Preliminary evaluation of dual-energy CT to quantitatively assess bone marrow edema in patients with diabetic foot ulcers and suspected osteomyelitis.

OBJECTIVES: The purpose of this study is to evaluate the value of dual-energy CT (DECT) with virtual non-calcium (VNCa) in quantitatively assessing the presence of bone marrow edema (BME) in patients with diabetic foot ulcers and suspected osteomyelitis. METHODS: Patients with a diabetic foot ulcer and suspected osteomyelitis that underwent DECT (80 kVp/Sn150 kVp) with VNCa were retrospectively included. Two observers independently measured CT values of the bone adjacent to the ulcer and a reference bone not related to the ulcer. The patients were divided into two clinical groups, osteomyelitis or no-osteomyelitis, based on the final diagnosis by the treating physicians. RESULTS: A total of 56 foot ulcers were identified of which 23 were included in the osteomyelitis group. The mean CT value at the ulcer location was significantly higher in the osteomyelitis group (- 17.23 ± 34.96 HU) compared to the no-osteomyelitis group (- 69.34 ± 49.40 HU; p < 0.001). Within the osteomyelitis group, the difference between affected bone and reference bone was statistically significant (p < 0.001), which was not the case in the group without osteomyelitis (p = 0.052). The observer agreement was good for affected bone measurements (ICC = 0.858) and moderate for reference bone measurements (ICC = 0.675). With a cut-off value of - 40.1 HU, sensitivity was 87.0%, specificity was 72.7%, PPV was 69.0%, and NPV was 88.9%. CONCLUSION: DECT with VNCa has a potential value for quantitatively assessing the presence of BME in patients with diabetic foot ulcers and suspected osteomyelitis. KEY POINTS: • Dual-energy CT (DECT) with virtual non-calcium (VNCa) is promising for detecting bone marrow edema in the case of diabetic foot ulcers with suspected osteomyelitis. • DECT with VNCa has the potential to become a more practical alternative to MRI in assessing the presence of bone marrow edema in suspected osteomyelitis when radiographs are not sufficient to form a diagnosis.

[Autoptical display of the nasopharyngeal space in cases of suspected SARS-Co2 infection]. / Autoptische Darstellung des Nasen-Rachen-Raumes bei Verdacht auf SARS-CoV2-Infektion.

This paper deals with a dissection technique in order to display the nasopharyngeal space. It consists of a parafrontal saw cut through the base of the skull at the level of the sella turcica. In this way the ventral part of the nasopharyngeal space can be separated from the cervical spine and the posterior base of the skull within an anatomically preformed border region. Apart from a comprehensive overview of the nasopharyngeal space, this technique also enables samples to be correctly taken. The time required takes approximately 2-3 min, the external appearance of the deceased is not affected and the preparation of the body is not complicated.

Functional bracing treatment for stable type B ankle fractures.

BACKGROUND: In general, stable type B ankle fractures are treated conservatively with cast immobilization or a walking boot during six weeks. Some disadvantages of casting are joint stiffness, muscle wasting and lack of comfort. This study was designed to evaluate whether functional treatment with a removable brace is a safe and more comfortable alternative. MATERIAL AND METHODS: Randomized controlled trial. In the period March 2013 - May 2015, 44 patients visiting the emergency department due to a stable type B ankle fracture were included. During the first week both groups received a splint. After one week the patients were randomized: one group received a cast, the other a removable brace. For outcome Olerud & Molander Ankle Score, Visual Analogue Score for comfort and pain, American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle score questionnaire, EuroQol-5D and range of motion were used. RESULTS: 44 patients participated (21 cast, 23 brace). There were no differences in baseline characteristics. After 6 weeks, VAS for comfort (cast vs brace; 5.74 vs 7.21; p = 0.02) and total range of motion (40° vs 49°; p = 0.00) showed significant differences in favour of the brace. VAS pain (3.15 vs 2.05; p = 0.16), OMA-score (51.75 vs 61.32; p = 0.22) en EuroQoL-5D (7.26 vs 6.74; p = 0.33) did not show significant differences. Week 52 showed no significant differences at OMA-score (89.29 vs 96.18; p = 0.16), EuroQoL-5D (6.00 vs 5.35; p = 0.15), VAS pain (1.07 vs 0.82; p = 0.69) and AAOS score (91.71 vs 96.06; p = 0.21). No complications occurred in both groups. CONCLUSION: Functional bracing showed significant differences for the VAS comfort score and range of motion at 6 weeks compared to casting. After a year no significant differences were found. Treatment with a brace is a safe and more comfortable option for stable type B ankle fractures.

Routine follow-up radiographs for distal radius fractures are seldom clinically substantiated.

INTRODUCTION: The value of routine radiographs during follow-up after distal radius fractures is unclear. The aim of this study was to evaluate whether routine radiographs performed during the follow-up period in patients with a distal radius fracture influenced clinical decision making. METHODS: This retrospective cohort study included patients aged ≥18 years who were treated for a distal radius fracture at four hospitals in The Netherlands in 2012. Demographic and clinical and radiographic characteristics were collected from medical records. RESULTS: 1042 patients were included. In 121 (14%) of the 841 radiographs, a clinical indication was reported. Treatment was affected by 22 (2.6%) radiographs, including 11 (1.5%) radiographs that were categorized as routine, 9 (1.2%) of which led to prolonged cast immobilization and 2 (0.2%) to surgery for conservatively treated patients. CONCLUSION: Although it is common practice to take radiographs after distal radius fractures, the study results indicate that routine radiographs seldom affect treatment. This finding should be weighed against the high health care costs associated with these fractures. We hope that the results of our study will trigger the awareness among surgeons that in the current practice, many radiographs are taken on routine without influencing clinical decision making and can probably be omitted. LEVEL OF EVIDENCE: Level III.

Radiographic fracture features predicting failure of internal fixation of displaced femoral neck fractures.

INTRODUCTION: Fixation-related complications of displaced femoral neck fractures treated by internal fixation are accompanied by high mortality and morbidity. The aim of this study is to investigate the pre- and postoperative radiographic fracture characteristics in relation to patient age and the occurrence of reoperation caused by fixation failure. METHODS: The preoperative radiographs of all patients presenting with a proximal femur fracture between January 2004 and December 2012 were retrospectively assessed for fracture type and dislocation (AP and lateral view). Patients with a displaced femoral neck fracture treated by closed reduction and internal fixation were included. The postoperative radiographs were assessed on adequate fracture reduction and correct position of the implant. Patient characteristics and outcome in terms of occurrence of fixation failure (implant breakout, non-union) and reoperation rate were recorded. RESULTS: Hundred and-forty-nine patients were admitted with a displaced femoral neck fracture and treated by internal fixation. Fixation failure was seen in 34 (23%) patients; 9 patients suffered from osteonecrosis. In total, 37 (25%) patients underwent reoperation caused by fixation-related complications. Taking the different age categories into account, 44% of the patients >75 years suffered fixation failure compared with 17% of the patients <65 years. Postoperative incorrect reduction, with persisting dorsoventral dislocation and/or lack of medial support resulted in reoperation in 37% of the patients, compared to 19% reoperations in patients with adequate reduction. CONCLUSION: The results of this study show that patient age and fracture reduction are important predictors for reoperation. In the preoperative treatment plan, patient age should be taken into account and surgeons should strive for anatomical reduction. Patients over 75 should always undergo arthroplasty. In patients aged 65-75, conversion to arthroplasty should be strongly considered if anatomical reduction is impossible.

Entropy-driven aggregation of adhesion sites of supported membranes.

We study, by means of mean-field calculations and Monte Carlo simulations of a lattice gas model, the distribution of adhesion sites of a bilayer membrane and a supporting flat surface. Our model accounts for the many-body character of the attractive interactions between adhesion points induced by the membrane thermal fluctuations. We show that while the fluctuation-mediated interactions alone are not sufficient to allow the formation of aggregation domains, they greatly reduce the strength of the direct interactions required to facilitate cluster formation. Specifically, for adhesion molecules interacting via a short-range attractive potential, the strength of the direct interactions required for aggregation is reduced by about a factor of two to below the thermal energy k(B)T.

The learning process in biofeedback: is it feed-forward or feedback?

Twenty participants responded to inquiries about strategies used, and thoughts during, each of three electromyograph biofeedback sessions. The purpose of the study was to learn more about what individuals report doing during biofeedback and, specifically, to determine if individuals construct a response using feedback to sense subtle differences in muscle tension (feedback processes), or select a response from an existing repertoire using feedback primarily for confirmation (feed-forward processes). Protocol analyses found considerable support for feed-forward processes and little support for feedback processes. Such results are important because early reliance on feed-forward processes may result in limited control and limited transfer.

Antigen capture ELISA for the identification of dengue viruses.

We developed a simple antigen capture enzyme immunosorbent assay (AgC-ELISA) for identifying dengue (DEN) virus. The method employed serotype-specific monoclonal antibodies as capture antibodies and an enzyme conjugate of a flavivirus-reactive monoclonal antibody as a detecting antibody. Most DEN virus strains, representing all 4 serotypes isolated from various parts of the tropics, were identical either visually of spectrophotometrically when infected cell culture fluids were used as sources of antigen. The shelf life of the solid phase presensitized with monoclonal antibodies was 4 mth at -15 degrees C. DEN prototype viruses were still identified after storage at -15 degrees C for 1 yr or at room temperature for 1 mth.

The role of facial expressions in the holding environment.

The significance of a visual dialogue between patient and therapist in assisting tension regulation for patients with severe narcissistic injury is proposed. Non-verbal interactions may unfold spontaneously and contribute to development of a "holding environment" in its broadest sense. There will be inevitably both countertransference and real elements in this bipersonal field. The development of a visual holding environment at a symbiotic level may be based on a counter-transference response by the therapist of an earlier need to "hold or be held." It has been suggested that it is difficult for the therapist to feel a "gleam in the eye" for patients who have missed early mirroring. Developmental stages of treatment involving active mutuality of eye contact, considered a "language of silence" beyond verbal interpretation, are suggested. These observations agree with Searles' paper that facial expressions form a bridge to personal relatedness.

Use of immunologic techniques to detect chemotherapeutic success in infections with Fasciola hepatica. II. The enzyme linked immunosorbent assay in infected rats and rabbits.

An enzyme-linked immunosorbent assay (ELISA) was developed using microtiter plates for the immunodiagnosis of fascioliasis in rats and rabbits using extracts of adult worms partially purified by gel filtration chromatography using Sephacryl S-200. Partial purification was necessary to eliminate cross-reactivity with antisera having antibodies to schistosomes. Soft polyvinyl plates clearly gave superior results over hard polystyrine plates. Titers rose by 4 weeks of infection in rats with fascioliasis, by 6 weeks in the case of rabbits, and remained high through at least 12 and 28 weeks, respectively. Titers drop rapidly when animals are successfully treated with a fasciolicidal drug at 4--6 weeks of infection. The results show that the ELISA can be employed for the serodiagnosis of fascioliasis in rats and rabbits and is useful for the prediction of chemotherapeutic success.

Partial purification of fasciola hepatica antigen for the immunodiagnosis of fascioliasis in rats.

When F. hepatica adult worm antigen is fractionated with Sephadex G-200, four major peaks are obtained. The first peak, when used as antigen in counterelectrophoresis, reacts with the serum of normal rats as well as from rats infected with F. hepatica for 5 weeks or longer. The crest and descending portion of peak II and the third peak are nonreactive with normal rat serum, but highly reactive with the serum of rats with F. hepatica. In addition, F. hepatica antigens cross-reacting with S. mansoni adult worm antisera are absent in these fractions. It is suggested, then, that these fractions of F. hepatica adult worm antigen be utilized for the immunodiagnosis of fascioliasis by CEP. Optimum antigen concentration for this test has been determined to be approximately 1.80 mg/ml protein.