bluuebunny/crossref_metadata_2025 huggingface dataset:
Normal Bone Marrow and Benign Bone Marrow Lesions
Authors: Samet Jonathan D.
Published: June 2019

Chapter 58 discusses normal bone marrow and benign bone marrow lesions. Bone marrow undergoes a predictable pattern of development throughout life, knowledge of which is essential for accurate assessment by the radiologist. It is a dynamic organ that can range in response from bone marrow failure to hyperactivity. Bone marrow can be affected by infectious, inflammatory, traumatic, and neoplastic causes, among other etiologies. This chapter discusses the normal appearance of bone marrow on imaging, with an emphasis on MRI. It will then discuss and show imaging examples of numerous benign entities that can affect the bone marrow. The reader will learn to predict the expected bone marrow appearance and therefore be able to distinguish this from benign pathologic states. The reader will also learn when to recommend a bone marrow aspiration/biopsy or further workup if confronted with an unexpected bone marrow appearance.
Malignant Marrow Bone Tumors
Authors: Samet Jonathan D.
Published: June 2019

Chapter 59 discusses malignant bone marrow tumors. Musculoskeletal radiologists are frequently confronted with bone marrow signal alterations on MRI that may represent physiologic variations or benign or malignant lesions. Although statistically most of these bone marrow signal abnormalities will be benign, distinguishing malignant from benign bone marrow entities is critical to patient management. This differentiation is not always possible on imaging, however, and biopsy may be necessary. This chapter will provide a practical approach to interpretation of diffuse and focal bone marrow abnormalities with an emphasis on malignant bone marrow lesions. With particular MRI criteria discussed, the reader will gain confidence in identifying malignant lesions and know for which lesions to recommend biopsy.
Hypertrophic Osteoarthropathy
Authors: Belkind Noam , Zoga Adam C.
Published: June 2019

Chapter 69 discusses hypertrophic osteoarthropathy (HOA), which is a clinical triad of periostitis, digital clubbing, and swollen joints. When caused by an underlying pulmonary disease, it is termed hypertrophic pulmonary osteoarthropathy (HPOA). HPOA is most commonly associated with neoplastic lung disease, however, HOA has also been described with cyanotic congenital heart disease, cirrhosis, biliary atresia, inflammatory bowel disease, gastrointestinal polyposis, and thalassemia. The principal imaging finding in HPOA is periostitis and periosteal new bone formation affecting the long bones of the appendicular skeleton in a bilateral and symmetric fashion. Radiographically this manifests as a smooth layer of periosteal new bone formation. Bone scintigraphy demonstrates a characteristic linear radiotracer uptake parallel to the normal cortical bone uptake known as the parallel track or double line sign. MRI similarly demonstrates hyperintense linear periosteal STIR signal that parallels the affected long bones.
Bleeding Diseases
Authors: Hoover Kevin B.
Published: June 2019

Chapter 79 discusses bleeding diseases, which result from disruption of the normal blood clotting process. Genetic diseases that cause reduction or dysfunction of clotting factors (hemophilia A and B) and less commonly platelets (von Willebrand disease) are the major bleeding diseases of the musculoskeletal system. The most common bleeding disease of the musculoskeletal system, hemophilia, is caused by deficiency of either factor VIII or factor IX. Hemophilia commonly results in intraarticular hemorrhage resulting in hemophiliac arthropathy and less commonly intramuscular hemorrhage. Imaging of the joints and soft tissues, especially by MRI, is important in disease management.
Pituitary Diseases
Authors: Hoover Kevin B.
Published: June 2019

Chapter 80 discusses pituitary diseases. Acromegaly and Cushing disease are the 2 pituitary diseases with the most significant effects on the musculoskeletal system. Acromegaly results in excess growth hormone with gradual bone and soft tissue overgrowth in adults. Cushing disease results in hypercortisolism resulting in osteoporosis, osteonecrosis, and myopathy. Osteoporosis and osteonecrosis are common sequelae of Cushing disease that can often be detected radiographically, but DXA and MRI are often used for confirmation and treatment planning. Both conditions require a high clinical suspicion to diagnose and are primarily treated surgically. Medical treatment with or without adjunctive radiation therapy is reserved for patients with unsuccessful surgical resection or unresectable disease.
Lipidoses
Authors: Hoover Kevin B.
Published: June 2019

Chapter 83 discusses lipidoses. The lipidoses are genetic diseases caused by enzyme deficiencies, which result in the cellular accumulation of lipids. These abnormal cells infiltrate tissues, including bone marrow, resulting in their dysfunction. Gaucher disease (GD) is the most common lysosomal storage disease (LSD) and lipidosis. Fabry disease (FD) is an X-linked recessive disease. Together, GD and FD account for 20% of LSDs. Nonspecific bone changes are detected using radiography, however, MRI is the most useful modality to evaluate involvement of the bone and bone marrow. MRI can also be used to detect treatment response. Enzyme replacement therapy (ERT) is the primary treatment for GD.
Pyogenic Spondylodiscitis
Authors: Shikhare Sumer N. , Peh Wilfred C. G.
Published: June 2019

Chapter 85 reviews the radiologic features of pyogenic spondylodiscitis and the diagnostic value of different imaging modalities such as conventional radiography, CT, MRI, and bone scintigraphy. Pyogenic spondylodiscitis is an infection of the intervertebral disc and adjacent vertebrae and may involve the paravertebral soft tissue and epidural space. The indolent clinical presentation poses a challenge in early diagnosis and management. Pyogenic spondylodiscitis can be diagnosed based on clinical findings and blood and tissue cultures and is supported by radiological and histopathologic findings. This chapter also reviews the imaging differential diagnoses, including tuberculous spondylodiscitis and malignancies. Imaging plays a crucial role in early diagnosis of disease and in demonstrating the extent of the disease process, as treatment delay significantly reduces the cure rate and increases the complication and morbidity rates.
Syphilis
Authors: Arkun Remide
Published: June 2019

Chapter 93 reviews musculoskeletal manifestations of syphilis, which is an infection caused by the bacterium Treponema pallidum and is acquired by sexual intercourse or transmitted vertically from mother to baby. In early congenital syphilis, radiographic findings include periostitis, metaphysitis, and diaphyseal osteomyelitis. In late congenital syphilis, osteomyelitis and periostitis are seen in long tubular and flat bones and the cranium. In the tibia, a typical saber shin deformity with anterior bending of the bone is seen. Acquired syphilis, seen in adults, is divided into primary, secondary, latent, and tertiary stages. Musculoskeletal manifestations are seen in latent and tertiary stages as periostitis and gummatous or nongummatous inflammation.
Wrist Arthrography
Authors: DelGiudice Matthew
Published: June 2019

Chapter 100 describes the indications, the technique, and the imaging findings of wrist arthrography. Wrist arthrography is selectively performed in routine clinical practice for MR arthrography (MRA), typically in younger patients. The main indications include evaluation of the intrinsic interosseous wrist ligaments (scapholunate and lunotriquetral) and triangular fibrocartilage complex (TFCC) injuries. Contrast should easily inject and disperse throughout the radiocarpal joint space. Complications from contrast injection are rare and include infection and bleeding. Full-thickness tearing of any of the 3 components of the scapholunate and/or lunotriquetral ligament allows abnormal communication with the midcarpal joint. Central tearing of the triangular fibrocartilage disc allows abnormal communication with the distal radioulnar joint.
Hypervitaminoses, Hypovitaminoses, Fluorosis, and Lead Poisoning
Authors: Mar Winnie A. , Blondieux Eléonore
Published: June 2019

Chapter 116 discusses hypervitaminoses, including hypervitaminosis A and D, and hypovitaminoses, particularly scurvy and its effects on the musculoskeletal system. Fluoride and lead poisoning are also discussed. The pathophysiology of these diseases and imaging findings are delineated. The main imaging findings of hypervitaminosis A are wavy metaphyseal periostitis in children and enthesopathy in adults. Metastatic calcification is seen with hypervitaminosis D. In scurvy, there is a dense line of the physis, at the zone of provisional calcification, and a lucent metaphyseal band, with possible periosteal elevation caused by subperiosteal hemorrhage. In fluorosis, there is increased bone density and periostitis. In lead poisoning, there are dense metaphyseal bands.
Ultrasound of the Wrist and Hand
Authors: Yablon Corrie M.
Published: June 2019

Chapter 122 covers US of the wrist and hand. US is gaining popularity as a useful modality for imaging wrist and hand pain, providing soft tissue resolution superior to MRI, with the additional benefits of real-time imaging, ease of comparison to the contralateral side, and dynamic imaging. US provides excellent visualization of tendons and the small joints of the hand. Peripheral nerves are easily identified and assessed with US with resolution surpassing MRI. Median nerve entrapment can be quickly and easily evaluated when carpal tunnel disease is suspected. Dynamic evaluation allows further assessment for the presence of Stener lesion, sagittal band and annular pulley injuries, and for tendon subluxation. US easily shows joint effusions, osteophytes, erosions, and synovial hypertrophy when arthritis is suspected. Soft tissue masses, such as ganglion cysts or giant cell tumor of the tendon sheath, are accurately imaged with US.
Ultrasound of the Knee
Authors: Morag Yoav
Published: June 2019

Chapter 124 discusses US scanning of the knee, which is commonly performed for assessment of superficial knee structures, such as the extensor mechanism tendons and collateral ligaments, as well as identification of Baker cysts or prepatellar bursae. Dynamic US evaluation, such as flexion/extension of the knee or varus/valgus stress maneuvers, may improve diagnostic performance and further characterize severity of tendon or ligamentous injury and ligament incompetence. US examination may be comprehensive or focused, with constant modification of patient and probe positioning to allow for optimal visualization of the knee structures. Common US artifacts, such as anisotropy of the extensor tendons or heterogeneous appearance of the distal joined attachment of the lateral collateral ligament proper and the distal biceps femoris tendon, should not be mistaken for pathology. Although parameniscal cysts can be readily identified by US, there is ongoing controversy regarding the role of US in evaluation of meniscal tears.
Urbanization and mental health
Authors: Carta Mauro G. , Bhugra Dinesh
Published: June 2019

Growth of the urban population worldwide is a critical issue for global mental health. Urban populations are exposed to several factors that may play a role in the modification of the profile of mental health risks. These factors are interlinked and their effects are cumulative. Synthesis of some of the research findings related to urbanization and increased psychopathological risks is presented. Studies have found associations of social and environmental determinats linked to living in cities and high rates of schizophrenia and other mental disorders. Given the hectic, haphazard, and rapid processes of global urbanization robust research and prospective approaches are needed to explore and clarify the causal links so far highlighted and the interactions between environmental and genetic factors. Urban rehabilitation interventions need to be studied over time in the wake of the welfare of populations, and should take a multidisciplinary collaborative approach.
Urbanization and marginalization
Authors: Krausz Michael , Strehlau Verena , Choi Fiona , Jang Kerry L.
Published: June 2019

From research among vulnerable urban individuals it is known that mental illness and substance use disorders are risk factors for social marginalization, homelessness, and poverty. The majority of homeless individuals have experienced early-childhood trauma, maltreatment, foster care, and family dysfunction. Limited access to physical and mental health care continuity further marginalizes the already vulnerable and creates social exclusion. The general migration of people towards big metropolitan areas also increases the pressure on limited infrastructure and health care in urban centres. This constitutes a significant public health threat and heralds the need to reposition the healthcare system and, in particular, mental health services to manage the situation. To provide equal access and a minimal quality of care the priorities of the healthcare systems need to be newly defined from the principles of harm reduction.
Urban design for adolescent mental health
Authors: Roe Jenny , Roe Alice
Published: June 2019

Young people today face a number of unprecedented social, cultural and economic challenges that pose a threat to their mental wellbeing. This includes rapid urbanization, globalisation and migration. It is increasingly recognised that intersectoral and multicomponent action is required to meet these challenges - yet so far the role of urban planning to promote adolescent health and wellbeing has been overlooked. This chapter provides an overview of the evidence showing the potential for the built environment to promote health and wellbeing among young people. This includes promoting an ‘active city’ that enables more walking, cycling, and provides integrated public transport facilities for young people. It requires that urban design is responsive to the integration of new technologies that can help forge mobility in, and engagement with, the city. The ‘playable city’ affords opportunities for adolescents to engage with a city through smart phones, whilst also promoting physical activity and social interaction. It also includes the provision of green space and ‘restorative niches’ that support emotional self-regulation in young people. In order to realise the full potential of urban design to promote adolescent mental health, we must engage young people in the debate on these new approaches.
Re-conceptualizing urban spaces: towards recovery and reintegration of women living with mental disorders
Authors: Maitra Shubhada
Published: June 2019

Urban spaces are negotiated by women living with mental disorders in a variety of ways. Often, this population lives on the fringes of the city, invisible, rarely occupying mainstream spaces. Reintegration of women with mental disorders is a long and arduous process. In India, women living with mental disorders experience long-term institutionalization and abandonment by the family. They are often admitted to the hospital in their late 20s/early 30s and despite becoming asymptomatic are unable to get out of the institution given the absence of their family. As a result, they grow old in the institution, with no skills to fend for themselves, no roof above their head, and no identity beyond ‘madness’. This chapter describes Tarasha, a community-based project working with women surviving mental disorders. Tarasha links shelter, livelihoods, and psycho-social issues to facilitate women’s recovery and reintegration, negotiating urban spaces in order to reduce stigma and discrimination.
EPAS1 Gain-of-Function Mutation Contributes to High-Altitude Adaptation in Tibetan Horses
Authors: Liu Xuexue , Zhang Yanli , Li Yefang , Pan Jianfei , Wang Dandan , Chen Weihuang , Zheng Zhuqing , He Xiaohong , Zhao Qianjun , Pu Yabin , Guan Weijun , Han Jianlin , Orlando Ludovic , Ma Yuehui , Jiang Lin
Published: June 2019

High altitude represents some of the most extreme environments worldwide. The genetic changes underlying adaptation to such environments have been recently identified in multiple animals but remain unknown in horses. Here, we sequence the complete genome of 138 domestic horses encompassing a whole altitudinal range across China to uncover the genetic basis for adaptation to high-altitude hypoxia. Our genome data set includes 65 lowland animals across ten Chinese native breeds, 61 horses living at least 3,300 m above sea level across seven locations along Qinghai-Tibetan Plateau, as well as 7 Thoroughbred and 5 Przewalski’s horses added for comparison. We find that Tibetan horses do not descend from Przewalski’s horses but were most likely introduced from a distinct horse lineage, following the emergence of pastoral nomadism in Northwestern China ∼3,700 years ago. We identify that the endothelial PAS domain protein 1 gene (EPAS1, also HIF2A) shows the strongest signature for positive selection in the Tibetan horse genome. Two missense mutations at this locus appear strongly associated with blood physiological parameters facilitating blood circulation as well as oxygen transportation and consumption in hypoxic conditions. Functional validation through protein mutagenesis shows that these mutations increase EPAS1 stability and its hetero dimerization affinity to ARNT (HIF1B). Our study demonstrates that missense mutations in the EPAS1 gene provided key evolutionary molecular adaptation to Tibetan horses living in high-altitude hypoxic environments. It reveals possible targets for genomic selection programs aimed at increasing hypoxia tolerance in livestock and provides a textbook example of evolutionary convergence across independent mammal lineages.
Same-Day HIV Pre-Exposure Prophylaxis (PrEP) Initiation During Drop-in Sexually Transmitted Diseases Clinic Appointments Is a Highly Acceptable, Feasible, and Safe Model that Engages Individuals at Risk for HIV into PrEP Care
Authors: Kamis Kevin F , Marx Grace E , Scott Kenneth A , Gardner Edward M , Wendel Karen A , Scott Mia L , Montgomery Angela E , Rowan Sarah E
Published: June 2019

Objective

Strategies to increase pre-exposure prophylaxis (PrEP) uptake are needed. We hypothesized that same-day PrEP initiation in a sexually transmitted diseases (STD) clinic would be acceptable, feasible, and safe, and that individuals would engage in ongoing PrEP care.

Method

Individuals aged ≥ 18 years were evaluated for PrEP. Exclusion criteria were HIV, history of renal dysfunction or chronic hepatitis B infection, pregnancy, indications for HIV post-exposure prophylaxis, or positive screen for acute HIV symptoms. One hundred individuals received a free 30-day PrEP starter pack and met with a patient navigator to establish ongoing care. Bivariate analysis and multivariable logistic regression were used to compare individuals who did and did not attend at least 1 PrEP follow-up appointment within 180 days of enrollment. Client satisfaction surveys were given 3 months after enrollment.

Results

The majority (78%) of participants completed at least 1 PrEP follow-up appointment, and 57% attended at least 2 follow-up appointments. After adjusting for race and ethnicity, age, health insurance status, and annual income, only income was associated with follow-up appointment attendance. Each additional $10,000 increase in income was associated with a 1.7-fold increase in the odds of attending a PrEP follow-up appointment (95% confidence interval, 1.07–2.66, P = .02). The majority (54%) of individuals completed the satisfaction survey and all respondents liked the option of same-day PrEP initiation.

Conclusions

Our study suggests STD clinic-based, same-day PrEP initiation is acceptable, feasible, safe, and links a high proportion of individuals into ongoing PrEP care. Additional resources may be needed to support low-income individuals’ retention in care.
More II It than Meets the Eye: Outcomes After Single-Fraction Stereotactic Radiosurgery in a Case Series of Low-Grade Arteriovenous Malformations
Authors: Graffeo Christopher S , Link Michael J , Stafford Scott L , Garces Yolanda I , Foote Robert L , Pollock Bruce E
Published: June 2019

BACKGROUND

Surgical resection is typically cited as the optimal treatment of patients with Spetzler-Martin Grade I-II arteriovenous malformation (AVM).

OBJECTIVE

To report our experience with single-fraction stereotactic radiosurgery (SRS) for Spetzler-Martin Grade I-II AVM.

METHODS

A prospectively maintained registry was reviewed for patients with nonsyndromic Spetzler-Martin Grade I-II AVM having SRS from 1990 to 2011. Patients with <24 mo of follow-up or prior radiotherapy/SRS were excluded, resulting in a study population of 173 patients. Actuarial analysis was performed using the Kaplan-Meier method, and Cox proportional hazards modeling was performed with excellent outcomes (obliteration without new deficits) as the dependent variable.

RESULTS

Median post-SRS follow-up was 68 mo (range, 24-275). AVM obliteration was achieved in 132 (76%) after initial SRS. Eleven additional patients achieved obliteration after repeat SRS for an overall obliteration rate of 83%. The rate of obliteration was 60% at 4 yr and 78% at 8 yr. Post-SRS hemorrhage occurred in 7 patients (4%), resulting in 3 minor deficits (2%) and 1 death (<1%). Radiation-induced complications occurred in 5 patients (3%), resulting in minor deficits only. One hundred and thirty-seven patients (79%) had excellent outcomes at last follow-up.

CONCLUSION

SRS is a safe and effective treatment for patients with Spetzler-Martin Grade I-II AVM. Selection bias is likely a contributing factor to explain the superior outcomes generally noted in reported series of microsurgery for patients with low grade AVM.
Position or Preference? Explaining Parliamentary Party Group Leaders’ Role Orientations in Belgium
Authors: de Vet Benjamin
Published: June 2019

Parliamentary party group leaders (PPG leaders) are understudied but important actors in contemporary parliaments. This article examines the role orientations of PPG leaders in Belgium, using data from 66 semi-structured elite interviews. Contradictory to theoretical views on frontbench roles as institutionally determined ‘position roles’ and despite Belgian PPG leaders’ comparatively limited intra-party authority, the findings indicate role variation on two dimensions, resulting in five distinct PPG leader role types. These are explained using multi-value Qualitative Comparative Analysis (mvQCA). We find that, while some roles are indeed heavily shaped by contextual factors such as parties’ government status, size or electoral performance, others are more clearly driven by individual-level factors such as prior experience or progressive ambitions. As such, this article provides substantial insights into an underexposed aspect of legislative organisation, introduces QCA as a novel method to explain parliamentary roles and makes a theoretical case that also among frontbenchers preference-driven roles are possible.
A Patient-Based National Survey and Prospective Evaluation of Postoperative Pain Management in Spain: Prevalent but Possibly Preventable
Authors: Torres Luis M , Sánchez-del-Águila Manuel J , Salazar Rafael , Failde Inmaculada , Leal Ana , Villoria Jesús
Published: June 2019

Objective

To evaluate the national general prevalence of postoperative pain and the associated organizational/structural factors related to the provision of health care services.

Design and Setting

Observational prospective cohort study performed in 46 tertiary hospitals that were randomly selected from the Spanish National Inventory of Hospitals through a two-stage balanced and stratified procedure.

Subjects and Methods

Nine-hundred surgical patients representing a wide spectrum of surgical procedures and anesthetic methods were recruited. Those suffering moderate or worse pain while in the postanesthesia care unit/surgery ward (PACU/SW) were followed for 72 hours. Site characteristics were also surveyed. Multilevel models were used to evaluate center- and patient-level factors associated with pain and quality of recovery (QoR). Weighted generalized estimating equations were used to analyze the evolution of pain intensity.

Results

The prevalence while in and at discharge from the PACU/SW was 48.7% (cluster-adjusted 95% confidence interval [CI] = 38.1–59.2%) and 21.6% (95% CI = 15.4–27.8%), respectively. Pain intensity decreased significantly over time. Less than 20% of the patients received systemic patient-controlled analgesia (PCA) or regional analgesic techniques. Age, preexisting pain, type of surgery, use of general anesthesia, and postoperative potent opioids were associated with pain risk and intensity, as were center-level factors such as patient information, protocol availability, and coordination of care. In turn, QoR was related to pain intensity and patient satisfaction with analgesia and side effects.

Conclusions

Compared with previous reports, the prevalence of moderate/severe postoperative pain has decreased but remains excessive. Organizational improvements to deploy procedure-specific, opioid-sparing analgesic strategies including regional techniques are recommended.
British Creoles: Nationhood, Identity, and Romantic Geopolitics in Robert Southey’s History of Brazil
Authors: Fermanis Porscha
Published: June 2019

This essay considers the nationalist preoccupations underpinning Robert Southey’s three-volume History of Brazil (1810–1819), maintaining that there are important links between his historiographical practices and his rethinking of British imperialism in relation to the challenges raised by the Peninsular War and Napoleonic France. It argues that Southey’s rejection of many of the discourses associated with European encodings of the imperial frontier—such as climatic determinism, sentimental and stirring descriptions, and conquest narratives—forms part of the emergence of a new legitimatory style of British national historiography. While Southey deflates sublime or heroic tales of discovery and conquest, he nonetheless naturalizes the European experience in Brazil via a latent Anglocentric subtext, simultaneously co-opting the hegemonic tendencies of Spanish/Portuguese imperialism, and representing Britain as a benign colonial power divorced from the violence and cruelty associated with those regimes. As Southey’s Brazilians progress towards independence from Portugal, they are invested with more refined moral sensibilities and peculiarly ‘British’ national qualities, making their drift towards emancipation a vindication of a superior British colonial culture. Southey thus uses Brazil as a complex geopolitical space with which to examine a number of his most pressing national concerns, including his fears regarding French imperialism, his residual support for anti-slavery and emancipatory movements, his faith in British expansionism and missionary interventionism, his understanding of the British national character, and his endorsement of new models of ethnic and civic nationalism pioneered in South America.
Pediatric Proximal Radial Shaft Fractures Treated Nonoperatively Fail to Maintain Acceptable Reduction up to 70% of the Time
Authors: Wacker Elizabeth M. , Denning Jaime R. , Mehlman Charles T.
Published: June 2019

Objective:

To compare early radiographic malalignment rates of conservatively treated proximal radial shaft fractures to more distal fractures.

Design:

Retrospective cohort study.

Setting:

A pediatric, Level 1 trauma center.

Patients/Participants:

We identified a group of 401 pediatric patients who were treated for a complete radial shaft fracture at our institution. Of this group, 309 patients met our inclusion criteria for attempted nonoperative management and were evaluated in our study.

Intervention:

Closed reduction and casting.

Main Outcome Measurement:

The primary outcome of the study was the failure rate of nonoperative management as defined by residual angulation of the radius assessed on follow-up radiographs.

Results:

Proximal third fractures were significantly more likely to fail conservative treatment (P < 0.0001) as they exceeded angulation criteria 70% (32/46) of the time compared with more distal fractures (33%; 87/263). In terms of halves (P = 0.0003), the proximal half fractures failed 50% (55/111) of the time while 29% (57/198) of distal half fractures failed conservative treatment. Failure of closed reduction and casting was 4.6 times higher (95% confidence interval, 2.3–9.1) in proximal third fractures and 2.4 times greater (95% confidence interval, 1.5–3.9) in proximal half fractures compared with their more distal counterparts.

Conclusions:

Given the impressive rate of failure of closed reduction and casting of proximal third radial shaft fractures, the treating orthopaedic surgeon should prudently consider all management options.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
The Size of Intramedullary Fixation Affects Endochondral-Mediated Angiogenesis During Fracture Repair
Authors: Yuasa Masato , Saito Masanori , Blum Deke M. , Hysong Alexander A. , Egawa Satoru , Uppuganti Sasidhar , Yoshii Toshitaka , Okawa Atsushi , Schwartz Herbert S. , Moore-Lotridge Stephanie N. , Nyman Jeffry S. , Schoenecker Jonathan G.
Published: June 2019

Objectives:

To explore the effect of intramedullary pin size on the biology of a healing fracture, specifically endochondral angiogenesis. We hypothesized that fracture fixation with a smaller pin would permit greater interfragmentary strain resulting in increased total amount of vascular endothelial growth factor within the callus and greater angiogenesis compared to fixation with a larger pin.

Methods:

Transverse mid-shaft femur fractures in 8-week-old mice were fixed with either a 23-gauge (G) or 30-G pin. Differences in interfragmentary strain at the fracture site were estimated between cohorts. A combination of histology, gene expression, serial radiography, and microcomputed tomography with and without vascular contrast agent were used to assess fracture healing and vascularity for each cohort.

Results:

Larger soft-tissue callus formation increased vascular endothelial growth factor—A expression, and a corresponding increase in vascular volume was observed in the higher strain, 30-G cohort. Radiographic analysis demonstrated earlier hard callus formation with greater initial interfragmentary strain, similar rates of union between pin size cohorts, yet delayed callus remodeling in mice with the larger pin size.

Conclusions:

These findings suggest that the stability conferred by an intramedullary nail influences endochondral angiogenesis at the fracture.
Evaluation of General and Musculoskeletal Health Literacy Disparities in Pediatric Sports Injury Patient and Guardian Populations
Authors: Su Lisa , Shaw Kylie , Serpa Rebecka O. , Grotts Jonathan , Bowen Richard , Beck Jennifer
Published: June 2019

Background:

Increased participation of adolescents in organized sports has led to an increase in pediatric sports injury. Limited health literacy puts patients at risk for worse outcomes through decreased compliance. We aim to evaluate the extent of health literacy disparities in pediatric sports medicine populations.

Methods:

Patients aged 10 to 17 years and their consenting guardians visiting clinic for treatment of a sports-related injury completed a unique questionnaire including self-reported health literacy measures and direct assessment of knowledge regarding care for musculoskeletal injuries. Statistical analysis based on socioeconomic factors and demographics was performed using t tests.

Results:

A total of 268 patient surveys (14.37±1.94 y) and 251 guardian surveys (43.62±9.08 y) were collected. In self-reported general health literacy scores for guardians, all categories except ethnicity played a statistically significant role, with higher health literacy scores associated with higher education, use of English as the primary language at home, private insurance, and female guardians (P<0.001, <0.001, <0.001, 0.011). In contrast, age was the only factor affecting scores in the patient population (P=0.015). Among self-reported musculoskeletal health literacy and directly measured musculoskeletal literacy scores, there were significant differences in groups by age, primary language, and level of education (P=0.020, 0.003).

Conclusions:

Significant disparities in general and musculoskeletal health literacy exist within pediatric sports medicine populations, most notably between guardian groups. Improving disparities in health literacy for these populations may best be aimed at guardians, using medical education through verbal/written instruction in multiple languages.

Level of Evidence:

Level IV.
The Flatfoot in Collapse Needs Stability and That is Why I Fuse It
Authors: Sposeto Rafael B. , Sakaki Marcos H. , Fernandes Tulio D. , Godoy-Santos Alexandre L.
Published: June 2019

The pathophysiology and treatment of the adult-acquired flatfoot is still quite controversial. Soft tissue reconstruction and tendon transfer surgery combined with corrective osteotomy for flexible deformities are well established in the literature. However, patients with signs of hindfoot osteoarthritis, rheumatological or neurological diseases, and obesity can benefit from surgical correction with arthrodesis because of greater outcome predictability. Various types of arthrodesis, including isolated, triple, double, or segmental procedures, have been described to treat this deformity. We will discuss the events leading to the progressive collapse of the medial arch and distinguish between patients who could benefit from reconstruction with arthrodesis from those who cannot, as well as the indications for these technical options.

Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.
Prenatal Diethylstilbestrol Exposure and Risk of Depression in Women and Men
Authors: Titus Linda , Hatch Elizabeth E. , Palmer Julie R. , Huo Dezheng , Strohsnitter William C. , Adam Ervin , Ricker Winnie , Hyer Marianne , Hoover Robert N. , Troisi Rebecca
Published: June 2019

Background:

Prenatal exposure to diethylstilbestrol (DES), an endocrine-disrupting chemical, may be associated with depression in adulthood, but previous findings are inconsistent.

Methods:

Women (3,888 DES exposed and 1,729 unexposed) and men (1,021 DES exposed and 1,042 unexposed) participating in the National Cancer Institute (NCI) DES Combined Cohort Follow-up Study were queried in 2011 for any history of depression diagnosis or treatment. Hazard ratios (HRs; 95% confidence intervals [CIs]) estimated the associations between prenatal DES exposure and depression risk.

Results:

Depression was reported by 993 (26%) exposed and 405 (23%) unexposed women, and 177 (17%) exposed and 181 (17%) unexposed men. Compared with the unexposed, HRs for DES and depression were 1.1 (95% CI = 0.9, 1.2) in women and 1.0 (95% CI = 0.8, 1.2) in men. For medication-treated depression, the HRs (CIs) were 1.1 (0.9, 1.2) in women and 0.9 (0.7, 1.2) in men. In women, the HR (CI) for exposure to a low cumulative DES dose was 1.2 (1.0, 1.4), and for DES exposure before 8 weeks’ gestation was 1.2 (1.0, 1.4). In men, the HR for low dose was 1.2 (95% CI = 0.9, 1.6) and there was no association with timing. In women, associations were uninfluenced by the presence of DES-related vaginal epithelial changes or a prior diagnosis of DES-related adverse outcomes.

Conclusions:

Prenatal DES exposure was not associated overall with risk of depression in women or men. In women, exposure in early gestation or to a low cumulative dose may be weakly associated with an increased depression risk.
Revisiting redundancy in hospitals—A case-based research study
Authors: Tay Huay Ling , Singh Prakash J.
Published: June 2019

Background

Redundancy is mostly conceived as “waste” resulting from inefficient operations that ought to be eliminated. However, there are scholars who challenge this view and argue that redundancy is an essential element in facilitating reliable and safe operations in health care delivery processes. The ambiguity on redundancy has led to limited insights in health care settings.

Purpose

This article seeks to provide clarity by investigating the conceptualization of redundancy within and across disparate contexts within hospital operations.

Design/Methodology/Approach

An exploratory study using different hospital departments was conducted in two large hospitals as case studies to allow for in-depth understanding of the conceptualization of redundancy across hospital departments. Data sources included 42 semistructured interviews, surveys, field notes from site observations, and document analysis.

Results/Findings

The findings revealed alternative conceptualizations of redundancy, these being safety, care, heterogeneity, sustenance, and waste, and highlight their dominance in distinct hospital departments. The first four categories are positive in connotation, whereas the last, waste, has a negative connotation. Further, the analysis revealed that the conceptualization of redundancy is context dependent.

Conclusion

Contrary to the general cognition of redundancy in the social science and management literature, our research found that redundancy might have a valuable role to play in core health care management concerns such as patient-centeredness, patient safety, and quality of care. This work is one of the first comprehensive studies on redundancy in the health care settings and is expected to steer scholarly conversations on redundancy in a more positive light.

Practical Implications

Overall, this article serves as a call to health care operations decision makers and chiefs of hospitals to reexamine their current approach and management practices on redundancy.
Ophthalmic Manifestation of Tsukamurella Species: A Case Series and First Report of Ocular Implant Infection After Enucleation
Authors: Leung Kai Ching Peter , Au Sunny Chi Lik , Ko Tak Chuen Simon
Published: June 2019

Purpose:

Tsukamurella is an important and emerging organism that causes opportunistic human infection. We present the largest case series of Tsukamurella species-associated ophthalmic infections, with an emphasis on clinical spectrum, risk factors, treatment, and outcome.

Methods:

A case series of culture-positive Tsukamurella species in ocular microbiological specimens was identified retrospectively from 2005 to 2018. Tsukamurella species were identified by phenotypic, molecular, and genotypic methods. Diagnoses were clinical and were supplemented by microbiological findings. Treatment including antibiotic type, number of antibiotics, treatment duration, and clinical outcome was documented.

Results:

Eleven cases of culture-positive Tsukamurella ocular infection were identified. Of these 54.5% (6/11) of cases resulted in conjunctivitis, 18% (2/11) of cases resulted in keratitis, and 9% (1/11) of cases resulted in blepharitis. One case of canaliculitis and 1 case of postenucleation ocular implant-related infection were reported, which were both novel findings. The presence of ocular implant and preexisting ocular surface diseases such as exposure keratopathy and ectropion were thought to be predisposing factors. We have demonstrated that treatment of Tsukamurella ocular conjunctivitis, keratitis, and blepharitis was effective using a combination therapy of 2 antibiotics (fluoroquinolone, fusidic acid, or chloramphenicol). Canaliculitis and ocular implant infection required further addition of oral antibiotics (macrolide or doxycycline), canaliculotomy, and removal of the infected implant for satisfactory management.

Conclusions:

Tsukamurella tyrosinosolvens and Tsukamurella pulmonis were found to be the predominant species that caused ocular infection. Ocular manifestation of Tsukamurella has a wider spectrum than that previously reported. A high-level of suspicion and a low threshold for microbiological sampling in cases with prolonged ocular surface infection are recommended to diagnose Tsukamurella infections.
Incidence of Vicarious Trauma in Correctional Health and Forensic Mental Health Staff in New South Wales, Australia
Authors: Newman Claire , Eason Michelle , Kinghorn Grant
Published: June 2019

Background:

Correctional health and forensic mental health (FMH) staff may experience vicarious trauma (VT) as a result of cumulative and repeated exposure to traumatic material in their professional roles.

Aim:

This study aimed to determine the incidence of VT in a sample of correctional health and FMH staff.

Methods:

A cross-sectional survey including 135 correctional health and FMH staff participating in a VT management program was conducted. Survey respondents completed the Vicarious Trauma Scale and Impacts of Events Scale-Revised.

Findings:

Most respondents had moderate or high VT (n = 78, 57.8%, and n = 40, 29.6%, respectively). Low psychological distress was reported, with posttraumatic stress disorder symptoms being experienced either mildly or not at all by most respondents. A significant relationship between total Vicarious Trauma Scale score and total Impacts of Events Scale-Revised score (r = 0.471, p = 0.000) was found, indicating that a higher level of VT was associated with an increased risk of posttraumatic stress disorder symptoms. A higher level of VT was also associated with increased reports of avoidance, intrusion, and hyperarousal (r = 0.382, p = 0.000; r = 0.489, p = 0.000; and r = 0.440, p = 0.000, respectively).

Conclusion:

Correctional health and FMH staff are at risk of developing VT and associated psychological distress.

Implications for Clinical FMH Nursing Practice:

Correctional health and FMH organizations have the responsibility to ensure nurses are aware of the effects of VT and to provide opportunities for nurses to participate in VT education and management programs.
There might be a distinctive clinical phenotype of constipation with non-cardiac chest pain which responds to combination laxatives
Authors: Park Jae Yong , Oh Sooyeon , Han Yoo Min , Lee Jooyoung , Kim Joo Sung , Jung Hyun Chae , Hong Kyoung Sup
Published: June 2019

Proton pump inhibitor (PPI)-refractory non-cardiac chest pain (NCCP) is often resolved when constipation was relieved. This study aimed to investigate the clinical features of patients with both NCCP and constipated functional bowel disorders (FBD).

Among 692 consecutive patients diagnosed with functional constipation or irritable bowel syndrome with constipation and underwent anorectal manometry (ARM) in our hospital, PPI-refractory NCCP was present in 37. The clinical course of various torso symptoms including NCCP and ARM findings were retrospectively evaluated.

The mean age was lower in the NCCP than in the non-NCCP group (57.4 vs 61.3 years, respectively,P = .042). Back pain (16.2% vs 2.0%,P < .001) and sharp abdominal pain (13.5% vs 0.9%,P < .001) were more common in the NCCP group. Increased resting pressure (16.2% vs 6.9%,P = .036) and squeezing pressure (62.2% vs 50.7%,P = .049) of the anal sphincter, increased urgency volume (40.5% vs 23.2%,P = .004), and maximal volume (25.7% vs 15.0%,P = .032) for rectal sensation were more frequently observed in the NCCP group. After taking laxatives for 1 to 3 months, 81.1% of patients with NCCP reported improvement.

Subjects with NCCP showed decreased rectal sensation more frequently at anorectal manometry. Majority of patients with NCCP reported improvement of symptom upon relief of constipation. Constipation might be a therapeutic target in patients with NCCP related to constipated functional bowel disorders.
Acute onset neurological symptoms in Wilson disease after traumatic, surgical or emotional events
Authors: Li Liang-Yong , Zhu Xiao-Qun , Tao Wei-Wei , Yang Wen-Ming , Chen Huai-Zhen , Wang Yu
Published: June 2019

Acute onset neurological symptoms evoked by traumatic, surgical, or emotional events in Wilson disease (WD) have never been reported and its clinical characteristics are unclear.

We aimed to summarize the clinical characteristics of a special WD whose neurological symptoms acutely developed after traumatic, surgical, or emotional events.

Retrospective pilot study.

Thirty-one patients who had acute onset neurological symptom as an initial presentation of WD or a new presentation of hepatic WD after mild trauma, surgery, or emotional events were retrospectively studied. All patients were followed for half to 1 year after regular anti-copper treatment.

The averaged latency for neurological symptom presentation was 2.79 ± 1.21 hours. The most frequent neurological symptoms were tremor (74%) and basal ganglia (BG) lesions were detected on magnetic resonance imaging in all patients. Lesions in other regions were much less frequently detected. Neurological symptom score and its recovery after treatment were correlated with lesion location: BG area and BG plus other brain areas. Neurological symptoms improved in 21 patients who received timely anti-copper treatment but continued to deteriorate in 6 patients who did not accept regular anti-copper treatment for delayed diagnosis.

A diagnosis of WD should be considered when adolescents or adults experience acute presentation of extrapyramidal systems after traumatic, surgical, or emotional stimulation. Timely anti-copper therapy usually gives rise to an excellent prognosis.
Correlation of fatigue with other disease related and psychosocial factors in patients with rheumatoid arthritis treated with tocilizumab
Authors: Corominas Héctor , Alegre Cayetano , Narváez Javier , Fernández-Cid Carlos Marras , Torrente-Segarra Vicenç , Gómez Manuel Rodríguez , Pan Francisco Maceiras , Morlà Rosa María , Martínez Fernando José Rodríguez , Gómez-Centeno Antoni , Ares Laura Losada , Molina Rocío González , González-Albo Silvia Paredes , Dalmau-Carolà Joan , Pérez-García Carolina , Álvarez Ceferino Barbazán , Ercole Liliana , Terrancle Maria Ángeles
Published: June 2019

To assess the hypothesis if tocilizumab (TCZ) is effective on disease activity, and also its effect in fatigue and other clinical and psychological disease-related factors in patients with rheumatoid arthritis (RA) treated with TCZ.

A 24-week, multicenter, prospective, observational study in patients with moderate to severe RA receiving TCZ after failure or intolerance to disease-modifying antirheumatic drugs or tumor necrosis factor-alpha was conducted.

Of the 122 patients included, 85 were evaluable for effectiveness (85% female, 51.9 ± 12.5 years, disease duration 8.7 ± 7.4 years). Mean change in C-reactive protein level from baseline to week 12 was −11.2 ± 4.0 (P < .001). Mean Disease Activity Index score (DAS28) decreased from 5.5 ± 1.0 at baseline to 2.7 ± 1.3 (P < .001) at week 24. Mean change in Functional Assessment of Chronic Illness Therapy score was −5.4 ± 11.2 points at week 24. Multiple regression analysis showed that the improvement in DAS28, sleep, and depression explained 56% and 47% of fatigue variance at week 12 and 24, respectively.

Tocilizumab is effective in reducing disease activity and results in a clinically significant improvement in fatigue, pain, swollen joint count, morning stiffness, sleepiness, depression, and DAS28; the last 3 were specifically identified as factors explaining fatigue variance with the use of TCZ in RA patients.