Computer-assisted virtual autopsy using surgical navigation techniques

UNLABELLED OBJECTIVE; Virtual autopsy methods, such as postmortem CT and MRI, are increasingly being used in forensic medicine. Forensic investigators with little to no training in diagnostic radiology and medical laypeople such as state's attorneys often find it difficult to understand the anatomic orientation of axial postmortem CT images. We present a computer-assisted system that permits postmortem CT datasets to be quickly and intuitively resliced in real time at the body to narrow the gap between radiologic imaging and autopsy. CONCLUSION Our system is a potentially valuable tool for planning autopsies, showing findings to medical laypeople, and teaching CT anatomy, thus further closing the gap between radiology and forensic pathology.

Computer Assisted Diagnosis and Treatment Planning of Femoroacetabular Impingement (FAI)

Femoroacetabular impingement (FAI) is a dynamic conflict of the hip defined by a pathological, early abutment of the proximal femur onto the acetabulum or pelvis. In the past two decades, FAI has received increasing focus in both research and clinical practice as a cause of hip pain and prearthrotic deformity. Anatomical abnormalities such as an aspherical femoral head (cam-type FAI), a focal or general overgrowth of the acetabulum (pincer-type FAI), a high riding greater or lesser trochanter (extra-articular FAI), or abnormal torsion of the femur have been identified as underlying pathomorphologies. Open and arthroscopic treatment options are available to correct the deformity and to allow impingement-free range of motion. In routine practice, diagnosis and treatment planning of FAI is based on clinical examination and conventional imaging modalities such as standard radiography, magnetic resonance arthrography (MRA), and computed tomography (CT). Modern software tools allow three-dimensional analysis of the hip joint by extracting pelvic landmarks from two-dimensional antero-posterior pelvic radiographs. An object-oriented cross-platform program (Hip2Norm) has been developed and validated to standardize pelvic rotation and tilt on conventional AP pelvis radiographs. It has been shown that Hip2Norm is an accurate, consistent, reliable and reproducible tool for the correction of selected hip parameters on conventional radiographs. In contrast to conventional imaging modalities, which provide only static visualization, novel computer assisted tools have been developed to allow the dynamic analysis of FAI pathomechanics. In this context, a validated, CT-based software package (HipMotion) has been introduced. HipMotion is based on polygonal three-dimensional models of the patient’s pelvis and femur. The software includes simulation methods for range of motion, collision detection and accurate mapping of impingement areas. A preoperative treatment plan can be created by performing a virtual resection of any mapped impingement zones both on the femoral head-neck junction, as well as the acetabular rim using the same three-dimensional models. The following book chapter provides a summarized description of current computer-assisted tools for the diagnosis and treatment planning of FAI highlighting the possibility for both static and dynamic evaluation, reliability and reproducibility, and its applicability to routine clinical use.

Twenty years' experience with the Swiss data registry for assisted reproductive medicine: outcomes, key trends and recommendations for improved practice.

QUESTIONS UNDER STUDY The impact of assisted reproductive technology (ART) on Swiss demography was quantified. From 1993 to 2012 the number of deliveries, including multiples, generated by ART was compared with overall delivery numbers. Swiss experts in ART collaborated in a consensus to increase successful outcomes, to reduce the incidence of complications of ART and to validate recommendations through statistical review of available data. METHODS Data generated between 1993 and 2012 and published by the Federal Office of Statistics (BfS) were compared with the Swiss database on ART (FIVNAT-CH) as organised by the Swiss Society of Reproductive Medicine (SGRM). From these analyses a panel of Swiss experts in ART extracted recommendations to improve current practice, to prevent complications related to ART and to recommend changes in current Swiss legislation dealing with ART. RESULTS Since 1993 the age of women giving birth rose together with the number of women asking for ART. This demographic trend was reflected in a rise in the number of deliveries generated by ART (in 2012: 2.2%) and the proportion of multiple births (in 2012: 17.6%). The outcome of ART was most negatively influenced by the age of the treated patient. The number of retrieved oocytes decisively impacted the likelihood of delivery, the risk of multiple births and the incidence of ovarian hyperstimulation syndrome. CONCLUSIONS Optimal ovarian stimulation should be designed for the retrieval of 10 to 15 oocytes per treatment. Swiss legislation should enable and stimulate a policy of elective single embryo transfer to avoid multiple births.

Complications with computer-aided designed/computer-assisted manufactured titanium and soldered gold bars for mandibular implant-overdentures: short-term observations

BACKGROUND Implant-overdentures supported by rigid bars provide stability in the edentulous atrophic mandible. However, fractures of solder joints and matrices, and loosening of screws and matrices were observed with soldered gold bars (G-bars). Computer-aided designed/computer-assisted manufactured (CAD/CAM) titanium bars (Ti-bars) may reduce technical complications due to enhanced material quality. PURPOSE To compare prosthetic-technical maintenance service of mandibular implant-overdentures supported by CAD/CAM Ti-bar and soldered G-bar. MATERIALS AND METHODS Edentulous patients were consecutively admitted for implant-prosthodontic treatment with a maxillary complete denture and a mandibular implant-overdenture connected to a rigid G-bar or Ti-bar. Maintenance service and problems with the implant-retention device complex and the prosthesis were recorded during minimally 3-4 years. Annual peri-implant crestal bone level changes (ΔBIC) were radiographically assessed. RESULTS Data of 213 edentulous patients (mean age 68 ± 10 years), who had received a total of 477 tapered implants, were available. Ti-bar and G-bar comprised 101 and 112 patients with 231 and 246 implants, respectively. Ti-bar mostly exhibited distal bar extensions (96%) compared to 34% of G-bar (p < .001). Fracture rate of bars extensions (4.7% vs 14.8%, p < .001) and matrices (1% vs 13%, p < .001) was lower for Ti-bar. Matrices activation was required 2.4× less often in Ti-bar. ΔBIC remained stable for both groups. CONCLUSIONS Implant overdentures supported by soldered gold bars or milled CAD/CAM Ti-bars are a successful treatment modality but require regular maintenance service. These short-term observations support the hypothesis that CAD/CAM Ti-bars reduce technical complications. Fracture location indicated that the titanium thickness around the screw-access hole should be increased.

Investigation of robotics-assisted tilt table technology for cardiopulmonary exercise testing in stroke patients

Due to the lack of exercise testing devices that can be employed in stroke patients with severe disability, the aim of this PhD research was to investigate the clinical feasibility of using a robotics-assisted tilt table (RATT) as a method for cardiopulmonary exercise testing (CPET) and exercise training in stroke patients. For this purpose, the RATT was augmented with force sensors, a visual feedback system and a work rate calculation algorithm. As the RATT had not been used previously for CPET, the first phase of this project focused on a feasibility study in 11 healthy able-bodied subjects. The results demonstrated substantial cardiopulmonary responses, no complications were found, and the method was deemed feasible. The second phase was to analyse validity and test-retest reliability of the primary CPET parameters obtained from the RATT in 18 healthy able-bodied subjects and to compare the outcomes to those obtained from standard exercise testing devices (a cycle ergometer and a treadmill). The results demonstrated that peak oxygen uptake (V'O2peak) and oxygen uptake at the submaximal exercise thresholds on the RATT were ̴20% lower than for the cycle ergometer and ̴30% lower than on the treadmill. A very high correlation was found between the RATT vs the cycle ergometer V'O2peak and the RATT vs the treadmill V'O2peak. Test-retest reliability of CPET parameters obtained from the RATT were similarly high to those for standard exercise testing devices. These findings suggested that the RATT is a valid and reliable device for CPET and that it has potential to be used in severely impaired patients. Thus, the third phase was to investigate using the RATT for CPET and exercise training in 8 severely disabled stroke patients. The method was technically implementable, well tolerated by the patients, and substantial cardiopulmonary responses were observed. Additionally, all patients could exercise at the recommended training intensity for 10 min bouts. Finally, an investigation of test-retest reliability and four-week changes in cardiopulmonary fitness was carried out in 17 stroke patients with various degrees of disability. Good to excellent test-retest reliability and repeatability were found for the main CPET variables. There was no significant difference in most CPET parameters over four weeks. In conclusion, based on the demonstrated validity, reliability and repeatability, the RATT was found to be a feasible and appropriate alternative exercise testing and training device for patients who have limitations for use of standard devices.

Litter nutrients and retranslocation in a central African rain forest dominated by ectomycorrhizal trees

In the strongly seasonal, but annually very wet, parts of the tropics, low-water availability in the short dry season leads to a semi-deciduous forest, one which is also highly susceptible to nutrient loss from leaching in the long wet season. Patterns in litterfall were compared between forest with low (LEM) and high (HEM) abundances of ectomycorrhizal trees in Korup National Park, Cameroon, over 26 months in 1990–92. Leaf litter was sorted into 26 abundant species which included six ectomycorrhizal species, and of these three were the large grove-forming trees Microberlinia bisulcata, Tetraberlinia bifoliolata and Tetraberlinia moreliana. Larger-tree species shed their leaves with pronounced peaks in the dry season, whereas other species had either weaker dependence, showed several peaks per year, or were wet-season shedders. Although total annual litterfall differed little between forest types, in the HEM forest (dominated by M. bisulcata) the dry-season peak was more pronounced and earlier than that in the LEMforest. Species differed greatly in their mean leaf litterfall nutrient concentrations, with an approx. twofold range for nitrogen and phosphorus, and 2.5–3.5-fold for potassium, magnesium and calcium. In the dry season, LEM and HEM litter showed similar declines in P and N concentration, and increases in K and Mg; some species, especially M. bisculcata, showed strong dry-wet season differences. The concentration of P (but not N) was higher in the leaf litter of ectomycorrhizal than nonectomycorrhizal species. Retranslocation of N and P was lower among the ectomycorrhizal than nonectomycorrhizal species by approx. twofold. It is suggested that, within ectomycorrhizal groves on this soil low in P, a fast decomposition rate with minimal loss of mineralized P is possible due to the relatively high litter P not limiting the cycle at this stage, combined with an efficient recapture of released P by the surface organic layer of ectomycorrhizas and fine roots. This points to a feedback between two essential controlling steps (retranslocation and mineralization) in a tropical rain forest ecosystem dominated by ectomycorrhizal trees.

Light and seed size affect establishment of grove-forming ectomycorrhizal rain forest tree species

• Regeneration of the dominant ectomycorrhizal tree Microberlinia bisulcata in groves in Korup, Central Africa, is very poor. The hypothesis was tested that this species is more shade intolerant than other co-occurring species. • In two 1-yr trials, each with M. bisulcata and four other species at a nursery close to Korup, growth was measured under five PAR levels, with ± added P and ± watering in the dry season. In parallel experiments the effects of PAR with two R : FR ratios were investigated. • Increasing PAR had a consistent effect on the rates of increase in plant mass and on changes in the other variables. Doubling soil P, watering and halving the R : FR ratio had almost no effect. However, across species, mass at low PAR and relative growth rate related positively and negatively, respectively, to seed mass. • One contributing factor for the poor recruitment of M. bisulcata is therefore its low survival and slow growth at low PAR, due to its small seed size. The two codominant ectomycorrhizal grove species of Tetraberlinia, with larger seeds, were less affected by low PAR.

Tree architecture in a Bornean lowland rain forest: intraspecific and interspecific patterns

Intraspecific and interspecific architectural patterns were studied for eight tree species of a Bornean rain forest. Trees 5--19 m tall in two 4-ha permanent sample plots in primary forest were selected, and three light descriptors and seven architectural traits for each tree were measured. Two general predictions were made: (1) Slow growing individuals (or short ones) encounter lower light, and have flatter crowns, fewer leaf layers, and thinner stems, than do fast growing individuals (or tall ones). (2) Species with higher shade-tolerance receive less light and have flatter crowns, fewer leaf layers, and thinner stems, than do species with lower shade-tolerance. Shade-tolerance is assumed to decrease with maximum growth rate, mortality rate, and adult stature of a species.

Does proximity to conspecific adults influence the establishment of ectomycorrhizal trees in rain forest?

Three ectomycorrhizal legume trees, Microberlinia bisulcata, Tetraberlinia bifoliolata and T. moreliana, form discrete groves in the southern part of Korup National Park, in southwest Cameroon and contribute c. 45–70% of stand basal area locally in a matrix of otherwise species-rich arbuscular mycorrhizal forest. A transplant experiment was performed to assess the importance of ectomycorrhizal infection associated with proximity to parents in seedling establishment of the grove-forming species. Nonectomycorrhizal seedlings of the three species were transplanted into plots of two forest types, one of high (HEM, within-grove) and one of very low (LEM, outside the grove) abundance of all three species as adult trees. For two species (T. moreliana and M. bisulcata) there was no difference in survival over 16 months, but for the third (T. bifoliolata) survival was best in HEM forest, and correlated with the basal area of adult trees of ectomycorrhizal species. Only one species (T. moreliana) increased in biomass over the experimental period; the others declined. There was no effect of forest type on overall growth of any species, but the survivors of two (T. moreliana and M. bisulcata) had heavier stems in the HEM forest. Differences in survival and growth of transplants between the three species were in accord with the ecology of the species as inferred from the frequency distributions of adult tree size in the forest. Seedlings became infected with ectomycorrhizas in both forest types; where there was a difference in extent of infection (T. moreliana) this was not related to survival or growth; and where there was a difference in survival (T. bifoliolata) this was not related to extent of infection. These results confirm that mycorrhizal inoculum associated with conspecific adults is neither a prerequisite nor a guarantee of seedling establishment, but indicates that in some circumstances there might be benefits of being close to parents. Further research is required to unravel the complexities of ectomycorrhizal community structure in this spatially and temporally heterogeneous forest, and to clarify the extent to which the various hosts share ectomycorrhizal partners.

A 3-D CT assisted Monte Carlo evaluation of intracavitary brachytherapy implants

Intracavitary brachytherapy (ICB) combined with external beam irradiation for treatment of cervical cancer is highly successful in achieving local control. The M.D. Anderson Cancer Center employs Fletcher Suit Delclos (FSD) applicators. FSD applicators contain shields to limit dose to critical structures. Dosimetric evaluation of ICB implants is limited to assessing dose at reference points. These points serve as surrogates for treatment intensity and critical structure dose. Several studies have mentioned that the ICRU38 reference points inadequately characterize the dose distribution. Also, the ovoid shields are rarely considered in dosimetry. ^ The goal of this dissertation was to ascertain the influence of the ovoid shields on patient dose distributions. Monte Carlo dosimetry (MCD) was applied to patient computed tomography(CT) scans. These data were analyzed to determine the effect of the shields on dose to standard reference points and the bladder and rectum. The hypothesis of this work is that the ICRU38 bladder and rectal points computed conventionally are not clinically acceptable surrogates for the maximum dose points as determined by MCD. ^ MCD was applied to the tandem and ovoids. The FSD ovoids and tandem were modeled in a single input file that allowed dose to be calculated for any patient. Dose difference surface histograms(DDSH) were computed for the bladder and rectum. Reference point doses were compared between shielded and unshielded ovoids, and a commercial treatment planning system. ^ The results of this work showed the tandem tip screw caused a 33% reduction in dose. The ovoid shields reduced the dose by a maximum of 48.9%. DDSHs revealed on average 5% of the bladder surface area was spared 53 cGy and 5% of the rectal surface area was spared 195 cGy. The ovoid shields on average reduced the dose by 18% for the bladder point and 25% for the rectal point. The Student's t-test revealed the ICRU38 bladder and rectal points do not predict the maximum dose for these organs. ^ It is concluded that modeling the tandem and ovoid internal structures is necessary for accurate dose calculations, the bladder shielding segments may not be necessary, and that the ICRU38 bladder point is irrelevant. ^

The Right to Die Debate: The Demonization of Dr. Kevorkian and the Creation of a Moral Panic Surrounding Physician-Assisted Suicide in the United States

The Right to Die Debate is a recent but highly controversial moral matter. In particular, physician-assisted suicide (PAS) is an issue that has been evaded by the medical community for years. As of 1990, most states had never encountered the issue before and therefore did not have any laws in place to prohibit PAS (Strate et. al, 2005). Dr. Jack Kevorkian, a retired pathologist from Royal Oak Michigan was the first to publicly address PAS. He brought the issue into the limelight through a bizarre and crude series of assisted deaths that had a lasting impact on not only the Right to Die Debate as whole, but on public policy and both federal and state governmental agendas. This study focuses on the way in which the media, in particular the New York Times (NYT) has portrayed Dr. Jack Kevorkian as incompetent, morally culpable and in an overall negative light in the past twenty years. Applying Stanley Cohen’s 1972 theory of moral panic, a content analysis of NYT media publications between 1990 and 1999 supports Cohen’s theory and reveals that the media has created a moral panic surrounding Kevorkian. This has in turn led to public policy that prevents both terminally ill individuals and their doctors from having a desirable choice; that of voluntary euthanasia and PAS.

Isotopic composition of water in fog, rain, throughfall and stemflow in the Monte Verde, Costa Rica

Fog deposition, precipitation, throughfall and stemflow were measured in a windward tropical montane cloud forest near Monteverde, Costa Rica, for a 65-day period during the dry season of 2003. Net fog deposition was measured directly using the eddy covariance (EC) method and it amounted to 1.2 ± 0.1 mm/day (mean ± standard error). Fog water deposition was 5-9% of incident rainfall for the entire period, which is at the low end of previously reported values. Stable isotope concentrations (d18O and d2H) were determined in a large number of samples of each water component. Mass balance-based estimates of fog deposition were 1.0 ± 0.3 and 5.0 ± 2.7 mm/day (mean ± SE) when d18O and d2H were used as tracer, respectively. Comparisons between direct fog deposition measurements and the results of the mass balance model using d18O as a tracer indicated that the latter might be a good tool to estimate fog deposition in the absence of direct measurement under many (but not all) conditions. At 506 mm, measured water inputs over the 65 days (fog plus rain) fell short by 46 mm compared to the canopy output of 552 mm (throughfall, stemflow and interception evaporation). This discrepancy is attributed to the underestimation of rainfall during conditions of high wind.

Soil, snow, weather, and sub-surface storage data from a mountain catchment in the rain-snow transition zone

A comprehensive hydroclimatic data set is presented for the 2011 water year to improve understanding of hydrologic processes in the rain-snow transition zone. This type of dataset is extremely rare in scientific literature because of the quality and quantity of soil depth, soil texture, soil moisture, and soil temperature data. Standard meteorological and snow cover data for the entire 2011 water year are included, which include several rain-on-snow events. Surface soil textures and soil depths from 57 points are presented as well as soil texture profiles from 14 points. Meteorological data include continuous hourly shielded, unshielded, and wind corrected precipitation, wind speed, air temperature, relative humidity, dew point temperature, and incoming solar and thermal radiation data. Sub-surface data included are hourly soil moisture data from multiple depths from 7 soil profiles within the catchment, and soil temperatures from multiple depths from 2 soil profiles. Hydrologic response data include hourly stream discharge from the catchment outlet weir, continuous snow depths from one location, intermittent snow depths from 5 locations, and snow depth and density data from ten weekly snow surveys. Though it represents only a single water year, the presentation of both above and below ground hydrologic condition makes it one of the most detailed and complete hydro-climatic datasets from the climatically sensitive rain-snow transition zone for a wide range of modeling and descriptive studies.