Remote ultrasound diagnostics disrupting traditional military frontline healthcare delivery.

Accurate and reliable diagnostic capability is essential in deployed healthcare to aid decision-making and mitigate risk. This is important for both the patient and the deployed healthcare system, especially when considering the prioritisation of scarce aeromedical evacuation assets and frontline resources. Novel ultrasound tele-guidance technology presents a valuable diagnostic solution for remotely deployed military clinicians. This report discusses the first use of a consultant radiologist guiding a clinician, untrained in ultrasound, to perform an ultrasound scan via a live tele-guidance feed in the deployed environment using the Butterfly iQ+ tele-guidance system. Distance scanning provided a diagnostic quality report when compared with locally performed imaging to improve patient care and maintain operational output. This example demonstrates feasibility of remote point-of-care imaging systems in provision of location-agnostic high-quality diagnostic capability. Future opportunities to develop care pathways using bedside tele-diagnostics will democratise access, drive efficiency and improve patient care experience and outcomes.

Mechanics of the kinesin step.

Kinesin is a molecular walking machine that organizes cells by hauling packets of components directionally along microtubules. The physical mechanism that impels directional stepping is uncertain. We show here that, under very high backward loads, the intrinsic directional bias in kinesin stepping can be reversed such that the motor walks sustainedly backwards in a previously undescribed mode of ATP-dependent backward processivity. We find that both forward and backward 8-nm steps occur on the microsecond timescale and that both occur without mechanical substeps on this timescale. The data suggest an underlying mechanism in which, once ATP has bound to the microtubule-attached head, the other head undergoes a diffusional search for its next site, the outcome of which can be biased by an applied load.

Comparison of a sprayable pheromone formulation and two hand-applied pheromone dispensers foruse in the integrated control of oriental fruit moth (Lepidoptera: Tortricidae).

The efficacy of integrated programs using a sprayable pheromone formulation or one of two hand-applied pheromone dispensers, and a conventional oriental fruit moth, Grapholita molesta (Busck) (Lepidoptera: Tortricidae) control program, was compared using 4-5-ha blocks of peach orchard at three Niagara Peninsula farms during 2000-2002. In the integrated programs, chlorpyrifos and mating disruption with 3M Sprayable Pheromone, Isomate OFM Rosso, or Rak 5 hand-applied dispensers were used to control first-generation larvae, and mating disruption alone was used to control second- and third-generation larvae. In the conventional program, chlorpyrifos was used to control first-generation larvae, and pyrethroid insecticides were used to control larvae of the later generations. All programs were effective at maintaining fruit infestation by G. molesta below the industry tolerance level of 1%. An integrated program using sprayable pheromone required the use of more supplementary insecticide applications to control second- and third-generation larvae than a program using hand-applied dispensers. The elimination of insecticide sprays from integrated program blocks did not result in an increase in damage by plant bugs, Lygus spp. (Hemiptera: Miridae) or by the plum curculio, Conotrachelus nenuphar (Herbst) (Coleoptera: Curculionidae).

99mTc-SnF2 colloid "LLK": particle size, morphology and leucocyte labelling behaviour.

99mTc-SnF2 colloid (Radpharm LLK) leucocyte labelling agent is used in whole blood, exploiting phagocytosis. The objectives of this work were to optimize leucocyte labelling in leucocyte-enriched plasma, and to investigate: (i) the effect of temperature and other factors on labelling efficiency; (ii) the selectivity for different leucocyte types; (iii) the viability of the labelled cells and efflux of the radiolabel; and (iv) the physical characteristics of the colloid. Density gradient centrifugation was used to investigate the labelling efficiency, cell selectivity and efflux, Trypan blue to study the viability, and laser scattering, electron microscopy and membrane filtration to investigate particle size and morphology. Particles appeared as loose, coiled, chain-like aggregates of much smaller particles (<0.05 microm). The aggregate diameter ranged from <0.1 to >5 microm and increased with time. The distribution of radioactivity amongst the particle sizes varied widely. The labelling efficiency in leucocyte-rich plasma was enhanced at 37 degrees C compared to room temperature, and by centrifuging during labelling. The selectivity for different leucocyte types varied markedly between batches and blood samples, in some cases showing preference for mononuclear cells and in others for granulocytes. Viability was excellent and comparable with 99mTc-hexamethylpropyleneamine oxime (99mTc-HMPAO)-labelled cells. A significant fraction of radiolabel, comparable to that observed with 99mTc-HMPAO, was lost from leucocytes during incubation in vitro over 4 h. Thus, 99mTc-SnF2 is a convenient, efficient labelling agent for leucocytes, but shows variable cell selectivity which may be linked to particle size variability, and there is significant efflux of radioactivity from labelled cells.

Imaging of abdominal infection using 99m Tc stannous fluoride colloid labelled leukocytes.

Radiolabelling of leukocytes using labelled phagocytosed technetium-99m (99mTc) colloidal radiopharmaceuticals has been reported as a method for imaging infection. This in vivo study compares the use of leukocytes labelled using 99mTc stannous fluoride colloid with leukocytes labelled using indium-111 (111In) oxinate. A total of 26 patients (10 male, 16 female; mean age 52 years, range 23-88 years) referred for the investigation of possible infection were studied using both leukocyte labelling methods simultaneously. Images were acquired 4h and 24h after re-injection of the labelled cells. The images were evaluated qualitatively by two nuclear medicine physicians. The results show a high degree of concordance between the techniques: 11 of the 28 images showed a focus of leukocyte accumulation with both techniques at 24h, and 13 out of 28 showed a normal appearance at 24h with both methods. In four cases the results were discordant; the 99mTc stannous fluoride colloid labelled leukocytes gave a false positive appearance at 24h in three patients and a false negative in one. In conclusion, colloid labelling of leukocytes offers a sensitive method for the detection of infective foci coupled with the high resolution imaging offered by 99mTc. It has the advantage over other in vitro labelling methods of being a simpler, non-labour-intensive procedure employing whole blood, and its use should be considered by departments that have limited facilities for in vitro leukocyte labelling.

Integrated control of oriental fruit moth (Lepidoptera: Tortricidae) in peach orchards using insecticide and mating disruption.

The efficacy of an integrated and a conventional oriental fruit moth, Grapholita molesta (Busck), control program was compared using 4-ha blocks of peach at three Niagara Peninsula farms during 1997-1999. In the integrated program, chlorpyrifos was used to control first-generation larvae and mating disruption using Isomate M100 pheromone dispensers was used to control the second and third generations. In the conventional program, chlorpyrifos was used to control first-generation larvae and pyrethroids were used to control larvae of the later generations. The average release rate of pheromone was 23.7-26.4 mg/ha/h over a period of 86-91 d. The pheromone treatment reduced the capture of moths in pheromone-baited traps on average by 98%, suggesting a high level of disruption. The integrated program provided control of oriental fruit moth similar to the control provided by a conventional program. The mean percentage of peach shoots infested with first- and second-generation larvae, and fruit infested with third-generation larvae was not significantly greater in the integrated-program blocks during the 3-yr study. The elimination of insecticide sprays from the integrated-program blocks did not result in an increase in damage caused by plant bugs. The incidence of damage caused by other pests was negligible in both the integrated and conventional blocks.

The conformational cycle of kinesin.

The stepping mechanism of kinesin can be thought of as a programme of conformational changes. We briefly review protein chemical, electron microscopic and transient kinetic evidence for conformational changes, and working from this evidence, outline a model for the mechanism. In the model, both kinesin heads initially trap Mg x ADP. Microtubule binding releases ADP from one head only (the trailing head). Subsequent ATP binding and hydrolysis by the trailing head progressively accelerate attachment of the leading head, by positioning it closer to its next site. Once attached, the leading head releases its ADP and exerts a sustained pull on the trailing head. The rate of closure of the molecular gate which traps ADP on the trailing head governs its detachment rate. A speculative but crucial coordinating feature is that this rate is strain sensitive, slowing down under negative strain and accelerating under positive strain.

Microbiological and radioactive contamination from radioaerosol ventilation scanning: is there a problem?

Radioaerosol lung imaging may result in (a) microbiological contamination of nebulizer circuits (a potential hazard to patients if the circuit is re-used), and (b) radioaerosol contamination of the atmosphere (a hazard to staff, particularly if inhaled, ingested or both). Altogether, 138 circuits were assessed for bacteriological contamination, 93 of which had been used for ventilation perfusion studies and 45 for lung permeability studies in human immunodeficiency virus (HIV) positive patients. The circuits used for ventilation/perfusion (V/Q) studies were re-used over a period of 1-5 days. The mouthpiece and Y-piece were changed between patients. The circuits used for permeability studies were changed in toto for each patient. Organisms belonging to normal respiratory flora were isolated from the Y-piece, mouthpiece or both in 9 of 138 cases. An additional case (from one of the HIV-positive patients) demonstrated a growth of methicillin-resistant Staphylococcus. We also demonstrated bacteriological growth, most likely of patient origin, in circuit tubing in 11 cases at the end of the first day's use and 9 cases by day 5. None of the circuits used for HIV-positive cases were culture-positive. Airborne radioactive contamination was assessed during radioaerosol inhalation with and without an air extractor device (Nederman) during 40 ventilation studies. The 20 studies with air extraction showed a large decrease in room air contamination. Nebulizer circuits can, and occasionally do, become contaminated with patients' organisms; this represents a potential infection control hazard and therefore re-use is contraindicated. The use of an air extractor will significantly reduce airborne radioaerosol contamination.

A one-hour walk-in service for wrist trauma imaging.

We investigated the feasibility of rapid imaging of wrist trauma following casualty presentation and any subsequent effect on image quality and interpretability. All patients referred for wrist imaging were injected with 370 MBq 99Tcm-hydroxymethyl diphosphonate (HDP) and imaged 1, 2 and 3 h later. Palmar images were acquired on a 256 x 256 x 16 matrix using a high-resolution collimator, 140 keV photopeak and a 20% window. The images were scored qualitatively by four qualified observers in three categories: image quality, lesion detection and lesion localization. Statistical analysis indicated a significant improvement in scan quality with time, the mean difference (+/- standard error of the mean) between the 1 and 3 h scans being 0.81 +/- 0.07 (P = 0.001). No significant differences were seen in lesion detection (0.05 +/- 0.08; P = 0.51) or localization (0.14 +/- 0.08; P = 0.10). We conclude that imaging of wrist trauma is possible as early as 1 h post-injection of 99Tcm-HDP, although negative studies at 1 h require a 3 h image to maintain diagnostic accuracy.

Evaluating the Swirler nebulizer: a user's perspective.

The change from multi-use to single-use nebulizer systems could potentially result in greatly increased expense for aerosol ventilation imaging and a larger waste disposal problem. We have therefore investigated a new compact single-use nebulizer system, the Swirler (Amici), for ventilation lung imaging using 99Tcm-DTPA aerosol. Seventy-five patients requiring lung ventilation/perfusion imaging were studied. The ventilation imaging was assessed using three different fills: Group 1, 1000 MBq in 2 ml; Group 2, 1000 MBq in 4 ml; and Group 3, 2000 MBq in 4 ml. The nebulization times to give 1200 counts s-1 on the posterior ventilation image were similar for Groups 1 and 3 (mean 4 min) but slower for Group 2 (mean 6 min). Room contamination was very low when performed in a room with an extractor device. The mean room air contamination was 117.0 Bq l-1 min-1 for Group 1 amd 27.6 Bq l-1 min-1 for Group 2, comparable to previous nebulizers we have used. Dose rates measured at the surface of the lead shielded nebulizer were 6.8 microSv h-1 for 1000 MBq in 2 ml and 10.9 microSv h-1 for 2000 MBq in 4 ml. The mass median diameter (span) without the extension tubing was 1.39 microns (1.85) and with a small extension tube reduced to 1.11 microns (1.70). Qualitative and quantitative assessment of image quality showed good peripheral airways penetration of particles with no uninterpretable scans, comparable with other systems we have used. In practical terms, the device is much more compact than other systems and therefore generates a much smaller volume of waste. It is an easy device to use. However, when ventilating patients supine or erect, we found that it was necessary to use the small extension tube.

Ventilation and perfusion lung imaging--which nebulizer?

Three commercially available 99Tcm-diethylenetriamine pentaacetate (99Tcm-DTPA) aerosol delivery nebulizers for lung ventilation imaging were investigated. Two were air-jet systems, 'Optimist' (Medicaid) and 'Microcirrus' (Amersham), and one was an ultrasonic device (Europlus). Altogether, 112 consecutive patients were scanned, 37 using the Optimist, 40 using the Microcirrus and 35 the Europlus. The age mix, FEV1, FVC and PEFR measurements of the patients in each group were similar. Each contained a proportion of patients with poor respiratory function, with PEFR rates ranging from 30 to 582 l min-1 for patients studied with all systems. Ease of use, image quality and cost were evaluated as well as radioactive and microbiological contamination. The Optimist system gave the best combination of image quality and cost, and was associated with the lowest level of radioactive contamination. It also proved the most popular. Airborne contamination for all nebulizers was lower than previously reported and was largely dependent on patient compliance. With poorly compliant patients, the contamination levels are sufficient to warrant an extraction device. There was no evidence of bacterial contamination of the nebulizers or tubing on repeated use over 5 days.

Radiation dose rates from paediatric patients undergoing 99Tcm investigations.

Infants or children undergoing nuclear medicine investigations may subsequently come into close contact with nurses or parents responsible for their care. In order to estimate the radiation dose to these individuals, and to formulate appropriate recommendations, dose rates were measured at distances of 0.1, 0.5 and 1.0 m from 148 paediatric patients who had undergone one of 12 99Tcm studies. The maximum dose rates of 70, 14 and 5 microSv h-1 at these distances were not greater than the corresponding maximum values found in an earlier study of adult patients. However, the maximum dose rates per unit activity of 0.5, 0.2 and 0.1 microSv h-1 MBq-1 were greater than the corresponding maximum 99Tcm adult values, consistent with a general increase of dose rate per unit activity with decrease of body weight observed in the paediatric measurements. A parent caring for and feeding a young infant is most unlikely to receive a dose equivalent of 1 mSv, and a nurse attending to one young radioactive patient is most unlikely to receive a dose equivalent in a working day of 60 microSv. The data obtained should allow radiation doses to be estimated and appropriate recommendations to be formulated for other circumstances, including any future legislative changes in dose limits or derived levels.

Rapid preparation of 123I-labelled methylene blue and toluidine blue: potential new agents for parathyroid scintigraphy.

Methylene blue and toluidine blue are phenothiazinium dyes used to localize parathyroid glands visually during surgery. For the purpose of assessing the potential of radiolabelled analogues for scintigraphic localization of parathyroids, a rapid and convenient method has been developed for covalently labelling the dyes with iodine-123. Treatment of aqueous methylene blue or toluidine blue with 123I-sodium iodide in the presence of potassium iodate and hydrochloric acid at 100 degrees C for 1 h results in incorporation of 80-90% of the radioiodine into the dye. The chemical and radiochemical impurities are readily removed by passage through a disposable sample preparation column. Using the optimized protocol, a sterile, pyrogen-free multi-dose solution of radioiodinated dye (pH 7, specific activity greater than or equal to 37 MBq mg-1, radioactivity concentration congruent to 37 MBq ml-1, radiochemical purity greater than 99%, overall activity yield available for injection 60-70%) can be prepared within 1.5 h.