Improving prediction of malignancy of cytologically indeterminate thyroid nodules.

BACKGROUND: Fine-needle aspiration (FNA) is essential in the investigation of thyroid nodules. The British Thyroid Association guidelines recommend clarification of whether follicular nodules are probable follicular neoplasms that require surgical excision. This study assessed the value of the subclassification of cytologically indeterminate thyroid nodules into either follicular neoplasms or other pathology. METHODS: The cytology reports of all thyroid FNAs performed between November 2005 and December 2007 at a single institution reported as Thy 3 (follicular lesions) were reviewed. They were reclassified as Thy 3A (probable follicular neoplasm) or Thy 3B (probable non-neoplastic lesion), and subsequently correlated with final clinical outcome to determine the predictive value of this subclassification. RESULTS: Forty-nine specimens were categorized as Thy 3A and 55 as Thy 3B. Of excised lesions, 14 (29 per cent) of 48 Thy 3A and 4 (10 per cent) of 42 Thy 3B nodules were malignant. If Thy 3A were to predict malignancy and Thy 3B benign disease, the sensitivity of the classification was 88 per cent, with a specificity of 55 per cent and negative predictive value of 91 per cent. CONCLUSION: Subclassification of Thy 3 nodules into Thy 3A and Thy 3B improves the assessment of risk for thyroid malignancy.

Hallux valgus: demographics, etiology, and radiographic assessment.

BACKGROUND: The purpose of the study was to preoperatively evaluate the demographics, etiology, and radiographic findings associated with moderate and severe hallux valgus deformities in adult patients (over 20 years of age) treated operatively over a 33-month period in a single surgeon's practice. METHODS: Patients treated for a hallux valgus deformity between September, 1999, and May, 2002, were identified. Patients who had mild deformities (hallux valgus angle < 20 degrees), concurrent degenerative arthritis of the first metatarsophalangeal joint, inflammatory arthritis, recurrent deformities, or congruent deformities were excluded. When enrolled, all patients filled out a standardized questionnaire and had a routine examination that included standard radiographs, range of motion testing, and first ray mobility measurement. A chart review and evaluation of preoperative radiographs were completed on all eligible patients. RESULTS: One-hundred and three of 108 (96%) patients (122 feet) with a diagnosis of moderate or severe hallux valgus (hallux valgus angle of 20 degrees or more)(70) qualified for the study. The onset of the hallux valgus deformity peaked during the third decade although the distribution of occurrence was almost equal from the second through fifth decades. Twenty-eight of 122 feet (23%) developed a deformity at an age of 20 years or younger. Eighty-six (83%) of patients had a positive family history for hallux valgus deformities and 87 (84%) patients had bilateral bunions. 15% of patients in the present series had moderate or severe pes planus based on a positive Harris mat study. Only 11% (14 feet) had evidence of an Achilles or gastrocnemius tendon contracture. Radiographic analysis found that 86 of 122 feet (71%) had an oval or curved metatarsophalangeal joint. Thirty-nine feet (32%) had moderate or severe metatarsus adductus. A long first metatarsal was common in patients with hallux valgus (110 of 122 feet; 71%); the mean increased length of the first metatarsal when compared to the second was 2.4 mm. While uncommon, the incidence of an os intermetatarsum was 7% and a proximal first metatarsal facet was 7%. The mean preoperative first ray mobility as measured with Klaue's device was 7.2 mm. 16 of 22 (13%) feet were observed to have increased first ray mobility before surgery. CONCLUSIONS: The magnitude of the hallux valgus deformity was not associated with Achilles or gastrocnemius tendon tightness, increased first ray mobility, bilaterality or pes planus. Neither the magnitude of the preoperative angular deformity nor increasing age had any association with the magnitude of the first metatarsophalangeal joint range of motion. Constricting shoes and occupation were implicated by 35 (34%) patients as a cause of the bunions. A familial history of bunions, bilateral involvement, female gender, a long first metatarsal, and an oval or curved metatarsophalangeal joint articular surface were common findings. Increased first ray mobility and plantar gapping of the first metatarsocuneiform joint were more common in patients with hallux valgus than in the general population (when compared with historical controls).

Prospective CT scan evaluation of hindfoot nonunions treated with revision surgery and low-intensity ultrasound stimulation.

BACKGROUND: The reported fusion rates of revision arthrodesis for hindfoot nonunions are relatively low compared to primary procedures. Exogenous ultrasound has been shown to accelerate the healing process of acute fractures and fracture nonunions but has not been previously evaluated for the treatment of hindfoot pseudarthroses. The purpose of this study was to evaluate the clinical and radiographic outcomes of revision hindfoot arthrodeses treated with postoperative low-intensity ultrasound. METHODS: Thirteen patients (13 feet) with established hindfoot nonunions were treated with revision arthrodesis and adjunctive postoperative low-intensity ultrasound. The patients were prospectively evaluated with hindfoot American Orthopaedic Foot Ankle Society (AOFAS) and pain visual analog scores, subjective satisfaction surveys, and serial radiographs. All patients underwent postoperative CT to evaluate the fusion mass, which was quantitated using a novel system. The mean follow-up from revision surgery was 16.3 (range 12 to 25) months. The 10 subtalar and three triple revision arthrodeses comprised a total of 19 joints. RESULTS: Based on the CT scans and the grading system devised, there was one nonunion (isolated subtalar revision), five partial unions, and 13 complete unions. The 10 isolated subtalar revision arthrodeses demonstrated a mean fusion ratio of 65.1% (range 14% to 100%). Excluding the one nonunion, the average fusion ratio for the subtalar revisions was 77.3%. The mean hindfoot AOFAS score improved significantly (p < 0.005) from 45.3 (range 18 to 65) preoperatively to 72.3 (range 47 to 92) postoperatively out of 94 possible points. There was a significant (p < 0.005) decrease in the pain visual analog scale (VAS) from a preoperative value of 7.7 (range 4 to 10) to a postoperative value of 2.5 (range 0 to 6). There was a weak inverse correlation between the fusion percentages and the pain VAS scores (r = -0.26) and a weak correlation (r = 0.29) between the fusion percentages and the final AOFAS scores. CONCLUSIONS: When used to evaluate hindfoot arthrodeses, plain radiographs may be misleading. CT provides a more accurate assessment of the healing, and we have devised a new system to quantitate the fusion mass. Postoperative low-intensity ultrasound is easy to apply and administer, with no identifiable risks or contraindications. Although this modality may facilitate the fusion process, we cannot definitely conclude the specific relative value of low-intensity ultrasound because this was not a controlled series.

Identification of gains and losses of DNA sequences in primary bladder cancer by comparative genomic hybridization.

Comparative genomic hybridization (CGH) makes it possible to detect losses and gains of DNA sequences along all chromosomes in a tumor specimen based on the hybridization of differentially labeled tumor and normal DNA to normal human metaphase chromosomes. In this study, CGH analysis was applied to the identification of genomic imbalances in 26 bladder cancers in order to gain information on the genetic events underlying the development and progression of this malignancy. Losses affecting 11p, 11q, 8p, 9, 17p, 3p, and 12q were all seen in more than 20% of the tumors. The minimal common region of loss in each chromosome was identified based on the analysis of overlapping deletions in different tumors. Gains of DNA sequences were most often found at chromosomal regions distinct from the locations of currently known oncogenes. The bands involved in more than 10% of the tumors were 8q21, 13q21-q34, 1q31, 3q24-q26, and 1p22. In conclusion, these CGH data highlight several previously unreported genetic alterations in bladder cancer. Further detailed studies of these regions with specific molecular genetic techniques may lead to the identification of tumor suppressor genes and oncogenes that play an important role in bladder tumorigenesis.

Comparative clinical evaluation of freeze-dried skin allografts and autogenous gingival grafts in humans.

Freeze-dried skin (FDS) allografts and fresh autogenous free gingival grafts (FGG) were placed in five paired sites in four patients. Both types of grafts healed uneventfully. Evaluation over a 1-year period demonstrated no statistically or clinically significant differences between the FDS and FGG when: a) increase in the width of keratinized gingiva, b) decrease in recession, c) decrease in sulcus depth, k) gain in attachment level, or e) percent shrinkage of the graft were compared. It was concluded that FDS performs essentially similar to FGG in the correction of mucogingival problems, and has the advantages of decreased patient morbidity (no donor site) and availability of abundant amounts of graft material when needed.