Preoperative grip strength measurement and duration of hospital stay in patients undergoing total hip and knee arthroplasty.

PURPOSE: This study explored whether a relationship exists between preoperative pinch and power grip strength, and length of hospital stay in patients undergoing hip and knee arthroplasty at a busy UK hospital. We investigated whether handgrip dynamometry could be used preoperatively to identify patients at greater risk of longer inpatient stays. This would allow focussed intervention preoperatively and facilitate predictors of length of stay postoperatively. METHODS: One hundred and sixty-four patients (64 male, 100 female) undergoing lower limb arthroplasty (83 total knee replacement, 81 total hip replacement) were assessed in pre-admission clinic. Average measurements of pinch grip, power grip and grip endurance were taken from each patient using the Jamar hydraulic dynamometer (Jamar, USA). Duration of inpatient stay of each patient was recorded. RESULTS: Average duration of hospital stay was 9.4 days. Both average pinch grip strength and average power grip strength had a significant negative correlation with duration of inpatient stay. Those patients with a pinch grip strength less than 6.3 kg remained an inpatient for an average of 2 days longer than those with a pinch grip greater than 6.3 kg. CONCLUSIONS: This simple test may be highly beneficial preoperatively in identifying those patients likely to require longer inpatient stays and therefore those who would benefit from early nutritional intervention and focussed physiotherapy. It may also facilitate predictors of length of stay postoperatively. We believe this may effect significant cost reductions in the NHS.

Laser-patterned paper-based flow-through filters and lateral flow immunoassays to enable the detection of C-reactive protein.

We report the use of a laser-based fabrication process in the creation of paper-based flow-through filters that when combined with a traditional lateral flow immunoassay provide an alternative pathway for the detection of a pre-determined analyte over a wide concentration range. The laser-patterned approach was used to create polymeric structures that alter the porosity of the paper to produce porous flow-through filters, with controllable levels of porosity. When located on the top of the front end of a lateral flow immunoassay the flow-through filters were shown to block particles (of known sizes of 200 nm, 500 nm, 1000 nm and 3000 nm) that exceed the effective pore size of the filter while allowing smaller particles to flow through onto a lateral flow immunoassay. The analyte detection is based on the use of a size-exclusive filter that retains a complex (∼3 µm in size) formed by the binding of the target analyte with two antibodies each of which is tagged with different-sized labels (40 nm Au-nanoparticles and 3 µm latex beads), and which is larger than the effective pore size of the filter. This method was tested for the detection of C-reactive protein in a broad concentration range from 10 ng/ml to 100,000 ng/ml with a limit-of-detection found at 13 ng/ml and unlike other reported methods used for analyte detection, with this technique we are able to counter the Hook effect which is a limiting factor in many lateral flow immunoassays.

The use of remote sensing in the identification of the eco-environmental factors associated with the risk of human visceral leishmaniasis (kala-azar) on the Gangetic plain, in north-eastern India.

Human visceral leishmaniasis (VL) or kala-azar remains a major cause of mortality, particularly in the developing world. The disease is common in the internal regions of north-eastern India, which have a tropical or sub-tropical climate. In a recent study on VL in this region, the relationship between the incidence of VL and certain physio-environmental factors was explored, using a combination of a geographical information system (GIS), satellite imagery and data collected 'on the ground'. Some eco-environmental parameters were then used to map and describe the spatial heterogeneity seen in the transmission of the parasite (Leishmania donovani) that causes VL in India, and to identify those habitats, on the Gangetic plain, where the sandfly vectors might thrive. It was found that the presence of waterbodies, woodland and urban, built-up areas, soil of the fluvisol type, air temperatures of 25.0-27.5 degrees C, relative humidities of 66%-75%, and an annual rainfall of 100-<160 cm were all positively associated with the incidence of VL. A VL map was created and stratified into areas of 'risk' and 'non-risk' for the disease, based on calculations of risk indices.

Survey of the initial management and imaging protocols for occult scaphoid fractures in UK hospitals.

OBJECTIVE: The aim of this research was to survey how occult fractures of the scaphoid bone are both imaged and managed initially. MATERIALS AND METHODS: A total of 832 questionnaires were sent via e-mail to active associate members of the British Orthopaedic Association. Included was a series of questions regarding the timing of initial and subsequent orthopaedic review of this group of patients and the use of serial radiographs and second-line imaging techniques. RESULTS: Nearly half of the UK's acute NHS trusts were represented (45%). The response rate was 16% (130 out of 832). Only 16% of respondents were aware of a local imaging protocol for the investigation of suspected fractures of the scaphoid. Ninety-four percent of respondents performed a second radiograph at first fracture clinic review. Fifty-eight percent used magnetic resonance imaging (MRI) as a second-line investigation; with computed tomography scan and radionuclide isotope bone scan being performed by 26% and 16% respondents, respectively. CONCLUSIONS: The survey revealed a wide variation in the management of occult fractures of the scaphoid. MRI has been shown to be both sensitive and specific in diagnosing occult carpal bone fractures. There is a need to standardise the management of these injuries to ensure early diagnosis and limit unnecessary wrist immobilisation.

Vector density and the control of kala-azar in Bihar, India.

Bihar, India has been in the grip of kala-azar for many years. Its rampant and severe spread has made life miserable in most parts of the state. Such conditions require a comprehensive understanding of this affliction. The numbers coming out of the districts prone to the disease in the north and south Ganges have provided us with several startling revelations, as there are striking uniformities on both sides, including similar vegetation, water storage facilities, house construction and little change in risk factors. The northern areas have been regularly sprayed with DDT since 1977, but eradication of the disease appears to be a distant dream. In 2007 alone, there were as many as 37,738 cases in that region. In contrast, the southern districts of Patna and Nalanda have never had the disease in its epidemic form and endemic disease has been present in only some pockets of the two districts. In those cases, two rounds of spraying with DDT had very positive results, with successful control and no new established foci. In addition, an eleven-year longitudinal study of the man hour density and house index for the vector Phlebotomus argentipes demonstrated that they were quite high in Patna and Nalanda and quite low in north Bihar. Given these facts, an attempt has been made to unravel the role of P. argentipes saliva (salivary gland) in the epidemiology of kala-azar. It was determined that patchy DDT spraying should be avoided for effective control of kala-azar.

A report on the indoor residual spraying (IRS) in the control of Phlebotomus argentipes, the vector of visceral leishmaniasis in Bihar (India): an initiative towards total elimination targeting 2015 (Series-1).

BACKGROUND & OBJECTIVES: Visceral leishmaniasis, commonly known as kala-azar is endemic in Bihar state, India. Current vector control programme in Bihar focuses mainly on spraying the sandfly infested dwellings with DDT. The Government of India in collaboration with WHO has fixed the target 2015 for total elimination of kala-azar. The present study was carried out to see the impact of DDT and improved IEC in the containment of vector density vis-à-vis disease transmission. METHODS: Before the start of the spraying operations training was imparted to all the medical and paramedical personnel regarding the methods of spraying operations. Pre- and post-sandfly density was monitored in four selected districts. Incidences of kala-azar cases were compared for pre- and post-spray periods. Social acceptability and perceptions of households was collected through questionnaires from 500 randomly selected households in the study districts. RESULTS: House index in three study districts reduced considerably during post-spray when compared to pre-spray. Kala-azar incidence in many districts was reduced after the DDT spray. Either partial or complete refusal was reported in 14.4%, while 35% were not satisfied with the suspension concentration and coverage; and 46.6% were found satisfied with the spraying procedure. INTERPRETATION & CONCLUSION: Strengthening the IEC activities to sensitise the community, proper training of health personnel, monitoring of spray, good surveillance, proper treatment of cases and two rounds of DDT spray with good coverage in the endemic districts up to three years are essential to achieve the desired total elimination of kala-azar in Bihar state.

The pattern of ankle fractures sustained by outdoor activities at the Snowdonia National Park, North Wales, United Kingdom.

OBJECTIVE: The aim of this study was to review the pattern of ankle fractures sustained by patients brought to the Emergency Department at Ysbyty Gwynedd from The Snowdonia National Park. MATERIALS AND METHODS: The study group included all patients with ankle fractures on the mountain medicine database between March 2004 and December 2006. The presence of talar shift and comminution of the medial malleolus was noted. The pattern of fractures were analysed and compared with the literature. Radiographs were obtained for 20 casualties. RESULTS: 70% of these were injured whilst hill walking. Open fractures represented 12% of injuries. 75% of fractures required operative fixation. Weber B injuries were the commonest followed by Weber C and A. Talar shift was seen in 80% of the cases and 45% showed comminution of the medial malleolus. CONCLUSIONS: In our case series we observed a high proportion of open and unstable ankle fractures, with the majority treated by operative fixation. The high rate of comminution of the medial malleolus has previously not been reported in the literature and has the potential of making operative fixation technically difficult. Encouraging the use of walking poles particularly at the time of descending may help to reduce the incidence of ankle fractures in hill walkers.

Statin-induced muscular symptoms: a report of 3 cases.

Although the prescription of statin medication has increased worldwide and especially in Europe, its musculoskeletal side effects and their management strategy has not been highlighted in orthopaedic literature. We present three cases of statin-induced musculoskeletal symptoms which presented to an orthopaedic department. There were two patients with statin induced muscle pain (one in the thigh and one around the hip), and one with both myositis (with raised creatine kinase) and lupus-like symptoms. All of the symptoms resolved with stopping the statin. Muscle pain (often with normal creatine kinase) is the commonest side effect of statins. It is usually bilateral, but two of our cases presented with unilateral symptoms which made it more difficult to exclude a primary orthopaedic pathology. The widespread use of statins is likely to lead to an increase in the number of patients presenting to orthopaedic surgeons with muscle pain. It is important to consider muscle pain induced by statins in the differential diagnosis of acute or chronic pain in the limbs.

Vector control in leishmaniasis.

Indoor residual spraying is a simple and cost effective method of controlling endophilic vectors and DDT remains the insecticide of choice for the control of leishmaniasis. However resistance to insecticide is likely to become more widespread in the population especially in those areas in which insecticide has been used for years. In this context use of slow release emulsified suspension (SRES) may be the best substitute. In this review spraying frequencies of DDT and new schedule of spray have been discussed. Role of biological control and environment management in the control of leishmaniasis has been emphasized. Allethrin (coil) 0.1 and 1.6 per cent prallethrin (liquid) have been found to be effective repellents against Phlebotomus argentipes, the vector of Indian kalaazar. Insecticide impregnated bednets is another area which requires further research on priority basis for the control of leishmaniasis. Role of satellite remote sensing for early prediction of disease by identifying the sandflygenic conditions cannot be undermined. In future synthetic pheromons can be exploited in the control of leishmaniasis.

Dynamic contrast-enhanced perfusion processing for neuroradiologists: model-dependent analysis may not be necessary for determining recurrent high-grade glioma versus treatment effect.

BACKGROUND AND PURPOSE: Dynamic contrast-enhanced perfusion MR imaging has proved useful in determining whether a contrast-enhancing lesion is secondary to recurrent glial tumor or is treatment-related. In this article, we explore the best method for dynamic contrast-enhanced data analysis. MATERIALS AND METHODS: We retrospectively reviewed 24 patients who met the following conditions: 1) had at least an initial treatment of a glioma, 2) underwent a half-dose contrast agent (0.05-mmol/kg) diagnostic-quality dynamic contrast-enhanced perfusion study for an enhancing lesion, and 3) had a diagnosis by pathology within 30 days of imaging. The dynamic contrast-enhanced data were processed by using model-dependent analysis (nordicICE) using a 2-compartment model and model-independent signal intensity with time. Multiple methods of determining the vascular input function and numerous perfusion parameters were tested in comparison with a pathologic diagnosis. RESULTS: The best accuracy (88%) with good correlation compared with pathology (P = .005) was obtained by using a novel, model-independent signal-intensity measurement derived from a brief integration beginning after the initial washout and by using the vascular input function from the superior sagittal sinus for normalization. Modeled parameters, such as mean endothelial transfer constant > 0.05 minutes(-1), correlated (P = .002) but did not reach a diagnostic accuracy equivalent to the model-independent parameter. CONCLUSIONS: A novel model-independent dynamic contrast-enhanced analysis method showed diagnostic equivalency to more complex model-dependent methods. Having a brief integration after the first pass of contrast may diminish the effects of partial volume macroscopic vessels and slow progressive enhancement characteristic of necrosis. The simple modeling is technique- and observer-dependent but is less time-consuming.

Cortical magnetic resonance imaging changes in elderly inpatients with major depression.

OBJECTIVE: The purpose of the study was to determine if magnetic resonance imaging (MRI) scans of elderly depressed patients differ from MRI scans of age-matched control subjects and age-matched patients with Alzheimer's disease. METHOD: The authors studied 21 patients 60 years or older with major depression, 16 patients with Alzheimer's disease, and 14 age-matched control subjects. RESULTS: Compared to control subjects, depressed patients had greater cerebral sulcal and temporal sulcal atrophy; larger sylvian fissures, lateral ventricles, third ventricles, and temporal horns; and greater severity of subcortical white matter lesions. Depressed patients also had more basal ganglia lesions but similar levels of periventricular hyperintensity. There were no differences between depressed patients with and without delusions on any MRI measure. Depressed patients who received ECT had more temporal horn atrophy and greater subcortical abnormality summary scores than normal subjects. Cortical sulcal atrophy correlated with age at onset of depression. CONCLUSIONS: The findings suggest that elderly hospitalized depressed patients have greater cortical as well as subcortical atrophy and more basal ganglia lesions than age-matched normal control subjects. The correlation of these abnormalities with outcome remains unknown.

Basal ganglia volumes and white matter hyperintensities in patients with bipolar disorder.

OBJECTIVE: Accumulating evidence suggests an association between abnormalities of the basal ganglia and affective disorders. The authors hypothesized that patients with bipolar disorder would demonstrate smaller basal ganglia volumes and a greater number of hyperintensities on magnetic resonance imaging than comparison subjects who were matched on age, race, sex, and education. METHOD: Volumes of the caudate, putamen, and globus pallidus were measured in 30 patients with bipolar disorder and 30 matched normal comparison subjects. The presence, number, and location of hyperintensities were also assessed. RESULTS: Male patients with bipolar disorder demonstrated larger caudate volumes than male comparison subjects. Older, but not younger, patients with bipolar disorder demonstrated more hyperintensities than comparison subjects, primarily in frontal lobe white matter. CONCLUSIONS: These results are not consistent with those of previous studies showing reduced basal ganglia volume in subjects with affective disorders, but they are consistent with previous findings of increased white matter hyperintensities, especially in older patients with bipolar disorder. Considered together with results from other studies, the findings suggest that the nature of basal ganglia/subcortical white matter involvement may differ according to the type of depression (unipolar versus bipolar) and the age and sex of the patient.

Incidental white matter hyperintensities on magnetic resonance imaging in HIV-1 infection. Multicenter AIDS Cohort Study.

Magnetic resonance (MR) scans were performed as part of a prospective neuropsychological study within the Multicenter AIDS Cohort Study. Fifty HIV-1-seronegative men, 85 HIV-1-seropositive men without constitutional symptoms, and 14 with symptomatic HIV disease underwent MR imaging using a uniform protocol. Scans were rated by neuroradiologists blinded to all clinical details except age. The majority of MR scans were normal in all of the clinical groups and no covert mass lesions or diffuse white matter abnormalities were identified. Focal hyperintensities in the white matter were observed in 24% of the HIV-1 seronegatives, 26% of HIV-1 asymptomatic seropositives (CDC II/III), and 17% of those with ARC/AIDS. No significant associations were noted between the white matter hyperintensities and HIV-1 serostatus, neurological abnormalities, CD4 count, alcohol or drug use, hypertension, or smoking. In one individual classified with early HIV-1 dementia, MR demonstrated several hyperintensities in the deep parietal white matter, but at autopsy no microscopic abnormalities corresponding to the MR findings were identified. Our studies imply that focal white matter hyperintensities identified on MR are not specific for HIV-1 infection and are probably incidental and of no clinical significance.

Traumatic vertebrobasilar occlusive disease in childhood.

Vigorous gymnastics and repeated manipulations of the cervical spine by a chiropractor were associated with headaches and transient cranial nerve deficits in a 7-year-old boy who had a history of birth trauma. Progressive cerebellar dysfunction was later accompanied by a visual field defect. A computerized axial tomography scan revealed a cerebellar infarction, and arteriograms showed vertebral and basilar occlusions. Passive stretching of the cervical spine during chiropractic maneuvers may lead to vertebral artery thrombosis with subsequent embolization into the basilar artery circulation.

Anti-Ro(SS-A) autoantibodies in central nervous system disease associated with Sjögren's syndrome (CNS-SS): clinical, neuroimaging, and angiographic correlates.

OBJECTIVE: To examine in Sjögren's syndrome (SS) the interrelationship between the presence of the anti-Ro(SS-A) antibody response and (1) concomitant presence and type (ie, focal or nonfocal) of CNS disease (CNS-SS), (2) cross-sectional brain MRI or CT, and (3) abnormal cerebral angiography. METHODS: Neurologic, neuroimaging, and angiographic features of CNS-SS patients were correlated with the presence of precipitating anti-Ro(SS-A) autoantibodies detected by gel double-immunodiffusion or quantitative ELISA, which detects antibodies directed against the 60-kd peptide. Statistical analyses were performed using Fisher's exact test (two-tailed) with Haldane's adjustment and odds ratio with Cornfield 95% confidence intervals. RESULTS: Precipitating antibodies against the Ro(SS-A) antigen, determined by gel double-immunodiffusion, were present in an increased frequency in CNS-SS patients with (1) documented clinical CNS disease, (2) focal clinical CNS manifestations and serious complications, (3) large regions of increased signal intensity, consistent with ischemia/infarcts on brain MRI scans or regions of decreased attenuation consistent with infarcts on CT, and (4) abnormal cerebral angiograms consistent with small-vessel angiitis. Finally, the anti-Ro(SS-A) antibody response in CNS was directed against the 60-kd peptide specificity, determined by ELISA. CONCLUSIONS: Clinical, neuroimaging (cerebral CT), and angiographic observation suggest that a subset of anti-Ro(SS-A) antibody-positive, in contrast with -negative, CNS-SS patients have more serious and extensive CNS disease, some with frank cerebral angiopathy. Anti-Ro(SS-A) antibodies are postulated to play a role in mediating or potentiating vascular injury in CNS-SS.

Patterns of cerebral atrophy in HIV-1-infected individuals: results of a quantitative MRI analysis.

Cerebral atrophy is a common radiologic manifestation of HIV dementia. To evaluate the relationship between cognitive impairment and cerebral atrophy, adjusting for age and immune status, we used standardized planimetry to measure the ventricle-brain ratio (VBR) and the bifrontal (BFR) and bicaudate (BCR) ratios, three measures of cerebral atrophy. We analyzed cranial MRIs of 23 HIV-1-seronegative controls (SN) and 116 HIV-1-infected individuals. Of the HIV-1-seropositive individuals, 37 had HIV dementia (DM group), 40 had neurologic or neuropsychological abnormalities insufficient for HIV dementia (NP+ group), and 39 were neurologically normal (NML group). We performed comparisons using analysis of covariance with correction for multiple comparisons. Both the VBR, a general measure of overall cerebral atrophy, and the BCR, a measure of atrophy in the region of the caudate nucleus, are significantly associated with dementia. The association is stronger for BCR enlargement than for VBR enlargement, suggesting that selective caudate region atrophy is associated with HIV dementia. These results indicate that overall cerebral atrophy and prominent caudate region atrophy are important radiographic features of HIV dementia.

The Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Part III. Reliability of a standardized MRI evaluation of Alzheimer's disease.

The Consortium to Establish a Registry for Alzheimer's Disease (CERAD) has developed procedures for standardized imaging and reporting of magnetic resonance (MR) findings in Alzheimer's disease (AD) for use by neuroradiologists in multiple medical centers using a variety of MR equipment and field strengths. After initial pretesting, we revised the protocol, expanded the summary rating scale to seven points, and added more illustrations. Fourteen participating neuroradiologists evaluated 28 MR scans of elderly patients, giving us the basis for judging interrater agreement. We obtained acceptable intraclass correlations (greater than 0.79) for rating the size of the lateral and third ventricles and the temporal horn. Less satisfactory intraclass correlations occurred when rating other areas, including (1) global atrophy of the brain (0.70); (2) dilatation of the sulci of the temporal lobe (0.66); (3) frequency, location, and severity of white matter lesions (0.77); (4) sylvian fissure enlargement (0.70); and (5) cerebral sulcal dilatation (0.64). We also saw considerable variation in the reporting of cortical and lacunar infarcts. Despite careful design of the rating methodology and readings by experienced neuroradiologists, we did not find satisfactory interrater agreement for interpreting MR findings in elderly subjects. These findings may explain the difficulties encountered in applying similar subjective rating techniques that meet with success at one institution to multicenter studies. More objective and reproducible procedures are needed for interpretation of neuroimaging findings of AD in multicenter studies.

The adrenoleukodystrophies.

Clinical, biochemical, and genetic studies of adrenoleukodystrophy (ALD) are of current interest for six main reasons. First, assays of plasma lipids or cultured skin fibroblasts or amniocytes permit precise diagnosis of persons affected by the disease, as well as prenatal diagnosis and carrier detection. Second, the general nature of the enzymatic defect has been identified and the ALD gene has been mapped to the q28 segment of the X-chromosome. Third, the disease is more common than had been previously recognized. We have identified 350 patients in over 200 kindreds. Fourth, phenotypic variability is a striking feature. The illness may present as a rapidly fatal neurological disorder in early childhood or as a chronic progressive paraparesis in young, middle-aged, or even older adults. The latter syndrome is referred to as adrenomyeloneuropathy (AMN). It is of particular interest that these variants occur regularly within the same kindred, so that the phenotypic variation cannot be attributed to different genetic mutations. A fifth feature of interest is that in this X-linked disorder 12 to 40% of female carriers show various degrees of neurological disability, although almost always milder than in the hemizygous male. Studies with cultured fibroblasts suggest that mutant ALD cell lines have a competitive advantage over normal cell lines, a phenomenon which has not been observed in any other disorder. Finally, ALD appears to be one example of a peroxisomal disorder. Knowledge about the normal function of this subcellular organelle has emerged only recently, and further studies of ALD and related disorders will contribute to this.

Preliminary communication: neuroanatomical variations of the posterior fossa in men with the fragile X (Martin-Bell) syndrome.

Four men with fragile X (fra (X], or Martin-Bell, syndrome were studied by magnetic resonance imaging (MRI) to determine whether detectable abnormalities of the cerebellum were present. The cerebellum was chosen because of the apparently increased tendency for fra (X) patients to demonstrate autistic behavior and accumulating evidence implicating cerebellar abnormalities in autism. Compared with a control group of four normal men, fra (X) patients had a significantly decreased area of the cerebellar vermis, particularly the posterior portion, on planimetric analysis in the midsagittal plane. The pons and fourth ventricular areas also were decreased and increased, respectively, in the fra (X) men. Neuroanatomical and animal research increasingly implicates the cerebellar vermis as an important component in functional brain systems subserving sensory and motor integration, learning, and modulation of affect, motivation, and social behavior. Thus, vermis dysfunction could account for many of the behavioral and cognitive abnormalities observed in fra (X) males, particularly those which overlap with the behavioral syndrome of autism.

Positive contrast ventriculography in cats with experimental obstructive hydrocephalus.

Cerebrospinal fluid pathways were studied in both normal and experimental obstructed hydrocephalic cats by positive contrast ventriculography. Either water soluble or insoluble contrast material was injected into the lateral cerebral ventricles, and radiographs were taken of the head and spinal cord. In the normal cat, the contrast material freely flowed throughout the spinal fluid spaces. The contrast material accumulated in the cisterna magna, and from there extended into the cranial and spinal subarachnoid spaces. In the kaolin-induced hydrocephalic cat, the outlets from the fourth ventricle were obstructed, and direct communication between the ventricular system and the subarachnoid spaces no longer existed. In these cats, the contrast material passed directly down the central canal of spinal cord and its movement was followed throughout the entire length of the canal. At the lower lumbar-sacral regions, the material perforated the cord and flowed into the subarachnoid space. At all levels, the central canal was enlarged and local dilatations were seen extending dorsally.