Heterogeneity in outcome selection, definition and measurement in studies assessing the treatment of cryptoglandular anal fistula: findings from a systematic review.

BACKGROUND: Treatment for cryptoglandular anal fistula (AF) is challenging and a lack of uniform outcomes in the literature prevents direct comparison of treatments. This can be addressed by developing a core outcome set, a standardised set of outcomes reported in all interventional studies for a specific condition. The aim of this systematic review is to assess the range of outcomes, their definitions, and the measurement instruments currently utilised in interventional studies for adult patients with AF. This will inform the development of an AF core outcome set. METHODS: Medline, Embase and The Cochrane Library were searched to identify all patient- and clinician-reported outcomes in studies assessing medical, surgical or combination treatment of adult patients with AF published from January 2008 to May 2020. The resulting outcomes were categorized according to the Core Outcome Measurement in Effectiveness Trials (COMET) taxonomy to better understand their distribution. RESULTS: In total, 155 studies were included, 552 outcomes were extracted, with a median of three outcomes (interquartile range 2-5) per study. Only 25% of studies demonstrated high-quality outcome reporting. The outcomes were merged into 52 unique outcomes and structured into four core areas and 14 domains, with the majority in the domain of physiological or clinical (gastrointestinal) outcomes. The most commonly reported outcomes were healing (77%), incontinence (63%), and recurrence (40%), with no single outcome assessed across all studies. There was a wide variation in outcome definitions and measurement instruments used. CONCLUSIONS: There is substantial heterogeneity in outcomes, definitions, and measurement instruments reported in interventional studies for cryptoglandular anal fistula. This emphasises the need for standardised outcome reporting and measurement.

Imaging of acute subarachnoid hemorrhage with a fluid-attenuated inversion recovery sequence in an animal model: comparison with non-contrast-enhanced CT.

BACKGROUND AND PURPOSE: Fluid-attenuated inversion recovery (FLAIR) MR imaging sequences have been previously described in the evaluation of acute subarachnoid hemorrhage (SAH) in human subjects and have demonstrated good sensitivity. The purpose of this study was to evaluate a FLAIR sequence in an animal model of SAH and to compare the results with those obtained with non-contrast-enhanced CT. METHODS: SAH was experimentally induced in 18 New Zealand rabbits by injecting autologous arterial blood into the subarachnoid space of the foramen magnum. Nine animals had high-volume (1-2 mL) injections, and nine animals had low-volume (0.2-0.5 mL) injections. Four control animals were injected with 0.5 mL of saline. The animals were imaged with a FLAIR sequence and standard CT 2-5 hours after injection. Gross pathologic evaluation of seven of the animals was performed. Four blinded readers independently evaluated the CT and FLAIR images for SAH and graded the probability of SAH on a scale of 1 to 5 (1 = no hemorrhage, 5 = definite hemorrhage). RESULTS: Overall, the sensitivity of FLAIR was 89%, and the sensitivity of CT was 39% (P <.01). In animals with a high volume of SAH, the sensitivity of FLAIR was 100%, and the sensitivity of CT was 56%. In animals with a low volume of SAH, the sensitivity of FLAIR was 78%, and the sensitivity of CT was 22%. The specificity of FLAIR in animals without SAH was 100%, and the specificity of CT was 100%. The average reader score for FLAIR was 3.8, and that for CT was 2.2 (P <.001). Reader scores for FLAIR were higher than those for CT in 94% (P <.01) of animals with SAH and in 25% of animals without SAH (P >.05). Seven animals underwent gross pathologic examination, and all had blood in the subarachnoid space around the brain stem. CONCLUSION: FLAIR was more sensitive than CT in the evaluation of acute SAH in this model, especially when a high volume of SAH was present. This study provides a model for further experimentation with MR imaging in the evaluation of SAH. These findings are consistent with those of current clinical literature, which show FLAIR to be an accurate MR sequence in the diagnosis of SAH.

Imaging of head trauma in infancy and childhood.

Neurologic trauma is one of the most common and challenging problems encountered in the pediatric emergency setting. Early and accurate diagnosis is essential to minimize morbidity and mortality. The primary goal of the neuroimager in the acute setting is to provide rapid diagnosis, to monitor the development of complications, and to aid in the determination of prognosis. Unique features of the immature brain and skull influence the patterns and types of injuries observed. It is incumbent on the radiologist to understand these features as an aid to diagnosis. Further, the radiologist must be aware of the pathophysiology and appearance of nonaccidental trauma to ensure recognition of this devastating problem. Lastly, the radiologic tools available, their appropriate use, and their limitations should be understood by the entire trauma team to provide cost-effective and timely care. This article summarizes the pathophysiology and current imaging of neurotrauma in the pediatric population, including trauma, nonaccidental trauma, accidental anoxic injury, and birth injury.

Bilateral type 1 proatlantal arteries with absence of vertebral arteries.

The persistent proatlantal artery is a well-described communication between the carotid and vertebrobasilar system. However, persistence of bilateral proatlantal arteries is exceptionally rare. Although usually noted as an incidental finding, the presence of a proatlantal artery, particularly when bilateral, may result in unusual symptoms or may have implications for therapy. We report a case of bilateral proatlantal arteries, describe their embryology, and consider potential clinical implications of this finding.

Acoustic radiation due to the inelastic impact of a sphere on a rectangular plate

Impact between two structures is an important source of noise in industry. However, it is not a well-known phenomenon from a theoretical point of view. The models available in the literature for impact noise often address only part of the phenomenon. In this paper, a more comprehensive model is developed. The acoustic radiation due to the inelastic impact of a sphere with a rectangular simply supported thin plate is formulated and validated experimentally. The impact force is calculated from Hertz's law, which has been extended to the case of plastic deformations, and the acoustic radiation in the time domain is obtained using Rayleigh's integral, the plate being discretized in rectangular elements. The model is used to show that the sound-radiation mechanism includes two separate sources: the initial deformation of the plate and the propagation of the bending waves. The model is also used to determine the contribution to impact noise of parameters that characterize the two impacting structures or the impact configuration such as plasticity, damping, materials, and impact velocity.

Needle diameter in outpatient myelography: rates of adverse effects and current practice trends.

Telephone calls were made to 1251 consecutive patients one day following outpatient myelography. Data were available on 518 patients punctured with 22-gauge (g) (large-diameter) and 465 with 25-g (small-diameter) spinal needles. We surveyed 48 academic and private practice groups regarding needle diameter use in myelography; data were obtained from 34 private practice and 14 academic radiology departments. Patients reported adverse effects including mild and severe headache, back pain and nausea. The percentage of total adverse effects was significantly greater in the 22-g than in the 25-g needle group. The percentage of patients with headache was higher in the 22-g than in the 25-g group, but this difference was not statistically significant. Only 19% of private practice groups and 17% of academic centers use 25-g needles; the remainder use 20-g or 22-g needles.

CO2 measurements for IAQ analysis.

These examples illustrate the utility of carbon dioxide measurements as a diagnostic tool for indoor air quality. Carbon dioxide is sometimes said to be an unreliable indicator because of uneven mixing. However, even though mixing does occur slowly in very still air, in nearly all cases there is enough air movement that mixing is not a misleading factor for diagnostic purposes. Measurements do have to be recorded with enough context for proper interpretation. For example, to distinguish between the effects of natural and mechanical ventilation. Or to understand how the results are affected by the number of people in the building and what they are doing. Or how they relate to the nature and layout of the HVAC system and how it is adjusted or intended to be used. Carbon dioxide measurements say little about how healthy an indoor environment is. But they can tell a great deal about how comfortable it is and, with good observation, can give important clues as to where to look for factors that may be affecting health. The interaction of subjective and objective elements in the interpretation of CO2 measurements makes them a fascinating and powerful tool in the hands of a careful investigator.

Uses of Rasch scaling in the measurement of cognitive development and growth.

This report describes two types of findings: (a) the consistency between two major cognitive tests in terms of their developmental scales based on item-response theory, and (b) the initial development of ideas and methods for the revival of the classic concept of ratio IQ. The ratio IQ (e.g., Stanford-Binet, 1937) was formed by the division of mental age (derived from test performance) by chronological age multiplied by 100. Following a multitude of criticisms about the scaling qualities of the ratio IQ, it was mostly abandoned by the major intelligence batteries, beginning with the Wechsler scales in the 1940's, in favor of standard scores. This study presents a new approach to age equivalence scores as a basis for mental age, and the calculation of ratio IQ, based on Rasch-model item response theory. The new ratio IQ was compared statistically with standard-score IQ (mean 100, SD 15) from the Leiter International Performance Scale--Revised (Leiter-R) and from the Woodcock-Johnson Psychoeducational Battery--Revised (WJ-R). The essential element of the new ratio IQ is the W-scale, a Rasch-based score employed in the WJ-R and in the Leiter-R. Mental age was estimated from the W-scale estimate of ability and chronological age from a W-scale age equivalence for each month of age. Statistical results showed a highly similar growth curve for the W-scale scores on the Leiter-R and the WJ-R, even though the two scales have different content and standardization samples. Also, high correlations were found between the new ratio IQ and standard-score IQ (e.g., correlations ranging from .87 to .95 depending on age range). Criterion-related evidence of validity was found in the correlation of .82 between the new ratio IQ and the Wechsler Intelligence Scale for Children--Third Edition (WISC-III) standard-score IQ and in correlations with achievement-test scores. Finally, the ratio IQ showed predictable mean differences between groups of children with typical cognitive ability, cognitive delay levels of performance and giftedness. The standard deviation of the new ratio IQ was somewhat variable across age groups, however, so new interpretive guidelines would be needed if the new index is to employed in published tests. Implications of the scaling methods are discussed.

Constructs underlying measures of sensory-motor functions.

Many pathognomonic indicators of brain damage are characterized by deficits in sensory and/or motor functions. The strength of these pathognomonic signs has led to reliance on clinical administration and interpretation in the assessment of sensory and motor functions. Subsequently, the majority of measures designed to assess sensory and motor functions lack adequate reliability and psychometric confirmation of their utility. The Dean-Woodcock Sensory-Motor Battery (DWSMB) was designed to standardize the administration and interpretation of sensory-motor functions and has demonstrated satisfactory reliability. The present study further examined the psychometric properties of the DWSMB through factor analysis. It was hypothesized that at least two factors would emerge representing sensory and motor functions, respectively. A third possible factor that would reflect subcortical functioning was also hypothesized. Principal components analysis on data from over 600 participants supported a three-factor solution which accounted for 50.9% of the total variance. However, factor loadings revealed more dual loadings than expected, and factors emerged according to complexity rather than basic sensory, motor, and subcortical factors. Regardless, these data provide empirical evidence for the conceptualization of sensory-motor skills in a manner that incorporates subcortical abilities. These data also provide support for the underlying constructs of the DWSMB.

Sinus histiocytosis (Rosai-Dorfman disease) of the suprasellar region: MR imaging findings--a case report.

Sinus histiocytosis with massive lymphadenopathy (SHML) is an uncommon disorder that typically manifests as systemic symptoms and lymphadenopathy. Extranodal, intracranial disease is uncommon. The authors report on a 15-year-old adolescent girl who had a suprasellar mass at magnetic resonance imaging. Biopsy results demonstrated lymphophagocytosis consistent with a diagnosis of SHML. The clinical, radiologic, and histologic aspects of the disease are discussed.

Angiographic correlation of CT calcification in the carotid siphon.

BACKGROUND AND PURPOSE: Calcification in the coronary arteries has been correlated with significant vessel stenosis. The predictive value of calcification within the carotid siphon has not been characterized; however, stenosis in the carotid siphon is potentially important in determining management of patients with ipsilateral carotid bifurcation stenosis. The purpose of this study was to determine optimal parameters for assessing carotid siphon calcification on head CT scans and to compare the CT findings with angiographic results. METHODS: We performed a retrospective review of patients referred for diagnostic carotid arteriography. Those patients who also had undergone a head CT study at our institution were selected. The CT scans and angiograms of 64 patients (128 vessels) were reviewed. Carotid siphon calcification on CT scans was characterized on brain and bone windows as mild, moderate, or severe. Comparison was then made with angiographic findings. RESULTS: The sensitivity and specificity of CT for depicting greater than 50% angiographic stenosis in the carotid siphon were 86% and 98%, respectively, for bone windows and 100% and 0%, respectively, for brain windows. The positive predictive value (PPV) for a stenosis of greater than 50% as evidenced by severe calcification was 86% on bone windows and 11% on brain windows. The PPV for mild and moderate calcification on bone windows was 2.5% and 0%, respectively. CONCLUSION: Severe CT calcification in the carotid siphon as characterized on bone windows correlates with a carotid siphon stenosis of greater than 50% as determined angiographically. Therefore, the identification of severe calcification offers a potential noninvasive method for identifying stenosis of the carotid siphon. This information may be essential in determining management and prognosis for patients with carotid bifurcation stenosis.

Complete duplication or extreme fenestration of the basilar artery.

We describe a 42-year-old man with complete duplication or extreme fenestration of the basilar artery. We review the developmental anatomy and embryology and discuss the possible clinical implications and associated findings of this anomaly.

Patterns of hemorrhage with ruptured posterior inferior cerebellar artery aneurysms: CT findings in 44 cases.

OBJECTIVE: We intended to characterize the CT patterns of hemorrhage associated with ruptured posterior inferior cerebellar artery (PICA) aneurysms. MATERIALS AND METHODS: CT scans of 44 cases of angiographically confirmed ruptured saccular PICA aneurysms (4) aneurysms at the junction of the vertebral artery and the PICA and three distal PICA aneurysms) were retrospectively reviewed. All scans had been obtained within 2 days of the subarachnoid hemorrhage (SAH) (day 0 [less than 24 hr], 35 patients; day 1, eight patients; day 2, one patient). Presence or absence of hemorrhage in specific subarachnoid, intraventricular, and intraparenchymal locations was noted, as were the presence and degree of hydrocephalus. RESULTS: Posterior fossa SAH was present in 95% of cases. Isolated posterior fossa SAH was present in 30% of cases, but in no case was isolated supratentorial SAH present. Supratentorial SAH was present in 70% of cases. SAH involving the sylvian fissure or the interhemispheric region was present in 25% and 23% of cases, respectively. SAH along the convexity was present in 2% of cases. Intraventricular hemorrhage (IVH) with or without associated SAH was seen in 95% of cases, whereas isolated IVH was seen in 5% of cases. Hydrocephalus was present in 95% of cases and was moderate to marked in 70%. Both IVH and hydrocephalus were present in 93% of cases. CONCLUSION: Ruptured PICA aneurysms almost always coexist with hydrocephalus and IVH, as seen in 93% of cases, and almost never coexist with SAH along the convexity. The most common pattern of hemorrhage associated with such aneurysms includes IVH and posterior fossa hemorrhage. Extensive supratentorial SAH, in conjunction with posterior fossa SAH, is a common finding in patients with ruptured PICA aneurysms. SAH isolated to the posterior fossa is present in a sizeable minority of cases.

Optimization of parameters for the detection of cerebral aneurysms: CT angiography of a model.

PURPOSE: To optimize parameters with computed tomographic angiography for the detection of cerebral aneurysms. MATERIALS AND METHODS: Model aneurysms were placed randomly at various branch points and scanned multiple times with spiral technique. The final analysis included 63 branch points and 22 aneurysms. Each spiral scan used a different parameter combination. Collimation ranged from 1.5 to 4.0 mm and pitch ranged from 1:1 to 1.5:1. Images were constructed with shaded surface display (SSD) and maximum intensity projection (MIP) algorithms and were interpreted by three readers for the presence or absence of aneurysm. RESULTS: The receiver operating characteristic (ROC) curve area for 1.5-mm collimation was greater than those of 3- or 4-mm collimation (P < .01 and P < .001, respectively). There was no statistically significant difference in the ROC curve areas between 3- and 4-mm collimation (P = .37). There was no statistically significant decrease in ROC curve area when increasing pitch from 1:1 to 1.5:1 for any value of collimation (P = .96). For all parameter combinations the ROC curve areas for SSD images was greater than that of MIP images (P < .0001). CONCLUSION: For cerebral aneurysm detection, narrow collimation is superior to wider collimation. Mild increases in pitch do not substantially degrade diagnostic accuracy. SSD offers improved diagnostic accuracy over MIP display in this model.

Consumer satisfaction in two small rural communities: a quick methodology to empower rural communities to assess their own healthcare needs.

This study was designed to develop a quick methodology to assess the healthcare needs of a rural community and to determine what factors make these communities 'happy' or 'unhappy' with respect to medical service provision. Two rural shires of approximately 4000 people each were chosen from different health regions of Western Australia. The methodology consisted of interviews with healthcare providers and key community informants as well as a community questionnaire. The interviewing process showed that key community informants offered no new information in addition to that already provided by the healthcare providers. Furthermore, all key points would have been covered by interviewing approximately 60% of all healthcare providers in each community. Hand delivery of the community questionnaire yielded the highest response rate. The level of community satisfaction with general practitioner (GP) and hospital services determines whether a community is medically 'happy' or 'unhappy'.