TNF-inhibitors or bisphosphonates in chronic nonbacterial osteomyelitis? - Results of an international retrospective multicenter study.

Chronic nonbacterial osteomyelitis (CNO) can cause significant morbidity, including bone pain and damage. In the absence of clinical trials, treatments include non-steroidal anti-inflammatory drugs, corticosteroids, TNF-inhibitors (TNFi) and/or bisphosphonates. In a retrospective chart review in the United Kingdom and Germany, we investigated response to TNFi and/or pamidronate. Ninety-one patients were included, receiving pamidronate (n = 47), TNFi (n = 22) or both sequentially (n = 22). Patients with fatigue [p = 0.003] and/or arthritis [p = 0.002] were more frequently treated with TNFi than pamidronate. Both therapies were associated with clinical remission at 6 months, and reduction of bone lesions on MRI at 12 months. While not reaching statistical significance, pamidronate resulted in faster resolution of MRI lesions. Fewer flares were observed with TNFi. Failure to respond to pamidronate was associated with female sex [p = 0.027], more lesions on MRI [p = 0.01] and higher CRP levels [p = 0.03]. Randomized clinical trials are needed to confirm observations and generate evidence.

Peracetic acid as an alternative disinfection technology for wet weather flows.

Rain-induced wet weather flows (WWFs) consist of combined sewer overflows, sanitary sewer overflows, and stormwater, all of which introduce pathogens to surface waters when discharged. When people come into contact with the contaminated surface water, these pathogens can be transmitted resulting in severe health problems. As such, WWFs should be disinfected. Traditional disinfection technologies are typically cost-prohibitive, can yield toxic byproducts, and space for facilities is often limited, if available. More cost-effective alternative technologies, requiring less space and producing less harmful byproducts are currently being explored. Peracetic acid (PAA) was investigated as one such alternative and this research has confirmed the feasibility and applicability of using PAA as a disinfectant for WWFs. Peracetic acid doses ranging from 5 mg/L to 15 mg/L over contact times of 2 to 10 minutes were shown to be effective and directly applicable to WWF disinfection.

Dual-Functional Nanofiltration and Adsorptive Membranes for PFAS and Organics Separation from Water.

Challenges associated with water separation technologies for per- and polyfluoroalkyl substances (PFASs) require efficient and sustainable processes supported by a proper understanding of the separation mechanisms. The solute rejections by nanofiltration (NF) at pH values near the membrane isoelectric point were compared to the size- and mass-transfer-dependent modeled rejection rates of these compounds in an ionized state. We find that the low pK a value of perfluorooctanoic acid (PFOA) relates to enhanced solute exclusions by minimizing the presence and partitioning of the protonated organic compound into the membrane domain. The effects of Donnan exclusion are moderate, and co-ion transport also contributes to the PFAS rejection rates. An additional support barrier with thermo-responsive (quantified by water permeance variation) adsorption/desorption properties allows for enhanced separations of PFAS. This was possible by successfully synthesizing an NF layer on top of a poly-N-isopropylacrylamide (PNIPAm) pore-functionalized microfiltration support structure. The support layer adsorbs organics (178 mg PFOA adsorbed/m2 membrane at an equilibrium concentration of 70 mg/L), and the simultaneous exclusion from the NF layer allows separations of PFOA and the smaller sized heptafluorobutyric acid from solutions containing 70 µg/L of these compounds at a high water flux of 100 L/m2-h at 7 bar.

Antibiotics in treatment of peritonsillar infection: clindamycin versus penicillin.

OBJECTIVE: This study aimed to compare antibiotic treatment with clindamycin versus penicillin V or G in terms of time to recovery and recurrence in patients with peritonsillar infection, including both peritonsillar cellulitis and peritonsillar abscess. METHOD: This retrospective cohort study examined the records of 296 patients diagnosed with peritonsillar infection. Based on the ENT doctor's choice of antibiotics, patients were divided into clindamycin and penicillin groups. RESULTS: Mean number of days in follow up was 3.5 days in the clindamycin group and 3.4 days in the penicillin group. The recurrence rate within 2 months was 7 per cent in the clindamycin group and 4 per cent in the penicillin group. CONCLUSION: This study found no significant differences in either recovery or recurrence between the groups. This supports the use of penicillin as a first-line treatment, considering the greater frequency of adverse effects of clindamycin shown in previous studies, as well as its profound collateral damage on the intestinal microbiota, resulting in antibiotic resistance.

Dose and image quality evaluation of a dedicated cone-beam CT system for high-contrast neurologic applications.

OBJECTIVE: The purpose of our study was to evaluate the dose and image quality performance of a dedicated cone-beam CT (CBCT) scanner in comparison with an MDCT scanner. MATERIALS AND METHODS: The conventional dose metric, CT dose index (CTDI), is no longer applicable to CBCT scanners. We propose to use two dose metrics, the volume average dose and the mid plane average dose, to quantify the dose performance in a circular cone-beam scan. Under the condition of equal mid plane average dose, we evaluated the image quality of a CBCT scanner and an MDCT scanner, including high-contrast spatial resolution, low-contrast spatial resolution, noise level, CT number uniformity, and CT number accuracy. RESULTS: For the sinus scanning protocol, the CBCT system had comparable high-contrast resolution and inferior low-contrast resolution to those obtained with the MDCT scanner when the doses were matched (mid plane average dose 9.2 mGy). The CT number uniformity and accuracy were worse on the CBCT scanner. The image artifacts caused by beam hardening and scattering were also much more severe on the CBCT system. CONCLUSION: With a matched radiation dose, the CBCT system for sinus study has comparable high-contrast resolution and inferior low-contrast resolution relative to the MDCT scanner. Because of the more severe image artifacts on the CBCT system due to the small field of view and the lack of accurate scatter and beam-hardening correction, the utility of the CBCT system for diagnostic tasks related to soft tissue should be carefully assessed.

Imaging Review of Paraneoplastic Neurologic Syndromes.

Paraneoplastic syndromes are systemic reactions to neoplasms mediated by immunologic or hormonal mechanisms. The most well-recognized paraneoplastic neurologic syndrome, both clinically and on imaging, is limbic encephalitis. However, numerous additional clinically described syndromes affect the brain, spinal cord, and peripheral nerves. Many of these syndromes can have imaging findings that, though less well described, are important in making the correct diagnosis. Moreover, imaging in these syndromes frequently mimics more common pathology, which can be a diagnostic challenge for radiologists. Our goal is to review the imaging findings of paraneoplastic neurologic syndromes, including less well-known entities and atypical presentations of common entities. Specifically, we discuss limbic encephalitis, paraneoplastic cerebellar degeneration, paraneoplastic brain stem encephalitis, cranial neuropathy, myelitis, and polyneuropathy. We also demonstrate common diagnostic pitfalls that can be encountered when imaging these patients.

Spinal extradural arteriovenous malformations with parenchymal drainage: venous drainage variability and implications in clinical manifestations.

OBJECT: Although nontraumatic spinal arteriovenous malformations and fistulas (AVMs and AVFs) restricted to the epidural space are rare, they can lead to significant neurological morbidity. Careful diagnostic imaging is essential to their detection and the delineation of the pathological anatomy. Aggressive endovascular and open operative treatment can provide arrest and reversal of neurological deficits. METHODS: The authors report on 6 cases of extradural AVMs/AVFs causing progressive myelopathy. Clinical findings, diagnostic evaluation, treatment, and outcome are discussed. Special consideration is given to the anatomy of the lesions and the operative techniques used to treat them. A review of the literature concerning extradural vascular malformations is also presented. RESULTS: All 6 cases of extradural AVMs had an extradural fistulous location with intradural medullary venous drainage. These cases illustrate progressive myelopathy through cord venous congestion (hypertension) that can be caused by an extradural nidus or fistula. In 4 cases, a large epidural lake was identified on angiography. At surgery, the epidural lake was obliterated and medullary drainage interrupted. All patients had stabilization of their neurological deficits and successful obliteration of the AVM/AVF was obtained. CONCLUSIONS: Extradural AVMs and AVFs are a poorly described entity with published clinical experience limited to sporadic case reports and small series. Although these lesions have a purely extradural location of arteriovenous shunting and early venous drainage, they can be responsible for acute and progressive neurological symptoms similar to those caused by their dural-based intradural counterparts. With careful imaging recognition of the pathological anatomy, surgical and endovascular techniques can be used for the treatment of extradural AVMs affording effective and durable obliteration with stabilization or reversal of neurological symptoms. Venous drainage directly correlates the pathologic mechanisms of presentation. Specific attention must be paid intraoperatively to the epidural lake common to both variants so that recurrence is avoided.

Investigation of self-reported dizziness in the elderly when lying down or turning over in bed, and possible benign paroxysmal positional vertigo.

OBJECTIVES: This study aimed to investigate the rate of dizziness and occurrence of benign paroxysmal positional vertigo in the elderly by physical examination in those reporting dizziness symptoms when lying down or turning over in bed. METHODS: A total of 498 people, aged 70-85 years, were asked to complete a questionnaire regarding dizziness symptoms. Subjects answering that they became dizzy in bed were asked to participate in a physical examination and diagnostic manoeuvres investigating benign paroxysmal positional vertigo. RESULTS: A total of 324 participants (65 per cent) completed the questionnaire. More than one-quarter (29 per cent) reported dizziness and 32 (10 per cent) reported dizziness when turning in bed. Of these 32 persons, 22 (69 per cent) underwent a physical examination. Six participants tested positive for benign paroxysmal positional vertigo. CONCLUSION: Ten per cent of the elderly participants reported positional symptoms, and 6 out of 22 fulfilled diagnostic criteria for benign paroxysmal positional vertigo. Furthermore, benign paroxysmal positional vertigo was established despite a delay between questionnaire completion and investigation, emphasising that this type of dizziness may not be a self-limiting disorder.

Multiple cranial neuropathies as a presentation of spontaneous internal carotid artery dissection: A case report and literature review.

Cervical artery dissection is an underrecognized cause of lower cranial neuropathies and diagnosis can remain elusive if not properly investigated. We present a case of an internal carotid artery dissection that was initially missed in a 48-year-old man who presented with subacute-onset of dysarthria, dysphagia, and unilateral tongue weakness. Knowledge of the most common presenting symptoms, relevant neuroanatomy, and neuroimaging techniques is essential to avoid misdiagnosis. Pseudoaneurysm formation from subadventitial carotid artery dissection may result in compressive neuropathies of cranial nerves IX, X, XI, and XII without associated cerebral ischemia. The absence of intraluminal narrowing on CT or MR angiography should not dissuade the clinician; T1-weighted axial cervical MRI with fat-saturation provides the highest sensitivity and specificity to identify these lesions.

CT Dental Artifact: Comparison of an Iterative Metal Artifact Reduction Technique with Weighted Filtered Back-Projection.

BACKGROUND: Dental hardware produces streak artifacts on computed tomography (CT) images reconstructed with the standard weighted filtered back projection (wFBP) method. PURPOSE: To perform a preliminary evaluation of an iterative metal artifact reduction (IMAR) technique to assess its ability to improve anatomic visualization over wFBP in patients with dental amalgam or other hardware. MATERIAL AND METHODS: CT images from patients with dental hardware were reconstructed using wFBP and IMAR software and soft-tissue or bone window/level settings. The anatomy most affected by metal artifacts was identified. Two neuroradiologists determined subjective and objective imaging features, including overall metal artifact score (1 = severe artifacts, 5 = no artifacts), soft-tissue visualization score of the most-compromised structure, and artifact length along the skin surface. CT numbers were used to quantify artifact severity. RESULTS: Twenty-four patients were included. IMAR improved overall metal artifact score in 18/24 cases (median =2 ± 0.9 vs. 1 ± 0.6, P < 0.001). Mean CT number in the most-affected anatomical structure significantly improved with IMAR (94.6 vs. 219 HU, P = 0.002) and length of affected skin surface decreased (40.4 mm vs. 118.7 mm, P < 0.001). However, osseous/dental artifactual defects were found in 22/24 cases with IMAR vs. 11/24 with wFBP. CONCLUSION: IMAR software reduced metal artifact both subjectively and objectively and improved visualization of adjacent soft tissues. However, it produced a higher rate of artifactual defects in the teeth and bones than wFBP. Our findings support the use of IMAR as a valuable complement to, but not a replacement for, standard wFBP image reconstruction.

Bovine aortic arch variant in humans: clarification of a common misnomer.

The term "bovine arch" is widely used to describe a common anatomic variant of the human aortic arch branching. This so-called bovine aortic arch has no resemblance to the bovine aortic arch. We describe the most common human aortic arch branching patterns and compare these with the bovine aortic arch.

Middle and inner ear: improved depiction with multiplanar reconstruction of volumetric CT data.

Many anatomic structures of the middle and inner ear are not optimally depicted at computed tomography (CT) with image reconstruction in the standard axial and coronal planes. Recent advances in multidetector CT, including the development of scanners with 32 detector rows, allow the acquisition of isotropic voxels that can be reconstructed in any plane of section. This technique gives radiologists the opportunity to visualize the anatomic structures of the middle and inner ear (the ossicular chain, stapedial footplate-oval window complex, round window, cochlea, vestibular aqueduct, and bones of the superior semicircular canal and facial nerve canal) in greater detail and may help increase the accuracy of CT for the diagnosis of diseases of the middle and inner ear.

Nonaneurysmal Perimesencephalic Hemorrhage Is Associated with Deep Cerebral Venous Drainage Anomalies: A Systematic Literature Review and Meta-Analysis.

BACKGROUND AND PURPOSE: Mechanisms underlying bleeding in nonaneurysmal perimesencephalic SAH remain unclear. Previous investigators have suggested a relationship between nonaneurysmal perimesencephalic SAH and primitive venous drainage of the basal vein of Rosenthal. We performed a meta-analysis to evaluate the relation between primitive basal vein of Rosenthal drainage and nonaneurysmal perimesencephalic SAH. MATERIALS AND METHODS: We performed a comprehensive literature search of all studies examining the prevalence of primitive basal vein of Rosenthal drainage in patients with aneurysmal SAH and nonaneurysmal perimesencephalic SAH. Data collected were primitive basal vein of Rosenthal drainage (direct connection of perimesencephalic veins into the dural sinuses instead of the Galenic system) in at least 1 cerebral hemisphere, normal bilateral basal vein of Rosenthal drainage systems, and the number of overall primitive venous systems in the nonaneurysmal perimesencephalic SAH and aneurysmal SAH groups. Statistical analysis was performed by using a random-effects meta-analysis. RESULTS: Eight studies with 888 patients (334 with nonaneurysmal perimesencephalic SAH and 554 with aneurysmal SAH) and 1657 individual venous systems were included. Patients with nonaneurysmal perimesencephalic SAH were more likely to have a primitive basal vein of Rosenthal drainage in at least 1 hemisphere (47.7% versus 22.1%; OR, 3.31; 95% CI, 2.15-5.08; P < .01) and were less likely to have bilateral normal basal vein of Rosenthal drainage systems than patients with aneurysmal SAH (18.3% versus 37.4%; OR, 0.27; 95% CI, 0.14-0.52; P < .01). When we considered individual venous systems, there were higher rates of primitive venous systems in patients with nonaneurysmal perimesencephalic SAH than in patients with aneurysmal SAH (34.9% versus 15.3%; OR, 3.90; 95% CI, 2.37-6.43; P < .01). CONCLUSIONS: Patients with nonaneurysmal perimesencephalic SAH have a higher prevalence of primitive basal vein of Rosenthal drainage in at least 1 hemisphere than patients with aneurysmal SAH. This finding suggests a venous origin of some nonaneurysmal perimesencephalic SAHs. A primitive basal vein of Rosenthal pattern is an imaging finding that has the potential to facilitate the diagnosis of nonaneurysmal perimesencephalic SAH.

Tachykinin-induced nasal fluid secretion and plasma exudation in the rat: effects of peptidase inhibition.

Substance P (SP) evokes fluid secretion and plasma extravasation when applied to the nasal mucosa of rats. SP and another tachykinin, neurokinin A (NKA), are degraded in vitro by neutral endopeptidase (NEP) and angiotensin-1-converting enzyme (ACE). In this study, NKA or SP were applied locally to the nasal mucosa of rats. Subsequent fluid secretion was measured by a filter paper technique. Plasma exudation was derived as the recovery of intravenous (i.v.) administered 125I-albumin from the fluid-containing filter papers. In order to inhibit enzymatic degradation of the tachykinins by NEP and ACE, the rats were treated with i.v. administered phosphoramidon or captopril respectively or their combination. SP evoked fluid secretion that was augmented by phosphoramidon and further enhanced by adding captopril. NKA evoked nasal fluid secretion less effectively than SP and the effect was unaffected by peptidase inhibition. SP, but not NKA, evoked increased plasma exudation but only after pre-treatment with phosphoramidon.

MR imaging and diffusion-weighted imaging changes in metronidazole (Flagyl)-induced cerebellar toxicity.

We describe a case demonstrating reversible MR imaging findings, including diffusion-weighted imaging changes in association with metronidazole (Flagyl) toxicity. The diagnosis of metronidazole toxicity was made clinically and supported by the MR imaging findings. Quantitative apparent diffusion coefficient (ADC) maps demonstrated edema with associated increased ADC values within the dentate nuclei of the cerebellum on initial imaging. Follow-up imaging performed 8 weeks after cessation of metronidazole therapy demonstrated resolution of imaging findings, including diffusion changes.

Diagnosis and treatment of destructive behavior in dogs.

Destructive behavior in dogs can be expensive for owners and life-threatening for dogs. The human-companion animal bond is jeopardized. A diagnostic plan should address both behavioral and medical causes of destructive behavior. Once a diagnosis has been established, a successful therapeutic plan can be formulated. Treatment includes modification of both behavior and environment and may incorporate the judicious use of psychotropic medication.

Limb salvage tumor surgery in children.

Limb salvage tumor surgery in children is quite popular. Low local recurrence rates and patient survival statistics prove it is a viable option for many patients. We review the major changes in medicine and paramedical fields that have allowed limb salvage to develop. We then discuss patient selection, limb salvage goals, review the surgical staging system, and examine common errors in evaluating a tumor patient. A discussion (with case examples) of various surgical options and a brief look at some current trends is then presented.

Reactive Functionalized Membranes for Polychlorinated Biphenyl Degradation.

Membranes have been widely used in water remediation (e.g. desalination and heavy metal removal) because of the ability to control membrane pore size and surface charge. The incorporation of nanomaterials into the membranes provides added benefits through increased reactivity with different functionality. In this study, we report the dechlorination of 2-chlorobiphenyl in the aqueous phase by a reactive membrane system. Fe/Pd bimetallic nanoparticles (NPs) were synthesized (in-situ) within polyacrylic acid (PAA) functionalized polyvinylidene fluoride (PVDF) membranes for degradation of polychlorinated biphenyls (PCBs). Biphenyl formed in the reduction was further oxidized into hydroxylated biphenyls and benzoic acid by an iron-catalyzed hydroxyl radical (OH•) reaction. The formation of magnetite on Fe surface was observed. This combined pathway (reductive/oxidative) could reduce the toxicity of PCBs effectively while eliminating the formation of chlorinated degradation byproducts. The successful manufacturing of full-scale functionalized membranes demonstrates the possibility of applying reactive membranes in practical water treatment.

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is not always completely reversible: a case series.

We retrospectively reviewed clinical and imaging findings in 11 patients with stroke-like migraine attacks after radiation therapy (SMART) syndrome to better understand this disorder previously thought to be reversible. Six men and 5 women had complex bouts of neurologic impairment beginning, on average, 20 years after cerebral irradiation. All had characteristic, unilateral gyriform enhancement on MR imaging that developed within 2-7 days and typically resolved in 2-5 weeks. Unlike prior reports, 45% had incomplete neurologic recovery manifesting as dysphasia, cognitive impairment, or hemiparesis. The remaining 55% recovered completely over an average of 2 months. Three of 11 patients developed cortical laminar necrosis. Brain biopsies in 4 of 11 did not demonstrate a specific pathologic substrate. These additional 11 patients contribute to the understanding of variability in stroke-like migraine attacks after radiation therapy syndrome, which often but not uniformly manifests with headaches and seizures, demonstrates a typical evolution of imaging findings, and may result in permanent neurologic and imaging sequelae.