When to image neurologically normal children with headaches: development of a decision rule

Aims: The aim of this study was to develop and refine a decision rule on when to undertake brain imaging (BI) in neurologically normal children with headaches. Methods: From the literature and a questionnaire study, a list of red flags (RFs) was drawn‐up. During the prospective 4‐year period, consecutive children with headache were classified according to RFs and the headache diagnosis. Result: Three of 709 (0.4%) neurologically normal children had significant brain abnormalities. BI was carried out in 389 of 498 (78%) children with RFs. Significant abnormalities were found in three of 389 children (0.8%), all had unclassified headache (UH). BI was not arranged for the 211 children with no RFs. None of these developed RFs or abnormal signs on follow‐up for a mean of 13 months. Conclusion: In addition to BI for those with neurological signs, we think BI should be considered for neurologically normal patients with UH and RFs. This would have saved imaging children needlessly: only 101 of 709 (14%) would have had scans arranged, instead of 389 of 709.     

Gait analysis after successful mobile bearing total ankle replacement

BACKGROUND: The effect of total ankle replacement on gait is not fully known in terms of joint kinematics, ground reaction force, and activity of the muscles of the lower leg. METHODS: A comparative gait study was done in 10 patients after uneventful unilateral mobile-bearing total ankle replacement and 10 healthy controls. A rigid body model was used to describe the motion of the knee and the three-dimensional motion of the ankle-hindfoot complex during barefoot walking. An opto-electronic motion analysis system was used to analyze bilateral movement patterns, synchronized with recordings of the ipsilateral vertical ground reaction forces and the electromyographic activity of four lower leg muscles. RESULTS: Velocity was 6% lower in the patient group. Dorsiflexion in the operated ankles was reduced (p < 0.001). No differences were found in the joint angular pattern of the knee joint and only minimal changes were found at the hindfoot-to-tibia and forefoot-to-hindfoot levels. The ground reaction force at midstance was somewhat increased (p = 0.005), while the magnitude of the vertical peak at terminal stance was decreased (p < 0.001). EMG activity patterns in the patient group were normal except for a higher activity of the gastrocnemius in early stance and the anterior tibial muscle in late stance. CONCLUSIONS: There is a near normal gait pattern in terms of joint kinematics of the knee, ankle, and foot after uneventful mobile-bearing total ankle replacement. The ground reaction forces and the EMG activity, however, do not fully normalize.     

Aortopulmonary window lesions: detection with chest radiography

A retrospective morphologic study of 80 cases was undertaken to determine factors affecting detectability of computed tomographically (CT) proved aortopulmonary (AP) window lesions on conventional posteroanterior (PA) and lateral chest radiographs. Criteria used for determining abnormality were: solitary lymph node enlargement over 1.5 cm or three or more 1-cm nodes and obvious large masses or vascular anomalies. CT scans and corresponding PA and lateral radiographs were analyzed for lesion detectability, size, and location. In 49% of cases there was no detectable lesion in the AP window on radiographs; a definite AP window lesion was seen in 41%, and 10% were equivocal. Major contributing factors to low detectability of AP window lesions on radiographs include size and, more important, location of the lesion. An additional 45 cases of CT-proved normal AP windows were retrospectively reviewed to determine the false-positive rate of PA and lateral radiographs in detection of AP window lesions: 43 (96%) were classified as negative, the remaining two (4%) as equivocal. Although the AP window is a small space, it is the site of many pathologic conditions; the study results indicate that CT may be an essential procedure for its evaluation.     

A perfusion chamber developed to investigate platelet interaction in flowing blood with human vessel wall cells, their extracellular matrix, and purified components

A flat perfusion chamber was developed to study the interaction of blood platelets in flowing blood with cultured human vessel wall cells, their connective tissue matrix, and isolated connective tissue components at defined shear rate conditions. A cover slip covered with endothelial cells or extracellular matrix components was introduced into the chamber. Laser-Doppler velocimetry showed a symmetrical flow profile at flow rates between 50 and 150 ml/min (wall shear rate 300 to 1100 sec-1). Platelet deposition was estimated by using blood platelets labeled with indium-111 or by a morphometric method. Blood platelets did not adhere to endothelial cells at wall shear rates of 765 sec-1 and the endothelial cells remained attached for at least 10 min of perfusion. In preconfluent cultures of endothelial cells, blood platelets adhered to extracellular material in areas between the cells. Removal of endothelial cells by treatment with 0.5% Triton X-100 induced increased platelet adherence with a preference for certain, as yet unidentified, fibrillar structures of the extracellular matrix. Platelet adherence to equine collagen was also studied after coating the cover slips by spraying of small collagen droplets followed by air drying. Platelet adherence and the subsequent platelet aggregate formation occurred predominantly along visible collagen fibers. These studies showed that this perfusion chamber has a laminar and symmetrical flow allowing qualitative and quantitative investigation of platelet interaction with endothelial cells, their extracellular matrix, and pure connective tissue components. A variety of wall shear rates and exposure times can be applied at controlled conditions without removing cells or extracellular material.     

Extremity bone tumors: evaluation by P-31 MR spectroscopy

High-resolution P-31 MR spectra were obtained in four patients with bone tumors of their distal extremities. In one case the tumor, a Ewing sarcoma of the tibia, was investigated during clinical remission after radiation therapy and chemotherapy. The other three cases - one low-grade chondrosarcoma of the tibial head, one malignant fibrous histiocytoma of the tibia, and one chondroblastoma of the medial femoral condyle - showed clinically active tumor growth, with corresponding increased metabolism as demonstrated by bone scintigraphy. The spectra of the three active tumors indicated a comparably high adenosine triphosphate content, similar to previously published spectra from animal tumors or human tumors implanted into animals. There were also high resonances of inorganic phosphate and low resonances of phosphocreatine; there were definite peaks in the phosphodiester and phosphomonoester regions, indicating the existence of these metabolites in the tumors. Slight but definite changes in the metabolite content were observed in one tumor after chemotherapy. The spectra of the unaffected leg did not show any well-resolved P-31 signals, which is typical for healthy bone. These are the first P-31 MR spectra of human bone tumors measured in patients to our knowledge.     

Suspected leaking abdominal aortic aneurysm: use of sonography in the emergency room

To determine the value of sonography in the emergent evaluation of suspected leaking abdominal aortic aneurysms, the authors examined 60 patients in the emergency department using sonography and a protocol involving advance radio notification from the ambulance; arrival of sonographic personnel and equipment in the triage room before patient arrival; and, during other triage activities, rapid sonographic evaluation of the aorta for aneurysm and of the paraaortic region for extraluminal blood. Sonographic findings were correlated with surgical results and clinical outcome. When performed under these circumstances, sonography was accurate in demonstrating presence or absence of aneurysm (98%), but its sensitivity for extraluminal blood was poor (4%). A combination of sonographic confirmation of aneurysm, abdominal pain, and unstable hemodynamic condition resulted in the correct decision to perform emergent surgery in 21 of 22 patients (95%). An abbreviated sonographic examination done in the emergency room can provide accurate, useful information about the presence of aneurysm; this procedure does not significantly delay triage of these patients.