Update
This article was updated on September 4, 2020, because of a previous error. On page 1211, in the author affiliation section, “W.L. Walter, MBBS, PhD
3
” now reads “W.L. Walter, MBBS, PhD
3,4
...,” the affiliation for Dr. Van Onsem that had read “
3
Specialist Orthopedic Group, The Mater Clinic, North Sydney, New South Wales, Australia” now reads “
3
Royal North Shore Hospital, St. Leonards, New South Wales, Australia,” and the affiliation for Dr. Walter that had read “
3
Specialist Orthopedic Group, The Mater Clinic, North Sydney, New South Wales, Australia” now reads “
3
Royal North Shore Hospital, St. Leonards, New South Wales, Australia” and “
4
University of Sydney, Sydney, New South Wales, Australia.”
An erratum has been published: J Bone Joint Surg Am. 2020 Oct 7;102(19):e113
» As we resume elective surgical procedures, it is important to understand what practices and protocols should be altered or implemented in order to minimize the risk of pathogen transfer during the severe acute respiratory syndrome (SARS)-CoV-2 pandemic.
» Each hospital and health system should consider their unique situation in terms of SARS-CoV-2 prevalence, staffing capabilities, personal protection equipment supply, and so on when determining how and when to implement these recommendations.
» All patients should be screened for SARS-CoV-2 by means of a thorough history and physical examination, as well as reverse transcription-polymerase chain reaction (RT-PCR) testing whenever possible, prior to undergoing elective surgery.
» Patients who are currently infected with coronavirus disease 2019 (COVID-19) should not undergo elective surgery.
» These guidelines are based on the available scientific evidence, albeit scant. The recommendations have been reviewed and voted on by the expert delegates who produced this document.
We measure the effects of transverse wakefields driven by a relativistic proton bunch in plasma with densities of 2.1×10^{14} and 7.7×10^{14} electrons/cm^{3}. We show that these wakefields ...periodically defocus the proton bunch itself, consistently with the development of the seeded self-modulation process. We show that the defocusing increases both along the bunch and along the plasma by using time resolved and time-integrated measurements of the proton bunch transverse distribution. We evaluate the transverse wakefield amplitudes and show that they exceed their seed value (<15 MV/m) and reach over 300 MV/m. All these results confirm the development of the seeded self-modulation process, a necessary condition for external injection of low energy and acceleration of electrons to multi-GeV energy levels.
Objectives
Imaging assessment for the clinical management of femoroacetabular impingement (FAI) syndrome remains controversial because of a paucity of evidence-based guidance and notable variability ...in clinical practice, ultimately requiring expert consensus. The purpose of this agreement is to establish expert-based statements on FAI imaging, using formal techniques of consensus building.
Methods
A validated Delphi method and peer-reviewed literature were used to formally derive consensus among 30 panel members (21 musculoskeletal radiologists and 9 orthopaedic surgeons) from 13 countries. Forty-four questions were agreed on, and recent relevant seminal literature was circulated and classified in five major topics (‘General issues’, ‘Parameters and reporting’, ‘Radiographic assessment’, ‘MRI’ and ‘Ultrasound’) in order to produce answering statements. The level of evidence was noted for all statements, and panel members were asked to score their level of agreement with each statement (0 to 10) during iterative rounds. Either ‘consensus’, ‘agreement’ or ‘no agreement’ was achieved.
Results
Forty-seven statements were generated, and group consensus was reached for 45 (95.7%). Seventeen of these statements were selected as most important for dissemination in advance. There was no agreement for the two statements pertaining to ‘Ultrasound’.
Conclusion
Radiographic evaluation is the cornerstone of hip evaluation. An anteroposterior pelvis radiograph and a Dunn 45° view are recommended for the initial assessment of FAI although MRI with a dedicated protocol is the gold standard imaging technique in this setting. The resulting consensus can serve as a tool to reduce variability in clinical practices and guide further research for the clinical management of FAI.
Key Points
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FAI imaging literature is extensive although often of low level of evidence.
•
Radiographic evaluation with a reproducible technique is the cornerstone of hip imaging assessment.
•
MRI with a dedicated protocol is the gold standard imaging technique for FAI assessment.
Objectives
Imaging assessment for the clinical management of femoroacetabular impingement (FAI) is controversial because of a paucity of evidence-based guidance and notable variability among ...practitioners. Hence, expert consensus is needed because standardised imaging assessment is critical for clinical practice and research. We aimed to establish expert-based statements on FAI imaging by using formal methods of consensus building.
Methods
The Delphi method was used to formally derive consensus among 30 panel members from 13 countries. Forty-four questions were agreed upon, and relevant seminal literature was circulated and classified in major topics to produce answering statements. The level of evidence was noted for all statements, and panel members were asked to score their level of agreement (0–10). This is the second part of a three-part consensus series and focuses on ‘General issues’ and ‘Parameters and reporting’.
Results
Forty-seven statements were generated and group consensus was reached for 45. Twenty-five statements pertaining to ‘General issues’ (9 addressing diagnosis, differential diagnosis, and postoperative imaging) and ‘Parameters and reporting’ (16 addressing femoral/acetabular parameters) were produced.
Conclusions
The available evidence was reviewed critically, recommended criteria for diagnostic imaging highlighted, and the roles/values of different imaging parameters assessed. Radiographic evaluation (AP pelvis and a Dunn 45° view) is the cornerstone of hip-imaging assessment and the minimum imaging study that should be performed when evaluating adult patients for FAI. In most cases, cross-sectional imaging is warranted because MRI is the ‘gold standard’ imaging modality for the comprehensive evaluation, differential diagnosis assessment, and FAI surgical planning.
Key Points
• Diagnostic imaging for FAI is not standardised due to scarce evidence-based guidance on which imaging modalities and diagnostic criteria/parameters should be used.
• Radiographic evaluation is the cornerstone of hip assessment and the minimum study that should be performed when assessing suspected FAI. Cross-sectional imaging is justified in most cases because MRI is the ‘gold standard’ modality for comprehensive FAI evaluation.
• For acetabular morphology, coverage (Wiberg’s angle and acetabular index) and version (crossover, posterior wall, and ischial spine signs) should be assessed routinely. On the femoral side, the head–neck junction morphology (α° and offset), neck morphology (NSA), and torsion should be assessed.
Objectives
Imaging diagnosis of femoroacetabular impingement (FAI) remains controversial due to a lack of high-level evidence, leading to significant variability in patient management. Optimizing ...protocols and technical details is essential in FAI imaging, although challenging in clinical practice. The purpose of this agreement is to establish expert-based statements on FAI imaging, using formal consensus techniques driven by relevant literature review. Recommendations on the selection and use of imaging techniques for FAI assessment, as well as guidance on relevant radiographic and MRI classifications, are provided.
Methods
The Delphi method was used to assess agreement and derive consensus among 30 panel members (musculoskeletal radiologists and orthopedic surgeons). Forty-four questions were agreed on and classified into five major topics and recent relevant literature was circulated, in order to produce answering statements. The level of evidence was assessed for all statements and panel members scored their level of agreement with each statement during 4 Delphi rounds. Either “group consensus,” “group agreement,” or “no agreement” was achieved.
Results
Forty-seven statements were generated and group consensus was reached for 45. Twenty-two statements pertaining to “Imaging techniques” were generated. Eight statements on “Radiographic assessment” and 12 statements on “MRI evaluation” gained consensus. No agreement was reached for the 2 “Ultrasound” related statements.
Conclusion
The first international consensus on FAI imaging was developed. Researchers and clinicians working with FAI and hip-related pain may use these recommendations to guide, develop, and implement comprehensive, evidence-based imaging protocols and classifications.
Key Points
• Radiographic evaluation is recommended for the initial assessment of FAI, while MRI with a dedicated protocol is the gold standard imaging technique for the comprehensive evaluation of this condition.
• The MRI protocol for FAI evaluation should include unilateral small FOV with radial imaging, femoral torsion assessment, and a fluid sensitive sequence covering the whole pelvis.
• The definite role of other imaging methods in FAI, such as ultrasound or CT, is still not well defined.
Aggressivity expressed as cannibalism in fish larvae is a problem that limits the development of many species in aquaculture, therefore, understanding it and generating strategies to reduce its ...impact is important. This study described cannibalistic attacks behavior in Tropical gar (Atractosteus tropicus) larvae. The larvae were exposed to different tank colors and shelters (rocks and plastic vegetation), in pairs (2 larvae) and in groups (10 larvae). In addition, attacks behavior, types of attacks, and morphometric aspects related to cannibalism were described. In pairs, attacks occurred in greater numbers with white background color (8.50 ± 0.70) and fewer for yellow and purple (0.66 ± 0.57, p < 0.05). The largest number of group attacks was observed with the background colors pink, blue and yellow, and purple to a lesser extent. The presence of shelters (artificial vegetation) decreased the attacks in pairs and in groups compared to the use of rocks as refuge. A. tropicus larvae show a clear preference for artificial vegetation. It was found that morphologically, both juveniles and larvae (10 Days after hatching (DAH)) can consume prey greater than their own body depth (1.59 ± 0.22, 1.00 ± 0.12) and body width (1.74 ± 0.29, 0.94 ± 0.12). The mouth depth angle was significantly higher in larvae (10 DAH) (85.63 ± 6.41°), which decreases as age increases. A total of 452 events were recorded, four behaviors were described: interaction (214 events, 47 attacks, effectiveness of the attack (EA) 21.96%), chasing (127 events, 44 attacks, EA 34.64%), escape (62 events), and fast swimming (47 events). Three types of attacks were recorded: frontal (41.24%), lateral (29.94%), and posterior (28.81%), with three attack regions: head (31.64%), body (10.72%), and tail (57.63%). The most frequent attack was posterior tail with 70 events (39.55%). Attacker presented a S-like curvature prior to the attack (30.50%). Differences were determined in the percentage of weight (g) and total length (cm) between the attacker larvae and the attacked larvae 16.39 ± 10.86% and 15.23 ± 5.68%, respectively. In conclusion, A. tropicus larvae show cannibalism Type I, II, and two variants of Type III. It is suggested that this species is a more efficient cannibal than an interspecific predator. The relation of the greater number of attacks in the white color tanks could be related to the contrast with the bottom, thus, there is a less preference for this color. This information is essential to carry out a more efficient sorting of the larvae during their culture and reduce cannibalism in the larval stage in A. tropicus. The results of this study could be useful to understand this behavior in other species.
•The tank color affects the number of attacks in A. tropicus larvae.•The use of artificial vegetation as refuges decreased attacks in A. tropicus.•First description of cannibalism behavior in Atractosteus: three types of cannibalism and “S” movement before an attack.•Cannibalism is present in A. tropicus larvae when there is a difference in weight 0.005 ± 0.004 g and 0.32 ± 0.123 cm length.•A. tropicus show morphometric conditions that limit the cannibalism to specific stages.
Abstract Background Acute symptomatic pulmonary embolism (PE) varies in its clinical manifestations in patients with cancer and entails specific issues. The objective is to assess the performance of ...five scores (PESI, sPESI, GPS, POMPE, and RIETE) and a clinical decision rule to predict 30-day mortality. Methods This is an ambispective, observational, multicenter study that collected episodes of PE in patients with cancer from 13 Spanish centers. The main criterion for comparing scales was the c-indices and 95% confidence intervals (CIs) of the models for predicting 30-day mortality. Results 585 patients with acute symptomatic PE were recruited. The 30-day mortality rate was 21.3 (95% CI; 18.2
–
24.8%). The specific scales (POMPE-C and RIETE) were equally effective in discriminating prognosis (c-index of 0.775 and 0.757, respectively). None of these best performing scales was superior to the ECOG-PS with a c-index of 0.724. The remaining scores (PESI, sPESI, and GPS) performed worse, with c-indexes of 0.719, 0.705, and 0.722, respectively. The dichotomic “clinical decision rule” for ambulatory therapy was at least equally reliable in defining a low risk group: in the absence of all exclusion criteria, 30-day mortality was 2%, compared to 5% and 4% in the POMPE-C and RIETE low-risk categories, respectively. Conclusion The accuracy of the five scales examined was not high enough to rely on to predict 30-day mortality and none of them contribute significantly to qualitative clinical judgment.
To develop recommendations for clinical and radiographic criteria to help define the “acceptable” surgical correction of femoroacetabular impingement syndrome (FAIS) and identify/define complications ...postoperatively.
A 3-phase modified Delphi study was conducted involving a case-based survey; a Likert/multiple choice-based survey concerning radiographic and physical examination characteristics to help define FAIS correction, as well as the prevalence and definition of potential postoperative complications; and 2 consensus meetings.
Of the 75 experts invited, 54 completed the Phase I survey, 50 completed the Phase II survey (72% and 67% response rate), and 50 participated in the Phase III consensus meetings. For both typical and atypical (complex) cases, there was consensus that fluoroscopy with multiple views and dynamic hip assessment should be used intraoperatively (96% and 100%, respectively). For typical FAIS cases, the Expert Panel agreed that Dunn lateral and anteroposterior radiographs were the most important radiographs to evaluate the hip postoperatively (88%, consensus). When asked about evaluating the correction of cam impingement postoperatively, 87% voted that they use subjective evaluation of the “sphericity” of the femoral head. In the case of focal and global pincer-type FAIS, there was consensus that the reduction or elimination of the crossover sign (84%) and lateral center-edge angle (91%) were important to inform the extent of the FAIS correction. There was consensus for recommending further investigation at 6 months postoperatively if hip pain had increased/plateaued (92% agreed); that additional investigation and treatment should occur between 6 and 12 months (90% agreed); and that a reoperation may be recommended at 12 months or later following this investigation period (89% agreed).
This consensus project identified the importance of using fluoroscopy and dynamic hip assessment intraoperatively; Dunn lateral and anteroposterior view radiographs postoperatively; evaluating the “sphericity” of the femoral head for cam-type correction and the use of dynamic hip assessment; reducing/eliminating the crossover sign for focal pincer-type FAIS; evaluating the lateral center-edge angle for global pincer-type FAIS; and avoiding overcorrection of pincer-type FAIS. In cases in which postoperative hip pain increased/plateaued, further investigation and treatment is warranted between 6 and 12 months, and a reoperation may be recommended at a minimum of 12 months depending on the cause of the hip pain.
Hip arthroscopy surgeons have yet to reach a firm agreement on what constitutes an “acceptable” or “good” surgery radiographically and how they can achieve desired clinical outcomes. Although this was a comprehensive effort, more study is needed to determine therapeutic thresholds that can be universally applied.
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