An Increased Iliocapsularis-to-rectus-femoris Ratio Is Suggestive for Instability in Borderline Hips

BACKGROUND The iliocapsularis muscle is an anterior hip structure that appears to function as a stabilizer in normal hips. Previous studies have shown that the iliocapsularis is hypertrophied in developmental dysplasia of the hip (DDH). An easy MR-based measurement of the ratio of the size of the iliocapsularis to that of adjacent anatomical structures such as the rectus femoris muscle might be helpful in everyday clinical use. QUESTIONS/PURPOSES We asked (1) whether the iliocapsularis-to-rectus-femoris ratio for cross-sectional area, thickness, width, and circumference is increased in DDH when compared with hips with acetabular overcoverage or normal hips; and (2) what is the diagnostic performance of these ratios to distinguish dysplastic from pincer hips? METHODS We retrospectively compared the anatomy of the iliocapsularis muscle between two study groups with symptomatic hips with different acetabular coverage and a control group with asymptomatic hips. The study groups were selected from a series of patients seen at the outpatient clinic for DDH or femoroacetabular impingement. The allocation to a study group was based on conventional radiographs: the dysplasia group was defined by a lateral center-edge (LCE) angle of < 25° with a minimal acetabular index of 14° and consisted of 45 patients (45 hips); the pincer group was defined by an LCE angle exceeding 39° and consisted of 37 patients (40 hips). The control group consisted of 30 asymptomatic hips (26 patients) with MRIs performed for nonorthopaedic reasons. The anatomy of the iliocapsularis and rectus femoris muscle was evaluated using MR arthrography of the hip and the following parameters: cross-sectional area, thickness, width, and circumference. The iliocapsularis-to-rectus-femoris ratio of these four anatomical parameters was then compared between the two study groups and the control group. The diagnostic performance of these ratios to distinguish dysplasia from protrusio was evaluated by calculating receiver operating characteristic (ROC) curves and the positive predictive value (PPV) for a ratio > 1. Presence and absence of DDH (ground truth) were determined on plain radiographs using the previously mentioned radiographic parameters. Evaluation of radiographs and MRIs was performed in a blinded fashion. The PPV was chosen because it indicates how likely a hip is dysplastic if the iliocapsularis-to-rectus-femoris ratio was > 1. RESULTS The iliocapsularis-to-rectus-femoris ratio for cross-sectional area, thickness, width, and circumference was increased in hips with radiographic evidence of DDH (ratios ranging from 1.31 to 1.35) compared with pincer (ratios ranging from 0.71 to 0.90; p < 0.001) and compared with the control group, the ratio of cross-sectional area, thickness, width, and circumference was increased (ratios ranging from 1.10 to 1.15; p ranging from 0.002 to 0.039). The area under the ROC curve ranged from 0.781 to 0.852. For a one-to-one iliocapsularis-to-rectus-femoris ratio, the PPV was 89% (95% confidence interval [CI], 73%-96%) for cross-sectional area, 77% (95% CI, 61%-88%) for thickness, 83% (95% CI, 67%-92%) for width, and 82% (95% CI, 67%-91%) for circumference. CONCLUSIONS The iliocapsularis-to-rectus-femoris ratio seems to be a valuable secondary sign of DDH. This parameter can be used as an adjunct for clinical decision-making in hips with borderline hip dysplasia and a concomitant cam-type deformity to identify the predominant pathology. Future studies will need to prove this finding can help clinicians determine whether the borderline dysplasia accounts for the hip symptoms with which the patient presents. LEVEL OF EVIDENCE Level III, prognostic study.

What supports students' education in the operating room? A focus group study including students' and surgeons' views.

BACKGROUND AND METHODS We conducted a focus group analysis with students and surgeons on factors which influence medical school students' education in the operating room (OR). The interviews were analyzed using grounded theory. RESULTS The analysis resulted in 18 detailed and easily applyable themes, which were grouped into the four categories: "Students' preparation and organizational aspects", "Learning objectives", "Educational strategies for the teacher", and "Social-environmental aspects". CONCLUSION By including students and surgeons, we were able to extend existing knowledge and enable better understanding of factors influencing teaching in the OR.

Diagnostic value of immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis.

Immunoassays are essential in the workup of patients with suspected heparin-induced thrombocytopenia. However, the diagnostic accuracy is uncertain with regard to different classes of assays, antibody specificities, thresholds, test variations, and manufacturers. We aimed to assess diagnostic accuracy measures of available immunoassays and to explore sources of heterogeneity. We performed comprehensive literature searches and applied strict inclusion criteria. Finally, 49 publications comprising 128 test evaluations in 15 199 patients were included in the analysis. Methodological quality according to the revised tool for quality assessment of diagnostic accuracy studies was moderate. Diagnostic accuracy measures were calculated with the unified model (comprising a bivariate random-effects model and a hierarchical summary receiver operating characteristics model). Important differences were observed between classes of immunoassays, type of antibody specificity, thresholds, application of confirmation step, and manufacturers. Combination of high sensitivity (>95%) and high specificity (>90%) was found in 5 tests only: polyspecific enzyme-linked immunosorbent assay (ELISA) with intermediate threshold (Genetic Testing Institute, Asserachrom), particle gel immunoassay, lateral flow immunoassay, polyspecific chemiluminescent immunoassay (CLIA) with a high threshold, and immunoglobulin G (IgG)-specific CLIA with low threshold. Borderline results (sensitivity, 99.6%; specificity, 89.9%) were observed for IgG-specific Genetic Testing Institute-ELISA with low threshold. Diagnostic accuracy appears to be inadequate in tests with high thresholds (ELISA; IgG-specific CLIA), combination of IgG specificity and intermediate thresholds (ELISA, CLIA), high-dose heparin confirmation step (ELISA), and particle immunofiltration assay. When making treatment decisions, clinicians should be a aware of diagnostic characteristics of the tests used and it is recommended they estimate posttest probabilities according to likelihood ratios as well as pretest probabilities using clinical scoring tools.

Sulfur Isotopic Ratios at 67P/Churyumov-Gerasimenko and Characterization of ROSINA-DFMS FM & FS

Comets are thought to be the most pristine bodies present in the Solar System. In consequence of spending the majority of their existence beyond 30 AU, their composition can give insights on the physical and chemical conditions during their formation. Since August 2014 the European Space Agency spacecraft Rosetta accompanies the Jupiter family comet 67P/Churyumov-Gerasimenko on its way to perihelion and beyond. In this study the isotope fractionation of 34S are reported in H2S, OCS, SO2, S2, and CS2 at 67P. In addition for the first time the isotope fractionation for 33S is presented for cometary volatiles. The ratio 32S/33S is given for H2S, SO2 and a tentative value is given for CS2. With a mean value of -50 ± 22‰ and -306 ± 31‰ for δ34S and δ33S respectively, H2S shows a significant depletion in both 34S and 33S. For SO2 the depletion is less distinct with δ34S and δ33S being -67 ± 40‰ and -130 ± 53‰, respectively. The strongest depletion is present for CS2 with -114 ± 21‰and -276 ± 55‰, respectively. For OCS and S2 only δ34S could be determined which is -252 ± 77‰ and -357 ± 145‰, respectively. A comparison with sulfur isotopic ratios measured in SiC grains revealed that both SiC grains and the five volatile species have similar sulfur isotopic ratios. However, it is beyond the scope of this work to investigate the possibility of a link between SiC grains and cometary ices. Nevertheless, mass-dependent or mass-independent fractionation due to photo dissociation can be ruled out as sole cause of the seen depletion of 33S and 34S. Furthermore, an upper limit of (9.64 ± 0.19)·10.4 for D/H in HDS has been determined. This value is about a factor two higher than D/H in H2O for the same comet reported by (Altwegg et al., 2015). Besides the investigation concerning isotopic ratios of sulfur bearing species in this work the calibration and characterization of ROSINA/DFMS has been continued. Here it is reported about the deviation of the mass scale for MCP/LEDA low resolution spectra and the calibration measurements performed in the laboratory. Furthermore the outcome of the attempt to describe the sensitivity of DFMS with an empirical function will be discussed. The last part of the characterization of DFMS is dedicated to determine the so-called individual pixel gain for the laboratory and the flight model. Moreover, correlation between the depletion’s manifestation of the MCP with respect to the applied voltages has been investigated for both models. It has been found that further measurements are needed to understand the manifestation of depletion at the laboratory model. For the model on board of Rosetta it could be shown that most of the present feature are due to the usage of the MCP and suggestions have been made in order to answer the remaining question considering the depletion of the MCP.

Noise peaks influence communication in the operating room. An observational study

Noise peaks are powerful distractors. This study focuses on the impact of noise peaks on surgical teams' communication during 109 long abdominal surgeries. We related measured noise peaks during 5-min intervals to the amount of observed communication during the same interval. Results show that noise peaks are associated with less case-relevant communication; this effect is moderated by the level of surgical experience; case-relevant communications decrease under high noise peak conditions among junior, but not among senior surgeons. However, case-irrelevant communication did not decrease under high noise level conditions, rather there was a trend to more case-irrelevant communication under high noise peaks. The results support the hypothesis that noise peaks impair communication because they draw on attentional resources rather than impairing understanding of communication. As case-relevant communication is important for surgical performance, exposure to high noise peaks in the OR should be minimised especially for less experienced surgeons. Practitioner Summary: This study investigated whether noise during surgeries influenced the communication within surgical teams. During abdominal surgeries, noise levels were measured and communication was observed. Results showed that high noise peaks reduced the frequency of patient-related communication, but did not reduce patient-irrelevant communication. Noise may negatively affect team coordination in surgeries.

Freshening of the Alaska Coastal Current Recorded By Coralline Algal Ba/Ca Ratios

Arctic Ocean freshening can exert a controlling influence on global climate, triggering strong feedbacks on ocean-atmospheric processes and affecting the global cycling of the world's oceans. Glacier-fed ocean currents such as the Alaska Coastal Current are important sources of freshwater for the Bering Sea shelf, and may also influence the Arctic Ocean freshwater budget. Instrumental data indicate a multiyear freshening episode of the Alaska Coastal Current in the early 21st century. It is uncertain whether this freshening is part of natural multidecadal climate variability or a unique feature of anthropogenically induced warming. In order to answer this, a better understanding of past variations in the Alaska Coastal Current is needed. However, continuous long-term high-resolution observations of the Alaska Coastal Current have only been available for the last 2 decades. In this study, specimens of the long-lived crustose coralline alga Clathromorphum nereostratum were collected within the pathway of the Alaska Coastal Current and utilized as archives of past temperature and salinity. Results indicate that coralline algal Mg/Ca ratios provide a 60 year record of sea surface temperatures and track changes of the Pacific Decadal Oscillation, a pattern of decadal-to-multidecadal ocean-atmosphere climate variability centered over the North Pacific. Algal Ba/Ca ratios (used as indicators of coastal freshwater runoff) are inversely correlated to instrumentally measured Alaska Coastal Current salinity and record the period of freshening from 2001 to 2006. Similar multiyear freshening events are not evident in the earlier portion of the 60 year Ba/Ca record. This suggests that the 21st century freshening of the Alaska Coastal Current is a unique feature related to increasing glacial melt and precipitation on mainland Alaska.

Use of Otolith Strontium:Calcium Ratios for Hindcasting Larval Cod Gadus Morhua Distributions Relative to Water Masses on Georges Bank

The concentration ratios of strontium to calcium in laboratory-reared larval cod otoliths are shown to be related to the water temperature (T) at the time of otolith precipitation. This relationship is curvilinear, and is best described by a simple exponential equation of the form (Sr/Ca x 1000 = a exp(-T/b). We show that when Sr/Ca elemental analyses are related to the daily growth increments in the larval otoliths, relative temperature histories of individual field-caught larvae can be reconstructed from the egg stage to the time of capture. We present preliminary examples of how such reconstructed temperature histories of Atlantic cod Gadus morhua larvae, collected on Georges Bank during April and May 1993, may be interpreted in relation to the broad-scale larval distributions and the hydrography of the Bank.

REGRESSION ANALYSIS FOR STANDARDIZED MORTALITY RATIOS WITH APPLICATION TO OCCUPATIONAL FOLLOW-UP STUDIES

Traditional comparison of standardized mortality ratios (SMRs) can be misleading if the age-specific mortality ratios are not homogeneous. For this reason, a regression model has been developed which incorporates the mortality ratio as a function of age. This model is then applied to mortality data from an occupational cohort study. The nature of the occupational data necessitates the investigation of mortality ratios which increase with age. These occupational data are used primarily to illustrate and develop the statistical methodology.^ The age-specific mortality ratio (MR) for the covariates of interest can be written as MR(,ij...m) = ((mu)(,ij...m)/(theta)(,ij...m)) = r(.)exp (Z('')(,ij...m)(beta)) where (mu)(,ij...m) and (theta)(,ij...m) denote the force of mortality in the study and chosen standard populations in the ij...m('th) stratum, respectively, r is the intercept, Z(,ij...m) is the vector of covariables associated with the i('th) age interval, and (beta) is a vector of regression coefficients associated with these covariables. A Newton-Raphson iterative procedure has been used for determining the maximum likelihood estimates of the regression coefficients.^ This model provides a statistical method for a logical and easily interpretable explanation of an occupational cohort mortality experience. Since it gives a reasonable fit to the mortality data, it can also be concluded that the model is fairly realistic. The traditional statistical method for the analysis of occupational cohort mortality data is to present a summary index such as the SMR under the assumption of constant (homogeneous) age-specific mortality ratios. Since the mortality ratios for occupational groups usually increase with age, the homogeneity assumption of the age-specific mortality ratios is often untenable. The traditional method of comparing SMRs under the homogeneity assumption is a special case of this model, without age as a covariate.^ This model also provides a statistical technique to evaluate the relative risk between two SMRs or a dose-response relationship among several SMRs. The model presented has application in the medical, demographic and epidemiologic areas. The methods developed in this thesis are suitable for future analyses of mortality or morbidity data when the age-specific mortality/morbidity experience is a function of age or when there is an interaction effect between confounding variables needs to be evaluated. ^

The relationship between hospital financial performance and information technology integration strategy selection

In light of the new healthcare regulations, hospitals are increasingly reevaluating their IT integration strategies to meet expanded healthcare information exchange requirements. Nevertheless, hospital executives do not have all the information they need to differentiate between the available strategies and recognize what may better fit their organizational needs. ^ In the interest of providing the desired information, this study explored the relationships between hospital financial performance, integration strategy selection, and strategy change. The integration strategies examined – applied as binary logistic regression dependent variables and in the order from most to least integrated – were Single-Vendor (SV), Best-of-Suite (BoS), and Best-of-Breed (BoB). In addition, the financial measurements adopted as independent variables for the models were two administrative labor efficiency and six industry standard financial ratios designed to provide a broad proxy of hospital financial performance. Furthermore, descriptive statistical analyses were carried out to evaluate recent trends in hospital integration strategy change. Overall six research questions were proposed for this study. ^ The first research question sought to answer if financial performance was related to the selection of integration strategies. The next questions, however, explored whether hospitals were more likely to change strategies or remain the same when there was no external stimulus to change, and if they did change, they would prefer strategies closer to the existing ones. These were followed by a question that inquired if financial performance was also related to strategy change. Nevertheless, rounding up the questions, the last two probed if the new Health Information Technology for Economic and Clinical Health (HITECH) Act had any impact on the frequency and direction of strategy change. ^ The results confirmed that financial performance is related to both IT integration strategy selection and strategy change, while concurred with prior studies that suggested hospital and environmental characteristics are associated factors as well. Specifically this study noted that the most integrated SV strategy is related to increased administrative labor efficiency and the hybrid BoS strategy is associated with improved financial health (based on operating margin and equity financing ratios). On the other hand, no financial indicators were found to be related to the least integrated BoB strategy, except for short-term liquidity (current ratio) when involving strategy change. ^ Ultimately, this study concluded that when making IT integration strategy decisions hospitals closely follow the resource dependence view of minimizing uncertainty. As each integration strategy may favor certain organizational characteristics, hospitals traditionally preferred not to make strategy changes and when they did, they selected strategies that were more closely related to the existing ones. However, as new regulations further heighten revenue uncertainty while require increased information integration, moving forward, as evidence already suggests a growing trend of organizations shifting towards more integrated strategies, hospitals may be more limited in their strategy selection choices.^

87Sr/86Sr ratios, Sr and Rb concentrations and stable oxygen isotope values for some basalts from ODP Hole 504B (Table 1)

Seventeen whole-rock samples, generally taken at 25-50 m intervals from 5 to 560 m sub-basement in Hole 504B, drilled in 6.2 m.y. old crust, were analysed for 87Sr/86Sr ratios, Sr and Rb concentrations, and 18O/16O ratios. Sr isotope ratios for 8 samples from the upper 260 m of the hole range from 0.70287 to 0.70377, with a mean of 0.70320. In the 330-560 m interval, 5 samples have a restricted range of 0.70255-0.70279, with a mean of 0.70266, the average value for fresh mid-ocean ridge basalts (MORB). In the 260-330 m interval, approximately intermediate Sr isotopic ratios are found. Delta18O values (?) range from 6.4 to 7.8 in the upper 260 m, 6.2-6.4 in the 270-320 m interval, and 5.8-6.2 in the 320-560 m interval. The values in the upper 260 m are typical for basalts which have undergone low-temperature seawater alteration, whereas the values for the 320-560 m interval correspond to MORB which have experienced essentially no oxygen isotopic alteration. The higher 87Sr/86Sr and 18O/16O ratios in the upper part of the hole can be interpreted as the result of a greater overall water/rock ratio in the upper part of the Hole 504B crust than in the lower part. Interaction of basalt with seawater (87Sr/86Sr = 0.7091) increased basalt 87Sr/86Sr ratios and produced smectitic alteration products which raised whole-rock delta18O values. Seawater circulation in the lower basalts may have been partly restricted by the greater number of relatively impermeable massive lava flows below about 230 m sub-basement. These flows may have helped to seal off lower basalts from through-flowing seawater.