Simulation-Based Abdominal Ultrasound Training - A Systematic Review.

PURPOSE: The aim is to provide a complete overview of the different simulation-based training options for abdominal ultrasound and to explore the evidence of their effect. MATERIALS AND METHODS: This systematic review was performed according to the PRISMA guidelines and Medline, Embase, Web of Science, and the Cochrane Library was searched. Articles were divided into three categories based on study design (randomized controlled trials, before-and-after studies and descriptive studies) and assessed for level of evidence using the Oxford Centre for Evidence Based Medicine (OCEBM) system and for bias using the Cochrane Collaboration risk of bias assessment tool. RESULTS: Seventeen studies were included in the analysis: four randomized controlled trials, eight before-and-after studies with pre- and post-test evaluations, and five descriptive studies. No studies scored the highest level of evidence, and 14 had the lowest level. Bias was high for 11 studies, low for four, and unclear for two. No studies used a test with established evidence of validity or examined the correlation between obtained skills on the simulators and real-life clinical skills. Only one study used blinded assessors. CONCLUSION: The included studies were heterogeneous in the choice of simulator, study design, participants, and outcome measures, and the level of evidence for effect was inadequate. In all studies simulation training was equally or more beneficial than other instructions or no instructions. Study designs had significant built-in bias and confounding issues; therefore, further research should be based on randomized controlled trials using tests with validity evidence and blinded assessors.

HIV-infected patients with a large thymus maintain higher CD4 counts in a 5-year follow-up study of patients treated with highly active antiretroviral therapy.

CD4 recovery in HIV-infected patients treated with highly active antiretroviral therapy (HAART) is in part believed to be dependent on the degree of preserved thymic function. We investigated whether the thymus has a prolonged effect on CD4 recovery. Total and naïve CD4 counts as well as thymic output determined as the number of CD4 + cells containing T-cell receptor-rearrangement excision DNA circles were measured prospectively in 25 HIV-infected patients with known thymic size during 5 years of HAART. Patients with larger thymic size had at all time points of follow-up significantly higher CD4 counts than patients with minimal thymic size (P = 0.0036). The CD4 increase from time of initiation of HAART until 6 months of follow-up differed significantly between the two thymic groups (P = 0.045), but did not at later time points. Thymic output remained significantly higher in patients with larger thymic size at follow-up. However, no difference in the increase in thymic output was seen between thymic groups. In conclusion, the importance of the thymus to the rate of cellular restoration seems primarily to lie within the first two years of HAART. However, patients with larger thymic size are able to maintain higher CD4 counts even after 5 years of HAART.

Limited impact of the thymus on immunological recovery during and after chemotherapy in patients with diffuse large B-cell lymphoma.

To investigate the impact of thymus on immunological recovery after dose-dense chemotherapy a prospective study of 17 patients diagnosed with diffuse large B-cell lymphoma (DLBCL) was conducted. Patients were monitored before, during and until 3 months after chemotherapy. The thymus was visualized using computer tomographic scans. Patients were divided into two groups according to thymic size, one group comprising of patients without detectable thymus and one group of patients with detectable thymus. Naïve CD4 and CD8 counts were measured by flow cytometry, and to measure thymic output determination of CD4+ cells containing T-cell receptor excision circles (TREC) was done. During chemotherapy, the naïve CD4 count decreased significantly as did the CD4-TREC%. Significant difference in recovery of naïve CD4 counts between patients with detectable and undetectable thymic tissue during treatment with chemotherapy was not found. CD4-TREC% was associated with lower age. It was not possible to demonstrate an association between thymic size and recovery of the naïve CD4+ cells. The study terminated 3 months after the last cycle of chemotherapy, and at that time point the naïve CD4 counts and the CD4-TREC% had not returned to pretreatment levels. However, patients with detectable thymic tissue had higher naïve CD4 counts after the first cycles of chemotherapy, suggesting that these patients may be less susceptible to infectious complications related to chemotherapy.

Does low-field dedicated extremity MRI (E-MRI) reliably detect bone erosions in rheumatoid arthritis? A comparison of two different E-MRI units and conventional radiography with high-resolution CT scanning.

OBJECTIVES: To compare the ability of two different E-MRI units and conventional radiography (CR) to identify bone erosions in rheumatoid arthritis (RA) metacarpophalangeal (MCP) and wrist joints with CT scanning as the standard reference method. METHODS: 20 patients with RA and 5 controls underwent CR, CT and two E-MRI examinations (Esaote Biomedica Artoscan and MagneVu MV1000) of one hand during a 2-week period. In all modalities, each bone of the wrist and MCP joints was blindly evaluated for erosions. MagneVu images were also assessed for the proportion of each bone being visualised. RESULTS: 550 bones were examined. CT, Artoscan, MagneVu and CR detected 188, 116, 55 and 45 bones with erosions, respectively. The majority were located in the carpal bones. The sensitivity of the Artoscan for detecting erosions was higher than that of the MagneVu and CR (MCP joints: 0.68, 0.54 and 0.57, respectively; wrists: 0.50, 0.23 and 0.29). Corresponding specificities for detecting erosions were 0.94, 0.93 and 0.99, respectively, in the MCP joints and 0.92, 0.98 and 0.98 in the wrist. The MagneVu allowed visualisation of 1.5 cm of the ventral-dorsal diameter of the bone. In the wrist, 31.6% of bones were visualised entirely and 37.9% of bones were 67-99% visualised. In MCP joints, 84.2% of bones were visualised entirely and 15.8% of bones were 67-99% visualised. CONCLUSION: With CT as the reference method for detecting erosions in RA hands, the Artoscan showed higher sensitivity than the MagneVu and CR. All imaging modalities had high specificities. The better performance of the Artoscan should be considered when selecting an imaging method in RA.

Acute patellofemoral pain: aggravating activities, clinical examination, MRI and ultrasound findings.

OBJECTIVE: To investigate acute anterior knee pain caused by overuse in terms of pain location, aggravating activities, findings on clinical examination and ultrasound/MRI examination. To determine if acute anterior knee pain caused by overuse should be classified as a subgroup of patellofemoral pain syndrome (PFPS). METHODS: In a observational study design 30 army recruits with anterior knee pain (mean duration of pain 4 weeks) were examined using the PFPS pain severity scale (PSS), knee pain diagrams, standardised clinical examination, ultrasound and MRI examinations. RESULTS: On PSS typical knee loading activities were the most painful, while sitting with knee bend for prolonged time caused surprisingly little pain. Pain was most commonly perceived in the peripatellar area (25 patients (83%)). The most common site of pain on clinical examination was the peripatellar area (25 patients (83%)), but other synovial covered structures including the fat pad of Hoffa (12 patients (40%)), the medial plica and the joint line (12 patients (40%)) were also involved. Only eight patients (27%) experienced pain on the patellofemoral compression test. Only discrete changes was detected on MRI/ultrasound. CONCLUSIONS: Acute anterior knee pain should be regarded as a subgroup of PFPS as both symptoms and clinical examination suggests this. The clinical examination with disseminated pain in all synovial covered structures is consistent with ideas of the importance of synovium in the genesis of pain.

Detection of rheumatoid arthritis bone erosions by two different dedicated extremity MRI units and conventional radiography.

OBJECTIVES: To compare the ability of two different dedicated extremity MRI (E-MRI) units and conventional radiography (CR) for identifying bone erosions in rheumatoid arthritis (RA) metacarpophalangeal (MCP) and wrist joints. METHODS: CR and two MRI examinations (using 0.2 T Esaote Artoscan and 0.2 T portable MagneVu MV1000 units) of 418 bones in the dominant wrist and second to fifth MCP joints of 15 patients with RA and 4 healthy controls were performed and evaluated blindly for bones being visible and for erosions. RESULTS: In MCP joints, MagneVu visualised 18.5% of bones entirely and 71.1% were 67-99% visualised. In wrists, MagneVu visualised 1.5% of bones entirely, 39.8% were 67-99% visualised and 19% were not visualised at all. Artoscan and CR visualised all bones entirely. Artoscan, MagneVu and CR found 22, 19 and 15 bones with erosions in MCP joints and 66, 40 and 13 bones with erosions in wrist joints, respectively. With the previously validated Artoscan unit as standard reference, MagneVu and CR had sensitivities of 0.82 and 0.55, respectively, in MCP joint bones and 0.41 and 0.14 in wrist bones. Specificities of CR and MagneVu were comparable (0.82-0.99). The MagneVu unit was particularly more sensitive than CR for metacarpal heads and carpal bones. MagneVu MRI and CR detected 100% and 89%, respectively, of large erosions (Outcome Measures in Rheumatoid Arthritis Clinical Trials-Rheumatoid Arthritis MRI Scoring System (OMERACT-RAMRIS) score >1 on Artoscan) in MCP joints and 69% and 15.8% of large erosions in wrists. CONCLUSIONS: Both E-MRI units detected more erosions than CR, in particular due to a higher sensitivity in metacarpal heads and carpal bones. The MagneVu unit detected fewer erosions than the Artoscan unit due to a lower average image quality and a smaller proportion of bones being visualised.

Reproducibility of ultrasound and magnetic resonance imaging measurements of tendon size.

PURPOSE: To investigate the intra- and inter-tester reproducibility of measurements of the Achilles tendon, tibialis anterior tendon, and the tibialis posterior tendon in football players using ultrasound (US) and magnetic resonance imaging (MRI). MATERIAL AND METHODS: Eleven asymptomatic football players were examined. Using a standardized US scanning protocol, the tendons were examined by two observers with US for thickness, width, and cross-sectional area. One observer conducted the procedure twice. The subjects also underwent an MRI examination, and the assessment of tendon size was conducted twice by two observers. RESULTS: The best reproducibility judged by coefficient of variation (CV) and 95% confidence interval was determined for the Achilles tendon on both US and MRI. The variability of US on measurements on the tibialis anterior and tibialis posterior tendons was less than that when using MRI. In 12 out of 18 measurements, there were systematic differences between observers as judged by one-sided F-test. CONCLUSION: The reproducibility of the three tendons was limited. Precaution should be taken when looking for minor quantitative changes, i.e., training-induced hypertrophy, and when doing so, the Achilles tendon should be used.

Adrenoleukodystrophy. A case report.

PURPOSE: Adrenoleukodystrophy is a hereditary, usually X-linked recessive disorder, characterized by progressive demyelination of cerebral white matter and adrenal insufficiency. MATERIAL AND METHODS AND RESULTS: We report the case of a 14-year-old boy, presenting the typical changes in CT and MR with almost symmetrical changes in the white matter only, with no mass effect and a rim of enhancement. Adrenoleukodystrophy may resemble tumour but shows no mass effect. DISCUSSION AND CONCLUSION: We discuss the differential diagnoses and underline the importance of the characteristic appearance of this disease. Adrenoleukodystrophy is diagnosed by serum analysis.

[Benign cerebral gliomas. Clinical and radiological characteristics]. / Benigne gliomer i storhjernen. Kliniske og radiologiske karakteristika.

Between July 1988 and July 1990, 42 patients with low-grade gliomas of the cerebrum were treated in our department. Their age ranged from six to 72, there were 27 males and 15 females. Seventy-nine percent of the patients had suffered from epileptic fits, in 69% it was the presenting symptom. Thirty-one percent had normal neurological examination. On CT-scanning most tumours were hypodense, one-third demonstrated enhancement after intravenous contrast. Midline shift suggested a grade two tumour, but otherwise it was not possible to distinguish between grade one and grade two tumours on CT or MR. There was an unaccountable overweight of tumours on the left side of the brain. Forty patients underwent surgery, in one-third a radical extirpation was undertaken. In six patients a biopsy was nondiagnostic. Twenty-five percent had postoperative radiation. Adult patients who suffer an epileptic seizure without any other obvious aetiology should have a CT or MR scan even in cases when the neurological examination is normal.

Antithrombotic efficacy of continuous extradural analgesia after knee replacement.

We have studied the effect of extradural analgesia on postoperative venous thrombosis in patients undergoing knee arthroplasty. Forty-eight patients were allocated randomly to receive either general anaesthesia or extradural analgesia with local anaesthetics for 3 days. All patients wore compressive elastic stockings and no anticoagulant drugs were administered. Bilateral venography was performed 10 days after surgery. Continuous extradural analgesia did not impede mobilization of the patients. One case of nonfatal pulmonary embolism occurred in a patient who received general anaesthesia. The use of continuous extradural analgesia resulted in a significant difference in the total incidence of deep vein thrombosis (18% compared with 59% after general anaesthesia (P = 0.02]. The incidence of calf vein thrombosis was 12% compared with 45% after general anaesthesia (P = 0.05).

Functional treatment of metacarpal fractures 100 randomized cases with or without fixation.

Totally, 100 hundred subcapital or diaphyseal fractures of the second through the fifth metacarpal were randomized to either a dorsal/ulnar plaster cast immobilizing the wrist and the joints of the involved digits or a functional cast allowing the wrist and the digits a free range of motion. Due to better retaining ability, functional casting reduced volar angulation by two thirds for metacarpal shaft fractures and by one third for metacarpal neck fractures when compared with plaster cast immobilization. Restriction of wrist, metacarpophalangeal, and interphalangeal joint movements was more frequent in the cast group, but did not influence the overall function 3 months postinjury. Sick leave was reduced by two thirds after functional casting compared with the plaster cast group.

Thrombin-antithrombin III-complex & fibrin degradation products in plasma: surgery and postoperative deep venous thrombosis.

Thrombin-antithrombin-III complexes (TAT) & D-dimer in plasma, and fibrin(ogen) degradation products (FDP) in serum, were measured in 48 patients subjected to total hip arthroplasty. Blood samples were collected on days -1, 0, 1, 3, 7 and 10. Five patients developed postoperative deep vein thrombosis (DVT) diagnosed by venography. A characteristic pattern of TAT and D-dimer secondary to surgery was demonstrated. A poor correlation was found between ELISA- and latex-D-dimer concentrations after the operation. Patients with DVT had significantly higher TAT-levels preoperatively, and on day 0, 7 and 10. The concentration of FDP was significantly elevated in patients with DVT on day 7 and that of ELISA D-dimer on days 0 & 10. None of the assays are clinically valuable for purposes of postoperative screening for DVT. The preoperative plasma TAT concentration may represent a valuable predictive marker of postoperative DVT.

Popliteal valve incompetence and postoperative deep vein thrombosis.

In 79 patients undergoing hip or knee replacement surgery the preoperative condition of the popliteal vein valves was assessed by Doppler ultrasonography. Presence of postoperative deep vein thrombosis was determined by bilateral ascending phlebography seven to ten days after surgery. Antithrombotic prophylaxis consisted solely of TED stockings and early mobilization. The overall incidence of deep vein thrombosis was 20%. All thrombi were calf vein thrombi. One of these thrombi extended into the popliteal region and two into the femoral region. The incidence of deep vein thrombosis in patients with preoperative popliteal vein reflux when compared with patients with a normal popliteal valvular function was 55-15% (p less than 0.01). The incidence of deep vein thrombosis was also significantly lower in patients operated under epidural anaesthesia compared with patients under general anaesthesia. It is concluded that valvular incompetence of the popliteal vein predisposes to postoperative deep vein thrombosis.

Lower thrombosis risk with epidural blockade in knee arthroplasty.

Thirty-six patients scheduled for knee arthroplasty were randomized to general or epidural anesthesia that was prolonged into the postoperative period. All the patients wore graded compression stockings until full ambulation. No other thrombo-prophylactic treatment was given. In diagnosing deep venous thrombosis, bilateral ascending venography was performed 9-11 days after surgery. The incidence of thrombosis was 2/13 in the epidural group versus 10/16 in the general anesthesia group (P less than 0.05).