Reinforcement feedback impairs locomotor adaptation and retention.

Introduction: Locomotor adaptation is a motor learning process used to alter spatiotemporal elements of walking that are driven by prediction errors, a discrepancy between the expected and actual outcomes of our actions. Sensory and reward prediction errors are two different types of prediction errors that can facilitate locomotor adaptation. Reward and punishment feedback generate reward prediction errors but have demonstrated mixed effects on upper extremity motor learning, with punishment enhancing adaptation, and reward supporting motor memory. However, an in-depth behavioral analysis of these distinct forms of feedback is sparse in locomotor tasks. Methods: For this study, three groups of healthy young adults were divided into distinct feedback groups [Supervised, Reward, Punishment] and performed a novel locomotor adaptation task where each participant adapted their knee flexion to 30 degrees greater than baseline, guided by visual supervised or reinforcement feedback (Adaptation). Participants were then asked to recall the new walking pattern without feedback (Retention) and after a washout period with feedback restored (Savings). Results: We found that all groups learned the adaptation task with external feedback. However, contrary to our initial hypothesis, enhancing sensory feedback with a visual representation of the knee angle (Supervised) accelerated the rate of learning and short-term retention in comparison to monetary reinforcement feedback. Reward and Punishment displayed similar rates of adaptation, short-term retention, and savings, suggesting both types of reinforcement feedback work similarly in locomotor adaptation. Moreover, all feedback enhanced the aftereffect of locomotor task indicating changes to implicit learning. Discussion: These results demonstrate the multi-faceted nature of reinforcement feedback on locomotor adaptation and demonstrate the possible different neural substrates that underly reward and sensory prediction errors during different motor tasks.

AccessPD as a next generation registry to accelerate Parkinson's disease research.

Recruitment is a major rate-limiting factor in Parkinson's disease (PD) research. AccessPD is a unique platform that aims to create a registry of more than 2000 PD patients and a rich database of PD-relevant information. Potential participants are identified using electronic health records (EHRs) in primary care. They are contacted via text message with an individualized link to the study portal. Electronic patient-reported outcomes (ePRO) are collected via online questionnaires and integrated with existing EHR. 200 participants were recruited within the first 6 months, of which 191 answered the follow-up questionnaire. Here, to showcase the potential of AccessPD, we described the most common diagnoses before and after PD diagnosis, the most commonly prescribed drugs, and identified participants who could benefit from device-aided therapies using consensus criteria. AccessPD shows its unique ability to link different data sources for patient stratification in longitudinal studies and recruitment into clinical trials.

Incidence of Nonunion of the First Metatarsophalangeal Joint Arthrodesis After Failed Implant Arthroplasty: A Systematic Review.

Joint arthroplasty of the first metatarsophalangeal (MTP) joint is an accepted surgical option for patients with hallux rigidus. However, this procedure has been reported to have a high complication rate and unpredictable survivorship. Implant arthroplasty failure is a devastating complication that results in significant osseous defect with altered biomechanics of the foot. Commonly, salvage options are limited to arthrodesis with bone grafting. However, outcomes are rarely reported. The purpose of this study is to investigate the fusion rates of first metatarsophalangeal joint arthrodesis after conversion from failed implant arthroplasty. A systematic review of electronic databases to find reports of conversion arthrodesis after failed implant arthroplasty was performed. Six studies involving a total of 76 patients with a weighted mean age of 54.9 met the inclusion criteria. Out of the 6 included articles, the nonunion rate was 16.5% at a weighted mean follow-up of 48.1 months. The nonunion rate in the current report is higher than reported nonunion rates of primary arthrodesis. More prospective studies with consistent and standard outcome measures are needed to further determine the success rate of this salvage procedure.Levels of Evidence: 4, Systematic Review of Level 4 Studies.

Investigation of Non-contact Electrodes for Electrocardiogram Monitoring.

This work investigates the use of an active noncontact electrode to monitor electrocardiogram (ECG) signals in the chest region of the human body across different interface materials. Non-contact electrodes provide an advantage over wet gel electrodes as they do not require direct contact with the skin which can lead to skin irritation. The key aspects and parameters of non-contact electrodes were discussed. Additionally, a printed circuit board (PCB) electrode was designed and prototyped. Experimental evaluations were performed to demonstrate the feasibility of the design as well as the impact of various interface materials. Results showed that R-peaks can be detected through all materials tested. The highest noise levels were observed in polyester, resulting in the highest signal standard deviation, followed by merino and cotton. The patch sensor with just a solder mask as an insulation layer provided the clearest ECG signal, with 100% accuracy on Rpeak detection.Clinical relevance- Non-contact electrodes offer a more comfortable solution for long-term heart monitoring with minimal discomfort due to less skin irritation when compared to conventional electrodes.

Pan-Cancer Proteomics Analysis to Identify Tumor-Enriched and Highly Expressed Cell Surface Antigens as Potential Targets for Cancer Therapeutics.

The National Cancer Institute's Clinical Proteomic Tumor Analysis Consortium (CPTAC) provides unique opportunities for cancer target discovery using protein expression. Proteomics data from CPTAC tumor types have been primarily generated using a multiplex tandem mass tag (TMT) approach, which is designed to provide protein quantification relative to reference samples. However, relative protein expression data are suboptimal for prioritization of targets within a tissue type, which requires additional reprocessing of the original proteomics data to derive absolute quantitation estimation. We evaluated the feasibility of using differential protein analysis coupled with intensity-based absolute quantification (iBAQ) to identify tumor-enriched and highly expressed cell surface antigens, employing tandem mass tag (TMT) proteomics data from CPTAC. Absolute quantification derived from TMT proteomics data was highly correlated with that of label-free proteomics data from the CPTAC colon adenocarcinoma cohort, which contains proteomics data measured by both approaches. We validated the TMT-iBAQ approach by comparing the iBAQ value to the receptor density value of HER2 and TROP2 measured by flow cytometry in about 30 selected breast and lung cancer cell lines from the Cancer Cell Line Encyclopedia. Collections of these tumor-enriched and highly expressed cell surface antigens could serve as a valuable resource for the development of cancer therapeutics, including antibody-drug conjugates and immunotherapeutic agents.

Chemical Characterization, Sensory Definition and Prediction Model of the Cider Dryness from New York State Apples.

Cider is a fermented drink obtained from apple juice. As a function of the used apple cultivar, cider can be classified in four different categories (dry, semi-dry, semi-sweet, sweet), distinguished by the attribute of "dryness," which reflects the sweetness and softness perceived. The dryness level is defined by scales (IRF, NYCA scales) based on the residual sugar, titratable acidity and tannin contents. Despite some adjustments, these scales show limitations in the prediction of actual perceived dryness, as they cannot consider the complicated interrelation between combined chemical compounds and sensory perception. After defining the perceived sensory dryness and its sensory description by using the quantitative descriptive analysis (QDA) method, a multivariate approach (PLS) was applied to define a predictive model for the dryness and to identify the chemical compounds with which it was correlated. Three models were developed, based on three different sets of chemical parameters, to provide a method that is easily applicable in the ordinary production process of cider. The comparison between the predicted rating and the relative scales scores showed that the models were able to predict the dryness rating in a more effective way. The multivariate approach was found to be the most suitable to study the relation between chemical and sensory data.

Lead Poisoning From Home-Prepared Indian Spices in 3 Families.

Spice consumption, along with other environmental factors, can contribute to pediatric lead poisoning. Although public health efforts have increased awareness of contamination of spices, false assumptions regarding the safety of home-prepared spices have emerged. Here, we present the clinical features, family beliefs, and environmental toxicology of 3 spice-associated pediatric lead poisoning cases.

Quantum and Classical Data Transmission through Completely Depolarizing Channels in a Superposition of Cyclic Orders.

Completely depolarizing channels are often regarded as the prototype of physical processes that are useless for communication: any message that passes through them along a well-defined trajectory is completely erased. When two such channels are used in a quantum superposition of two alternative orders, they become able to transmit some amount of classical information, but still no quantum information can pass through them. Here, we show that the ability to place N completely depolarizing channels in a superposition of N alternative causal orders enables a high-fidelity heralded transmission of quantum information with error vanishing as 1/N. This phenomenon highlights a fundamental difference with the N=2 case, where completely depolarizing channels are unable to transmit quantum data, even when placed in a superposition of causal orders. The ability to place quantum channels in a superposition of orders also leads to an increase of the classical communication capacity with N, which we rigorously prove by deriving an exact single-letter expression. Our results highlight the more complex patterns of correlations arising from multiple causal orders, which are similar to the more complex patterns of entanglement arising in multipartite quantum systems.

B2 or not B2? That is the question: a review of periprosthetic fractures around cemented taper-slip femoral components.

AIMS: Periprosthetic fractures (PPFs) around cemented taper-slip femoral prostheses often result in a femoral component that is loose at the prosthesis-cement interface, but where the cement-bone interface remains well-fixed and bone stock is good. We aim to understand how best to classify and manage these fractures by using a modification of the Vancouver classification. METHODS: We reviewed 87 PPFs. Each was a first episode of fracture around a cemented femoral component, where surgical management consisted of revision surgery. Data regarding initial injury, intraoperative findings, and management were prospectively collected. Patient records and serial radiographs were reviewed to determine fracture classification, whether the bone cement was well fixed (B2W) or loose (B2L), and time to fracture union following treatment. RESULTS: In total, 47 B2W fractures (54.0%) and one B3 fracture (1.1%) had cement that remained well-fixed at the cement-bone interface. These cases were treated with cement-in-cement (CinC) revision arthroplasty. Overall, 43 fractures with follow-up united, and two patients sustained further fractures secondary to nonunion and required further revision surgery. A total of 19 B2L fractures (21.8%) and 19 B3 fractures (21.8%) had cement that was loose at the cement-bone interface. These cases were managed by revision arthroplasty with either cemented or uncemented femoral components, or proximal femoral arthroplasty. One case could not be classified. CONCLUSION: We endorse a modification of the original Vancouver system to include a subclassification of B2 fractures around cemented femoral prostheses to include B2W (where cement is well-fixed to bone) and B2L (where the cement is loose). Fractures around taper-slip design stems are more likely to fracture in a B2W pattern compared to fractures around composite beam design stems which are more likely to fracture in a B2L pattern. B2W fractures can reliably be managed with CinC revision. Cite this article: Bone Joint J 2021;103-B(1):71-78.

Multi-center implementation of automated age-adjusted D-dimer results reduces unnecessary PE imaging.

BACKGROUND: Several previous studies have investigated the clinical utility of age-adjusted D-dimer cutoffs for diagnosing pulmonary embolism (PE). OBJECTIVES: We performed a pre/post implementation study, using data from a mid-Atlantic healthcare system comprising 6 hospitals and 400,000 ED visits to determine whether implementing age adjusted D-dimer cutoffs reduced the number of imaging tests performed. METHODS: Retrospective study of all patients who had a D-dimer performed during ED visits between September 2015 to September 2018. On March 21, 2017, the D-dimer upper limit of normal system-wide was increased for patients over 50 to: Age (years) x 0.01µg/mL. D-dimer results were displayed as normal or high based on automated age adjustment. EHR Chart review was performed 1.5 years prior to implementation of age-adjusted D-dimer cutoffs, as well as 1.5 years after to evaluate mortality and test accuracy characteristics such as false negative rates. Comparisons were made using chi-square testing. RESULTS: 22,302 D-dimers were performed pre-implementation of which 10,837 (48.6%) were positive resulting in 7218 (32.3%) imaging studies. After implementation of age-adjusted d-dimer, 25,082 were performed of which 10,851 (43.2%) were positive resulting in 7017 (28.0%) imaging studies. (pre: 48.6%, post: 43.2%; p < 0.01). A significantly lower proportion of patients had a positive d-dimer (pre: 48.6%, post: 43.2%; p < 0.01) and underwent imaging post-implementation (pre: 32.3%, post: 28.0%; p < 0.05) a relative risk reduction of 13.3. This absolute risk reduction of 4.4% is associated with 1104 less scans in the post-implementation group while still increasing test accuracy from 53.7% to 59.2% (p < 0.05). CONCLUSION: Implementation of an automated age-adjusted D-dimer positive reference value reduced CT and V/Q imaging in this population by 4.4% while increasing test accuracy in a regional, heterogeneous six-hospital system.

Accuracy of Hemolyzed Potassium Levels in the Emergency Department.

INTRODUCTION: In the emergency department (ED), pseudohyperkalemia from hemolysis may indirectly harm patients by exposing them to increased length of stay, cost, and repeat blood draws. The need to repeat hemolyzed potassium specimens in low-risk patients has not been well studied. Our objective was to determine the rate of true hyperkalemia among low-risk, adult ED patients with hemolyzed potassium specimens. METHODS: We conducted this prospective observational study at two large (129,000 annual visits) academic EDs in the mid-Atlantic. Data were collected from June 2017-November 2017 as baseline data for planned departmental quality improvement and again from June 2018-November 2018. Inclusion criteria were an initial basic metabolic panel in the ED with a hemolyzed potassium level > 5.1 milliequivalents per liter that was repeated within 12 hours, age (≥18, and bicarbonate (HCO3) > 20. Exclusion criteria were age > 65, glomerular filtration rate (GFR) < 60, creatine phosphokinase > 500, hematologic malignancy, taking potassium-sparing or angiotensin-acting agents, or treatment with potassium-lowering agents (albuterol, insulin, HCO3, sodium polystyrene sulfonate, or potassium-excreting diuretic) prior to the repeat lab draw. RESULTS: Of 399 encounters with a hemolyzed, elevated potassium level in patients with GFR ≥ 60 and age > 18 that were repeated, we excluded 333 patients for age > 64, lab repeat > 12 hours, invalid identifiers, potassium-elevating or lowering medicines or hematologic malignancies.This left 66 encounters for review. There were no instances of hyperkalemia on the repeated, non-hemolyzed potassium levels, correlating to a true positive rate of 0% (95% confidence interval 0-6%). Median patient age was 46 (interquartile range [IQR] 34 - 56) years. Median hemolyzed potassium level was 5.8 (IQR 5.6 - 6.15) millimoles per liter (mmol/L), and median repeated potassium level was 3.9 (IQR 3.6 - 4.3) mmol/L. Median time between lab draws was 145 (IQR 87 - 262) minutes. CONCLUSION: Of 66 patients who met our criteria, all had repeat non-hemolyzed potassiums within normal limits. The median of 145 minutes between lab draws suggests an opportunity to decrease the length of stay for these patients. Our results suggest that in adult patients < 65 with normal renal function, no hematologic malignancy, and not on a potassium-elevating medication, there is little to no risk of true hyperkalemia. Further studies should be done with a larger patient population and multicenter trials.

Causal inference in perioperative medicine observational research: part 1, a graphical introduction.

Graphical models have emerged as a tool to map out the interplay between multiple measured and unmeasured variables, and can help strengthen the case for a causal association between exposures and outcomes in observational studies. In Part 1 of this methods series, we will introduce the reader to graphical models for causal inference in perioperative medicine, and set the framework for Part 2 of the series involving advanced methods for causal inference.

Causal inference in perioperative medicine observational research: part 2, advanced methods.

Although RCTs represent the gold standard in clinical research, most clinical questions cannot be answered using this technique, because of ethical considerations, time, and cost. The goal of observational research in clinical medicine is to gain insight into the relationship between a clinical exposure and patient outcome, in the absence of evidence from RCTs. Observational research offers additional benefit when compared with data from RCTs: the conclusions are often more generalisable to a heterogenous population, which may be of greater value to everyday clinical practice. In Part 2 of this methods series, we will introduce the reader to several advanced methods for supporting the case for causality between an exposure and outcome, including: mediation analysis, natural experiments, and joint effects methods.

A multicentre, randomised controlled trial of position during the late stages of labour in nulliparous women with an epidural: clinical effectiveness and an economic evaluation (BUMPES).

BACKGROUND: Epidural analgesia leads to increased risk of instrumental vaginal delivery (IVD). There is debate about whether or not posture in second-stage labour influences the incidence of spontaneous vaginal birth (SVB). OBJECTIVES: In nulliparous women with epidural analgesia, does a policy of adopting an 'upright position' throughout second-stage labour increase the incidence of SVB compared with a policy of adopting a 'lying-down' position? DESIGN: Two-arm randomised controlled trial. SETTING: Maternity units in England and Wales. PARTICIPANTS: Nulliparous women aged ≥ 16 years, at ≥ 37 weeks' gestation with singleton cephalic presentation and intended SVB, in second-stage labour with an epidural providing effective pain relief. INTERVENTIONS: (1) Upright position to maintain the pelvis in as vertical a plane as possible; and (2) lying-down position to maintain the pelvis in as horizontal a plane as possible. MAIN OUTCOME MEASURES: The primary outcome measure was incidence of SVB. Secondary outcomes included augmentation, interventions to maintain blood pressure, duration of labour, episiotomy, genital tract trauma, post-partum haemorrhage, maternal satisfaction, neonatal metabolic acidosis, 5-minute Apgar score of < 4, resuscitation at birth and admission to neonatal unit. At 1 year for (1) women: urinary or faecal incontinence, dyspareunia and health-related quality of life; (2) for infants: major morbidity. A cost-consequences analysis with a time horizon of 1 year after the birth from a NHS perspective. RESULTS: Between October 2010 and January 2014, 3236 women were randomised from 41 centres in England and Wales. There was a statistically significant difference in the incidence of SVB between groups, with 35.2% of women achieving a SVB in the upright group, compared with 41.1% in the lying-down group (adjusted risk ratio 0.86, 95% confidence interval 0.78 to 0.94). There was no evidence of differences in most of the secondary maternal or neonatal outcomes, or in long-term outcomes at the 12-month follow-up. No significant overall cost differences were observed between upright and lying-down positions for mothers or their babies. LIMITATIONS: Measurement of adherence was challenging in this unmasked trial, and adherence could be influenced by midwives' beliefs about the allocated positions. If adherence was poor, this would have diluted the difference between the two groups. CONCLUSIONS: There is clear evidence of the benefit of adopting a lying-down position in second-stage labour in nulliparous women with epidural analgesia, with no apparent disadvantages in either short- or long-term outcomes for mother or baby, and this is cost neutral for the NHS. FUTURE WORK: Questions remain about whether or not other positions could increase the incidence of SVB further in this group of women. The results also raise questions about the role of maternal position in second-stage labour in women without an epidural. TRIAL REGISTRATION: Current Controlled Trials ISRCTN35706297. FUNDING: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in Health Technology Assessment, Vol 21, No. 65. See the NIHR Journals Library website for further project information.

Mean HEART scores for hospitalized chest pain patients are higher in more experienced providers.

BACKGROUND: The HEART score has been validated as a predictor of major adverse cardiac events (MACEs) in emergency department patients complaining of chest pain. Our objective was to determine the extent of physician variation in the HEART score of admitted patients stratified by years of experience. METHODS: We performed a retrospective medical record review at an academic tertiary care emergency department to determine HEART score, outcome of hospitalization, and 30-day MACE. Electrocardiograms were graded by consensus between 3 physicians. We used analysis of variance to determine the difference in mean HEART scores between providers, Fisher's exact test to determine difference in MACE by duration of training, and logistic regression to determine predictors of low-risk admission (HEART score≤3). RESULTS: The average mean HEART score for 19 full-time physicians was 4.41 (SD 0.43). Individually, there was no difference in mean scores (P=.070), but physicians with 10-15 years of experience had significantly higher mean scores than those with 0-5 years of experience (mean HEART score 4.65 vs 3.93, P=.012). Those with 10-15 years of experience also had a significantly higher proportion of MACE in their admitted cohort (15.3%, P=.002). CONCLUSIONS: More experienced providers admitted higher-risk patients and were more likely to admit patients who would experience a MACE. More research is needed to determine whether adding the HEART score for clinical decision making can be used prospectively to increase sensitivity for admitting patients at high risk for MACE and to decrease admissions for chest pain in lower-risk patients by less experienced providers.

Single nucleotide seed modification restores in vivo tolerability of a toxic artificial miRNA sequence in the mouse brain.

Huntington's disease is a fatal neurodegenerative disease caused by polyglutamine-expansion in huntingtin (HTT). Recent work showed that gene silencing approaches, including RNA interference (RNAi), improve disease readouts in mice. To advance RNAi to the clinic, we designed miHDS1, with robust knockdown of human HTT and minimized silencing of unintended transcripts. In Rhesus macaque, AAV delivery of miHDS1 to the putamen reduced HTT expression with no adverse effects on neurological status including fine and gross motor skills, no immune activation and no induction of neuropathology out to 6 weeks post injection. Others showed safety of a different HTT-targeting RNAi in monkeys for 6 months. Application of miHDS1 to Huntington's patients requires further safety testing in normal rodents, despite the fact that it was optimized for humans. To satisfy this regulatory requirement, we evaluated normal mice after AAV.miHDS1 injection. In contrast to monkeys, neurological deficits occurred acutely in mice brain and was attributed to off-target silencing through interactions of miHDS1 with the 3'UTR of other transcripts. While we resolved miHDS1 toxicity in mouse brain and maintained miHDS1-silencing efficacy, these studies highlight that optimizing nucleic acid-based medicines for safety in humans presents challenges for safety testing in rodents or other distantly related species.

Dynamic modulation of shared sensory and motor cortical rhythms mediates speech and non-speech discrimination performance.

Oscillatory models of speech processing have proposed that rhythmic cortical oscillations in sensory and motor regions modulate speech sound processing from the bottom-up via phase reset at low frequencies (3-10 Hz) and from the top-down via the disinhibition of alpha/beta rhythms (8-30 Hz). To investigate how the proposed rhythms mediate perceptual performance, electroencephalographic (EEG) was recorded while participants passively listened to or actively identified speech and tone-sweeps in a two-force choice in noise discrimination task presented at high and low signal-to-noise ratios. EEG data were decomposed using independent component analysis and clustered across participants using principle component methods in EEGLAB. Left and right hemisphere sensorimotor and posterior temporal lobe clusters were identified. Alpha and beta suppression was associated with active tasks only in sensorimotor and temporal clusters. In posterior temporal clusters, increases in phase reset at low frequencies were driven by the quality of bottom-up acoustic information for speech and non-speech stimuli, whereas phase reset in sensorimotor clusters was associated with top-down active task demands. A comparison of correct discrimination trials to those identified at chance showed an earlier performance related effect for the left sensorimotor cluster relative to the left-temporal lobe cluster during the syllable discrimination task only. The right sensorimotor cluster was associated with performance related differences for tone-sweep stimuli only. Findings are consistent with internal model accounts suggesting that early efferent sensorimotor models transmitted along alpha and beta channels reflect a release from inhibition related to active attention to auditory discrimination. Results are discussed in the broader context of dynamic, oscillatory models of cognition proposing that top-down internally generated states interact with bottom-up sensory processing to enhance task performance.

Identification of hearing loss in pediatric patients with Down syndrome.

OBJECTIVE: To determine the type of hearing loss, incidence of the lost to follow-up rate, and the time to diagnose sensorineural hearing loss (SNHL) in children with Down syndrome (DS) identified from a statewide database. STUDY DESIGN: Case series with chart review. SETTING: Pediatric referral center. SUBJECTS AND METHODS: Three hundred forty-four patients with DS born in Utah between January 2002 and December 2006 were identified using the Utah Department of Health's Newborn Hearing Screening database and birth defects registry. RESULTS: Three hundred thirty-two patients were included in the study. Eighty-seven infants (26.2%) did not pass their newborn hearing screening (NBS). Thirty-three of these children (37.9%) had a conductive hearing loss attributed to serous otitis media. Five infants had SNHL; 3 children were diagnosed with a mixed hearing loss (MHL). The average time to diagnose a sensorineural hearing loss was 485 ± 601 days. One child who passed his NBS was subsequently found to have an SNHL. More than 43% of the newborns with DS who passed their NBS developed a conductive hearing loss requiring insertion of ventilation tubes. Eighty-four percent of newborns with DS who did not undergo NBS did not have any apparent subsequent audiologic testing. CONCLUSION: Patients with DS present with a relatively high incidence of conductive hearing loss, MHL, and SNHL and a higher lost to follow-up rate compared to patients without DS. The authors were not able to diagnose SNHL within the 90-day period recommended by the Joint Committee on Infant Hearing.

Retinoblastoma in Jordan: an epidemiological study (2006-2010).

BACKGROUND AND OBJECTIVE: The epidemiological characteristics of retinoblastoma have been extensively studied in developed countries, however epidemiological data is scarce in the Middle East. We present a de- tailed epidemiological analysis of retinoblastoma in Jordan in an attempt to aid national and regional strategies for improved cancer surveillance and control. DESIGN AND SETTING: Retrospective review of retinoblastoma cases presenting to the sole and exclusive ocular oncology referral center in Jordan. PATIENTS AND METHODS: Forty children (59 eyes) presenting with clinically and/or histologically confirmed retinoblastomas were treated at King Hussein Cancer Center (Amman, Jordan) between January 2006 and December 2010. This case series included 28 boys and 12 girls. Data relating to age at diagnosis, laterality, gender, treatment modality and survival were recorded. RESULTS: The mean age-adjusted incidence of retinoblastoma in Jordan was 9.32 cases per million children per year for children aged 0-5 years. The male: female ratio was 2.3:1. Bilateral cases were encountered in 19 pa- tients (47.5%) while 21 patients (52.5%) harbored unilateral retinoblastoma. At the time of follow-up, 38 patients (95%) were alive. Overall, 40 eyes (67.8%) were successfully preserved without the need for enucleation. CONCLUSIONS: The national epidemiological data gathered in this study indicates that the incidence of retinoblastoma in Jordan is similar to that reported in various countries of the world. Jordanian boys, however, are at significantly higher risk for developing retinoblastoma than age-matched girls. Furthermore, Jordanian patients are more likely to harbor bilateral retinoblastoma.

Extracorporeal septoplasty: complications and new techniques.

OBJECTIVES: To report our complication rates during extracorporeal septoplasty (ECS) and to describe a new fixation and splinting technique we developed to simplify stable midline fixation of the neocaudal septum. Correction of the caudally deviated septum remains one of the more difficult surgical goals in functional nasal surgery. METHODS: A retrospective medical record review of patients undergoing ECS at our institution. We report our complications and describe a new technique for ECS. RESULTS: Forty-six patients underwent ECS from June 1, 2007, through April 30, 2010. Twenty-six of these patients underwent primary surgical repair, whereas 20 presented for revision surgery from outside facilities. Ten revision cases required an ear cartilage graft, and 5 required a rib graft. The overall complication rate was 9% (4 patients), with 4% (2 patients) each for minor and major complications. CONCLUSIONS: Complication rates of ECS are similar to those of endonasal septoplasty. Stable midline fixation of a reconstructed neocaudal septum is possible with a new technique that relies on novel splinting instead of suture fixation to the midline of the nasal spine.