Ankylosis of a knee joint from Medieval London: Trauma, congenital anomaly or osteoarthritis?

OBJECTIVE: To explore the differential diagnoses of a fused left knee joint and the subsequent impairment. MATERIALS: An adult female skeleton from the Medieval cemetery of St Mary Spital (London, England). METHODS: We employed digital radiography and macroscopic observation to record the changes observed throughout the skeleton. We also used the Index of Care to explore the subsequent impairment. RESULTS: A range of congenital and developmental conditions were identified throughout the axial skeleton, with changes to the spine, pelvis, arms and leg bones reflecting adaptation to the mobility impairment. CONCLUSIONS: In all probability, the left knee reflects a case of congenital ankylosis with a differential diagnosis of subadult trauma. The female's skeleton had adapted to the impairment. Their risk is likely to have been elevated because of climatic and pandemic events during this period. SIGNIFICANCE: First reported case of congenital knee ankylosis. LIMITATIONS: The left knee joint was damaged during excavation. SUGGESTIONS FOR FURTHER RESEARCH: Additional imaging is advised.

A new method for investigating the relationship between diet and mortality: hazard analysis using dietary isotopes.

Background: The population of Roman Britain are renowned for having elevated nitrogen (δ15) stable isotope values, which have been interpreted as evidence for the increased consumption of marine products. However, such results are now understood to also reflect episodes of stress and disease, suggesting that new interpretations are warranted.Aim: To test a novel approach which combines hazard mortality analysis and stable isotope data to determine whether there is a relationship between age-at-death, elevated δ15N values and mortality risk.Subjects and methods: This study used published osteological and dietary stable isotope data for nitrogen (δ15N) and carbon (δ13C) of 659 1st-5th century AD individuals aged >12 years old excavated from Roman cemeteries in Britain. The relationship between diet and mortality risk was assessed using the Gompertz hazard model, and differences in median reported isotope values between the sexes was determined using a Mann Whitney test.Results: It was discovered that higher δ15N levels are associated with elevated risks of mortality, whereas the opposite pattern was observed for δ13C, and males had higher median δ13C and δ15N values.Conclusion: This study successfully demonstrated that stable isotope data can be integrated into hazard models, allowing one to connect diet and mortality in past populations. It supports the findings of other isotope studies which have established that individuals with childhood stress/trauma will have different isotope patterns.

High jugular bulb in a cohort of patients with definite Ménière's disease.

OBJECTIVE: To determine the incidence of high jugular bulb in a group of patients with definite Ménière's disease, and to investigate whether the position or size of the jugular bulb is significantly different in the affected ear than in the unaffected ear. METHODS: Retrospective review of patient charts, audiograms, and computed tomography scans to determine the position and size of the jugular bulb in the affected and contralateral ears, as well as other abnormalities. RESULTS: High jugular bulb was found in 57.1 per cent of affected ears. Encroachment of the cochlear and vestibular aqueducts was apparent in 39.3 per cent and 35.7 per cent, respectively, of affected ears. Diverticulum and dehiscence were observed in 28.6 per cent of affected ears. High jugular bulb was significantly associated with encroachment of the cochlear aqueduct (p = 0.003). CONCLUSION: The mediolateral and anteroposterior position of the jugular bulb determines encroachment of the surrounding structures. An abnormal position is postulated to contribute to the development of Ménière's disease.

The causes of hypopituitarism in the absence of abnormal pituitary imaging.

BACKGROUND: Hypopituitarism in the absence of a history of pituitary pathology or abnormal pituitary imaging is rare. AIM: To identify the cause of hypopituitarism in individuals in whom pituitary imaging was normal. DESIGN: Retrospective analysis of electronic patient record. METHOD: A review of the pituitary function in the 506 patients on the Morriston Hospital pituitary database revealed 230 had some degree of hypopituitarism and of these, 21 (9%) had normal pituitary imaging. RESULTS: Of this group, six patients had a past medical history of subarachnoid haemorrhage, head injury or meningitis, and mainly suffered from a deficiency of antidiuretic hormone. One patient had a stroke resulting in multiple anterior hormone deficiencies and six individuals had idiopathic cranial diabetes insipidus (DI). Subsequent investigations of the remaining eight patients with normal pituitary imaging revealed that two had neurosarcoidosis both of whom had panhypopituitarism. Four patients had haemochromatosis which resulted in gonadotropin deficiency in two, DI in one and panhypopituitarism in the other. There were two individuals with confirmed hypopituitarism and multiple hormone deficiencies in which no cause could be identified. CONCLUSION: These results show that hypopituitarism in the absence of pituitary pathology or an identifiable cause is rare. In patients with multiple anterior pituitary hormone deficiencies haemochromatosis and sarcoidosis should be considered.

Difficult leg wounds successfully closed with decortication, bioresorbable ECM and NPWT.

Complications of a missed compartment syndrome are severe. This case demonstrates the difficulty in dealing with such complications, including the difficult situation of being faced with limb salvage when amputation is the best option. Through a short case description and several images, it is demonstrated how even the most difficult wounds in cases like this can be dealt with and achieve a non-painful limb salvage. In particular, an extreme technique of decorticating the bone and applying bioresorbable extracellular matrix with negative pressure wound therapy was applied in order to achieve final wound closure and pain relief. This case demonstrates integration of multiple modalities for complex wound closure.

Magnetic Resonance Spectroscopy for Differentiating Pseudo-Progression from True Progression in GBM on Concurrent Chemoradiotherapy.

Neoadjuvant chemo-radiation therapy including temozolomide is commonly used for the treatment of gliomas. However, increased lesion size and contrast enhancement are frequently observed following this therapy and this appearance is termed as 'pseudo-progression'. Since conventional imaging is unable to differentiate pseudo-progression from tumour recurrence, we evaluated the utility of MR spectroscopy (MRS) to differentiate these two pathological entities. Longitudinal MRI and MRS studies prior to and within four months post chemo-radiation therapy including diffusion-weighted imaging and single voxel spectroscopy (short and intermediate echo) were performed in 62 glioblastoma (GBM) patients undergoing chemo-radiation therapy. Clinical follow-up demonstrated four cases of pseudo-progression. In this study, results from these four cases and a known case of tumour recurrence are reported. Metabolite ratios and presence or absence of lipids at 1.3 ppm were used to differentiate between pseudo-progression and tumour recurrence. All four cases of pseudo-progression demonstrated elevated lipid signals on MRS. Additionally, an absence of choline or a low choline/NAA ratio was also observed. In comparison, the patient with tumour recurrence showed lower lipid signals and a high choline/NAA ratio. The presence of elevated lipid signals along with low choline/NAA ratios can aid in differentiation of pseudo-progression from tumour recurrence.

Different forms of DMP1 play distinct roles in mineralization.

Dentin matrix protein-1 (DMP1) is a major synthetic product of hypertrophic chondrocytes and osteocytes. Previous in vitro studies showed full-length DMP1 inhibits hydroxyapatite (HA) formation and growth, while its N-terminal fragment (37K) promotes HA formation. Since there are 3 fragments within the mineralized tissues [N-terminal, C-terminal (57K), and a chondroitin-sulfate-linked N-terminal fragment (DMP1-PG)], we predicted that each would have a distinct effect on mineralization related to its interaction with HA. In a gelatin-gel system, 37K and 57K fragments were both promoters of HA formation and growth; DMP1-PG was an inhibitor. The secondary structures of the 3 fragments and the full-length protein in the presence and absence of Ca2+ and HA determined by FTIR showed that the full-length protein undergoes slight conformational changes on binding to HA, while 37K, 57K, and DMP1-PG do not change conformation. These findings indicate that distinct forms of DMP1 may work collectively in controlling the mineralization process.

Posterior circulation stroke following embolization of glomus tympanicum?relevance of anatomy and anastomoses of ascending pharyngeal artery. A case report.

SUMMARY: Embolization in the territory of the ascending pharyngeal artery (APA) can be unsafe even after detailed pretherapeutic angiographic evaluation due to changes in haemodynamics and opening of anastomotic channels. A 60-year-old woman underwent angiogram and embolization for glomus tympanicum tumour. The glomus tympanicum tumour was embolized using contour PVA particles of 150-250 um. At the end of the particulate injection the patient had posterior circulation stroke. The check angiogram showed near total devascularisation of the tumour and in addition filling of the left vertebral artery through an anastomotic channel. MRI confirmed the infarct in the posterior circulation. The ascending pharyngeal artery has potential anastomoses to all neighbouring major arteries, and the anastomoses to the vertebral artery in our case were through the musculospinal artery. This case highlights the importance of potential vascular anastomotic channels as a cause of ischaemic complication during the embolization procedure. It also highlights the fact that dangerous anastomoses may only be visualised in the later phase of embolization probably due to changes in the haemodynamic pressure. The angiographic anatomy of APA is reviewed with potential communications with the internal and external carotid and vertebrobasilar systems.

Carotid-cavernous fistula after blunt trauma to the neck.

Carotid-cavernous fistulas (CCF) are uncommon conditions, but cause significant morbidity if untreated. The majority of CCFs in young men are attributed to direct skull trauma. We present a case of CCF following a blunt injury to the neck.

Laparoscopic Heller myotomy and fundoplication: findings and predictive value of early postoperative radiographic studies.

BACKGROUND: We describe the findings on esophagography, the frequency and appearance of leaks after laparoscopic Heller myotomy and fundoplication, and the utility of early postoperative studies for predicting clinical outcome. METHODS: Our study group consisted of 40 patients who underwent laparoscopic Heller myotomy and fundoplication in whom radiographic studies were performed during the early postoperative period. The radiographic reports and images were reviewed to determine the esophageal diameter, visualization or nonvisualization of the wrap, and the presence or absence of a leak. The esophageal diameter subsequently was correlated with the clinical findings to determine whether this was a useful parameter for predicting clinical outcome. RESULTS: Two patients (5%) had small, sealed-off leaks on radiographic studies, and four (10%) had pseudo-leaks resulting from trapping of contrast material alongside the fundoplication wrap. Twelve (60%) of 20 patients with a dilated esophagus had esophageal symptoms on short-term follow-up versus three (15%) of 20 with a normal-caliber esophagus (p = 0.008), and five (56%) of nine patients with a dilated esophagus had symptoms on long-term follow-up versus six (43%) of 14 with a normal-caliber esophagus (p = 0.68). CONCLUSION: Radiographic studies are useful for showing leaks after laparoscopic Heller myotomy and fundoplication, but radiologists should differentiate true leaks from trapping of contrast material alongside the fundoplication wrap. The caliber of the esophagus on early postoperative studies is also a useful parameter for predicting short-term clinical outcome in these patients.

Assessment of fusion after anterior cervical discectomy.

There is no established method to assess fusion in patients following anterior cervical discectomy. In this study we have made a series of measurements to detect movement between vertebrae adjacent to an operated space. The absence of movement implies structural union between adjacent vertebrae. Measurements have been made in two distinct surgical groups. Group A patients had anterior cervical discectomy with insertion of a BOP graft into the disc space. Group B patients underwent simple anterior cervical discectomy with no spacer or graft material inserted, the disc space being left empty. Details of the measurements and interpretation of results are described. In the absence of a 'gold standard' to assess bony union we propose that these measurement methods provide an objective and scientific method to assess fusion at the operated level after anterior cervical discectomy. Objective measurement of fusion will allow comparison between different surgical techniques that claim fusion as an end point. It will also become possible to study the influence of fusion on clinical outcome in different surgical populations.

Deafness--a complication of nasopharyngeal airways.

We report a patient who developed temporary deafness secondary to oedema of the uvula and soft palate following prolonged continuous positive airway pressure via a nasopharyngeal airway.

The effect of PACS on the time required for technologists to produce radiographic images in the emergency department radiology suite.

The purpose of this study was to evaluate the effect of a switch to a filmless image management system on the time required for technologists to produce radiographic images in the emergency department (ED) after controlling for exam difficulty and a variable workload. Time and motion data were collected on patients who had radiographic images taken while being treated in the emergency department over the 3 1/2-year period from April 1997 to November 2000. Event times and demographic data were obtained from the radiology information system, from the hospital information system, from emergency department records, or by observation by research coordinators. Multiple least squares regression analysis identified several independent predictors of the time required for technologists to produce radiographic images. These variables included the level of technologist experience, the number of trauma-alert patient arrivals, and whether a filmless image management system was used (all P <.05). Our regression model explained 22% of the variability in technologist time (R2 Adjusted, 0.22; F = 24.01; P <.0001). The regression model predicted a time saving of 2 to 3 minutes per patient in the elapsed time from notification of a needed examination until image availability because of the implementation of PACS, a delay of 4 to 6 minutes per patient who were imaged by technologists who spent less than 10% of their work assignments within the ED, and a delay of 18 to 27 minutes in radiology workflow because of the arrival of a trauma alert patient. A filmless system decreased the amount of time required to produce radiographs. The arrival of a trauma alert patient delayed radiology workflow in the ED. Inexperienced technologists require 4 to 6 minutes of additional time per patient to complete the same amount of work accomplished by an experienced technologist.

Radiographically diagnosed antral gastritis: findings in patients with and without Helicobacter pylori infection.

The purpose of this study was to characterize the radiographic findings of antral gastritis and to determine whether there are differences in the appearance of antral gastritis in patients with and without Helicobacter pylori infection. A search of radiology, endoscopy and pathology files revealed 90 patients with antral gastritis on double contrast upper gastrointestinal tract studies who had endoscopy with testing for H. pylori. The barium studies were evaluated to further characterize the findings of antral gastritis without knowledge of the H. pylori status of the patients or of the endoscopy or pathology findings. The radiographic findings of antral gastritis included thickened folds in 67 patients (74%), polypoid antral gastritis (a subset of patients with thickened folds) in 6 (9%), antral erosions in 21 (23%), enlarged areae gastricae in 14 (16%), crenulation of the lesser curvature in 4 (4%), mucosal nodularity in 2 (2%), a hypertrophied antral-pyloric fold in 2 (2%) and antral striae in 1 (1%). 43 patients (48%) with antral gastritis were H. pylori positive and 47 patients (52%) were H. pylori negative. Thickened folds were detected in 39 H. pylori-positive patients (91%) with antral gastritis vs 28 H. pylori-negative patients (60%) (p<0.001); polypoid gastritis in 6 H. pylori-positive patients (14%) vs 0 H. pylori-negative patients (p<0.05); enlarged areae gastricae in 14 H. pylori-positive patients (33%) vs 0 H. pylori-negative patients (p<0.0001); and antral erosions in 2 H. pylori-positive patients (5%) vs 19 H. pylori-negative patients (40%) (p<0.0001). Our experience suggests that antral gastritis caused by H. pylori infection is associated with characteristic features on double contrast studies (including thickened folds, polypoid gastritis and enlarged areae gastricae) and that this condition is rarely associated with antral erosions. Thus, radiologists can often suggest whether the patient's gastritis is caused by H. pylori on the basis of radiographic findings.

From being a radiologist to watching a radiologist: impact of filmless operation on the training of radiology residents.

RATIONALE AND OBJECTIVES: The authors performed this study to investigate the impact of changing from a film-based image interpretation system to one using digital image workstations on the training of radiology residents in the interpretation of radiographs. MATERIALS AND METHODS: Data were collected during a period when a conventional system of image interpretation with hard-copy images and multiviewers was used and during a period when digital image workstations were used. During each period, it was noted whether the first interpretation of the radiographs was performed by a radiology resident, by an attending radiologist, or as a group effort including both an attending radiologist and a radiology resident(s). In addition, it was noted whether a radiology resident or an attending radiologist dictated the report. RESULTS: The proportion of images first interpreted by the radiology resident alone decreased from 38% (53 of 139) when using the conventional system to 17% (34 of 199) after the switch to interpreting images on the workstations (P = .001). During the film-based period, radiology residents dictated 45% of reports (141 of 312), but during the workstation period, radiology residents dictated only 4% of reports (24 of 667; P = .001). CONCLUSION: The authors observed a decrease in autonomous participation by radiology residents in image interpretation and dictation of reports and an increase in "group reading" after the switch from a film-based system to a workstation system.

Human beta-defensin 2 is up-regulated during re-epithelialization of the cornea.

PURPOSE: Human beta-defensins 1 and 2 (hBD-1, -2) are antimicrobial peptides found in several epithelia including corneal epithelium. Breach of the epithelium leaves the cornea vulnerable to infection so we sought to determine if there is an increase in defensin expression after injury. METHODS: The epithelium from human cadaver corneas was collected by scraping (original samples). The corneas were then placed into organ culture to permit regeneration of the epithelium. Samples of re-grown epithelium were collected when healing was partially and 100% complete as determined by fluorescein staining. Total RNA was extracted from original and re-grown samples and used in RT-PCR reactions using primers specific for hBD-1 and hBD-2 and the constitutively expressed gene glyceraldehyde-3-phosphate dehydrogenase. Immunoblotting was performed to detect defensin peptide in original and re-grown samples. RESULTS: hBD-1 mRNA was detected in all original epithelial tissue samples (n = 10) examined suggesting that it is constitutively expressed. hBD-2 mRNA was detectable in only two of the ten samples. Of six corneas placed in to organ culture, hBD-1 mRNA expression was unchanged in the re-grown epithelial samples compared to the original epithelium samples, however the expression of hBD-2 mRNA was markedly increased. hBD-1 and hBD-2 peptides showed the same pattern of expression as their respective transcripts. CONCLUSIONS: These data show that hBD-2 mRNA and peptide is up-regulated in the corneal epithelium during re-epithelialization which is in keeping with the role of this defensin as an antimicrobial peptide.

An automated results notification system for PACS.

The purpose of this study was to determine if the interval between an examination being ordered by an Emergency Department physician and his or her review of the report and images could be shortened by notifying the physician that the results were available. This hypothesis was based on work done previously in the Medical Intensive Care Unit that showed that physicians would wait to review results for a time considerably longer than the time required for the radiologist to review the images and provide a preliminary report. The software developments operate properly and show that even simple integration of multiple information systems (PACS, RIS, speech recognition) can provide useful features. Early results indicate that the Emergency Department (ED) physicians prefer the notification system over the previous (travel to check on images and reports) methods. The hypothesized time reductions did occur, although it is not clear that the notification system accounted for all of them. A system for automated notification of radiology results availability has been shown to be possible and practical. To do this automated interaction of 3 systems with a low-level or no electronic integration was required. Although not fully successful for this study, early physician response has been positive, and requests to expand this service hospitalwide now are common.

Cervical esophageal webs: association with gastroesophageal reflux.

BACKGROUND: We investigated whether there is a significant association between cervical esophageal webs and gastroesophageal reflux on pharyngoesophagography. METHODS: We studied 50 patients with cervical esophageal webs on pharyngoesophagrams and 50 control subjects. The control group was matched to the webs group for age, sex, and symptomatology. Patients with cervical esophageal webs and controls were compared to determine the prevalence of gastroesophageal reflux, hiatal hernias, reflux esophagitis, and abnormal esophageal motility. Pearson's chi-square test was used to determine any statistically significant differences in the frequencies of these findings between groups. RESULTS: Thirty-nine (78%) of 50 patients with cervical esophageal webs versus 27 (54%) of 50 patients in the control group had gastroesophageal reflux (p = 0.01). When patients were classified based on degree of gastroesophageal reflux, 22 (44%) of 50 patients with cervical esophageal webs versus 21 (42%) of 50 controls had mild reflux (p = 0.84), whereas 17 (34%) of 50 patients with webs versus six (12%) of 50 controls (p < 0.009) had moderate/marked reflux. Thus, the prevalence of moderate/marked gastroesophageal reflux was significantly greater in patients with webs than in the controls. However, no significant differences were found in the prevalence of mild gastroesophageal reflux, hiatal hernias, reflux esophagitis, or abnormal esophageal motility. CONCLUSION: We found a significant association between cervical esophageal webs and gastroesophageal reflux independent of age, sex, or symptomatology. Radiologists should be aware of this association, so that patients with cervical esophageal webs on pharyngoesophagography are evaluated for gastroesophageal reflux at the time of the barium study or advised to undergo further testing for gastroesophageal reflux disease.