Low Rates of Colorectal Cancer Screening in First-Degree Relatives of Our Patients: Are We Failing Them?

BACKGROUND: Guidelines recommend screening those with a family history of early-onset colorectal cancer at age 40 years or 10 years before the age of their relative's diagnosis. Currently, there is no literature reporting the screening rate in these individuals, and no protocols are in place to identify and target this population for screening awareness. OBJECTIVE: This study aimed to assess adherence to current screening guidelines among first-degree relatives of patients with early-onset colorectal cancer. DESIGN: Retrospective and qualitative study involving a telephone survey where patients were asked about relative's screening status and barriers to screening. SETTINGS: Two community-based institutions between January 2018 and December 2021. PATIENTS: Individuals diagnosed with early-onset colorectal cancer who had undergone surgery at our institutions. MAIN OUTCOME MEASURES: Rate of screening in first-degree relatives of our patients with early-onset colorectal cancer. Other factors measured included demographics, clinicopathologic characteristics, and screening barriers. RESULTS: Thirty-six patients were identified. The survey response rate was 66.6% (n = 24). A total of 88 first-degree relatives who met the screening criteria resulted in 67.1% of patients (n = 59) having a known screening status. Of the 59 patients with known screening status, only 44% (n = 26) had undergone screening. Patients of Black race, having stage III/IV disease, having Medicare/Medicaid insurance, and living within Baltimore City County were more likely to have family members with unknown or no screening. Lack of insurance coverage was the most common barrier, which was noted in 12.5% of patients (n = 3), whereas 54.1% of patients (n = 13) reported no barriers to screening. LIMITATIONS: Retrospective design. CONCLUSIONS: Most first-degree relatives of patients diagnosed with early-onset colorectal cancer do not undergo colorectal cancer screening. This could be attributed to the lack of protocols that could guarantee these individuals are informed of their elevated risk and the different options available for screening. Furthermore, our study suggests that racial and socioeconomic disparities exist among high-risk patients who should pursue screening. See Video Abstract . BAJAS TASAS DE DETECCIN DEL CNCER COLORRECTAL EN LOS FAMILIARES DE PRIMER GRADO DE NUESTROS PACIENTES LES ESTAMOS FALLANDO: ANTECEDENTES:Las directrices recomiendan realizar pruebas de detección a las personas con antecedentes familiares de cáncer colorrectal de aparición temprana a los 40 años o 10 años antes de la edad del diagnóstico de su familiar. Actualmente, no hay literatura que informe la tasa de detección en estos individuos y no existen protocolos para identificar y dirigirse a esta población para concientizar sobre la detección.OBJETIVO:Evaluar el cumplimiento de las pautas de detección actuales entre los FDR de pacientes con cáncer colorrectal de aparición temprana.DISEÑO:Estudio retrospectivo y cualitativo que incluyó una encuesta telefónica en la que se preguntó a los pacientes sobre el estado de detección de sus familiares y las barreras para la detección.AJUSTES:Dos instituciones comunitarias entre enero de 2018 y diciembre de 2021.PACIENTES:Personas diagnosticadas con cáncer colorrectal de inicio temprano que habían sido intervenidas quirúrgicamente en nuestras instituciones.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de detección en familiares de primer grado de nuestros pacientes con cáncer colorrectal de aparición temprana. Otros factores medidos incluyeron datos demográficos, características clínico-patológicas y barreras de detección.RESULTADOS:Se identificaron treinta y seis pacientes. La tasa de respuesta a la encuesta fue del 66,6% (n = 24). Resultaron un total de 88 familiares de primer grado que cumplieron con los criterios para la detección, y el 67,1% (n = 59) tenía un estado de detección conocido. De los 59 con estado de detección conocido, se informó que solo el 44% (n = 26) se había sometido a pruebas de detección. Los pacientes de raza afroamericana, enfermedad en etapa III/IV, Medicare/Medicaid y que vivían dentro del condado de la ciudad de Baltimore tenían más probabilidades de tener familiares con pruebas de detección desconocidas o sin ellas. La falta de cobertura de seguro fue la barrera más común observada por el 12,5% (n = 3); mientras que el 54,1% (n = 13) no informó ninguna barrera para el cribado.LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:La mayoría de los familiares de primer grado de pacientes diagnosticados con cáncer colorrectal de aparición temprana no se someten a pruebas de detección de cáncer colorrectal. Esto podría atribuirse a la falta de protocolos que garanticen que estas personas estén informadas sobre su elevado riesgo y las diferentes opciones disponibles para el cribado. Además, nuestro estudio sugiere que existen disparidades raciales y socioeconómicas entre los pacientes de alto riesgo que deberían someterse a pruebas de detección. (Traducción-Dr. Francisco M. Abarca-Rendon).

The Effect of Obesity on Vaginoplasty Outcomes.

BACKGROUND: Some surgeons use body mass index criteria within the patient selection processes before vaginoplasty, thereby limiting access to select obese patients. We sought to better characterize the effect of obesity on postoperative outcomes across multiple vaginoplasty techniques. METHODS: A single-center retrospective review of all transfeminine patients undergoing primary vaginoplasty procedures from December 2018 to July 2022 was conducted. Patients were stratified into cohorts according to the World Health Organization Obesity Class criteria. Data regarding demographics, comorbidities, operative details, postoperative complications, and all-cause revision were collected. RESULTS: A total of 237 patients met the inclusion criteria. Average follow-up duration was 9.1 ± 4.7 months. Multivariate regression revealed that patients with class I and class II/III obesity were associated with higher odds of developing vaginal stenosis (class I: odds ratio [OR], 7.1 [ P = 0.003]; class II/III: OR, 3.4 [ P = 0.018]) and all-cause revision (class I: OR, 3.7 [ P = 0.021]; class II/III: OR, 4.8 [ P = 0.027]). Undergoing either robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (peritoneal: OR, 0.2 [ P < 0.001]; intestinal: OR, 0.2 [ P = 0.011]). Lastly, adherence to dilation regimen was negatively associated with development of vaginal stenosis (OR, 0.04; P < 0.001). CONCLUSIONS: Patients with obesity may be at a higher risk of developing vaginal stenosis after vaginoplasty, which may ultimately necessitate operative revision. Although patients with obesity may remain surgical candidates, proper preoperative counseling and adherence to postoperative vaginal dilation regimens are critical to optimizing outcomes.

The robotic-assisted free jejunal flap for neovaginal canal creation in gender-affirming vaginoplasties.

INTRODUCTION: One of the biggest challenges with gender-affirming vaginoplasty was the creation of a long-lasting, durable, patent, and self-lubricating neovaginal canal that allowed for spontaneous, pain-free sexual intercourse. The jejunum was a durable, physiologic, and intestinal option to create the neovaginal canal that minimizes the adverse effects of skin graft, peritoneal, and colonic vaginoplasties. Free jejunal vaginoplasties had been performed in cis females for congenital genitourinary anomalies like Mullerian agenesis or after gynecologic-oncologic surgery but had yet to be reported for gender-affirming vaginoplasties. The purpose of this report was to present a technique for a physiologic, intestinal, gender-affirming vaginoplasty without the disadvantages of colonic vaginoplasties. PATIENTS AND METHODS: This report presented six patients, all natal males who identified as female, undergoing robotic-assisted free jejunal flap gender-affirming vaginoplasty. Mean age was 35.8 years (range: 21-66). Mean body mass index was 33.2 kg/m2 (range: 28.0-41.0). The proximal aspect of the neovaginal canal was created intra-abdominally by elevating peritoneal flaps from the posterior bladder wall to be reflected downward into the external neovaginal canal. The jejunal flap was harvested. The greater saphenous vein was harvested to create an arteriovenous loop between the flap vessels and the recipient femoral artery in an end-to-side fashion and a branch of the femoral vein. The jejunal flap was passed intra-abdominally through the groin incision and then trans-peritoneally into the neovaginal canal. The jejunal segment was inset to the proximal peritoneal flaps and the distal inverted penoscrotal skin of the neovaginal introitus. RESULTS: Mean length of the harvest jejunal segment was 19.2 cm (range: 15-20). Mean time to ambulation, foley removal, and first vaginal dilation were 3.3 (range: 3-4), 4.0 (range: 3-5), and 4.5 days (range: 4-6), respectively. By a mean follow-up duration of 8.0 months (range: 1-14), mean vaginal depth and diameter were 7.0 and 1.3 cm (range: 1.0-1.5), respectively. Two (33.3%) patients experienced postoperative complications, including groin hematoma (n = 1, 16.7%) and reoperation for correction of dehiscence of the jejunal flap to the vaginal introitus (n = 1, 16.7%). CONCLUSION: Gender-affirming surgeons should consider a free vascularized segment of jejunum as an option to line the neovaginal canal in the correct patients.

Robotic transanal minimally invasive surgery: a case series.

INTRODUCTION: This study describes the experience with robot-assisted transanal minimally invasive surgery (rTAMIS) at a single institution. TAMIS has become a popular minimally invasive technique for local excision of well-selected rectal lesions. rTAMIS has been proposed as another option as it improves the ergonomics of conventional laparoscopic techniques. METHODS: Retrospective case series of patients with rectal lesions who underwent rTAMIS. Patient demographics, final pathology, surgical and admission details, and clinical outcomes were recorded. Successful procedures were defined as having negative margins on final pathology. RESULTS: A total of 16 patients underwent rTAMIS by a single surgeon between April 2018 and December 2019. Mean age of patients was 63 years. Final pathologies were negative for tumor (n = 4), tubulovillous adenoma (n = 4), tubulovillous adenoma with high-grade dysplasia (n = 4), and invasive rectal adenocarcinoma (n = 4). 43% were located in the middle rectum and 56% were located in the distal rectum. Mean maximum diameter was 4.1 cm (IQR 2-3.1 cm). Negative margins were seen in 100% of the excision cases, and 100% were intact. Mean operative time was 87 min (IQR 54.8-97.3 min), and median length of stay was 0 days (IQR 0-1 days). Postoperative complications included incontinence (n = 1) and abscess formation (n = 2). rTAMIS provided curative treatment for 12/16 patients, and the remaining 4 patients received the appropriate standard of care for their respective pathologies. CONCLUSIONS: Robot-assisted TAMIS is a safe alternative to laparoscopic TAMIS for resection of appropriate rectal polyps and early rectal cancers. rTAMIS may provide a modality for resecting larger or more proximal rectal lesions due to the wristed instruments and superior visualization with the robotic camera. Future studies should focus on comparing outcomes between robotic and laparoscopic TAMIS, and whether rTAMIS allows for the removal of larger, more complex lesions, which may save patients from a more morbid radical proctectomy.

Surgical Management of Complicated Colon Cancer.

The management of complicated colon cancer (locally invasive, obstructed, or perforated cancers) can pose diagnostic and therapeutic challenges to surgical management. Adherence to traditional surgical oncologic principles must often be balanced with the patients' clinical presentation and other parameters. While the goal of an R0 (no residual microscopic disease) resection must always be kept in mind, situations sometimes arise which can make this difficult to achieve. Recognition of complicated disease and availability of varied therapeutic modalities is important to ensure favorable patient outcomes. This review will discuss the surgical management of complicated colon cancer, with special focus on locally advanced disease.

Predictors of Timely Initiation and Completion of Adjuvant Chemotherapy in Stage II/III Colorectal Adenocarcinoma.

Background: Adjuvant chemotherapy (AC) for colorectal cancer (CRC) has led to substantial improvement in survival. Several clinical trials advocate the initiation of AC within 6-8 weeks of surgical resection based on evidence of improved survival with early initiation of AC. We aim to evaluate factors that predict initiation and completion of AC, subsequently improving survival. Methods: We identified 451 patients who underwent resection for CRC between 2014 and 2022. One hundred ten patients had stage II/III colorectal cancer who underwent resection followed by AC. Multivariable logistic regression analysis was performed to identify factors significantly predicting delay in AC >8 weeks. Secondary outcomes included chemotherapy completion rate, recurrence-free survival, and overall survival. Results: The final analysis included 110 patients. The median time to initiation of adjuvant chemotherapy (TIAC) was 6.9 weeks (IQR: 5.8-9.5). In total, 36.4% of patients had a delay >8 weeks to initiation of AC, and only 40% completed treatment. The surgical approach (open vs laparoscopic vs robotic) had no effect on the TIAC. On multivariable logistic regression analysis, preoperative albumin ≥3.5 (OR = .31; 95% CI: .12-.80) was an independent predictor of timely initiation of AC. Completion of AC was associated with a higher overall survival. Discussion: Preoperative nutritional status predicted delay in initiation of AC. Patients with a delay in AC beyond eight weeks had a lower rate of AC completions and worse survival. It is imperative to optimize this aspect of treatment as it correlates with survival.

Impact of Surgical Resident Education and EMR Standardization in Enhancing ERAS Adherence and Outcomes in Colorectal Surgery.

OBJECTIVE: Our study aimed at investigating the degree of adherence to ERAS pathway at our institution and to evaluate the role of providing resident education and a standardized EMR order set in improving adherence and patient surgical outcomes. DESIGN: The study is prospective in nature and consists of two phases with a preintervention cohort to assess adherence to ERAS protocol and a postintervention cohort to evaluate improvement in adherence and patient outcomes. Adherence with the ERAS protocol was assessed across preoperative, intraoperative, and postoperative phases. SETTING: The study took place at MedStar Franklin Square Medical Center in Baltimore, Maryland, involving inpatient care at a surgical ward. PARTICIPANTS: During the preintervention phase, patients undergoing elective colorectal surgery were identified over 6 months (N = 77), and their adherence to the ERAS protocol was assessed. Following the intervention of surgical resident and faculty education sessions on the ERAS protocol and the implementation of a standardized order set in the Electronic Medical Record, a postintervention cohort (N = 54) was selected for comparison over another 6 months. RESULTS: Among 77 patients who underwent elective colorectal surgery, the adherence rate to ERAS protocol was notably below 80% for most elements of the postoperative phase. When pre- and postintervention cohorts were compared, there were no significant differences in the baseline demographics and perioperative variables. After the implementation of our intervention, adherence rates were significantly improved in 7 out of 8 ERAS protocol elements of the postintervention phase. Among primary outcome measures, readmission rate (24.7% vs.9.4%; p = 0.022) and length of stay (7.3 ± 4.5 vs. 5.5 ± 3.6; p = 0.014) were significantly lower in the postintervention cohort. Although the rate of postoperative complications did not decrease significantly (33.8% vs. 31.5%; p = 0.284), there were fewer patients with postoperative ileus and surgical site infections. Outcomes were evaluated based on an 8-point score of postoperative ERAS elements. A significant decrease in mean length of stay and readmission rates is observed when at least 5 elements are completed, emphasizing the ERAS pathway's importance as a complementary bundle. CONCLUSION: Our study highlights the impact of resident education and electronic medical record standardization on ERAS adherence in colorectal surgery. This multidisciplinary approach improves adherence, reduces hospital stay, and enhances communication among healthcare providers for better patient outcomes.

A comparative analysis of peritoneal flap and intestinal vaginoplasty for management of vaginal stenosis.

BACKGROUND: In transgender or non-binary patients (TGNB) with failed penile inversion vaginoplasty (PIV), peritoneal flap vaginoplasty (PFV) and intestinal segment vaginoplasty (ISV) facilitate restoration of neovaginal depth and sexual function. This study compared the outcomes of revision PFV and ISV in TGNB patients with failed PIV. METHODS: TGNB patients who underwent secondary PFV or ISV from December 2018 to April 2023 were reviewed. RESULTS: Twenty-one (5.8%) patients underwent secondary PFV and 24 (6.6%) underwent secondary ISV, due to vaginal stenosis (n = 45, 100.0%). Mean duration to first successful dilation and average vaginal depth were comparable between the groups. Seven (33.3%) PFV patients experienced short-term complications, including introital dehiscence (n = 2, 9.5%), vaginal stenosis (n = 2, 9.5%), vaginal bleeding (n = 2, 9.5%), and reoperation (n = 2, 9.5%). Nine (42.9%) experienced long-term complications, including urethrovaginal fistula formation (n = 2, 9.5%), hypergranulation (n = 2, 9.5%), vaginal stenosis (n = 7, 33.3%), and reoperation (n = 6, 28.6%). Ten (41.7%) ISV patients experienced short-term complications, including dehiscence (n = 4, 19.0%), ileus (n = 2, 8.3%), introital stenosis (n = 2, 9.5%), and reoperation due to vaginal bleeding (n = 2, 8.3%). Six (25.0%) experienced long-term complications, including introital stenosis (n = 3, 12.5%), mucosal prolapse (n = 2, 8.3%), and reoperation due to mucosal prolapse (n = 4, 16.7%). Secondary PFV had a higher rate of vaginal stenosis (p = 0.003). There were no cases of partial or full-thickness flap necrosis. CONCLUSION: Revision PFV and ISV represent viable techniques for addressing vaginal stenosis secondary to PIV. Although PFV and ISV had comparable rates of short-term complications, ISV demonstrated a lower incidence of recurrent vaginal stenosis, which may inform operative decision-making.

Managing the athlete with type 1 diabetes.

Type 1 diabetes is a chronic disease that can lead to many serious complications if not properly managed. The patient and physician must work together to optimize glucose control involving both insulin administration and caloric intake. Exercise has numerous benefits and the type 1 diabetic should take advantage of these benefits. Athletes with type 1 diabetes are capable of undertaking a wide array of exercise activities and there are no longer firm contraindications to certain sports for diabetic patients. This article will aid the sports physician in understanding the effects of exercise on diabetes, educating patients to exercise safely, advising when exercise is contraindicated, and providing guidelines for optimal management of the diabetic athlete.

Timing of rotator cuff activation during shoulder external rotation in throwers with and without symptoms of pain.

STUDY DESIGN: Fine-wire EMG rotator cuff onset time analysis in 2 matched groups of throwers with and without pain. OBJECTIVE: To identify if there is a difference in the activation patterns of the rotator cuff muscles during a rapid shoulder external rotation task between throwers with and without pain. BACKGROUND: The coordinated action of the rotator cuff is recognized as essential for glenohumeral joint control in the throwing athlete. Identification of abnormalities occurring in muscle activation patterns for injured athletes is relevant when prescribing rehabilitative exercises. METHODS AND MEASURES: Twelve throwers with shoulder pain were compared to a matched group of 11 asymptomatic throwers. Participants were matched for age, height, body mass, and habitual activity. Fine-wire EMG electrodes were inserted into the subscapularis, supraspinatus, and infraspinatus. EMG activity was measured during a reaction time task of rapid shoulder external rotation in a seated position. The timing of onset of EMG activity was analyzed in relation to visualization of a light (reaction time) and to the onset of infraspinatus activity (relative latency). RESULTS: In the group with shoulder pain, the onset of subscapularis activity was found to be significantly delayed (reaction time, P = .0018; relative latency, P = .0005) from the onset of infraspinatus activity when compared to the control group. CONCLUSIONS: The presence of shoulder pain in these athletes was associated with a difference in the onset of subscapularis EMG activity during a rapid shoulder external rotation movement. This was an initial step in the understanding of the joint protection mechanisms of the glenohumeral joint and the problems that occur in throwers. This information may assist in providing future guidelines for more effective rehabilitation and prevention strategies for this condition.

Exertional compartment syndrome in an equestrian does inadequate staffing compromise healthcare?

When evaluating lower-leg pain, the clinician must consider compartment syndrome resulting from exercise, even in the absence of trauma or if the exercise is seemingly benign. Equestrian sports would seem an unlikely source of acute compartment syndrome, but the examiner should consider unusual mechanisms of injury in any case. Although intracompartment tissue pressure measurements can help make the diagnosis, excessive pain is a more reliable early warning sign of acute compartment syndrome. A timely diagnosis and immediate surgical treatment may prevent serious long-term sequelae.

Automated External Defibrillators and Emergency Planning for Sudden Cardiac Arrest in Vermont High Schools: A Rural State's Perspective.

BACKGROUND: Sudden cardiac death (SCD) events are tragic. Secondary prevention of SCD depends on availability of automated external defibrillators (AEDs). High school athletes represent a high-risk group for SCD, and current efforts aim to place AEDs in all high schools. HYPOTHESIS: The prevalence of AEDs and emergency planning for sudden cardiac arrest (SCA) in Vermont high schools is similar to other states. Understanding specific needs and limitations in rural states may prevent SCD in rural high schools. STUDY DESIGN: Cross-sectional survey. METHODS: A survey was distributed to all 74 Vermont high school athletic directors. Outcome measures included AED prevalence, AED location, individuals trained in cardiopulmonary resuscitation (CPR) and AED utilization, funding methods for AED attainment, and the establishment of an emergency action plan (EAP) for response to SCA. RESULTS: All schools (100%, 74 of 74) completed the survey. Of those, 60 (81%) schools have at least 1 AED on school premises, with the most common location for AED placement being the main office or lobby (50%). Larger sized schools were more likely to have an AED on the premises than smaller sized schools (P = 0.00). School nurses (77%) were the most likely individuals to receive formal AED training. Forty-one schools (55%) had an EAP in place for response to SCA, and 71% of schools coordinated AED placement with local emergency medical services (EMS) responders. CONCLUSION: In Vermont, more than two-thirds of high schools have at least 1 AED on school premises. However, significant improvement in the establishment of EAPs for SCA and training in CPR and AED utilization is essential given the rural demography of the state of Vermont. CLINICAL RELEVANCE: Rural high schools inherently have longer EMS response times. In addition to obtaining AEDs, high schools must develop a public access to defibrillation program to maximize the chance of survival following cardiac arrest, especially in rural settings.

Male genital trauma in sports.

Male genital trauma is a rare but potentially serious sports injury. Although such an injury can occur by many different mechanisms, including falls, collisions, straddle injuries, kicks, and equipment malfunction, the clinical presentation is typically homogeneous, characterized by pain and swelling. Almost all sports-related male genital injury comes from blunt force trauma, with involvement of scrotal structures far more common than penile structures. Most injuries can be treated conservatively, but catastrophic testicular injury must first be ruled out. Despite being relatively uncommon compared with other sports injuries, more than half of all testicular injuries are sustained during sports.

Imaging of peripheral nerve lesions in the lower limb.

Lower limb peripheral neuropathy may have a variety of causes. This article focuses on focal neural lesions because of neural entrapment associated with static mechanical compression or dynamic compression/stretching. Mechanical compression may relate to direct blunt trauma, surgical injury, mass effect associated with adjacent mass lesions, and frictional effects associated with fibrous bands. Stretching neural injury may be associated with abnormalities in alignment such as plano-valgus hindfoot and hindfoot pronation. Recurrent inversion ankle injuries may also cause neural injury. Neural injury may be associated with denervation of the muscles supplied by the nerve. Electromyography (EMG) remains the gold standard for diagnosis of denervation. Diagnostic imaging plays a complementary role to EMG in difficult cases, the anticoagulated patient, and in clarifying the etiology of an EMG-demonstrated neuropathy. Magnetic resonance imaging and ultrasound can be used in peripheral nerve imaging to demonstrate extrinsic compressive lesions, focal neural lesions such as neural edema and swelling, focal neural scarring (posttraumatic neuroma in continuity) and intraneural ganglia. Imaging can also demonstrate the effects of muscle denervation. Focal areas of tenderness can be highlighted using skin markers for magnetic resonance imaging and by transducer palpation on ultrasound. Ultrasound can be particularly useful in assessing for intrinsic lesions in small peripheral nerves because of the superior spatial resolution of ultrasound in assessing superficial structures. Plain x-rays (and sometimes computed tomography scanning) may show significant bone changes and should be the initial imaging modality.

Plasma Amyloid-ß Peptides and Homocysteine in Depression in the Homebound Elderly.

OBJECTIVES: Both plasma amyloid-ß peptide 40 (Aß40) and homocysteine (tHcy) are linked to vascular disease, which is related to depression in the elderly. We sought to study whether the relationship between tHcy and plasma Aß40 differs in those with and without depression. STUDY DESIGN AND METHODS: In a cross-sectional study of 1058 homebound elders, vascular depression was defined as a score ≥ 16 on the Center for Epidemiological Studies Depression scale (CES-D) along with self-reported cardiovascular disease (CVD). Plasma Aß40 and Aß42, and serum tHcy and creatinine were measured. RESULTS: Elders with high tHcy had higher concentrations of plasma Aß40 (median: 147.5 vs. 123.1 pg/ml, P < 0.0001) and Aß42 (median: 20.2 vs. 16.6 pg/ml, P < 0.0001) than those with low tHcy. In elders with depression, the relationship between logarithm of plasma Aß40 (LogAß40), but not LogAß42, and tHcy was significant (ß = +0.010, SE = 0.004, P = 0.007); in contrast, this relationship was not observed in those without depression. Subjects with vascular depression had the highest concentration of tHcy (mean ± SD: 12.8 ± 4.6 vs. 11.7 ± 4.5 vs. 11.9 + 5.5, P = 0.008) compared to those without CVD and those without depression. Depressed subjects without CVD had the lowest concentration of plasma Aß42 (median: 15.5 vs. 19.1 vs. 18.7, P = 0.01) compared to those with CVD and those without depression. CONCLUSIONS: Vascular depression, which is associated with tHcy and Aß40 in blood, appears to be different from depression that is associated with low plasma Aß42. This suggests that reducing tHcy and Aß40 may be an adjunct treatment for vascular depression.

Overuse and impingement syndromes of the shoulder in the athlete.

Overuse and impingement syndromes in the shoulders of athletes are predominantly caused by instability of the glenohumeral joint. Glenohumeral joint instability is usually acquired from repetitive overuse of the rotator cuff and shoulder girdle muscles, or injury of the static and dynamic stabilizers of the glenohumeral joint. Congenital hypermobility of the joint may also contribute to these syndromes in some individuals. The throwing action may lead to a cascade of injuries to the static and dynamic stabilizers of the posterosuperior glenohumeral joint, caused by the repetitive, high-energy nature of the action rather than a specific injury. Injury to the anterosuperior stabilizers of the glenohumeral joint may also lead to anterosuperior impingement syndrome. The role of MR in overuse and impingement syndromes of the shoulder is to accurately diagnose the underlying structural changes and serves to assist the clinician in instituting the appropriate conservative or surgical treatment for individual athletes.

MR imaging of traumatic and overuse injuries of the wrist and hand in athletes.

Traumatic and overuse injuries of the hand and wrist are common in athletes. Increasingly, MR imaging is being used to complement clinical and radiographic assessment in the diagnosis and management of these injuries. MR imaging is able to image accurately the bones, tendons, ligaments, nerves, and other small structures of the hand and wrist. This article provides an overview of traumatic and overuse injuries of the hand and wrist in athletes and a review of the MR imaging appearances.

Ultrasound evaluation of soft tissue masses and fluid collections.

Musculoskeletal ultrasound has utility as a first-line screening modality in the evaluation of soft tissue masses. The sonographic appearances of cysts or lipomas may be sufficient to obviate the need for further imaging. For other complex cystic or solid masses, ultrasound is an inexpensive, widely available imaging modality that can evaluate lesion vascularity, guide diagnostic and therapeutic aspiration or biopsy procedures, and be used for follow-up examinations to determine response to therapeutic interventions.

A "paneful" perforation.

Radiographs of a woman presenting with abdominal pain revealed a large foreign body within the pelvis. A diagnosis of perforation of the colon was made, and at laparotomy an 8.5 cm long glass fragment was removed from the bowel. A laceration to the lower back, sustained in a fall onto a glass coffee table, had been explored and sutured 20 months earlier. Imaging findings showed the subsequent course of the overlooked glass fragment within the pelvis.