Ultrasound of the knee during voluntary quadriceps contraction: A technique for detecting otherwise occult effusions

Objective To describe 1) a technique that can detect synovial effusions not seen on static ultrasound (US) examination and 2) the characteristics of patients with knee osteoarthritis (OA) for whom this technique proved useful. Methods From reviewed records of 76 patients with knee OA (112 knees) that we had seen for US-guided injections over a defined period, we found 45 knees with no detectable effusion on static US, of which 18 (14 patients) showed fluid when scanned during voluntary quadriceps contraction. For all patients, we had recorded effusion features (physical examination, presence and size on US), and success of joint entry was determined by getting synovial fluid and/or seeing an air echo or inflow of injected material. Results The 14 patients we studied were obese (mean ± SEM body mass index 32.7 ± 2.3 kg/m 2 ; 3 morbidly obese), with moderate to severe OA by radiography in most (Kellgren/Lawrence class 3 or 4 in 10 of 14 knees for which radiographs were available). The suprapatellar synovial space seen by US was small (mean ± SEM depth 0.38 ± 0.04 cm). Arthrocentesis obtained 0.5–16 ml of synovial fluid (mean ± SEM 2.9 ± 0.6 ml), which correlated with the depth of effusion as seen on US with the quadriceps in maximum contraction (Spearman's Ρ = 0.5597, P = 0.0157). In 4 knees where arthrocentesis failed to retrieve fluid, we observed at injection the inflow of material and a linear air echo. Conclusion US of the knee during voluntary quadriceps contraction can find effusions not detectable on static US. Such effusions provide targets for accurate aspiration and injection that would not be appreciated with static US.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75770/1/20047_ftp.pd

An Intrathermocline Eddy and a tropical cyclone in the Bay of Bengal

The Bay of Bengal, subjected to monsoonal forcing and tropical cyclones, displays a complex field of ocean eddies. On 5 December 2013 a sub-surface vortex or Intrathermocline Eddy (ITE) composed of water characteristic of the Andaman Sea was observed within the thermocline of the western Bay of Bengal. We propose that the ITE was the product of Tropical Cyclone Lehar interaction on 27 November 2013 with a westward propagating surface eddy from the eastern Bay of Bengal. While Lehar’s interaction with the ocean initially removes heat from the upper layers of the eddy, air-sea flux is limited as the deeper portions of the eddy was subducted into the stratified thermocline, inhibiting further interaction with the atmosphere. The ITE core from 30 to 150m is thus isolated from local air-sea fluxes by strong stratification at the mixed layer base, and its periphery is stable to shear instability, suggestive of longevity and the ability to carry water far distances with minimal modification

Bay of Bengal : 2013 northeast monsoon upper-ocean circulation

Author Posting. © The Oceanography Society, 2016. This article is posted here by permission of The Oceanography Society for personal use, not for redistribution. The definitive version was published in Oceanography 29, no. 2 (2016): 82–91, doi:10.5670/oceanog.2016.41.The upper 200 m of the two northern Indian Ocean embayments, the Bay of Bengal (BoB) and the Arabian Sea (AS), differ sharply in their salinity stratification, as the Asian monsoon injects massive amounts of freshwater into the BoB while removing freshwater via evaporation from the AS. The ocean circulation transfers salt from the AS to the BoB and exports freshwater from the BoB to mitigate the salinity difference and reach a quasi-steady state, albeit with strong seasonality. An energetic field of mesoscale features and an intrathermocline eddy was observed within the BoB during the R/V Revelle November and December 2013 Air-Sea Interactions Regional Initiative cruises, marking the early northeast monsoon phase. Mesoscale features, which display a surprisingly large thermohaline range within their confines, obscure the regional surface water and thermohaline stratification patterns, as observed by satellite and Argo profilers. Ocean processes blend the fresh and salty features along and across density surfaces, influencing sea surface temperature and air-sea flux. Comparing the Revelle observations to the Argo data reveals a general westward migration of mesoscale features across the BoB.Support for Bay of Bengal research is provided by the Office of Naval Research. ALG award number N00014-14-10065. AM and MF award number N00014-13-10451 and for MF a WHOI summer student fellowship. ES award number N00014-14-10236

Using Low-Dose Radiation to Potentiate the Effect of Induction Chemotherapy in Head and Neck Cancer: Results of a Prospective Phase 2 Trial

Purpose: Low-dose fractionated radiation therapy (LDFRT) induces effective cell killing through hyperradiation sensitivity and potentiates effects of chemotherapy. We report our second investigation of LDFRT as a potentiator of the chemotherapeutic effect of induction carboplatin and paclitaxel in locally advanced squamous cell cancer of the head and neck (SCCHN). Experimental Design: Two cycles of induction therapy were given every 21 days: paclitaxel (75 mg/m2) on days 1, 8, and 15; carboplatin (area under the curve 6) day 1; and LDFRT 50 cGy fractions (2 each on days 1, 2, 8, and 15). Objectives included primary site complete response rate; secondary included overall survival, progression-free survival (PFS), disease-specific survival, and toxicity. Results: A total of 24 evaluable patients were enrolled. Primary sites included oropharynx (62.5%), larynx (20.8%), oral cavity (8.3%), and hypopharynx (8.3%). Grade 3/4 toxicities included neutropenia (20%), leukopenia (32%), dehydration/hypotension (8%), anemia (4%), infection (4%), pulmonary/allergic rhinitis (4%), and diarrhea (4%). Primary site response rate was 23/24 (95.8%): 15/24 (62.5%) complete response, 8/24 (33.3%) partial response, and 1/24 (4.2%) stable disease. With median follow-up of 7.75 years, 9-year rates for overall survival were 49.4% (95% confidence interval [CI], 30.5-79.9), PFS was 72.2% (CI, 55.3-94.3), and disease-specific survival was 65.4% (44.3-96.4). Conclusion: Chemopotentiating LDFRT combined with paclitaxel and carboplatin is effective in SCCHN and provided an excellent median overall survival of 107.2 months, with median PFS not yet reached in this locally advanced SCCHN cohort. This compares favorably to prior investigations and caused fewer grade 3 and 4 toxicities than more intensive, 3-drug induction regimens. This trial demonstrates the innovative use of LDFRT as a potentiator of chemotherapy

New insights into the application of pair distribution function studies to biogenic and synthetic hydroxyapatites

Biogenic and synthetic hydroxyapatites are confounding materials whose properties remain uncertain, even after years of study. Pair distribution function (PDF) analysis was applied to hydroxyapatites in the 1970’s and 1980’s, but this area of research has not taken full advantage of the relatively recent advances in synchrotron facilities. Here, synchrotron X-ray PDF analysis is compared to techniques commonly used to characterise hydroxyapatite (such as wide angle X-ray scattering, Fourier-transform infrared spectroscopy and thermogravimetric analysis) for a range of biogenic and synthetic hydroxyapatites with a wide range of carbonate substitution. Contributions to the pair distribution function from collagen, carbonate and finite crystallite size were examined through principal component analysis and comparison of PDFs. Noticeable contributions from collagen were observed in biogenic PDFs when compared to synthetic PDFs (namely r < 15 Å), consistent with simulated PDFs of collagen structures. Additionally, changes in local structure were observed for PDFs of synthetic hydroxyapatites with differing carbonate content, notably in features near 4 Å, 8 Å and 19 Å. Regression models were generated to predict carbonate substitution from peak position within the PDFs

The use of μCT and fractal dimension for fracture prediction in osteoporotic individuals

Osteoporosis (OP) is a widespread condition with commonly associated fracture sites at the hip, vertebra and wrist. This study examines the effects of age and osteoporosis on bone quality by comparing the efficacy of using parameters which indicate bone quality (both traditional clinical parameters such as bone mineral density (BMD), as well as apparent Young's modulus determined by finite element analysis, among others) to predict fracture. Non-fracture samples were collected from the femoral heads of 83 donors (44 males, 39 females), and fracture samples were obtained from the femoral heads of 17 donors (female). Microarchitectural parameters (Bone Volume/Total Volume [BV/TV], Bone Surface/Bone Volume [BS/BV], Tissue Mineral Density [TMD, etc.]) were measured from μCT of each sample as well as 2D and 3D fractal dimension (D2D and D3D respectively). A cube was cropped from μCT images and an isotropic hexahedral element was assigned to each voxel. Finite element analysis was used to calculate the Young's modulus for each sample. Overall, values for microarchitectural characteristics, fractal dimension measurements and Young's Modulus were consistent with values within literature. Significant correlations are observed between age and BV/TV for non-fracture males and females, as well as between age and volumetric BMD (vBMD) for the same groups. Significant differences are present between age-matched non-fracture and fracture females for BV/TV, BS/BV, vBMD, TMD, D2D, D3D, (p < 0.01 for all). Properties which are not age dependent are significantly different between age-matched non-fracture and fracture specimens, indicating OP is a disease, and not just an accelerated aging process

Influenza vaccine effectiveness among outpatients in the US Influenza Vaccine Effectiveness Network by study site 2011‐2016

BackgroundInfluenza vaccination is recommended for all US residents aged ≥6 months. Vaccine effectiveness (VE) varies by age, circulating influenza strains, and the presence of high‐risk medical conditions. We examined site‐specific VE in the US Influenza VE Network, which evaluates annual influenza VE at ambulatory clinics in geographically diverse sites.MethodsAnalyses were conducted on 27 180 outpatients ≥6 months old presenting with an acute respiratory infection (ARI) with cough of ≤7‐day duration during the 2011‐2016 influenza seasons. A test‐negative design was used with vaccination status defined as receipt of ≥1 dose of any influenza vaccine according to medical records, registries, and/or self‐report. Influenza infection was determined by reverse‐transcription polymerase chain reaction. VE estimates were calculated using odds ratios from multivariable logistic regression models adjusted for age, sex, race/ethnicity, time from illness onset to enrollment, high‐risk conditions, calendar time, and vaccination status‐site interaction.ResultsFor all sites combined, VE was statistically significant every season against all influenza and against the predominant circulating strains (VE = 19%‐50%) Few differences among four sites in the US Flu VE Network were evident in five seasons. However, in 2015‐16, overall VE in one site was 24% (95% CI = −4%‐44%), while VE in two other sites was significantly higher (61%, 95% CI = 49%‐71%; P = .002, and 53%, 95% CI = 33,67; P = .034).ConclusionWith few exceptions, site‐specific VE estimates aligned with each other and overall VE estimates. Observed VE may reflect inherent differences in community characteristics of the sites and highlights the importance of diverse settings for studying influenza vaccine effectiveness.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/155981/1/irv12741_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/155981/2/irv12741.pd

Investigating pair distribution function use in analysis of Nanocrystalline Hydroxyapatite and Carbonate Substituted Hydroxyapatite

Hy­droxy­apatite (HA) is a com­plex material, which is often nanocrystalline when found within a biological setting. This work has directly com­pared the structural characteristics derived from data collected using a conventional laboratory-based X-ray diffractometer with those collected from a dedicated pair distribution function (PDF) beamline at Diamond Light Source. In particular, the application of PDF analysis methods to carbonated HA is evaluated. 20 synthetic samples were measured using both X-ray diffraction (XRD) and PDFs. Both Rietveld refinement (of laboratory XRD data) and real-space refinement (of PDF data) were used to analyse all samples. The results of Rietveld and real-space refinements were com­pared to evaluate their application to crystalline and nanocrystalline hy­droxy­apatite. Significant relationships were observed between real-space refinement parameters and increasing carbonate substitution. Understanding the local order of synthetic hy­droxy­apatite can benefit several fields, including both biomedical and clinical settings.Engineering and Physical Sciences Research Council (EPSRC): EP/T034238/1. Royal Society Wolfson Fellowship: RSWF/R1/180012. Diamond Light Source, instrument I15-1: proposal ee18638

Epidural Hematoma Following Cervical Spine Surgery.

STUDY DESIGN: A multicentered retrospective case series. OBJECTIVE: To determine the incidence and circumstances surrounding the development of a symptomatic postoperative epidural hematoma in the cervical spine. METHODS: Patients who underwent cervical spine surgery between January 1, 2005, and December 31, 2011, at 23 institutions were reviewed, and all patients who developed an epidural hematoma were identified. RESULTS: A total of 16 582 cervical spine surgeries were identified, and 15 patients developed a postoperative epidural hematoma, for a total incidence of 0.090%. Substantial variation between institutions was noted, with 11 sites reporting no epidural hematomas, and 1 site reporting an incidence of 0.76%. All patients initially presented with a neurologic deficit. Nine patients had complete resolution of the neurologic deficit after hematoma evacuation; however 2 of the 3 patients (66%) who had a delay in the diagnosis of the epidural hematoma had residual neurologic deficits compared to only 4 of the 12 patients (33%) who had no delay in the diagnosis or treatment (P = .53). Additionally, the patients who experienced a postoperative epidural hematoma did not experience any significant improvement in health-related quality-of-life metrics as a result of the index procedure at final follow-up evaluation. CONCLUSION: This is the largest series to date to analyze the incidence of an epidural hematoma following cervical spine surgery, and this study suggest that an epidural hematoma occurs in approximately 1 out of 1000 cervical spine surgeries. Prompt diagnosis and treatment may improve the chance of making a complete neurologic recovery, but patients who develop this complication do not show improvements in the health-related quality-of-life measurements

Evaluating the impact of a community health worker program on non-communicable disease, malnutrition, tuberculosis, family planning and antenatal care in Neno, Malawi : protocol for a stepped-wedge, cluster randomized controlled trial

Introduction: This protocol concerns the implementation and evaluation of an intervention designed to realign the existing cadre of Community Health Workers (CHWs) in Neno District, Malawi to better support the care needs of the clients they serve. The proposed intervention is a ‘Household Model’ where CHWs will be reassigned to households, rather than to specific patients with HIV and/or TB. Methods and Analysis: Using a stepped-wedge, cluster-randomized design, this study investigates whether high HIV retention rates can be replicated for non-communicable diseases (NCDs), and the Model’s impact on TB and pediatric malnutrition case-finding, as well as the uptake of family planning and antenatal care. Eleven sites (health centres and hospitals) were arranged into six clusters (average cluster population 21,800). Primary outcomes include retention in care for HIV and chronic NCDs, TB case finding, pediatric malnutrition case finding, and utilization of early and complete antenatal. Clinical outcomes are based on routinely collected data the Ministry of Health’s District Health Information System 2 and an OpenMRS Electronic Medical Record supported by Partners In Health. Additionally, semi-structured qualitative interviews with various stakeholders will assess community perceptions and context of the Household Model. Ethics and dissemination: Ethics approval has been obtained from the Malawian National Health Science Research Committee (#16/11/1694) in Lilongwe, Malawi; Partners Healthcare Human Research Committee (#2017P000548/PHS) in Somerville, Massachusetts; and by the Biomedical and Scientific Research Ethics Sub-Committee (REGO-2017-2060) at the University of Warwick in Coventry, United Kingdom. Dissemination will include manuscripts for peer-reviewed publication as well as a full report detailing the findings of the intervention for the Malawian Ministry of Health. Registration: Registered on ClinicalTrials.gov in April 2017. Identifier: NCT0310672