacts. A modified ultrafast T2-weighted sequence was therefore developed to replace the default ultrafast T2-weighted sequence. Thirty-five patients with clinical indication for neuroimaging underwent ultrafast MRI, modified ultrafast T2-weighted sequence and standard MRI at 3 T. Image quality of ultrafast MRI sequences were graded as clinically "diagnostic" or "non-diagnostic" and compared against the corresponding standard MRI sequences as the reference standard. The modified ultrafast T2-weighted sequence surpassed the default ultrafast T2-weighted sequence in image quality. The ultrafast MRI protocol was therefore replaced with the modified ultrafast T2-weighted sequence creating a modified ultrafast MRI protocol. The clinical reports of modified ultrafast MRI were compared against standard MRI for diagnostic concordance, categorised further as "normal", "clinically significant", or "clinically minor" abnormalities.

RESULTS

Ultrafast T1-weighted, FLAIR, and DWI sequences had comparable image quality to standard MRI sequences. The ultrafast T2∗-weighted sequence had significantly higher non-diagnostic images (42.9%) compared to the standard MRI sequence (2.9%). The default ultrafast T2-weighted sequence had significantly higher non-diagnostic images compared to the modified ultrafast T2-weighted sequence and standard T2-weighted sequence (82.9%, 5.7%, 8.6%, respectively). There was 100% concordance for normal and clinically significant abnormalities and 23% discordance for clinically minor abnormalities. Modified ultrafast MRI takes 5 minutes 41 seconds compared to standard MRI time of 14 minutes 57 seconds.

CONCLUSION

The modified ultrafast MRI protocol for brain imaging demonstrates clinically acceptable image quality in four out of five sequences and has high accuracy in diagnosing normal and clinically significant abnormalities when compared against the standard MRI protocol for brain imaging. It could potentially benefit a select group of paediatric patients who require neuroimaging.

TEK is a novel prognostic marker for clear cell renal cell carcinoma

OBJECTIVE

Clear cell renal cell carcinoma (ccRCC) is the most common type of kidney cancer. However, effective therapeutics for ccRCC are lacking. Novel biomarkers could provide critical information when determining prognoses for patients with ccRCC. In this study, we sought to determine if the expression of receptor tyrosine kinase (TEK) could be a potential novel prognostic biomarker for ccRCC. TEK, originally identified as an endothelial cell-specific receptor, plays an important role in the modulation of vasculogenesis and remodeling. Altered TEK expression has been observed in tumor tissues (e.g., oral squamous cell carcinomas, leukemia) and breast, gastric and thyroid cancers. However, the role of TEK in ccRCC remains unknown.

PATIENTS AND METHODS

Differential TEK expression between non-metastatic (stage M0) and metastatic (stage M1) ccRCC patient cohorts was determined from The Cancer Genome Atlas (TCGA) and the International Cancer Genome Consortium (ICGC). Furthermore, TEK expression was assessed as a prognostic factor using the time-dependent area under the curve (AUC) of Uno's C-index, the AUC value of the receiver operating characteristics (ROC) at 5 years, Kaplan-Meier survival curves and multivariate analyses.

RESULTS

A Kaplan-Meier curve analysis revealed that the downregulation of TEK expression was associated with a poor prognosis for patients with ccRCC with good discrimination (p<0.0001 and p=0.0044 for the TGCA and ICGC cohorts, respectively). Analyses of C-indices and receiver operating characteristic AUC values further support this discriminative ability. Moreover, multivariate analyses showed the prognostic significance of TEK expression levels (p<0.001).

CONCLUSIONS

Although additional clinical investigations will be needed, our results suggest that TEK is a potential biomarker for ccRCC.

Otolaryngologist as a Political Leader?

Otolaryngologists are in a good position to advocate for our patients and our specialty. We can do it as a volunteer or as a full-time job running for political office at the state or federal level. To be taken seriously, we need to offer solutions besides citing the problems. We encourage otolaryngologists to work with our Academy and its ENT-PAC (Ear, Nose, Throat Political Action Committee). Medicine is a great profession and Otolaryngology-Head and Neck Surgery is an even better specialty.

The interplay of sun damage and genetic risk in Australian multiple and single primary melanoma cases and controls

BACKGROUND

Skin phenotype, host genotype and ultraviolet (UV) damage play a role in the development of melanoma.

OBJECTIVES

To ascertain whether the level of UV damage at the site of melanomas was associated with genetic polymorphisms.

METHODS

Deep phenotyping was performed on 1244 individuals; 281 with multiple primary melanomas (MPMs), 304 with single primary melanoma (SPM) and 659 convenience controls. Genotype data was generated using the Illumina CoreExome microarray platform, assaying over 500 000 single-nucleotide polymorphisms. A subset of variants were combined to assess a polygenic risk score (PRS) for melanoma.

RESULTS

Most MPM cases were diagnosed in patients aged > 40 years, in sites with visible chronic UV damage. Women and those diagnosed at age ≤ 40 years were less likely to have perilesional UV damage. Patients with MPM had higher frequencies of MITF E318K, MC1R R-alleles and the ASIP risk haplotype. Individuals who had melanoma in a visibly UV-damaged site were more likely to carry MC1R rs75570604 [odds ratio (OR) 2·5], 9q31.2 rs10816595 (OR 1·4) and MTAP rs869329 (OR 1·4). These same alleles were more common in patients with MPM who were diagnosed at age ≤ 40 years. The mean PRS was significantly higher in MPM than in SPM and controls. Naevus count was comparable in early-onset MPM cases and those diagnosed at age > 40 years.

CONCLUSIONS

Our cohort demonstrated higher frequencies of previously reported alleles associated with melanoma. MPM melanomas more commonly occur in UV-damaged areas, and these individuals are more likely to carry MC1R red hair colour alleles. Awareness of the interplay of genetic vulnerability with UV damage can stratify risk and guide recommendations for melanoma screening. What's already known about this topic? Skin phenotype, host genotype and ultraviolet (UV) damage all play a role in melanoma development. One of the main risk factors is a personal history of melanoma; second and subsequent primary melanomas account for over 20% of all melanomas registered in Queensland. Multiple loci are associated with melanoma risk, including many low-penetrance loci, which may have a cumulatively significant risk. Population-wide screening programmes for melanoma are not yet economically viable. What does this study add? Patients diagnosed with melanoma at age ≤ 40 years were more likely than older patients to have melanomas in non-UV-damaged sites. Patients with multiple melanomas had higher frequencies of MITF E318K, MC1R R-alleles, and the ASIP extended risk haplotype than patients with single melanoma. CDKN2A, MC1R and MTAP variants were more frequent in patients who developed melanomas at a younger age, but also in those whose melanomas were all on visibly UV-damaged sites. What is the translational message? Incorporating these genetic findings into the known risk factors of skin phenotype and visible UV damage may allow for a more customized and economically feasible approach to early detection of melanoma, particularly in younger patients. Plain language summary available online.

Prospective randomized comparison of cerebrospinal fluid aspiration and conventional popping methods using 27-gauge spinal needles in patients undergoing spinal anaesthesia

Background

Performing spinal anaesthesia using the conventional popping method with a 27-gauge (27G) spinal needle is technically difficult. In this study, we compared the aspiration and conventional popping method for spinal anaesthesia using 27G Quincke-type needles.

Methods

This prospective, randomized study enrolled 90 patients, aged 19 to 65 years, with American Society of Anesthesiologists physical status I-III, who were undergoing spinal anaesthesia. Patients were randomly assigned to one of two groups using a computer-generated random number table: patients receiving spinal anaesthesia using the aspiration method, in which the needle is advanced with continuous aspiration, or the conventional popping method. The primary outcome measure was the success rate of the first attempt to perform dural puncture. Number of attempts and passages, withdrawal cases, successful attempt time, total procedure time, and actual depth of dural puncture were recorded.

Results

Eighty-eight patients were included in the study. In the aspiration group, the success rate of first attempt for dural puncture was 93.3%, compared with 72.1% in the popping group (P = 0.019). Success involving needle withdrawal was recorded in 4 (8.9%) patients in the aspiration group and 13 (30.2%) in the popping group (P = 0.024). In the popping group, the number of attempts was significantly higher (P = 0.044), and total procedure time was significantly longer (P = 0.023). Actual depths of dural puncture were deeper in the popping group than in the aspiration group (P = 0.019).

Conclusions

The aspiration method using a 27G Quincke-type needle offers clinical benefits for dural puncture compared with the conventional popping method for spinal anaesthesia.

Trial registration

Clinical research information service number: KCT0002815, registered 21/Apr/2018. Retrospectively registered.

Phenotypic and genotypic analysis of amelanotic and hypomelanotic melanoma patients

BACKGROUND

Amelanotic/hypomelanotic melanoma is associated with poorer outcomes due to a more advanced disease stage at diagnosis.

OBJECTIVE

To determine phenotypic risks and genotypic associations with amelanotic/hypomelanotic melanoma to develop a clinical and genetic profile that could assist in identifying high-risk individuals.

METHODS

The Brisbane Naevus Morphology Study conducted from 2009 to 2016 has recruited a core of 1254 participants. Participants were drawn from a combination of volunteers from dermatology outpatient clinics, private dermatology clinics, the Brisbane Longitudinal Twin Study and QSkin study. Case participants had a personal history of melanoma and control participants no personal history of melanoma. We specifically examined seven known candidate pigmentation and melanoma genes and pigmentary phenotypic characteristics in participants with amelanotic/hypomelanotic melanoma compared to pigmented melanomas. This assayed single nucleotide polymorphisms in MC1R, TYR, HERC/OCA2, IRF4, MTAP, PLA2G6 and MITF.

RESULTS

Forty-seven participants had at least one amelanotic/hypomelanotic melanoma, and 389 had pigmented melanomas, with amelanotic/hypomelanotic melanoma patients significantly older than pigmented melanoma participants (63.3 ± 13.0 vs. 54.6 ± 15.3 years; P < 0.001). Amelanotic/hypomelanotic melanoma patients were more likely than pigmented melanoma patients to have red hair (34% vs. 15%; P = 0.01), severe hand freckling (13% vs. 5%; P = 0.01) and propensity to sunburn (63% vs. 44%; P = 0.01). MC1R R/R genotype was much more frequent in our amelanotic/hypomelanotic melanoma population (31.1% vs. 11%; P < 0.001; OR 26.4 vs. 5.9; control 1.0). Amelanotic/hypomelanotic melanoma was associated with TYR rs1126809*A/A [OR (CI 95%) 2.7 (1.1-6.8) vs. 1.2 (0.8-1.9)] and PLA2G6 rs11570734*A/A [OR (CI 95%) 3.7 (1.0-13.6) vs. 1.3 (0.9-2.0)]. The MTAP melanoma risk SNP genotype, associated with darker pigmentation, (rs4636294*A/A) was less common in amelanotic/hypomelanotic melanoma patients [OR (CI 95%) 0.8 (0.3-2.1) vs. 2.0 (1.3-3.1)].

CONCLUSIONS

Knowledge of phenotypic and genotypic associations of amelanotic/hypomelanotic melanoma can help predict risks and associations of this difficult to diagnose melanoma, which may ultimately assist clinical management and patient skin self-examination.

Longitudinal Preterm Cerebellar Volume: Perinatal and Neurodevelopmental Outcome Associations

Impaired cerebellar development is an important determinant of adverse motor and cognitive outcomes in very preterm (VPT) infants. However, longitudinal MRI studies investigating cerebellar maturation from birth through childhood and associated neurodevelopmental outcomes are lacking. We aimed to compare cerebellar volume and growth from term-equivalent age (TEA) to 7 years between VPT (< 30 weeks' gestation or < 1250 g) and full-term children; and to assess the association between these measures, perinatal factors, and 7-year outcomes in VPT children, and whether these relationships varied by sex. In a prospective cohort study of 224 VPT and 46 full-term infants, cerebellar volumes were measured on MRI at TEA and 7 years. Useable data at either time-point were collected for 207 VPT and 43 full-term children. Cerebellar growth from TEA to 7 years was compared between VPT and full-term children. Associations with perinatal factors and 7-year outcomes were investigated in VPT children. VPT children had smaller TEA and 7-year volumes and reduced growth. Perinatal factors were associated with smaller cerebellar volume and growth between TEA and 7 years, namely, postnatal corticosteroids for TEA volume, and female sex, earlier birth gestation, white and deep nuclear gray matter injury for 7-year volume and growth. Smaller TEA and 7-year volumes, and reduced growth were associated with poorer 7-year IQ, language, and motor function, with differential relationships observed for male and female children. Our findings indicate that cerebellar growth from TEA to 7 years is impaired in VPT children and relates to early perinatal factors and 7-year outcomes.

Tinnitus: A Stepchild in Our Specialty

Many patients are not satisfied with their doctor's answer when they complain about tinnitus. The proposed classification can be used to communicate with patients as well as guide future research. Type A itemizes the treatable causes of tinnitus. Type B itemizes tinnitus with a lack of medical explanation. Type C tinnitus is caused by diagnosable and treatable conditions, as listed in tinnitus type A, but the tinnitus persists after the successful treatment of the other symptoms.

Postnatal Brain Growth Assessed by Sequential Cranial Ultrasonography in Infants Born <30 Weeks' Gestational Age

BACKGROUND AND PURPOSE

Brain growth in the early postnatal period following preterm birth has not been well described. This study of infants born at <30 weeks' gestational age and without major brain injury aimed to accomplish the following: 1) assess the reproducibility of linear measures made from cranial ultrasonography, 2) evaluate brain growth using sequential cranial ultrasonography linear measures from birth to term-equivalent age, and 3) explore perinatal predictors of postnatal brain growth.

MATERIALS AND METHODS

Participants comprised 144 infants born at <30 weeks' gestational age at a single center between January 2011 and December 2013. Infants with major brain injury seen on cranial ultrasonography or congenital or chromosomal abnormalities were excluded. Brain tissue and fluid spaces were measured from cranial ultrasonography performed as part of routine clinical care. Brain growth was assessed in 3 time intervals: <7, 7-27, and >27 days' postnatal age. Data were analyzed using intraclass correlation coefficients and mixed-effects regression.

RESULTS

A total of 429 scans were assessed for 144 infants. Several linear measures showed excellent reproducibility. All measures of brain tissue increased with postnatal age, except for the biparietal diameter, which decreased within the first postnatal week and increased thereafter. Gestational age of ≥28 weeks at birth was associated with slower growth of the biparietal diameter and ventricular width compared with gestational age of <28 weeks. Postnatal corticosteroid administration was associated with slower growth of the corpus callosum length, transcerebellar diameter, and vermis height. Sepsis and necrotizing enterocolitis were associated with slower growth of the transcerebellar diameter.

CONCLUSIONS

Postnatal brain growth in infants born at <30 weeks' gestational age can be evaluated using sequential linear measures made from routine cranial ultrasonography and is associated with perinatal predictors of long-term development.