Osteomyelitis in infants and children

Infection of the pediatric skeletal system is a dramatic diagnostic and therapeutic challenge. The consequences of a missed diagnosis could lead to long-lasting functional sequelae. This disease has multiple aspects according to the clinical presentation and evolution, the causative microorganism, the site of infection, and, finally, the patient's age and immunological status. The choice of the most appropriate imaging modality according to the clinical presentation is very important to assess the diagnosis, the extent of the disease, and to obtain the causative germ when needed; thus, plain films, ultrasound, nuclear medicine, computed tomography, and MR imaging are discussed, each of them having pros and cons. This multimodality approach of the musculoskeletal infections is mandatory to guide surgery, to deliver an appropriate antibiotic therapy, and to reduce the rate of long-term functional sequelae.     

Ultrasonography of the tendons: from image to pathology

Radiology allows to define etiologies of tendon injuries and authorize a most suitable treatment. For that reason, the use of the sonography has been developed from several years and has four main purposes to define the type of injury and to orient the treatment: to confirm the real existence of the tendon tear, to need the exact location the same one, to determine the gravity of the lesion, and finally, to evaluate its acute or chronic character. In this paper, we will try to define the normal pattern of the tendon and describe the more frequent lesions of the shoulder or the ankle: complete or partial tear, tendinopathy, dislocation and enthesopathy.     

Apnoeic heart rate responses in humans. A review

Research examining the heart rate response of humans to apnoea and apnoeic immersion in water has tended to produce equivocal results. Controversy exists in relation to the existence and onset, course and ultimate extent of apnoeic bradycardia, either at rest or during exercise. The reduction in heart rate that has been observed in response to apnoea and apnoeic immersion is considered by some to be a component of an oxygen conserving mechanism termed the mammalian dive reflex. Doubt has been expressed, however, as to whether humans do possess the complex cardiovascular response evident in diving mammals. A bradycardial response to apnoea at rest is reasonably well established. Reports conflict with regard to apnoeic responses to exercise in both terrestrial and aquatic environments, and for the temporal onset of apnoeic bradycardia in general, and the time course required for the maximal development of the response. It is suggested that the existing discrepancies with regard to heart rate responses to apnoea are due in part to the large variety of research protocols employed, with, in many cases, a lack of control of those factors said to modify apnoeic heart rates, and in part to a lack of uniformity in the interpretation of the obtained results. Conflicting evidence exists for almost all of the factors said to modify the apnoeic heart rate response in humans. Factors implicated in the phenomenon of apnoeic bradycardia include the influence of temperature and the physical condition of the individual, varying lung volumes, the depth of immersion in water, the body position during the apnoeic episode, and the psychological state of the individual. The influence of the sex and age of the subjects is equally contentious. Finally, the role of breath-holding capacity as it influences the extent of bradycardia remains to be examined further. Additional research requires the adoption of an integrative, holistic approach if a comprehensive understanding of apnoeic heart rate responses is to be achieved.     

The future quality and safety of medical imaging: proceedings of the third annual ACR FORUM

The ACR annually engages in a long-range planning activity called the FORUM on a specific issue deemed important to the specialty of radiology over a horizon of 5 to 10 years. The FORUM brings together experts from multiple disciplines to discuss the topic, develop scenarios, and make recommendations to the ACR and the specialty on what courses to take to improve the development of radiology. The Third Annual FORUM, held May 21 to 23, 2003, was on the subject of improving quality and safety. The sessions ended with numerous recommendations as to how the specialty of radiology could promote safer, higher quality imaging that would also engage the interest and participation of the public, employers, insurers, and government. These fell into the following categories: (1) how to measure the performance of radiologists, (2) how to use measurements of performance to improve quality and safety, (3) means of working with employers and insurers to improve care and reduce waste, (4) the development of new ACR programs intended to foster change, and (5) disseminating information about ACR efforts on behalf of improving quality and safety.     

Neuroendocrine-immune interactions and responses to exercise

This article reviews the interaction between the neuroendocrine and immune systems in response to exercise stress, considering gender differences. The body's response to exercise stress is a system-wide effort coordinated by the integration between the immune and the neuroendocrine systems. Although considered distinct systems, increasing evidence supports the close communication between them. Like any stressor, the body's response to exercise triggers a systematic series of neuroendocrine and immune events directed at bringing the system back to a state of homeostasis. Physical exercise presents a unique physiological stress where the neuroendocrine and immune systems contribute to accommodating the increase in physiological demands. These systems of the body also adapt to chronic overload, or exercise training. Such adaptations alleviate the magnitude of subsequent stress or minimize the exercise challenge to within homeostatic limits. This adaptive capacity of collaborating systems resembles the acquired, or adaptive, branch of the immune system, characterized by the memory capacity of the cells involved. Specific to the adaptive immune response, once a specific antigen is encountered, memory cells, or lymphocytes, mount a response that reduces the magnitude of the immune response to subsequent encounters of the same stress. In each case, the endocrine response to physical exercise and the adaptive branch of the immune system share the ability to adapt to a stressful encounter. Moreover, each of these systemic responses to stress is influenced by gender. In both the neuroendocrine responses to exercise and the adaptive (B lymphocyte) immune response, gender differences have been attributed to the 'protective' effects of estrogens. Thus, this review will create a paradigm to explain the neuroendocrine communication with leukocytes during exercise by reviewing (i) endocrine and immune interactions; (ii) endocrine and immune systems response to physiological stress; and (iii) gender differences (and the role of estrogen) in both endocrine response to physiological stress and adaptive immune response.     

Patient's rights in Poland against the background of new regulations

Patient rights are the specification of general human rights. The rights define the patient position in relation to health institutions or medical professions providing, broadly understood, health services. The protection system of patient rights outlined by international legal and ethical regulations is detailed to specific social, political and economic realities by internal legal systems of individual states. Imperfections of the Polish health care system in relation to achieving adequate protection of patient rights, resulting, inter alia, from the lack of comprehensive regulation of the matter of patient rights, led the legislature to introduce new regulations concerning this aspect to the Polish legal order. The new Act of 6 November 2008 on Patient Rights and the Patient Rights Ombudsman (binding from 5 March 2009) is the first universally binding legal act in the Polish legal system entirely dealing with the matter of patient rights. It regulates the rights of the patient and correlated with them obligations of health care providers (public and non-public) irrespectively of both the legal form providers, as well as the sources of funding of the benefits provided. In particular, the Act states: the patient right to health services, right to obtain information, right to confidentiality of patient-linked information, right to consent to obtain health services, right to respect privacy and dignity of the patients, right to medical records and objecting to the doctor's opinion or decision, right to respect private and family life, right to pastoral care. The new regulations--besides the specification of the catalogue of patient rights--reinforced the institutional protection of patient rights by establishing a new central public administrative body having jurisdiction to protect patient rights--the Patient Rights Ombudsman. Poland, like other European countries, makes an attempt to improve the protection of patient rights. The introduction of the Act entirely devoted to patient rights is undoubtedly an important step towards creating the optimum protection of the patient.     

Interpretation and reporting of myocardial perfusion SPECT: a summary for technologists

Interpretation of cardiac perfusion SPECT images, and the subsequent reporting of results to referring physicians, are sometimes taken to be outside the sphere of the nuclear medicine technologist. However, all personnel involved with nuclear medicine procedures contribute to the timeliness and usefulness of the final report. The goal of this article is to review the principles of scan interpretation and reporting, from the standpoint of what technologists need to understand about these processes. In addition, software tools to aid these processes will be discussed, including quantitative image analysis, telemedicine, computer-aided scan interpretation, databases, computer-aided reporting, and Internet-based reporting. Finally, the accuracy of the scan report will be related to the tasks normally performed by technologists, such as the acquisition and processing of images and the entry, transfer, and networking of data. After reading this article, the reader will be able to describe the principles of scan interpretation and reporting, the software tools for telemedicine and computer-aided interpretation, and the role of the technologist in this process.     

1.5 T MR in the diagnosis of parotid masses: comparison with ultrasonography

Twenty-two patients who presented with laterocervical retromandibular enlargement were examined with both US and MR imaging to assess the intrinsic/extrinsic relationship of the mass to the parotid gland, the involvement of the facial nerve and adjacent structures, as well as the nature of the mass. Both US and MR imaging proved to be poorly specific in the characterization of the inflammatory lesions. Within the mass, both methods revealed high sensitivity (100%) in identifying the lesions, even very small ones. MR imaging allowed the lesion to be accurately located, the facial nerve to be identified, and its possible infiltration to be evaluated, with higher reliability than US, thanks to its higher contrast resolution and to its multiplanarity. Neither US nor MR imaging allowed the benign/malignant nature of the lesion to be assessed. On the basis of their experience, the authors suggest the use of T2-weighted MR sequences, with long TR and TE, to differentiate pleomorphic adenomas from other histotypes, after US assessment of the solid nature of parotid masses.     

How to evaluate the quality of health related websites

To establish reliable quality criteria for medical websites is of foremost importance in relation to the increasing number of Internet users, both health professionals and lay people, searching for medical information in the mass of these sites. Quality in general refers to a set of features that distinguish one person or thing from others of the same type. The quality of a website is usually related to its content and usability. The first criteria we considered are contents and readability, which must be targeted to the intended type of user. Other important criteria include: transparency, consistency, honesty, references to sources, accountability, respect of privacy, currency of content material, responsibility, and accessibility. Technical criteria are the use of consolidated and standard technologies, soft colours, short page download time. Good medical websites should also follow the suggestions of organizations such as the World Health Organization, the Food and Drug Administration, the European Communities. Another organization, Health On Net Foundation, has issued some guidelines for medical websites, summarized in eight points, fundamental to assign real scientific value to a site. We believe, in agreement with the literature, that it is unnecessary to apply strict rules to medical website developers. We want to stress the importance of guidelines and recommendations to be modified with the development of web technology and the cultural evolution of patient and physicians. In the near future the presence on the Internet of websites certified by national or international medical web authorities will lead users to trust and give their preference to such sites, leading to the self-regulation of website developers and users.     

Forensic data exchange: ensuring integrity

A growing chorus of forensic professionals believe that forensic science has undersold its potential contribution to crime reduction and has a more significant role to play in policing, with collation and analysis of forensic information used to inform policing tactics, operations or strategy. Domestic law enforcement agencies, as producers, consumers and purveyors of forensic information and intelligence, are also responding to political pressures to expand and accelerate their technological abilities to gather and disseminate forensic information and intelligence within expanding operational boundaries. For example, there are a number of agreements that promise the automated exchange of forensic data internationally, in particular fingerprints and DNA profiles, and many that share other law enforcement information via a variety of channels. However, there is yet to be any detailed consideration of the multifaceted issues raised by the production of forensic intelligence, and the impact of direct access and/or exchanges of forensic intelligence. While technologies are increasingly interoperable, traditional parameters restraining law enforcement information sharing are increasingly inadequate. The lack of oversight of the transnational flows of law enforcement information mean that current processes lack transparency and, consequently, citizens’ ability to know of, understand, and challenge exchanges of their data is almost non-existent. Yet the expectation is that the power to generate, gather, store and share forensic intelligence will be used with integrity. Integrity is essential for generalised trust among not just the direct consumers of forensic intelligence, but also the public. For the integrity of forensic intelligence to be maintained, critical attention must be paid not only to the viability of forensic intelligence production and sharing, but also to its legitimacy and acceptability.     

Osteomyelitis in infants and children

Infection of the pediatric skeletal system is a dramatic diagnostic and therapeutic challenge. The consequences of a missed diagnosis could lead to long-lasting functional sequelae. This disease has multiple aspects according to the clinical presentation and evolution, the causative microorganism, the site of infection, and, finally, the patient's age and immunological status. The choice of the most appropriate imaging modality according to the clinical presentation is very important to assess the diagnosis, the extent of the disease, and to obtain the causative germ when needed; thus, plain films, ultrasound, nuclear medicine, computed tomography, and MR imaging are discussed, each of them having pros and cons. This multimodality approach of the musculoskeletal infections is mandatory to guide surgery, to deliver an appropriate antibiotic therapy, and to reduce the rate of long-term functional sequelae.     

Analysis of radiation scatter during angiographic procedures: evaluation of a phantom model and a modified radiation protection system

PURPOSE: To study the radiation scattering associated with the digital subtraction angiography (DSA) unit in angiographic procedures and to design an effective radiation protection shield based on these data. MATERIALS AND METHODS: The number of scattered photons was measured at three points relative to the operator's position. Anteroposterior abdominal and lateral cranial fluoroscopy were evaluated. As protective devices, a lead curtain, sliding shields, and a brim-shaped image intensifier (II) hood were designed. RESULTS: In abdominal fluoroscopy, radiation was found to scatter to the operator's lower limbs from the underside of the catheter table, to the abdomen from the side of the patient's body, and to the head and neck from the table surface adjacent to the patient. The use of protective devices reduced exposure from 2.89 to 0.058 mR/min for the operator's lower limbs, from 0.987 to 0.069 mR/min for the operator's abdomen, and from 0.696 to 0.139 mR/ min for the operator's head and neck area. With lateral cranial fluoroscopy, radiation was detected to scatter to the operator's lower limbs from the underside of the catheter table, to the abdomen from the patient's temporal area, and to the head and neck from the patient's face. The use of protective devices reduced exposure from 0.248 to 0.010 mR/min for the operator's lower limbs, from 0.129 to 0.010 mR/min for the operator's abdomen, and from 0.162 to 0.018 mR/min for the operator's head and neck area. CONCLUSIONS: The characteristic directions of scattering to the operator were identified. An effective modified radiation protection system was designed based on this information.     

掌指骨的X线测量及相互间数学比例关系的临床应用研究

目的　对掌、指骨进行X线测量 ,为临床诊断及手外科提供可靠的解剖学数据和资料 ,同时提供掌骨长、指骨长之间的数学比例关系式 ,对手外科掌指骨长度的确定和假体的设计提供参考依据。方法　随机选择健康汉族大学生 186人 (男 90人 ,女 96人 ) ,进行双手后前位X线拍片 ,分别测量各掌骨与指骨长 ,将所得数据应用SPSS软件进行统计学分析。结果　得出各掌骨长、各节指骨长的比例关系 ,其中一 /二、二 /四、二 /五、三 /四掌骨长比值 ,拇指 /示指、拇指 /环指、示指 /小指近节指骨长比 ,示指 /小指、中指 /小指、环指 /小指中节指骨长比 ,拇指 /示指、拇指 /中指远节指骨长比值性别差异均有显著性意义。结论　以上比例关系式在手矫形外科中对各种原因引起的手骨缺陷进行理想的掌长及指长选择 ,从而为假体设计提供帮助     

Characteristics of domestic violence incidents reported at the scene by volunteer victim advocates

At a single U.S. Army installation from 1997 to 2005, domestic violence volunteer victim advocates assisted 1,417 clients in 1,380 physical and 301 verbal abuse incidents. The average soldier and spouse population during this time was slightly less than 10,000. Advocates went to the scene of the incident to talk to the victim to ensure that her/his rights were observed, to determine whether the victim was safe, was referred to the hospital social work service for assessment, and had the information necessary to negotiate the complex military and community systems. The advocate inquired of the victim the characteristics of the incident and risk factors in the history of the relationship. In many incidents, risk factors indicated a history of serious violence by the offender including an increasing level of violence, stalking, and assaults. Frequently reported precipitants of incidents were relationship problems, jealously, and infidelity. Spouses often reported previous attempts to leave and to get help. Advocates play an important role in gathering information uniquely available at the scene that can be useful in planning education and intervention programs to reduce domestic violence in the Army, the military services, and civilian society.     

Hamstring injuries. Proposed aetiological factors, prevention, and treatment

Injuries to the hamstring muscles can be devastating to the athlete because these injuries frequently heal slowly and have a tendency to recur. It is thought that many of the recurrent injuries to the hamstring musculotendinous unit are the result of inadequate rehabilitation following the initial injury. The severity of hamstring injuries is usually of first or second degree, but occasionally third-degree injuries (complete rupture of the musculotendinous unit) do occur. Most hamstring strain injuries occur while running or sprinting. Several aetiological factors have been proposed as being related to injury of the hamstring musculotendinous unit. They include: poor flexibility, inadequate muscle strength and/or endurance, dyssynergic muscle contraction during running, insufficient warm-up and stretching prior to exercise, awkward running style, and a return to activity before complete rehabilitation following injury. Treatment for hamstring injuries includes rest and immobilisation immediately following injury and then a gradually increasing programme of mobilisation, strengthening, and activity. Permission to return to athletic competition should be withheld until full rehabilitation has been achieved (complete return of muscle strength, endurance, and flexibility in addition to a return of co-ordination and athletic agility). Failure to achieve full rehabilitation will only predispose the athlete to recurrent injury. The best treatment for hamstring injuries is prevention, which should include training to maintain and/or improve strength, flexibility, endurance, co-ordination, and agility.     

创伤中心评审及指标体系

国家卫生计生委、国家中医药管理局2017年2月颁发通知要求创新急诊急救服务,为抢救患者生命赢得时间。台湾医院创伤急救评审重点关注完善组织与处置流程、良好的处置质量和具备实时处置能力,且强调创伤中心需有足够的"治疗伤员的总数量",区分创伤中心紧急医疗能力为"重度级、中度级、一般级",评审指标包括人力设施、作业能量、能提供的紧急医疗种类与相关紧急医疗处理能力。本文简述了台湾医院紧急医疗能力评审的历史与不足,希望有助于指导规范化建设创伤中心,进一步提高创伤救治质量。     

Developments in judicial approaches to sexual and reproductive health

This article reviews the jurisprudence on reproductive and sexual health of national and international tribunals. This review reveals a shift from controlling reproduction and sexuality through the use of criminal law to impose a moral order, to the use of administrative law to ensure availability of safe and effective services, and, finally, to the use of human rights to promote respect for human dignity. The conventional use of criminal law to prohibit provision of reproductive and sexual health services, underage sex, and relations between same-sex partners is waning. Due in part to research showing how criminal law harms reproductive health, an emerging judicial trend is toward the more pragmatic use of law to reduce the harm to health associated with sexuality and reproduction. Most recently, courts are recognizing that respect for individuals' needs to protect their reproductive and sexual health is a matter of social justice.     

Towards beneficence for young children in research: challenges for bioethics committees

Bioethics committees are the focus of international scrutiny, particularly in relation to their application of the principle of beneficence, ensuring that risks incurred in research are outweighed by benefits to those involved directly and to the broader society. Beneficence, in turn, has become an international focus in research with young children, who hitherto had been rarely seen or heard in their own right in research. Twenty years ago, The United Nations Convention on the Rights of the Child 1989 raised global awareness of children's human rights to both participation and protection, and articulation of children's rights came to inform understandings of young children's rights in research. In the intervening period, countries such as Australia came to favour child protection and risk minimisation in research over the notion of children's bone fide participation in research. A key element of the protection regime was the theoretical understanding of young children as developmentally unable and, therefore, unfit to understand, consent to and fully participate as research participants. This understanding has been challenged in recent decades by new theoretical understandings of children's competence, where children can be seen to demonstrate competence, even at an early age, in consenting to, participating in and withdrawing from research. The paper draws on these understandings to provide insights for human research gatekeepers, such as bioethics committees, to deal with the challenges of research with young children and to realize the benefits that may accrue to children in research.     

Microbial forensics: the next forensic challenge

Pathogens and toxins can be converted to bioweapons and used to commit bioterrorism and biocrime. Because of the potential and relative ease of an attack using a bioweapon, forensic science needs to be prepared to assist in the investigation to bring perpetrators to justice and to deter future attacks. A new subfield of forensics—microbial forensics—has been created, which is focused on characterization of evidence from a bioterrorism act, biocrime, hoax, or an inadvertent release. Forensic microbiological investigations are essentially the same as any other forensic investigation regarding processing. They involve crime scene(s) investigation, chain of custody practices, evidence collection, handling and preservation, evidence shipping, analysis of evidence, interpretation of results, and court presentation. In addition to collecting and analyzing traditional forensic evidence, the forensic investigation will attempt to determine the etiology and identity of the causal agent, often in a similar fashion as in an epidemiologic investigation. However, for attribution, higher-resolution characterization is needed. The tools for attribution include genetic- and nongenetic-based assays and informatics to attempt to determine the unique source of a sample or at least eliminate some sources. In addition, chemical and physical assays may help determine the process used to prepare, store, or disseminate the bioweapon. An effective microbial forensics program will require development and/or validation of all aspects of the forensic investigative process, from sample collection to interpretation of results. Quality assurance (QA) and QC practices, comparable to those used by the forensic DNA science community, are being implemented. Lastly, partnerships with other laboratories will be requisite, because many of the necessary capabilities for analysis will not reside in the traditional forensic laboratory.