Graft vasculopathy in clinical hand transplantation.

Allogeneic hand transplantation is now a clinical reality. While results have been encouraging, acute rejection rates are higher than in their solid-organ counterparts. In contrast, chronic rejections, as defined by vasculopathy and/or fibrosis and atrophy of skin and other tissues, as well as antibody mediated rejection, have not been reported in a compliant hand transplant recipient. Monitoring vascularized composite allograft (VCA) hand recipients for rejection has routinely involved punch skin biopsies, vascular imaging and graft appearance. Our program, which has transplanted a total of 6 hand recipients, has experience which challenges these precepts. We present evidence that the vessels, both arteries and veins may also be a primary target of rejection in the hand. Two of our recipients developed severe intimal hyperplasia and vasculopathy early post-transplant. An analysis of events and our four other patients has shown that the standard techniques used for surveillance of rejection (i.e. punch skin biopsies, DSA and conventional vascular imaging studies) are inadequate for detecting the early stages of vasculopathy. In response, we have initiated studies using ultrasound biomicroscopy (UBM) to evaluate the vessel wall thickness. These findings suggest that vasculopathy should be a focus of frequent monitoring in VCA of the hand.

Prenatal diagnosis of a severe deforming type of osteogenesis imperfecta.

A pregnancy at risk for a severe deforming type of osteogenesis imperfecta (OI) was monitored by ultrasonography and radiography. Long bone measurements were normal at 15 1/2 weeks gestation, but ultrasound detected an abnormality of one femur that appeared to be a fracture. The ultrasound study at 19 weeks revealed severe shortness of the femora, and radiographs showed only vertebral bodies with no other fetal skeletal parts clearly visible. These studies indicate the feasibility of prenatal diagnosis before 20 weeks for the more severe handicapping types of OI that are compatible with survival past the newborn period and that can result in death during later infancy.

Effects of deep inhalation in asthma: relative airway and parenchymal hysteresis.

Asthmatic subjects were screened for the effects or volume history on the degree of induced airway obstruction with methacholine by comparing isovolumic maximal expiratory flows (Vmax) from partial expiratory flow-volume curves (P) begun near functional residual capacity (FRC) followed by maximal expiratory flow-volume (M) maneuvers begun from total lung capacity (TLC). The isovolumic Vmax values from M and P maneuvers defined two groups: one had a high M/P ratio (high group), indicating a large degree of reversal with deep inhalation, another had a low M/P ratio (low group), indicating minimal reversal. No differences were found between groups. A more complete study was later performed in which we measured specific airway conductance (sGaw) and anatomical dead space (VD) as indices of airway size and hysteresis before and after deep inhalation. The area of quasi-static transpulmonary pressure (Ptp) volume (V) curves from FRC to TLC and back to FRC was measured as an index of parenchymal hysteresis. At base line both groups showed a decrease in both sGaw and VD after a deep inhalation (DI). After constriction neither group changed VD after DI, whereas sGaw increased significantly in the high group after DI. This suggests that dilation of airways with DI occurred peripheral to those contributing to VD in the high group. The areas of the Ptp-V curves were equal at base line; yet the increase in areas with constriction in the low group was much greater.(ABSTRACT TRUNCATED AT 250 WORDS)

Educational outreach to mammography facility staff to assist with compliance with the Mammography Quality Standards Act in rural North Carolina.

RATIONALE AND OBJECTIVES: The purpose of this project was to develop and evaluate an educational program targeted at mammography facilities in rural areas of North Carolina that were having difficulty complying with the 1992 Mammography Quality Standards Act (MQSA). MATERIALS AND METHODS: Fourteen facilities deemed at risk for closure under MQSA were identified by state inspection personnel. Problems at the facilities were evaluated by a radiologist, a physicist-educator, and a radiation physicist through a written survey, review of phantom and clinical images, and a site visit. Individual advice and instruction were provided on-site by the physicist-educator, with written materials provided in follow-up. A repeat site visit was made 4-6 months after the initial visit. RESULTS: Of 51 problems identified at the 12 institutions that completed the program, 35 (69%) were corrected. All facilities that had failing phantom scores at the inspection prior to the intervention had passing scores at the inspection after the intervention. There was a statistically significant increase in the sum of the phantom scores for the facilities offered this intervention compared with those not offered it (P = .03). CONCLUSION: This educational program improved mammography quality at participating facilities.

Factors affecting phantom scores at annual mammography facility inspections by the U.S. Food and Drug Administration.

RATIONALE AND OBJECTIVES: The authors performed this study to evaluate the factors affecting phantom image score at the annual inspection of mammography facilities. MATERIALS AND METHODS: In 1997, three U.S. Food and Drug Administration (FDA)-trained inspectors performed inspections of all mammography facilities in North Carolina. All federal and state inspection data were collected and evaluated by using linear regression analysis. Factors affecting the American College of Radiology phantom scores were assessed. RESULTS: Phantom score was affected by inspector identity, view box luminance, and optical density. All of these factors had a statistically significant effect on mass score (P < .05). Inspector identity yielded a statistically significant effect on speck group score, fibril score, and total score. Luminance yielded a statistically significant effect on both speck group score and total score. CONCLUSION: Phantom scoring should be automated to allow for more consistent interobserver scoring. In addition, radiology facilities can improve the likelihood of receiving a passing phantom score by reducing the ambient light and increasing the view box luminance in the location where the images are evaluated and the phantom is scored routinely. Radiologists should also consider increasing phantom and clinical image optical density to allow for improved phantom testing outcomes.

Effects of processing conditions on mammographic image quality.

RATIONALE AND OBJECTIVES: Any given mammographic film will exhibit changes in sensitometric response and image resolution as processing variables are altered. Developer type, immersion time, and temperature have been shown to affect the contrast of the mammographic image and thus lesion visibility. The authors evaluated the effect of altering processing variables, including film type, developer type, and immersion time, on the visibility of masses, fibrils, and speaks in a standard mammographic phantom. MATERIALS AND METHODS: Images of a phantom obtained with two screen types (Kodak Min-R and Fuji) and five film types (Kodak Min-R M, Min-R E, Min-R H; Fuji UM-MA HC, and DuPont Microvision-C) were processed with five different developer chemicals (Autex SE, DuPont HSD, Kodak RP, Picker 3-7-90, and White Mountain) at four different immersion times (24, 30, 36, and 46 seconds). Processor chemical activity was monitored with sensitometric strips, and developer temperatures were continuously measured. The film images were reviewed by two board-certified radiologists and two physicists with expertise in mammography quality control and were scored based on the visibility of calcifications, masses, and fibrils. RESULTS: Although the differences in the absolute scores were not large, the Kodak Min-R M and Fuji films exhibited the highest scores, and images developed in White Mountain and Autex chemicals exhibited the highest scores. CONCLUSION: For any film, several processing chemicals may be used to produce images of similar quality. Extended processing may no longer be necessary.

Resource requirements to develop a large, remote aboriginal health service: whose responsibility?

In 1994 the Commonwealth funded studies to establish and develop Aboriginal health services. One such study was undertaken in 1995 at Maningrida, Northern Territory: to identify the health-service needs of the population and consider community management structures; to identify Northern Territory expenditure for primary health care; and to provide a three- to five-year development budget. Approximately 2100 Aboriginal residents in the region used the service, including 750 living on 24 outstations within 75 km. Nearly 40 per cent were aged under 15 years. Childhood morbidity was high, with children under two averaging 1.4 hospital admissions per year. The age pyramid reflected premature adult mortality from the third decade of life. Service providers identified inadequate staffing and infrastructure as barriers to service development. Community consultations emphasised the need for resident doctors, improved outstation services and aged and respite care, local training for Aboriginal health workers and housing for staff. These developments would require per capita primary health care expenditure ($872) to be doubled. Aboriginal people in remote areas are disadvantaged through Commonwealth Grants Commission funding formulae and lack of Medicare access. As the sole funding source, the Northern Territory spends over $1.83 million per year providing health services at Maningrida. Additionally, the study proposed that the Commonwealth spend $1.96 million a year over five years on staffing and infrastructure. Local Aboriginal organisations also agreed to allocate resources for health service development. Ineffective implementation, lack of clarification of government responsibilities and funding shortfalls remain barriers to developing remote Aboriginal health services.

Patterns of petrol sniffing and other drug use in young men from an Australian Aboriginal community in Arnhem Land, Northern Territory.

Petrol sniffing and use of other drugs were examined among 48 males aged 13-32 years resident in a remote Aboriginal community in Arnhem Land. The study group consisted of 13 non-sniffers, 13 ex-sniffers and 22 current sniffers. Unemployment was highest among those with a history of petrol sniffing. Employment and family influence emerged as major reported reasons for individuals stopping petrol sniffing. The findings of the study suggest that strategies to reduce petrol sniffing should not only focus on education, employment, skills training and recreation, but should further encourage Aboriginal communities to utilize family relationships to dissuade young people from the practice. Unlike ex-sniffers and current sniffers, non-sniffers tended to be abstainers from tobacco, kava and alcohol. Of the selected study group, 52% smoked >or=25 cigarettes per day. On the basis of the research findings, the local community Council has implemented employment, skills training and recreation strategies to reduce petrol sniffing in this age group. A reduction in tobacco consumption in both adults and young people has also been targeted through health education programmes developed by the community health clinic and the school.

Effect of knee angle and ligament insufficiency on anterior tibial translation during quadriceps muscle contraction: a preliminary report.

Additional information is needed regarding the effects of exercise protocols on the injured or reconstructed anterior cruciate ligament (ACL). The purpose of this investigation was to assess the effects of knee flexion angle and ACL insufficiency on anterior tibial translation (ATT) and patellar ligament insertion angle as subjects performed maximal isometric quadriceps muscle contractions. The subjects were two females and two males between the ages of 18 and 24 who had sustained injuries that resulted in unilateral ACL insufficiency. Each subject performed maximum isometric quadriceps muscle contractions with each leg on a Cybex II dynamometer at each of three positions: 15, 45, and 75 degrees knee flexion. A lateral knee roentgenogram was obtained as each subject maintained each isometric muscle contraction. A roentgenogram also was taken as subjects rested each knee in each of the three target positions. Anterior tibial translation for each isometric muscle contraction was assessed by measuring the anterior displacement of the tibial plateau on the isometric resisted roentgenogram relative to the resting roentgenogram. Patellar ligament insertion angle also was measured for each roentgenogram. Maximum ATT occurred at the 15 degrees knee flexion target angle for two subjects and at the 45 degrees target angle for the other two subjects. Patellar ligament insertion angle decreased as knee flexion angle increased. Appreciable stress may be imposed on the ACL as patients perform maximum quadriceps muscle contractions in positions of terminal knee extension and in midrange positions previously reported as being safe for maximal effort quadriceps exercise. Magnitude of stress imposed on the ACL is discussed as a function of the length-tension relationship of the quadriceps muscle-tendon unit and insertion angle of the patellar ligament. Suggestions are made for additional research regarding appropriate muscle strengthening protocols for patients who have undergone ACL reconstruction.

Reliability and validity of rigid lift and pelvic leveling device method in assessing functional leg length inequality.

Clinicians commonly include an assessment of leg length inequality (LLI) as a component of a musculoskeletal examination. Little research is available, however, documenting reliability and validity of clinical methods for assessing LLI. The purpose of this study was to determine the reliability and validity of assessing functional LLI using a pelvic leveling device. Subjects were 19 women and 13 men between the ages of 18 and 55 who reported having a diagnosed or suspected LLI. Clinical determination of LLI was made by placing rigid lifts under the suspected shorter lower extremity until the leveling device indicated that the iliac crests were level. This measurement was made twice by one investigator and once by a second investigator. Standing radiographic measurements of LLI using rigid lifts were used to establish validity of the clinical method. Intraclass correlation coefficients [ICC(2,1)] and absolute difference values were computed to assess reliability and validity. The mean absolute difference between the two clinical measurements of LLI by the same investigator was 0.29 cm (+/- 0.52), with an ICC = 0.84. The mean absolute difference between clinical measurements of LLI by the two investigators was 0.49 cm (+/- 0.46), with an ICC = 0.77. The ICC and mean absolute difference reflecting agreement between radiographic measurements and clinical measurements of LLI was 0.64 and 0.58 cm (+/- 0.58), respectively, for one investigator and 0.76 and 0.55 cm (+/- 0.37), respectively, for the second investigator. The intratester reliability, intertester reliability, and validity assessments included instances in which paired observations disagreed regarding which lower extremity was the shorter lower extremity. Factors that may be associated with the unacceptable reliability and validity of the clinical assessment method include asymmetric positioning of the ilia, body composition of the patient, and design of the clinical instrument. The authors discuss clinical implications related to assessment of LLI.

The effect of decreased developer activity on patient exposure.

Overexposing and underdeveloping a radiographic image is not a common practice, but it has been observed to occur as a result of poor processing protocols. This study discovered that, as a result of decreased developer activity, the patient exposure could be three times as great as it would be under normal conditions.

Molybdenum/aluminum filters perform effectively.

In this study, the performances of stacked niobium/aluminum and molybdenum/aluminum filters were compared to that of a standard 2.5 mm aluminum filter. The molybdenum/aluminum filter had the same performance characteristics as the niobium/aluminum filter but was less expensive. The study results show that the molybdenum/aluminum filter should be a good filter choice for facilities embracing ALARA principles.

Erect position/tangential projection of the patellofemoral joint.

This paper presents an erect position, using 40 degrees knee flexion and a vertical central ray, as a simple alternative to help overcome the problems encountered with the standard "sunrise" view of the patella and patellofemoral joint.

Advantages of a 400 speed image receptor system for cast radiography.

By using a faster intensifying screen as opposed to the traditional extremity system for cast radiography, one can reduce the dose to the patient significantly while maintaining quality cast radiographs. In this study a 400 speed Lanex Regular, TMG film system was compared to a 100 speed Lanex Fine, TMG film system. The findings suggest that slow speed, high resolution systems are unnecessary for cast radiography. Evidence demonstrated reduced patient exposure and suggested decreased motion and increased tube life as a result of shorter exposures.

Using the same exposure factors for wet and dry casts.

This article presents laboratory and clinical findings that suggest the exposure factors for wet and dry casts should be the same and the selection of factors should be based on cast thickness rather than water content.

Niobium/aluminum filters reduce patient exposure.

Reducing patient exposure while maintaining image quality is key to radiographers. In a comparison study of different filters, the authors found that a combined niobium/aluminum filter provides substantial reduction of entrance skin exposure with fairly small increases in tube loading and little loss of image contrast.

Erect positions for "tunnel" views of the knee.

Two erect methods of radiographing the knee to produce tunnel views of the joint space are presented. Each method produces an excellent image of the intercondyloid fossa without distortion seen with some previous methods. Both erect methods are simple to perform and appear to be more comfortable for patients.