Punctate Radiation Dermatitis of the Foot and Ankle Caused by Distal Embolization of 90Y Microspheres During Liver Directed Therapy.

A 41-year-old man with gastric adenocarcinoma presented with hepatic metastases. The metastases were refractory to systemic chemotherapy, so radioembolization with Y microspheres was performed. Because of stasis or saturation of the tumor with embolic particles, 79% of the microspheres were injected. At follow-up, the patient complained of "red bumps" that had developed on his right foot/ankle the day after the radioembolization. Because a portion of the dose was still in the catheter when withdrawn from the right femoral artery, the interventional radiologist used a Geiger counter to confirm radioactivity in the cutaneous lesions and thus the distal embolization of the microspheres.

Laser acupuncture versus reflexology therapy in elderly with rheumatoid arthritis.

The purposes of this study are to determine and compare efficacy of laser acupuncture versus reflexology in elderly with rheumatoid arthritis. Thirty elderly patients with rheumatoid arthritis aged between 60 and 70 years were classified into two groups, 15 patients each. Group A received laser acupuncture therapy (904 nm, beam area of 1cm2, power 100 mW, power density 100 mW/cm2, energy dosage 4 J, energy density 4 J/cm2, irradiation time 40 s, and frequency 100,000 Hz). The acupuncture points that were exposed to laser radiation are LR3, ST25, ST36, SI3, SI4, LI4, LI11, SP6, SP9, GB25, GB34, and HT7. While group B received reflexology therapy, both offered 12 sessions over 4 weeks. The changes in RAQoL, HAQ, IL-6, MDA, ATP, and ROM at wrist and ankle joints were measured at the beginning and end of treatment. There was significant decrease in RAQoL, HAQ, IL-6, and MDA pre/posttreatment for both groups (p < 0.05); significant increase in ATP pre/posttreatment for both groups (p < 0.05); significant increase in ankle dorsi-flexion, plantar-flexion, wrist flexion, extension, and ulnar deviation ROM pre/posttreatment in group A (p < 0.05); and significant increase in ankle dorsi-flexion and ankle plantar-flexion ROM pre/posttreatment in group B (p < 0.05). Comparison between both groups showed a statistical significant decrease in MDA and a statistical significant increase in ATP in group A than group B. Percent of changes in MDA was 41.82%↓ in group A versus 21.68%↓ in group B; changes in ATP was 226.97%↑ in group A versus 67.02%↑ in group B. Moreover, there was a statistical significant increase in ankle dorsi-flexion, ankle plantar-flexion, wrist flexion, wrist extension, and radial deviation in group A than group B. Laser therapy is associated with significant improvement in MDA and ATP greater than reflexology. In addition, it is associated with significant improvement in ankle dorsi-flexion, ankle plantar-flexion, wrist flexion, wrist extension, and radial deviation greater than reflexology in elderly patients with rheumatoid arthritis.

Postoperative Radiotherapy After Limb-sparing Surgery for Soft-tissue Sarcomas of the Distal Extremities.

BACKGROUND: Soft-tissue sarcomas (STS) of the distal extremities are a rare disease entity, hence proper treatment strategy is not well established. We evaluated the local control, survival and complications of treating sarcomas in the wrist, hand, ankle and foot with limb-sparing surgery (LSS) and postoperative radiotherapy (PORT). PATIENTS AND METHODS: Seventeen patients with STS in wrist, hand, ankle and foot who received PORT after LSS from August 2008 to November 2015 were retrospectively reviewed. Primary outcome was 5-year local recurrence-free survival (LRFS). Secondary outcomes were 5-year distant metastasis-free survival (DMFS) and toxicities. RESULTS: The median age was 32 (range=12-78) years. The most frequent STS location was the foot in 11 patients (64%) followed by two patients each in the wrist, hand and ankle, respectively. Fourteen patients (82%) underwent wide resection with flap grafts and the same number of patients achieved clear resection margins. The median postoperative radiation dose was 54 (range=46-60) Gy. Five patients also received chemotherapy. At a median follow-up of 39 (range=6-87) months, 5-year LRFS and DMFS were both 100%. Only one patient experienced grade 3 radiation dermatitis and there was no major wound complication. Radiation-induced bone fracture occurred in two patients. CONCLUSION: PORT after LSS showed excellent local control for STS in the wrist, hand, ankle and foot. Considering the good local control and saving of limb function without any significant toxicity, the combination of LSS followed by PORT could be an appropriate and safe modality for STS of the distal extremities.

Low-level laser therapy reduces the fatigue index in the ankle plantar flexors of healthy subjects.

Low-level laser therapy (LLLT) has been suggested as a resource capable of increasing resistance to fatigue and enhancing muscle performance through its metabolic and photochemical effects. This study evaluated the immediate effects of the application of LLLT on neuromuscular performance of the plantar ankle flexors in healthy subjects through a fatigue-induced protocol. This is a randomized controlled clinical trial, attended by 60 young and physically active volunteers of both genders. The subjects were randomly assigned into three groups, control, placebo, and laser, and underwent a preliminary evaluation of the isokinetic performance of plantar flexors and electromyographic activity of the soleus muscle to ensure homogeneity between groups. After the application of the respective intervention protocols, participants were induced to fatigue by performing 100 isokinetic concentric contractions of ankle plantar flexors at a speed of 90°/s. The dynamometric fatigue index (DFI) and median frequency were recorded during the fatigue protocol for comparison between groups. The group receiving the laser application showed significantly lower dynamometric fatigue index (p = 0.036) when compared to control and placebo groups. In relation to the median frequency during the fatigue test, there was a decrease in all groups, however with no differences between them. We suggest that LLLT being applied prior to exercise can reduce the fatigue index in the ankle plantar flexors of healthy subjects.

La estimulación eléctrica neuromuscular del tibial anterior vs superficie viscoelástica en la reeducación de la propiocepción del tobillo. Un estudio piloto / Neuromuscular electrical stimulation on the tibialis anterior vs viscoelastic surface in the re-education of ankle proprioception. A pilot study

Objetivo: Analizar las diferencias en el recorrido del centro de presiones durante la realizaciónde 3 tests de equilibrio estáticos, en que se incluyen dos de las técnicas usadas en lostratamientos de la rehabilitación del esguince de tobillo.Material y método: Participaron voluntariamente 14 sujetos sanos, sin signo de bostezo articular(8 hombres y 6 mujeres), deportistas, con una media de edad de 19,9±3,8 años. Se midióel recorrido del centro de presiones durante tests de equilibrio monopodal sobre plataformade fuerzas (duración de 60 s), en tres condiciones: sobre superficie estable (plataforma), sobresuperficie viscoelástica, y aplicando estimulación eléctrica neuromuscular en el músculo tibialanterior.Resultados: La amplitud de desplazamiento del centro de presiones en el eje anteroposteriorfue mayor en el test con estimulación eléctrica neuromuscular que en el realizado sobre superficieestable (p < 0,01) y viscoelástica (p < 0,05). La posición media del centro de presiones sesituó más lateral (53,00±7,60mm) y anterior (128,40±10,70mm) en el test sobre superficieviscoelástica. Las mayores áreas barridas por el centro de presiones se obtuvieron en el testcon estimulación eléctrica neuromuscular (1.115,96±411,40mm2).Conclusiones: Con la electroestimulación se obtuvieron mayores amplitudes de desplazamientodel centro de presiones en el eje anteroposterior, una posición media más retrasada, y mayoresáreas barridas. Con la superficie viscoelástica se obtuvo un mayor recorrido y velocidad, y unaposición media del centro de presiones más lateral(AU)

Objective: To analyse the differences in the path of the centre of pressures during the performanceof 3 static balance tests, which included two of the techniques used in the rehabilitationof ankle sprain rehabilitation.Material and method: Fourteen healthy subjects, without ligament loosening in the ankle wererecruited for the study (8 male and 6 female) voluntary participated in this study, all of themphysically active, with a mean age of 19.9±3.8 years. The path of the centre of pressures wasmeasured during monopodal balance tests on a force platform (60 s last), in three different conditions:on stable surface (force platform), on a viscoelastic surface, and during the applicationof electrical stimulation on the tibialis anterior muscle.Results: The anterior-posterior path of the centre of pressures was greater in the test with electricalstimulation than in the tests on the stable surface (P < .01), and on the viscoelastic surface(P < .05).The mean position of the centre of pressures was more lateral (53.00±7.60mm) andmore posterior (128.40±10,70mm) in the test on the viscoelastic surface. The greatest excursionareas of the centre of pressures were found in the test with neuromuscular electricalstimulation (1115.96±411.40mm2).Conclusions: Greater anterior-posterior path length and excursion areas and a more posteriormean position of the centre of pressures were found in the neuromuscular electrical stimulationtest. We also found greater total excursions and velocity, and a more lateral mean position ofthe centre of pressures in the viscoelastic surface tests(AU)

Results of the EURADOS extremity dosemeter intercomparison 2009.

This paper presents the results of an intercomparison for extremity dosemeters organised by the European radiation dosimetry group in 2009. In total, 59 systems were tested during this exercise including ring, stall and wrist dosemeters. A total of 1652 dosemeters were irradiated in the selected fields of photons and beta radiation qualities on appropriate phantoms (ISO finger and pillar phantom) in the dose quantity H(p)(0.07). All irradiations were carried out in selected accredited reference dosemetry laboratories (Seibersdorf Laboratories, Austria and IRSN, France). The results show that, especially at low-energy beta radiations ((85)Kr) and for beta irradiations with large angles of incidence (60°), many tested systems show pronounced under responses. On the other hand, for photon irradiations down to energies of 16 keV most systems showed good results. A participants meeting was held at IM2010 with discussion on both general aspects of this intercomparison and specific problems.

Hp(0.07) photon irradiations at Seibersdorf for the EURADOS extremity dosemeter intercomparison 2009.

In August 2009, almost 1000 passive extremity dosemeters were irradiated at the Dosimetry Laboratory Seibersdorf as part of the EURADOS intercomparison IC2009. Forty-four European individual monitoring services participated, with a total of 59 dosimetry systems (46 finger ring, 4 finger tip and 9 wrist/ankle dosemeter systems). Additionally, finger-ring dosemeters from the Dosimetry Service Seibersdorf were irradiated in a non-competitive manner. Dosemeter irradiations on rod and pillar phantoms in four photon-radiation fields complying with the ISO standard 4037 were performed with personal dose equivalent values (H(p)(0.07)) ranging from 4 to 480 mSv. Traceability was established by using an air-kerma-calibrated monitor ionisation chamber together with the X-ray facility as well as a calibrated (137)Cs gamma radiation field with a collimated beam geometry. The ISO-tabulated conversion coefficients from air kerma free-in-air to H(p)(0.07) were applied, resulting in the main contribution to the expanded measurement uncertainties.

Valoración pedobarográfica de 17 pacientes intervenidos con artrodesis de tobillo / Pedobarographic assessment of 17 patients with ankle arthrodesis

Objetivo. Analizar la modificación de las presiones plantares durante la marcha en pacientes con artrodesis de tobillo. Pacientes y metodología. Se estudió el apoyo plantar en 17 pacientes (14 hombres y 3 mujeres) intervenidos con una artrodesis de tobillo, 13 del lado derecho y 4 del izquierdo, de causa postraumática, con un seguimiento mínimo de tres años (3 a 9). Se descartaron pacientes con patologías asociadas que afectaban a la extremidad intervenida. La edad media fue de 40 (26 a 54) años y el peso medio de 89 (54 a 117)kg. Se realizó una exploración clínica y se obtuvieron las huellas plantares al caminar sobre una plataforma de presiones. El pie fue dividido en 6 zonas y comparamos el pie operado con el contralateral. Resultados. El pie operado presentaba una presión total, fuerza, y área de apoyo total menor que el pie no operado. Por el contrario, el tiempo de apoyo fue superior en el pie operado. Las presiones del talón, mediopié y en el antepié en conjunto, aunque no significativas, fueron mayores en el pie artrodesado. Sin mostrar significación, la porción interna del antepié y el apoyo sobre los dedos fueron menores en el pie artrodesado mientras que aumentaron en la porción central y externa del antepié. Conclusión. Las presiones en el mediopié y en la zona interna y central del antepié aumentan con la artrodesis por la modificación de la bóveda plantar que descarga el apoyo del talón y del primer dedo (AU)

Aim. The aim of this study is to compare and analyse the changes in plantar pressure whilst walking, in patients with ankle arthrodesis by means of kinetic and kinematical motion analysis and plantar support studies. Patients and method. We studied 17 patients (14 males and 3 females) with post-traumatic ankle arthrodesis (13 right side and 4 left side) with a minimum follow up of three years (3–9 years). There were no other associated lower extremity pathologies. The mean age was 40 years (26–54 yrs.) and mean weight 89kg (54–117kg). A physical examination and pedography was performed (Emed®, Novel, Munich, Germany). The foot was divided into 6 zones and we compared the fused one with the control. Results. The fused ankle had lower total pressures, vertical forces and support area compared to the non-fused. On the other hand, the support time was greater in the fused ankle. Pressures on the heel, midfoot and forefoot were higher in the fused side. We confirmed higher pressures in the forefoot and toes in the external and central part of the fused side. Conclusion. Pressures on the midfoot and internal and central part of the forefoot are greater after an ankle arthrodesis due to changes in the plantar arch that release support from the heel and the first toe (AU)

Impact of tissue inhomogeneity on dose distribution in the canine carpal and tarsal regions for cobalt and 6 MV photons.

We quantified the effect of tissue inhomogeneity on dose distribution in a canine distal extremity resulting from treatment with cobalt photons and photons from a 6MV accelerator. Monitor units for a typical distal extremity treatment were calculated by two methods, using equally weighted, parallel-opposed fields. The first method was a computed tomography (CT)-based, computerized treatment plan, calculated without inhomogeneity correction. The second method was a manual point dose calculation to the isocenter. A computerized planning system was then used to assess the dose distribution achieved by these two methods when tissue inhomogeneity was taken into account. For cobalt photons, the median percentage of the planning target volume (PTV) that received < 95% of the prescribed dose was 4.5% for the CT-based treatment plan, and 26.2% for the manually calculated plan. For 6 MV photons, the median percentage of the PTV that received < 95% of the prescribed dose was < 1% for both planning methods. The PTV dose achieved without using inhomogeneity correction for cobalt photons results in potentially significant under dosing of portions of the PTV.

Rewarming index of the lower leg assessed by infrared thermography in adolescents with type 1 diabetes mellitus.

The aim of this study was to determine whether infrared thermography before and after challenge of the lower leg in cold water may be a useful tool to detect abnormalities in skin blood flow in adolescent asymptomatic patients with type 1 diabetes mellitus (DM1) and to assess the optimal setting of skin temperature measurements. Twenty-five adolescents (10 female, 15 male, mean age 21.2 +/- 6.2 years, body mass index [BMI] 23.0 +/- 2.1 kg/m2) with a duration of DMI of 13.8 +/- 5.4 years and mean HbA1c levels 8.5 +/- 1.3% were compared to age- and sex-matched controls (BMI 22.9 +/- 2.2 kg/m2). Seven defined sites of the lower leg were assessed by infrared thermography before and for 10 min after exposure of the leg to 14 degrees C cold water. As skin temperature before exposure to cold water differs from individual to individual and basal temperature was significantly warmer in patients at the tip of the first (p < 0.05) and fifth (p < 0.05) toe, the rewarming index was calculated in order to compare data. Rewarming indexes of skin temperature during the whole measurement procedure (0-10 min) were significantly lower at the tip of the first (p < 0.05) and fifth (p < 0.01) toes and from minute 2-10 also at the inner ankle (p < 0.05) in patients compared to healthy controls. Rewarming indexes of the other four sites were not significantly different between patients and controls. Infrared thermography of the lower leg after cold water exposure is an easily applicable method and a useful tool to detect abnormalities of skin blood flow in adolescents with DM1 especially at the tips of the first and fifth toes and the inner ankle.

Fine resolution calculations of SAR in the human body for frequencies up to 3 GHz.

Finite-difference time-domain (FDTD) calculations of whole-body averaged specific energy absorption rate (SAR) have been performed from 100 MHz to 3 GHz at the basic 2 mm resolution of the voxel (volume pixel) model NORMAN without any rescaling to larger cell sizes. The reduction in the voxel size from previous work allows SAR to be calculated at higher frequencies. Additionally, the calculations have been extended down to 10 MHz, covering the whole-body resonance regions at a resolution of 4 mm. As well as for the adult phantom, SAR values are calculated for scaled versions representing 10-, 5- and 1-year-old children for both grounded and isolated conditions. External electric field levels are derived from limits of whole-body averaged SAR and localized SAR in the ankle, and compared with NRPB investigation levels and ICNIRP reference levels. The ICNIRP field reference levels alone would not provide a conservative estimate of the localized SAR exposure in the leg for grounded conditions. It would be necessary to invoke the secondary reference level on limb current to provide compliance with basic restrictions on localized SAR averaged over 10 g.

Radiation dose and image information in computed radiography. A phantom study of angle measurements in the weight-bearing knee.

PURPOSE: To establish a correlation between radiation dose and diagnostic accuracy when employing a new digital method for angle determinations. The specific intention was to determine how far the radiation dose can be reduced without losing measuring accuracy and to compare this radiation dose with that employed with our conventional method. MATERIAL AND METHODS: An image succession of an anthropomorphic phantom was generated with a computed radiography (CR) system, by reducing the exposure stepwise. The images were archived and transferred to a workstation for evaluation. The intraobserver variation of two angle determinations was used as an indicator of the evaluation accuracy. Patient radiation doses were measured with thermoluminescent dosimeters. The energy imparted, indicating the relative risk associated with exposure to ionising radiation, and the effective dose, which determines the absolute risk, were calculated. RESULTS AND CONCLUSION: No significant correlation was found between patient dose and measuring accuracy within the evaluated exposure interval. At the lowest exposure of the CR system, the energy imparted to the patient was 30 microJ. Compared with our conventional analogue method this is a reduction by 98%. The effective dose was as low as 1.5 microSv. The CR technique creates possibilities to adapt exposure parameters, and thus the radiation dose to the patient, according to the purpose of the investigation.

MRI findings in haemophilic joints treated with radiosynoviorthesis with development of an MRI scale of joint damage.

We hypothesized that magnetic resonance imaging (MRI) scans taken prior to radiosynoviorthesis may be predictive of response to the procedure in persons with haemophilia. Specifically, response would be inversely related to the severity of synovial hyperplasia. Radiosynoviorthesis was administered to 21 joints with recurrent haemorrhage (target joints). A detailed self-report of haemorrhage history, joint evaluation with scoring according to the World Federation of Haemophilia orthopaedic joint and pain scales, plain radiographs, and MRI studies of the joints were performed pre- and post-radiosynoviorthesis. To augment comparison of the MRI findings to those assessed using the Arnold-Hilgartner and Pettersson scales, a provisional MRI scale for evaluation of haemophilic arthropathy was designed. We found the MRI findings prior to the procedure were not predictive of clinical response; independent of the severity of synovial hyperplasia, most joints bled less and showed improvement by the WFH orthopaedic score. There was generally no change in the severity of synovial hyperplasia after the procedure. We conclude that MRI evaluation is not routinely indicated prior to radiosynoviorthesis.

In-vivo dosimetry by diode semiconductors in combination with portal films during TBI: reporting a 5-year clinical experience.

BACKGROUND AND PURPOSE: In-vivo dosimetry is vital to assure an accurate delivery of total body irradiation (TBI). In-vivo lung dosimetry is strongly recommended because of the risk of radiation-induced interstitial pneumonia (IP). Here we report on our 5-year experience with in-vivo dosimetry using diodes in combination with portal films and assessing the effectiveness of in-vivo dosimetry in improving the accuracy of the treatment. Moreover, we wished to investigate in detail the possibility of in-vivo portal dosimetry to yield individual information on the lung dose and to evaluate the impact of CT planning on the correspondence between stated and in-vivo measured doses. MATERIALS AND METHODS: From March 1994 to March 1999, 229 supine-positioned patients were treated at our Institute with TBI, using a 6 MV X-rays opposed lateral beam technique. 146 patients received 10 Gy given in three fractions, once a day (FTBI), shielding the lungs by the arms; 70 received 12-13.2 Gy, given in 6-11 fractions, 2-3 fractions per day (HFTBI): in this case about 2/3 of the lungs were shielded by moulded blocks (mean shielded lung dose equal to 9 or 9.5 Gy). Thirteen patients received 8 Gy given in a single fraction (SFTBI, lung dose: 7 Gy). For all HFTBI and FTBI patients, midline in-vivo dosimetry was performed at the first fraction by positioning two diodes pairs (one at entrance and one at the exit side) at the waist (umbilicus) and at the pelvis (ankles). If at least one of the two diodes doses (waist-pelvis) was outside +/-5% from the prescribed dose, actions could be initiated, together with possible checks on the following fractions. Transit dosimetry by portal films was performed for most patients; for 165 of them (117 and 48, respectively for FTBI and HFTBI) the midline in-vivo dose distribution of the chest region was derived and mean lung dose assessed. As a CT plan was performed for all HFTBI patients, for these patients, the lung dose measured by portal in-vivo dosimetry was compared with the expected value. RESULTS: Concerning all diodes data, 528 measurements were available: when excluding the data of the first fraction(s) of the patients undergoing corrections (n = 392), mean and SD were respectively 0.0% and 4.5% (FTBI: -0.3 +/- 4.8%; HFTBI: 0.4 +/- 3.9%). In total 105/229 patients had a change after the first fraction and 66/229 were controlled by in-vivo dosimetry for more than one fraction. Since January 1998 a CT plan is performed for FTBI patients too: when comparing the diodes data before and after this date, a significant improvement was found (i.e. rate of deviations larger than 5% respectively equal to 30.7% and 13.1%, P = 0.007). When considering only the patients with a CT plan, the global SD reduced to 3.5%. Concerning transit dosimetry data, for FTBI, the mean (midline) lung dose was found to vary significantly from patient to patient (Average 9.13 +/- 0.81 Gy; range 7.4-11.4 Gy); for the HFTBI patients the mean deviation between measured and expected lung dose was 0.0% (1 SD = 3.8%). CONCLUSIONS: In vivo dosimetry is an effective tool to improve the accuracy of TBI. The impact of CT planning for FTBI significantly improved the accuracy of the treatment delivery. Transit dosimetry data revealed a significant inter-patient variation of the mean lung dose among patients undergoing the same irradiation technique. For patients with partial lung shielding (HFTBI), an excellent agreement between measured and expected lung dose was verified.

A cohort study with regard to the risk of haematological malignancies in patients treated with x-rays for benign lesions in the locomotor system. II. Estimation of absorbed dose in the red bone marrow.

A cohort study with regard to the risk of haematological malignancies was performed on about 20,000 patients who in 1950-1964 received roentgen treatment for benign conditions in the locomotor system. In order to estimate the mean absorbed red bone marrow dose the treatments were classified as concerning 10 sites (cervical spine, thoracic spine, lumbar spine, sacral region, shoulder, hip, elbow, wrist, knee and ankle). The four last-mentioned sites do not normally contain red bone marrow in adults and their contribution to the mean absorbed dose was regarded as zero. For the other 6 sites random samples consisting of 30 patients for each site were drawn from the cohort. By use of the treatment records and data from the literature on some physical parameters and red bone marrow distribution in normal adult persons, average conversion factors were calculated by which the subscribed surface dose could be converted into mean absorbed dose in red bone marrow. These conversion factors were then applied on the whole cohort and used for stratification of it according to different levels of exposure.

Radiation necrosis overlying the ankle joint after injection with yttrium-90.

A 35-year-old woman with rheumatoid arthritis presented with radiation necrosis and an open wound overlying her ankle joint, 8 months after injection with yttrium-90 to facilitate radiosynovectomy. This problem was successfully treated by surgical excision of the area of radiation damage and closure with a fasciocutaneous flap.