Bilateral Tibial Stress Fracture in an Inexperienced Athlete

PURPOSE: An abrupt increase in duration, intensity, or frequency of physical activity without adequate periods of rest can make patients susceptible to stress fractures, which are typically unilateral and located in the posteromedial tibia diaphysis. METHODS: We present a unique case report of a bilateral proximal epiphysis stress fracture. RESULTS: Here we present a young female patient presenting with bilateral tibia stress fractures after running in a half marathon that she had not trained for. Initial radiographs did not reveal any acute abnormalities, but subsequent MRI demonstrated incomplete stress fractures of the bilateral medial tibial epiphysis. Conservative management including compressive knee sleeves was initiated, with reduced pain reported at the follow-up visit. This patient’s intrinsic risk factors for stress included female gender, while her extrinsic risk factors included poor footwear, improper training, and foot anomalies. Even in the absence of significant intrinsic risk factors, stress fractures should be included on the differential if history reveals recent intense physical exercise. CONCLUSION: History was vital in detecting and treating this patient’s bilateral knee pain. We were fortunate enough to have a clinical suspicion of stress fracture and our patient is progressing towards her baseline

Snapping Triceps Syndrome: A Rare Cause of Medial Elbow Pain

PURPOSE: Snapping medial triceps is a relatively rare cause of medial elbow pain that occurs when the tricep tendon dislocates over the medial or lateral epicondyle. Physical exams usually demonstrate intermittent medial elbow pain with extreme elbow flexion or extension, however dynamic diagnostic studies allow for direct visualization of the dislocating tricep. This case report adds to the sparse literature on snapping medial triceps. METHODS: We report a rare occurrence of snapping medial triceps in a young female who initially presented with pain at the posteromedial right elbow with extreme flexion and extension. Intermittent snapping of the medial elbow was noted on physical exam. Ultrasound confirmed snapping of the medial triceps head over osteophytes of the posteromedial olecranon. The patient agreed to surgical right medial triceps release with excision of elbow osteophytes. RESULTS: As demonstrated with our case, static diagnostic imaging such as radiographs and MRI may not adequately characterize snapping triceps syndrome. It is crucial for providers to be aware of subtle differences between dynamic and static diagnostics imaging for snapping medial tricep syndrome. Another important diagnostic tools are electrodiagnostic studies, however as displayed with our patient there may be absence of any ulnar neuropathy at the level of the elbow, which could hinder providers from concerning snapping medial tricep syndrome. CONCLUSION: It is important to consider a broad differential that includes snapping triceps syndrome in a patient presenting with medial elbow pain. EMG and ultrasonography can be useful in differentiating snapping medial triceps from ulnar nerve instability. Treatment can include activity modification, elbow splinting, or surgical release of the snapping part of the triceps

Cataract prevalence, cataract surgical coverage and barriers to uptake of cataract surgical services in Pakistan: the Pakistan National Blindness and Visual Impairment Survey.

AIM: To estimate the prevalence of visual impairment and blindness caused by cataract, the prevalence of aphakia/pseudophakia, cataract surgical coverage (CSC) and to identify barriers to the uptake of cataract services among adults aged >or=30 years in Pakistan. METHODS: Probability proportional-to-size procedures were used to select a nationally representative sample of adults. Each subject underwent interview, visual acuity measurement, autorefraction, biometry and ophthalmic examination. Those that saw <6/12 in either eye underwent a more intensive examination procedure including corrected visual acuity, slit lamp and dilated fundus examination. CSC was calculated for different levels of visual loss by person and by eye. Individuals with <6/60 in the better eye as a result of cataract were interviewed regarding barriers. RESULTS: 16 507 Adults were examined (95.5% response rate). The crude prevalence of blindness (presenting <3/60 in the better eye) caused by bilateral cataract was 1.75% (95% CI 1.55%, 1.96%). 1317 Participants (633 men; 684 women) had undergone cataract surgery in one or both eyes, giving a crude prevalence of 8.0% (95% CI 7.6%, 8.4%). The CSC (persons) at <3/60, <6/60 and <6/18 were 77.1%, 69.3% and 43.7%, respectively. The CSC (eyes) at <3/60, <6/60 and <6/18 were 61.4%, 52.2% and 40.7%, respectively. Cost of surgery (76.1%) was the main barrier to surgery. CONCLUSION: Approximately 570 000 adults are estimated to be blind (<3/60) as a result of cataract in Pakistan, and 3,560000 eyes have a visual acuity of <6/60 because of cataract. Overall, the national surgical coverage is good but underserved populations have been identified

Current concepts in diastolic heart failure

Heart failure is a highly prevalent condition, particularly among elderly adults and women. In diastolic heart failureor heart failure with normal ejection fraction-left ventricular systolic function is preserved. Although diastolic heart failure is clinically and radiographically indistinguishable from systolic heart failure, echocardiography can reveal a preserved ejection fraction with abnormal diastolic function. The present article reviews current medical concepts related to diastolic heart failure for medical practitioners, particularly primary care physicians, who play a vital role in the care of patients with heart failure. Treatment options, focusing on calcium channel blockers and angiotensin receptor blockers, are discussed. With early diagnosis and proper management, the prognosis of diastolic heart failure can be more favorable than that of systolic heart failure. J Am Osteopath Assoc. 2008;108:203-209 I ncreasingly, left ventricular (LV) diastolic dysfunction is being recognized as a pathophysiologic entity which predisposes certain patients to a distinct form of heart failure called diastolic heart failure (DHF)-or heart failure with normal ejection fraction (HFNEF). The term diastolic dysfunction indicates abnormal diastolic distensibility, filling, or LV relaxation, regardless of whether the ejection fraction is preserved or abnormal or whether the patient is symptomatic or asymptomatic. Thus, diastolic dysfunction refers to abnormal mechanical (diastolic) properties of the left ventricle and is present in virtually all patients with heart failure. The terms DHF and HFNEF are used to describe patients with the signs and symptoms of heart failure, a preserved ejection fraction, and LV diastolic dysfunction. Epidemiology Epidemiologic studies have suggested that 30% to 50% of patients with active congestive heart failure (CHF) have adequate LV systolic function. 6-10 Kitzman et al 10 found that 8% of patients older than 65 years have heart failure, 55% of whom have a preserved LV ejection fraction (LVEF). In addition, diastolic dysfunction has been shown to affect elderly women more than any other population subgroup. 6,7, Pathophysiology Pressure-Volume Relationships Studies related to pressure and volume changes during ventricular function provide unique insights into the diastolic, systolic, and overall pumping characteristics of the heart. Although a detailed discussion of such pressure and volume changes is beyond the scope of this article, a brief review of common principles is helpful. Patients with DHF have a preserved ejection fraction despite increased LV diastolic pressure and pulmonary venous pressure. These patients have both increased passive stiffness and abnormal active relaxation of the left ventricle, which may work independently to cause abnormal diastolic physiology

Prevalence of USA300 colonization or infection and associated variables during an outbreak of community-associated methicillin-resistant Staphylococcus aureus in a marginalized urban population

et al. Prevalence of USA300 colonization or infection and associated variables during an outbreak of community-associated methicillin-resistant Staphylococcus aureus in a marginalized urban population. Can J Infect Dis Med Microbiol 2007;18(6):357-362. BACKGROUND: In 2004, an outbreak of the USA300 strain of methicillin-resistant Staphylococcus aureus (MRSA) was identified in persons with histories of homelessness, illicit drug use or incarceration in the Calgary Health Region (Calgary, Alberta). A prevalence study was conducted to test the hypotheses for factors associated with USA300 colonization or infection. METHODS: Participants were recruited at sites accessed by this marginalized population. Health care staff administered a questionnaire and collected crack pipes and nasal, axillary and skin infection swabs. Pipes and swabs were cultured according to standard techniques. MRSA isolates were further characterized by polymerase chain reaction (mecA, Panton-Valentine leukocidin and Staphylococcal cassette chromosome mec) and typing methods (pulsed-field gel electrophoresis, staphylococcal protein A typing and multilocus sequence typing). Colonization or infection was determined by having any one of nasal, axillary, skin infection or pipe swabs positive for USA300. Colonized participants had one or more nasal, axillary or pipe swab positive for USA300; infected participants had one or more skin infection swab positive for USA300. RESULTS: The prevalence of USA300 colonization or infection among 271 participants was 5.5% (range 3.1% to 9.0%). USA300 cases were more likely to report manipulation of skin infections (OR 9.55; 95% CI 2.74 to 33.26); use of crack pipes was not significant despite identification of the USA300 strain on two of four crack pipes tested. USA300 cases were more likely to report drug use between sex trade workers and clients (OR 5.86; 95% CI 1.63 to 21.00), and with casual sex partners (OR 5.40; 95% CI 1.64 to 17.78). CONCLUSION: Ongoing efforts to promote the appropriate treatment of skin infections in this population are warranted. The association of USA300 colonization or infection and drug use with sexual partners suggest a role for sexual transmission of the USA300 strain of MRSA

The patient patient: The importance of knowing your navigator

In Ontario, Diagnostic Assessment Programs (DAPs) have been implemented to improve the quality of care patients receive during the diagnostic phase of the cancer journey. Patient navigators play a critical role in this model by coordinating care and providing information and support to patients and their families. The objectives of this study were 1) to determine whether patient navigation in DAPs is associated with a better patient experience and 2) to examine whether patient navigation in DAPs modifies the effect of wait times and patient volumes on patient experience. Data reflecting patients’ experience within the DAP were collected via survey and an average experience score was calculated for each region. To ascertain the relationship between patient experience, wait times and volumes, correlation coefficients were computed between regional patient experience scores and total regional patient volumes and between regional patient experience score and regional diagnostic wait times. To understand the impact of navigators on the patient experience, the sample was subdivided according to whether or not the respondent reported knowing their navigator. Patients who knew their navigator rated their experience significantly better than those who did not. For those who did not know their navigator, there was an inverse and significant correlation between patient experience scores and wait times; patients in regions with long waits had poorer experience scores overall. Patients who knew their navigator reported consistently good experience regardless of their diagnostic wait. The navigator appears to mitigate the negative impact of longer wait times on experience

Non-communicable diseases in antiretroviral therapy recipients in Kagera Tanzania: A cross-sectional study

Introduction: The aim of this study was to describe the extent of  self-reported non-communicable diseases (NCDs) among highly activeantiretroviral therapy (HAART) recipients in Kagera region in Tanzania and their effect on health-related quality of life (HRQOL). This study was conducted 2 years after HAART administration was started in Kagera region. Methods: The SF-36 questionnaire was used to collect the HRQOLdata of 329 HAART recipients. Questions on the NCDs, socio-demographic characteristics and treatment information were validated and added tothe SF-36. Bivariate analyses involving socio-demographic characteristics and SF-36 scores of the recipients were performed. Multiple logisticregression was employed to compute adjusted odds ratios for different explanatory variables on physical functioning and mental health scores.Results: Respondents who reported having 1 or more NCDs were 57.8% of all the respondents. Arthritis was the commonest NCD (57.8%).Respondents with the NCDs were more likely to have HRQOL scores below the mean of the general Tanzanian population. The populationattributable fraction (PAF) for the NCDs on physical functioning was 0.28 and on mental health was 0.22. Conclusion: Self-reported NCDs were prevalent among the HAART recipients in Kagera region. They accounted for 28% of the physical  functioning scores and 22% of the mental health scores that were below the mean of the general Tanzanian population. Therefore, the integration of NCD care is important in the management of HIV/AIDS

Validation of some disease-resistance molecular markers associated with multiple diseases in tomato for marker-assisted selection program

Marker-assisted selection (MAS) is a tool that is widely applied in tomato resistance breeding. To determine the robustness of some molecular markers commonly used in MAS, extensive screening of 964 tomato lines was performed under a controlled experimental condition. Initially, the application of 36 molecular markers targeting 26 resistance genes (R genes) and 14 major diseases was evaluated. Here, we employed basic molecular biology and bioinformatics techniques for analysis where polymorphism, accuracy and clearness of amplicons constituted the selection criteria of markers. Upon initial analysis, 20 of these markers designated as efficient markers, among which 8 were considered gene-based markers and referred to as perfect markers were selected for detail evaluation. Information extrapolated from PCR result revealed 18 R genes that control 12 diseases were grouped under efficient markers. On the other hand, grouping of breeding lines based on the number of R gene harbored comprehensively revealed 62% of the lines to be void of R gene, while 38% carry different types of R genes. This provides us with an avenue to better understand new sources of resistance in the breeding lines. Conclusively, these efficient markers and their limited PCR condition can be suggested as basis of a diagnostic kit for MAS applications against 12 major tomato diseases and the identified resistant breeding lines could be conserved in order to be propagated as different sources of resistance for the development of new resistant varieties. Therefore, in areas with high vulnerability to diseases, high efficiency combination of the relevant R genes and their pyramiding into commercial tomato varieties are proposed to be implemented as a pragmatic approach

The optimisation of deep neural networks for segmenting multiple knee joint tissues from MRIs.

Automated semantic segmentation of multiple knee joint tissues is desirable to allow faster and more reliable analysis of large datasets and to enable further downstream processing e.g. automated diagnosis. In this work, we evaluate the use of conditional Generative Adversarial Networks (cGANs) as a robust and potentially improved method for semantic segmentation compared to other extensively used convolutional neural network, such as the U-Net. As cGANs have not yet been widely explored for semantic medical image segmentation, we analysed the effect of training with different objective functions and discriminator receptive field sizes on the segmentation performance of the cGAN. Additionally, we evaluated the possibility of using transfer learning to improve the segmentation accuracy. The networks were trained on i) the SKI10 dataset which comes from the MICCAI grand challenge "Segmentation of Knee Images 2010″, ii) the OAI ZIB dataset containing femoral and tibial bone and cartilage segmentations of the Osteoarthritis Initiative cohort and iii) a small locally acquired dataset (Advanced MRI of Osteoarthritis (AMROA) study) consisting of 3D fat-saturated spoiled gradient recalled-echo knee MRIs with manual segmentations of the femoral, tibial and patellar bone and cartilage, as well as the cruciate ligaments and selected peri-articular muscles. The Sørensen-Dice Similarity Coefficient (DSC), volumetric overlap error (VOE) and average surface distance (ASD) were calculated for segmentation performance evaluation. DSC ≥ 0.95 were achieved for all segmented bone structures, DSC ≥ 0.83 for cartilage and muscle tissues and DSC of ≈0.66 were achieved for cruciate ligament segmentations with both cGAN and U-Net on the in-house AMROA dataset. Reducing the receptive field size of the cGAN discriminator network improved the networks segmentation performance and resulted in segmentation accuracies equivalent to those of the U-Net. Pretraining not only increased segmentation accuracy of a few knee joint tissues of the fine-tuned dataset, but also increased the network's capacity to preserve segmentation capabilities for the pretrained dataset. cGAN machine learning can generate automated semantic maps of multiple tissues within the knee joint which could increase the accuracy and efficiency for evaluating joint health.European Union's Horizon 2020 Framework Programme [grant number 761214] Addenbrooke’s Charitable Trust (ACT) National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre University of Cambridge Cambridge University Hospitals NHS Foundation Trust GSK VARSITY: PHD STUDENTSHIP Funder reference: 300003198