Imaging appearances of Buerger's disease complications in the upper and lower limbs.

Thromboangiitis obliterans (Buerger's disease) is a rare, non-atherosclerotic, segmental, inflammatory vasculitis that most commonly involves small and medium-sized arteries, veins and nerves of the extremities and affects tobacco smokers between the ages of 25 and 45 years. The manifestations of Buerger's disease can be extremely variable and, therefore, awareness of the condition is important for both general and musculoskeletal radiologists. This paper presents the radiological appearance of the sequelae of Buerger's disease involving the upper and lower limbs.

Accuracy and interobserver reliability of three-dimensional rotational angiography versus mathematical models for volumetric measurement of intracranial aneurysms.

We aimed to compare the inter-rater reliability relating to the volumetric measurement of intracranial aneurysms obtained with three-dimensional rotational angiography (3D-RA) compared with two commonly used mathematical models. Ten randomly selected aneurysms were measured by 3 independent assessors using 3D-RA and 2 mathematical models for the calculation of an ellipsoid: Equation (1), Vab=4/3pi x (a/2)x(b/2)x(a + b/4); and Equation (2), Vabc=(4/3)pi x (a/2)x(b/2)x(c/2). The inter-rater reliability for each method was: 3D-RA, 0.99; Vabc, 0.90; and Vab, 0.89. The 95% confidence interval for the mean difference between 3D-RA and Vabc was not significantly different, whereas there was a significant difference between 3D-RA and Vab. Vab gave consistently higher estimates than 3D-RA. This was especially true for aneurysms with larger volumes. The use of 3D-RA to undertake volumetric measurements of intra-cranial aneurysms is both valid and reproducible for different assessors.

Evaluation of thickness and appearance of anterior talofibular and calcaneofibular ligaments in normal versus abnormal ankles with MRI.

Injuries to the lateral ligaments of the ankle are common in medical practice. The most commonly injured ligaments are the anterior talofibular (ATFL) and calcaneofibular (CFL) ligaments. When undertaking MRI evaluation of ankle injuries it is important to understand the normal dimensions, appearance and variations of these ligaments. Twenty-eight consecutive patients referred for MRI of the ankle underwent bilateral scanning. The thickness of normal and abnormal ATFL and CFL was determined. The mean thickness of the ATFL was 2.19 +/- 0.6 mm and the CFL measured 2.13 +/- 0.5 mm. One normal ankle had an extremely thin ATFL (0.8 mm) with an otherwise normal appearance, whereas two ankles had an ATFL with a high attachment, both of which were deemed to be normal variants. Nineteen per cent of normal CFLs were noted to consist of a lateral hypointense band with a medial isointense medial band. Two variations of normal ATFL, one normal variant CFL and a measurement of the normal thickness of the ATFL and CFL have been presented in this paper. These variations have not been described previously by other authors. It is envisaged that these findings will assist in the MRI assessment of the lateral ankle ligaments.

Fenestrated anterior cerebral artery with associated arterial anomalies. Case reports and literature review.

SUMMARY: Fenestration of the A2 segment is extremely rare. Cerebrovascular fenestration may be associated with an increased incidence of cerebral aneurysm and other vascular anomalies. Two case reports are presented which identify a fenestration of the A2 segment and other normal variations of the intra-cerebral circulation. A review of the literature has been undertaken to determine the prevalence and embryology of anterior cerebral artery fenestrations, their clinical significance and the association with aneurysm formation and other intracranial vascular anomalies.

Coaxial cutting needle biopsies: how important is it to rotate the cutting needle between passes?

AIM: To use an in-vitro model to measure the effect of turning the notch of the cutting needle between passes on the mass of core biopsy material obtained from a typical coaxial biopsy system when multiple passes are performed. METHODS: A coaxial guide needle was placed within tissue-equivalent agar cylinders and a cutting biopsy needle was used to take core biopsies. Two, three, or four sequential biopsies were performed on the same cylinder with the notch of the cutting needle either inserted facing in the same direction (no rotation) or placed in a sequence of different directions (rotation). The mass of the tissue core obtained at each biopsy pass was measured. A post hoc telephone questionnaire of radiologists across Australia was also undertaken to analyse current practice in the context of these results. RESULTS: There were statistically significant increases in the mass of tissue obtained using rotation compared with no rotation. Using rotation, the total mass of tissue obtained from three passes was increased by 32.8% (95% CI 23.9-41.7%) and from four passes was increased by 45% (95% CI 37.2-52.9%). The mass of the second pass cores was statistically significantly greater (p<0.001). Fifty-nine percent of Australian radiologists surveyed do not currently change the rotation of the biopsy needle between passes. CONCLUSION: This in-vitro model confirms that the notch of the cutting needle should be placed into different directions at each pass whenever a coaxial cutting biopsy system is being used to maximize the mass of tissue obtained.

CT-guided procedures: evaluation of a phantom system to teach accurate needle placement.

AIM: To evaluate the use of a phantom system to help teach the basic techniques of accurate CT-guided needle placement, thereby avoiding the risks associated with teaching on patients. MATERIALS AND METHODS: Gelatine phantoms with five, 1.9 cm embedded spherical wooden targets were constructed. Four trainee operators performed 15 simulated biopsy procedures on the targets (series one) and repeated identical procedures 2 weeks later (series two). Statistical analysis of accuracy of needle placement and subject confidence were performed. RESULTS: Significant sequential improvement in axial plane angular error was noted with the average error decreasing by 0.33 degrees after every five procedures performed (95% CI: -0.58 to -0.08, p=0.01). Operator confidence indicated significant improvement both within each series and from series one to series two (95% CI: 0.08 to 1.17, p=0.025 and 95% CI: 0.00 to 0.58, p=0.05) respectively. However, variability in operator performance made statistically significant improvement in other variables unproven. CONCLUSION: Despite the study comprising a relatively small number of participants and procedures, it clearly demonstrated the effectiveness of teaching operators to perform CT-guided procedures using a phantom system. Needle placement accuracy significantly improved, with a reduction in axial angular error, and improved operator confidence without the risks associated with training on patients. Three of the operators in this study had never performed a CT-guided procedure previously, and their proficiency, after a relatively short but intense period of training, was impressive. The use of phantoms should be considered routinely for basic training of CT-guided needle placement.

Thyroid hormone supplementation for the prevention of morbidity and mortality in infants undergoing cardiac surgery.

BACKGROUND: Paediatric studies have demonstrated that cardiopulmonary bypass is associated with a decline in thyroid hormone levels. Adult patients who undergo open heart surgery and receive triiodothyronine supplementation have demonstrated a dose-dependent increase in cardiac output which has been associated with an improved clinical outcome. Thyroid hormone supplementation in infants may also reduce post-operative morbidity and mortality. OBJECTIVES: To determine if peri-operative thyroid hormone supplementation or replacement in infants undergoing cardiac surgery on cardiopulmonary bypass improves post-operative and longer term morbidity and mortality. SEARCH STRATEGY: The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of The Oxford Database of Perinatal Trials, MEDLINE (1966 - December 2003), EMBASE (1980 - December 2003), CINAHL (1982 - December 2003), The Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), previous reviews including cross references, abstracts, conferences, symposia proceedings, expert informants and journal handsearching in the English language. SELECTION CRITERIA: All trials using random allocation to peri-operative thyroid hormone therapy (supplementation or replacement) compared to control (placebo or no therapy) in infants (birth to one year of age) undergoing cardiac surgery requiring cardiopulmonary bypass. Thyroid hormone therapy must be tri-iodothyronine. DATA COLLECTION AND ANALYSIS: Primary clinical outcomes included measures of post-operative morbidity and mortality. The standard methods of the Cochrane Neonatal Review Group were used in the assessment of trial quality. Treatment effects were expressed using relative risk (RR) and mean difference (MD). MAIN RESULTS: Two very small studies were identified that tested peri-operative thyroid hormone supplementation or replacement in infants aged less than one year undergoing cardiac surgery (Chowdhury 2001; Portman 2000). In the Chowdhury 2001 study, a subgroup of nine neonates was eligible for this review. No deaths occurred during either study. Chowdhury 2001 found no significant effect of peri-operative thyroid hormone supplementation in neonates on either length of hospital stay or duration of mechanical ventilation. Portman 2000 found no significant difference in dopamine requirements for the treatment versus control groups for the first 24 hours post operatively, while in the Chowdhury neonatal subgroup, inotrope requirements were significantly lower in the treatment group. Portman 2000 reported significant differences between the two groups at 1 and 24 hours post operatively for free T3 and at 1 hour post operatively for total T3 levels. Total T4 levels showed no significant difference between groups, either pre-cardiopulmonary bypass or up to 72 hours post operatively. REVIEWERS' CONCLUSIONS: At present, there is a lack of evidence concerning the effects of tri-iodothyronine supplementation in infants undergoing cardiac surgery. Further randomised controlled trials which include sufficiently large subject numbers in a variety of different age strata (neonates, infants and older children) need to be undertaken.

A case study of benefits & potential savings in rural home telemedicine.

This case study reports results from a federally funded home telemedicine program in rural Grainger County, Tennessee. Patients, family caregivers, and providers were generally satisfied with this low-cost, user-friendly telemedicine program that used the plain-old-telephone system. Mileage and nurse drive time were reduced and nursing productivity was improved during this demonstration project.