Feasibility of delivering foot and ankle surgical courses in a partnership in Eastern, Central and Sothern Africa

BACKGROUND

Foot and ankle pathology if not treated appropriately and in a timely manner can adversely affect both disability and quality adjusted life years. More so in the low- and middle-income countries where ambulation is the predominant means of getting around for the majority of the population in order to earn a livelihood. This has necessitated the equipping of the new generation of orthopaedic surgeons with the expertise and skills set to manage these conditions. To address this need, surgeons from the British Orthopaedic Foot & Ankle Society (BOFAS) and College of Surgeons of Eastern, Central and Southern Africa (COSECSA) transferred the "Principles of Foot and Ankle Surgery" course to an African regional setting. The course was offered to surgical trainees from 14-member countries of the COSECSA region and previously in the UK. The faculty was drawn from practicing surgeons experienced in both surgical education and foot and ankle surgery. The course comprises didactic lectures, case-based discussions in small groups, patient evaluations and guided surgical dissections on human cadavers. It was offered free to all participants. The feasibility of the course was evaluated using the model defined by Bowen considering the eight facets of acceptability, demand, implementation, practicality, adaptation, integration, expansion and limited efficacy. At the end of the course participants were expected to give verbal subjective feedback and objective feedback using a cloud based digital feedback questionnaire. The course content was evaluated by the participants as "Poor", "Below average", "Average", "Good" and "Excellent", which was converted into a value from 1-5 for analysis. The non-parametric categorical data was analysed using the Two-sample Wilcoxon rank-sum (Mann-Whitney) test, and significance was considered to be p < 0.05.

RESULTS

Six courses in total were held between 2018 and 2020. Three in the UK and three in the COSECSA region. There were 78 participants in the three UK courses and 96 in the three courses run in the COSECSA region. Hundred percent of the UK participants and 97% of the COSECSA participants completed the feedback. Male to female ratio was 4:1 for the UK courses and 10:1 for the COSECSA Courses. In both regions all the participants responded that they would recommend the course to their colleagues. Among the COSECSA participants 91% reported that the course was pitched at the right level, which is similar to the 89% of the UK participants (p = 0.28).

CONCLUSION

The BOFAS Principles of Foot and Ankle Surgery course design provides core knowledge, with an emphasis on clinical examination techniques of the foot and ankle, while at the same time, caters for the anticipated difference in the local clinical case mix and resources. This study establishes that by attending the course surgical trainees can achieve their learning goals in foot and ankle surgery with the same high quality qualitative and quantitative feedback in both regions. This would improve their clinical practice and confidence. The multifaceted approach adopted in this course blending didactic teaching, small group discussions, interactive sessions, case-based discussions, cadaveric surgical skills training printed educational materials and feedback helped fulfil these educational objectives. Working in partnership with local expert orthopaedic surgeons from a number of Sub-Saharan countries, was key to adapting the course to local pathology and the COSECSA setting.

Evidence for a connection between coronavirus disease-19 and exposure to radiofrequency radiation from wireless communications including 5G

BACKGROUND AND AIM

Coronavirus disease (COVID-19) public health policy has focused on the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and its effects on human health while environmental factors have been largely ignored. In considering the epidemiological triad (agent-host-environment) applicable to all disease, we investigated a possible environmental factor in the COVID-19 pandemic: ambient radiofrequency radiation from wireless communication systems including microwaves and millimeter waves. SARS-CoV-2, the virus that caused the COVID-19 pandemic, surfaced in Wuhan, China shortly after the implementation of city-wide (fifth generation [5G] of wireless communications radiation [WCR]), and rapidly spread globally, initially demonstrating a statistical correlation to international communities with recently established 5G networks. In this study, we examined the peer-reviewed scientific literature on the detrimental bioeffects of WCR and identified several mechanisms by which WCR may have contributed to the COVID-19 pandemic as a toxic environmental cofactor. By crossing boundaries between the disciplines of biophysics and pathophysiology, we present evidence that WCR may: (1) cause morphologic changes in erythrocytes including echinocyte and rouleaux formation that can contribute to hypercoagulation; (2) impair microcirculation and reduce erythrocyte and hemoglobin levels exacerbating hypoxia; (3) amplify immune system dysfunction, including immunosuppression, autoimmunity, and hyperinflammation; (4) increase cellular oxidative stress and the production of free radicals resulting in vascular injury and organ damage; (5) increase intracellular Ca2+ essential for viral entry, replication, and release, in addition to promoting pro-inflammatory pathways; and (6) worsen heart arrhythmias and cardiac disorders.

RELEVANCE FOR PATIENTS

In short, WCR has become a ubiquitous environmental stressor that we propose may have contributed to adverse health outcomes of patients infected with SARS-CoV-2 and increased the severity of the COVID-19 pandemic. Therefore, we recommend that all people, particularly those suffering from SARS-CoV-2 infection, reduce their exposure to WCR as much as reasonably achievable until further research better clarifies the systemic health effects associated with chronic WCR exposure.

Water Sensitive Cities Index: A diagnostic tool to assess water sensitivity and guide management actions

Cities are wrestling with the practical challenges of transitioning urban water services to become water sensitive; capable of enhancing liveability, sustainability, resilience and productivity in the face of climate change, rapid urbanisation, degraded ecosystems and ageing infrastructure. Indicators can be valuable for guiding actions for improvement, but there is not yet an established index that measures the full suite of attributes that constitute water sensitive performance. This paper therefore presents the Water Sensitive Cities (WSC) Index, a new benchmarking and diagnostic tool to assess the water sensitivity of a municipal or metropolitan city, set aspirational targets and inform management responses to improve water sensitive practices. Its 34 indicators are organised into seven goals: ensure good water sensitive governance, increase community capital, achieve equity of essential services, improve productivity and resource efficiency, improve ecological health, ensure quality urban spaces, and promote adaptive infrastructure. The WSC Index design is a quantitative framework based on qualitative rating descriptions and a participatory assessment methodology, enabling local contextual interpretations of the indicators while maintaining a robust universal framework for city comparison and benchmarking. The paper demonstrates its application on three illustrative cases. Rapid uptake of the WSC Index in Australia highlights its value in helping stakeholders develop collective commitment and evidence-based priorities for action to accelerate their city's water sensitive transition. Early testing in cities in Asia, the Pacific and South Africa has also showed the potential of the WSC Index internationally.

Water Sensitive Cities Index: A diagnostic tool to assess water sensitivity and guide management actions

Cities are wrestling with the practical challenges of transitioning urban water services to become water sensitive; capable of enhancing liveability, sustainability, resilience and productivity in the face of climate change, rapid urbanisation, degraded ecosystems and ageing infrastructure. Indicators can be valuable for guiding actions for improvement, but there is not yet an established index that measures the full suite of attributes that constitute water sensitive performance. This paper therefore presents the Water Sensitive Cities (WSC) Index, a new benchmarking and diagnostic tool to assess the water sensitivity of a municipal or metropolitan city, set aspirational targets and inform management responses to improve water sensitive practices. Its 34 indicators are organised into seven goals: ensure good water sensitive governance, increase community capital, achieve equity of essential services, improve productivity and resource efficiency, improve ecological health, ensure quality urban spaces, and promote adaptive infrastructure. The WSC Index design as a quantitative framework based on qualitative rating descriptions and a participatory assessment methodology enables local contextual interpretations of the indicators, while maintaining a robust universal framework for city comparison and benchmarking. The paper demonstrates its application on three illustrative cases. Rapid uptake of the WSC Index in Australia highlights its value in helping stakeholders develop collective commitment and evidence-based priorities for action to accelerate their city's water sensitive transition. Early testing in cities in Asia and the Pacific has also showed the potential of the WSC Index internationally.

Modelling transitions in urban water systems

Long term planning of urban water infrastructure requires acknowledgement that transitions in the water system are driven by changes in the urban environment, as well as societal dynamics. Inherent to the complexity of these underlying processes is that the dynamics of a system's evolution cannot be explained by linear cause-effect relationships and cannot be predicted under narrow sets of assumptions. Planning therefore needs to consider the functional behaviour and performance of integrated flexible infrastructure systems under a wide range of future conditions. This paper presents the first step towards a new generation of integrated planning tools that take such an exploratory planning approach. The spatially explicit model, denoted DAnCE4Water, integrates urban development patterns, water infrastructure changes and the dynamics of socio-institutional changes. While the individual components of the DAnCE4Water model (i.e. modules for simulation of urban development, societal dynamics and evolution/performance of water infrastructure) have been developed elsewhere, this paper presents their integration into a single model. We explain the modelling framework of DAnCE4Water, its potential utility and its software implementation. The integrated model is validated for the case study of an urban catchment located in Melbourne, Australia.

Towards water sensitive cities in Asia: an interdisciplinary journey

Rapid urbanisation, population growth and the effects of climate change drive the need for sustainable urban water management (SUWM) in Asian cities. The complexity of this challenge calls for the integration of knowledge from different disciplines and collaborative approaches. This paper identifies key issues and sets the stage for interdisciplinary research on SUWM in Asia. It reports on the initial stages of a SUWM research programme being undertaken at Monash University, Australia, and proposes a framework to guide the process of interdisciplinary research in urban water management. Three key themes are identified: (1) Technology and Innovation, (2) Urban Planning and Design, and (3) Governance and Society. Within these themes 12 research projects are being undertaken across Indonesia, China, India and Bangladesh. This outward-looking, interdisciplinary approach guides our research in an effort to transgress single-discipline solutions and contribute on-ground impact to SUWM practices in Asia.

Gut microbiota drive the development of neuroinflammatory response in cirrhosis in mice

The mechanisms behind the development of hepatic encephalopathy (HE) are unclear, although hyperammonemia and systemic inflammation through gut dysbiosis have been proposed. The aim of this work was to define the individual contribution of hyperammonemia and systemic inflammation on neuroinflammation in cirrhosis using germ-free (GF) and conventional mice. GF and conventional C57BL/6 mice were made cirrhotic using CCl4 gavage. These were compared to their noncirrhotic counterparts. Intestinal microbiota, systemic and neuroinflammation (including microglial and glial activation), serum ammonia, intestinal glutaminase activity, and cecal glutamine content were compared between groups. GF cirrhotic mice developed similar cirrhotic changes to conventional mice after 4 extra weeks (16 vs. 12 weeks) of CCl4 gavage. GF cirrhotic mice exhibited higher ammonia, compared to GF controls, but this was not associated with systemic or neuroinflammation. Ammonia was generated through increased small intestinal glutaminase activity with concomitantly reduced intestinal glutamine levels. However, conventional cirrhotic mice had intestinal dysbiosis as well as systemic inflammation, associated with increased serum ammonia, compared to conventional controls. This was associated with neuroinflammation and glial/microglial activation. Correlation network analysis in conventional mice showed significant linkages between systemic/neuroinflammation, intestinal microbiota, and ammonia. Specifically beneficial, autochthonous taxa were negatively linked with brain and systemic inflammation, ammonia, and with Staphylococcaceae, Lactobacillaceae, and Streptococcaceae. Enterobacteriaceae were positively linked with serum inflammatory cytokines.

CONCLUSION

Gut microbiota changes drive development of neuroinflammatory and systemic inflammatory responses in cirrhotic animals. (Hepatology 2016;64:1232-1248).

The impact of the Major Trauma Network: will trauma units continue to treat complex foot and ankle injuries?

INTRODUCTION

April 1st 2012 saw the introduction of National Trauma Networks in England. The aim to optimise the management of major trauma. Patients with an ISS≥16 would be transferred to the regional Major Trauma Centre (level 1). Our premise was that trauma units (level 2) would no longer manage complex foot and ankle injuries thereby obviating the need for a foot and ankle specialist service.

METHODS

Retrospective analysis of the epidemiology of foot and ankle injuries, using the Gloucestershire trauma database, from a trauma unit with a population of 750,000. Rates of open fractures, complex foot and ankle injuries and requirement for stabilisation with external fixation were reviewed before and after the introduction of the regional Trauma Network. Secondly, using the Trauma Audit & Research Network (TARN) database, all foot and ankle injuries triaged to the regional Major Trauma Centre (MTC) were reviewed.

RESULTS

Incidence of open foot and ankle injuries was 2.9 per 100,000 per year. There were 5.1% open injuries before the network and 3.2% after (p>0.05). Frequency of complex foot and ankle injuries was 4.2% before and 7.5% after the network commenced, showing no significant change. There was no statistically significant change in the numbers of patients with complex foot and ankle injuries treated by application of external fixators. Analysis of TARN data revealed that only 18% of patients with foot and ankle injuries taken to the MTC had an ISS≥16. The majority of these patients were identified as requiring plastic surgical intervention for open fractures (69%) or were polytrauma patients (43%). Only 4.5% of patients had isolated, closed foot and ankle injuries.

CONCLUSION

We found that at the trauma unit there was no decrease in the numbers of complex foot and ankle injuries, open fractures, or the applications of external fixators, following the introduction of the Trauma Network. These patients will continue to attend trauma units as they usually have an ISS<16. Our findings suggest that there is still a need for foot and ankle specialists at trauma units, in order to manage patients with complex foot and ankle injuries.

Enabling sustainable urban water management through governance experimentation

A shift towards sustainable urban water management is widely advocated but poorly understood. There is a growing body of literature claiming that social learning is of high importance in restructuring conventional systems. In particular, governance experimentation, which explicitly aims for social learning, has been suggested as an approach for enabling the translation of sustainability ideas into practice. This type of experimentation requires a very different dynamic within societal relations and necessitates a changed role for professionals engaged in such a process. This empirically focused paper investigates a contemporary governance experiment, the Cooks River Sustainability Initiative, and determines its outcome in terms of enabling social learning for attaining sustainable water practice in an urban catchment. Drawing on the qualitative insights of the actors directly involved in this novel process, this paper provides evidence of changes in individual and collective understanding generated through diverse forms of social interaction. Furthermore, the research reveals perceived key-factors that foster and/or hamper the execution of this new form of experimentation, including project complexity, resource intensity and leadership. Overall, this paper highlights that, while implementation of governance experimentation in a conventional setting can be highly challenging, it can also be highly rewarding in terms of learning.

Realising sustainable urban water management: can social theory help?

It has been acknowledged, in Australia and beyond, that existing urban water systems and management lead to unsustainable outcomes. Therefore, our current socio-technical systems, consisting of institutions, structures and rules, which guide traditional urban water practices, need to change. If a change towards sustainable urban water management (SUWM) practices is to occur, a transformation of our established social-technical configuration that shapes the behaviour and decision making of actors is needed. While some constructive innovations that support this transformation have occurred, most innovations remain of a technical nature. These innovative projects do not manage to achieve the widespread social and institutional change needed for further diffusion and uptake of SUWM practices. Social theory, and its research, is increasingly being recognised as important in responding to the challenges associated with evolving to a more sustainable form of urban water management. This paper integrates three areas of social theories around change in order to provide a conceptual framework that can assist with socio-technical system change. This framework can be utilised by urban water practitioners in the design of interventions to stimulate transitions towards SUWM.

Capacity attributes of future urban water management regimes: projections from Australian sustainability practitioners

Transitioning to more sustainable urban water management is widely accepted as an essential societal objective. While there has been significant progress in developing technical solutions to the challenges faced, numerous barriers remain at the regime level, indicating that further investigation into the regime is required. This paper reports on a social research project aimed at identifying capacity attributes of a more sustainable urban water management regime. Attributes were identified for the administrative and regulatory framework, inter- and intra-organisational and individual regime spheres. Over 125 urban water practitioners specialising in sustainability in Sydney and Melbourne were interviewed to identify the attributes of a more sustainable regime. The attributes reveal that a sustainable urban water management regime emphasises learning, diverse policy tools and institutional arrangements, together with interaction among stakeholders and professional disciplines. The interaction is characterised by respect, trust and mutual understanding. The sustainable regime attributes are compared to the traditional regime and reveal that while progress has been made towards a sustainable regime, additional improvement is required. Attributes identified across multiple regime spheres indicate potential focus areas for capacity building programs or reform efforts to more effectively enable regime change towards sustainable urban water management.

Transitioning to a waterways city: municipal context, capacity and commitment

In Melbourne, Australia, the adoption of Water Sensitive Urban Design (WSUD) and the inclusion of best practice in new urban development has shifted the "drained city" of the 1960s toward an environmentally-oriented "waterways city" for the future. However, the "waterways city" is tenuous owing to the variable commitment of local municipalities to WSUD. This paper reports on the first phase of a social research project, which aims to secure a model of the waterways city by addressing the commitment and capacity deficits of local municipalities. Municipal commitment and capacity across three geographical areas in Melbourne are measured quantitatively using an innovative, comprehensive, and replicable assessment technique. The results show variability in municipal capacity and commitment across the areas, with a pronounced deficit in the rural-regional area. Consequently, intergovernmental attempts to normalise modes of integrated urban water management (such as WSUD) need to include innovative and flexible mechanisms that are responsive to the dynamics of municipal commitment and capacity. These principles have broader application to cities internationally where the management of urban stormwater is the shared responsibility of multiple governments.

Urban water management in cities: historical, current and future regimes

Drawing from three phases of a social research programme between 2002 and 2008, this paper proposes a framework for underpinning the development of urban water transitions policy and city-scale benchmarking at the macro scale. Through detailed historical, contemporary and futures research involving Australian cities, a transitions framework is proposed, presenting a typology of six city states, namely the 'Water Supply City', the 'Sewered City', the 'Drained City', the 'Waterways City', the 'Water Cycle City', and the 'Water Sensitive City'. This framework recognises the temporal, ideological and technological contexts that cities transition through when moving towards sustainable urban water conditions. The aim of this research is to assist urban water managers with understanding the scope of the hydro-social contracts currently operating across cities in order to determine the capacity development and cultural reform initiatives needed to effectively expedite the transition to more sustainable water management and ultimately to Water Sensitive Cities. One of the values of this framework is that it can be used by strategists and policy makers as a heuristic device and/or the basis for a future city state benchmarking tool. From a research perspective it can be an underpinning framework for future work on transitions policy research.

Exploring sustainable urban water governance: a case study of institutional capacity

The sustainable urban water management system is likely to be characterised by complex and flexible governance arrangements, increased inter-organisational interaction and wide stakeholder participation, which contrasts significantly with the traditional approach. Recently there has been significant financial investment in urban water reform, however the reforms have not been as successful as anticipated and numerous institutional barriers remain. Understanding and assessing institutional capacity is central to addressing institutional impediments. Institutional capacity comprises individual, intra- and inter-organisational and external rules and incentives capacities. This paper reports on the first case study of a social research project that aims to develop an institutional capacity assessment framework. Empirical data from semi-structured interviews with 59 water industry experts in Sydney, Australia, and a broad literature survey were used. The key capacity attributes identified could form the basis of an institutional capacity assessment tool and reveal common and differing attributes across stakeholder groups which provide insight into stakeholder relations. Synthesis of the results revealed that intra- and inter-organisational capacities were facing particular challenges and should be explicitly addressed in reform, policy and capacity development initiatives.

Extreme events: being prepared for the pitfalls with progressing sustainable urban water management

It is widely accepted that new, more sustainable approaches to urban water management are required if cities and ecosystems are to become resilient to the effects of growing urban populations and global warming. Climate change predictions show that it is likely that cities around the world will be subject to an increasing number of extreme and less predictable events including flooding and drought. Historical transition studies have shown that major events such as extremes can expedite the adoption of new practices by destabilising existing management regimes and opening up new windows of opportunity for change. Yet, they can also act to reinforce and further entrench old practices. This case study of two Australian cities responding to extreme water scarcity reveals that being unprepared for extremes can undermine progress towards sustainable outcomes. The results showed that despite evidence of significant progress towards sustainable urban water management in Brisbane and Melbourne, the extreme water scarcity acted to reinforce traditional practices at the expense of emerging sustainability niches. Drawing upon empirical research and transitions literature, recommendations are provided for developing institutional mechanisms that are able to respond proactively to extreme events and be a catalyst for SUWM when such opportunities for change arise.

Challenges ahead: social and institutional factors influencing sustainable urban stormwater management in Australia

In a time of climate uncertainty and drought in Australia, improved urban stormwater quality management practices are required not only for protecting waterway health, but also as a fit-for-purpose supply source. To conceive of urban stormwater as an environmental threat as well as a water supply source requires a substantial shift in our traditional linear supply and wastewater structures towards more hybrid and complex infrastructure systems. To understand what drives and limits treatment technology adoption for stormwater management, over 800 urban water professionals in three Australian capital cities completed an online questionnaire survey in November 2006. Using the conceptual framework of receptivity assessment, the results revealed the professional community to be highly associated with the importance of improving stormwater quality for receiving waterway health, yet they do not consider that politicians share this perspective by placing a substantially lower level of importance on stormwater quality management. Significant acquisition barriers within each city, including institutional arrangements, costs, responsibilities, and regulations and approvals processes were all identified as constraining more sustainable practices. Capacity building programs, fostering greater socio-political capital and developing key demonstration projects with training events are recommended as useful policy interventions for addressing current institutional impediments.

The water sensitive city: principles for practice

With the widespread realisation of the significance of climate change, urban communities are increasingly seeking to ensure resilience to future uncertainties in urban water supplies, yet change seems slow with many cities facing ongoing investment in the conventional approach. This is because transforming cities to more sustainable urban water cities, or to Water Sensitive Cities, requires a major overhaul of the hydro-social contract that underpins conventional approaches. This paper provides an overview of the emerging research and practice focused on system resilience and principles of sustainable urban water management Three key pillars that need to underpin the development and practice of a Water Sensitive City are proposed: (i) access to a diversity of water sources underpinned by a diversity of centralised and decentralised infrastructure; (ii) provision of ecosystem services for the built and natural environment; and (iii) socio-political capital for sustainability and water sensitive behaviours. While there is not one example in the world of a Water Sensitive City, there are cities that lead on distinct and varying attributes of the water sensitive approach and examples from Australia and Singapore are presented.

Delivering sustainable urban water management: a review of the hurdles we face

Sustainable urban water management (SUWM) requires an integrated, adaptive, coordinated and participatory approach. Current urban water policies are beginning to reflect this understanding yet the rhetoric is often not translated to implementation. Despite the 'new' philosophy, urban water management remains a complex and fragmented area relying on traditional, technical, linear management approaches. Despite widespread acknowledgement of the barriers to change, there has been little systematic review of what constitutes the scope of such barriers and how these should be addressed to advance SUWM. To better understand why implementation fails to occur beyond ad hoc project interventions, an extensive literature review of observed and studied barriers was conducted. Drawing on local, national and international literature from the field of integrated urban water management and other similar fields, 53 studies were assessed, resulting in a typology of 12 barrier types. The analysis revealed the barriers are largely socio-institutional rather than technical, reflecting issues related to community, resources, responsibility, knowledge, vision, commitment and coordination. Furthermore, the meta-analysis demonstrated a paucity of targeted strategies for overcoming the stated institutional barriers. Evaluation of the typology in relation to capacity building suggests that these systemic issues require a sophisticated programme of change that focuses on fostering social capital, inter-sectoral professional development, and inter-organisational coordination.

Slipped capital femoral epiphysis

Slipped capital femoral epiphysis is a condition likely to be encountered by all practising orthopaedic surgeons. A sound knowledge of the risk factors, presentation, investigation and management is essential to prevent the potentially significant consequences of missing the diagnosis. We present an overview of the condition, along with a review of the relevant literature to date.

Understanding community receptivity to water re-use: Ku-ring-gai Council case study

This social research project investigated community receptivity to using rainwater and greywater as alternative domestic water sources. It was focused in the Ku-ring-gai local government area in northern Sydney, and involved a household questionnaire followed by community leader interviews and resident focus groups. Trends, such as a prolonged drought and increasing population, compound the current crisis and concern facing Sydney's available water supply. Substitution of domestic potable water has been promoted as part of the solution. The research results revealed that community receptivity was highest for external uses, such as watering gardens and flushing toilets, and progressively decreased with increasing personal contact. Receptivity to greywater reuse fell more rapidly with the community believing there was a higher health risk associated with its use. Gender and cultural background were revealed as significant variables and give insight into the design of strategies to target these demographic groups. This evidence provides a reliable stocktake of current receptivity revealing that the community has good awareness and positive association with water reuse for many household activities. This now needs to be harnessed through programs targeted at developing skills, resources and motivation for new water reuse practices and technologies across diverse social groupings.

Implementation impediments to institutionalising the practice of sustainable urban water management

It is now well accepted that there are significant challenges to realising the widespread and self-sustaining implementation of sustainable urban water management. It is argued that these challenges are entrenched within the broader socio-political framework, yet often unsuccessfully addressed within the more narrow scope of improving technical knowledge and design capacity. This hypothesis is investigated through a comparative analysis of three independent research projects investigating different dimensions of the water cycle, including stormwater management in Australia and sanitary waste management and implementation of innovative technologies in the U.K. The analysis reveals significant and common socio-political impediments to improved practice. It was evident that the administrative regime, including implementing professionals and institutions, appears to be largely driven by an implicit expectation that there is a technical solution to solve water management issues. This is in contrast to addressing the issues through broader strategies such as political leadership, institutional reform and social change. It is recognised that this technocratic culture is inadvertently underpinned by the need to demonstrate implementation success within short-term political cycles that conflict with both urban renewal and ecological cycles. Addressing this dilemma demands dedicated socio-technical research programs to enable the much needed shift towards a more sustainable regime.

MRI of medial malleolar bursa

OBJECTIVE

This study was designed to assess the MR appearance of the medial perimalleolar fat in an asymptomatic population and describe the MRI appearance of the medial malleolar bursa.

CONCLUSION

The MRI findings of medial perimalleolar fat in asymptomatic individuals and in patients with suspected medial malleolar bursa include normal fat, minimal or extensive subcutaneous edema, and a fluid-filled sac. The latter pattern is consistent with the MR appearance of the medial malleolar bursa.

A case–control study of erectile dysfunction among men diagnosed with panic disorder

The association between panic disorder and erectile dysfunction (ED) among men was examined in the Integrated Healthcare Information Services National Managed Care Benchmark Database (IHCIS). The IHCIS is a fully de-identified, HIPAA compliant database and includes complete medical history for more than 17 million managed care lives; data from more than 30 US health plans, covering seven census regions; and patient demographics, including morbidity, age and gender. A total of 60,949 ED cases and 243,796 controls were included for analysis. Unconditional logistic regression analyses were first performed to assess the crude risk of ED, and adjusted risks of ED that accounted for comorbid conditions and comedications. A second set of analyses measured the crude and adjusted risks after restricting the patient population to men who were diagnosed with panic disorder at least 1 month prior to an ED diagnosis. In the first set of analyses, men with panic disorder were observed to have more than a two-fold increase in risk for ED (OR=2.29, 95% CI=2.03, 2.58). After adjusting for comorbid conditions, a 52% increase in risk of ED was observed (OR=1.52, 95% CI=1.34, 1.72). Following subsequent adjustment for comorbidities and comedications, a 33% increased risk of ED was detected (OR=1.33, 95% CI=1.17, 1.51). In the second set of analyses studying panic disorder that preceded ED, only a 13% higher risk was noted (OR=1.13, 95% CI=0.97, 1.31). However, after adjusting for comorbid conditions, a 25% reduction in risk was observed (OR=0.75, 95% CI=0.64, 0.88). A 35% risk reduction was seen after adjusting for comorbidities and comedications (OR=0.65, 95% CI=0.56, 0.77).

Antihypertensive treatment and erectile dysfunction in a cohort of type II diabetes patients

The association between different antihypertensive drugs and erectile dysfunction (ED) was examined in a cohort of type II diabetes patients identified in the UK General Practice Research Database (GPRD). The GPRD contains details of diagnoses, prescribing, investigations, risk factors, outcomes, and hospital referrals, together with basic demographic information for approximately six million patients from more than 450 representative general practices throughout the UK. A total of 634 cases and 2526 controls were included for analysis. Unconditional logistic regression analysis was performed to assess the risk of ED after adjusting for age at diabetes diagnosis date, cigarette smoking, depression, glycemic control, use of HMG-CoA reductase inhibitors, use of histamine receptor antagonists, use of digitalis medicines, and use of nitrates. Increased risk of ED was observed among patients taking the following antihypertensives: ACE inhibitors (OR=1.47, 95% CI=1.21, 1.80) and alpha blockers (OR=1.54, 95% CI=1.11, 2.12). However, we identified a nearly 30% reduction in risk among patients on diuretics (OR=0.73, 95% CI=0.54, 0.99). No statistically significant increase in risk was observed among users of beta blockers and calcium channel blockers (OR=1.05, 95% CI=0.85, 1.31) and (OR=1.14, 95% CI=0.91, 1.43), respectively. The results of this study confirm the strong and recognized effect of comorbidities in a diabetic population, but also require additional experimental and observational studies to further understand the potential benefit of diuretics and other ED treatments such as PDE5 inhibitors.

Single-dose gabapentin pharmacokinetics and safety in healthy infants and children

Gabapentin (Neurontin) is a gamma-aminobutyric acid analogue indicated in adults for adjunctive treatment of partial seizures with or without secondary generalization. Two studies were conducted to determine the single-dose pharmacokinetics of gabapentin in healthy subjects age 1 month to 12 years and to guide dose selection in safety and efficacy trials in pediatric patients. Forty-eight subjects were given single oral doses of gabapentin (10 mg/kg) while fasting. Enrollment was homogeneously distributed throughout the age range. Plasma samples were drawn predose and then serially for 24 hours postdose. Single doses of gabapentin were well tolerated by healthy pediatric subjects. Plots of pharmacokinetic parameters versus age suggested significant differences between younger (1 month to < 5 years) and older (> or =5 to 12 years) subjects. Mean area under the plasma concentration-time curve from zero to infinity (AUC(0-infinity)) was 25.6 microg x h/mL in younger subjects and 36.0 microg x h/mL in older subjects (p < 0.001). Corresponding mean peak plasma concentrations (Cmax) were 3.74 and 4.52 microg/ml (p < 0.05). Oral clearance (normalized for body weight) was 7.40 and 4.41 mL/min/kg in younger subjects and older subjects, respectively (p < 0.001). It was concluded that children between 1 month and < 5 years of age require approximately 30% higher daily doses of gabapentin than those > or =5 to 12 years of age.

MR imaging of exercise-induced lower leg pain

MR imaging of the lower leg is frequently performed to evaluate the active patient who presents with an exercise-induced injury. This article discusses both common and obscure osseous and soft tissue conditions that are seen in the athletic population with leg pain.

The C sign: more specific for flatfoot deformity than subtalar coalition

OBJECTIVE

To assess the sensitivity and specificity of the C sign, a C-shaped line created by the outline of the talar dome and the inferior margin of the sustentaculum tali on lateral ankle radiographs, for patients with both flatfoot deformity and specifically talocalcaneal (TC) coalition.

DESIGN AND PATIENTS

All patients in this retrospective study were under 35 years of age and had a lateral ankle radiograph and follow-up CT scan for a non-traumatic indication. Forty-eight cases over the past 5 years fulfilled these criteria. Two masked musculoskeletal radiologists determined the presence or absence of the C sign for each lateral radiograph by consensus. Each CT study was then assessed by a third musculoskeletal radiologist for the presence of tarsal coalition. Observations were correlated with clinical history regarding presence or absence of flatfoot deformity.

RESULTS

Ten cases of TC coalition were diagnosed, four of which demonstrated a C sign (40%). Eight cases with a C sign were encountered, four of which had TC coalition (50%) and four did not. All patients with a positive C sign had a flatfoot clinically (100%), while only eight of 24 flatfooted patients had a C sign (33%).

CONCLUSION

The C sign is specific, but not sensitive, for flatfoot deformity, and is neither sensitive nor specific for subtalar coalition.

Is a mixture of gadolinium and iodinated contrast material safe during MR arthrography?

OBJECTIVE

This study was designed to determine whether a mixture of iodinated contrast material and gadopentetate dimeglumine used during MR arthrography yields free gadolinium ion, a systemically toxic metal.

MATERIALS AND METHODS

Mixtures of commercially available nonionic and ionic iodinated contrast agent, gadopentetate dimeglumine, lidocaine, and epinephrine were analyzed using a spectrophotometric titration with a gadolinium ion titrant and methyl thymol blue indicator.

RESULTS

We found no significant dissociation of gadolinium ion when gadopentetate dimeglumine was mixed with iodinated contrast agents, lidocaine, or epinephrine in any of the dilutions tested.

CONCLUSION

Gadopentetate dimeglumine and iodinated contrast material can be mixed before MR imaging without any release of free gadolinium and are therefore safe for confirming the intraarticular placement of contrast material before MR arthrography.

Traumatic musculotendinous injuries of the knee: diagnosis with MR imaging

Magnetic resonance (MR) imaging is the imaging modality of choice for evaluation of acute traumatic musculotendinous injuries of the knee. Three discrete categories of acute injuries to the musculotendinous unit can be defined: muscle contusion, myotendinous strain, and tendon avulsion. Among the quadriceps muscles, the rectus femoris is the most susceptible to injury at the myotendinous junction due to its superficial location, predominance of type II fibers, eccentric muscle action, and extension across two joints. Among the muscles of the pes anserinus, the sartorius is the most susceptible to strain injury due to its superficial location and biarticular course. The classic fusiform configuration of the semimembranosus along with a propensity for eccentric actions also make it prone to strain injury. MR imaging findings associated with rupture of the iliotibial tract include discontinuity and edema, which are best noted on coronal images. The same mechanism of injury that tears the arcuate ligament from its fibular insertion can also result in avulsion injury of the biceps femoris. The gastrocnemius muscle is prone to strain injury due to its action across two joints and its superficial location. Injuries of the muscle belly and myotendinous junction of the popliteus are far more common than tendinous injuries.

Melorheostosis: case report with radiologic-pathologic correlation

Melorheostosis is an unusual mesenchymal dysplasia, which commonly presents on radiographs as longitudinal bars of hyperostosis in osseous structures. We present a case of melorheostosis in the lower extremity of a 20-year-old woman for which detailed radiologic- pathologic correlation was achieved due to amputation of the involved limb.

Vitamin effects on tryptophan-niacin metabolism in primary hepatoma patients

Metabolism of 14C-labeled tryptophan and 3-hydroxyanthranilic acid were administered to early hepatoma patients to evaluate the conversion of these precursors to niacin metabolites and to assess the effect of dietary supplementation with vitamin B-6, riboflavin, thiamin and vitamin C on the extent of conversion. Expired labeled carbon dioxide and urinary excretion of picolinic acid (PA), quinolinic acid (QA), nicotinic acid (NA), N1-methylnicotinamide (N1MeNAm) and N1-methyl-2-pyridone-5-carboxamide (MPCA) were measured by carrier isolations. There were no consistent statistical differences in these conversions before and after vitamin supplementation, suggesting that the patients' nutrition was adequate and that none of the vitamins were rate-limiting under these conditions.

Flt3-ligand induces transient tumor regression in an ectopic treatment model of major histocompatibility complex-negative prostate cancer

We assessed the in vivo efficacy of Flt3-ligand (Flt3-L) treatment in C57BL/6 mice bearing a well-established MHC class I-negative prostate carcinoma TRAMP-C1. Flt3-L immunotherapy was initiated approximately 30 days after tumor inoculation, a time when > or =80% of the mice had palpable TRAMP-C1 tumors. Treatment with Flt3-L at 10 microg/day for 21 consecutive days suppressed TRAMP-C1 tumor growth and induced tumor stabilization (P = 0.0337). Enhanced tumor regression was demonstrated at a higher dose of 30 microg/day (P < 0.0001). Tumors excised from mice treated with Flt3-L were smaller than carrier-treated controls and contained a more pronounced mixed inflammatory cell infiltrate primarily composed of mphi. In regressor nice, tumors reappeared at the site of injection when Flt3-L therapy was terminated. When the experiment was repeated with MHC class I-positive TRAMP-C1 cells, tumor stabilization and/or regression was again observed after treatment (P < 0.0001); however, once again, tumors reappeared after the termination of therapy despite an extended treatment schedule (35 days). MHC class I-negative variants were present in tumors isolated from carrier- and Flt3-L-treated mice, and this phenotype could be reversed by IFN-gamma treatment in vitro. Thus, Flt3-L treatment of mice with preexisting transplantable prostate tumors results in tumor regression that is dose-dependent and accompanied by a pronounced mixed-cell inflammatory tumor infiltrate. However, disease relapse was invariably observed after the termination of therapy, which suggests that Flt3-L treatment of advanced MHC- prostate cancers will require adjuvant modalities to achieve a durable response.

Allometric pharmacokinetic scaling: towards the prediction of human oral pharmacokinetics

PURPOSE

To evaluate (1) allometric scaling of systemic clearance (CL) using unbound drug concentration, (2) the potential usage of brain weight (BRW) correction in allometric scaling of both CL and oral clearance (CL/F).

METHODS

Human clearance was predicted allometrically (CLu = a x W(biv)) using unbound plasma concentration for eight Parke-Davis compounds and 29 drugs from literature sources. When the exponent b(iv) was higher than 0.85, BRW was incorporated into the allometric relationship (CLu*BRW = a x W(biv)). This approach was also applied to the prediction of CLu/F for 10 Parke-Davis compounds. Human oral t1/2, Cmax, AUC, and bioavailability were estimated based on allometrically predicted pharmacokinetic (PK) parameters.

RESULTS

Human CL and CL/F were more accurately estimated using unbound drug concentration and the prediction was further improved when BRW was incorporated into the allometric relationship. For Parke-Davis compounds, the predicted human CL and CL/F were within 50-200% and 50-220% of the actual values, respectively. The estimated human oral t1/2, Cmax, and AUC were within 82-220%, 56-240%, and 73-190% of the actual values for all 7 compounds, suggesting that human oral PK parameters of those drugs could be reasonably predicted from animal data.

CONCLUSIONS

Results from the retrospective analysis indicate that allometric scaling of free concentration could be applied to orally administered drugs to gain knowledge of drug disposition in man, and to help decision-making at early stages of drug development.

A new classification for cervical vertebral injuries: influence of CT

OBJECTIVE

Computed tomography (CT) has been demonstrated to be superior to radiography in identifying cervical vertebral injuries. However, many of these injuries may not be clinically significant, and require only minimal symptomatic and supportive treatment. It is therefore imperative that radiologists and spine surgeons have criteria for distinguishing between those injuries requiring surgical stabilization and those that do not. The authors propose a new classification of cervical vertebral injuries into two categories: major and minor.

DESIGN AND PATIENTS

A data base, acquired on 1052 separate cervical injuries in 879 patients seen between 1983 and 1998, was reviewed. Four categories of injury based on mechanism [hyperflexion (four variants), hyperextension (two variants), rotary (two variants), and axial compression (five variants)] were identified. "Major" injuries are defined as having either radiographic or CT evidence of instability with or without associated localized or central neurologic findings, or have the potential to produce the latter. "Minor" injuries have no radiographic and/or CT evidence of instability, are not associated with neurologic findings, and have no potential to cause the latter.

RESULTS AND CONCLUSIONS

Cervical injury should be classified as "major" if the following radiographic and/or CT criteria are present: displacement of more than 2 mm in any plane, wide vertebral body in any plane, wide interspinous/interlaminar space, wide facet joints, disrupted posterior vertebral body line, wide disc space, vertebral burst, locked or perched facets (unilateral or bilateral), "hanged man" fracture of C2, dens fracture, and type III occipital condyle fracture. All other types of fractures may be considered "minor".

Evaluation of the postoperative meniscus of the knee: a study comparing conventional arthrography, conventional MR imaging, MR arthrography with iodinated contrast material, and MR arthrography with gadolinium-based contrast material

OBJECTIVE

To compare four imaging methods in the evaluation of the postoperative meniscus: conventional arthrography, conventional MR imaging, MR arthrography with iodinated contrast material, and MR arthrography with gadolinium-based contrast material.

DESIGN AND PATIENTS

Thirty-three patients referred for knee MR examinations with a history of meniscal surgery were studied prospectively. At the first patient visit, conventional MR examination was followed by an MR arthrogram with gadolinium-based contrast material. At the second visit, a conventional arthrogram with iodinated contrast material was followed immediately by an MR examination. Imaging examinations were interpreted by a masked reader, and then compared with the results of repeat arthroscopic surgery in 12 patients.

RESULTS

The correct evaluation of the status of postoperative menisci was allowed in 12 of 13 patients (92%) by MR arthrography using gadolinium-based contrast agent, 10 of 13 patients (77%) by conventional MR examination, 9 of 12 patients (75%) by MR arthrography, and 7 of 12 patients (58%) by conventional arthrography.

CONCLUSION

Intra-articular fluid is advantageous in the evaluation of patients with a suspected meniscal retear. MR arthrography with gadolinium-based contrast material is the most accurate imaging method for the diagnosis of meniscal retears.

Caffeine based measures of CYP1A2 activity correlate with oral clearance of tacrine in patients with Alzheimer's disease

AIMS

To study the potential utility of caffeine based probes of CYP1A2 enzyme activity in predicting the pharmokinetics of tacrine in patients with Alzheimer's disease.

METHODS

The pharmokinetics of a single 40 mg oral dose of tacrine were measured in 19 patients with Alzheimer's disease. Each patient also received 2 mg kg(-1) [13C-3-methyl] caffeine orally and had breath and urine samples collected.

RESULTS

Tacrine oral clearance (CL F(-1) kg(-1)), which varied 15-fold among the patients, correlated significantly with the 2 h total production of 13CO2 in breath (r=0.56, P=0.01), and with each of two commonly used urinary caffeine metabolite ratios: the 'paraxanthine/caffeine ratio' (1,7X + 1, 7U)/1,3,7X) (r=0.76, P=0.0002) and the 'caffeine metabolic ratio' (AFMU + 1X + 1U)/1, 7U)(r=0.76, P=0.0001).

CONCLUSIONS

These observations support a central role for CYP1A2 in the in vivo disposition of tacrine and the potential for drug interactions when tacrine treated patients receive known inducers or inhibitors of this enzyme. The magnitude of the correlations we observed, however, are probably not sufficient to be clinically useful in individualizing tacrine therapy.

Prevalence and patterns of tendon calcification in patients with chondrocalcinosis of the knee: radiologic study of 156 patients

The presence or absence of tendon calcification was studied at six anatomic sites: Achilles, gastrocnemius, quadriceps, triceps (elbow), triceps long head (shoulder), and rotator cuff. The morphology of the calcifications was categorized in 156 patients with chondrocalcinosis in the knee. Achilles tendon, gastrocnemius, and quadriceps tendon calcifications were most common, ranging from 21%-25% of our patient population was thin linear bands. Triceps calcification at the elbow, rotator cuff calcifications, and long head of triceps tendon calcification were less common.

Glenohumeral joint: comparison of shoulder positions at MR arthrography

PURPOSE

To compare neutral, external rotation, and abduction external rotation positions of the glenohumeral joint during magnetic resonance (MR) arthrography in the assessment of the joint capsule, biceps-labral complex, and glenohumeral ligaments.

MATERIALS AND METHODS

MR imaging with intraarticular administration of gadopentetate dimeglumine was performed in 10 adult cadaveric glenohumeral joints. Fat-suppressed oblique coronal, oblique sagittal, and axial. T1-weighted spin-echo imaging and axial three-dimensional spoiled gradient-recalled imaging were performed with each shoulder in the neutral, external rotation, and abduction external rotation positions. Shoulders were sectioned in the planes that yielded optimal MR images. Anatomic and MR imaging findings were correlated.

RESULTS

The biceps-labral complex was best visualized on oblique coronal and axial images obtained in external rotation. Oblique axial abduction external rotation imaging best delineated the inferior glenohumeral ligament but did not improve assessment of the superior and middle glenohumeral ligaments in comparison with findings in neutral and external rotation.

CONCLUSION

Although MR arthrography of the glenohumeral joint clearly delineates the biceps-labral complex and glenohumeral ligaments, external rotation of the shoulder optimizes visualization of the former structures. Abduction external rotation is the best position for evaluation of the inferior glenohumeral ligament and anterior capsular attachment.

Evaluation of the triangular fibrocartilage and the scapholunate and lunotriquetral ligaments in cadavers with low-field-strength extremity-only magnet. Comparison of available imaging sequences and macroscopic findings

RATIONALE AND OBJECTIVES

The authors assessed the ability of a low-field-strength extremity-only magnet to provide visualization of the triangular fibrocartilage and the scapholunate and lunotriquetral ligaments.

METHODS

Twelve human wrists were examined with a 0.2 T extremity-only magnet. T1-weighted spin echo, proton density-weighted, and T2-weighted turbo spin echo, short-tau inversion recovery, and three-dimensional gradient recalled echo images were acquired, and sections of the specimens were then made that corresponded to the magnetic resonance images. Masked imaging analyses were correlated with macroscopic and limited histopathologic findings.

RESULTS

Low-field-strength extremity-only magnet allowed consistent visualization of the triangular fibrocartilage and accurate assessment of a small number of complete tears of the triangular fibrocartilage. The scapholunate ligaments in all cases were identified using a combination of imaging sequences. Consistent visualization of the lunotriquetral ligament with a low-field-strength extremity magnet was difficult.

CONCLUSIONS

Magnetic resonance imaging with a low-field-strength extremity-only magnet can be used to visualize the triangular fibrocartilage and the scapholunate ligament, but not the lunotriquetral ligament.

Extrinsic and intrinsic ligaments of the wrist: normal and pathologic anatomy at MR arthrography with three-compartment enhancement

The ligaments of the wrist have been demonstrated with magnetic resonance (MR) imaging by many authors. Distinction has been made between the extrinsic, or radiocarpal and ulnocarpal, ligaments and the intrinsic, or intercarpal, ligaments. The stability of the wrist depends on numerous ligaments: The volar ligaments are important stabilizers of the wrist, whereas the dorsal ligaments are less crucial for wrist stability. An MR imaging protocol that demonstrates these structures with high resolution has been developed. Cadaveric wrists are imaged with a spoiled gradient-recalled-echo volume-acquisition technique with fat suppression after three-compartment enhancement with a contrast agent containing gadolinium. The specimens are then sectioned, and the anatomic and pathologic findings are correlated with the findings on the MR images. The extrinsic and intrinsic ligaments of the wrist are clearly demonstrated with this technique. This protocol was designed for anatomic study and promotes understanding of the anatomy and biomechanics of the wrist; it is not intended for clinical use.

4-Hydroxynonenal, a product of lipid peroxidation, damages cholinergic neurons and impairs visuospatial memory in rats

The mechanisms that underlie cholinergic neuronal degeneration in Alzheimer disease (AD) are unclear, but recent data suggest that oxidative stress plays a role. We report that 4-hydroxynonenal (HNE), an aldehydic product of lipid peroxidation, damages and kills basal forebrain cholinergic neurons when administered intraparenchymally. Examination of Nissl-stained brain sections following unilateral HNE infusion revealed widespread neuronal loss in basal forebrain ipsilateral to the injection, but not on the contralateral side. Levels of choline acetyltransferase activity and immunoreactivity in the ipsilateral basal forebrain and hippocampus were significantly reduced by 60-80% seven days following HNE administration. Performance in Morris water maze tasks of visuospatial memory was severely impaired in a dose-dependent manner seven days following bilateral administration of HNE. Bilateral infusion of FeCl2 (an inducer of membrane lipid peroxidation) into the basal forebrain caused neuron loss and decreased choline acetyltransferease immunoreactivity and deficits in visuospatial memory. Additionally, FeCl2 infusion increased HNE immunoreactivity, implicating HNE in iron-induced oxidative damage. Because recent studies have demonstrated HNE adducts in degenerating neurons in AD brain, the present findings suggest a role for HNE in damage to cholinergic neurons in AD.

Purified streptococcal cell wall (PG-APS) causes experimental otitis media

Purified peptidoglycan-polysaccharide from Group A Streptococcus pyogenes cell wall (PG-APS) was prepared under sterile, pyrogen-free conditions and injected percutaneously into the middle ear cavities (MEC) of groups of gerbils. Each group was observed otoscopically at 1, 2, 5, 7, 9, 12 and 14 days. Histologic specimens were obtained from each group at 2, 5, 7, 9 and 14 days. Histologically, PG-APS produced mild, acute inflammation during the first 3 days and mild to moderate inflammation with features of both acute and chronic pathology from days 5 through 9. An early response by plasma cells and macrophages was seen. Most animals had recovered with minor sequelae by day 14. Challenge intraperitoneally with 20 micrograms of PG-APS at 14 days following MEC injection of PG-APS did not exacerbate the middle ear inflammation. Five chinchillas, tested for comparison, responded similarly to PG-APS.