A Comparison of Different Thyroid Imaging Reporting and Data Systems to Reduce Unnecessary FNAs and Missed Malignancies

Objective: The Thyroid Imaging Reporting and Data System (TIRADS) has been proposed to reduce the number of unnecessary fine needle aspirations (FNA) from thyroid nodules. Materials and Methods: An individual radiologist provided sonographic examinations and FNA on a collection of 188 thyroid nodules. The recommendations based on the TIRADS system, for each nodule, was determined and evaluated against the cytology results. Results: The American College of Radiology (ACR), artificial intelligence (AI), European (EU), and Korean (K) scoring systems reduced FNAs by 53%, 56%, 48%, and 28%, respectively. Among those lesions without a recommendation for immediate FNA, The ACR would have missed four malignant nodules, the AI would have missed four malignant nodules, and K TIRADS would have missed three malignant nodules but with a recommended follow-up imaging. The ACR would have missed three malignant nodules, the AI would have missed four malignant nodules, and EU TIRADS would have missed four malignant nodules, without a recommended follow-up examination. The highest and lowest kappa interrelated agreements were between ACR and AI (0.902) and AI and K (0.448). Conclusion: The ACR and AI TIRADS could substantially decrease the number of FNAs but rely on follow-up imaging. The EU TIRADS reduced the number of FNAs, the least however this system had less dependence on follow-up imaging. The K TIRADS was the most conservative method and the least dependent on follow-up diagnostics.

Block What You Can, Except When You Shouldn’t

Several branches of the potential outcome causal inference literature have discussed the merits of blocking versus complete randomization. Some have concluded it can never hurt the precision of estimates, and some have concluded it can hurt. In this article, we reconcile these apparently conflicting views, give a more thorough discussion of what guarantees no harm, and discuss how other aspects of a blocked design can cost, all in terms of estimator precision. We discuss how the different findings are due to different sampling models and assumptions of how the blocks were formed. We also connect these ideas to common misconceptions; for instance, we show that analyzing a blocked experiment as if it were completely randomized, a seemingly conservative method, can actually backfire in some cases. Overall, we find that blocking can have a price but that this price is usually small and the potential for gain can be large. It is hard to go too far wrong with blocking.

Saving private W. H.: The surgical experiences of Dugald Blair Brown (1847–1896): Lieutenant-Colonel, FRCS, Edin., AMD

Dugald Blair Brown, a military surgeon and Fellow of the Royal College of Surgeons, Edinburgh, published twelve papers containing 77 case studies of gunshot wounds that he had treated in the Anglo-Zulu War of 1879 and in the First Anglo-Boer War of 1880–1881. Brown devised a “conservative” method of surgery, the early development of which had been influenced by Thomas Longmore (1816–1895), Joseph Lister (1827–1912), F. J. von Esmarch (1823–1912), and Carl von Reyher (1846–1890). During these conflicts, Brown reacted to surgical practices unsuited to the battlefield and not in the interest of the wounded. One such practice was “expectant” surgery, the practitioners of which dangerously substituted natural healing for immediate wound resection. Brown also criticized “operative” surgeons who, when faced with gunshot wounds of the extremities, expeditiously amputated limbs. Viewing each case as diagnostically unique, Brown tried to salvage limbs, to preserve function, and to accelerate recovery. To achieve these objectives, he used debridement, antisepsis, drainage, nutrition, and limited post-operative intervention.

Autonomous Vehicle Safe Operating Speeds on the Automated Skyway Express in Jacksonville, Florida

Autonomous vehicles (AV) differ significantly from traditional passenger vehicles in both their behavior and physical characteristics. As such, the validity of the guidance provided in the Manual for Assessing Safety Hardware, Second Edition (MASH 2016) is questionable in AV applications. Impact angles, speeds, and vehicle weights specified in MASH 2016 are inextricably linked to the traditional vehicles underlying the estimates. For AV applications, these parameters must be estimated from the ground up, stepping outside the guidance of MASH 2016. In this paper, a conservative method for evaluating existing infrastructure to support AV traffic is proposed. The method integrates traditional structural analyses with unconventional methods of estimating impact conditions. This methodology was developed for the Jacksonville Transportation Authority, who, when faced with unique challenges in maintaining and expanding their Automated Skyway Express, opted to convert the system from monorail to AV traffic. Leading AV developers were surveyed to develop a portfolio of potential candidates for the conversion. Estimated impact conditions were then compared against the capacity of the system’s existing concrete parapets. Ultimately, safe operating speeds for each AV candidate were recommended on the bases of structural capacity and vehicle stability. All but one AV candidate were deemed capable of safely operating at the desired speed of 25 mph without any modifications to the barrier. Although the methodology was developed for a particular case, it is applicable to future implementations of AVs on existing infrastructure, provided the roadway is confined similarly to the Skyway deck.

Distalization in Orthodontics: A Review and Case Series

Distalization is a conservative method that is utilized in orthodontics to gain space by moving posterior teeth distally. It may be combined with other space gaining strategies, such as expansion, or can be used alone. Many methods have been used for distalization. These methods differ significantly in their place, whether to be extraoral or intraoral, site of action in upper and/or lower arch, and cooperation needed by the patient if it is removable or fixed. This review illustrates some of the most commonly used methods for distalization with a brief presentation of three cases that incorporated successful distalization techniques.

Clinico-radiological correlation during the course and healing of Legg-Calve-Perthes’ disease treated by a non-intensive conservative method

Introduction. The purpose of this study is to signify any clinical and radiological correlation, if present, in patients of Legg-Calve-Perthes’ disease (LCPD) who underwent an ambulatory conservative method of containment and their final outcome. Material and methods. Retrospective study over an 8-year period including patients of LCPD who were treated by an ambulatory conservative method showing signs of healing in the last radiological assessment was done. Clinically, gait, limb length discrepancy, range of motion of the hip, and Harris hip score were noted. The radiological parameters assessed in this study were epiphyseal index, epiphyseal quotient, acetabular head index, and epiphyseal extrusion index. Stulberg criteria was used to assess final outcome. Results. A total of 24 patients (17 males, 7 females) with a mean age of 7.9±3 years (5–9 years) who had a clinic-radiological diagnosis of LCPD were included in the study. There was a significant improvement of range of motion of the hip joint along with Harris hip score (t(18)= -16.77, p<0.001) but no significant changes in the radiological parameters during the course of the disease. There was no correlation between radiological parameters and Harris hip score. 79.1% (19/24) had a good outcome at final follow up. Conclusion. The function and clinical outcome during the course and healing of LCPD does not correlate with the radiographic changes and ambulatory conservative management leads to satisfactory improvement in functional activity. Age at onset and lateral pillar classification are important factors influencing final outcome in LCPD.