Posterosuperior glenoid impingement: Is microinstability really the problem?

Posterosuperior glenoid impingement (PSGI) is defined as mechanical impingement of the greater tuberosity onthe posterosuperior aspect of the glenoid rim during shoulder abduction, external rotation, and extension. Although this contact is present in most of the population, throwing athletes are particularly vulnerable to developing symptoms related to this impingement, predominantly from partial thickness tears of the rotator cuff. It has been suggested that subtle or “micro”-instability is the underlying source of this “internal” impingement. After examining these claims with regard to our experience and experience of others, this does not seem to be the case. Additionally, we report our preferred treatment regimen for PSGI including our technique for humeral derotational osteotomy.     

From MSc dissertations to quantitative research papers in leading journals: A practical guide

This article discusses the reasons for publishing dissertations produced for a taught MSc as quantitative research papers. Based on the authors’ personal experience and a review of the literature, insights are offered regarding why publication is important within radiography. The factors that encourage publication and the key questions that have to be addressed before writing are considered. Common pitfalls that prevent publication are tabulated. There is a discussion regarding how the potentially daunting but worthwhile task of writing should be undertaken. The principles of reducing a dissertation to a quantitative paper suitable for publication are considered. It is concluded that much can be done to make the process of converting a dissertation to a quantitative paper more successful, provided that key questions are asked prior to writing. If there is a decision to proceed, a structured formulaic approach can be applied to reducing the dissertation which will be both “process” and “content” focused to a “content” focused quantitative paper.     

A primer on molecular biology for imagers IX. How to become a "molecular imager"

This is the conclusion of our series of articles entitled “A Primer on Molecular Biology for Imagers,” and hopefully this will serve as the beginning of many readers’ journey in becoming a molecular imager. There is no real barrier to achieving stage one of development, which requires only acquisition of the knowledge base and the use of this knowledge in our practice of imaging sciences and also in our everyday life. We have made much progress in building the foundation for further development of molecular imaging and we are optimistic that many of our readers will participate in the revolution of biomedicine in the genomic era.     

Value added radiology: using existing radiology services to improve cancer screening

Consumers, clinicians, and health care payers accept the clinical and economic benefits of cancer prevention/early detection and encourage their use. It is clearly evident that radiologists will remain at the forefront of innovation in screening technologies. Because nearly all Americans undergo at least one imaging test, radiologists should give strong consideration to using these existing diagnostic tests as “teachable moments” to educate and motivate their patients to increase participation in underused yet potentially life-saving interventions. The opportunities for radiologists to adopt this approach can be considered for several reasons. From a basic point of view, acceptance of the “teachable moment” concept will increase the use of evidence-based diagnostic interventions. From a more idealistic standpoint, the adoption will foster more interdisciplinary collaboration with radiologists that will likely demonstrate an important “added value” of radiographic services.     

Cost-benefit analysis, medical decision making and the individual radiologist

We have covered a lot of territory in our discussion, and a brief summation is in order. It has been our intention to convey the following major points:

1. In his role as diagnostician, the radiologist need not—indeed, should not—be influenced by consideration of costs and benefits. Instead, he should be critically concerned with reporting as accurately as possible in quantitative terms his degree of certainty about the diagnostic possibilities.

2. In his role as consultant in patient management, the radiologist must be aware of, and take into account, all relevant costs and benefits that potentially could result from his decision recommendations.

3. The basic strategy in his role as consultant is to think ahead to the possible outcomes of the alternative courses of action, and to relate the net benefits (or costs) associated with these outcomes to the diagnostic probabilities for the specific patient at hand. The problem of recommending the best decision then reduces to identifying which alternative course of action will, on the average, result in maximum net benefit to the patient.

We have deliberately avoided, wherever possible, presenting these ideas in mathematical form. We have chosen to keep our discussion on a more intuitive level for two reasons. First, it seemed unreasonable to us to expect the nonmathematically inclined reader to seriously consider conclusions derived and stated mathematically. Second, and perhaps more importantly, the results of our experiment strongly indicate that radiologists can achieve substantive improvements in their decision recommendations without using the numerical analysis explicity. All that is required is that they begin to think in terms of exploiting their subjective diagnostis certainties to identify that decision alternative representing the best choice.There are cogent theoretical and practical reasons to believe that, of the total improvement in decision making that can be achieved by using the analytic approach, the largest part is achieved by looking ahead to the future potential outcomes of the present decision and recognizing that its alternatives may be conceptualized in terms of gambles involving the outcomes. After the decision problem has been formulated in these terms any further improvement that may be achieved by using numerical techniques versus “ballpark” intuitive estimate is at best characterized as “fine-tuning”.We hope that radiologists will not be put off by the use of terms like “best bet” and “gambles”. We well recognize that many radiologists' first reaction will be like Bill's when he said, “I don't know if it's a better bet or not, but when it comes to gambling on something, I'd rather pick a sure thing!” We all would like to pick “sure things” but pathognomonic signs in radiologic diagnosis really are rare and are thus rarely encountered.Since we do live and function as radiologists in a probabilistic diagnostic world, it behooves us to understand the nature of the choices we are making or recommending. These choices assume the characteristics of a gamble when the stakes are considered, and the stakes here are the costs and benefits of our diagnostic test recommendations. The odds are our diagnostic probability estimates. Putting the odds and stakes together in optimum fashion is what this monograph has been all about.We have provided only the very beginning steps of the analytical approach. It is hoped that the reader will be sufficiently tantalized to attempt formulating decision problems in the fashion illustrated here. Undoubtedly he will run into problems that seem too complex to be attacked by the informal reasoning approach we present here. To aid in applying the ideas to more complex problems, we have attempted to provide the reader with adequate entry points to the relevant literature to assist in more complex applications. We hope that our intuitive discussion in this paper will facilitate an understanding of the more mathematical and detailed presentations.     

A remedy for resident evaluation and remediation

Resident evaluation and remediation are critical components of a residency program. This article describes a comprehensive method of resident evaluation that supplements the rotation evaluation with several additional methods, including a regularly scheduled faculty “roundtable” discussion of resident performance. It has also described a framework with which to approach resident remediation, including a resident-residency program director-educational liaison agreement form for dealing with resident performance issues in specific rotations. Throughout, an emphasis has been placed on the need to involve the resident in both the evaluation and remediation process. As we gain experience with this new system, and as new research emerges in the field of evaluation and remediation, our process will continue to evolve, with the goal of continuously improving our ability to detect problems early and to effectively deal with issues after they are identified.     

Radiography of the patellofemoral joint

Radiographs of the knee, and especially the patellofemoral joint, are indeed important, but they must be kept inperspective. There is a tendency for the orthopedist to rely too heavily upon the “x-ray.” Perhaps this is natural because we treat so much trauma, and the diagnostic answers, the fracture classification, and even the preferred treatment are often suggested by the initial radiograph. When it comes to patellofemoral disorders, the history, the physical examination, and the initial radiographs assume nearly equal importance, with the physical examination providing perhaps the best information to explain each patient's pathophysiology and to develop a treatment plan. The patellofemoral joint is unique, so its radiographic evaluation will be unique as well. The axial radiograph, which provides the most information, demands that the clinician know exactly what technique was used before an intelligent interpretation can be made. An understanding of the advantages and disadvantages of these different techniques, as well as an appreciation for the various radiographic measurements that separate “normal” from “abnormal,” will make the clinician's task much easier.     

The process of evidence-based practice in radiology: an introduction

EBP can be used by radiologists to assess imaging modalities using the recognized “Ask, Search, Appraise, Apply, and Evaluate” steps. The technology assessment framework is also a useful tool to stratify an imaging modality according to its technical and diagnostic performance. It can also be used to assess its therapeutic and diagnostic impact as part of the “Evaluate” step of EBP. We have described how these two processes can be combined and used in a synergistic way. While its format may appear unorthodox compared to conventional research methodology (i.e., aims, methods, results, and conclusion), it is a practical and readily interpreted way of bridging the gap between EBP and primary research. An example of its application entitled “Combining ‘Evidence-Based Practice’ and ‘Technology Assessment’ Methods to Develop Departmental Imaging Protocols: Should FDG PET Be Routinely Used in the Preoperative Assessment of Patients With Colorectal Liver Metastases?” is published in this issue. Further details of this process and its potential impact on technology assessment, education, ethics, and radiology literature has been considered in a recent Radiology special series (11).     

Double bundle posterior cruciate ligament reconstruction technique: University of Pittsburgh Approach

Posterior cruciate ligament (PCL) reconstruction has traditionally focused on the larger and stronger anterolateral bundle. Persistent low-grade laxity frequently occurs with this technique. Recent biomechanical data has shown that reconstruction of the posteromedial bundle, in addition to the anterolateral bundle, more closely restores knee kinematics to normal. Therefore, this type of “double-bundle” reconstruction may be superior to “single” bundle techniques. This article addresses the basic science rationale behind double bundle PCL reconstruction and discusses in detail the technique used at the University of Pittsburgh.     

How do training, education, and experience affect quality in radiology?

The quality of care is attracting increasing attention from payers, regulators, and consumers. The assumption that training, education, and experience are major determinants of quality and safety permeates the health care delivery system. However, the relationship between quality and training, education, and experience is neither straightforward nor well documented, particularly for the practice of radiology. A recent Institute of Medicine report questioned the effectiveness of the existing system for the education and training of health care professionals. In this article, “quality” in radiology is defined, and evidence for a relationship between quality care and experience and traditional continuing medical education is reviewed. Alternative approaches to education and training, with an emphasis on systems rather than individuals, are elucidated. The nature of radiologist training, education, and experience should be reexamined and adjusted to meet the changing demands of the health care delivery system.     

The added value of screening mammography in improved screening for other cancers

As part of day-to-day practice, the most frequent role of the radiologist is to provide diagnostic information derived from imaging that will help the clinician better manage patient care. In essence, radiologists are reimbursed for the information we provide. The value of diagnostic information, however, extends beyond strict clinical and monetary value.The objectives of this paper are to provide the framework for understanding the “value” of diagnostic imaging. The article focuses on the application of these concepts using examples from the literature with particular emphasis on screening and suggests using a screening test experience as a means of improving health behavior.     

L''hémorhéologie permet-elle de comprendre le « paradoxe de l''hématocrite » lors de l’entraînement et du surentraînement ?Does hemorheology explain the paradox of hematocrit in training and overtraining?

Purpose. – Doping with EPO increases both hematocrit and performance. On the opposite, training reduces hematocrit due to plasma volume extension and overtraining both increases hematocrit and decreases performance. This apparent paradox seems to be explained by a new concept proposed interpreting the interactions between viscosity factors and blood flow.Facts. – Viscosity factors exert a non linear “all or none” effect that can be described according to the “ percolation theory”. Blood viscosity has no hemodynamic relevance by its own, but viscosity factors (hematocrit, red cell deformability and aggregability, plasma viscosity) can result according to flow conditions in self-potentiating phenomena of quick transition between a state of high fluidity and a state of red cell aggregate clumping. In muscle, this model predicts that: (a) during exercise the only viscosity factor that could influence flow is plasma viscosity; (b) at rest all viscosity factors (including high hematocrit) may induce a self-potentiating “viscidation” process.Conclusion. – According to these concepts, supraphysiologic hematocrit values are probably unable to disturb muscular perfusion at exercise, but are likely to promote self-potentiated stasis at rest and thus to increase the risk of thrombosis.     

Anterior-superior internal impingement of the shoulder: an evidence-based review

Purpose  

Internal impingement syndrome is a painful shoulder condition related to the impingement of the soft tissue, including the rotator cuff, joint capsule and the long head of the biceps tendon and glenoid labrum. Two types of internal impingement syndrome can be differentiated: posterior-superior impingement and anterior-superior impingement (ASI). The aetiology of ASI in particular is not clear. The purpose of this paper is to discuss the different aetiological theories relating to ASI, try to clarify the clinical, radiological and arthroscopic findings and, finally, suggesting treatment for this complex shoulder syndrome.     

And 'the best job in the world award' goes to...classic lifeguard

“Medic One, Medic Three: 9-1-1 to the North Rim ranger station. Fall with possible serious head injuries. Unknown patient condition at this time.”     

Early adipocere formation: A case report and review of literature

Adipocere has a long history of frightening and fascinating mankind, from so called “incorruptible saints” to the famous “iceman” and its formation on human remains has long been known and feared. Adipocere formation replaces the putrefactive changes, when the body lies buried in shallow, moist, clay, soiled grave or it is thrown into cess pools or submerged in water. As the progression of putrefaction is arrested, the facial features and wounds are preserved without much alteration, thereby aiding the identification and to certain extent, the cause of death. The time required for the formation of adipocere is a subject of controversy. Here we present a case of early adipocere formation within 3 days and the review of literature pertaining to it.     

Yorkshire Laser Centre mobile photodynamic therapy unit: For service to district general hospitals

A mobile laser unit, principally for the provision of photodynamic therapy (PDT) services to District General Hospitals was designed and put into operation by the Yorkshire Laser Centre (YLC). The concept grew out of observation that the majority of patients who could potentially benefit from PDT are investigated and hospitalised in their District General Hospital (GDH) and not easily transferred to or treated and followed up by a PDT centre. Therefore, a mobile PDT unit (MPDTU) could facilitate the availability of PDT to patients on their “home ground” where they have been investigated and selected. The treatment is carried out at the host hospital by the patient's own local medical team assisted by the YLC through the MPDTU.Our MPDTU comprises of:

• A van.

• Comprehensive equipment for illumination (a light source and appropriate delivery system to the patient).

• Personnel consisting of a driver/technician, a PDT physician, a nurse or a carer, and a co-ordinator.

During the past 3 years our MPDTU has had 43 sorties to six different hospitals in the region for PDT covering a variety of specialities. There has not been any failure of the organisation or operational system.

Conclusions

The YLC model of MPDTU allows many more patients to benefit from this treatment who otherwise would be excluded from it because of lack of facilities and expertise locally at the patient's “home ground”.     

Les effets d''une exposition répétée à l''oxygène hyperbare (OHB) sur la performance physique du sportif

Objectifs. – Le but de cette étude a été de vérifier que l'hyperoxie permettait d'augmenter les performance d'un exercice physique.Méthodes. – Vingt-deux sportifs de spécialités différentes, « explosif » (musculation) et « endurance » (cyclisme) ont été étudiés. Les groupes « explosif » et « endurance » comportaient respectivement six sujets hyperoxie + trois contrôles et six sujets hyperoxie + sept contrôles. Douze séances d'entraînement de 90 minutes ont été réalisées : groupe hyperoxie = 100 % d'oxygène à 1,6 b (PO2 = 160 kPa), groupe témoin = pression atmosphérique normale (PO2 = 21 kPa). Des paramètres anthropométriques et biologiques , la force utile maximale (groupe « explosif ») et la VO2 max (groupe « endurance ») ont été mesurés avant et après les 12 séances. L'évolution des puissances développées à la fréquence cardiaque correspondant au seuil de 4 mmol d'acide lactique a été suivie dans le groupe « endurance ».Résultats. – Il n'existait pas de différence significative entre les groupes pour les paramètres anthropométriques, sanguins et la VO2 max. Le groupe « explosif » hyperoxie présentait à la fin des séances, une force utile maximale plus importante (p = 0,03) que celle des témoins. Le groupe « endurance » présentait une augmentation plus importante (p < 0,05) des puissances sous-maximales que le groupe témoin.Conclusion. – L'hyperoxie permet une optimisation de l'entraînement du sportif.Aims. – Evaluate the effect of hyperbaric oxygen on physical exercise performance.Methods. – Twenty two athletes with different specialties: “explosive” (musculation) and “endurance” (cycling), were studied. The “explosive” and “endurance” groups included respectively 6 “hyperoxy” subjects + 3 controls and 6 “hyperoxy” subjects + 7 controls. Twelve 90 min-sessions of training were scheduled: “hyperoxy” group = 100% oxygen at 1.6 b (PO₂ = 160 kPa), control group = atmospheric pressure (PO₂ =21 kPa). Anthropometric and biologic parameters, useful maximum strength (“explosive” group) and VO_2max (“endurance” group) were assessed before and after the 12 sessions. Modifications of strength developed at the cardiac frequency corresponding to the 4 mmol threshold of lactic acid were noted in the “endurance” group.Results. – No difference was noted between the two groups in the variations of the anthropometric and biologic parameters as well as in the VO_2max determinations. The “explosive/hyperoxy” group developed, at the end of the sessions, a more important (P = 0.03) increase of the useful maximum strength that controls. The “endurance” group developed a more important increase (P < 0.05) of sub maximum powers that controls.Conclusion. – Hyperbaric oxygen optimize athletic training.     

Using static MLC fields to replace partial transmission cerrobend blocks in treatment planning of rectal carcinoma cases

A treatment planning technique has been developed for using static multileaf collimators to replace partial transmission blocks for treating rectal or cervix carcinoma. The static MLC fields were used to replace the partial transmission block of the anterior-posterior pelvis field for the so-called “thunderbird” technique. Treatment plans were developed and evaluated on a commercial three-dimensional treatment planning system (FOCUS, Computerized, Medical Systems, St. Louis, MO). The result of the treatment plan comparison indicates that the static MLC fields are capable of achieving the same target, inguinal and pelvic dose distribution as the partial transmission cerrobend blocked fields. The MLC fields are easy to modify particularly for the match line adjustments. In conclusion, it is efficient and effective to use static MLC fields to replace partial transmission blocks in the “thunderbird” technique for treating rectal or cervix carcinoma.     

Exclusive hospital-based service agreements: what radiologists need to know

This article provides radiologists with the information that they need to know to participate meaningfully in negotiating or renegotiating an exclusive hospital-based radiology service agreement. It discusses the contract negotiation process, including how to identify and prioritize contract objectives, and how to assess and create bargaining leverage. Options for achieving contract longevity, for resolving “turf” issues and for achieving financial objectives are also addressed. The article further explains the key regulatory issues that shape exclusive hospital-based radiology service agreements, including antitrust, fraud and abuse, Stark Law, HIPAA, tax, and Medicare reimbursement considerations. The author discusses the contract negotiation process from both the radiology group and hospital perspectives. He suggests that successful negotiation will depend on “fitting” the group’s contracting agenda with the hospital’s priorities, organizational structure, culture and resources.     

Rapid determination of Sr impurities in freshly “generator eluted” Y for radiopharmaceutical preparation

⁹⁰Y is one of the most useful radionuclides for radioimmunotherapeutic applications and has a half-life (t_1/2=64.14 h) suitable for most therapeutic applications, beta particles of high energy and decays to a stable daughter. It is significant that ⁹⁰Y is available conveniently and inexpensively from a radionuclide “generator” by decay of its parent, ⁹⁰Sr. Nevertheless, current and planned clinical applications with [⁹⁰Y] labelled compounds employ activity levels that cannot be readily obtained from an in-house generator, but from commercial sources. We have evaluated Eichrom's Sr-resin, either as an “in-house” generator or as a fast QC method for analysis of ⁹⁰Y solutions.In particular, for the development as a generator, we investigated the percentage of the radio-Sr in the first 8 M HNO₃ eluate: in this fraction the concentration of ⁹⁰Sr must be smaller than 10⁻⁵% (recommendations of the International Commission on Radiological Protection). For evaluation as a rapid QC method, we analyzed the concentration of ⁹⁰Y in all the fractions containing “only” radio-Sr: ⁹⁰Y should not be present in these eluates. After the collection of β⁻ and γ spectra and analysis of them, we concluded that commercial Sr-resin minicolumn cannot give us the results expected; we developed an in-house system loaded with 4 mL of Sr-resin which gave better results as a generator and a rapid QC method.