The role of diffusion-weighted MRI in the accurate diagnosis of vertebral compression fractures: A comparative study

INTRODUCTION

Accurately distinguishing between benign and malignant vertebral compression fractures is crucial for clinical management. This study evaluated the predictive accuracy of diffusion-weighted imaging (DWI) in differentiating the cause of vertebral fractures using MRI.

METHODS

A longitudinal cross-over study was conducted at Jinnah Postgraduate Medical Centre (JPMC) Karachi from July 2018 to January 2021. Patients with vertebral compression fractures underwent T1-weighted, T2-weighted, and DWI imaging with ADC mapping on a 1.5 T MRI scanner. Imaging findings were compared with histopathologic results and clinical follow-up. Sensitivity, specificity, and ROC curve analyses were performed.

RESULTS

The study enrolled 303 patients with a mean age of 43.6 ± 10.9 years, of whom 118 were male. DWI demonstrated high accuracy in predicting the cause of vertebral compression fractures, with a sensitivity of 96.2 %, a specificity of 76.2 %, and an area under the ROC curve of 0.857. The optimal ADC cut-off value was 0.82 × 10˄-3 mm˄2/s, which yielded a positive predictive value of 79.7 % and a negative predictive value of 95.4 %.

CONCLUSIONS

DWI is a safe and non-invasive imaging modality with excellent predictive accuracy in differentiating between benign and malignant vertebral compression fractures. Iso- or hypointensity of collapsed vertebral bodies on DWI suggests a benign lesion, while T2-weighted hyperintensity is highly indicative of malignancy. Low signal on ADC is also highly indicative of malignant vertebral fractures. Incorporating DWI improves accuracy in assessing vertebral lesions, especially when standard sequences are inconclusive.

IMPLICATIONS FOR PRACTICE

DWI revolutionizes vertebral compression fracture diagnosis, distinguishing between benign and malignant cases. This precision guides treatment decisions, minimizing the necessity for invasive procedures like biopsy. As a safe and reliable imaging method, DWI elevates patient care, ensuring accurate diagnostics and improved outcomes.

Borjeson-Forssman-Lehmann Syndrome: Clinical Features and Diagnostic Challenges

Borjeson-Forssman-Lehmann syndrome (BFLS) is an X-linked recessive disorder resulting from mutations in the PHF6 gene. The syndrome is characterized by short stature, obesity, hypogonadism, hypotonia, intellectual disability, distinctive facial features, fleshy ears, and finger and toe abnormalities. However, the diagnostic challenge in identifying BFLS remains a topic of interest. In this case report, we present the clinical characteristics of a proband with BFLS, highlighting the additional features of hypotonia, intellectual disability, and distinctive facial features. While no definitive treatment exists for BFLS, patients benefit from specialized education and ongoing supervision from early childhood through adulthood. Symptomatic treatment, including close follow-up, may be necessary for complications such as seizures and hearing problems. Mastectomy or testosterone replacement therapy may be considered on a case-by-case basis. Genetic counseling for X-linkage should be offered to affected families.

Treatment of Pantothenate-Kinase Neurodegeneration With Baclofen, Botulinum Toxin, and Deferiprone: A Case Report

Pantothenate kinase-associated neurodegeneration (PKAN) is a rare autosomal recessive disorder characterized by progressive motor symptoms, such as dystonia and spasticity. Classical PKAN is the most common subtype of neurodegeneration with brain iron accumulation (NBIA). Currently, there is no established treatment for PKAN. However, baclofen and botulinum toxin have been reported to improve motor symptoms and ease care in these patients. Additionally, Deferiprone is a well-tolerated iron chelator that has been shown to be effective in reducing brain iron accumulation. In this case report, we present the case of a seven-year-old boy who presented to our ward with spastic gait and extrapyramidal signs. Brain magnetic resonance imaging was performed, which showed features of neurodegeneration secondary to brain iron accumulation with a specific appearance of the eye-of-the-tiger sign. Genetic testing was positive for a homozygous mutation in PANK2, and the diagnosis of early-stage classical PKAN was made. This case report highlights the potent efficacy of baclofen, botulinum toxin, and deferiprone in slowing down the disease progression at an early stage and improving the severity of symptoms.

Treatment Tolerance and Toxicity in Elderly Oropharyngeal Cancer Patients and Implication on Outcomes

PURPOSE/OBJECTIVE(S)

To investigate the tolerance level and toxicity for standard of care treatment for oropharyngeal cancer (OP) in elderly patients and their impact on outcomes.

MATERIALS/METHODS

Using our in-house head and neck cancer database, we looked for non-metastatic OP cases that received definitive treatment between 1/2009-6/2020. All patients received either definitive radiation therapy (RT) +/- concomitant systemic therapy (ST), or surgery followed by adjuvant RT or RT-ST. For the elderly (age at diagnosis ≥65 years) and young (<65 years) patients, we compared treatment package time (TPT) (time from surgery to RT conclusion) for adjuvant RT, total RT duration and unplanned RT interruptions. ST details and dose/protocol modifications were also compared. We evaluated worst grade of pain and mucositis, hospitalization for non-hydration causes and febrile neutropenia (FN) during RT. Feeding tube (FT) use and weight loss were compared. The independent effect of these indicators on locoregional (LRFS), distant (DRFS) recurrence free and overall (OS) survival was assessed using multivariate analyses (MVA).

RESULTS

A cohort of 326 patients was included: 36% elderly (n = 118) and 64% young (n = 208), with no differences in AJCC stage distribution (8th), treatment received and HPV status (HPV+ve: 73% vs 74.6%; p = 0.86). In 23.6 % who received adjuvant RT, median TPT was 86 (range 72-128) and 81 (65-137) days for elderly vs young (p = 0.27); whereas in the definitive RT cases 76.4%, total RT duration was 49 days for both age groups. Overall, prescribed RT course was not completed in 4% and unplanned RT interruptions occurred in 22.8% and both were non-significant between age groups. Among the 261 patients that received ST, elderly utilized more cetuximab (26 vs 12%; p = 0.007). For those who received cisplatin, 20% of elderly had cumulative dose <200 mg/m2 compared to 6% among the younger age group (p = 0.006); and cisplatin was changed to carboplatin or cetuximab in 18% vs 8% (p = 0.019). Delayed/cancelled cycles and dose reductions were similar. There were more hospitalizations (47% vs 27%; p<0.001) and a trend for more FN (9% vs 3%; p = 0.09) with older age, while worst pain and mucositis was similar. FTs were used more in elderly patients (64% vs 50%; p = 0.02), for a median of 97 vs 64 days (p = 0.31); of which 19.5% vs 11% (p = 0.28) were inserted before RT start. However, % weight loss was non-significant. On MVA, longer RT duration, FT use and hospitalizations predicted worse LRFS and DRFS; and they were prognostic for OS in addition to TPT >90 days (p<0.05 for all). Nevertheless, elderly vs young had non-significant 3-year LRFS (91% vs 90% and 67% vs 69%), DRFS (86% vs 90% and 79% vs 81%) & OS (85% vs 81% and 39% vs 52%) for HPV+ve and HPV-ve respectively (p>0.05).

CONCLUSION

Elderly patients with OP need more multi-disciplinary supportive care when receiving RT and concurrent ST. However, survival outcomes are equivalent to younger patients. Ongoing studies should enroll more elderly candidates and stratify endpoints with age.

Multi-Institutional Validation of the Recursive Partitioning Analysis for Overall Survival in Patients Undergoing Spine Radiosurgery for Spine Metastasis

PURPOSE/OBJECTIVE(S)

The recently published spine radiosurgery (sSRS) recursive partitioning analysis (RPA) for overall survival (OS) separated patients into 3 distinct prognostic groups. We sought to externally validate this RPA using 3 separate multi-institutional datasets.

MATERIALS/METHODS

A total of 444 patients were utilized to develop the recently published sSRS RPA predictive of OS in patients with spine metastases. The RPA identified three distinct prognostic classes. RPA Class 1 was defined as KPS >70 and controlled systemic disease (n = 142); RPA Class 2 was defined as KPS>70 with uncontrolled systemic disease or KPS ≤70, age ≥54 and absence of visceral metastases (n = 207); RPA Class 3 was defined as KPS ≤70 and age <54 years or KPS≤70, age ≥54 years and presence of visceral metastases (n = 95). We utilized data from 3 large tertiary care centers to independently validate this RPA. Data from each institution was utilized independently to validate the RPA to minimize confounding based on institutional differences in patient selection. A total of 1,184 patients (221 patients from institution A, 749 institution B, and 214 from institution C) were in the validation cohort and were divided based on their RPA Class. Kaplan-Meier method was used to estimate OS and log-rank test was used to compare OS between RPA classes.

RESULTS

In each of the validation cohorts, the median OS was 19.9 months (institution A), 11.0 months (institution B), and 24.4 months (institution C). The patient distribution into RPA classification based on Institution A/B/C was, Class 1 (19.4%, 15.1%, 50.5%), Class 2 (74.7%, 57.7%%, 37.9%), and Class 3 (5.9%, 27.2%%, 11.2%), respectively. The median OS for patients in the validation cohort at Institution A/B/C based on RPA class was Class 1 (54 months, 27.1 months, 50.0 months), Class 2 (15.9 months, 13.0 months, 15.1 months) and Class 3 (6.9 months, 3.5 months, 6.1 months), respectively. Patients in RPA Class 1 had a significantly better OS compared to those in Class 2 of the each of the three external institution validation cohorts (p<0.01). Similarly, patients in RPA Class 2 had a significantly better OS compared to those in Class 3 (p<0.01).

CONCLUSION

The external datasets from three large institutions independently validated the spine SRS RPA successfully for OS in patients undergoing sSRS for spinal metastases. This is the first RPA for OS to have been externally validated using multiple large datasets. Based on this validation, upfront spine SRS is strongly supported for patients in RPA Class 1 and Class 2 and is also cost effective with median OS >11 months for these patients. Patients in RPA Class 3 would benefit most from upfront conventional radiotherapy given their poor expected survival. Given successful external validation, this RPA helps guide physicians to identify those patients with spinal metastases who most benefit from sSRS.

Definitive and Salvage Radiotherapy Compared to Other Modalities for Laryngeal Carcinoma in Situ

PURPOSE/OBJECTIVE(S)

We sought to analyze survival endpoints for laryngeal carcinoma in situ (CIS) undergoing definitive radiotherapy (RT) compared to other modalities.

MATERIALS/METHODS

Usingour prospectively maintained head and neck cancer database, we identified laryngeal CIS patients treated between 6/2001 and 12/2021. We excluded low-grade dysplasia, CIS with any synchronous invasive squamous cell carcinoma (SCC) within 3 months of the initial CIS biopsy and cases with inadequate follow up. Patients were offered either definitive RT, CO2/KTP laser ablation, photodynamic therapy (PDT) or any sort of therapeutic excision. After first line treatment, follow-up includes visits every 3-6 months with laryngoscopy and biopsies as appropriate. For recurrent CIS beyond 6 months of first line treatment, we reported salvage therapies received and long-term outcomes were reported. Using Kaplan-Meier curves and log-rank test we investigated recurrence free (RFS), progression to invasive SCC free (IFS) and overall (OS) survival across treatment groups. Patients managed with salvage RT were compared to first line RT recipients.

RESULTS

Atotal of 85 CIS cases were included: median age 65 years (IQR: 55-74), 73 males (85%) and 70 white (82.4%). 86% had a history of smoking with median pack year of 38 (IQR: 20-55) and 66% had a history of alcohol use. CIS was glottic in most of the cases (90.6%: 66% unilateral, 21% bilateral & 13% involved commissure); with only 9.4% in the supraglottic region. RT was used in 49.4% (n = 42) after biopsy (55%) or surgery (45%) with median dose of 63 Gy/28 fractions, mainly by 3D conformal RT (76%). The remaining 50.6% (n = 43) got therapeutic excision alone (commonly microflap excision) (46.5%), CO2/KTP laser (32.6%) or PDT (20.9%). Demographics and clinicopathological details were non-different between RT and non-RT patients except for Charlson comorbidity index: median 2 (IQR 1-3) in non-RT vs 1 (IQR 0-2) in 1ry RT; p = 0.007. After a median follow-up of 4.8 years (IQR 3.5), 51.8% had recurrent disease, 21.2% progressed to invasive SCC and 9.4% had laryngectomies mainly for invasive SCC after RT. First line RT had improved 2-(83% vs 39%) and 5-(74% vs 22%) year RFS vs non-RT therapies (p<0.001). Nevertheless, 2- and 5-year IFS (89% vs 98% and 80% vs 79%) and OS (92% vs 93% and 81% vs 77%) were non-significant among both (p>0.05 for all). Among non-RT cases with CIS recurrences, 12/35 (34%) had salvage RT. Following RT, salvage RT patients had similar 2- and 5-year RFS (81% vs 83% and 81% vs 74%) and IFS (81% vs 89% and 81% vs 80%) compared to first line RT (p>0.05 for all). All cases with CIS recurrences were salvaged successfully with 100% living with no CIS at latest follow-up.

CONCLUSION

Laryngeal CIS can be treated with a wide range of modalities including 1ry RT which has better recurrence free survival. Nevertheless, non-RT recurrent CIS can be salvaged successfully with many options including RT with equivalent long-term results.

Feasibility of Using Zero-Shot Learning in Transformer-Based Natural Language Processing Algorithm for Key Information Extraction from Head and Neck Tumor Board Notes

PURPOSE/OBJECTIVE(S)

Natural language processing (NLP) technology has the potential to automate information aggregation and summarization in oncology. One example is the automation of patient registry creation. In this work, we aim to show (1) the feasibility of using modern NLP algorithms to extract key information from tumor board notes, and (2) the impact of prompt engineering on the quality of the results.

MATERIALS/METHODS

In this IRB-approved study, we obtained the texts of head and neck tumor board notes for 306 unique patients. Five key pieces of information used to create a patient registry were predefined: age, gender, tumor histology, tumor stage, and primary location. The NLP algorithm used was a modified Text-To-Text Transfer Transformer (T5) model that was initially trained on the Colossal Clean Crawled Corpus (C4) dataset and subsequently fine-tuned on the Stanford Question Answering Dataset (SQuAD) to perform the downstream task of extractive question answering. The NLP model and trained weights were obtained from the Hugging Face platform. During inference, the entire body of the tumor board note and a related question were fed as inputs, and the model predicted a sequence of texts in response to the question. Two sets of questions of similar semantic meanings were used. Questions in prompt set #1 included "What is the gender?", "What is the age?", "What is the type of carcinoma in pathological diagnosis?", "What is the stage?", and "Where is the carcinoma located at?". Questions in prompt set #2 include "Is the patient male or female?", "How old is the patient?", "What kind of cancer?", "What is the cancer stage?", and "What is the tumor location?". Each model-predicted response was compared to the ground truth extracted from the tumor board notes. A response was classified as true if it is consistent with the ground truth, otherwise, it was deemed false. The response accuracy for each question was subsequently calculated.

RESULTS

The median number of words in each tumor board note was 448 (range, 219 - 1505). The accuracy of the NLP algorithm for each question from either set is reported in Table 1. Algorithm performance is higher for extracting objective information such as age, gender, and histology. In addition, it was found that questions of similar semantic meanings but with different wording can lead to significantly different results.

CONCLUSION

We demonstrated that a transformer-based extractive question-answering NLP algorithm can be successfully used for extracting information from head and neck tumor board notes with zero-shot learning. Furthermore, our results highlight the significance of prompt engineering for applying NLP for this task. Future work on finetuning these algorithms to oncology-specific texts can potentially enhance algorithm performance for more difficult tasks.

Disease Characteristics, Treatment and Survival for Oropharyngeal Squamous Cell Carcinoma of Elderly

PURPOSE/OBJECTIVE(S)

Incidence of oropharyngeal cancers (OP) has been increasing over the past few decades, mainly driven by human papilloma virus (HPV) associated cancers in younger men. However, a large number of OP patients in recent years are ≥65 years of age. We wanted to determine if there is a difference in outcomes in elderly patients with OP as compared to younger patients.

MATERIALS/METHODS

We queried our institutional prospectively maintained head and neck cancer database for patients with non-metastatic OP treated between 1/2009-6/2020. We excluded patients who did not receive any definitive treatment. We analyzed clinicopathological and treatment characteristics for elderly (age at diagnosis ≥65 years) compared to young (<65 years) across HPV subtypes. We also studied survival endpoints among age groups using Kaplan-Meier curves and log-rank test. Independent predictors were estimated using multivariate (MVA) Cox regression models for each HPV subtype.

RESULTS

We identified 340 patients who met our inclusion criteria: elderly 123 (36%) and young 213 (64%). The proportion of elderly HPV+ve patients showed an increasing trend over the years studied. Median age was 70 years (range 65-91) in elderly and 56 years (38-64) in young (p<0.001); and HPV+ve/-ve were 73.2/26.8% vs 74.6/25.3% for both age groups respectively (p = 0.86). Elderly patients had higher Charlson Comorbidity Index (CCI) and included more divorcees (p<0.05). There were more elderly current/former smokers (97% vs 82%; p = 0.007) within HPV-ve cases. Definitive radiotherapy (RT) +/- systemic therapy (CRT) was utilized in 73.2% (n = 249), while the remainder had surgery +/- adjuvant RT/CRT. There was no difference with age for OP subsite, 8th edition AJCC stage and treatment received except for more use of cetuximab (22.5% vs 10.2%; p<0.001) and weekly cisplatin (32.4% vs 25.8%; p<0.001) among elderly patients. After a median follow up of 5.24 years (IQR: 3.53), 3-year overall (OS) (HPV+ve: 85 vs 81%; HPV-ve: 39 vs 52%), locoregional free (LRFS) (HPV+ve: 86 vs 90%; HPV-ve: 67 vs 69%) and distant metastasis free (DMFS) survival (HPV+ve: 91 vs 90%; HPV-ve: 79 vs 81%) were all non-significant for elderly vs young respectively. On MVA, CCI and AJCC stage for HPV+ve; and smoking, T-stage and lymphovascular space invasion for HPV- were associated with OS. For HPV+ve, AJCC stage, adjuvant vs definitive RT and treatment in later years were predictive of better LRFS, whereas smoking index and extracapsular space invasion were deterministic for DMFS. Interestingly, outcomes among those who received cetuximab was similar to those who received concurrent cisplatin for all endpoints.

CONCLUSION

We did not note any significant difference in outcomes among elderly patients treated for OP when compared to the younger patients when multi-disciplinary head and neck cancer care is provided. This was noted even though a significantly larger proportion of elderly patients received cetuximab concurrent with RT as opposed to standard of care cisplatin.

Introducing Paediatric Radiology As A Subspecialty In Pakistan: Bridging The Gap In Healthcare

Madam, Radiology is a rapidly progressing field that significantly contributes to disease diagnosis and treatment monitoring. Recent advancements in the field have improved evidence-based medicine for patient care. Despite substantial growth in Pakistan, limited opportunities for sub-specialisation training in radiology are available in Pakistan. Just a few institutions offer training in sub-specialties such as women's imaging, neurologic radiology, interventional radiology, and body imaging. There has been significant evolution in pediatric radiology, which has now emerged as a distinct field requiring solid foundations. Unfortunately, due to undefined training opportunities, pediatric radiology is being neglected in Pakistan. Pediatric radiology requires specialized training due to anatomical variations and unique disease presentations in children. Even senior general radiologists may lack confidence when reporting pediatric cases. Radiology demands updated knowledge and expertise in diagnostic tools, making it challenging to keep up. Reporting pitfalls in pediatrics differ from adults due to varying growth patterns and myelination making expert knowledge essential for accurate reporting in multiple conditions. The acceptable radiation doses and protocols for imaging studies are also different, considering children’s susceptibility to ionizing radiation3. The European Society of Radiology highlighted the importance of integrating pediatric radiology training4. Many other countries, including the USA and Europe, have sub-specializations and accreditations despite having lower proportions of children in their populations compared to Pakistan. Advocacy movements for pediatric radiology have also emerged in other developing nations like Nigeria5. Pakistan is a largely populated country, with approximately 35% being pediatric population and multiple radiological cases being reported daily. It seems a gross neglect not to cater specifically to such a large proportion of the people. Therefore, there is a dire need to recognize pediatric radiology as a formal subspeciality that requires redrafting of the curriculum. The subspecialty should focus on a particular area and offer comprehensive and consistent training to interested individuals.

Asthma exacerbations and body mass index in children and adolescents: experience from a tertiary care center

The prevalence and incidence of asthma continue to rise globally. Obesity has been identified as a potential risk factor for asthma exacerbations. The association between body mass index (BMI) and asthma is not well studied in some regions. This study aims to investigate the impact of BMI in pediatric asthmatic patients. This retrospective study was conducted at the Aga Khan University Hospital from 2019 to 2022. Children and adolescents with asthma exacerbation were included. The patients were classified into four groups based on their BMI: underweight, healthy weight, overweight, and obese. The demographic characteristics, medications used, predicted FEV1 measurements, asthma exacerbations per year, length of stay per admission, and the number of patients requiring High Dependency Unit (HDU) care were recorded and analyzed. Our results demonstrated that patients in the healthy weight category had the highest percentage of FEV1 (91.46±8.58) and FEV1/FVC (85.75±9.23) (p<0.001). The study found a significant difference in the average number of asthma exacerbations per year between the four groups. Obese patients had the highest number of episodes (3.22±0.94), followed by the underweight group (2.42±0.59) (p<0.01). The length of stay per admission was significantly shorter for patients with a healthy weight (2.0±0.81), and there was a statistically significant difference observed in the number of patients requiring HDU care among the four groups, as well as in the average length of stay at the HDU (p<0.001). Elevated BMI is related to an increased number of annual asthma exacerbations, a low FEV1 and FEV1/FVC, increased length of stay at admission, and increased stay in the HDU.

Direct current cardioversion in pregnancy: a multicentre study

OBJECTIVE

Direct current cardioversion (DCCV) in pregnancy is rarely required and typically only documented in single case reports or case series. A recent UK confidential enquiry reported on several maternal deaths where appropriate DCCV appeared to have been withheld.

DESIGN

Retrospective cohort study.

SETTING

Seventeen UK and Ireland specialist maternity centres.

SAMPLE

Twenty-seven pregnant women requiring DCCV in pregnancy.

MAIN OUTCOME MEASURES

Maternal and fetal outcomes following DCCV.

RESULTS

Twenty-seven women had a total of 29 DCCVs in pregnancy. Of these, 19 (70%) initial presentations were to Emergency Departments and eight (30%) to maternity settings. There were no maternal deaths. Seventeen of the women (63%) had a prior history of heart disease. Median gestation at DCCV was 28 weeks, median gestation at delivery was 35 weeks, with a live birth in all cases. The abnormal heart rhythms documented at the first cardioversion were atrial fibrillation in 12/27 (44%) cases, atrial flutter in 8/27 (30%), supraventricular tachycardia in 5/27 (19%) and atrial tachycardia in 2/27 (7%). Fetal monitoring was undertaken following DCCV on 14/29 (48%) occasions (10 of 19 (53%) at ≥26 weeks) and on 2/29 (7%) occasions, urgent delivery was required post DCCV.

CONCLUSIONS

Direct current cardioversion in pregnancy is rarely required but should be undertaken when clinically indicated according to standard algorithms to optimise maternal wellbeing. Once the woman is stable post DCCV, gestation-relevant fetal monitoring should be undertaken. Maternity units should develop multidisciplinary processes to ensure pregnant women receive the same standard of care as their non-pregnant counterparts.

Relationship between musculoskeletal discomfort and cell phone use among young adults: A cross-sectional survey

BACKGROUND

Cell phone usage is highly prevalent among young adults. They are used for multiple purposes including communication, studies, social networking and entertainment. However, its excessive usage has been associated with adverse health outcomes.

OBJECTIVE

The objective was to find the association of cell phone usage with musculoskeletal discomfort (MSD) and its associated factors.

METHODS

A cross-sectional study was conducted on young adult students from a low-middle income country over a period of 3 months from December 2018 to February 2019. A structured questionnaire based on the Disabilities of the Arm, Shoulder and Hand (QuickDASH scoring) was used to record the musculoskeletal discomfort.

RESULTS

Out of 803 questionnaires, data of 754 (94%) were entered and the remaining questionnaires (n = 49) were discarded due to incomplete answers. The mean age was 20.83 (1.62) years. In our study, there were 194 (25.7%) males and 560 (74.3%) female participants. Neck and shoulder were the most frequently affected regions. A significant difference in QuickDASH score was observed between genders (p-value p ≤ 0.001). Left-handed individuals scored significantly higher on QuickDASH score compared to right-handed individuals (p < 0.05). Increased musculoskeletal discomfort was reported by individuals with daily cell phone use of more than four hours (p < 0.05). A positive significant correlation was found between continuous one hour cell-phone use and higher mean QuickDASH scores (correlation coefficient 0.124, p value 0.001). Shorter eye-to-screen distance was significantly associated with MSD (p < 0.05).

CONCLUSION

Musculoskeletal discomfort is associated with the female gender, duration of cell phone use and a small eye-to-screen distance.

Knowledge, Attitudes, and Perceptions Toward Dementia Among Middle-Aged Singapore Residents

Background: Dementia is the decline in cognitive function sufficient to impair one’s accustomed functioning. Countries with aging populations, such as Singapore, face rising rates of dementia. Dementia patients and their caregivers endure great financial and emotional stress. With the broad aim of minimizing these stresses, this study provides a cross-sectional view of the knowledge, attitudes, and perceptions (KAP) towards dementia in middle-aged Singaporean residents. Objective: We aim to examine 1) the associations between demographic correlates and KAP; and 2) the effect of dementia knowledge on attitudes and perceptions towards dementia. Methods: An online anonymous cross-sectional questionnaire was administered to Singaporeans and Permanent Residents aged 45 to 65 years old in English, Mandarin, and Malay. Knowledge was evaluated across three domains: symptoms, risk factors, and management. Total and domain scores were dichotomized as good or poor knowledge using median cut-offs. Attitudes/perceptions across six domains were evaluated on Likert scales, and responses to each question were dichotomized into positive or negative attitudes/perceptions. Results: From 1,733 responses, 1,209 valid complete responses were accepted (mean age±SD 54.8±5.12 years old, females = 69.6%). Lower socioeconomic status was associated with poorer knowledge and greater barriers to risk-mitigating lifestyle modifications. Lack of personal experience with dementia and poor knowledge were also associated with erroneous attitudes/perceptions. Conclusion: Socioeconomic status and personal experience affect KAP towards dementia. Policy and education campaigns to address KAP towards dementia should account for baseline differences across demographics, for greater improvements in dementia incidence and support.

Characteristics of electrolyte imbalance and pseudo-bartter syndrome in hospitalized cystic fibrosis children and adolescents

INTRODUCTION

Pseudo-Bartter syndrome (PBS) is a rare manifestation of Cystic fibrosis (CF) and can often be the initial presentation in these patients, however, due to significantly overlapping symptoms it is often misdiagnosed as simple dehydration or Bartter syndrome. The objective of our study was to highlight the key features of PBS and electrolyte imbalance in CF patients helping in early and prompt diagnosis.

METHOD

We performed a retrospective study from January 2015 to December 2019 at the Aga Khan University Hospital (AKUH), Pakistan. CF patients aged from 1-18 years, admitted at AKUH were enrolled and their laboratory data and individual charts were reviewed. Patients were categorized into three groups based on their serum electrolyte profile and their clinical findings were compared.

RESULT

We enrolled 72 CF patients, out of which 42 (58%) were categorized into the Normal Electrolyte (NE) group, 19 (26%) into the Electrolyte Imbalance (EI) group and 11 (15%) in the PBS group. Out of 11 cases, 6 (54.54%) patients in PBS group presented with features consistent with PBS leading to CF diagnosis labeled as "early presenters". Mean age of patients in the PBS group was 3.81± 0.86 years and their age at diagnosis were significantly lower as compared to other groups. Gastrointestinal disturbances including diarrhea, vomiting and constipation were more common in the EI and PBS groups. Polyuria was most common in the PBS (72%) group. Length of hospital stay showed no significant difference.

CONCLUSION

Pseudo-Bartter syndrome can be a presenting feature of cystic fibrosis. Electrolyte imbalance should be anticipated in hospitalized CF children and adolescent.

Pierson Syndrome Associated with Hypothyroidism and Septic Shock

Pierson syndrome is caused by mutations in the laminin β2 gene causing absent β2 laminin, which is a normal component of the basement membranes of the mature glomerulus, structures in the anterior eye and neuromuscular junctions. The mutations manifest as congenital nephrotic syndrome and microcoria which are characteristic ocular features of this disease. These mutations may also result in neurological abnormalities such as hypotonia and psychomotor retardation. We report a two-month old boy who presented to the Pediatrics Department of Dr. Ruth K. M. Pfau Civil Hospital, Karachi, Pakistan, in 2015, with the typical features of microcoria and congenital nephrotic syndrome. The hypocalcaemia, hypoproteinaemia and probable immunocompromised state consequent to nephrotic syndrome resulted in seizures, hypothyroidism and urosepsis. Despite being treated aggressively with high dose antibiotics, ionotropic support, angiotensin-converting enzyme inhibitors, thyroxine replacement and nutritional support, the infant died due to significant multiorgan disease including renal failure and septic shock.

Prevalence and Predictors of Contraception Usage in Karachi, Pakistan

Background Contraception, also known as family planning, refers to methods that intercept unwanted pregnancies. The modalities of contraception have evolved and multiplied over time to facilitate users. Despite enormous benefits, the contraceptive methods remain underutilized in developing countries such as Pakistan. Accordingly, the primary purpose of our study is to determine the prevalence, perception, and attitude of contraceptive usage in Karachi. The study further assesses the knowledge and core determinants of contraception. Methods A cross-sectional study was conducted in Karachi, Pakistan. The sample population comprised currently married males and females residing in Karachi, with females from 16 to 45 years of age and males of 16 years of age and forth. Pregnant females, divorcees, and widowed individuals were excluded. A pre-tested questionnaire was administered to record the demographics, knowledge, and frequency of contraceptive usage, and attitude and perception towards contraception. The data were analyzed using the Statistical Package for the Social Sciences (SPSS( v. 23.0 (IBM Corp. Armonk, NY). Results Results depicted that 93.4% (n=468) had knowledge of contraception while 49.7% (n=249) were currently using contraception. The most frequently employed contraceptive modality emerged as condoms (n=163, 65.5%), followed by withdrawal (n=71, 28.5%) and pills (n=62, 24.9%). The prevalence of contraceptive usage was more inclined towards the educated stratum and higher socioeconomic class. Potential predictors for contraceptive usage came out as the number of children, knowledge regarding contraception, spouse's support for usage, a desire for more children, and family planning counseling (p<0.05). Conclusion There is a drastic increase in the prevalence of contraceptive usage in Pakistan as compared to previous studies. Efforts must be made to further augment the knowledge and awareness regarding contraceptive modalities to increase acceptability and eliminate myths prevalent in society regarding contraception.

1201 Performance Evaluation Of A Novel Contactless Breathing Monitor And Machine Learning Algorithm For Sleep Stage Classification In A Healthy Population

Introduction

Although polysomnography (PSG) remains the gold standard for sleep assessment in a lab setting, non-EEG signals such as respiration and motion are directly affected by sleep stages and can be used for sleep stage prediction. Importantly, these signals can be obtained in a low-cost and unobtrusive manner, allowing for large scale and longitudinal data collection in a home environment. The Circadia C100 System (FDA 510(k) clearance expected Q1 2020) is a novel ‘nearable’ device that uses radar for contactless monitoring of respiration and motion. The current study aims to validate the performance of the associated sleep analysis algorithm.

Methods

A total of 41 nights of sleep data were recorded from 33 healthy participants using the device, alongside PSG. Data were recorded both in a sleep lab and home environment. PSG data were scored by RPSGT-certified technicians. Respiration and movement features were extracted, and machine learning algorithms were developed to perform sleep stage classification and predict sleep metrics. Algorithms were trained and validated on PSG data using cross-validation.

Results

An epoch-by-epoch true positive rate of 56.2%, 79.4%, 55.5% and 72.6% was found for ‘Wake’, ‘REM’, ‘Light’ and ‘Deep’ respectively. No statistical differences in performance were found between home-recorded and lab-recorded contactless data. Mean absolute error of total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE) was 13.2 minutes, 11.3 minutes and 3%, respectively. The contactless monitor was found to outperform both medical grade and clinical grade actigraphy based devices: The Philips Actiwatch Spectrum Plus and the Fitbit Alta HR.

Conclusion

Current results are encouraging and suggest that the contactless monitor could be used for long-term sleep assessment and continuous evaluation of sleep therapy outcomes. Further clinical validation work is ongoing in subjects diagnosed with sleep disorders such as obstructive sleep apnea.

Support

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Anisotropy of Graphene Nanoflake Diamond Interface Frictional Properties

Using molecular dynamics (MD) simulations, the frictional properties of the interface between graphene nanoflake and single crystalline diamond substrate have been investigated. The equilibrium distance between the graphene nanoflake and the diamond substrate has been evaluated at different temperatures. This study considered the effects of temperature and relative sliding angle between graphene and diamond. The equilibrium distance between graphene and the diamond substrate was between 3.34 Å at 0 K and 3.42 Å at 600 K, and it was close to the interlayer distance of graphite which was 3.35 Å. The friction force between graphene nanoflakes and the diamond substrate exhibited periodic stick-slip motion which is similar to the friction force within a graphene–Au interface. The friction coefficient of the graphene–single crystalline diamond interface was between 0.0042 and 0.0244, depending on the sliding direction and the temperature. Generally, the friction coefficient was lowest when a graphene flake was sliding along its armchair direction and the highest when it was sliding along its zigzag direction. The friction coefficient increased by up to 20% when the temperature rose from 300 K to 600 K, hence a contribution from temperature cannot be neglected. The findings in this study validate the super-lubricity between graphene and diamond and will shed light on understanding the mechanical behavior of graphene nanodevices when using single crystalline diamond as the substrate.

Maternal and fetal outcomes in pregnancies complicated by the inherited aortopathy Loeys-Dietz syndrome

OBJECTIVE

Pregnancies in women with Loeys-Dietz syndrome (LDS) are rare and are typically documented in case reports only. Early reports suggested high rates of maternal complications during pregnancy and the puerperium, including aortic dissection and uterine rupture, but information on fetal outcomes was very limited.

DESIGN

A retrospective cohort study.

SETTING

Eight specialist UK centres.

SAMPLE

Pregnant women with LDS.

METHODS

Data was collated on cardiac, obstetric, and neonatal outcomes.

MAIN OUTCOME MEASURES

Maternal and perinatal outcomes in pregnancies complicated by LDS.

RESULTS

Twenty pregnancies in 13 women with LDS were identified. There was one miscarriage, one termination of pregnancy, and 18 livebirths. In eight women the diagnosis was known prior to pregnancy but only one woman had preconception counselling. In four women the diagnosis was made during pregnancy through positive genotyping, and the other was diagnosed following delivery. Five women had a family history of aortic dissection. There were no aortic dissections in our cohort during pregnancy or postpartum. Obstetric complications were common, including postpartum haemorrhage (33%) and preterm delivery (50%). In all, 14/18 (78%) of deliveries were by elective caesarean section, at a median gestational age at delivery of 37 weeks. Over half the infants (56%) were admitted to the neonatal unit following delivery.

CONCLUSION

Women with LDS require multidisciplinary specialist management throughout pregnancy. Women should be referred for preconception counselling to make informed decisions around pregnancy risk and outcomes. Early elective preterm delivery needs to be balanced against a high infant admission rate to the neonatal unit.

TWEETABLE ABSTRACT

Pregnancy outcomes in women with Loeys-Dietz syndrome.

Effect of Prolonged Endodontic Treatment on Temporomandibular Joint and Masticatory Muscles

Aims and objectives

The objective of the study is to assess the outcome of lengthy root canal sessions (more than 2 hours) on temporomandibular joint (TMJ) and its associated structures.

Materials and methods

Totally, 250 patients who had undergone root canal treatment that lasted for more than 2 hours were examined for the status of TMJ and masticatory muscles. The second part of the examination was performed after 1 week to check for any pain and tenderness. Data were analyzed using Statistical Package for the Social Sciences (SPSS).

Results

Results showed that patients of older age suffered from more pain postoperatively. Similarly, women experienced more pain than males. Those patients who were treated for their posterior teeth complained of more pain than those treated for anterior teeth.

Conclusion

Prolonged root canal sessions result in longer and wider opening of mouth for longer period of time, thus causing harm to TMJ and associated masticatory structures and may give rise to sign and symptoms of temporomandibular disorder (TMD).

Clinical significance

It is prudent to break treatment sessions into shorter appointments and let patients relax during the treatment to prevent any extra stress on the TMJ and associated masticatory apparatus.

How to cite this article

Siddiqui TM, Wali A, Siddiqui F, Naireen D. Effect of Prolonged Endodontic Treatment on Temporomandibular Joint and Masticatory Muscles. World J Dent 2018;9(1):38-42.