COMPARISON OF ABDOMINAL EXERCISES AND NEUROMUSCULAR ELECTRICAL STIMULATION ON DIASTASIS RECTI ABDOMINIS MUSCLE IN POSTNATAL FEMALES WITH CAESAREAN SECTION.

The separation of the two rectus abdominis muscles along the linea alba is termed diastasis of recti abdominis muscles (DRAM). DRAM is a common health problem in people that are both pregnant and postpartum. With a 100% frequency at gestational week 35, it is extremely frequent during pregnancy. Control and function of the trunk are greatly influenced by the musculature of the abdomen. The existence, extent, and duration of DRAM have been connected to low back and pelvic discomfort however the relationship is not conclusive. It has been proven to weaken abdominal muscles and impair their functioning in lumbo-pelvic stability. Additionally, DRAM has been linked to pelvic floor dysfunction. The mechanical control and function of the abdomen can be compromised by diastasis recti, which compromises the abdominal muscles. This study examined the impact of abdominal exercises and neuromuscular electrical stimulation on the DRAM in postnatal females who underwent Caesarean section. A total of 208 individuals, aged between 20 and 34, who had recti diastasis measuring more than 2.5 cm, underwent screening. They were split into two groups at random. Group B only received abdominal exercises, whereas Group A received NMES in addition to their activities. For a period of 12 weeks, the intervention was given to both groups three times a week. Changes have been recorded before and after the intervention. The pressure biofeedback unit, measuring tape, and vernier caliper were employed to evaluate the outcome measures of inter-recti distance, abdominal muscle strength, and waist-hip ratio, respectively. In every outcome, both groups had a highly significant (p<0.05) improvement. Furthermore, after 12 weeks, group A had improved in all measures with highly significant (p<0.05) intergroup comparisons. In comparison to MNES alone, NMES can have a more significant effect on reducing DRAM in postpartum women when paired with abdominal Exercise.

The first joint ESGAR/ ESPR consensus statement on the technical performance of cross-sectional small bowel and colonic imaging.

OBJECTIVES: To develop guidelines describing a standardised approach to patient preparation and acquisition protocols for magnetic resonance imaging (MRI), computed tomography (CT) and ultrasound (US) of the small bowel and colon, with an emphasis on imaging inflammatory bowel disease. METHODS: An expert consensus committee of 13 members from the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) and European Society of Paediatric Radiology (ESPR) undertook a six-stage modified Delphi process, including a detailed literature review, to create a series of consensus statements concerning patient preparation, imaging hardware and image acquisition protocols. RESULTS: One hundred and fifty-seven statements were scored for agreement by the panel of which 129 statements (82 %) achieved immediate consensus with a further 19 (12 %) achieving consensus after appropriate modification. Nine (6 %) statements were rejected as consensus could not be reached. CONCLUSIONS: These expert consensus recommendations can be used to help guide cross-sectional radiological practice for imaging the small bowel and colon. KEY POINTS: • Cross-sectional imaging is increasingly used to evaluate the bowel • Image quality is paramount to achieving high diagnostic accuracy • Guidelines concerning patient preparation and image acquisition protocols are provided.

Implementation of a new CT colonography service: 5 year experience.

AIM: To describe our experience using a 5 year audit of computed tomography colonography (CTC) practice and identify factors that influence diagnostic performance to guide implementation in other centres. MATERIAL AND METHODS: Consecutive patients referred for CTC at a single institution over a 5 year period were identified, and reporting rates and positive predictive value (PPV) calculated for small polyps, large polyps, and colorectal cancer. Diagnostic performance was compared using the Chi-squared test, and trends over time were examined with logistic regression. The effect of faecal tagging and an intravenous spasmolytic were investigated using Fisher's exact test. RESULTS: In total, 4355 CTC examinations were performed. Overall reporting rates and PPV were 17% and 92%, respectively. Negative predictive value (NPV) for cancer was 99.9%. A significant decrease in reporting rate (p < 0.001) was accompanied by an increase in PPV for small polyps (p = 0.02) following the introduction of faecal tagging. Adequacy rates for CTC improved over time (96% to 99%), with improved adequacy rates when using a spasmolytic, 98% versus 96% without. A significant difference in reporting rates, but not PPV, was found between radiologists. CONCLUSION: Accurate colonic investigation using CTC can be delivered safely to a high-risk patient population at a single centre. Faecal tagging and an intravenous spasmolytic improve diagnostic performance.

The role of multidetector computed tomography coronary angiography in imaging complications post-cardiac surgery.

There have been numerous advances in the field of cardiac imaging. The advent of multidetector computed tomography coronary angiography (MDCT-CA) and in particular electrocardiographic (ECG)-gated acquisition has revolutionized the investigation of the complete spectrum of complications of common cardiothoracic surgical procedures. Generic complications, such as mediastinitis, pericardial effusion, sternal osteomyelitis, and mediastinal fibrosis, are discussed with illustrative examples of multiplanar and volume-rendered three-dimensional reconstructions. Graft-related complications of both coronary artery bypass grafts and aortic root grafts are reviewed. The role of MDCT-CA in the investigation of prosthetic valve endocarditis and root abscesses is outlined. We present a complete illustration of the detailed images that are obtained when investigating a full range of graft-related complications from both aortic and coronary surgery using ECG-gated MDCT-CA. MDCT-CA has the potential to become established as the optimal technique with which to image a multitude of complications post-cardiac surgery.

The increasing role of endoscopic ultrasound (EUS) in the management of pancreatic and biliary disease.

Pancreatic and biliary disease continues to have a significant impact on the workload of the National Health Service (NHS), for which there exists a multimodality approach to investigation and diagnosis. Endoscopic ultrasound (EUS) is fast becoming a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but also because of its valuable role as a problem-solving tool and ever-improving ability in an interventional capacity. We provide a comprehensive review of the benefits of EUS in everyday clinical practice.

Extra-pulmonary manifestations of sarcoidosis.

Although, the diagnosis and evaluation of sarcoidosis has traditionally remained confined to the chest, its multi-system nature has been widely recognized. Radiological features of pulmonary sarcoidosis are well known but extra-pulmonary manifestations can produce a plethora of non-specific imaging findings that can affect subcutaneous tissue, and the neurological, cardiac, gastrointestinal, urological, liver, spleen, and skeletal systems. In the literature, there are various case reports and specific system reviews but there are few reviews that encompass all the extra-pulmonary manifestations. In this paper, we comprehensively review the imaging features of extra-pulmonary sarcoidosis with characteristic features as well as atypical presentations. In addition, we discuss the emerging role of nuclear medicine in sarcoidosis.

The varied sonographic appearances of focal fatty liver disease: review and diagnostic algorithm.

Focal fat infiltration and focal fat sparing of the liver are less common than diffuse fat infiltration but present a greater diagnostic conundrum. Although typical features of these conditions are well described, there is a wide variety of different appearances. These atypical patterns present significant difficulty in differentiation from other pathological processes and often require additional investigation. We present an innovative diagnostic algorithm and illustrate its effectiveness in diagnosing focal fatty liver disease with typical and atypical examples.

Value of trainees in a radiology department. A retrospective semi-quantitative analysis.

AIM: To examine the productivity (both economic and otherwise) of trainees within a radiology department at our institution. MATERIALS AND METHODS: Productivity was measured in three ways: (1) independent workload contribution, (2) impact on on-call services, and (3) impact on day-to-day practice as perceived by consultant radiologists. Data were collected using retrospective searches on computerized radiology information system (CRIS), analysis of trainees and consultant rotas, and a questionnaire to consultants and trainees. Where possible, productivity was quantified in terms of number of programmed activities (PAs). RESULTS: The contribution of independent work by trainees in a single week was 52.75 PAs (or 1.45 PAs per trainee per week). In addition, the on-call contribution was 23.1 PAs per week (or 0.93 PAs per trainee per week). When both trainees and consultants report independently, productivity in a single list in most cases increased and can be as much as 197%. On calculating the economic impact, this amounts to significant savings of around £1.2million per year at our institution. CONCLUSION: Based upon objectively measurable areas of service provision, the employment of trainees yields considerable economic benefit. Furthermore, based upon qualitative methods we have shown that trainees contribute positively in those areas, which are much harder to quantifiably evaluate. These are benefits in addition to fundamental requirement to train future competent radiologists.

Diffusion-weighted imaging for evaluating inflammatory activity in Crohn's disease: comparison with histopathology, conventional MRI activity scores, and faecal calprotectin.

PURPOSE: To evaluate whether the extent of enteric diffusion-weighted imaging (DWI) signal abnormality reflects inflammatory burden in Crohn's disease (CD), and to compare qualitative and quantitative grading. METHODS: 69 CD patients (35 male, age 16-78) undergoing MR enterography with DWI (MRE-D) and the same-day faecal calprotectin (cohort 1) were supplemented by 29 patients (19 male, age 16-70) undergoing MRE-D and terminal ileal biopsy (cohort 2). Global (cohort 1) and terminal ileal (cohort 2) DWI signal was graded (0 to 3) by 2 radiologists and segmental apparent diffusion coefficient (ADC) calculated. Data were compared to calprotectin and a validated MRI activity score [MEGS] (cohort 1), and a histopathological activity score (eAIS) (cohort 2) using nonparametric testing and rank correlation. RESULTS: Patients with normal (grades 0 and 1) DWI signal had lower calprotectin and MEGS than those with abnormal signal (grades 2 and 3) (160 vs. 492 µg/l, p = 0.0004, and 3.3 vs. 21, p < 0.0001), respectively. Calprotectin was lower if abnormal DWI affected <10 cm of small bowel compared to diffuse small and large bowel abnormality (236 vs. 571 µg, p = 0.009). The sensitivity and specificity for active disease (calprotectin > 120 µg/l) were 83% and 52%, respectively. There was a negative correlation between ileal MEGS and ADC (r = -0.41, p = 0.017). There was no significant difference in eAIS between qualitative DWI scores (p = 0.42). Mean ADC was not different in those with and without histological inflammation (2077 vs. 1622 × 10-6mm2/s, p = 0.10) CONCLUSIONS: Qualitative grading of DWI signal has utility in defining the burden of CD activity. Quantitative ADC measurements have poor discriminatory ability for segmental disease activity.

Early outcomes of coronary artery bypass with and without cardiopulmonary bypass in octogenarians.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) surgery has been successfully used in diverse patient populations and has been postulated to be safer than conventional coronary artery bypass (CCAB) surgery in some high-risk patients, including the elderly. OBJECTIVE: To compare the safety of OPCAB surgery versus CCAB surgery in the octogenarian population of two large southwestern Ontario cardiac surgical units. RESULTS: Two hundred thirty-six consecutive octogenarians underwent primary isolated coronary artery bypass surgery from November 2000 to March 2005. Patients undergoing OPCAB surgery tended to have higher Parsonnet scores, while patients undergoing CCAB surgery had a greater number of emergent operations. The Canadian Cardiovascular Network predicted that mortality risk was similar in both groups. In-hospital mortality was similar between groups, as was postoperative myocardial infarction and new onset of renal dysfunction. However, in the OPCAB group, there was a decreased incidence of postoperative neurological dysfunction (2.3% in the OPCAB group versus 10.5% in the CCAB group, P=0.01), in particular cerebrovascular accidents (1.5% in the OPCAB group versus 7.6% in the CCAB group, P=0.05), and a decreased incidence of prolonged intubation (5.3% in the OPCAB group versus 13.3% in the CCAB group, P=0.04). Multivariable analysis found that cardiopulmonary bypass had no significant impact on mortality or length of stay. CONCLUSIONS: In octogenarian patients, OPCAB surgery is as safe as CCAB surgery in terms of mortality and major morbidity. Furthermore, a significant reduction in neurological dysfunction and prolonged intubation was seen in the OPCAB group compared with the CCAB group.

Insulin protects against hepatic bioenergetic deterioration induced by cancer cachexia: an in vivo 31P magnetic resonance spectroscopy study.

The bioenergetic effects of cancer cachexia on the livers of male Fischer rats inoculated with a methylcholanthrene-induced sarcoma were assessed using serial in vivo 31P magnetic resonance spectroscopy. Rats were randomized into three groups: tumor-bearing controls (n = 7); an insulin-treated group receiving 2 units/100 g body weight/day starting 21 days after implantation (n = 8); and a chronic insulin-treated group receiving insulin every day after implantation (n = 3). During the 32-day study, serial measurements of food intake, body weight, and tumor volume were taken, and 31P magnetic resonance spectroscopy analyses of the livers were conducted every 7 days after tumor implantation. Neither the short-term nor the chronic insulin treatment regimens stimulated the progress of tumor growth. However, both treatments prevented body weight loss, and the short-term insulin treatment prevented tumor-induced decrease in food intake relative to the control group. Liver bioenergetic deterioration was evaluated from the increase in the ratio of Pi to ATP obtained from the hepatic 31P magnetic resonance spectra. At day 28 postimplantation, control rats exhibited appreciable hepatic bioenergetic deterioration, i.e., a Pi/ATP ratio of 1.41 +/- 0.35 (SE), significantly higher (P < 0.05) than the Pi/ATP ratio for short-term or chronic insulin treatment groups (Pi/ATP 0.92 +/- 0.22 and 0.84 +/- 0.22, respectively) or rats before tumor implantation (Pi/ATP 0.76 +/- 0.14). This insulin-induced bioenergetic protection occurred at any given tumor burden up to at least 10%. Thus, both short-term insulin given just prior to the frank manifestations of cancer cachexia and chronic insulin treatment given throughout tumor growth ameliorated host hepatic bioenergetic deterioration without significantly stimulating tumor growth. Insulin may act by altering the host metabolism (stimulation of liver glucose uptake and utilization, decreased energy-requiring gluconeogenesis, and general protein-sparing action) at the expense of the tumor.

Contractile proteins in epidermis. Isolation and properties of guinea-pig epidermal myosin.

Proteins of apparent molecular weights between 10 000 and 250 000 could be solubilized from guinea pig epidermis using a Tris/sucrose/ATP buffer. When the ionic concentration of the solubilized extract was made 75 mM with respect to KCl and 2 mM with respect to MgCl2, a protein complex precipitated which on SDS-polyacrylamide gel electrophoresis resolved into bands corresponding in migration to myosin, actin and a number of low molecular weight proteins. Myosin was dissociated from the complex with 0.6 M KI and purified by gel filtration chromatography on an agarose column. The purified epidermal myosin fraction contained a polypeptide of 200 000 molecular weight andtwo low molecular weight polypeptides of 16 500 and 13 000. The amino acid composition of the epidermal myosin heavy chain was similar to that of muscle myosin. At high ionic strength epidermal myosin had high specific (K+ + Ca2+)- and (K+ + EDTA)-ATPase activities and low specific (K+ + Mg2+)-ATPase activity. The pH activity curves of the (K+ + Ca2+)- and (K+ + EDTA)-ATPase were different. ATP was hydrolyzed faster than other nucleoside triphosphates. At low ionic strength, the (K+ + Mg2+)-ATPase activity of epidermal myosin was stimulated two fold by skeletal muscle actin. The myosin formed bipolar filaments in 50 mM KCl in the presence of 5 mM Mg2+.

Fractionation and characterization of low molecular weight solubilized proteins of newborn rat keratohyalin granules.

Newborn rat epidermis was extracted using methods reported to extract keratohyalin granules. All extraction techniques yielded preparations of solubilized proteins with similar sodium dodecyl sulfate-polyacrylamide electrophoretograms. The solubilized proteins were fractionated on a Sephadex G-200 column and six low molecular weight protein fractions (apparent molecular weights between 10000 and 18000) have been identified. Four of these have been isolated and partially characterized. Two of the fractions are characterized by high histidine, arginine, serine and glutamic acid concentrations and have an amino acid composition similar to that of the histidine-rich protein characteristic of keratohyalin granules. One of these histidine-rich fractions (molecular weight 13700) has ribonuclease activity. The other two isolated fractions are basic proteins, one of which (molecular weight 12800) is a basic lysine-rich protein. This protein is not found in any other tissues of the new born or adult rat.

Scattered-light intensity fluctuations in diastolic rat cardiac muscle caused by spontaneous Ca++-dependent cellular mechanical oscillations.

Laser light scattered by nonstimulated rat cardiac muscle bathed in physiological saline containing a [Ca++] of 0.4-2.5 mM displays scattered-light intensity fluctuations (SLIF); the frequencies of both SLIF and resting force are Ca++ dependent. Direct inspection of these muscles by phase-contrast microscopy under incoherent illumination revealed the presence of spontaneous asynchronous cellular motions that are also Ca++ dependent. The physical properties of the scattered light are compatible with the hypothesis that SLIF are due to the diastolic motion, except for the dependence on scattering angle, which may be perturbed because the muscles are optically thick. To determine whether diastolic SLIF and motion are an intrinsic property of activated myofilaments, photon-counting auto-correlation of the scattered light was performed both in rat right-ventricular papillary muscles skinned with the detergent Triton X-100 (1%) and in muscles with intact membranes under conditions that alter cellular Ca++ fluxes. In skinned muscles activated over a range of Ca++ from threshold to maximum force production, neither SLIF nor asynchronous motion was observed when Ca++ was buffered to constant values. In intact muscles the frequency of SLIF and the amplitude of diastolic motion were (a) markedly increased by substituting K+ or Li+ for Na+ in the bath; (b) not altered by verapamil (1 microM); and (c) reversibly abolished by caffeine (greater than or equal to 10 mM). These properties are exactly those of mechanical oscillations that have been observed in isolated cardiac cell fragments, which are the result Ca++ oscillations caused by Ca++ release from the sarcoplasmic reticulum (SR). We infer that mechanical oscillations caused by spontaneous Ca++-induced Ca++ release from the SR occur in intact nonstimulated cardiac muscle even in the absence of Ca++ overload and are the principle cause of SLIF, and that myoplasmic [Ca++] in "resting" muscle is not in a microscopic steady state.

Magnetic resonance imaging-quantified small bowel motility is a sensitive marker of response to medical therapy in Crohn's disease.

BACKGROUND: Magnetic resonance enterography (MRE) can measure small bowel motility, reduction in which reflects inflammatory burden in Crohn's Disease (CD). However, it is unknown if motility improves with successful treatment. AIM: To determine if changes in segmental small bowel motility reflect response to anti-TNFα therapy after induction and longer term. METHODS: A total of 46 patients (median 29 years, 19 females) underwent MRE before anti-TNFα treatment; 35 identified retrospectively underwent repeat MRE after median 55 weeks of treatment and 11 recruited prospectively after median 12 weeks. Therapeutic response was defined by physician global assessment (retrospective group) or a ≥3 point drop in the Harvey-Bradshaw Index (prospective group), C-reactive protein (CRP) and the MaRIA score. Two independent radiologists measured motility using an MRE image-registration algorithm. We compared motility changes in responders and nonresponders using the Mann-Whitney test. RESULTS: Anti-TNFα responders had significantly greater improvements in motility (median = 73.4% increase from baseline) than nonresponders (median = 25% reduction, P < 0.001). Improved MRI-measured motility was 93.1% sensitive (95%CI: 78.0-98.1%) and 76.5% specific (95% CI: 52.7-90.4%) for anti-TNFα response. Patients with CRP normalisation (<5 mg/L) had significantly greater improvements in motility (median = 73.4% increase) than those with persistently elevated CRP (median = 5.1%, P = 0.035). Individuals with post-treatment MaRIA scores of <11 had greater motility improvements (median = 94.7% increase) than those with post-treatment MaRIA score >11 (median 15.2% increase, P = 0.017). CONCLUSIONS: Improved MRI-measured small bowel motility accurately detects response to anti-TNFα therapy for Crohn's disease, even as early as 12 weeks. Motility MRI may permit early identification of nonresponse to anti-TNFα agents, allowing personalised treatment.

Immunofluorescent visualization of myosin in human epidermal cells.

An antiserum against guinea pig epidermal myosin was used for the localization of myosin in frozen sections of human epidermis and cultured human epidermal cells. The antiserum gave a single precipitin band with epidermal myosin but did not cross react with muscle myosin or epidermal keratin in immunodiffusion plates. Strong staining, in the indirect immunofluorescence technique, was observed in cells of the lower layers of human and guinea pig epidermis. The antibody also reacted with myofibrils, intracellular filaments in cultured human epidermal cells and fibers in 3T3, HeLa and PtK2 cells. Double immunofluorescence staining using antisera against myosin and keratin revealed no obvious differences in staining patterns in filaments of cultured human epidermal cells.

A novel comparison of stentless versus stented valves in the small aortic root.

BACKGROUND: Previous studies have compared prosthetic valves on the basis of industry-labeled valve sizes. Unfortunately, the relationship between the labeled size and the true measured external or internal diameter differs between valve manufacturers. Therefore hemodynamic comparisons between prosthetic valves are inaccurate if based solely on industry-labeled valve sizes. METHODS: We have previously demonstrated that the internal diameter of a 21-mm Carpentier-Edwards pericardial stented valve is similar to that of a 25-mm Toronto stentless porcine valve. Therefore we chose to compare postoperative hemodynamics in patients who received 19-, 21-, or 23-mm Carpentier-Edwards pericardial stented valves (inner diameter 18-22 mm, n = 69) with those in patients who received 23- or 25-mm stentless porcine valves (internal diameter 19-21 mm, n = 41). RESULTS: Patients in the Carpentier-Edwards group were more likely to be elderly and more likely to require concomitant revascularization. Operative mortality was lower in the stentless porcine valve group (0% vs 9%, P =.06). Hospital stay and ventilation requirements were shorter in the stentless porcine valve group. Postoperative hemodynamics were similar in the two groups. CONCLUSIONS: These data provide evidence that stentless and stented valves have similar hemodynamic profiles in the small aortic root when matched on true measured internal diameters. The clinical benefit of the stentless porcine valve may be due to patient selection or the lack of a rigid stent in the small aortic root, but it is not due to hemodynamic superiority over stented aortic valves of similar sizes.

Technique for reconstruction of the sinotubular junction.

Correct geometric relationships between the annulus and sinotubular junction during stentless valve implantation are critical to minimize the development of insufficiency. Some patients with aortic valve disease have dilatation of the sinotubular junction and are unable to have a stentless valve placed by standard techniques. We recently encountered such a patient and reconstructed the sinotubular junction by aortic crenation. Multiple interrupted plicating sutures were used to reduce the aorta from a diameter of 42 mm to 28 mm. This method allows tailoring of the aorta to appropriate size by varying the number of crenating sutures.

Trends in coronary artery bypass surgery results: a recent, 9-year study.

BACKGROUND: The demographics of patients undergoing coronary artery bypass grafting (CABG) have changed over time and may contribute to differing operative mortality and the combination of mortality and morbidity (M + M). In this study, the trends in results are analyzed and causes are suggested. METHODS: Prospectively collected data concerning 4,839 CABG operations was divided into three time cohorts (1990 to 1992, 1993 to 1995, 1996 to 1998) and analyzed by univariate and multivariate techniques. RESULTS: Mean age and female gender frequency increased in the later time cohorts (60.7 +/- 9.0 to 63.4 +/- 9.9 years and 16.5% to 21.4%, respectively). The following comorbidities were more prevalent in the later time cohorts: diabetes (26.7% versus 18.6%), renal failure (8.5% versus 2.2%), peripheral vascular disease (20.7% versus 11.0%), previous cerebrovascular accident (6.7% versus 5.0%), urgent procedures (41.5% versus 26.9%), unstable angina (47.8% versus 31.7%), urgent CABG following myocardial infarction (17.1% versus 7.3%), previous percutaneous transluminal coronary angioplasty (8.0% versus 4.5%), ejection fraction less than 35% (20.5% versus 10.4%), (all p < 0.05). Procedurally, increased utilization of the left internal mammary artery, multiple arterial conduits, and warm blood cardioplegia occurred in the later cohorts (91.2%, 22.2%, and 80.4% versus 78.7%, 3.4%, and 38.0%, respectively). The mortality rate was 2.0% and the M + M rate was 15.6% in all 4,839 patients. The mortality and M + M for the three cohorts were 1.6%, 2.0%, and 2.3% and 18.4%, 17.2% and 12.5%, respectively. The risk-adjusted mortality and M + M decreased from 2.4% and 15.9%, respectively, in 1990 to 1992 to 1.8% and 8.4% in 1996 to 1998 (p < 0.001). The difference in adjusted event rates was minimized when the surgical factors were entered into the model. CONCLUSIONS: Over time, there has been a trend toward operating on older patients with more comorbidities. Though hospital mortality has been stable, risk-adjusted M + M has been in a constant decline. This decline was associated with an increased use of left internal mammary artery grafts, multiple arterial conduits, and warm blood cardioplegia during the later years of the study.