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PubMed2005

[HIV management in Africa].

Africa is the continent hardest hit by the HIV pandemic with, according to the WHO for 2004, more than 25 million people infected. Although the mortality and socioeconomic consequences of HIV infection have been visible and predictable, only since 2000 has the catastrophic situation in Africa and other developing areas mobilized international political and medical attention, in view of the impressive results from antiretroviral treatments where they are accessible. The intolerable lack of access to medical care and effective treatments has engendered a fusion of energy and will - political and scientific, local and international - to make HIV treatment available in Africa. Access to treatment must be accompanied by creation of national public health programs and establishment of infrastructures and trained teams. Necessary steps including anticipation and prevention of pitfalls in the large-scale use of antiretrovirals, long-term planning, organization of supplies and distribution, ensuring the permanence of financial support, and making appropriate strategic choices. These steps are required to guarantee the future and to prevent an epidemic rebound due to drug-resistant HIV strains. The conditions of international economic and medical aid have been clarified and are now better adapted to real needs. Nonetheless large disparities still exist according to country and region. The initial results of cohorts of treated patients show results similar to those in the industrialized countries and provide encouragement about the future. Results in countries such as Uganda and Senegal show that local political involvement is primordial for long-term success. Access to antiretroviral drugs is an urgent and essential marker of comprehensive management, but the conditions of their use must be taken into account in assessing future projects if we want to change the course of HIV in Africa.

Africa↗

PubMed2003

Treatment of bleeding colonic diverticula by endoscopic band ligation: an in-vivo and ex-vivo pilot study.

BACKGROUND AND STUDY AIMS: Angiographic and surgical therapy are standards of care for persistent diverticular bleeding. Colonoscopic intervention using epinephrine injection, multipolar electrocautery, and placement of an Endoclip has not gained widespread acceptance due to concerns about complications,and the widespread management of severe lower gastrointestinal bleeding by surgeons and interventional radiologists. The utility of colonoscopic band ligation for control of diverticular bleeding was evaluated both in vivo and ex vivo. PATIENTS AND METHODS: Endoscopic band ligation of diverticula was performed on surgical resection specimens and in patients with actively bleeding colonic diverticula. RESULTS: In the in-vivo study, active diverticular bleeding was completely controlled in four patients by endoscopic band ligation. In two cases, a visible vessel was seen on the everted and banded diverticulum. Procedure time ranged from 45 to 140 min. The total lengths of hospital stays for the four patients were 2, 6, 14, and 35 days. The long hospital stays (> 7 days)were associated with non-gastrointestinal co-morbidity. There were no acute complications of band ligation. No rebleeding or need for surgery occurred during a follow-up period of 12 months in any of the patients. In the ex-vivo study, 11 diverticula were successfully everted and banded in five of nine surgical specimens (one right colon and four left colons). Mucosa was identified in all of the "banded" segments. Ten of 11 ligated diverticula revealed evidence of blood vessels or submucosal tissue. The presence of subserosal fat was suggested in three of the 11 "banded" segments, and none of the ex-vivo ligated diverticula contained muscularis propria or serosal involvement. There was no evidence of perforation. CONCLUSIONS: Both in-vivo and ex-vivo data suggest that endoscopic band ligation may be a safe and effective therapy for actively bleeding colonic diverticula.

Aged↗

PubMed1999

Improved imaging of liver metastases with stimulated acoustic emission in the late phase of enhancement with the US contrast agent SH U 508A: early experience.

PURPOSE: To see whether stimulated acoustic emission (SAE) in the liver parenchyma in the late phase of enhancement with SH U 508A increases the conspicuity of occult metastases at ultrasonography (US). MATERIALS AND METHODS: Eighteen patients with known hypo- or hypervascular hepatic metastases underwent US after SH U 508A administration, after a delay of at least 5 minutes, to ensure decay of blood pool enhancement. In 16 patients with visible metastases, conspicuity was compared on registered SAE and gray-scale scans by two blinded readers and by using computerized analysis of relative gray-scale and color Doppler conspicuity scores inside and outside the lesion. In nine patients, areas suspected of being involved but without definite gray-scale masses were imaged in the same way. Paired sections were analyzed by two blinded readers looking for parenchymal color defects without corresponding gray-scale masses; nine control images from three healthy volunteers were also included. RESULTS: Intense, transient parenchymal SAE was seen in all subjects. All metastases appeared as areas of reduced or absent signal. The conspicuity score was 80% for SAE versus 9% for gray-scale US (P < .001, Wilcoxon signed rank test). SAE-specific defects were seen in all patients but in none of the volunteers. Metastases seen on SAE but undetectable on gray-scale images were proved in three patients. CONCLUSION: SAE with SH U 508A improves the conspicuity of metastases. SAE-specific defects may reveal isoechoic or subtle metastases.

Biopsy↗

PubMed1999

Prevalence of respiratory and atopic disorders among children in the East and West of Germany five years after unification.

Living conditions in eastern Germany have changed rapidly since unification in 1990 and little is known about how these changes affect the prevalence of atopic diseases. This study describes methods and prevalences of a large epidemiological project investigating determinants of childhood asthma and allergies in eastern (Dresden and Leipzig) and western (Munich) Germany in 1995/1996. Community based random samples of 9-11 yr old children in Dresden (n=3,017) and Munich (n=2,612), and of 5-7 yr old children in Dresden (n=3,300), Leipzig (n=3,167) and Munich (n=2,165) were studied by parental questionnaires, bronchial challenges with hypertonic saline, skin examination, skin-prick tests, and measurements of specific and total serum immunoglobulin (Ig)E using Phase II modules of the International Study of Asthma and Allergies in Childhood (ISAAC). In 9-11 yr old children, the prevalence of physician diagnosed asthma (7.9% versus 10.3%; p<0.01) and bronchial hyperresponsiveness (15.7% versus 19.9%; p<0.05) was lower in Dresden than in Munich. No difference between Munich and Dresden was observed in the prevalence of diagnosed hay fever, skin test reactivity to > or = 1 allergen, and increased levels (>0.35 kU x L(-1)) of specific IgE against inhalant and food allergens. Symptoms and visible signs of atopic eczema tended to be more prevalent in Dresden. Similar East-West differences between the three study areas were seen in the younger age group. These findings are in line with recently observed increases in the prevalence of hay fever and atopic sensitization, but not of asthma and bronchial hyperresponsiveness, among 9-11 yr old children in Leipzig.

Air Pollution↗

PubMed2001

Local detection of prostate cancer by positron emission tomography with 2-fluorodeoxyglucose: comparison of filtered back projection and iterative reconstruction with segmented attenuation correction.

BACKGROUND: To compare filtered back projection (FBP) and iterative reconstruction with segmented attenuation correction (IRSAC) in the local imaging of prostate cancer by positron emission tomography with 2-fluorodeoxyglucose (FDG-PET). METHODS: We retrospectively identified 13 patients with primary (n=7) or recurrent (n=6) prostate cancer who had increased uptake in the prostate on FDG-PET performed without urinary catheterization, contemporaneous biopsy confirming the presence of active tumor in the prostate, and correlative cross-sectional imaging by MRI (n=8) or CT (n=5). FDG-PET images were reconstructed by FBP and IRSAC. Two independent nuclear medicine physicians separately rated FBP and IRSAC images for visualization of prostatic activity on a 4-point scale. Results were compared using biopsy and cross-sectional imaging findings as the standard of reference. RESULTS: IRSAC images were significantly better that FBP in terms of visualization of prostatic activity in 12 of 13 patients, and were equivalent in 1 patient (p<0.001, Wilcoxon signed ranks test). In particular, 2 foci of tumor activity in 2 different patients seen on IRSAC images were not visible on FBP images. In 11 patients who had a gross tumor mass evident on cross-sectional imaging, there was good agreement between PET and cross-sectional anatomic imaging with respect to tumor localization. CONCLUSIONS: In selected patients, cancer can be imaged within the prostate using FDG-PET, and IRSAC is superior to FBP in image reconstruction for local tumor visualization.

Aged↗

PubMed2005

Effect of segmentation errors on 3D-to-2D registration of implant models in X-ray images.

In many biomedical applications, it is desirable to estimate the three-dimensional (3D) position and orientation (pose) of a metallic rigid object (such as a knee or hip implant) from its projection in a two-dimensional (2D) X-ray image. If the geometry of the object is known, as well as the details of the image formation process, then the pose of the object with respect to the sensor can be determined. A common method for 3D-to-2D registration is to first segment the silhouette contour from the X-ray image; that is, identify all points in the image that belong to the 2D silhouette and not to the background. This segmentation step is then followed by a search for the 3D pose that will best match the observed contour with a predicted contour. Although the silhouette of a metallic object is often clearly visible in an X-ray image, adjacent tissue and occlusions can make the exact location of the silhouette contour difficult to determine in places. Occlusion can occur when another object (such as another implant component) partially blocks the view of the object of interest. In this paper, we argue that common methods for segmentation can produce errors in the location of the 2D contour, and hence errors in the resulting 3D estimate of the pose. We show, on a typical fluoroscopy image of a knee implant component, that interactive and automatic methods for segmentation result in segmented contours that vary significantly. We show how the variability in the 2D contours (quantified by two different metrics) corresponds to variability in the 3D poses. Finally, we illustrate how traditional segmentation methods can fail completely in the (not uncommon) cases of images with occlusion.

Algorithms↗

PubMed2003

The annular fat stripe as a fluoroscopic guide to anatomic sites during diagnostic and interventional electrophysiology studies.

Few radiographic landmarks are visible during electrophysiology procedures to aid in catheter positioning other than the catheters themselves. In the 35 degrees -45 degrees RAO projection, a linear radio-opacity corresponding to the rings of fat surrounding both annuli can be easily identified. This "fat stripe" can serve as a useful landmark for several important anatomic sites. Intracardiac catheters positioned left of (posterior) the fat stripe lie within an atrial cavity while those positioned to the right (anterior) lie within a ventricular cavity. The superior third of the stripe corresponds to the region of the right and left atrial appendages while the inferior end identifies the site of the coronary sinus os. The middle third serves as a reference for the fast AV nodal pathway and compact AV node. The region corresponding to the slow AV nodal pathway superimposes on the lower third of the fat stripe. Electrophysiological recordings from catheters positioned along the fat stripe always exhibit both an atrial and ventricular component consistent with an annular recording, whether the catheter is septal or free wall in its location. Coronary sinus os engagement and catheterization can be simplified by using the fat stripe as an anatomic guide. In addition to facilitating catheter positioning for evaluating normal AV conduction, the fat stripe can serve as an excellent guide for targeting the majority of structures intended for ablation because of their annular location. These include the compact AV node, the slow AV nodal pathway, the subeustachian isthmus and any accessory pathway. Good ablation catheter tip contact with annular structures is confirmed by observing its movement in unison with the fat stripe.

Adipose Tissue↗

PubMed1996

[Magnetic resonance imaging of the olfactory pathways in Kallmann de Morsier syndrome].

INTRODUCTION: Kallmann syndrome is a disease clinically characterized by the association of hypogonadotrophic hypogonadism and anosmia or hyposmia. Most cases have been recorded among men. It is a genetic disorder with a specific gene location on the X chromosome. The cells that normally express luteinizing hormone-releasing hormone or LHRH fail to migrate the olfactory placode to the forebrain. The lateral projections of the olfactory placode also fail to induce development of the olfactory bulbs and tracts. MATERIAL AND METHODS: The aim of this study was to compare the MRI appearance of the olfactory sulci, the olfactory bulbs and frontal lobe between groups. The first reference group was composed of 20 subjects and the second group of 18 patients suffering from Kallmann syndrome. For all studies we used a 1.5 T magnet system (Signa GE). We performed two sagittal and coronal T1-weighted sequences in spin echo (TR = 600 ms, TE = 12 ms) with interleaved 3 mm slices and a 14 cm field of view. RESULTS: In the first group, the two olfactory bulbs were always seen on coronal slices just behind the crista galli measuring 2 to 3.2 mm transversally. On sagittal slices, in 60% of the cases two bulbs were seen (3 mm laterally of the pituitary stalk) and in the other 40% only one bulb was seen. The length of the bulb has been measured between 6 and 11 mm. We noticed a plat frontal lobe in 85% of the cases. In the second group the olfactory bulbs were never visible among the 18 patients suffering from Kallmann syndrome. The hypoplasic sulci were hardly visible and their size was less or equal to 1 cm and the frontal lobe was triangular in 80% of the cases. One patient had hypoplasia of corpus callosum. CONCLUSION: MRI is helpful tool to demonstrate abnormalities of the olfactory system which are always present among patients suffering from Kallmann syndrome. MRI can also show, at the same time, a possible associated brain abnormality.

Adult↗

PubMed1981

[Counterclockwise rotation of the heart: a correlative study with tomographic echocardiography].

On the long-axis view of tomographic echocardiography, the aorto-septal angle (AS angle) of cases with straight back syndrome was wide and was thought to be due to clockwise rotation of the heart rather than right ventricular enlargement. In the present study, the AS angle of 21 cases with counterclockwise rotation of the heart (CCW) was measured on the long-axis view. The counterclockwise rotation of the heart defined here as having a shift of the transitional zone to the right with a small septal q wave at V2 and/or V3 to V6 in the precordial leads. Every case of CCW was found to have an absence of main pulmonary artery shadow on posteroanterior projection of the chest X-ray film. The control groups consisted of 40 normal individuals and 14 cases of straight back syndrome. The AS angle of normals ranged from 120 degrees to 158 degrees with a mean of 142 degrees. The AS angle of the latter varied from 140 degrees to 165 degrees with a mean of 150 degrees. On the other hand, the 21 cases with CCW showed the AS angle from 80 degrees to 129 degrees with a mean of 102 degrees. Since every CCW showed dilatation and/or elongation of the thoracic aorta on their radiographs, the narrowed AS angle was probably due to rightward twist of left ventricular outflow tract with some posterior retraction of the aorta. This causes the rightward twist of upper portion of the septum and results in a shift of the transitional zone to the right with a small q wave at V2 and/or V3 to V6 in the precordial leads. When normally visible main pulmonary artery shadow disappears on the postero-anterior chest X-ray film, the CCW is indicated radiographically. The narrowing of the AS angles on the long-axis views of tomographic echocardiography also indicates the CCW and correlate with both electrocardiographic and radiographic findings of CCW. The cause of CCW has not been well delineated. In the previous paper, we have suggested that the left ventricular overloading has little influence in producing CCW. In the present study, the 21 cases with CCW did not show either the left ventricular hypertrophy or the dilatation on their echocardiograms further supporting our hypothesis.

Aged↗

PubMed1984

[Clinical and surgical anatomy of the lymphatic circulation of pancreas].

Data was collected from results of injection and dissection of 100 autopsy specimens; the examination of 34 case-reports of cancer patients; the injection of lymphatics in 14 live dogs; and the reconstruction of the mesodorsal region of the pancreas from a 30 mm embryo using Born's technique. Anatomy of the pancreas and lymph vessels shows that the "primary mesodorsal region" of the pancreas is two-fold; a right part for the right side of pancreas: the retroportal process (RPP); a left part for the left side of pancreas, a formation not previously described: the left lateroportal process (LLPP). Whereas lymphatic drainage visible on the anterior surface of the pancreas is apparently as described, posterior drainage, which collects lymph from posterior and anterior vessels, is quite atypical. The right portion drains into the RPP and the left into the LLPP. Terminal collecting vessels of pancreatic lymphatics have only a short distance to travel before emptying into the thoracic duct. The study of lymph node metastases from pancreatic cancer appears to confirm these cadaver anatomic results but the series is too small for valid exploitation. The very rapid passage into the thoracic duct probably greatly diminishes the value of widely extended surgery, justification for the latter being exclusively to remove lymph nodes insofar as adjuvant therapy has currently failed to demonstrate absolute efficacy. Precise knowledge of the anatomy of the pancreatic lymphatics should allow development of experimental models to study lymph circulation changes during acute pancreatitis. Pancreatic edema, an enzyme-rich fluid, is an essentially "lymphatic" edema. The interstitial and lymphatic shunt pathways due to increased duct pressure were evident during the dog study. The lymphatic system acts as a "buffer system" or "safety valve" against progression to necrosis. Ligature of very proximal pancreatic lymphatic efferents (included in the bands) was followed by a fatal necrotic pancreatitis on both occasions when this was performed. Development and study of a lymphagogue drug for the treatment of acute pancreatitis is a justifiable project. A protocol is proposed which combines lymphagogue treatment with anti-enzymes, the former assists use of the enzymes by the lymphatic system. The anti-proteases prevent the onset of fatal shock caused by the outpouring of enzymes into the lymphatic system and the general circulation.

Adult↗

PubMed2003

Integrated density of a lesion: a quantitative, mammographically derived, invariable measure.

A method for quantitatively estimating lesion "size" from mammographic images was developed and evaluated. The main idea behind the measure, termed "integrated density" (ID), is that the total x-ray attenuation attributable to an object is theoretically invariant with respect to the projected view and object deformation. Because it is possible to estimate x-ray attenuation of a lesion from relative film densities, after appropriate corrections for background, the invariant property of the measure is expected to result in an objective method for evaluating the "sizes" of breast lesions. ID was calculated as the integral of the estimated image density attributable to a lesion, relative to surrounding background, over the area of the lesion and after corrections for the nonlinearity of the film characteristic curve. This effectively provides a measure proportional to lesion volume. We computed ID and more traditional measures of size (such as "mass diameter" and "effective size") for 100 pairs of ipsilateral mammographic views, each containing a lesion that was relatively visible in both views. The correlation between values calculated for each measure from corresponding pairs of ipsilateral views were computed and compared. All three size-related measures (mass diameter, effective size, and ID) exhibited reasonable linear relationship between paired views (r2>0.7, P<0.001). Specifically, the ID measures for the 100 masses were found to be highly correlated (r2=0.9, P<0.001) between ipsilateral views of the same mass. The correlation increased substantially (r2=0.95), when a measure with linear dimensions of length was defined as the cube root of ID. There is a high degree of correlation between ID-based measures obtained from different views of the same mass. ID-based measures showed a higher degree of invariance than mass diameter or effective size.

Absorptiometry, Photon↗

PubMed2001

Interreader variability and predictive value of US descriptions of solid breast masses: pilot study.

RATIONALE AND OBJECTIVES: This study evaluated the specificity of ultrasound (US) characteristics of solid breast lesions and the interreader variability in their interpretation. MATERIALS AND METHODS: In 61 patients, 70 sonographically visible solid masses, scheduled for biopsy because of findings from conventional imaging, were prospectively and sequentially accrued for evaluation. Three readers interpreted the sonograms and described the solid masses in terms of established US characteristics. The specificity and positive predictive value (PPV) for each characteristic were calculated by comparing US findings with biopsy findings, and interreader variability was evaluated. Five assessment categories were developed to guide recommendations for patient care. The relative performance of each reader was assessed by measuring the PPV for each assessment category and by measuring the area under the receiver operating characteristic curve. RESULTS: The specificity and PPV were calculated for all characteristics and for each reader. The average specificities of the three readers for the most frequently used six characteristics were as follows: spiculation, 97%+/-5 (standard deviation); taller than wide, 91%+/-4; central shadowing, 77%+/-1; markedly hypoechoic, 86%+/-5; duct extension, 95%+/-5; and microlobulation, 84%+/-3 (overall average specificity, 88.5%). The average PPVs for categories II-V were 5%, 10%, 63%, and 94%, respectively. The readers' interpretations were similar and correlated well. CONCLUSION: The proposed US recommendation system is an accurate predictor of histologic findings. A sonographic classification lexicon should prove valuable.

Breast↗

PubMed2005

Emerging credentialing practices, malpractice liability policies, and guidelines governing complementary and alternative medical practices and dietary supplement recommendations: a descriptive study of 19 integrative health care centers in the United States.

BACKGROUND: Little is known about policies governing the integration of complementary and alternative medical (CAM) therapies and providers. METHODS: To document emerging approaches in 19 US hospitals regarding credentialing, malpractice liability, and pharmacy policies governing integration of CAM therapies and providers into conventional medical settings, we surveyed 21 academic medical centers and 13 non-academically affiliated hospitals that are nationally visible and are integrating CAM therapies into conventional medical settings. Of the 19 respondents, 11 were tertiary care hospitals, 6 were community hospitals, 1 was a freestanding center associated with a community-based hospital, and 1 was a university-based rehabilitation hospital. RESULTS: Institutions had no consistent approach to provider mix and authority within the integrative care team, and minimum requirements for professional liability insurance, informed consent disclosure, and hiring status. Less than a third had a formal (stated) policy concerning dietary supplements; those selling supplements in their pharmacy lacked consistent, evidence-based rationales regarding which products and brands to include or exclude. Although many hospitals confiscated patient supplements on admission, institutions had inconsistent criteria regarding allowance of home supply. CONCLUSIONS: Hospitals are using heterogeneous approaches to address licensure, credentialing, scope of practice, malpractice liability, and dietary supplement use in developing models of integrative care. The environment creates significant impediments to the delivery of consistent clinical care and multisite evaluations of the safety, efficacy, and cost-effectiveness (or lack thereof) of CAM therapies (or integrative models) as applied to management of common medical conditions. Consensus policies need to be developed.

Complementary Therapies↗

PubMed2005

Estimation of transverse plane pelvic rotation using a posterior-anterior radiograph.

STUDY DESIGN: Experimental and analytical study of transverse plane pelvic rotation. OBJECTIVES: To determine how pelvic rotation projected onto the transverse plane relates to coronal plane anatomic landmark location. SUMMARY OF BACKGROUND DATA: Current spine deformity instrumentation may be used to apply transverse plane loads to the spine that may be transmitted to regions not included in the instrumentation, including the pelvis. METHODS: An anatomically correct, sawbones model of an adult female pelvis was marked with lead shot at prominent radiographic landmarks, rotated at different angles in the sagittal, transverse, and coronal planes, and left/right (L/R) ratios of the medial-lateral distances between similar landmarks determined. An analytical equation was also derived to determine the degree of rotation in the transverse plane, using medial-lateral and anterior-posterior distances between same landmarks. RESULTS: The L/R ratio for the coronal plane distance between the inferior ilium at the sacro iliac joint (SI) and anterior superior iliac spine (ASIS), the SI-ASIS measurement, proved the most reliable of the four ratios studied to determine the extent of pelvic rotation in the transverse plane. Assuming the pelvis is symmetric, the most important factor is location of the compared landmarks. A long distance between the landmarks in both the coronal and transverse plane and a large angle between the line joining the two landmarks and the coronal plane of the pelvis, as viewed in the transverse plane, are best. Transverse plane pelvic rotation up to 20 degrees is accurately reflected nearly linearly by L/R SI-ASIS ratios. CONCLUSIONS: Bony pelvis landmarks visible on coronal plane radiographs can be used to estimate transverse plane pelvic rotation, but precise conversion to degrees rotation requires additional information on specific patient pelvic morphology.

Adult↗

PubMed2006

Use of intense pulsed light and a retinyl-based cream as a potential treatment for cellulite: a pilot study.

BACKGROUND: There are few therapeutic treatments established for cellulite. OBJECTIVE: We studied the response of intense pulsed light (IPL) treatment with or without a compounded prescription retinyl-based cream on a small group of patients who had visible cellulite present on the buttocks and thigh regions. PATIENTS AND METHODS: Twenty patients were selected to complete a 12-week course of IPL treatment either with or without a retinyl-based cream. Assessment was based on visual evaluation, photographs, skin ultrasounds, and patient satisfaction. RESULTS: Fifteen (75%) completed the study, and nine (60%) had a self-improvement rating of >or= 50%. Seven (78%) of nine patients used IPL/cream. Of the remaining six (40%) completing the study, four (27%) had self-improvement ratings of 25-50% and two (13%; IPL only) were considered treatment failures with a rating of 10-25%. Both IPL/cream and IPL-only groups exhibited an improvement in the smoothness of the affected area even following weight gain. Skin ultrasounds confirmed an increase in the deposition of collagen. During an 8-month phone follow-up, 8 (67%) of 12 responding reported the same or improved results. CONCLUSION: IPL treatment with or without a retinyl-based cream can improve the appearance of peau d'orange cellulite, though the cream may augment cosmetic improvement. This approach is well tolerated, has minimal side effects, and is accompanied by a high degree of patient satisfaction.

Adipose Tissue↗

PubMed2003

Image-guided virtual autopsy findings of gunshot victims performed with multi-slice computed tomography and magnetic resonance imaging and subsequent correlation between radiology and autopsy findings.

Because the use of radiology in modern forensic medicine has been, until today, mostly restricted to conventional X-rays, which reduces a 3D body to a 2D projection, a detailed 3D documentation of a gunshot's wound ballistic effects was not possible. The aim of our study was to evaluate whether the progress in imaging techniques over the last years has made it possible to establish an observer-independent and reproducible forensic assessment using multi-slice computed tomography (MSCT) and magnetic resonance imaging (MRI) technologies for the documentation and analysis of gunshot wounds. The bodies of eight gunshot victims were scanned by MSCT and by MRI; the data of these imaging techniques were post-processed on a workstation, interpreted and subsequently correlated with the findings of classical autopsy. With the spiral CT and MRI examinations and the subsequent 2D multi-planar reformation (MPR) and 3D shaded surface display (SSD) reconstruction, the entire gunshot-created complex skull fractures and brain injuries (such as wound channels and deeply-driven bone splinters) could be documented in complete and graphic detail. CT and MRI also documented vital reaction to the gunshot by demonstrating air emboli in the heart and blood vessels and the classic pattern of blood aspiration to the lung. Gunshot residues deposited within and under the skin were visible. In conclusion, we think that the radiological methods of MSCT and MRI have the potential to become a routine "virtual autopsy" tool in the future. Bullets and relevant histological samples from specific sites then might be won in image-guided minimally invasive fashion via percutaneous biopsy. The rapid application of developing radiological methods may lead to new horizons in forensic documentation and intravital as well as postmortem examination.

Autopsy↗

PubMed1998

Pilot study on the use of impression cytology specimens for quantitative assessment of the surface area of bulbar conjunctival cells.

PURPOSE: To assess whether impression cytology samples could be used to assess cell conjunctival cell surface areas, and to obtain an estimate of these for normal appearing cells vs. those with squamous metaplasia. METHODS: Small sheets of nasal bulbar conjunctival cells (c. 0.03 mm2) were obtained from 17 subjects aged 25 to 78 years by manual application of a 0.45 microm Millipore filter without topical anesthetic. Outlines of cells, visible as a rarefaction of the general cell cytoplasmic staining, were made on an optical overlay and then planimetry was carried out. RESULTS: Reasonable estimates (with +/-2.5%) of the average cell area can be obtained from samples containing contiguous sets of 100 cells. From 14 separate samples of normal cells [subjective assignment of nucleus:cytoplasm (N:C) ratios of 1:1 to 1:2], cell surface area values ranged from 11 to 426 microm2, with an overall average value of 108 +/- 43 microm2. Samples from individuals with symptoms suggestive of borderline dry eye tended to have slightly higher proportions of larger cells (so increasing the average cell area), and there was a trend for samples from older individuals to contain more smaller cells (so decreasing the average cell area). In marked contrast, cells showing evidence of squamous metaplasia and with N:C ratios of 1:6 or higher were found to have an average area of 543 +/- 76 microm2 (range 310 to 1529 microm2). CONCLUSIONS: Morphometry of impression cytology specimens is possible. The average cell size in normal individuals is considerably smaller than previously reported (108 vs. 585 microm2), but this is consistent with a range of studies on animal tissue using scanning electron microscopy.

Adult↗

PubMed2005

Pressure ulcers: implementation of evidence-based nursing practice.

AIMS: A 2-year project was carried out to evaluate the use of multi-component, computer-assisted strategies for implementing clinical practice guidelines. This paper describes the implementation of the project and lessons learned. The evaluation and outcomes of implementing clinical practice guidelines to prevent and treat pressure ulcers will be reported in a separate paper. BACKGROUND: The prevalence and incidence rates of pressure ulcers, coupled with the cost of treatment, constitute a substantial burden for our health care system. It is estimated that treating a pressure ulcer can increase nursing time up to 50%, and that treatment costs per ulcer can range from US$10,000 to $86,000, with median costs of $27,000. Although evidence-based guidelines for prevention and optimum treatment of pressure ulcers have been developed, there is little empirical evidence about the effectiveness of implementation strategies. METHOD: The study was conducted across the continuum of care (primary, secondary and tertiary) in a Canadian urban Health Region involving seven health care organizations (acute, home and extended care). Trained surveyors (Registered Nurses) determined the prevalence and incidence of pressure ulcers among patients in these organizations. The use of a computerized decision-support system assisted staff to select optimal, evidence-based care strategies, record information and analyse individual and aggregate data. RESULTS: Evaluation indicated an increase in knowledge relating to pressure ulcer prevention, treatment strategies, resources required, and the role of the interdisciplinary team. Lack of visible senior nurse leadership; time required to acquire computer skills and to implement new guidelines; and difficulties with the computer system were identified as barriers. CONCLUSIONS: There is a need for a comprehensive, supported and sustained approach to implementation of evidence-based practice for pressure ulcer prevention and treatment, greater understanding of organization-specific barriers, and mechanisms for addressing the barriers.

Evidence-Based Medicine↗