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An instructional program to facilitate teaching joint/soft-tissue injection and aspiration.

OBJECTIVE: We developed an instructional program to teach aspiration and injection techniques of the knee and shoulder to medical students and residents. METHODS: Residents and fourth-year medical students participating in a rheumatology elective were assigned by deterministic allocation into 3 groups: the Traditional group received no specific instruction in arthrocentesis but simply rotated through rheumatology, learning injection techniques only if they saw patients who required them; the Lecture-only group received only the didactic lecture and did not have the opportunity to practice on the models; the Program group participated in the newly developed program of instruction that combined a didactic lecture and a hands-on workshop using the anatomic models to practice arthrocentesis techniques. RESULTS: The scores on the written examination for those in the Program group (mean score 37.46 out of 40 possible) and the Lecture-only group (mean 37.75) were significantly higher than those of the Traditional group (mean 33.15) (P <.05). The scores on the practical examination for those in the Program group (mean score 24.08 out of 26 possible) were significantly higher than those of the Lecture-only (mean 20.50) and Traditional (mean 17.33) (P <.05) CONCLUSION: The addition of this type of instruction to supplement a traditional internal medicine rotation can enhance a learner's ability to perform joint/soft-tissue injection and aspiration.

Clinical Competence↗

Models of antidepressant action.

Although immediate pharmacologic targets can be identified for most antidepressant treatments, elucidation of the critical biological mechanisms leading to symptom relief has defied decades of research. In this review, selected neurotransmitter, biochemical, and anatomic models of antidepressant action are considered with regard to their explanatory power and therapeutic applicability. Monoamine models have been a focus of research attention on antidepressant action, an appropriate emphasis in that virtually all antidepressant medications have high affinity for monoamine substrates. Furthermore, prevailing monoamine models have suggested some promising therapeutic strategies. Nevertheless, these models are ultimately incomplete and do not fully explain important clinical limitations of current treatment: delayed response, incomplete efficacy, and unsustained remissions. Continued therapeutic advancements will likely require the development of models of antidepressant action that extend beyond the monoamines.

Antidepressive Agents↗

Assessment of the tilting properties of the human mitral valve during three main phases of the heart cycle: an echocardiographic study.

RATIONALE AND OBJECTIVES: In experimental models of the left heart, the mitral valve (MV) is commonly implanted perpendicular to a central axis of the apex/MV. To adapt this to a more correct anatomical model, as well as for further studies of the left ventricle, we created a database of implantation angles of the MV and annulus during three main phases of the heart cycle, based on standard cardiac ultrasound measurements. MATERIALS AND METHODS: Twenty-eight patients were studied with the standard cardiac ultrasound equipment. From the apical echo window, an anteroposterior (AP) plane and a perpendicular commisure-commisure (CC) plane were generated during three critical moments in the heart cycle: systole (S); diastole early filling (E); and diastole late filling (A). In both planes, the angles between the annular plane and each mitral leaflet, as well as the angle between a theoretical longitudinal axis through the apex and center of the MV orifice and the mitral annulus plane, were measured with a custom-made application of Matlab R14. RESULTS: We observed an inclination of the angle mitral annulus/central left ventricle axis, with its lowest point in the direction of the aortic valve (AP plane) of 85 degrees+/-7 degrees in systole (S), 88 degrees+/-8 degrees in early diastole (E), and 88 degrees+/-7 degrees in late diastole (A). In the CC plane, we observed an almost horizontal implantation of 91 degrees+/-5 degrees in systole (S), 91 degrees+/-8 degrees in early diastole (E), and 91 degrees+/-7 degrees in late diastole (A).

Adult↗

Vascular perfusion of human lung cancer in a rat orthotopic model using dynamic contrast-enhanced magnetic resonance imaging.

Lung cancer is the leading cause of death among cancers. Early detection and diagnosis present a major goal in the efforts to improve survival rates of lung cancer patients. Changes in angiogenic activity and microvascular perfusion properties in cancers can serve as markers of malignancy. The aim of this study was to employ MRI means to measure the microvascular perfusion parameters of orthotopic nonsmall cell lung cancer, using the experimental rat model. Anatomical and dynamic contrast-enhanced lung images were acquired at high spatial resolution, and registered and analyzed, pixel by pixel and globally, by means of a model-based algorithm. The MRI output yielded color-coded parametric images of the influx and efflux transcapillary transfer constants that indicated rapid microvascular perfusion. The transfer constants were about 1 order of magnitude higher than those found in other tumors or in nonorthotopic lung cancer, with the influx constant median value of 0.42 min(-1) and the efflux constant median value of 1.61 min(-1). The rapid perfusion was in accord with the immunostaining of the capillaries, which suggested the tumor exploitation of the existing alveolar vessels. The results showed that high resolution, dynamic, contrast-enhanced MRI is an effective tool for the quantitative measurement of spatial and temporal changes in lung cancer perfusion and vasculature.

Algorithms↗

Radiation environment on the Mir orbital station during solar minimum.

The Mir station has been in a 51.65 degrees inclination orbit since March 1986. In March 1995, the first US astronaut flew on the Mir-18 mission and returned on the Space Shuttle in July 1995. Since then three additional US astronauts have stayed on orbit for up to 6 months. Since the return of the first US astronaut, both the Spektr and Priroda modules have docked with Mir station, altering the mass shielding distribution. Radiation measurements, including the direct comparison of US and Russian absorbed dose rates in the Base Block of the Mir station, were made during the Mir-18 and -19 missions. There is a significant variation of dose rates across the core module; the six locations sampled showed a variation of a factor of nearly two. A tissue equivalent proportional counter (TEPC) measured a total absorbed dose rate of 300 microGy/day, roughly equally divided between the rate due to trapped protons from the South Atlantic Anomaly (SAA) and galactic cosmic radiation (GCR). This dose rate is about a factor of two lower than the rate measured by the thinly shielded (0.5 g cm-2 of Al) operational ion chamber (R-16), and about 3/2 of the rate of the more heavily shielded (3.5 g cm-2 of Al) ion chamber. This is due to the differences in the mass shielding properties at the location of these detectors. A comparison of integral linear energy transfer (LET) spectra measured by TEPC and plastic nuclear track detectors (PNTDs) deployed side by side are in remarkable agreement in the LET region of 15-1000 keV/micrometer, where the PNTDs are fully efficient. The average quality factor, using the ICRP-26 definition, was 2.6, which is higher than normally used. There is excellent agreement between the measured GCR dose rate and model calculations, but this is not true for trapped protons. The measured Mir-18 crew skin dose equivalent rate was 1133 microSv/day. Using the skin dose rate and anatomical models, we have estimated the blood-forming organ (BFO) dose rate and the maximum stay time in orbit for International Space Station crew members.

Atlantic Ocean↗

Cortical change in Alzheimer's disease detected with a disease-specific population-based brain atlas.

We report the first detailed population-based maps of cortical gray matter loss in Alzheimer's disease (AD), revealing prominent features of early structural change. New computational approaches were used to: (i) distinguish variations in gray matter distribution from variations in gyral patterns; (ii) encode these variations in a brain atlas (n = 46); (iii) create detailed maps localizing gray matter differences across groups. High resolution 3D magnetic resonance imaging (MRI) volumes were acquired from 26 subjects with mild to moderate AD (age 75.8+/-1.7 years, MMSE score 20.0+/-0.9) and 20 normal elderly controls (72.4+/-1.3 years) matched for age, sex, handedness and educational level. Image data were aligned into a standardized coordinate space specifically developed for an elderly population. Eighty-four anatomical models per brain, based on parametric surface meshes, were created for all 46 subjects. Structures modeled included: cortical surfaces, all major superficial and deep cortical sulci, callosal and hippocampal surfaces, 14 ventricular regions and 36 gyral boundaries. An elastic warping approach, driven by anatomical features, was then used to measure gyral pattern variations. Measures of gray matter distribution were made in corresponding regions of cortex across all 46 subjects. Statistical variations in cortical patterning, asymmetry, gray matter distribution and average gray matter loss were then encoded locally across the cortex. Maps of group differences were generated. Average maps revealed complex profiles of gray matter loss in disease. Greatest deficits (20-30% loss, P<0.001-0.0001) were mapped in the temporo-parietal cortices. The sensorimotor and occipital cortices were comparatively spared (0-5% loss, P>0.05). Gray matter loss was greater in the left hemisphere, with different patterns in the heteromodal and idiotypic cortex. Gyral pattern variability also differed in cortical regions appearing at different embryonic phases. 3D mapping revealed profiles of structural deficits consistent with the cognitive, metabolic and histological changes in early AD. These deficits can therefore be (i) charted in a living population and (ii) compared across individuals and groups, facilitating longitudinal, genetic and interventional studies of dementia.

Aged↗

Use of a model of small bowel mucosa to predict passive absorption.

The purpose of this study was to determine if the observed rate of passive absorption of inert gases from the canine small bowel could be predicted by the use of an anatomical model of the mucosa and measurements of villus blood flow and the diffusive barrier to absorption. Villus blood flow was measured with microspheres and the diffusive barrier separating bulk luminal contents and blood was estimated from CO absorption. The model predicts initial uptake of the inert gases (H2, He, CH4, and 133Xe) in blood at the villus tip, subsequent countercurrent exchange in the villus, and longitudinal diffusion of the gases down the villus to a subvillus blood flow. Observed absorption rates for each of these four gases were reasonably accurately predicted by the model at both basal villus blood flow and at low villus blood flow induced by hypotension. We suggest that this model can be used to predict passive absorption kinetics over a range of villus blood flows and to predict the influence of a variety of parameters on the rate of passive absorption of diffusible substances.

Animals↗

Wavelengths for laser treatment of port wine stains and telangiectasia.

BACKGROUND AND OBJECTIVE: This report presents analytical modelling of the influence of wavelength on the amount of volumetric rate of heat produced in dermal blood vessels by millisecond laser radiation. STUDY DESIGN/MATERIALS AND METHODS: A new anatomical model is proposed that represents port wine stains as well as telangiectatic lesions. It consists of a target blood vessel, representing the deepest dermal blood vessel that requires irreversible injury, and a layer of whole blood, representing all other dermal blood vessels above the target vessel. The laser light that interacts with the blood vessels is assumed to be diffuse. Selective photothermolysis is the basis for the analysis. We consider wavelengths between 577 nm and 600 nm, the argon laser wavelengths at 488/515 nm, and the frequency doubled Nd:YAG laser wavelength at 532 nm. RESULTS: The rate of volumetric heat production of absorbed laser light in the target blood vessel is expressed analytically as a function of blood absorption, the concentration of additional dermal blood, and the depth of the target vessel. CONCLUSION: The model explains why 585 nm is a good compromise for treating port wine stains that vary widely in number of dermal blood vessels. It predicts that wavelengths between 577 nm and 582 nm are excellent for the treatment of port wine stains in young children, and it suggests a possible explanation as to why the argon laser is sometimes said to be capable of treating dark mature port wine stains. The copper vapour laser wavelength at 578 nm, and the frequency doubled Nd:YAG laser wavelength at 532 nm, are predicted to be suitable for the treatment of port wine stains that contain, respectively, a small to moderate and a moderate number of dermal blood vessels. When laser beam spotsize becomes smaller, the best wavelength for producing maximal rate of heat in the target vessel is predicted to shift to 577 nm.

Animals↗

Comparative study of the laryngeal innervation in humans and animals employed in laryngeal transplantation research.

Laryngeal transplantation is receiving increased attention. Re-innervation of the transplanted larynx is critical for a successful functional outcome. Different anatomical models (dog, cat, rat, pig) have been employed for experimental purposes. Interspecies similarities and differences are important for extrapolating the experimental results to humans. We present a review of the anatomical course and regional branching patterns of the laryngeal nerves in both humans and animals currently being employed in laryngeal transplantation. The clinical and surgical implications are also discussed.

Animals↗

ICTS, an interventional cardiology training system.

In this article, we present an Interventional Cardiology Training System developed by the Medical Application Group at Mitsubishi Electric in collaboration with the Center for Innovative Minimally Invasive Therapy. The core of the ICTS is a computer simulation of interventional cardiology catheterization. This simulation integrates clinical expertise, research in learning, and technical innovations to create a realistic simulated environment. The goal of this training system is to augment the training of new cardiology fellows as well as to introduce cardiologists to new devices and procedures. To achieve this goal, both the technical components and the educational content of the ICTS bring new and unique features: a simulated fluoroscope, a physics model of a catheter, a haptic interface, a fluid flow simulation combined with a hemodynamic model and a learning system integrated in a user interface. The simulator is currently able to generate--in real-time--high quality x-ray images from a 3D anatomical model of the thorax, including a beating heart and animated lungs. The heart and lung motion is controlled by the hemodynamic model, which also computes blood pressure and EKG. The blood flow is then calculated according to the blood pressure and blood vessel characteristics. Any vascular tool, such as a catheter, guide wire or angioplasty balloon can be represented and accurately deformed by the flexible tool physics model. The haptics device controls the tool and provides appropriate feedback when contact with a vessel wall is detected. When the catheter is in place, a contrast agent can be injected into the coronary arteries; blood and contrast mixing is computed and a visual representation of the angiogram is displayed by the x-ray renderer. By bringing key advances in the area of medical simulation--with the real-time x-ray renderer for instance--and by integrating in a single system both high quality simulation and learning tools, the ICTS opens new perspectives for computer based training systems.

Angioplasty, Balloon, Coronary↗

Role of the cerebellum in reaching movements in humans. II. A neural model of the intermediate cerebellum.

The cerebellum is essential for the control of multijoint movements; when the cerebellum is lesioned, the performance error is more than the summed errors produced by single joints. In the companion paper (Schweighofer et al., 1998), a functional anatomical model for visually guided arm movement was proposed. The model comprised a basic feedforward/feedback controller with realistic transmission delays and was connected to a two-link, six-muscle, planar arm. In the present study, we examined the role of the cerebellum in reaching movements by embedding a novel, detailed cerebellar neural network in this functional control model. We could derive realistic cerebellar inputs and the role of the cerebellum in learning to control the arm was assessed. This cerebellar network learned the part of the inverse dynamics of the arm not provided by the basic feedforward/feedback controller. Despite realistically low inferior olive firing rates and noisy mossy fibre inputs, the model could reduce the error between intended and planned movements. The responses of the different cell groups were comparable to those of biological cell groups. In particular, the modelled Purkinje cells exhibited directional tuning after learning and the parallel fibres, due to their length, provide Purkinje cells with the input required for this coordination task. The inferior olive responses contained two different components; the earlier response, locked to movement onset, was always present and the later response disappeared after learning. These results support the theory that the cerebellum is involved in motor learning.

Arm↗

A generic morphological model of the anatomic variability in the m. flexor digitorum profundus, m. flexor pollicis longus and mm. lumbricales complex.

In the present study a generic model is presented of the anatomic variability in the muscle group formed by the m. flexor digitorum profundus, m. flexor pollicis longus and mm. lumbricales. This model provides a hypothesis about the structural causes of the frequent interdependence of tendons and muscle bellies in this muscle group. The model considers the muscle group as composed of two simple elementary building blocks: the monogastric contractile units of the FDP-FPL, and the digastric contractile elements of the lumbrical, and shows that these units can be assembled into complex entities, to which in reality a third structural element, the synovial membranes, not discussed in the present paper, adds a further complexity. The model allows to generate homologues of the existing anatomical variants, which are illustrated by typical dissection results. The present study should be of relevance to the morphologist, embryologist, surgeon, and musician/pedagogue. To the morphologist, it presents an alternative method of description or understanding of anatomic variability, based on (i) the 'atomary' concept that the anatomic structure is assembled from simple basic elements, and (ii) the local spatial constraints. To the embryologist, it raises the question to what degree the 'atomary' anatomical components of this model, which describes the macroscopic anatomy of the muscle group in detail, have an embryological basis. To the surgeon, the study presents detailed information about the scope of the variability in the deep flexor group, and the nature of its intertendinous connections. To the musician/pedagogue, it presents a visual illustration of the congenital interdependence of the muscles and tendons of an important finger motor group, as a possible cause of lack in finger independence which may hamper a fluent instrumental technique.

Dissection↗

Projected tetrahedra revisited: a barycentric formulation applied to digital radiograph reconstruction using higher-order attenuation functions.

This paper presents a novel method for volume rendering of unstructured grids. Previously, we introduced an algorithm for perspective-correct interpolation of barycentric coordinates and computing polynomial attenuation integrals for a projected tetrahedron using graphics hardware. Here, we enhance the algorithm by providing a simple and efficient method to compute the projected shape (silhouette) and tessellation of a tetrahedron, in perspective and orthographic projection models. Our tessellation algorithm is published here for the first time. Compared with works of other groups on rendering unstructured grids, the main contributions of this work are: 1) A new algorithm for finding the silhouette of a projected tetrahedron. 2) A method for interpolating barycentric coordinates and thickness on the faces of the tetrahedron. 3) Visualizing higher-order attenuation functions using GPU without preintegration. 4) Capability of applying shape deformations to a rendered tetrahedral mesh without significant performance loss. Our visualization model is independent of depth-sorting of the cells. We present imaging and timing results of our implementation, and an application in time-critical "2D-3D" deformable registration of anatomical models. We discuss the impact of using higher-order functions on quality and performance.

Algorithms↗

Numerical and experimental study of steady-state CO2 and inert gas washout.

The predictions of a single-path trumpet-bell numerical model of steady-state CO2 and infused He and sulfur hexafluoride (SF6) washout were compared with experimental measurements on healthy human volunteers. The mathematical model used was a numerical solution of the classic airway convention-diffusion equation with the addition of a distributed source term at the alveolar end. In the human studies, a static sampling technique was used to measure the exhaled concentrations and phase III slopes of CO2, He, and SF6 during the intravenous infusion of saline saturated with a mixture of the two inert gases. We found good agreement between the experimentally determined normalized slopes (phase III slope divided by mixed expired concentration) and the numerically determined normalized slopes in the model with no free parameters other than the physiological ones of upper airway dead space, tidal volume, breathing frequency, and breathing pattern (sinusoidal). We conclude 1) that the single-path (Weibel) trumpet-bell anatomic model used in conjunction with the airway convection-diffusion equation with a distributed source term is adequate to describe the steady-state lung washout of CO2 and infused He and SF6 in normal lungs and 2) that the interfacial area separating the tidal volume fron from the functional residual capacity gas, through which gas diffusion into the moving tidal volume occurs, exerts a major effect on the normalized slopes of phase III.

Carbon Dioxide↗

Physics-driven CFD modeling of complex anatomical cardiovascular flows-a TCPC case study.

Recent developments in medical image acquisition combined with the latest advancements in numerical methods for solving the Navier-Stokes equations have created unprecedented opportunities for developing simple and reliable computational fluid dynamics (CFD) tools for meeting patient-specific surgical planning objectives. However, for CFD to reach its full potential and gain the trust and confidence of medical practitioners, physics-driven numerical modeling is required. This study reports on the experience gained from an ongoing integrated CFD modeling effort aimed at developing an advanced numerical simulation tool capable of accurately predicting flow characteristics in an anatomically correct total cavopulmonary connection (TCPC). An anatomical intra-atrial TCPC model is reconstructed from a stack of magnetic resonance (MR) images acquired in vivo. An exact replica of the computational geometry was built using transparent rapid prototyping. Following the same approach as in earlier studies on idealized models, flow structures, pressure drops, and energy losses were assessed both numerically and experimentally, then compared. Numerical studies were performed with both a first-order accurate commercial software and a recently developed, second-order accurate, in-house flow solver. The commercial CFD model could, with reasonable accuracy, capture global flow quantities of interest such as control volume power losses and pressure drops and time-averaged flow patterns. However, for steady inflow conditions, both flow visualization experiments and particle image velocimetry (PIV) measurements revealed unsteady, complex, and highly 3D flow structures, which could not be captured by this numerical model with the available computational resources and additional modeling efforts that are described. Preliminary time-accurate computations with the in-house flow solver were shown to capture for the first time these complex flow features and yielded solutions in good agreement with the experimental observations. Flow fields obtained were similar for the studied total cardiac output range (1-3 1/min); however hydrodynamic power loss increased dramatically with increasing cardiac output, suggesting significant energy demand at exercise conditions. The simulation of cardiovascular flows poses a formidable challenge to even the most advanced CFD tools currently available. A successful prediction requires a two-pronged, physics-based approach, which integrates high-resolution CFD tools and high-resolution laboratory measurements.

Blood Flow Velocity↗

Computer-generated microsurgical anatomy of the basilar artery bifurcation. Technical note.

The authors' goal was to develop a computer graphics model to represent the microsurgical anatomy of the basilar artery (BA) bifurcation and surrounding structures to simulate surgery of a BA bifurcation aneurysm performed via the transsylvian approach. The source of the input data was a variety of publications that showed detailed anatomy of the area. A computer graphics model of the area near the BA bifurcation including relevant structures, such as perforating branches or cranial nerves, was depicted in detail. A BA bifurcation aneurysm was added to the computer graphics model and it was rotated to simulate the transsylvian approach. After the internal carotid artery was displaced using a virtual retractor, the aneurysm was exposed, thus providing an understanding of the three-dimensional surgical orientation of the area. Designing a standard anatomical model on the basis of data culled from a variety of publications and adding morphological changes by using a virtual retractor to displace structures that obstruct the view along a critical path at the base of the brain are useful strategies of computer manipulation for surgical simulation in open microneurosurgery. This methodological tool would be useful in teaching surgical microanatomy and in introducing a new navigational system for virtual reality. Both concept and technical details are discussed.

Basilar Artery↗

Anatomical and physiological simulation for respiratory mechanics.

Injuries in trauma affect anatomical structures, indirectly affecting physiological systems through mechanical behavior and physical proximity. This paper describes the theory for and preliminary results from our approach to couple a three-dimensional (3-D) anatomical model of the chest with a physiological model of respiratory mechanics. In particular, we investigated behavior in quiet, normal breathing and in an open, sucking chest wound. We envision that our integrated simulation of respiratory anatomy and respiratory mechanics could assist students in visualizing and predicting relationships between structural-anatomical and functional-physiological changes in an interactive, 3-D environment.

Computer Simulation↗

A three-dimensional, anatomically detailed foot model: a foundation for a finite element simulation and means of quantifying foot-bone position.

We generated an anatomically detailed, three-dimensional (3-D) reconstruction of a human foot from 286 computerized topographic (CT) images. For each bone, 2-D cross-sectional data were obtained and aligned to form a stacked image model. We calculated the inertial matrix of each bone from the stacked image model and used it to determine the principal axes. Relative angles between the principal axes of the bones were employed to describe the shape of the foot, i.e., the relationships between the bones of the foot. A 3-D surface model was generated from the stacked image models and a detailed 3-D mesh for each bone was created. Additionally, the representative geometry of the plantar soft tissue was obtained from the CT scans, while the geometries of the cartilage between bones were obtained from the 3-D surface bone models. This model served dual purposes: it formed the anatomical foundation for a future finite element model of the human foot and we used it to objectively quantify foot shape using the relationships between the principal axes of the foot bones.

Aged↗