Challenges of imaging injured Paralympic Athletes.

The pattern and mechanism of sports injuries in disabled athletes and the challenges to overcome such injuries is well documented. However, there is limited information regarding the specifics of medical imaging of the injured disabled athletes. This article, reflects on the experience gained during the organisation and provision of the imaging services for the London 2012 Paralympic games. The knowledge gained during these games, in conjunction with information from the existing literature on sporting injuries in disabled athletes can help planning and delivery of well-coordinated imaging services at major disability sporting events.

Life threatening chop injuries to the head: optimising injury interpretation using three dimensional computerised tomography (3DCT) reconstruction of pre-treatment imaging.

Computerised tomography (CT) is being increasingly advocated to support post mortem investigation of death but the value of using CT data already captured during emergency imaging, prior to treatment of life threatening injuries, remains under recognised and inadequately explored. We demonstrate the value of three dimensional computerised tomography (3D CT) reconstructions of such data, in interpreting the injuries sustained by a male who survived after being subjected to an assault with an axe and whose surface injuries had been debrided and sutured, before any photography was undertaken. The 3D CT images captured most of the scalp, face and skull vault trauma prior to the surgical intervention. Taken with other evidence, this indicated that the victim had received at least four separate blows to the face and head with a sharp chopping weapon; evidence which proved to be centrally important in the subsequent criminal court proceedings. This case also illustrated the effectiveness of joint interpretation of 3D CT reconstructed images in medico-legal casework, by experienced consultants in forensic pathology and radiology and the potential value of reviewing emergency pre-treatment CT imaging in any serious head injury allegedly sustained in an assault. This is likely to be particularly valuable when sharp or blunt weapon damage to bone is suspected.

Radiological interventions for soft tissue injuries in sport.

Injection therapy has played an integral role in the rehabilitation of sports injuries for many years. The athlete's primary goal is a rapid return to sporting activity. This may be achieved by a combination of either a temporary or permanent reduction in pain, and by a pharmacological or physiological effect that promotes or accelerates a healing response. A wide variety of pharmacological agents are used. However, there is often a lack of good evidence that quantifiable effects can be achieved. There are restrictions on the use of some pharmaceutical agents. This article reviews the various pharmacological agents and bioactive substrates that are available, and discusses the current evidence base of their use in common sports injuries.

Trypanosoma irwini n. sp (Sarcomastigophora: Trypanosomatidae) from the koala ( Phascolarctos cinereus).

The morphology and genetic characterization of a new species of trypanosome infecting koalas (Phascolarctos cinereus) are described. Morphological analysis of bloodstream forms and phylogenetic analysis at the 18S rDNA and gGAPDH loci demonstrated this trypanosome species to be genetically distinct and most similar to Trypanosoma bennetti, an avian trypanosome with a genetic distance of 0.9% at the 18S rDNA and 10.7% at the gGAPDH locus. The trypanosome was detected by 18S rDNA PCR in the blood samples of 26 out of 68 (38.2%) koalas studied. The aetiological role of trypanosomes in koala disease is currently poorly defined, although infection with these parasites has been associated with severe clinical signs in a number of koalas. Based on biological and genetic characterization data, this trypanosome species infecting koalas is proposed to be a new species Trypanosome irwini n. sp.

Compliance with biologic therapies for rheumatoid arthritis: do patient out-of-pocket payments matter?

OBJECTIVE: To assess the impact of patient out-of-pocket (OOP) expenditures on adherence and persistence with biologics in patients with rheumatoid arthritis (RA). METHODS: An inception cohort of RA patients with pharmacy claims for etanercept or adalimumab during 2002-2004 was selected from an insurance claims database of self-insured employer health plans (n=2,285) in the US. Adherence was defined as medication possession ratio (MPR): the proportion of the 365 followup days covered by days supply. Persistence was determined using a survival analysis of therapy discontinuation during followup. Patient OOP cost was measured as the patient's coinsurance and copayments per week of therapy, and as the proportion of the total medication charges paid by the patient. Multivariate linear regression models of MPR and proportional hazards models of persistence were used to estimate the impact of cost, adjusting for insurance type and demographic and clinical variables. RESULTS: Mean +/- SD OOP expenditures averaged $7.84+/-$14.15 per week. Most patients (92%) paid less than $20 OOP for therapy/week. The mean +/- SD MPR was 0.52+/-0.31. Adherence significantly decreased with increased weekly OOP (coeff= -0.0035, P<0.0001) and with a higher proportion of therapy costs paid by patients (coeff= -0.8794, P<0.0001), translating into approximately 1 week of therapy lost per $5.50 increase in weekly OOP. Patients whose weekly cost exceeded $50 were more likely to discontinue than patients with lower costs (hazard ratio 1.58, P<0.001). CONCLUSION: Most patients pay less than $20/week for biologics, but a small number have high OOP expenses, associated with lower medication compliance. The adverse impact of high OOP costs on adherence, persistence, and outcomes must be considered when making decisions about increasing copayments.

Experimental Trypanosoma evansi infection in the goat. II. Pathology.

Infection of male goats aged 8-10 months with 5000 or 50 000 organisms of a Mindanao strain of Trypanosoma evansi was observed over a period of 90 days. The infection induced clinical disease which was lethal, especially at the higher dose rate. Lesions were more acute in goats that received the higher dose. Gross and microscopical changes were not pathognomonic, except in the presence of demonstrable trypanosomes. At necropsy, a combination of lymphadenopathy, splenomegaly, hepatomegaly, testicular enlargement, anaemic signs and consolidation of the anterior lobes of the lungs was suggestive of surra. Testicular changes, especially aspermia, indicated probable infertility. The cytopathology of the lungs, liver, intestine, kidneys, testes, bone marrow, brain and other organs was immunological in nature, characterized by mononuclear infiltration of interstitial tissues, with minor cellular damage and the presence of trypanosomes. B- and T- cell responses were observed in the lymphatic system, but the findings indicated immunosuppression in the lymph nodes, spleen and bone marrow during the third month after infection. Exudative inflammatory changes were mild. It is suggested that the cytopathology of most haemophilic trypanosomal infections is predominantly an immunological process.

Juvenile spondylolysis: a comparative analysis of CT, SPECT and MRI.

OBJECTIVE: To evaluate whether MRI correlates with CT and SPECT imaging for the diagnosis of juvenile spondylolysis, and to determine whether MRI can be used as an exclusive image modality. DESIGN AND PATIENTS: Juveniles and young adults with a history of extension low back pain were evaluated by MRI, CT and SPECT imaging. All images were reviewed blindly. Correlative analyses included CT vs MRI for morphological grading and SPECT vs MRI for functional grading. Finally, an overall grading system compared MRI vs CT and SPECT combined. Statistical analysis was performed using the kappa statistic. RESULTS: Seventy-two patients (mean age 16 years) were recruited. Forty pars defects were identified in 22 patients (31%), of which 25 were chronic non-union, five acute complete defects and ten acute incomplete fractures. Kappa scores demonstrated a high level of agreement for all comparative analyses. MRI vs SPECT (kappa: 0.794), MRI vs CT (kappa: 0.829) and MRI vs CT/SPECT (kappa: 0.786). The main causes of discrepancy were between MRI and SPECT for the diagnosis of stress reaction in the absence of overt fracture, and distinguishing incomplete fractures from intact pars or complete defects. CONCLUSIONS: MRI can be used as an effective and reliable first-line image modality for diagnosis of juvenile spondylolysis. However, localised CT is recommended as a supplementary examination in selected cases as a baseline for assessment of healing and for evaluation of indeterminate cases.

A cholesterol-containing foreign body granuloma presenting as an inter-metatarsal bursa.

A 68-year-old man presented with progressive forefoot swelling which coincided with the onset of type 2 diabetes mellitus. Imaging revealed a cystic inter-metatarsal mass containing two foreign bodies, which had been present for many years. Following aspiration of the mass, cholesterol crystals were observed on polarised microscopy. It is postulated that the development of diabetes triggered the shedding of cholesterol crystals around a long-standing quiescent foreign body granuloma.

Single Nucleotide Polymorphisms and Microarray Technology in Forensic Genetics - Development and Application to Mitochondrial DNA.

Variations in the genome, due to base substitutions, insertions, or deletions at single positions, are known as single nucleotide polymorphisms (SNPs). Approximately 85% of human variation is based on such polymorphisms. Therefore, there is an abundance of human SNPs that are available for forensic identity testing purposes. SNP analyses also may be suitable for some forensic identity cases, because they can be detected in smallsized amplicons, allowing for genetic analysis of substantially degraded DNA. While SNP analysis is unlikely to replace short tandem repeat loci typing for routine casework, SNPs may prove useful for certain circumstances, for example, typing mitochondrial DNA (mtDNA). Although sequencing mtDNA enables detection of all SNPs contained within the region of interest, it is currently not a practical approach for simultaneously typing SNPs that reside throughout the entire mtDNA genome. A variety of alternate methods to detect SNPs are available that may facilitate mtDNA analysis. All the methods include amplification, typically by the polymerase chain reaction, of the region containing the SNP of interest. Most assays are based on either hybridization of a probe to amplified product or primer extension chemistry, and multiplexing is possible. Some of these methodologies are: chips, SNaP shot™, Luminex 100™, SNPstream® UHT, and Pyrosequencing™. SNP analysis of mtDNA, both in the noncoding and coding regions, has been demonstrated using a number of these formats.

Intraosseous lipoma: report of 35 new cases and a review of the literature.

OBJECTIVE: To identify the common imaging features of intraosseous lipomas on radiographs, magnetic resonance imaging (MRI) and computed tomography (CT), and review their histological features. DESIGN AND PATIENTS: Thirty-five previously unreported cases of intraosseous lipoma were reviewed and a meta-analysis was performed of another 110 cases identified from the English language literature. RESULTS: The mean age at presentation is 43 years. Sex distribution is nearly equal. Lipomas occur most frequently in the lower limb (71% overall), particularly in the os calcis (32%). Other common sites include the metaphyses of long bones, where lesions are typically eccentric. Lipomas are usually well defined, but marginal sclerosis is commoner in lesions of the os calcis (61%) than at other sites (38%). Calcification is also more frequent in the os calcis (62%), and almost invariably centrally located. Calcification at other sites is less common (30%), and is more variable in appearance. Bone expansion is less common (30%), and usually minimal. Fat necrosis and cyst formation identified on MRI is common (67%), and more frequent in the os calcis. CONCLUSIONS: Although there is correlation between the histological and radiological features of intraosseous lipomas in general, some discrepancies occur in the radiological appearances of lipomas in different sites. The evidence that these lesions are true benign tumours of fat is controversial. Several aetiological factors have been implicated in their development. The constant location of os calcis lesions at the critical angle suggests an aetiology that may be related to biomechanical lines of stress. In other instances it is possible that involution of pre-existing lesions may lead to the development of lipomas.

The role of diagnostic radiology in compressive and entrapment neuropathies.

Diagnostic imaging is increasingly being utilised to aid the diagnosis of compression and entrapment neuropathies. Cross-sectional imaging, primarily ultrasound and magnetic resonance imaging, can provide exquisite anatomical detail of peripheral nerves and the changes that may occur as a result of compression. Imaging can provide a useful diagnostic aid to clinicians, which may supplement clinical evaluation, and may eventually provide an alternative to other diagnostic techniques such as nerve conduction studies. This article describes the abnormalities that may be demonstrated by current imaging techniques, and critically analyses the impact of imaging in diagnosis of peripheral compressive neuropathy.

Fully automated software to monitor wear in prosthetic knees using fluoroscopic images.

Total knee arthroplasty is now a widely accepted treatment for late-stage arthritis. Wear of the polyethylene layer in prosthetic knees is a known cause of implant failure. Early detection of wear may allow prediction of device failure. In this paper we describe a fully automated image processing algorithm to measure the minimum tibiofemoral joint space width (mJSW) for monitoring prosthesis wear radiographically. The femoral portion and tibial plate were automatically delineated and mJSW was calculated in each compartment. The software also delineated the tip of the prosthesis pin in order to make a magnification correction. The algorithm was tested with a set of triplicate acquisitions of 18 fluoroscopic knee images. The RMS standard deviation (RMSSD) for the triplicate measurements was calculated as a figure of merit. The RMSSD was 0.077 and 0.087 mm for the lateral and medial compartments. The computer successfully found the minimum JSW for both compartments in all 54 images. A single case (2% of total) required user interaction to correct for an obvious failure to delineate the prosthesis pin. We document a robust and precise tool for quantifying mJSW to monitor prosthesis wear.

Surface temperature of two portable ventilators during simulated use under clinical conditions.

During performance testing of portable ventilators, it was noted that an area on the case of one of the devices, the LTV 1000, was noticeably warm. This investigation examined the case temperatures of this portable ventilator and a portable ventilator currently in the Department of Defense inventory, the Uni-Vent 754, during simulated clinical conditions. Both have an integral method of producing compressed air. The hottest portion of the cases of the LTV 1000 and the Uni-Vent 754 reached temperatures of 39.9 to 46.7 degrees C and 35.4 to 35.9 degrees C, respectively, across a range of simulated clinical conditions. Investigations have found the risk of burns to increase with temperatures greater than 40 degrees C. The cases of these devices are not designed to be in contact with the skin. Personnel should properly position these and other devices during patient transport and not allow contact with the patient's skin.

Adaptive support ventilation.

Adaptive support ventilation (ASV) is a newer form of closed-loop ventilation control available on the Galileo ventilator (Hamilton Medical). ASV provides automated selection of initial ventilator parameters based on measurements of patient lung mechanics and breathing effort. After initiation, ASV will "titrate" ventilator output (mandatory breath rate, tidal volume, inspiratory pressure, inspiratory time, and I to E ratio) to maintain a calculated optimal breathing pattern that ensures delivery of a clinician selected minute ventilation target. ASV may be thought of as an "electronic" ventilator management protocol that may improve the safety and efficacy of mechanical ventilation. Additional clinical investigations regarding the effect of ASV on outcome, ventilator days, and so forth are forthcoming.

Work of breathing characteristics of seven portable ventilators.

Portable ventilators (PVs) are used for patient transport with increasingly frequency. Due to design differences it would not be unexpected to find differences among these ventilators in the imposed work of breathing (WOBI) during spontaneous respiratory efforts. The purpose of this investigation was to compare the WOBI characteristics during spontaneous breathing of seven PVs; Bird Avian, Bio-Med Crossvent 4, Pulmonetics LTV 1000, Hamilton Max, Drägerwerk Oxylog 2000, Impact Uni-Vent 750, and Impact Uni-Vent 754 using a model of spontaneous breathing. Differences between the PVs in regards to the measured parameters increased with increases in simulated breathing demand. WOBI, peak inspiratory pressure, and pressure-time product were consistently less with the LTV 1000 over the range of simulated breathing conditions. During pressure support ventilation these parameters were significantly less with the LTV 1000 compared with the Crossvent 4. Only the WOBI produced by the LTV was consistently lower than the physiologic work of breathing across the simulated spontaneous breathing conditions. Based on these results it is predicted PVs with flow triggering and positive end-expiratory pressure compensation will consistently offer the least WOBI. Clinicians should be aware of these characteristics when using PVs with spontaneous breathing patients.

Prone positioning and inhaled nitric oxide: synergistic therapies for acute respiratory distress syndrome.

BACKGROUND: Inhaled nitric oxide (INO) and prone positioning have both been advocated as methods to improve oxygenation in patients with acute respiratory distress syndrome (ARDS). This study was designed to evaluate the relative contributions of INO and prone positioning alone and in combination on gas exchange in trauma patients with ARDS. METHODS: Sixteen patients meeting the consensus definition of ARDS were studied. Patients received mechanical ventilation in the supine position, mechanical ventilation plus INO at 1 part per million in the supine position, mechanical ventilation in the PP, and mechanical ventilation in the prone positioning plus INO at 1 part per million. A stabilization period of 1 hour was allowed at each condition. After stabilization,hemodynamic and gas exchange variables were measured. RESULTS: INO and prone positioning both increased PaO2/FIO2 compared with ventilation in the supine position. PaO2/FIO2 increased by 14% during use of INO, and 10 of 16 patients (62%) responded to INO in the supine position. PaO2/FIO2 increased by 33%, and 14 of 16 patients (87.5%) responded to the prone position. The combination of INO and prone positioning resulted in an improvement in PaO2/FIO2 in 15 of 16 patients(94%), with a mean increase in PaO2/FIO2 of 59%. Pulmonary vascular resistance was reduced during use of INO, with a greater reduction in pulmonary vascular resistance seen with INO plus prone positioning (175 +/- 36 dynes x s/cm5 vs. 134 +/- 28 dynes x s/cm5) compared with INO in the supine position (164 +/- 48 dynes x s/cm5 vs.138 +/- 44 dynes x s/cm5). There were no significant hemodynamic effects of INO or prone positioning and no complications were seen during this relative short duration of study. CONCLUSIONS: INO and prone positioning can contribute to improved oxygenation in patients with ARDS. The two therapies in combination are synergistic and may be important adjuncts to mechanical ventilation in the ARDS patient with refractory hypoxemia.

Current concepts in imaging of tendinopathy.

With the rising popularity of recreational sports, radiologists are being asked to image tendons with increasing frequency. Recognition of the critical link tendons provide between muscle and bone has also led to a better understanding of the processes leading to tendon damage. While plain radiography and CT have only a limited role to play in the diagnosis of tendon abnormality, the improvements in ultrasound and MRI technology mean that tendons can now be demonstrated in exquisite detail and previously undetectable abnormalities are readily demonstrated. This article reviews the structure and pathological processes affecting tendons and discusses the role of imaging in their assessment with an emphasis on ultrasound and MRI.