Estimating the effects of vegetation and increased albedo on the urban heat island effect with spatial causal inference.

The urban heat island effect causes increased heat stress in urban areas. Cool roofs and urban greening have been promoted as mitigation strategies to reduce this effect. However, evaluating their efficacy remains a challenge, as potential temperature reductions depend on local characteristics. Existing methods to characterize their efficacy, such as computational fluid dynamics and urban canopy models, are computationally burdensome and require a high degree of expertise to employ. We propose a data-driven approach to overcome these hurdles, inspired by recent innovations in spatial causal inference. This approach allows for estimates of hypothetical interventions to reduce the urban heat island effect. We demonstrate this approach by modeling evening temperature in Durham, North Carolina, using readily retrieved air temperature, land cover, and satellite data. Hypothetical interventions such as lining streets with trees, cool roofs, and changing parking lots to green space are estimated to decrease evening temperatures by a maximum of 0.7-0.9   [Formula: see text], with reduced effects on temperature as a function of distance from the intervention. Because of the ease of data access, this approach may be applied to other cities in the U.S. to help them come up with city-specific solutions for reducing urban heat stress.

Report on 7 Years' Experience Implementing an Undergraduate Medical Curriculum for Osteopathic Medical Students Using Entrustable Professional Activities.

Calls for changes in undergraduate medical education and the advent of the single graduate medical education accreditation system have challenged the osteopathic medical profession to maintain its identity and distinctiveness while adapting to innovations. For the osteopathic medical profession to thrive, its colleges must provide students with an educational framework that solidifies their osteopathic identity. The authors developed an integrated anatomy-clinical skills course at the University of New England College of Osteopathic Medicine, Osteopathic Clinical Skills, that used the performance benchmarks of the Entrustable Professional Activities and the Osteopathic Core Competencies for Medical Students from the American Association of Colleges of Osteopathic Medicine. A primary tenet of osteopathic medicine is the relationship of structure and function; Osteopathic Clinical Skills fuses anatomical sciences with clinical skills and underscores this tenet in clinical diagnosis and treatment. This article describes the development and implementation of an educational framework that integrates anatomy, physical examination, history taking, and other clinical skills with osteopathic medicine principles and practice and osteopathic manipulative treatment.

Synovial Cysts Confounding Access to the Dorsal S1 Neural Foramen in Transforaminal Epidural Steroid Injections.

OBJECTIVES: The S1 dorsal foramen is the route for 30% of lumbar transforaminal epidural injections; it is therefore important to identify structures impeding S1 foraminal access. The study objective was to characterize the imaging findings, prevalence, and anatomic origin of synovial cysts presenting within the S1 neural foramen. METHODS: A case series (N = 14) established imaging characteristics of S1 synovial cysts. Imaging studies of 400 patients undergoing epidural injections were reviewed for lesions compromising S1 foraminal access. Cadaveric dissections defined the relationship of the inferior recess of the L5-S1 facet to the S1 dorsal foramen. RESULTS: Elderly patients (mean age = 76) exhibited S1 synovial cysts. Synovial cysts were typically 1-2 cm in diameter, hyperintense on sagittal T2 weighted magnetic resonance images (MRIs), fluid-density on computed tomography, and dorsal to the S1 spinal nerve. Sixty percent of cysts exhibited complex MRI signal characteristics (thick wall, internal structure). Tarlov cysts, in contrast, were larger, lobular, and exhibited pure fluid intensity. Lesions impeded access to the S1 dorsal foramina in 5% of reviewed imaging studies (16 Tarlov cysts, three synovial cysts, one conjoint S1-S2 nerve root). The multifidus muscle was interposed between the L5-S1 facet inferior recess and the S1 dorsal foramen on dissection specimens; severe atrophy of the ipsilateral multifidus was noted on imaging in 17/18 synovial cysts. CONCLUSIONS: The S1 neural foramina should be inspected on sagittal MRI, when available, for confounding lesions before performing S1 epidural injections. Tarlov cysts are more common than synovial cysts; the latter are seen in elderly patients with severe multifidus atrophy.

The ability of single site, single depth sacral lateral branch blocks to anesthetize the sacroiliac joint complex.

OBJECTIVE: To determine the physiologic effectiveness of single site, single depth sacral lateral branch injections. DESIGN: Randomized, controlled, and double-blinded study. SETTING: Outpatient pain management center. PATIENTS: Fifteen asymptomatic volunteers. INTERVENTIONS: The dorsal sacroiliac ligament was probed and the sacroiliac joint was injected with contrast medium until capsular distension occurred. The presence or absence of pain with each maneuver was noted. Under double-blind conditions, subjects returned 1 week later for L5 dorsal ramus and S1-4 lateral branch injections; 10 subjects received 4% lidocaine (active) injections while five subjects received saline (control) injections. After 30 minutes, subjects had repeat ligamentous probing and capsular distension of the same sacroiliac joint that was previously tested. The presence or absence of pain with each maneuver was noted. In a parallel anatomic study, S1 and S2 lateral branch injections with green dye were performed on two nonembalmed cadavers. Dissection was undertaken to quantify the degree of staining of these target lateral branch nerves. OUTCOME MEASURES: Presence or absence of pain for ligamentous probing and sacroiliac joint capsular distension. RESULTS: Forty percent had no discomfort upon repeat ligamentous probing after active lateral branch injections while 100% retained pain upon repeat ligamentous probing with control lateral branch injections. Forty percent of the active group and 20% of the control group did not feel repeat capsular distension of the sacroiliac joint after the lateral branch injections. In the anatomic study, 11 lateral branch nerves were isolated while staining occurred in only four cases or 36%. CONCLUSIONS: Anatomic limitations exist with single site, single depth sacral lateral branch injections rendering them physiologically ineffective on a consistent basis.

Ventral innervation of the lateral C1-C2 joint: an anatomical study.

OBJECTIVE: Clinical observation has suggested the presence of ventral cervical extra-articular pain pathways in patients with C1-C2 joint pain. However, the existence of ventral innervation to the C1-C2 joint has not been documented. The objective of this study was to determine whether ventral innervation to the lateral C1-C2 joint exists, and to describe its relational anatomy. DESIGN: Gross and microscopic dissection was performed on 11 embalmed human cadavers. Wire segments were placed on identified ventral plexus nerves and radiographic imaging obtained in multiple planes. Histologic staining of prevertebral plexus nerves was performed with Osmium and compared with tissue controls. RESULTS: A superficial and deep cervical prevertebral plexus was identified terminating in the ventral joint capsule of the C1-C2 joint in all cadavers examined (21 sides). The location of the deep cervical prevertebral plexus was consistent within the C2 ventral gutter. Osmium staining confirmed the presence of myelin in plexus specimens. CONCLUSION: In this study, two cervical prevertebral plexuses (superficial and deep) were identified that have not previously been described. Terminal branches of the plexuses entered the ventral joint capsule of the lateral C1-C2 joint and were seen approaching the dens. Findings provide and explanation for the clinical observation that electrical stimulation in the C2 ventral gutter can reproduce headache in patients with C1-C2 joint pain.

Sensory stimulation-guided sacroiliac joint radiofrequency neurotomy: technique based on neuroanatomy of the dorsal sacral plexus.

STUDY DESIGN: A retrospective audit and examination of anatomic findings. OBJECTIVE: To examine the effectiveness of sensory stimulation-guided radiofrequency neurotomy for the treatment of recalcitrant sacroiliac joint pain. SUMMARY OF BACKGROUND DATA: Sacroiliac joint-mediated pain is a distinct clinical entity. The prevalence of intra-articular pain arising from the sacroiliac joint in patients with low back pain has been estimated at 15% to 30%. Unfortunately, the clinical success of current treatment methods for chronic sacroiliac pain is discouraging. Based on the anatomy of the sacral posterior primary rami and their lateral branch nerves, an anatomically based sensory stimulation-guided radiofrequency technique was developed to overcome the inherent challenge posed by the variable topography of the sacral lateral branch nerves. MATERIALS AND METHODS ANATOMIC STUDY: Meticulous dissection exposing the dorsal sacral plexus and lateral branch nerves entering the sacroiliac joint complex was performed on three cadaveric specimens. Small-gauge wires were placed adjacent to the lateral branch nerves entering the joint and over the dorsal sacrum to the dorsal sacral foramina. Fluoroscopic images were obtained correlating the location and number of these branches arising from the posterior primary rami of S1-S3 to identifiable bony landmarks. CLINICAL STUDY: A retrospective chart review was performed selecting patients who underwent sensory stimulation-guided sacral lateral branch radiofrequency neurotomy after dual analgesic sacroiliac joint deep interosseous ligament analgesic testing between February 17, 1998 and March 15, 1999. RESULTS: A total of 14 patients met inclusion criteria for this retrospective study. Success was defined as greater than 60% consistent subjective relief and greater than a 50% consistent decrease in visual integer pain score, maintained for at least 6 months after the procedure. Sixty-four percent of patients experienced a successful outcome, with 36% experiencing complete relief. Fourteen percent of patients did not achieve any improvement. No patients experienced a complication or worsening of their pain from the procedure. CONCLUSIONS: A sensory stimulation-guided approach toward the identification and subsequent radiofrequency thermocoagulation of symptomatic sacral lateral branch nerves appears to offer significant therapeutic advantages over existing therapies for the treatment of chronic sacroiliac joint complex pain.