Increased time between diagnosis and surgery in slipped capital femoral epiphysis results in increased radiographic deformity.

PURPOSE: Previous work has examined the impact of delay of diagnosis in slipped capital femoral epiphysis (SCFE) but not the impact of delay in treatment after radiographic diagnosis. Due to requirements for long distance transportation from less developed regions for many of our patients, our hospital was able to study variation in time between diagnosis and surgery for SCFE, as related to slip severity. METHODS: This is a retrospective review of patients treated for SCFE between 2005 and 2014 at a tertiary care paediatric hospital. Demographics, time between diagnosis and surgery, radiographic deformity (Southwick angle), postoperative complications and need for further surgery were variables of interest. Statistical analysis included Pearson and Spearman rank correlations and chi-squared tests. RESULTS: The study sample included 147 hips (119 patients). Mean time between radiographic diagnosis and surgery was 20.9 days (sd 46, 0 to 321). The mean Southwick angle (SA) at the time of surgery was 31.9˚ (sd 19.6˚, 1° to 83˚). There was a significant relationship between increased delay and increased SA (0.34, p < 0.001). Increased SA was correlated with need for future significant surgery (0.27, p < 0.01).Patients from less-developed regions, with barriers to timely care, had moderate and severe deformity (SA) (p < 0.01), and required significant further surgery more often than SCFE patients from the local population (p < 0.01). CONCLUSION: The unique referral environment of our hospital provided an opportunity to examine traditional recommendations for treating SCFE promptly after radiographic diagnosis. Delay in treatment is correlated with increased radiographic deformity. LEVEL OF EVIDENCE: III.

Postmortem computed tomography (PMCT) and disaster victim identification.

Radiography has been used for identification since 1927, and established a role in mass fatality investigations in 1949. More recently, postmortem computed tomography (PMCT) has been used for disaster victim identification (DVI). PMCT offers several advantages compared with fluoroscopy, plain film and dental X-rays, including: speed, reducing the number of on-site personnel and imaging modalities required, making it potentially more efficient. However, there are limitations that inhibit the international adoption of PMCT into routine practice. One particular problem is that due to the fact that forensic radiology is a relatively new sub-speciality, there are no internationally established standards for image acquisition, image interpretation and archiving. This is reflected by the current INTERPOL DVI form, which does not contain a PMCT section. The DVI working group of the International Society of Forensic Radiology and Imaging supports the use of imaging in mass fatality response and has published positional statements in this area. This review will discuss forensic radiology, PMCT, and its role in disaster victim identification.

The role of micro-computed tomography in forensic investigations.

The use of micro-CT within forensic practice remains an emerging technology, principally due to its current limited availability to forensic practitioners. This review provides those with little or no previous experience of the potential roles of micro-CT in forensic practice with an illustrated overview of the technology, and the areas of practice in which micro-CT can potentially be applied to enhance forensic investigations.

Characterisation of products of tricalcium silicate hydration in the presence of heavy metals.

The hydration of tricalcium silicate (C(3)S) in the presence of heavy metal is very important to cement-based solidification/stabilisation (s/s) of waste. In this work, tricalcium silicate pastes and aqueous suspensions doped with nitrate salts of Zn(2+), Pb(2+), Cu(2+) and Cr(3+) were examined at different ages by X-ray powder diffraction (XRD), thermal analysis (DTA/TG) and (29)Si solid-state magic angle spinning/nuclear magnetic resonance (MAS/NMR). It was found that heavy metal doping accelerated C(3)S hydration, even though Zn(2+) doping exhibited a severe retardation effect at an early period of time of C(3)S hydration. Heavy metals retarded the precipitation of portlandite due to the reduction of pH resulted from the hydrolysis of heavy metal ions during C(3)S hydration. The contents of portlandite in the control, Cr(3+)-doped, Cu(2+)-doped, Pb(2+)-doped and Zn(2+)-doped C(3)S pastes aged 28 days were 16.7, 5.5, 5.5, 5.5, and <0.7%, respectively. Heavy metals co-precipitated with calcium as double hydroxides such as (Ca(2)Cr(OH)(7).3H(2)O, Ca(2)(OH)(4)4Cu(OH)(2).2H(2)O and CaZn(2)(OH)(6).2H(2)O). These compounds were identified as crystalline phases in heavy metal doping C(3)S suspensions and amorphous phases in heavy metal doping C(3)S pastes. (29)Si NMR data confirmed that heavy metals promoted the polymerisation of C-S-H gel in 1-year-old of C(3)S pastes. The average numbers of Si in C-S-H gel for the Zn(2+)-doped, Cu(2+)-doped, Cr(3+)-doped, control, and Pb(2+)-doped C(3)S pastes were 5.86, 5.11, 3.66, 3.62, and 3.52. And the corresponding Ca/Si ratios were 1.36, 1.41, 1.56, 1.57 and 1.56, respectively. This study also revealed that the presence of heavy metal facilitated the formation of calcium carbonate during C(3)S hydration process in the presence of carbon dioxide.

Cement solidification of simulated off-gas condensates from vitrification of low-level nuclear waste solutions.

Solidification in a cementitious matrix is a viable alternative for low-level nuclear waste management; it is therefore important to understand the behavior and properties of such wasteforms. We have examined the cementitious solidification of simulated off-gas waste streams resulting from the vitrification of low-level nuclear waste. Different possible methods for scrubbing the off-gasses from a vitrifier give rise to three possible types of waste compositions: acidic (from aqueous dissolution of volatile NOx and POx carried over from the vitrifier), basic (from neutralizing the former with sodium hydroxide), and fully carbonated (arising from a direct-combustion vitrifier). Six binder compositions were tested in which ordinary Portland cement was replaced at different proportions by fly ash and/or ground granulated blast furnace slag. A high solution to binder ratio of 1l/1 kg was used to minimize the volume of the wasteform and 10% attapulgite clay was added to all mixes to ensure that the fresh mix did not segregate prior to setting. The 28-day compressive strengths decreased when a high proportion of cement was replaced with fly ash, but were increased significantly when the cement was replaced with slag. The heats of hydration at early age for the various solids compositions decreased when cement was replaced with either fly ash or slag; however, for the fly ash mix the low heat was also associated with a significant decrease in compressive strength. High curing temperature (60 degrees C) or the use of extra-fine slag did not significantly affect the compressive strength. Recommendations for choice of binder formulations and treatment of off-gas condensates are discussed.

Rapid onset of stupor.

Catatonia is a syndrome with many causes that can be difficult to diagnose. In this report, we describe a case of rapid onset of stupor and loss of consciousness, subsequent evaluation, and treatment of catatonia in an HIV-positive man.

Morphometric analysis of nuclear/cytoplasmic ratios in normal and perineoplastic vulvar skin.

Analysis of vulvar skin adjacent to squamous carcinoma has demonstrated abnormal deoxyribonucleic acid (DNA) content in histologically unremarkable specimens. Analysis of DNA by microdensitometry is time-consuming. Morphometric analysis by point counting was used to compare the nuclear/cytoplasmic ratios of normal vulvar skin and skin adjacent to malignancy. This showed elevated ratios in the latter specimens although there was no linear relationship to increasing ploidy.

Should patients with mild atypia in a cervical smear be referred for colposcopy?

Significant premalignant disease of the cervix was found in 37% of women referred to a colposcopy clinic because of a smear that showed no more than mildly atypical cells, and in 49% of women whose smears showed mild dyskaryosis. This did not seem to be related to the number of times the abnormal smear had been repeated and was not confined to patients whose smears had been reported by only one laboratory. In another group of 102 women whose first abnormal smear was graded as atypical: 10 had cervical intraepithelial neoplasia; 9 still had abnormal smears and 27 had been lost to follow-up, possibly because the potential importance of this finding was not recognised by the doctor to whom the smear report had been returned. Women with midly atypical or mildly dyskaryotic smears are at considerable risk of having cervical intraepithelial neoplasia. All patients with a smear report showing dyskaryosis of any degree of severity should be referred for colposcopy. Those with atypical cytology should be referred for colposcopy if a second smear, repeated after 3 months, is not normal.

Significance of mediastinal metastatic disease in Wilms' tumor of favorable histology.

Although the results of the National Wilms' Tumor Study suggest poor outcome for children with metastases to intra-abdominal, intracranial, skeletal, skin, diaphragm, or mediastinal sites, the incidence and course of mediastinal disease has not been described. Fifty-four newly diagnosed Wilms' tumor patients at Children's Hospital of Michigan (1972-1980) were studied for patterns of intrathoracic metastases. All had favorable histology; mean age (MA) at diagnosis was 4.5 years. Initial chemotherapy ranged from single agent to three-drug combination (actinomycin, vincristine, adriamycin). Intrathoracic metastases occurred in 14 (26%) from 0-28 months (median, 3.5 months) from diagnosis (MA, 5.8 years). Upon the discovery of intrathoracic metastases all received radiation (1,200-2,000 rads) to the chest, some with supplementary doses to the mediastinum. Five children with parenchymal and one with parenchymal and hilar metastases appearing 0-28 months after the time of diagnosis survive disease-free 44-127 months after metastases appeared (MA, 6.3 years). Eight children developed parenchymal and mediastinal metastases (MA, 5.4 years). Time from diagnosis to parenchymal metastases was 0-7 months; time from diagnosis to mediastinal metastases was 0-16 months; and in four, both sites appeared simultaneously. Death occurred in all eight patients 7-25 months from diagnosis. Only one child had evidence of recurrence outside the chest. Potential risk factors and influence on survival are discussed.

Rhabdomyosarcoma and benign teratoma.

A case of mediastinal embryonal rhabdomyosarcoma occurring with a benign teratoma is reported. In all histologic sections of tumor, the two elements were distinctly separate. This is felt to represent two independently developing tumors that ultimately fused to form a "collision tumor" rather than a sarcoma arising in a benign teratoma.

Cervical intraepithelial neoplasia and 'wary' atypia: a study of colposcopic, histological and cytological characteristics.

Colposcopic, histological and cytological characteristics of 168 consecutive patients attending a colposcopy clinic were reviewed. A group of patients demonstrated a cluster of histological features previously related to possible human papilloma virus infection of cervical epithelium, including particularly koilocytosis, double nucleation and dyskeratosis. These patients had a significantly greater occurrence of colposcopic 'finger-like' lesion outline and colposcopic impression of warty change, but not of other specific colposcopic features. Over two-thirds of patients with histological warty features did not show these colposcopic changes. Cytological changes previously related to warty lesions did not occur commonly, and appeared to underestimate the histological occurrence of such changes. Histological changes considered to represent CIN were uncommon in patients who said that they had begun sexual activity less than 10 years ago, whereas patients with warty characteristics on histology showed no such bias.

Cystadenoma of the pancreas with cytomegalovirus infection in a female infant.

Cystadenoma of the pancreas, principally a disease of adult women, was found in a female infant. This benign, nonfunctional tumor is usually amenable to surgery and a cure is to be expected after extirpation. The pathogenesis of this mass is unknown, but the finding of a cytomegalovirus infection in an excretory duct at the tumor base in this case leads us to speculate that obstruction of the excretory duct is a possible cause.

Primary malignant lymphoma cutis in an infant: case report and review of literature.

A 6-month-old infant with primary malignant cutaneous lymphoma is presented. The histologic differentiation between benign cutaneous lymphoid hyperplasia and cutaneous malignant lymphoma is discussed. Intensive therapy is warranted at the onset because of early dissemination and poor response to treatment after dissemination.

Relative cervical incompetence in twin pregnancy. Assessment and efficacy of cervical suture.

A total of 88 women with a twin pregnancy who had elective cervical suture were compared with 76 women with a twin pregnancy who had cervical assessment between the 13th and the 28th weeks of gestation but received no active treatment. The incidence of spontaneous onset of labour before 36 weeks was higher in the cervical suture group, and 53.4% of them sustained cervical damage.

Pulmonary calcifications in a child with renal failure.

A chronically azotemic 2 6/12 boy developed diffuse, bilateral pulmonary calcification. The radiographic features and pathologic mechanism of such pulmonary calcification is discussed.

Upper cervical myelopathy in achondroplasia.

Two achondroplastic infants had small foramina magna with lethal compression of the corresponding upper cervical spinal cords. The damage was histologically comparable to the hyperextension type of spinal cord injury. An anterior displacement of the foramen magnum was demonstrated in one of the two cases. The displacement is considered worthy of future verification as it may be an additional factor in susceptibility to hyperextension injury to the spinal cord. The second patient survived 6 months, demonstrating that not all upper cervical spinal cord injuries are immediately fatal. Patients who have sublethal lesions are potentially salvageable by surgery. It is also speculated that there might be more cases of nonlethal upper cervical spinal-cord damage in achondroplasia, especially in early infancy when infants are unable to hold their heads erect. The true incidence of slight upper cervical spinal cord damage is not known, although it is considered rare at present. As a result of the findings in these two cases, it is suggested that hyperextension of the head be avoided, when possible.