Enhanced tES and tDCS computational models by meninges emulation.

OBJECTIVE: Understanding how current reaches the brain during transcranial electrical stimulation (tES) underpins efforts to rationalize outcomes and optimize interventions. To this end, computational models of current flow relate applied dose to brain electric field. Conventional tES modeling considers distinct tissues like scalp, skull, cerebrospinal fluid (CSF), gray matter and white matter. The properties of highly conductive CSF are especially important. However, modeling the space between skull and brain as entirely CSF is not an accurate representation of anatomy. The space conventionally modeled as CSF is approximately half meninges (dura, arachnoid, and pia) with lower conductivity. However, the resolution required to describe individual meningeal layers is computationally restrictive in an MRI-derived head model. Emulating the effect of meninges through CSF conductivity modification could improve accuracy with minimal cost. APPROACH: Models with meningeal layers were developed in a concentric sphere head model. Then, in a model with only CSF between skull and brain, CSF conductivity was optimized to emulate the effect of meningeal layers on cortical electric field for multiple electrode positions. This emulated conductivity was applied to MRI-derived models. MAIN RESULTS: Compared to a model with conventional CSF conductivity (1.65 S m-1), emulated CSF conductivity (0.85 S m-1) produced voltage fields better correlated with intracranial recordings from epilepsy patients. SIGNIFICANCE: Conventional tES models have been validated using intracranial recording. Residual errors may nonetheless impact model utility. Because CSF is so conductive to current flow, misrepresentation of the skull-brain interface as entirely CSF is not realistic for tES modeling. Updating the conventional model with a CSF conductivity emulating the effect of the meninges enhances modeling accuracy without increasing model complexity. This allows existing modeling pipelines to be leveraged with a simple conductivity change. Using 0.85 S m-1 emulated CSF conductivity is recommended as the new standard in non-invasive brain stimulation modeling.

Septic Arthritis of the Shoulder: A Comparison of Treatment Methods.

INTRODUCTION: In-hospital outcomes were compared among patients with shoulder septic arthritis treated with arthrocentesis, open irrigation and débridement, or arthroscopic irrigation and débridement. METHODS: The Nationwide Inpatient Sample database was queried for all cases of native shoulder septic arthritis between 2002 and 2011. Patient demographics, comorbidities, and hospitalization complications were compared for the shoulder arthrocentesis (nonsurgical) and open or arthroscopic irrigation and débridement (surgical) groups. RESULTS: Data for 7,145 patients were analyzed. Medical comorbidities and complications were more common in the nonsurgical group than in the open surgical group (septicemia, 36.7% versus 23.6%, P < 0.001; death, 6.5% versus 2.5%, P < 0.001; pneumonia, 11.3% versus 6.2%, P < 0.001; septic shock, 4% versus 2.2%, P < 0.001; and urinary tract infection, 15.5% versus 10.2%, P < 0.001). The mean length of stay was longer in the nonsurgical group compared with the open surgical group (11.5 days versus 10.5 days, respectively; P = 0.002) and the percentage of patients discharged to home was lower (55.1% versus 64.0%, respectively; P < 0.001). Compared with the open surgical group, the arthroscopic surgical group had higher incidences of perioperative septicemia and urinary tract infection and similar average length of stay, hospital charges, and blood transfusion rates, but a lower incidence of osteomyelitis (P < 0.001). In a subgroup of patients with septicemia, Staphylococcus aureus was the most frequently cultured causative organism. DISCUSSION: Septic arthritis in the shoulder is challenging to manage, and patients often have medical comorbidities and complications. In this study, the nonsurgically treated patients had substantially more preexisting comorbidities and in-hospital complications than the surgically treated patients had, which likely contributed to the longer average length of stay and lower discharge percentage in the nonsurgical group. CONCLUSION: Patients with septic arthritis of the shoulder frequently experience substantial systemic complications regardless of the treatment method. Septicemia was a common complication among all treatment groups, with cultures most frequently indicating Staphylococcus aureus as the causative organism. LEVEL OF EVIDENCE: Therapeutic level III.

Thromboembolic Disease in Patients with Metastatic Femoral Lesions: A Comparison Between Prophylactic Fixation and Fracture Fixation.

BACKGROUND: We are not aware of any previous studies that have compared the rate of venous thromboembolic events in patients who underwent prophylactic intramedullary nailing because of an impending fracture with the rate in patients who underwent intramedullary nailing after a pathological fracture. The objective of the present study was to determine if the rate of venous thromboembolic events varies between patients who are managed with prophylactic fixation and those who are managed with fixation after a pathological fracture. METHODS: We performed a retrospective comparative study in which the Nationwide Inpatient Sample database was used to identify all patients who had undergone femoral stabilization, either for a pathological femoral fracture or for prophylactic fixation of femoral metastatic lesion, over a period of 10 consecutive years (between 2002 and 2011) in the United States. Demographic data, comorbidities, venous thromboembolic event rates, and other common postoperative complications were compared between the 2 groups. RESULTS: Patients who were managed with prophylactic fixation had significantly higher rates of pulmonary embolism (p < 0.001; adjusted odds ratio, 2.1) and deep-vein thrombosis (p = 0.03; adjusted odds ratio, 1.5). Patients who were managed with fixation after a pathological fracture had a significantly greater need for blood transfusion, higher rates of postoperative urinary tract infection, and a decreased likelihood of being discharged to home (p < 0.001 for all). CONCLUSIONS: Patients with metastatic disease who undergo prophylactic intramedullary nailing have higher observed rates of venous thromboembolic events than those who undergo nailing for the treatment of a pathological fracture and should be actively and vigilantly managed in the postoperative period. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Safety of Transcranial Direct Current Stimulation: Evidence Based Update 2016.

This review updates and consolidates evidence on the safety of transcranial Direct Current Stimulation (tDCS). Safety is here operationally defined by, and limited to, the absence of evidence for a Serious Adverse Effect, the criteria for which are rigorously defined. This review adopts an evidence-based approach, based on an aggregation of experience from human trials, taking care not to confuse speculation on potential hazards or lack of data to refute such speculation with evidence for risk. Safety data from animal tests for tissue damage are reviewed with systematic consideration of translation to humans. Arbitrary safety considerations are avoided. Computational models are used to relate dose to brain exposure in humans and animals. We review relevant dose-response curves and dose metrics (e.g. current, duration, current density, charge, charge density) for meaningful safety standards. Special consideration is given to theoretically vulnerable populations including children and the elderly, subjects with mood disorders, epilepsy, stroke, implants, and home users. Evidence from relevant animal models indicates that brain injury by Direct Current Stimulation (DCS) occurs at predicted brain current densities (6.3-13 A/m(2)) that are over an order of magnitude above those produced by conventional tDCS. To date, the use of conventional tDCS protocols in human trials (≤40 min, ≤4 milliamperes, ≤7.2 Coulombs) has not produced any reports of a Serious Adverse Effect or irreversible injury across over 33,200 sessions and 1000 subjects with repeated sessions. This includes a wide variety of subjects, including persons from potentially vulnerable populations.

Obesity is Not Associated with Increased Short-term Complications After Primary Total Shoulder Arthroplasty.

BACKGROUND: Few studies have analyzed the association between elevated BMI and complications after total shoulder arthroplasty (TSA). Previous studies have not consistently arrived at the same conclusion regarding whether obesity is associated with a greater number of postoperative complications. We used a national surgical database to compare the 30-day complication profile and hospitalization outcomes after primary TSA among patients in different BMI categories. QUESTIONS/PURPOSES: We asked: (1) Is obesity associated with an increased risk of complications within 30 days of primary TSA? (2) Is obesity associated with increased operative time? METHODS: The American College of Surgeons National Surgical Quality Improvement Program(®) database for 2006 to 2012 was queried to identify all patients who underwent a primary TSA for osteoarthritis of the shoulder. The ACS-NSQIP(®) database was selected for this study as it is a nationally representative database that provides prospectively collected perioperative data and a comprehensive patient medical profile. Exclusion criteria included revision TSA, infection, tumor, or fracture. We analyzed 4796 patients who underwent a primary TSA for osteoarthritis of the shoulder. Patients who underwent a TSA were divided in four BMI categories: normal (18.5-25 kg/m(2)), overweight (25-30 kg/m(2)), obesity Class 1 (30-35 kg/m(2)), and obesity Class 2 or greater (> 35 kg/m(2)). Perioperative hospitalization data and 30-day postoperative complications were compared among different BMI classes. Differences in patient demographics, preoperative laboratory values, and preexisting patient comorbidities also were analyzed among different BMI groups, and multivariate analysis was used to adjust for any potential confounding variables. RESULTS: There was no association between BMI and 30-day complications after surgery (normal as reference, overweight group relative risk: 0.57 [95% CI, 0.30-1.06], p = 0.076; obesity Class 1 relative risk: 0.52 [95% CI, 0.26-1.03], p = 0.061; obesity Class 2 or greater relative risk: 0.54 [95% CI, 0.25-1.17], p = 0.117). However, greater BMI was associated with longer surgical times (for normal BMI control group: 110 minutes, SD, 42 minutes; overweight group: 115 minutes, SD, 46 minutes, mean difference to control: 5 minutes [95% CI, -1 to 10 minutes], p = 0.096; obesity Class 1: 120 minutes, SD, 43 minutes, mean difference: 10 minutes [95% CI, 5-15 minutes], p < 0.001; obesity Class 2 or greater: 122 minutes, SD, 45 minutes, mean difference: 12 minutes [95% CI, 6-18 minutes], p < 0.001). CONCLUSIONS: Although the surgical time increased for patients with greater BMI, the 30-day complications and perioperative hospitalization data after TSA were not different in patients with increased BMI levels. Obesity alone should not be a contraindication for TSA, and obese patients can expect similar incidences of postoperative complications. The preoperative medical optimization plan should be consistent with that of patients who are not obese who undergo TSA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Failure of the lesser tuberosity osteotomy after total shoulder arthroplasty.

BACKGROUND: Lesser tuberosity osteotomy (LTO) as an approach during total shoulder arthroplasty (TSA) is a reliable technique with strong biomechanical fixation and a low failure rate. Complications have been infrequently reported in the literature. METHODS: We report a case series of 5 patients who sustained failure of the LTO repair after primary TSA. The data on the patient demographic characteristics, surgical technique, postoperative care, revision surgery, and clinical outcomes are reported. RESULTS: The mean age of the 5 patients was 52 years, all patients were men, and the mean body mass index was 28 kg/m(2). They were followed up for a mean of 29 months (range, 24-38 months). The mean time from initial TSA to diagnosis of LTO failure was 9 weeks (range, 5-12 weeks). Two patients reported no trauma, 2 had minor trauma (using a pulley, rolling over in bed), and 1 sustained a fall. At the latest follow-up, the mean visual analog scale; Single Assessment Numeric Evaluation; University of California, Los Angeles; and American Shoulder and Elbow Surgeons scores were 4 (range, 0-6), 48 (range, 20-70), 19 (range, 11-22), and 63 (range, 48-83), respectively. Only 1 patient required no additional procedures beyond the revision LTO repair. Another patient required a second revision LTO repair. The remaining 3 patients either underwent or were recommended to undergo reverse arthroplasty. CONCLUSION: Failure of the LTO repair after TSA may possibly be an under-reported complication that is associated with poor clinical outcomes and limited options for revision surgery. In patients with a high risk of LTO failure, considerations should be made to augment the LTO repair during the index TSA procedure.

Effect of diabetes mellitus on perioperative complications and hospital outcomes after ankle arthrodesis and total ankle arthroplasty.

BACKGROUND: The aim of this investigation was to analyze a nationally representative admissions database to evaluate the effect of diabetes mellitus on the rate of perioperative complications and hospitalization outcomes after ankle arthrodesis (AAD) and total ankle arthroplasty (TAA). METHODS: Using the Nationwide Inpatient Sample database, 12 122 patients who underwent AAD and 2973 patients who underwent TAA were identified from 2002 to 2011 based on ICD-9 procedure codes. The perioperative complications and hospitalization outcomes were compared between diabetic and nondiabetic patients for each surgery during the index hospital stay. RESULTS: The overall complication rate in the AAD group was 16.4% in diabetic patients and 7.0% in nondiabetic patients (P < .001). Multivariate analysis demonstrated that diabetes mellitus was independently associated with an increased risk of myocardial infarction (relative risk [RR] = 3.2, P = .008), urinary tract infection (RR = 4.6, P < .001), blood transfusion (RR = 3.0, P < .001), irrigation and debridement (RR = 1.9, P = .001), and overall complication rate (RR = 2.7, P < .001). Diabetes was also independently associated with a statistically significant increase in length of hospital stay (difference = 0.35 days, P < .001), more frequent nonhome discharge (RR = 1.69, P < .001), and higher hospitalization charges (difference = $1908, P = .04). The overall complication rate in the TAA group was 7.8% in diabetic patients and 4.7% in nondiabetic patients. Multivariate analysis demonstrated that diabetes was independently associated with increased risk of blood transfusion (RR = 9.8, P = .03) and overall complication rate (RR = 4.1, P = .02). Diabetes was also independently associated with a statistically significant increase in length of stay (difference = 0.41 days, P < .001) and more frequent nonhome discharge (RR = 1.88, P < .001), but there was no significant difference in hospitalization charges (P = .64). CONCLUSION: After both AAD and TAA, diabetes mellitus was independently associated with a significantly increased risk of perioperative complications, nonhome discharge, and length of hospital stay during the index hospitalization.

Comparison of perioperative complications and hospitalization outcomes after ankle arthrodesis versus total ankle arthroplasty from 2002 to 2011.

BACKGROUND: The aim of this study was to analyze a validated, nationally representative admissions database in order to compare perioperative complications and hospitalization outcomes associated with ankle arthrodesis (AAD) versus ankle arthroplasty (TAA). METHODS: Using the Nationwide Inpatient Sample (NIS) database from 2002 to 2011, 12 250 patients who underwent AAD and 3002 patients who underwent TAA were identified based on International Classification of Diseases, Ninth Revision (ICD-9) codes. The demographics, comorbidities, and perioperative outcomes during the index hospital stay were compared between patients who underwent AAD and TAA. Multivariate analysis was performed to adjust for differences in demographics and comorbidities between the 2 groups. RESULTS: Multivariate analysis demonstrated that TAA was independently associated with a decreased risk of blood transfusion (relative risk [RR] = 0.53, P < .001), non-home discharge (RR = 0.70, P < .001), and overall complication (RR = 0.79, P = .03). There were similar rates of pneumonia, deep vein thrombosis, pulmonary embolus, cerebrovascular accident, myocardial infarction, and mortality. TAA was independently associated with a significantly higher hospital charge (difference = $24 431, P < .001). There was no significant difference in the adjusted length of stay between the 2 groups (P = .13). CONCLUSION: TAA was independently associated with a lower risk of blood transfusion, non-home discharge, and overall complication when compared to AAD during the index hospitalization period. TAA was also independently associated with a higher hospitalization charge, but length of stay was similar between the 2 groups. Until long-term comparative studies are performed, the optimal treatment for end-stage ankle arthritis remains controversial, this study provides greater clarity with regard to hospitalization outcomes after the 2 procedures and shows no significant difference in risk for the majority of medical perioperative complications. LEVEL OF EVIDENCE: Level III, comparative series.

Risk factors for complications following open reduction internal fixation of distal radius fractures.

PURPOSE: A national surgical database was used to determine risk factors for complications in patients undergoing open reduction internal fixation (ORIF) for distal radius fractures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database for the 2006-2012 years was queried to identify all patients who underwent an ORIF of a distal radius fracture based on Current Procedural Terminology codes 25607, 25608, or 25609. The database is a statistically representative sample of prospectively collected perioperative surgical data from hospitals primarily in the United States. Demographics, comorbidities, preoperative laboratory values, and 30-day complications were compared between the patient groups with and without a postoperative complication. Multivariate analysis was performed to identify patient characteristics and comorbidities that were independently associated with early postoperative complications. RESULTS: This retrospective analysis identified 3,003 patients who underwent an ORIF of the distal radius over 7 years. The number of patients with a complication within 30 days after surgery was 62 (2%), totaling 90 complications. Incidence of return to the operative room for the entire study population was 1.1%. Multivariate analysis, adjusting for confounding variables, showed that patients with a complication were more likely to have hypertension, congestive heart failure, preoperative chemotherapy or radiotherapy, longer operating time, and manifest preoperative impairment in independent living. CONCLUSIONS: Approximately 2% of patients sustained a complication within 30 days following ORIF of a distal radius fracture. Recognition of the risk factors may help avoid complications in the identified high-risk patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Comparison of perioperative complications after total elbow arthroplasty in patients with and without diabetes.

BACKGROUND: Few studies have analyzed the effect of diabetes on outcomes after total elbow arthroplasty (TEA). We investigated the perioperative complications after TEA in patients with and without diabetes. METHODS: We evaluated the Nationwide Inpatient Sample (NIS) database from 2005 to 2010 for patients who underwent a TEA. Our retrospective study included 3184 patients based on International Classification of Diseases-Ninth Revision, Clinical Modification codes. We compared outcomes in 488 patients with diabetes and in 2696 patients without diabetes. RESULTS: Patients with diabetes had a significantly older mean age (66.8 vs 58.5 years, P < .001). There was no statistically significant difference when comparing length of stay (4.1 vs 3.7 days, P = .056) and cost of surgery ($56,582 vs $56,092, P = .833). A significantly higher percentage of diabetic patients underwent TEA for the indication of fracture (73.4% vs 65.3%), but a lower percentage for rheumatoid arthritis (10.2% vs 19.2%). They also had significantly increased rates of pneumonia (odds ratio [OR], 2.7), urinary tract infection (OR, 2.2), blood transfusion (OR, 2.1), and nonroutine discharge (OR, 1.9). After adjusting for significantly increased rates of comorbidities in diabetic patients, our multivariate analysis showed that having diabetes was independently associated with an increased risk of pneumonia (relative risk [RR], 2.6), urinary tract infection (RR, 1.9), and cerebrovascular accident (RR, 9.1). However, diabetes was not independently associated with hospital length of stay (P = .75), after correction, hospital cost (P = .63), or proportion of routine discharges (P = .12). CONCLUSION: Patients with diabetes have higher rates of comorbidities and perioperative complications after TEA.

Analysis of perioperative complications in patients after total shoulder arthroplasty and reverse total shoulder arthroplasty.

BACKGROUND: Data directly comparing the perioperative complication rates between total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) are limited. METHODS: The Nationwide Inpatient Sample database, which comprises data from a statistically representative sample of hospitals across the United States, was analyzed for the years 2010 and 2011. The International Classification of Diseases, Ninth Revision procedure codes differentiated the patients who received TSA (81.80) and RTSA (81.88). Demographic data, comorbidities, perioperative complications, and hospitalization data were compared. RESULTS: This retrospective analysis included 19,497 patients, with 14,031 patients in the TSA group and 5466 patients in the RTSA group. Patients who underwent RTSA were older (P < .001), were more likely to be female (P < .001), and had increased rates of fracture (P < .001). The RTSA group had significantly higher perioperative rates of mortality (P = .004), pneumonia (P < .001), deep venous thrombosis (P < .001), myocardial infarction (P = .005), urinary tract infection (P < .001), and blood transfusions (P < .001). In addition, the RTSA patients had longer hospital stays (P < .001) and higher hospital charges (P < .001). The rates of comorbidities were also higher in the patients who underwent RTSA. After adjustment for these differences in comorbidities and surgical indications with our multivariate analysis, RTSA was still independently associated with increased hospital charges (difference of $11,530; P < .001), longer hospitalization (difference of 0.24 day; P < .001), more blood transfusions (relative risk, 1.43; P < .001) and higher rates of pneumonia (relative risk, 1.61; P = .04) and deep venous thrombosis (relative risk, 2.24; P = .01). CONCLUSION: We found that RTSA patients, compared with TSA patients, had significantly longer length of stay, higher hospital charges that are not completely attributable to increased implant costs alone, and increased rates of perioperative complications.

Analysis of pitching velocity in major league baseball players before and after ulnar collateral ligament reconstruction.

BACKGROUND: Ulnar collateral ligament (UCL) reconstructions are relatively common among professional pitchers in Major League Baseball (MLB). To the authors' knowledge, there has not been a study specifically analyzing pitching velocity after UCL surgery. These measurements were examined in a cohort of MLB pitchers before and after UCL reconstruction. HYPOTHESIS: There is no significant loss in pitch velocity after UCL reconstruction in MLB pitchers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between the years 2008 to 2010, a total of 41 MLB pitchers were identified as players who underwent UCL reconstruction. Inclusion criteria for this study consisted of a minimum of 1 year of preinjury and 2 years of postinjury pitch velocity data. After implementing exclusion criteria, performance data were analyzed from 28 of the 41 pitchers over a minimum of 4 MLB seasons for each player. A pair-matched control group of pitchers who did not have a known UCL injury were analyzed for comparison. RESULTS: Of the initial 41 players, 3 were excluded for revision UCL reconstruction. Eight of the 38 players who underwent primary UCL reconstruction did not return to pitching at the major league level, and 2 players who met the exclusion criteria were omitted, leaving data on 28 players available for final velocity analysis. The mean percentage change in the velocity of pitches thrown by players who underwent UCL reconstruction was not significantly different compared with that of players in the control group. The mean innings pitched was statistically different only for the year of injury and the first postinjury year. There were also no statistically significant differences between the 2 groups with regard to commonly used statistical performance measurements, including earned run average, batting average against, walks per 9 innings, strikeouts per 9 innings, and walks plus hits per inning pitched. CONCLUSION: There were no significant differences in pitch velocity and common performance measurements between players who returned to MLB after UCL reconstruction and pair-matched controls.

Primary meningococcal arthritis requiring surgical drainage.

Primary meningococcal arthritis (PMA) is a relatively rare diagnosis where the role of early surgical intervention for its treatment is not well defined. We report a case of PMA in a young otherwise healthy patient who developed polyarticular joint pain secondary to Niessieria meningitidis without systemic symptoms of meningitis or meningococcemia. He underwent a prolonged course of intravenous antibiotics and serial aspirations of his shoulder. However, symptoms in his shoulder did not improve and he later underwent surgical irrigation and debridement.Intraoperatively, the patient had no signs of articular damage to his right shoulder despite prolonged clinically symptomatic disease. Six weeks after surgery, he has regained normal strength and full range of motion without any deficits.Nonoperative management of PMA is frequently, but not invariably, successful. We report a patient with this diagnosis who ultimately needed surgical evacuation of his shoulder joint to achieve resolution of his symptoms.

Bone impaction grafting of the lateral femoral condyle in a pediatric patient.

Avascular necrosis of the femoral condyle is an uncommon but serious sequela in patients who have received chemotherapy or corticosteroid treatment. The optimal treatment of avascular necrosis of the femoral condyles in pediatric patients is not well established. Nonoperative management has had limited long-term success, and many of the surgical procedures available for adults, including core decompression, osteotomy, and femur resurfacing, are undesirable in skeletally immature patients with open physes.This article describes a case of a 7-year-old girl with acute lymphocytic leukemia who developed avascular necrosis of the lateral femoral condyle that was treated with bone impaction grafting. The patient experienced right knee pain and swelling shortly after the initiation of chemotherapy. The radiological studies obtained showed subchondral collapse of the lateral femoral condyle. After a course of nonoperative management failed to improve symptoms, she underwent bone impaction allografting of the lateral femoral condyle using a physis-sparing approach. More than 5 years postoperatively, she has achieved excellent clinical results. Postoperative imaging of the knee has also confirmed good integration of the bone graft, an open physis, and preservation of the articular surface. This technique is a relatively less invasive surgical procedure for the treatment of avascular necrosis of the femoral condyle in a pediatric patient.

A prospective study on the effectiveness of cotton versus waterproof cast padding in maintaining the reduction of pediatric distal forearm fractures.

BACKGROUND: Distal forearm fractures, one of the most common fractures seen in the pediatric population, are regularly treated by closed reduction and casting. Our study investigates the effectiveness of Gore-Tex-lined casting in maintaining the reduction of 100% displaced distal forearm fractures compared with traditional cotton-lined casts. METHODS: We screened all patients from February 2007 to July 2009 who presented to Children's Hospital in Birmingham, AL with a distal radius fracture. Only patients with 100% displaced distal radius fractures were eligible to be assigned to either the cotton-lined or Gore-Tex-lined cast groups. Power analysis was performed to identify an adequate patient sample size. The mean maximum change between initial post-reduction x-rays and follow-up x-rays for anterior-posterior (AP) angulation, AP displacement, lateral angulation, and lateral displacement of the radius were calculated for both cotton and Gore-Tex groups. The rate of subsequent intervention and/or unacceptable results for each group was also analyzed. RESULTS: Seven hundred and twenty-two patients were treated with distal radius fractures at our hospital with 59 patients eligible for inclusion in our study. Thirty-six of our patients were treated with cotton-lined casts, and 23 patients were treated with Gore-Tex-lined cast. The mean maximum change in AP angulation, AP displacement, lateral angulation, and lateral displacement of the radius after initial reduction was 9.2 degrees, 6.9%, 13.9 degrees, and 13.6%, respectively, for the cotton-lined cast group and 7.7 degrees, 6.1%, 14.6 degrees, and 9.6%, respectively, for the Gore-Tex-lined cast group. There were no statistical differences between the means of the 4 measurements (P=0.33, 0.69, 0.73, and 0.10, respectively). There were also no significant differences between groups for final AP and lateral angulation and displacement. Subgroup analysis showed no significant differences in all measurements between cotton and Gore-Tex groups. CONCLUSION: Gore-Tex and cotton-lined casts are equally effective in their ability to maintain the reduction of 100% displaced distal forearm fractures. Thus, Gore-Tex-lined casts can be offered to pediatric patients immediately after closed reduction of distal radius fractures of any severity. LEVEL OF EVIDENCE: Therapeutic level II.

A simple method for estimating the optimum number of prostate biopsy cores needed to maintain high cancer detection rates while minimizing unnecessary biopsy sampling.

OBJECTIVE: The objective was to provide urologists with a simple basis for optimizing the number of prostate biopsy cores that should be taken. METHODS: The records of 1024 patients who had undergone transrectal ultrasound-guided biopsies were reviewed. The prostate volume was divided by the number of biopsies to obtain the volume/biopsy ratio (VBR). Univariate and multivariate analyses were performed to determine the best predictors for positive biopsies. RESULTS: The analysis included 939 patients who had prostatic-specific antigen <20 ng/mL. The significant independent variables for positive biopsies were age, prostatic-specific antigen, and prostate volume and VBR (p < 0.001). VBR had the strongest correlation coefficient out of all significant variables. Stepwise analysis showed a consistent increase in cancer detection rates as VBR was decreased. The detection rates for VBRs of 2, 3, and 4 were 59%, 53%, and 50%, respectively. The detection rates dropped sharply to 42% and 30% for VBRs of 5 and 6, respectively. Cancers diagnosed with low VBRs were similar to those diagnosed with high VBRs in regard to Gleason scores and percentages of cancer in the prostatectomy specimens. CONCLUSION: Using VBR of 4 maintains high cancer detection rates without taking an excessive number of biopsy specimens. This is a simple and easy-to-remember method.