The Incidence and Risk Factors of Third- and Fourth-Degree Perineal Tears in Ministry of Health in Bahrain over 5 Years

Background: Perineal trauma and vaginal laceration are considered a common complication associated with vaginal delivery. Well established risk factors, recognized by the Royal College of Obstetricians and Gynecologists, are ethnicity, birth weight over 4 kg persistent occipital posterior position, null parity, induction of labor, shoulder dystocia, instrumental delivery. There are other risk factors that were suggested in the literature, but data are conflicting, such as prolonged second stage of labor, episiotomy and obesity. Objective: To evaluate third- and fourth-degree perineal rears rates and the impact of related risk factors on perineal tears in Ministry of health in Bahrain over 5 years (which includes Salmanyia Medical complex (SMC) and Jidhafs maternity hospital (JMH)). Methods: This retrospective descriptive cross-sectional study analyzed all vaginal deliveries from January 2015 to December 2019 in Obstetrics and Gynecology department in Salmanyia Medical Complex (the main hospital in Kingdom of Bahrain which received all kinds of cases including low and high risks) and Jidhafs Maternity Hospital (tertiary hospital which received only low risk cases), Kingdom of Bahrain. During the period of interest 33,694 records were identified. Data were extracted from observational recording from SMC and JMH labour registry books. Results: There was no statistically significant difference between groups according to age (p = 0.199). On the other hand, there was statistically significant higher cases of >40 weeks at gestational age, obesity > 35 kg/mr, vacuum delivery, pushing stage > 90 min, birth weight > 4 kg, head circumference > 34 cm, fetal length at birth > 50 cm, episiotomy and lower cases of nulliparity in study group compared to control group 16 (66.7%) vs. 13,805 (41.0%), 3 (12.5%) vs. 1448 (4.3%), 3 (12.5%) vs. 1414 (4.2%), 4 (16.7%) vs. 1751 (5.2%), 3 (12.5%) vs. 1751 (5.2%), 12 (50.0%) vs. 15,926 (47.3%), 15 (62.5%) vs. 20,135 (59.8%) and 17 (70.8%) vs. 29,024 (86.2%);(p = 0.027, 0.009, Conclusion: Gestational age > 40 weeks, obesity > 35 kg/mr, pushing stage > 90 min, birth weight > 4 kg, head circumference > 34 cm, fetal length at birth > 50 cm and using of vacuum increase incidence of 3rd and 4th degree perineal tears with vaginal delivery however maternal age and nulliparity have no significant role. Finally, episiotomy did not represent as protective factor for perineal damage. .

Rotator cuff tears: An evidence based approach

Lesions of the rotator cuff(RC) are a common occurrence affecting millions of people across all parts of the globe. RC tears are also rampantly prevalent with an agedependent increase in numbers. Other associated factors include a history of trauma, limb dominance, contralateral shoulder, smoking-status, hypercholesterolemia, posture and occupational dispositions. The challenge lies in early diagnosis since a high proportion of patients are asymptomatic. Pain and decreasing shoulder power and function should alert the heedful practitioner in recognizing promptly the onset or aggravation of existing RC tears. Partial-thickness tears(PTT) can be bursalsided or articular-sided tears. Over the course of time, PTT enlarge and propagate into full-thickness tears(FTT) and develop distinct chronic pathological changes due to muscle retraction, fatty infiltration and muscle atrophy. These lead to a reduction in tendon elasticity and viability. Eventually, the glenohumeral joint experiences a series of degenerative alterations- cuff tear arthropathy. To avert this, a vigilant clinician must utilize and corroborate clinical skill and radiological findings to identify tear progression. Modern radio-diagnostic means of ultrasonography and magnetic resonance imaging provide excellent visualization of structural details and are crucial in determining further course of action for these patients. Physical therapy along with activity modifications, antiinflammatory and analgesic medications form the pillars of nonoperative treatment. Elderly patients with minimal functional demands can be managed conservatively and reassessed at frequent intervals. Regular monitoring helps in isolating patients who require surgical interventions. Early surgery should be considered in younger, active and symptomatic, healthy patients. In addition to being costeffective, this helps in providing a functional shoulder witha stable cuff. An easily reproducible technique of maximal strength and sturdiness should by chosen among the armamentarium of the shoulder surgeon. Grade 1 PTTs do well with debridement while more severe lesions mandate repair either by trans-tendon technique or repair following conversion into FTT. Early repair of repairable FTT can avoid appearance and progression of disability and weakness. The choice of surgery varies from surgeon-to-surgeon with arthroscopy taking the lead in the current scenario. The double-row repairs have an edge over the single-row technique in some patients especially those with massive tears. Stronger, costeffective and improved functional scores can be obtained by the former. Both early and delayed postoperative rehabilitation programmes have led to comparable outcomes. Guarded results may be anticipated in patients in extremes of age, presence of comorbidities and severe tear patters. Overall, satisfactory results are obtained with timely diagnosis and execution of the appropriate treatment modality.

Treatment of meniscal tears: An evidence based approach

Treatment options for meniscal tears fall into three broad categories;non-operative,meniscectomy or meniscal repair.Selecting the most appropriate treatment for a given patient involves both patient factors(e.g.,age,co-morbidities and compliance)and tear characteristics(e.g.,location of tear/age/reducibility of tear).There is evidence suggesting that degenerative tears in older patients without mechanical symptoms can be effectively treated non-operatively with a structured physical therapy programme as a first line.Even if these patients later require meniscectomy they will still achieve similar functional outcomes than if they had initially been treated surgically.Partial meniscectomy is suitable for symptomatic tears not amenable to repair,and can still preserve meniscal function especially when the peripheral meniscal rim is intact.Meniscal repair shows 80%success at 2 years and is more suitable in younger patients with reducible tears that are peripheral(e.g.,nearer the capsular attachment)and horizontal or longitudinal in nature.However,careful patient selection and repair technique is required with good compliance to post-operative rehabilitation,which often consists of bracing and non-weight bearing for 4-6 wk.

A Comparative Assessment of the Efficacy of Carbomer Gel and Carboxymethyl Cellulose Containing Artificial Tears in Dry Eyes

The present study aimed to compare the clinical efficacy of a 0.4% carbomer gel and 1% carboxymethyl cellulose （CMC） containing artificial tears in treatment of dry eye patients. Sixty subjects with mean age of 45.89 years who had symptoms and signs of dry eye were enrolled in this prospective, investigator-masked and stratified random sampling study. The subjects were divided into two parallel groups with 30 subjects （60 eyes） in each group. One group received carbomer gel, and the other group received 1% CMC containing artificial tears. Subjects received the drops 3 to 4 times or more per day for 3 months. At the first visit time, the precorneal residence time of these two drops was measured. The efficacy was assessed by comparing the subjective symptoms （ocular dry- ness, foreign body sensation, burning sensation and pain）, and the objective test results of tears breakup time, Schirmer＇s test and corneal fluorescein staining prior to the study and after the treat- ment. As a result, the ocular residence time of carbomer gel was significantly longer than that of 1% CMC （P〈0.001）. Most of the primary subjective symptoms and objective test results were improved after treatment in both carbomer gel group and 1% CMC group. As to the improvement of each symptom and objective test result, carbomer gel was more effective than 1% CMC group （P〈0.01）. In conclusion, carbomer gel had longer precorneal residence time and was more effective than 1% CMC in the treatment of patients with dry eyes.

Association between the levels of prostaglandin E2 in tears and severity of dry eye

AIM: To investigate the relationship between the levels of prostaglandin E2(PGE2) in tears and dry eye disease severity based on both clinical symptoms and signs.METHODS: Tear samples were collected from 36 non-Sj?gren syndrome dry eye patients(10 males and 26 females, mean age 50.11±11.17 y). All participants completed the Ocular Surface Disease Index(OSDI) questionnaire and underwent a detailed ophthalmic examination including, tear film breakup time(TBUT), ocular surface fluorescein staining, Schirmer I test, and meibomian gland assessment. The level of PGE2 in tears was measured using enzyme-linked immunosorbent assay(ELISA). The independent associations between tear PGE2 levels and other variables including demographics, OSDI scores, TBUT, Schirmer scores, ocular surface staining scores, and stage of meibomian gland dysfunction(MGD) were evaluated using linear regression analysis. RESULTS: The mean PGE2 level in tears of dry eye patients was 537.85±234.02 pg/mL. The tear PGE2 levels significantly positively correlated with OSDI scores(R=0.608, P<0.001), however, they did not significantly associate with TBUT(R=0.153, P=0.373), Schirmer scores(R=-0.098, P=0.570), ocular surface staining scores(R=0.282, P=0.095), and stage of MGD(R=-0.107, P=0.535).Male sex was significantly negatively correlated with tear PGE2 levels.CONCLUSION: The levels of PGE2 in tears are positively correlated with dry eye symptoms. However, no significant association was found between tear PGE2 levels and the results of other common dry eye diagnostic tests.

Reporting rotator cuff tears on magnetic resonance arthrography using the Snyder's arthroscopic classification

AIM To determine diagnostic performance of magnetic resonance arthrography(MRA) in evaluating rotator cuff tears(RCTs) using Snyder's classification for reporting.METHODS One hundred and twenty-six patients(64 males, 62 females; median age 55 years) underwent shoulder MRA and arthroscopy, which represented our reference standard. Surgical arthroscopic reports were reviewed and the reported Snyder's classification was recorded. MRA examinations were evaluated by two independent radiologists(14 and 5 years' experience) using Snyder's classification system, blinded to arthroscopy. Agreement between arthroscopy and MRA on partial-and fullthickness tears was calculated, first regardless of their extent. Then, analysis took into account also the extent of the tear. Interobserver agreement was also calculated the quadratically-weighted Cohen kappa statistics.RESULTS On arthroscopy, 71/126 patients(56%) had a fullthickness RCT. The remaining 55/126 patients(44%) had a partial-thickness RCT. Regardless of tear extent, out of 71 patients with arthroscopically-confirmed fullthickness RCTs, 66(93%) were correctly scored by both readers. All 55 patients with arthroscopic diagnosis of partial-thickness RCT were correctly assigned as having a partial-thickness RCT at MRA by both readers. Interobserver reproducibility analysis showed total agreement between the two readers in distinguishing partial-thickness from full-thickness RCTs, regardless of tear extent(k = 1.000). With regard to tear extent, in patients in whom a complete tear was correctly diagnosed, correct tear extent was detected in 61/66 cases(92%); in the remaining 5/66 cases(8%), tear extent was underestimated. Agreement was k = 0.955. Interobserver agreement was total(k = 1.000).CONCLUSION MRA shows high diagnostic accuracy and reproducibility in evaluating RCTs using the Snyder's classification for reporting. Snyder's classification may be adopted for routine reporting of MRA.

Quantification of HBsAg:Basic virology for clinical practice

Hepatitis B surface antigen (HBsAg) is produced and secreted through a complex mechanism that is still not fully understood. In clinical fields, HBsAg has long served as a qualitative diagnostic marker for hepatitis B virus infection. Notably, advances have been made in the development of quantitative HBsAg assays, which have allowed viral replication monitoring, and there is an opportunity to make maximal use of quantitative HBsAg to elucidate its role in clinical fields. Yet, it needs to be underscored that a further understanding of HBsAg, not only from clinical point of view but also from a virologic point of view, would enable us to deepen our insights, so that we could more widely expand and apply its utility. It is also important to be familiar with HBsAg variants and their clinical consequences in terms of immune escape mutants, issues resulting from overlap with corresponding mutation in the P gene, and detection problems for the HBsAg variants. In this article, we review current concepts and issues on the quantification of HBsAg titers with respect to their biologic nature, method principles, and clinically relevant topics.

Spontaneous or secondary to intravitreal injections of anti-angiogenic agents retinal pigment epithelial tears in age-related macular degeneration

·AIM:Toevaluatethevisualfunctionevolutionofretinal pigment epithelial(RPE) tears in patients with age-related macular degeneration(AMD) according to type of occurrence [spontaneous or secondary to anti-vascular endothelial growth factor(anti-VEGF) injection] and the topographic location of the tear after a two-year followup period.·METHODS: A total of 15 eyes of 14 patients with RPE tears in exudative AMD were analyzed retrospectively at the University Eye Clinic of Trieste. Inclusion criteria were: patient age of 50 or older with AMD and RPE tears both spontaneous occurring or post anti-VEGF treatment. Screening included: careful medical history,complete ophthalmological examination, fluorescein angiography(FA), indocyanine green angiography(ICG),autofluorescence and infrared imaging and optical coherence tomography(OCT). Patients were evaluated every month for visual acuity(VA), fundus examination and OCT. Other data reported were: presence of PED,number of injections before the tear, location of the lesion.·RESULTS:Meanfollow-up was24wk(SD±4wk). Atotal of 15 eyes were studied for RPE tear. In 6 cases(40%),the RPE tears occurred within two years of anti-VEGF injections the others occurred spontaneously. In 13cases(86.6%), the RPE tear was associated with pigment epithelial detachment(PED). In 7 cases(46.6%), the RPE tear occurred in the central area of the retina and involved the fovea. Two lesions were found in the parafoveal region, six in the extra-macular area. In all cases visual acuity decreased at the end of the follow-up period(P <0.01) independently of the type or the topographical location of the lesion.·CONCLUSION: RPE tear occurs in exudative AMD as a spontaneous complication or in relation to anti-VEGF injections. Visual acuity decreased significantly and gradually in the follow-up period in all cases. No correlation was found between visual loss and the type of onset or the topographic location of the tears.

Effects of Drought Stress Simulated by Polyethylene Glycol on Seed Germination, Root and Seedling Growth, and Seedling Antioxidant Characteristics in Job’s Tears

Two Job’s tears cultivars, yy18-1 (high resistance to drought stress) and yy12-7 (susceptible to drought stress) were used to investigate the responses of seed germination, root and seedling growth, and seedling antioxidant characteristics to drought stress simulated by polyethylene glycol (PEG) 6000 solutions with 0, -0.05, -0.1, -0.15, and -0.2 MPa osmotic potentials. The results showed that the germination energy, germination rate, germination index, root and seedling lengths, root and seedling diameters, root and seedling fresh masses, root and seedling dry masses, and seedling relative water content (RWC) decreased with the decrease of the osmotic potential of PEG 6000 solution. The contents of hydrogen peroxide (H2O2), malondialdehyde (MDA), and proline in seedling increased with the decrease of the osmotic potential of PEG 6000 solution. The activities of peroxidase (POD), catalase (CAT), ascorbate peroxidase (APX), and glutathione reductase (GR) in seedling increased and then decreased with the decrease of osmotic potential of PEG 6000 solution. -0.1 MPa was the optimal osmotic potential of PEG 6000 solution simulated drought stress at germination stage for Job’s tears. The proline content and activities of POD and CAT were important mechanisms for the maintenance of drought resistance in Job’s tears seedling.

Partial anterior cruciate ligament tears treated with intraligamentary plasma rich in growth factors

AIM:To evaluate the effect of the application of plasma rich in growth factors(PRGF)-Endoret to the remaining intact bundle in partial anterior cruciate ligament(ACL)tears.METHODS:A retrospective review of the rate of return to play in football players treated with the application of PRGF-Endoret in the remaining intact bundle in partial ACL injuries that underwent surgery for knee instability.Patients with knee instability requiring revision surgery for remnant ACL were selected.PRGF was applied in the wider part of posterolateral bundle and the time it took patients to return to their full sporting activities at the same level before the injury was evaluated.RESULTS:A total of 19 patients were reviewed.Three had a Tegner activity level of 10 and the remaining 16level 9.The time between the injury and the time of surgery was 5.78 wk(SD 1.57).In total,81.75%(16/19)returned to the same pre-injury level of sport activity(Tegner 9-10).17 males and 2 females were treated.The rate of associated injury was 68.42%meniscal lesions and 26.31%cartilage lesions.The KT-1000 values were normalized in all operated cases.One patient was not able to return to sport due to the extent of their cartilage lesions.The 15 patients with Tegner activity level 9 returned to play at an average of 16.20 wk(SD1.44)while the 3 patients with Tegner activity level 10did so in 12.33 wk(SD 1.11).CONCLUSION:With one remaining intact bundle the application of PRGF-Endoret in instability cases due to partial ACL tear showed high return to sport rates at pre-injury level in professional football players.

Diversity in metagenomic sequences reveals new pathogenic fungus associated with smut in Job's tears

Smut is a serious disease in Job's tears,also known as adlay,and contributes to the reduction of crop yield in agricultural fields.In this study,the key pathogenic fungi in adlay smut disease were first identified by internal transcribed spacer region(ITS)high-throughput sequencing and then used to elucidate the composition and diversity of the fungal community in adlay smut.Results indicate that an abundance of operational taxonomic units(OTUs)were detected in the infected involucres of flowering plants and the OTUs were classified to nine phyla,20 classes,45 orders,90 families and 119 genera.A total of 4986 OTUs clustered together,sharing six core OTUs in all samples,while 145 OTUs were shared among four geographical groups.The Shannon and Simpson indices ranged from 0.137–1.629 and 0.357–0.970,respectively.Community diversity ranked as Anshun(AS)>Qinglong(QL)>Xingren(XR)>Xingyi(XY)among the four geographical groups by Shannon and Simpson indices,exhibiting complex community diversities among accessions and geographical groups.The richness and diversity data imply a weak relationship between the accession community richness and geographical origins of samples.Two closely related fungal genera,Sporisorium and Ustilago,were implicated as causes of smut disease.The genus Sporisorium appears to be more commonly found among accessions and thus is more likely to be the fungal pathogen causing smut in adlay.This work can facilitate strategies to control and prevent smut infection to improve adlay yield.

International multi-center study of iatrogenic retinal tears in pars plana vitrectomy

AIM: To study and compare the effect of different surgical settings on the development of iatrogenic retinal tears(IRT) in conventional(20-gauge) and microincisional vitrectomy.METHODS: An international retrospective comparative study of 394 patients who had simple vitrectomy at three tertiary centers. Surgeries were performed by four retina surgeons using different viewing systems. Two groups of eyes were compared: microincisional vitrectomy(327 eyes) and conventional(67 eyes) vitrectomy. An iatrogenic tear was defined as the occurrence of one or more peripheral retinal tears during surgery or at any visit in the first 6 wk postoperatively.RESULTS: Mean age was 67±12 y and 55% were female. Iatrogenic tears occurred in 11/394(2.8%) of eyes. The rate of tears was similar among different surgeons and viewing systems(P=0.93 and P=0.76, respectively). Surgical indication, preexisting pseudophakia/aphakia, induction of posterior vitreous detachment(PVD) during surgery, and the use triamcinolone acetonide didn’t significantly affect the rate of tears(P>0.1 for all factors). A higher rate of tears was found in the conventional group compared to the microincisional group(respectively, 7.5%, 1.8%, P=0.02).CONCLUSION: The rate of IRT in vitrectomy is not significantly affected by surgical indication, preexisting PVD or pseudophakia, or use of triamcinolone or different viewing systems but is significantly higher in conventional vitrectomy. Microincisional platforms improve the safety of vitrectomy regardless of the viewing system used.

Evaluation of artificial tears on cornea epithelium healing

AIM： To observe the efficacy of different artificial eye drops on corneal epithelium healing in rabbit. METHODS： Thirty-five rabbits with 6 mm diameter central corneal epithelium removed were randomly assigned to six groups： 0.9% normal saline（NS） group, 0.1% hyaluronate（HA） group, 0.3% HA group, Tears Naturale Free？（TNF） group, 0.4% polyethylene glycol（PEG） group, 0.5% carboxymethyl cellulose（CMC） group and blank control group. Treatments were administered topically four times daily. Corneal epithelium healing was evaluated by the percentage reduction in wound area at 24, 36, 48, 60, and 72 h after removal of the corneal epithelium. Cornea re-epithelialization was also assessed by histological analysis and electron microscopy. RESULTS： All corneal wounds completely re-epithelialized in less than 72 h. The average re-epithelialization time was 47.61±4.25 h in the 0.3% HA group and 49.72±1.05 h in the 0.9% NS group, followed by 0.1% HA, TNF, 0.4% PEG, 0.5% CMC, and lastly by the control group. Compared to the control group, there were significant differences among 0.3% HA, 0.9% NS, PEG, and TNF（P〈0.05） groups. At the first 24 h, re-epithelialization at the 0.3% HA, TNF, and 0.9% NS treatment groups were significantly faster than the other groups. At 48 h post-wounding, corneal epithelium is nearly completing re-epithelialization at 0.3% HA and 0.9% NS treatment groups. Electron microscopy revealed that there were a large number of vacuoles in the cells of the 0.9% NS group at 72 h. CONCLUSION： Artificial tears promote corneal reepithelium varied in the efficacy. Obviously, all artificial eye drops better than blank group. In the process of corneal healing, corneal epithelium cells suffered from hypoxia caused by NS.

Three-dimensional reconstructed magnetic resonance scans:Accuracy in identifying and defining knee meniscal tears

AIM To determine whether three-dimensional(3D) reconstruction from conventional magnetic resonance imaging(MRI) is able to accurately detect a meniscal tear, and define the configuration.METHODS Thirty-three patients' 3T MRI scan data were collected and sagittal uni-planar 3D reconstructions performed from the preoperative MRI. There were 24 meniscal tears in 24 patients, and nine controls. All patients had arthroscopic corroboration of MRI findings. Two independent observers prospectively reported on all 33 reconstructions. Meniscal tear presence or absence was noted, and tear configuration subsequently categorised as either radial, bucket-handle, parrot beak, horizontal or complex.RESULTS Identification of control menisci or meniscal tear presence was excellent(Accuracy: observer 1 = 90.9%; observer 2 = 81.8%). Of the tear configurations, bucket handle tears were accurately identified(Accuracy observer 1 and 2 = 80%). The remaining tear configurations were notaccurately discernable.CONCLUSION Uni-planar 3D reconstruction from 3T MRI knee scan sequences are useful in identifying normal menisci and menisci with bucket-handle tears. Advances in MRI sequencing and reconstruction software are awaited for accurate identification of the remaining meniscal tear configurations.

Natural History of Symptomatic Meniscal Tears: Arthroscopic Evaluation of Chondral Damage at 4-Year Minimum

Background: The natural history of meniscal tears is unclear. Studies have tried to clarify many aspects. Association with chondral injuries are of main relevance to the long-term status of the knee but evidence is limited. Objective: The aim of this study is to describe the intraarticular state of the knee focused on chondral injury in patients with persistent symptomatic meniscal tears that were untreated for a minimum period of 4 years. Methods: A total of 47 patients with symptomatic meniscal tears in whom surgery was indicated but was delayed mainly for administrative reasons, were recruited between January 1st, 2004 and April 30th, 2010 in a regional hospital. Follow up ended until circumstances allowed surgical resolution through arthroscopy. Only patients with meniscal tear in which diagnosis was confirmed and remained symptomatic were included. Patients with initial grade IV Kellgren-Lawrence osteo-arthritis were excluded. Statistical chi-square and logistic regression analysis were used. Results: Mean follow up period was 5.8 years (range: 4.3 - 10.2 years). 57 meniscal injuries were found in 47 patients. 25 were lateral and 32 medial meniscal tears. Overall, 29 patients had articular cartilage damage (51%). Chondral injuries were found in 15 of 25 lateral meniscal lesions (60%) and 14 of 32 medial lesions (44%). Patients with lateral compartment meniscal injury had a relative risk (RR) of 2.5 of developing chondral injury (p-value 0.05). Compared to 51% of patients with associated chondral and meniscal damage (n = 29), only 12% of patients with healthy meniscus (n = 7) had chondral injury (p-value 0.05). Conclusion: Persistent symptomatic meniscal tears after medium to long term (4 to 10 years) are associated with chondral damage in 51% of patients. Chondral damage associated with meniscal tears is usually deep and involves femur and tibial sides. Lateral menisci injury is significantly associated with articular cartilage damage in the ipsilateral compartment. This study demonstrates a significant association between meniscal injury and chondral damage.

Elasticity of the Coracoacromial Ligament in Shoulders with Rotator Cuff Tears: Measurement with Ultrasound Elastography

Background: The symptoms of rotator cuff tear vary and may even be absent. Thus, the symptoms cannot be explained solely by the presence of rotator cuff tear, and other factors are thought to be involved. Because the rotator cuff comes in contact with the coracoacromial ligament, the elasticity of the ligament may be a factor of the symptoms. The purpose of this study was to clarify the elasticity of the coracoacromial ligament in live shoulders with rotator cuff tears. Methods: Forty-one shoulders in 24 persons were enrolled in this study. The average age was 52 years old (range, 15 - 84 years old). We investigated the presence of rotator cuff tear and measured the elasticity of the coracoacromial ligament by ultrasound elastography (EUB-7500, HITACHI, Japan). Ultrasound elastography was a useful method to quantify the strain of soft tissue when pressure was added. The strain ratio (the ratio of strain of the coracoacromial ligament to that of the rotator cuff) was used as the index of the elasticity of coracoacromial ligament. Thus, the higher the strain ratio was, the softer the ligament was. Results: The strain ratio of the coracoacromial ligaments without rotator cuff tear showed a negative correlation to the age (r = ﹣0.825, P 0.01). The strain ratio of the ligaments with rotator cuff tear (23.75 ± 15.05, 69.6 years old) was higher than that of the older ligaments without cuff tear (12.62 ± 7.94, 64.6 years old) (P = 0.0486). In shoulders with rotator cuff tear, the strain ratio of the ligaments with pain (14.37 ± 10.15, 66.7 years old) was lower than that of ligaments without pain (33.12 ± 13.59, 69.1 years old) (P = 0.0221). Conclusions: The coracoacromial ligament became stiffened with aging but softened with the existence of rotator cuff tear. The ligaments with symptomatic cuff tear are more stiffened than the ligaments with asymptomatic cuff tear.

Assessing the accuracy of arthroscopic and open measurements of the size of rotator cuff tears: A simulation-based study

BACKGROUND Arthroscopic procedures are commonly performed for rotator cuff pathology.Repair of rotator cuff tears is a commonly performed procedure.The intraoperative evaluation of the tear size and pattern contributes to the choice and completion of the technique and the prognosis of the repair.AIM To compare the arthroscopic and open measurements with the real dimensions of three different patterns of simulated rotator cuff tears of known size using a plastic shoulder model.METHODS We created three sizes and patterns of simulated supraspinatus tears on a plastic shoulder model(small and large U-shaped,oval-shaped).Six orthopaedic surgeons with three levels of experience measured the dimensions of the tears arthroscopically,using a 5 mm probe,repeating the procedure three times,and then using a ruler(open technique).Arthroscopic,open and computerized measurements were compared.RESULTS A constant underestimation of specific dimensions of the tears was found when measured with an arthroscope,compared to both the open and computerized measurements(mean differences up to-7.5±5.8 mm,P<0.001).No differences were observed between the open and computerized measurements(mean difference-0.4±1.6 mm).The accuracy of arthroscopic and open measurements was 90.5%and 98.5%,respectively.When comparing between levels of experience,senior residents reported smaller tear dimensions when compared both to staff surgeons and fellows.CONCLUSION This study suggests that arthroscopic measurements of full-thickness rotator cuff tears constantly underestimate the dimensions of the tears.Development of more precise arthroscopic techniques or tools for the evaluation of the size and type of rotator cuff tears are necessary.

Surgeon-Operated In-Office Ultrasonography for the Diagnosis of Rotator Cuff Tears: A Comparison with Magnetic Resonance Imaging

Objective: Few investigators have evaluated whether ultrasonography operated by a surgeon during a patient’s clinic visit is capable of obtaining a similar degree of accuracy as magnetic resonance imaging in regard to the diagnosis of rotator cuff tears and lesions of the biceps tendon. The purpose of this study was to clarify the accuracy of in-office ultrasonography for the diagnosis of rotator cuff tears in comparison to magnetic resonance imaging. Methods: One hundred and three patients (105 shoulders) with a clinical diagnosis of impingement and suspected rotator cuff tear, who subsequently underwent arthroscopic surgery were retrospectively enrolled in this study, including 7 males with 89 shoulders, and 33 females with 33 shoulders, and their mean age was 60.9 years (range, 30 to 83 years). The subjects were examined using ultrasonography and magnetic resonance imaging within three months pre-operatively per normal practice of the outpatient clinic. The two modalities were then compared to the reference standard, arthroscopic findings. Results: Intra-operatively, 79 full-thickness and 15 partial-thickness rotator cuff tears were found. The agreement between ultrasonography and magnetic resonance imaging for diagnosis of rotator cuff tears was statistically good;observed degree of agreement was 87% with Kappa coefficient of 0.73. Ultrasonography showed a sensitivity of 94% and a specificity of 100% for full-thickness tears, and a sensitivity of 80% and a specificity of 91% for partial-thickness tears. The agreement of the two modalities for diagnosis of lesions of the biceps tendon was also good;observed degree of agreement was 93% with Kappa coefficient of 0.76. In addition, ultrasonography showed comparable accuracy for classifying the size of rotator cuff tears to that of magnetic resonance imaging. Conclusion: Surgeon-operated in-office ultrasonography is an appropriate technique for the assessment of rotator cuff tears with a comparable sensitivity and specificity to that of magnetic resonance imaging.

Role of artificial tears with and without hyaluronic acid in controlling ocular discomfort following PRK: a randomized clinical trial

AIM:To compare outcomes of applying preservative free artificial tears(PFAT)with and without hyaluronic acid(HA)in early postoperative course following photorefractive keratectomy(PRK).METHODS:In this triple-blinded randomized clinical trial,PRK procedure was performed on both eyes of 230 patients.Following PRK,patients were divided into three groups:the HA^(+)group,44 patients PFAT containing HA;the HA-group,71 patients PFAT without HA were administered 5 times per day(every 4 h);the third group,115 patients received no PFAT before lens removal.On the 1st and 4th postoperative day,Visual Analogue Score(VAS)was utilized to evaluate patient’s level of pain.Participants were asked to complete a questionnaire about the severity of eye discomfort ranked from 0 to 10(0=no complaint;10=most severe complaint experienced).RESULTS:In eyes receiving PFAT with or without HA(Drop group),mean scores for epiphora,foreign body sensation,and blurred vision on the 1st postoperative day were statistically lower(P<0.05).Filamentous keratitis(FK)was detected in 11(4.7%)eyes,and recurrent corneal erosion(RCE)was observed in 5(2.1%)eyes.In the control group,FK was noted in 16(6.9%)eyes while 13(5.6%)eyes had RCE and 5(2.1%)eyes had corneal haze.The rate of complications was statistically lower in Drop group(P=0.009).However,the aforementioned scores were not statically different between HA^(+)and HA-group one and two(P=0.29).CONCLUSION:Following PRK,applying PFAT with and without HA yields faster visual recovery,decreases postoperative ocular discomfor t and haze formation;however there is no additive effect for HA.

The effect of plastic constraint on the initiation of ductile tears in shipbuilding structural steels

In this paper, the effect of plastic constraint on the initiation of ductile tears in four different shipbuilding structural steels has been experimentally studied by measuring the J-integral and crack opening displacement COD at initiation in three-point bend specimens with deep and shallow notches. Experimental results of seven groups of different strength alloy steels show that both Si and Ji values of ductile tear from the shallow crack specimens which have less constraint flow field are significantly higher than those of deeply notched specimens. Slip-line-field analysis shows that, for shallow crack, the hydrostatic stress is lower than that from standard deeply cracked bend specimen, which develops a high level of crack tip constraint, provides a lower bound estimate of toughness, and will ensure an unduly conservative approach when applied to structural defects, especially if initiation values of COD and J-integral are used.