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Repetitive strain injuries (RSIs) encompass a broad clinicopathologic spectrum which includes discrete patterns of tissue injury involving tendons, bursae and nerves although an element of subjective symptomatology may be contributory. Upper extremity RSIs include De Quervain's tenosynovitis, intersection syndromes, epicondylitis, ulnar, and median neuritis as well as other compressive neuropathies. It is estimated that RSIs cost the US economy over $60 billion annually and while detailed clinical examination remains the diagnostic mainstay, imaging can aid in diagnosis, guide management and reduce costs.

The main purpose of the study is to determine if the presence of a particular computed tomography (CT) imaging finding, a bursal lipohematoma, portends the presence of a concomitant rotator cuff tear (RCT) in patients with proximal humerus fractures by reviewing previous CTs. Three hundred eighty-six CT scans were retrospectively reviewed by two board-certified radiologists to determine the presence of a proximal humerus fracture and to assess for the presence of a subacromial/subdeltoid or subcoracoid bursal hematoma. The medical record including operative documentation was then examined in the patients with proximal humerus fractures, with or without a concomitant bursal lipohematoma. Of the surgically managed patients, four had an intraoperative diagnosis of RCT. The preoperative CT scans of all of these patients demonstrated a bursal lipohematoma. Additionally, a non-surgically managed patient with a subacromial/subdeltoid bursal lipohematoma on CT scan was found to have a RCT on subsequent MRI. Of note, a rotator cuff tear was not documented in operative reports of patients with CT scans that were not found to contain a bursal lipohematoma. Bursal lipohematoma is a potentially useful preoperative CT sign of full thickness rotator cuff tear in patients with proximal humerus fractures, providing the clinician with more information in the optimization of the management approach.

Rationale and Objectives The conceptualization of acetabular fractures can present a daunting challenge to radiology residents. 3D models have been shown to aid in the spatial perception of complicated anatomy and may help residents grasp the elaborate classification systems for these anatomically complex fractures. Prior studies have explored the utility of 3D printed models for surgical planning in various settings. To our knowledge, no study has evaluated their efficacy in radiology resident training. Materials and Methods Following IRB approval, 22 radiology residents were randomized and stratified by Post Graduate Year into two groups of 11 residents. Both groups received separate identical presentations on the 5 most common acetabular fractures given by a musculoskeletal trained radiologist. Residents in the experimental group received 3D printed models of the five most common fracture types with which to interact during the presentation, while the control group did not. Both groups received a pretest and a follow up posttest three weeks later. Results A Wilcoxon rank sum test was performed to determine if statistically significant differences between the pretest and posttest scores of the experimental and control groups existed. There was no statistically significant difference in scores on the pre-test, which confirmed successful randomization. There was a statistically significant difference (P = 0.02) on the posttest scores between the experimental and control groups. Conclusion 3D printed models promise as an effective educational tool for resident learning with respect to acetabular fractures, improving short-term understanding of complex anatomy and classification systems.

PURPOSE Compression of the sciatic nerve in its path along the piriformis muscle can produce sciatica-like symptoms. There are 6 predominant types of sciatic nerve variations with type 1 being the most common (84.2%), followed by type 2 (13.9%). However, there is scarce literature on the prevalence of sciatic nerve variation in those diagnosed with sciatica. MATERIALS AND METHODS The charts of 95 patients clinically diagnosed with sciatica who had a magnetic resonance imaging of the pelvis/hip were retrospectively studied. All patients had T1-weighted axial, coronal, and sagittal images. Magnetic resonance imagings were interpreted separately by 2 board-certified fellowship-trained musculoskeletal radiologists to identify the sciatic nerve variant. RESULTS Seven cases were excluded because of inadequate imaging. Of the remaining 88 patients, 5 had bilateral sciatica resulting in a sample size of 93 limbs. Fifty-two (55.9%) had type 1 sciatic nerve anatomy, 39 (41.9%) had type 2, and 2 (2.2%) had type 3. The proportions of type 1 and 2 variations were significantly different from the normal distribution (P < 0.001), whereas type 3, 4, 5, and 6 variants were not (P = 1.00). CONCLUSIONS There is strong statistical significance regarding the relationship between sciatic nerve variation and the clinical diagnosis of sciatica. Preoperative magnetic resonance imaging can be considered in sciatica patients to prevent iatrogenic injury in pelvic surgery.

Although rare in everyday practice, malignancies that classically arise from bone or cartilage have been reported to arise de novo in various soft tissues in the body, resulting in a diagnostic challenge for the clinician, radiologist, and pathologist. Differential diagnoses of bone tumors often depend on anatomic location of the lesion. For example, the classic location of osteosarcoma is in the metaphysis of long bones about the knee. Histologically osteosarcoma is characterized by tumor cells that directly produce osteoid, bone, or cartilaginous matrix. In extraskeletal osteosarcoma, the clinical and radiologic picture is very different from a conventional osteosarcoma. They occur in older patients, present as a soft tissue mass often coincidentally following trauma and have a worse prognosis. The imaging characteristics are often nonspecific with mineralized elements in a well-defined soft tissue mass. The mineralized elements may or may not be visible. Magnetic Resonance sequences demonstrate a well circumscribed soft tissue mass with hemorrhagic and enhancing solid components. The pathologic features of extraskeletal osteosarcoma on a microscopic scale are identical to that of skeletal lesions. Likewise, conventional chondrosarcomas present in older patients with a growing, painful soft tissue prominence most commonly involving the long tubular bones. In extraskeletal chondrosarcoma however, the presentation is in somewhat younger patients with a painful soft tissue prominence typically in the head (meninges), neck, or upper leg. The pathologic features are most often that of a myxoid chondrosarcoma which is characterized by strands of small cells over a myxoid matrix. Imaging features include chondroid matrix, heterogenous contrast enhancement, and amorphous internal calcification on Computed Tomography. On Magnetic Resonance sequences the matrix has a low signal on all sequences, and variable inhomogeneity depending on grade of the lesion. Other extraskeletal bone tumors include Ewing's sarcoma and osteoid osteoma amongst other lesions. Although these malignancies may be rare clinical entities, they often exhibit characteristic clinical, imaging, and histopathological findings although differing in treatment and prognosis. Knowledge of these and other common mimicking lesions will help guide the clinician and radiologist to make an accurate diagnosis.

BACKGROUND: Fentanyl is a powerful analgesic, the prescription of which has increased markedly in recent years. The emergence of the drug at the Sydney Medically Supervised Injecting Centre (MSIC) warranted a retrospective clinical audit to assess the risk of fentanyl overdose in comparison with other opioids, in the context of a drug consumption room. METHOD: Heroin, fentanyl or other prescription opioids (PO) injections resulting in overdose were audited (September 1, 2012 and August 31, 2015). Rates of overdose per 1000 injections and relative risks (RR) of overdose were calculated. RESULTS: In the audit period 189,203 injections by 4177 individuals occurred, with fentanyl injections increasing by 1000%, heroin injections increasing by 70% and, inversely, a sharp decline in other PO injections. Fentanyl injections had approximately four and half times the risk of resulting in overdose than heroin or other PO injections combined (RR=4.6); and, had two times the risk of heroin injections, and eight times the risk of resulting in overdose than other PO injections (RR=2.2 and RR=7.9). CONCLUSION: Findings from a drug consumption room, such as the Sydney MSIC can effectively inform harm reduction services and emergency services of the increased use of, and therefore risk of, fentanyl overdose relative to other opioids. The dynamic nature of drug markets mean that services such as MSIC are uniquely placed to provide not only real-time data on drug use trends, but also safer injecting advice to those engaging in new practices.Copyright © 2016. Published by Elsevier B.V. Language: en

Computed tomography (CT) scans are increasingly ordered in the emergent setting, for diagnosis of occult fractures and treatment planning of known fractures or fracture dislocations. Although having inferior soft tissue contrast resolution compared to magnetic resonance imaging (MRI), CT may provide important information regarding tendon pathology that is often under-recognized but may better serve patient outcomes, whether in or out of the operative setting. In this pictorial essay, we present CT cases which demonstrate some of the more commonly encountered tendon abnormalities in patients with acute trauma.

Experiences in smallholder contexts indicate frequent mismatches between technologies introduced and needs of farmers who must make complex decisions in reallocating their limited resources under highly risky ecological and market contexts. This study proposes a cost- and time-effective, easy-to-implement approach to identify farmers’ priorities and critical intervention areas, and presents its application in guiding an agroforestry strategy in Rwanda. It was found that different tree species have distinctive enabling vs. constraining conditions under different agroecological contexts in the perspective of smallholder farmers. Tree species preferred by farmers were not necessarily widely adopted if multitudes of conditions were not enabling. The essential conditions for sustainable adoption include: quality materials/inputs are available; technologies are compatible with existing local farming systems; they are resilient to climate risks/resistant to pests-diseases; management is not complicated; and, there is guaranteed access to markets. The results show that there will not be a silver bullet national strategy to scale up agroforestry. Instead a matrix kind of strategies -to promote enabling conditions and address constraining conditions for priority species in specific agroecologies- will be required. The proposed concept should be further refined for wider agricultural technology transfer debates to break the myths of low uptakes by smallholders.

The aim of this article is to assess a large tertiary care medical center's emergency radiology response after the 2015 Amtrak Philadelphia train derailment.A total of 55 patients with 308 total CTs and radiographs ordered within 12 hours of arrival to Temple University Health System (combining Temple University Hospital and Episcopal Hospital) emergency departments on May 12 to 13, 2015, were included in this study. A retrospective PACS and electronic medical record chart review of emergency department imaging turnaround times (TAT) during this event was completed and compared with emergency department radiology operations for the same 12-hour period throughout the preceding year. Wilcoxon's rank-sum test analysis was performed.A total of 308 CTs and radiographs were performed, and 91 radiologically evident injuries were observed in a total of 30 patients, with fractures (n = 51) as the most common type of injury. There were no significant differences in time from patient arrival to beginning of radiological examination (26 min; interquartile range [IQR], 11-58 min) compared with annual median (28 min; IQR, 10-131 min; P = .232). Examination completion TATs were significantly increased (35 min; IQR, 17-112 min) compared with annual median (10 min; IQR, 5-15 min; P.001), and time required from viewing of the examination by the radiologist to the examination being marked as read was significantly decreased (17 min; IQR, 6-45 min) compared with annual median (248 min; IQR, 126-441 min; P.001).The analysis highlights areas of efficiency in our response but also indicates areas for process improvement in future potential mass casualty events.

Densely populated rural areas in the East African Highlands have faced significant intensification challenges under extreme population pressure on their land and ecosystems. Sustainable agricultural intensification, in the context of increasing cropping intensities, is a prerequisite for deliberate land management strategies that deliver multiple ecosystem goods (food, energy, income sources, etc.) and services (especially improving soil conditions) on the same land, as well as system resilience, if adopted at scale. Tree based ecosystem approaches (TBEAs) are among such multi-functional land management strategies. Knowledge on the multi-functionality of TBEAs and on their scaling up, however, remains severely limited due to several methodological challenges. This study aims at offering an analytical perspective to view multi-functional TBEAs as an integral part of sustainable agricultural intensification. The study proposes a conceptual framework to guide the analysis of socio-economic data and applies it to cross-site analysis of TBEAs in extremely densely populated Rwanda. Heterogeneous TBEAs were identified across Rwanda’s different agro-ecological zones to meet locally-specific smallholders’ needs for a set of ecosystem goods and services on the same land. The sustained adoption of TBEAs would be guaranteed if farmers subjectively recognize their compatibility and synergy with sustainable intensification of existing farming systems, supported by favorable institutional conditions.

The purpose of this article is to describe the injury patterns observed in the 2015 Philadelphia Amtrak train derailment.Fractures accounted for most observed injuries, but uncommon and potentially serious injuries included posterior sternoclavicular dislocation and mesenteric contusion. Imaging plays a critical role in the triage of patients during mass-casualty events, and familiarity with the injury patterns associated with high-velocity unrestrained blunt force trauma will aid diagnosis in any future similar occurrence.

Background: Parental smoking remains a significant risk to the preterm infant both pre and post delivery. Pharmacologically supported interventions have been previously contraindicated in this group during the perinatal period and during breastfeeding. We designed an evidence-based intervention for use in our high-risk population. This report assesses our outcomes after one year. Method: Questionnaire administered a median of 6 months after intervention. Results: There was no significant difference between those participants who returned the survey (n = 42) versus the group as a whole (n = 70). A total of 33% ceased smoking, p < .0001. If no nonresponders ceased smoking then this gives an overall success rate of 20%, p < .0001. Successful quitters had been smoking for a mean of 11 (SD = 7) years. Self-reported light smokers (< 10 cigarettes per day) were significantly more likely to quit (p < .01). Purchase of follow-on nicotine patches was a significant predictor of success in quitting (p = .02). If relapse occurred, it appeared to happen early and was mainly associated with current stressors. Conclusions: We have designed and applied a multidisciplinary intervention for parents and carers to be used in the perinatal period to decrease the postnatal risk for neonatal intensive care graduates. Our rates of successful smoking cessation are as good as, or better than, many published rates for opportunistic intervention. We suggest that randomised trials be focused on ways to further improve interventions at this time of opportunity for these infants and their families.

A case study is given of a conservation management planning exercise underway in Cat Tien National Park and its surrounding areas in southern Vietnam. The importance of reliable information in this process is demonstrated using the Park's mammalian diversity. Opportunities and constraints to engage the local communities in conservation management planning and implementation are reviewed. The spatial element in protected area management planning is stressed; in some areas strict preservation management regimes are needed to conserve critical biodiversity values while in other areas conservation benefits could be gained from engaging local communities in resource management. Pragmatic conservation management planning decisions address identified threats, to be resolved by re-demarcation of boundaries, resettlement of people, and community-based conservation initiatives. These should result in a more viable Park as well as provide more secure livelihood conditions for the people elsewhere. This case study is put in the context of the wider conservation management debate.

This chapter discusses the spectrum of available imaging studies employed in routine diagnostic imaging. Many of the associated advantages, deficiencies, concepts, and applications covered here can guide referring clinicians in selection of the appropriate imaging modality across organ systems, i.e., neurologic, cardiothoracic, gastrointestinal, genitourinary, vascular, and musculoskeletal (MSK). Regardless of the organ system, the choice of the appropriate study depends on multiple factors, including the clinical question to be addressed, the availability and accuracy of the imaging modality, study contraindications, risks of the imaging examination including those from contrast agent administration, and financial cost. Some very brief data regarding the Medicare reimbursements for several commonly ordered imaging examinations is also provided at the end of the chapter (Table 1.1).

Summary Introduction and aims To examine barriers senior rural nurses in New South Wales drug and alcohol clinical settings perceive when considering endorsement to Nurse Practitioner (NP). Design and methods A survey was designed to record views of senior alcohol and drug nurses in rural New South Wales about becoming a NP. Participants were identified by Area Health Service Directors of Drug and Alcohol Services for each Area Health Service in NSW excluding metropolitan Sydney. Forty eight surveys were distributed, with 17 (35%) completed surveys included in the results. Results Of the 17 participants, 12 (70.6%) expressed interest in becoming a NP. The majority (12, 70.6%) were unaware or unsure of endorsement processes. Lack of clarity about the NP role and processes and benefits to becoming a NP was found to be of most concern to all participants. Only 6 participants (35%) indicated they would consider seeking endorsement to NP. Discussion and conclusion Despite agreeing that NP positions in alcohol and drug settings would improve patient access to treatment and care, senior nurses working in these settings in regional areas are unfamiliar with pathways to becoming endorsed. Barriers, such as a lack of internal support from management and colleagues, as well as the fact that respondents reported no foreseeable financial gain in endorsement, also need to be addressed, before more nurses will consider endorsement. Further evaluation of the views of senior nurses in metropolitan alcohol and other drug settings in the process to NP endorsement is needed before clients will benefit from the expertise and enhanced care that NP's may provide.

Although no specific radiographic appearance has emerged to date for the epithelioid subtype of hemangioma, these lesions most typically exhibit well-defined osteolysis. Other relatively common features include surrounding sclerosis, cortical expansion and cortical destruction. We present a case of epithelioid hemangioma of the spine with an unusual radiological appearance which to our knowledge has not previously been reported: diffuse sclerosis of the involved vertebral body. The diffuse sclerosis seen in this case resembles the osteosclerotic process seen not only in benign entities such as subacute and chronic osteomyelitis, but also in malignant lesions such as osteoblastic metastatic disease and lymphoma.