Spatiotemporal distribution of Borrelia miyamotoi (Spirochaetales: Spirochaetaceae) and coinfection with other tick-borne pathogens in host-seeking Ixodes scapularis (Acari: Ixodidae) from New York State, USA

Blacklegged ticks (Ixodes scapularis Say, Acari: Ixodidae) were collected from 432 locations across New York State (NYS) during the summer and autumn of 2015-2020 to determine the prevalence and geographic distribution of Borrelia miyamotoi (Spirochaetales: Spirochaetaceae) and coinfections with other tick-borne pathogens. A total of 48,386 I. scapularis were individually analyzed using a multiplex real-time polymerase chain reaction assay to simultaneously detect the presence of Bo. miyamotoi, Borrelia burgdorferi (Spirochaetales: Spirochaetaceae), Anaplasma phagocytophilum (Rickettsiales: Anaplasmataceae), and Babesia microti (Piroplasmida: Babesiidae). Overall prevalence of Bo. miyamotoi in host-seeking nymphs and adults varied geographically and temporally at the regional level. The rate of polymicrobial infection in Bo. miyamotoi-infected ticks varied by developmental stage, with certain co-infections occurring more frequently than expected by chance. Entomological risk of exposure to Bo. miyamotoi-infected nymphal and adult ticks (entomological risk index [ERI]) across NYS regions in relation to human cases of Bo. miyamotoi disease identified during the study period demonstrated spatial and temporal variation. The relationship between select environmental factors and Bo. miyamotoi ERI was explored using generalized linear mixed effects models, resulting in different factors significantly impacting ERI for nymphs and adult ticks. These results can inform estimates of Bo. miyamotoi disease risk and further our understanding of Bo. miyamotoi ecological dynamics in regions where this pathogen is known to occur.

Associations of Anaplasma phagocytophilum Bacteria Variants in Ixodes scapularis Ticks and Humans, New York, USA

Anaplasmosis, caused by the tickborne bacterium Anaplasma phagocytophilum, is an emerging public health threat in the United States. In the northeastern United States, the blacklegged tick (Ixodes scapularis) transmits the human pathogenic genetic variant of A. phagocytophilum (Ap-ha) and a nonpathogenic variant (Ap-V1). New York has recently experienced a rapid and geographically focused increase in cases of anaplasmosis. We analyzed A. phagocytophilum-infected I. scapularis ticks collected across New York during 2008-2020 to differentiate between variants and calculate an entomological risk index (ERI) for each. Ap-ha ERI varied between regions and increased in all regions during the final years of the study. Space-time scan analyses detected expanding clusters of Ap-ha located within documented anaplasmosis hotspots. Ap-ha ERI was more positively correlated with anaplasmosis incidence than non-genotyped A. phagocytophilum ERI. Our findings help elucidate the relationship between the spatial ecology of A. phagocytophilum variants and anaplasmosis.

Predicting spatio-temporal population patterns of Borrelia burgdorferi, the Lyme disease pathogen

The causative bacterium of Lyme disease, Borrelia burgdorferi, expanded from an undetected human pathogen into the etiologic agent of the most common vector-borne disease in the United States over the last several decades. Systematic field collections of the tick vector reveal increases in the geographic range and prevalence of B. burgdorferi-infected ticks that coincided with increases in human Lyme disease incidence across New York State.We investigate the impact of environmental features on the population dynamics of B. burgdorferi. Analytical models developed using field collections of nearly 19,000 nymphal Ixodes scapularis and spatially and temporally explicit environmental features accurately explained the variation in the nymphal infection prevalence of B. burgdorferi across space and time.Importantly, the model identified environmental features reflecting landscape ecology, vertebrate hosts, climatic metrics, climate anomalies and surveillance efforts that can be used to predict the biogeographical patterns of B. burgdorferi-infected ticks into future years and in previously unsampled areas.Forecasting the distribution and prevalence of a pathogen at fine geographic scales offers a powerful strategy to mitigate a serious public health threat. Synthesis and applications. A decade of environmental and tick data was collected to create a model that accurately predicts the infection prevalence of Borrelia burgdorferi over space and time. This predictive model can be extrapolated to create a high-resolution risk map of the Lyme disease pathogen for future years that offers an inexpensive approach to improve both ecological management and public health strategies to mitigate disease risk.

A Comparative Spatial and Climate Analysis of Human Granulocytic Anaplasmosis and Human Babesiosis in New York State (2013-2018)

Human granulocytic anaplasmosis (HGA) and human babesiosis are tick-borne diseases spread by the blacklegged tick (Ixodes scapularis Say, Acari: Ixodidae) and are the result of infection with Anaplasma phagocytophilum and Babesia microti, respectively. In New York State (NYS), incidence rates of these diseases increased concordantly until around 2013, when rates of HGA began to increase more rapidly than human babesiosis, and the spatial extent of the diseases diverged. Surveillance data of tick-borne pathogens (2007 to 2018) and reported human cases of HGA (n = 4,297) and human babesiosis (n = 2,986) (2013-2018) from the New York State Department of Health (NYSDOH) showed a positive association between the presence/temporal emergence of each pathogen and rates of disease in surrounding areas. Incidence rates of HGA were higher than human babesiosis among White and non-Hispanic/non-Latino individuals, as well as all age and sex groups. Human babesiosis exhibited higher rates among non-White individuals. Climate, weather, and landscape data were used to build a spatially weighted zero-inflated negative binomial (ZINB) model to examine and compare associations between the environment and rates of HGA and human babesiosis. HGA and human babesiosis ZINB models indicated similar associations with forest cover, forest land cover change, and winter minimum temperature; and differing associations with elevation, urban land cover change, and winter precipitation. These results indicate that tick-borne disease ecology varies between pathogens spread by I. scapularis.

Epidemiology and Spatial Emergence of Anaplasmosis, New York, USA, 2010‒2018

Human granulocytic anaplasmosis, a tickborne disease caused by the bacterium Anaplasma phagocytophilum, was first identified during 1994 and is now an emerging public health threat in the United States. New York state (NYS) has experienced a recent increase in the incidence of anaplasmosis. We analyzed human case surveillance and tick surveillance data collected by the NYS Department of Health for spatiotemporal patterns of disease emergence. We describe the epidemiology and growing incidence of anaplasmosis cases reported during 2010–2018. Spatial analysis showed an expanding hot spot of anaplasmosis in the Capital Region, where incidence increased >8-fold. The prevalence of A. phagocytophilum increased greatly within tick populations in the Capital Region over the same period, and entomologic risk factors were correlated with disease incidence at a local level. These results indicate that anaplasmosis is rapidly emerging in a geographically focused area of NYS, likely driven by localized changes in exposure risk.

Normal CMR bi-atrial and biventricular reference values in sickle cell disease patients without heart damage

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The MIOT project receives “no-profit support” from industrial sponsorships (Chiesi Farmaceutici S.p.A., ApoPharma Inc.).

Background. Cardiac function indices in patients with hemoglobinopathies are different from those in healthy population, mainly due to chronic anemia. Normal reference values specific for SCD patients are not available by CMR.

Aim. We aimed to define the normal cut-off value in SCD patients for bi-atrial and biventricular cardiac magnetic resonance (CMR) parameters.

Methods. We considered forty-eight adult SCD patients with no known risk factors or cardiac disease, normal electrocardiogram, no macroscopic myocardial fibrosis, and all cardiac segments with T2*≥20 ms, consecutively enrolled in the MIOT network (Myocardial iron overload in thalassemia). SCD patients were compared with ninety-six healthy controls and 96 thalassemia major (TM) patients without cardiac damage, both matched for age and gender. Nine pediatric SCD patients were also analysed in comparison with 9 TM patients and 9 healthy subjects matched for age and gender. Cine images were acquired to quantify biventricular function parameters: LV and RV end-diastolic volume (EDV), end-systolic volume (ESV) and stroke volume (SV) were normalized for body surface area (EDVI, ESVI, SVI), as well as biventricular mass and atrial areas. Myocardial iron overload was assessed by segmental T2* technique. Late gadolinium enhancement (LGE) images were acquired for evaluation of macroscopic myocardial fibrosis.

Results. In all three groups males showed higher biventricular volumes and mass indexes than females. SCD male patients had significantly higher LVEDVI (p < 0.0001), LVESVI (p = 0.010), LVSVI (p = 0.003), cardiac index (p = 0.002), LV and RV mass index  (p = 0.008 and p = 0.001, respectively) and left and right atrial areas (p < 0.001 and p = 0.011) than healthy subjects. No significant differences were found in RVEDVI, EVESVI and biventricular EF. Compared to healthy volunteers, females with SCD showed a larger LVEDVI (p = 0.020), LVSVI (p = 0.039), RV mass index (p = 0.002) and left atrial area (p = 0.008).

SCD and TM patients showed comparable values of bi-atrial and biventricular volumes and function. When compared to TM, SCD patients showed a larger LV (p < 0.001) and RV mass index (p = 0.001) in male group and a larger RV mass index (p = 0.001) in female group. Table 1 shows the cut-offs for bi-atrial and biventricular MR parameters for adult SCD patients by gender.

No significant differences in MR parameters were found among the pediatric groups.

Conclusions. Normal reference ranges of bi-atrial and biventricular MR parameters for adult males and females SCD patients were established. The use of these reference values will prevent possible misdiagnosis of cardiomyopathy in patients with SCD.

Spatio-temporal variation in environmental features predicts the distribution and abundance of Ixodes scapularis

Many species have experienced dramatic changes in both geographic range and population sizes in recent history. Increases in the geographic range or population size of disease vectors have public health relevance as these increases often precipitate the emergence of infectious diseases in human populations. Accurately identifying environmental factors affecting the biogeographic patterns of vector species is a long-standing analytical challenge, stemming from a paucity of data capturing periods of rapid changes in vector demographics. We systematically investigated the occurrence and abundance of nymphal Ixodes scapularis ticks at 532 sampling locations throughout New York State (NY), USA, between 2008 and 2018, a time frame that encompasses the emergence of diseases vectored by these ticks. Analyses of these field-collected data demonstrated a range expansion into northern and western NY during the last decade. Nymphal abundances increased in newly colonised areas, while remaining stable in areas with long-standing populations over the last decade. These trends in the geographic range and abundance of nymphs correspond to both the geographic expansion of human Lyme disease cases and increases in incidence rates. Analytic models fitted to these data incorporating time, space, and environmental factors, accurately identified drivers of the observed changes in nymphal occurrence and abundance. These models accounted for the spatial and temporal variation in the occurrence and abundance of nymphs and can accurately predict nymphal population patterns in future years. Forecasting disease risk at fine spatial scales prior to the transmission season can influence both public health mitigation strategies and individual behaviours, potentially impacting tick-borne disease risk and subsequently human disease incidence.

First Recognized Human Bite in the United States by the Asian Longhorned Tick, Haemaphysalis longicornis

We present the case summary of the first human recognized to have been bitten by the Haemaphysalis longicornis tick in the United States, which occurred in New York State. Subsequent field studies confirmed that this tick was present in multiple geographic locations near the patient's residence, including on manicured lawns.

Assessment of Duration of Tick Feeding by the Scutal Index Reduces Need for Antibiotic Prophylaxis After Ixodes scapularis Tick Bites

Doxycycline is recommended for persons with Ixodes scapularis tick bites in certain geographic areas, if the tick had fed for at least 36 hours. Based on the scutal index, over 40% of I. scapularis tick bites from patients seen at the Lyme Disease Diagnostic Center did not warrant antibiotic prophylaxis.

MRI and US in the evaluation of fetal anomalies: The need to work together

PURPOSE

Real-time virtual sonography (RVS) is a new technique that synchronizes real-time ultrasonography (US) and multiplanar reconstructed magnetic resonance imaging (MRI). The purpose of this study was to evaluate the feasibility and ability of RVS to assess the main pathologies in fetuses with suspected US anomalies.

METHOD AND MATERIALS

Real-time virtual sonography (Hitachi, HI VISION Ascendus) was offered to 30 patients who had undergone fetal MRI. The acquired MRI image dataset was loaded into the fusion system and displayed together with the real-time US image. The ability of RVS to assess the main anatomical sites and fetal anomalies was evaluated.

RESULTS

Real-time virtual sonography was technically possible in all cases. From a total of 30 patients, RVS helped the diagnosis in 10 cases. In 15 cases of encephalic pathology, fusion imaging improved the accuracy of the diagnosis; in the other 5 cases, MRI was superior to US even when using the RVS.

CONCLUSION

This is a study on the feasibility and practical use of RVS. Thanks to information from both US and MRI, RVS allowed better identification of the fetal pathologies and improved the performance of the ultrasound examination. In our experience, it was really helpful in pathologies that would benefit from US follow-up.

Early and late onset complications of gynaecologic surgery: a multimodality imaging approach

The role of imaging after surgery is pivotal to drive clinical management of early and/or late onset complications. Most frequently used imaging technique after pelvic surgery is Ultrasound (US), Magnetic Resonance Imaging (MRI) and Computed Tomography (CT). While Ultrasound is a standard procedure, using grey scale and/or colour Doppler evaluation, MRI and CT scan protocols should be derived on the basis of the specific indication of the exam. Correct evaluation of female pelvis after gynaecologic surgery, having in mind the most frequent complications, is based on the correct use of the instruments and on the experience of the examiner, who should be aware of the history of the patient, type of surgery and clinical symptoms for which the exam is required; the clinician should be aware of the possibilities and limits of the different techniques, in order to choose the most appropriate imaging modality and promptly make a correct diagnosis.

Magnetic resonance imaging of fetal heart: anatomical and pathological findings

Congenital heart disease is one of the most frequent prenatal malformation representing an incidence of 5/1000 live births; moreover, it represents the first cause of death in the first year of life. There is a wide range of severity in congenital heart malformations from lesions which require no treatment such as small ventricular septal defects, to lesions which can only be treated with palliative surgery such as hypoplastic left heart syndrome. A good prenatal examination acquires great importance in order to formulate an early diagnosis and improve pregnancy management. Nowadays, echocardiography still represents the gold standard examination for fetal heart disease. However, especially when preliminary ultrasound is inconclusive, fetal MRI is considered as a third-level imaging modality. Preliminary experiences have demonstrated the validity of this reporting a diagnostic accuracy of 79%. Our article aims to outline feasibility of fetal MRI in the anatomic evaluation, the common indication to fetal MRI, its role in the characterization of congenital heart defects, and at last its main limitations.

Diagnostic imaging of ankle impingement syndromes in athletes

The chronic ankle pain is a very frequent clinical problem, which is often characterized by a painful mechanical limitation of full-range ankle movement. A large amount of causes are involved in its pathogenesis, but the most common forms are secondary to an osseous or soft tissue abnormality. Especially for professional athletes, impingement lesions are the most important causes of chronic pain; however, this symptomatology can also affect ordinary people, mostly in those who work in environments that cause severe mechanical stress on the joints. This group of pathologies is characterized by a joint conflict secondary to an abnormal contact among bone surfaces or between bones and soft tissues. Diagnosis is mainly clinic and secondly supported by imaging in order to localize the critical area of impingement and determine the organic cause responsible for the joint conflict. Treatments for different forms of impingement are similar. Usually, the first step is a conservative approach (rest, physiotherapy, ankle bracing, shoe modification and local injection of corticosteroids), and only in case of unsuccessful response, the second step is the operative treatment with open and arthroscopic techniques. The aim of the study is to describe different MR imaging patterns, comparing our data with those reported in the literature, in order to identify the best accurate diagnostic protocol.

Femoroacetabular impingement: role of imaging

The femoroacetabular impingement (FAI) is an impingement characterized by repetitive abutment between the femur and the acetabular rim during hip motion due to loss of joint clearance (Imam and Khanduja in Int Orthop 35(10):1427-1435, 2011; James et al. in AJR Am J Roentgenol 187(6):1412-1419, 2006). Femoroacetabular impingement (FAI) can be classified as either cam or pincer type, and it can be differentiated on the basis of a predominance of either a femoral or an acetabular abnormality (Pfirrmann et al. in Radiology 244(2):626, 2007; Ganz et al. in Clin Orthop Relat Res 466(2):264-272, 2008). In cases of cam FAI, the nonspherical shape of the femoral head at the femoral head-neck junction and reduced depth of the femoral waist lead to abutment of the femoral head-neck junction against the acetabular rim. In cases of pincer FAI, acetabular overcoverage limits the range of motion and leads to a conflict between the acetabulum and the femur. The most important role of preoperative MR evaluation in patients affected by FAI is the accurate assessment of the damage's extension.

Predictors of dropout from in-patient treatment of eating disorders: an Italian experience

INTRODUCTION

The aim of the study was to examine possible risk factors for dropout from in-patient treatment for eating disorders (ED).

MATERIALS AND METHODS

The present study consisted of a retrospective analysis of clinical and non-clinical available information about 186 patients suffering from ED consecutively admitted into the Villa Maria Luigia Private Hospital (Parma, Italy) in a three-year period (01/01/2006 - 31/12/2009). Sociodemographics, clinical history and current features, and results to the following psychometric instruments were analysed: Eating Disorder Questionnaire (EDQ), Predisposing, On-set and Maintaining risk factors list for Eating Disorders, Eating Disorders Inventory-II, Body Uneasiness Test and SCL-90.

RESULTS

Of the 186 patients, 46 (24.7%) voluntarily left the treatment program prematurely. Predictive factors included poor educational and professional achievements, parents' divorcing, parents' history of substance abuse and difficulties in interpersonal relationships.

DISCUSSION

Dropout is a multifactorial phenomenon with deep clinical consequences: the recognition of possible risk factors may support the choice of specific therapeutic strategies to improve the treatment of ED and its outcomes.

Diagnostic accuracy of sonohysterography and transvaginal sonography as compared with hysteroscopy and endometrial biopsy: a prospective study

AIM

The aim of the study was to compare the diagnostic accuracy between transvaginal sonography (TVS) and sonohysterography (SHG) versus hysteroscopy (Hys) plus endometrial biopsy (EB) to evaluate uterine cavity.

METHODS

One hundred and sixteen patients were enrolled. These presented with infertility and/or abnormal uterine bleeding and/or suspicious uterine cavity pathology. Women consecutively underwent during the same day, to TVS, SHG and Hys plus EB by three different operators.

RESULTS

TVS shows excellent specificity (95.7%) in uterine polyps detection, good sensitivity (85,7%) and specificity (89.2%) in investigating endometrial hyperplasia, and excellent NPV (92.2%) in the diagnosis of submucous myomas. Diagnostic accuracy of TVS for synechiae is not evaluable. SHG demonstrates high specificity (92.8%) in the detection of uterine polyps, and high sensitivity (92.9%) and specificity (96.8%) in the diagnosis of endometrial hyperplasia. In addition it shows high sensitivity (90%), specificity (99%), PPV (92.2%), and NPV (99%) for detection of submucous myomas. Finally, SHG shows high PPV (100%) and NPV (100%) for synechiae assessment.

CONCLUSION

TVS could be used as first step investigation to exclude uterine pathologies. TVS could reduce the number of diagnostic Hys normally performed in women with normal uterine cavity. Furthermore SHG should be useful to diagnose the pathologies and to decide between operative Hys in-office or resectoscopic treatment.

Feasibility of 3.0T pelvic MR imaging in the evaluation of endometriosis

INTRODUCTION

Endometriosis represents an important clinical problem in women of reproductive age with high impact on quality of life, work productivity and health care management. The aim of this study is to define the role of 3T magnetom system MRI in the evaluation of endometriosis.

MATERIALS AND METHODS

Forty-six women, with transvaginal (TV) ultrasound examination positive for endometriosis, with pelvic pain, or infertile underwent an MR 3.0T examination with the following protocol: T2 weighted FRFSE HR sequences, T2 weighted FRFSE HR CUBE 3D sequences, T1 w FSE sequences, LAVA-flex sequences. Pelvic anatomy, macroscopic endometriosis implants, deep endometriosis implants, fallopian tube involvement, adhesions presence, fluid effusion in Douglas pouch, uterus and kidney pathologies or anomalies associated and sacral nervous routes were considered by two radiologists in consensus. Laparoscopy was considered the gold standard.

RESULTS

MRI imaging diagnosed deep endometriosis in 22/46 patients, endometriomas not associated to deep implants in 9/46 patients, 15/46 patients resulted negative for endometriosis, 11 of 22 patients with deep endometriosis reported ovarian endometriosis cyst. We obtained high percentages of sensibility (96.97%), specificity (100.00%), VPP (100.00%), VPN (92.86%).

CONCLUSION

Pelvic MRI performed with 3T system guarantees high spatial and contrast resolution, providing accurate information about endometriosis implants, with a good pre-surgery mapping of the lesions involving both bowels and bladder surface and recto-uterine ligaments.

Pathways to Care, Duration of Untreated Psychosis and Treatments Received by Patients with First-Episode Psychosis

Introduction

Pathways to care and duration of untreated psychosis (DUP) strongly influence the long-term outcome of schizophrenia.

Aims

To investigate pathways to care, duration of untreated psychosis (DUP) and treatments received by a sample of individuals aged between 18 and 35 years meeting diagnostic criteria for psychosis.

Methods

Pathways to care and DUP were explored by an “ad-hoc” schedule administered to patients and caregivers.

Results

The sample consists of 30 patients. The first episode of psychosis, which occurred at 19.7 (± 4.7) years, was characterized by negative symptoms and disorganized behaviours in more than half of the sample, suicide attempts (28%) and hospital admissions (26%). DUP was 41.6 ± 60.4 weeks, being longer than that reported in international literature. In 76% of cases patients’ relatives asked for a first contact with health professionals, referring the patients to psychiatrists (34% of cases), general practitioners (31%), neurologists (21%) or psychologists (13%). When professionals other than psychiatrists were contacted, the interval between the contact and receipt of appropriate psychiatric treatment (according to the current guidelines) was particularly long (15.2 ± 32.1 weeks). 34% of patients were treated with a monotherapy of psychotropic drugs: 24% with antipsychotics, 7% with anxiolytics and 3% with antidepressants; 48% received a poly-pharmacotherapy. 35% were treated with psychotherapy (in most of the cases cognitive-behavioural therapy), which was the only treatment for 18% of patients.

Conclusions

These results emphasize the need to train health professionals on diagnosis and treatment of first episode psychosis. DUP may be reduced by anti-stigma campaigns among general population.

Papillary thyroid cancer in a young woman affected by giant congenital melanocytic nevus, ultrasound diagnosis

Data literatures report numerous association between giant congenital nevus and development alteration; only two cases describe its coexistence with thyroid disorders. However, we report the association of papillary thyroid cancer and giant congenital nevus. Papillary thyroid cancer is the most common differentiated thyroid cancer and has high prevalence in young women. In this paper we report: the case of a 18 years-old woman, affected by giant congenital melanocytic nevus on her back, who came to our observation because of one month of fever and increased volume of latero-cervical lymph nodes. Negative serologic tests allowed us to exclude lymphoma and mononucleosis. Because of the high risk (6%) that giant congenital melanocytic nevi could transform into malignant melanoma, we performed an ultrasound examination (US) of the cervical lymph nodes. The examination extended to the thyroid gland enabled us to visualize the same parenchyma alteration in both thyroid gland and lymph nodes. At last, fine-needle percoutaneus aspiration on thyroid lesion confirmed the presence of papillary carcinoma. In our case, thank to the optimal visualization of the parenchyma structure, US was diriment allowing a diagnosis of primitive thyroid lesion with an involvement of all lymph nodes in the neck. This findings legitimate the role of US as an accurate, noninvasive, radiation free and low-cost imaging technique in detecting differential diagnosis in the cervical lymphadenopathy, as well in preoperative staging thyroid carcinoma.

Intrapartum translabial three-dimensional ultrasound visualization of levator trauma

OBJECTIVES

The aim of this study was to visualize levator trauma by three-dimensional (3D) ultrasound performed during labor and soon after the crowning of the fetal head and to determine how often levator trauma occurs.

METHODS

This was a prospective, observational study of 66 women enrolled during the first stage of labor. The women underwent intrapartum 3D transperineal ultrasound examination during the first and second stages of labor and within 12 h after delivery. Volume datasets were acquired and analyzed to determine the presence of levator trauma.

RESULTS

Data from 10 of the 66 women were excluded from analysis-nine because they underwent Cesarean section in the first or second stage of labor and one because she underwent hysterectomy and no postpartum volumes were collected. Thus our study group comprised 56 women-35 nulliparous and 21 parous. A total of 504 volumes were collected in the 56 women (three volumes for each stage of labor). One hundred and twenty levator volumes were excluded from analysis, but volumes of acceptable quality were available for all three stages of labor in all women. Eleven (31.4%) of the 35 nulliparae had levator lesions detected postpartum and none of them had levator lesions before delivery. Five (23.8%) of the 21 parous women had a levator tear detected in their postpartum volumes. In two of these five women the levator tear was also present in both volumes taken during labor.

CONCLUSIONS

Visualization of the levator ani during labor by 3D ultrasound examination is feasible. Comparison of volumes obtained during labor and within the first 2 h after delivery supports the theory that crowning of the head is the immediate cause of avulsion of the levator ani muscle.

Correction of cicatricial ectropion by autologous fat graft

BACKGROUND

Over the past few years, treatment of burn scars with lipofilling has shown encouraging clinical results in terms of texture, color, softness, and quality of skin patterns. This clinical application has been widened to include treatment for scars resulting from surgical correction of cicatricial ectropion. In fact, although standard surgery with flaps and skin grafts can grant significant functional and cosmetic improvements, these often are not complete because of secondary surgical scars.

METHODS

The case of a 43-year-old man with cicatricial outcomes from chemical burns and subsequent surgical repair of medial ectropion in the lower eyelid is reported. The scar area was treated with injection of adipose tissue harvested from abdominal subcutaneous fat and processed according to Coleman's technique.

RESULTS

At the 1-year follow-up assessment after lipostructure, the patient no longer reported xeroftalmia and epiphora. He had experienced complete functional recovery with excellent cosmetic results.

CONCLUSIONS

Lipostructure of cicatricial ectropion seems to complete and improve the results of the standard surgical approach, and its long-lasting benefits are in keeping with the theoretical basis of this procedure.

Hepatic artery aneurysm, an unusual cause of obstructive jaundice: MR cholangiography findings

Hepatic artery aneurysms are rare vascular lesions, often with a nonspecific clinical presentation, and difficult to diagnose before rupture. We report the case of a patient with obstructive jaundice caused by a compression on the right biliary duct by a right hepatic artery aneurysm in which the diagnosis was suggested by magnetic resonance cholangiography and confirmed by Doppler sonography and preoperative digital subtraction angiography.

Implementation of ALARA radiation protection on the ISS through polyethylene shielding augmentation of the Service Module Crew Quarters

With 5-7 month long duration missions at 51.6 degrees inclination in Low Earth Orbit, the ionizing radiation levels to which International Space Station (ISS) crewmembers are exposed will be the highest planned occupational exposures in the world. Even with the expectation that regulatory dose limits will not be exceeded during a single tour of duty aboard the ISS, the "as low as reasonably achievable" (ALARA) precept requires that radiological risks be minimized when possible through a dose optimization process. Judicious placement of efficient shielding materials in locations where crewmembers sleep, rest, or work is an important means for implementing ALARA for spaceflight. Polyethylene (CnHn) is a relatively inexpensive, stable, and, with a low atomic number, an effective shielding material that has been certified for use aboard the ISS. Several designs for placement of slabs or walls of polyethylene have been evaluated for radiation exposure reduction in the Crew Quarters (CQ) of the Zvezda (Star) Service Module. Optimization of shield designs relies on accurate characterization of the expected primary and secondary particle environment and modeling of the predicted radiobiological responses of critical organs and tissues. Results of the studies shown herein indicate that 20% or more reduction in equivalent dose to the CQ occupant is achievable. These results suggest that shielding design and risk analysis are necessary measures for reducing long-term radiological risks to ISS inhabitants and for meeting legal ALARA requirements. Verification of shield concepts requires results from specific designs to be compared with onboard dosimetry.

Appropriateness of hospital utilisation in Italy

The purpose of this study was to determine the extent of inappropriate hospital admission and inappropriate days of stay and the effect of variables on such inappropriateness on an adult population in Italy. A review was made of medical records of patients admitted to any one of the following specialities: medicine, surgery, gynaecology or traumatology/orthopaedics at one of five hospitals located respectively in Siena, Frosinone, Rome and Catanzaro, and who were in-patients during one of four pre-selected index days. To determine the appropriateness of hospital admission and length of hospitalisation, a retrospective application was made using the Italian version of Appropriateness Evaluation Protocol (AEP). A total of 1299 patient days were reviewed. 14.2% of the hospital admissions and 37.3% of the number of hospitalisation days were judged to be inappropriate. Multiple logistic regression analysis showed that inappropriate admission was significantly increased with relation to: greater distance from hospital to patient's home; admission to a medical ward; planned admissions; and admission over a weekend. Multiple logistic regression analysis indicated that the inappropriate number of days of hospitalisation was significantly higher for medicine and for patients who were inappropriately admitted. The main reason for categorising an admission as inappropriate was that the patient's problems could be treated on an out-patient basis, and, for inappropriate days of care, the physician was overtly cautious in the management of a patient. Changing the physicians' behaviour and the organisation of hospital activities may be effective in improving the quality and efficiency of hospital care.

Left trochlear nerve palsy, unique symptom of an arachnoid cyst of the quadrigeminal plate. Case report

An arachnoid cyst of the quadrigeminal plate in a 49-year-old female is reported. This is the seventh published case of a cyst of this kind in an adult. The presenting symptom was an isolated left fourth cranial nerve palsy. Up to now, no other case with isolated superior oblique muscle palsy has been described which was caused by an arachnoidal cyst of the quadrigeminal plate.