Multi-perspective region-based CNNs for vertebrae labeling in intraoperative long-length images

PURPOSE

Effective aggregation of intraoperative x-ray images that capture the patient anatomy from multiple view-angles has the potential to enable and improve automated image analysis that can be readily performed during surgery. We present multi-perspective region-based neural networks that leverage knowledge of the imaging geometry for automatic vertebrae labeling in Long-Film images - a novel tomographic imaging modality with an extended field-of-view for spine imaging.

METHOD

A multi-perspective network architecture was designed to exploit small view-angle disparities produced by a multi-slot collimator and consolidate information from overlapping image regions. A second network incorporates large view-angle disparities to jointly perform labeling on images from multiple views (viz., AP and lateral). A recurrent module incorporates contextual information and enforce anatomical order for the detected vertebrae. The three modules are combined to form the multi-view multi-slot (MVMS) network for labeling vertebrae using images from all available perspectives. The network was trained on images synthesized from 297 CT images and tested on 50 AP and 50 lateral Long-Film images acquired from 13 cadaveric specimens. Labeling performance of the multi-perspective networks was evaluated with respect to the number of vertebrae appearances and presence of surgical instrumentation.

RESULTS

The MVMS network achieved an F1 score of >96% and an average vertebral localization error of 3.3 mm, with 88.3% labeling accuracy on both AP and lateral images - (15.5% and 35.0% higher than conventional Faster R-CNN on AP and lateral views, respectively). Aggregation of multiple appearances of the same vertebra using the multi-slot network significantly improved the labeling accuracy (p < 0.05). Using the multi-view network, labeling accuracy on the more challenging lateral views was improved to the same level as that of the AP views. The approach demonstrated robustness to the presence of surgical instrumentation, commonly encountered in intraoperative images, and achieved comparable performance in images with and without instrumentation (88.9% vs. 91.2% labeling accuracy).

CONCLUSION

The MVMS network demonstrated effective multi-perspective aggregation, providing means for accurate, automated vertebrae labeling during spine surgery. The algorithms may be generalized to other imaging tasks and modalities that involve multiple views with view-angle disparities (e.g., bi-plane radiography). Predicted labels can help avoid adverse events during surgery (e.g., wrong-level surgery), establish correspondence with labels in preoperative modalities to facilitate image registration, and enable automated measurement of spinal alignment metrics for intraoperative assessment of spinal curvature.

Joint synthesis and registration network for deformable MR-CBCT image registration for neurosurgical guidance

Objective.The accuracy of navigation in minimally invasive neurosurgery is often challenged by deep brain deformations (up to 10 mm due to egress of cerebrospinal fluid during neuroendoscopic approach). We propose a deep learning-based deformable registration method to address such deformations between preoperative MR and intraoperative CBCT.Approach.The registration method uses a joint image synthesis and registration network (denoted JSR) to simultaneously synthesize MR and CBCT images to the CT domain and perform CT domain registration using a multi-resolution pyramid. JSR was first trained using a simulated dataset (simulated CBCT and simulated deformations) and then refined on real clinical images via transfer learning. The performance of the multi-resolution JSR was compared to a single-resolution architecture as well as a series of alternative registration methods (symmetric normalization (SyN), VoxelMorph, and image synthesis-based registration methods).Main results.JSR achieved median Dice coefficient (DSC) of 0.69 in deep brain structures and median target registration error (TRE) of 1.94 mm in the simulation dataset, with improvement from single-resolution architecture (median DSC = 0.68 and median TRE = 2.14 mm). Additionally, JSR achieved superior registration compared to alternative methods-e.g. SyN (median DSC = 0.54, median TRE = 2.77 mm), VoxelMorph (median DSC = 0.52, median TRE = 2.66 mm) and provided registration runtime of less than 3 s. Similarly in the clinical dataset, JSR achieved median DSC = 0.72 and median TRE = 2.05 mm.Significance.The multi-resolution JSR network resolved deep brain deformations between MR and CBCT images with performance superior to other state-of-the-art methods. The accuracy and runtime support translation of the method to further clinical studies in high-precision neurosurgery.

Deformable MR-CT image registration using an unsupervised, dual-channel network for neurosurgical guidance

PURPOSE

The accuracy of minimally invasive, intracranial neurosurgery can be challenged by deformation of brain tissue - e.g., up to 10 mm due to egress of cerebrospinal fluid during neuroendoscopic approach. We report an unsupervised, deep learning-based registration framework to resolve such deformations between preoperative MR and intraoperative CT with fast runtime for neurosurgical guidance.

METHOD

The framework incorporates subnetworks for MR and CT image synthesis with a dual-channel registration subnetwork (with synthesis uncertainty providing spatially varying weights on the dual-channel loss) to estimate a diffeomorphic deformation field from both the MR and CT channels. An end-to-end training is proposed that jointly optimizes both the synthesis and registration subnetworks. The proposed framework was investigated using three datasets: (1) paired MR/CT with simulated deformations; (2) paired MR/CT with real deformations; and (3) a neurosurgery dataset with real deformation. Two state-of-the-art methods (Symmetric Normalization and VoxelMorph) were implemented as a basis of comparison, and variations in the proposed dual-channel network were investigated, including single-channel registration, fusion without uncertainty weighting, and conventional sequential training of the synthesis and registration subnetworks.

RESULTS

The proposed method achieved: (1) Dice coefficient = 0.82±0.07 and TRE = 1.2 ± 0.6 mm on paired MR/CT with simulated deformations; (2) Dice coefficient = 0.83 ± 0.07 and TRE = 1.4 ± 0.7 mm on paired MR/CT with real deformations; and (3) Dice = 0.79 ± 0.13 and TRE = 1.6 ± 1.0 mm on the neurosurgery dataset with real deformations. The dual-channel registration with uncertainty weighting demonstrated superior performance (e.g., TRE = 1.2 ± 0.6 mm) compared to single-channel registration (TRE = 1.6 ± 1.0 mm, p < 0.05 for CT channel and TRE = 1.3 ± 0.7 mm for MR channel) and dual-channel registration without uncertainty weighting (TRE = 1.4 ± 0.8 mm, p < 0.05). End-to-end training of the synthesis and registration subnetworks also improved performance compared to the conventional sequential training strategy (TRE = 1.3 ± 0.6 mm). Registration runtime with the proposed network was ∼3 s.

CONCLUSION

The deformable registration framework based on dual-channel MR/CT registration with spatially varying weights and end-to-end training achieved geometric accuracy and runtime that was superior to state-of-the-art baseline methods and various ablations of the proposed network. The accuracy and runtime of the method may be compatible with the requirements of high-precision neurosurgery.

Deformable 3D-2D registration for high-precision guidance and verification of neuroelectrode placement

Purpose.Accurate neuroelectrode placement is essential to effective monitoring or stimulation of neurosurgery targets. This work presents and evaluates a method that combines deep learning and model-based deformable 3D-2D registration to guide and verify neuroelectrode placement using intraoperative imaging.Methods.The registration method consists of three stages: (1) detection of neuroelectrodes in a pair of fluoroscopy images using a deep learning approach; (2) determination of correspondence and initial 3D localization among neuroelectrode detections in the two projection images; and (3) deformable 3D-2D registration of neuroelectrodes according to a physical device model. The method was evaluated in phantom, cadaver, and clinical studies in terms of (a) the accuracy of neuroelectrode registration and (b) the quality of metal artifact reduction (MAR) in cone-beam CT (CBCT) in which the deformably registered neuroelectrode models are taken as input to the MAR.Results.The combined deep learning and model-based deformable 3D-2D registration approach achieved 0.2 ± 0.1 mm accuracy in cadaver studies and 0.6 ± 0.3 mm accuracy in clinical studies. The detection network and 3D correspondence provided initialization of 3D-2D registration within 2 mm, which facilitated end-to-end registration runtime within 10 s. Metal artifacts, quantified as the standard deviation in voxel values in tissue adjacent to neuroelectrodes, were reduced by 72% in phantom studies and by 60% in first clinical studies.Conclusions.The method combines the speed and generalizability of deep learning (for initialization) with the precision and reliability of physical model-based registration to achieve accurate deformable 3D-2D registration and MAR in functional neurosurgery. Accurate 3D-2D guidance from fluoroscopy could overcome limitations associated with deformation in conventional navigation, and improved MAR could improve CBCT verification of neuroelectrode placement.

3D vertebrae labeling in spine CT: an accurate, memory-efficient (Ortho2D) framework

Purpose.Accurate localization and labeling of vertebrae in computed tomography (CT) is an important step toward more quantitative, automated diagnostic analysis and surgical planning. In this paper, we present a framework (called Ortho2D) for vertebral labeling in CT in a manner that is accurate and memory-efficient.Methods. Ortho2D uses two independent faster R-convolutional neural network networks to detect and classify vertebrae in orthogonal (sagittal and coronal) CT slices. The 2D detections are clustered in 3D to localize vertebrae centroids in the volumetric CT and classify the region (cervical, thoracic, lumbar, or sacral) and vertebral level. A post-process sorting method incorporates the confidence in network output to refine classifications and reduce outliers. Ortho2D was evaluated on a publicly available dataset containing 302 normal and pathological spine CT images with and without surgical instrumentation. Labeling accuracy and memory requirements were assessed in comparison to other recently reported methods. The memory efficiency of Ortho2D permitted extension to high-resolution CT to investigate the potential for further boosts to labeling performance.Results. Ortho2D achieved overall vertebrae detection accuracy of 97.1%, region identification accuracy of 94.3%, and individual vertebral level identification accuracy of 91.0%. The framework achieved 95.8% and 83.6% level identification accuracy in images without and with surgical instrumentation, respectively. Ortho2D met or exceeded the performance of previously reported 2D and 3D labeling methods and reduced memory consumption by a factor of ∼50 (at 1 mm voxel size) compared to a 3D U-Net, allowing extension to higher resolution datasets than normally afforded. The accuracy of level identification increased from 80.1% (for standard/low resolution CT) to 95.1% (for high-resolution CT).Conclusions. The Ortho2D method achieved vertebrae labeling performance that is comparable to other recently reported methods with significant reduction in memory consumption, permitting further performance boosts via application to high-resolution CT.

Data-Driven Deformable 3D-2D Registration for Guiding Neuroelectrode Placement in Deep Brain Stimulation

PURPOSE

Deep brain stimulation is a neurosurgical procedure used in treatment of a growing spectrum of movement disorders. Inaccuracies in electrode placement, however, can result in poor symptom control or adverse effects and confound variability in clinical outcomes. A deformable 3D-2D registration method is presented for high-precision 3D guidance of neuroelectrodes.

METHODS

The approach employs a model-based, deformable algorithm for 3D-2D image registration. Variations in lead design are captured in a parametric 3D model based on a B-spline curve. The registration is solved through iterative optimization of 16 degrees-of-freedom that maximize image similarity between the 2 acquired radiographs and simulated forward projections of the neuroelectrode model. The approach was evaluated in phantom models with respect to pertinent imaging parameters, including view selection and imaging dose.

RESULTS

The results demonstrate an accuracy of (0.2 ± 0.2) mm in 3D localization of individual electrodes. The solution was observed to be robust to changes in pertinent imaging parameters, which demonstrate accurate localization with ≥20° view separation and at 1/10^th the dose of a standard fluoroscopy frame.

CONCLUSIONS

The presented approach provides the means for guiding neuroelectrode placement from 2 low-dose radiographic images in a manner that accommodates potential deformations at the target anatomical site. Future work will focus on improving runtime though learning-based initialization, application in reducing reconstruction metal artifacts for 3D verification of placement, and extensive evaluation in clinical data from an IRB study underway.

Data-Driven Detection and Registration of Spine Surgery Instrumentation in Intraoperative Images

PURPOSE

Conventional model-based 3D-2D registration algorithms can be challenged by limited capture range, model validity, and stringent intraoperative runtime requirements. In this work, a deep convolutional neural network was used to provide robust initialization of a registration algorithm (known-component registration, KC-Reg) for 3D localization of spine surgery implants, combining the speed and global support of data-driven approaches with the previously demonstrated accuracy of model-based registration.

METHODS

The approach uses a Faster R-CNN architecture to detect and localize a broad variety and orientation of spinal pedicle screws in clinical images. Training data were generated using projections from 17 clinical cone-beam CT scans and a library of screw models to simulate implants. Network output was processed to provide screw count and 2D poses. The network was tested on two test datasets of 2,000 images, each depicting real anatomy and realistic spine surgery instrumentation - one dataset involving the same patient data as in the training set (but with different screws, poses, image noise, and affine transformations) and one dataset with five patients unseen in the test data. Assessment of device detection was quantified in terms of accuracy and specificity, and localization accuracy was evaluated in terms of intersection-over-union (IOU) and distance between true and predicted bounding box coordinates.

RESULTS

The overall accuracy of pedicle screw detection was ~86.6% (85.3% for the same-patient dataset and 87.8% for the many-patient dataset), suggesting that the screw detection network performed reasonably well irrespective of disparate, complex anatomical backgrounds. The precision of screw detection was ~92.6% (95.0% and 90.2% for the respective same-patient and many-patient datasets). The accuracy of screw localization was within 1.5 mm (median difference of bounding box coordinates), and median IOU exceeded 0.85. For purposes of initializing a 3D-2D registration algorithm, the accuracy was observed to be well within the typical capture range of KC-Reg.¹.

CONCLUSIONS

Initial evaluation of network performance indicates sufficient accuracy to integrate with algorithms for implant registration, guidance, and verification in spine surgery. Such capability is of potential use in surgical navigation, robotic assistance, and data-intensive analysis of implant placement in large retrospective datasets. Future work includes correspondence of multiple views, 3D localization, screw classification, and expansion of the training dataset to a broader variety of anatomical sites, number of screws, and types of implants.

Known-component metal artifact reduction (KC-MAR) for cone-beam CT

Intraoperative cone-beam CT (CBCT) is increasingly used for surgical navigation and validation of device placement. In spinal deformity correction, CBCT provides visualization of pedicle screws and fixation rods in relation to adjacent anatomy. This work reports and evaluates a method that uses prior information regarding such surgical instrumentation for improved metal artifact reduction (MAR). The known-component MAR (KC-MAR) approach achieves precise localization of instrumentation in projection images using rigid or deformable 3D-2D registration of component models, thereby overcoming residual errors associated with segmentation-based methods. Projection data containing metal components are processed via 2D inpainting of the detector signal, followed by 3D filtered back-projection (FBP). Phantom studies were performed to identify nominal algorithm parameters and quantitatively investigate performance over a range of component material composition and size. A cadaver study emulating screw and rod placement in spinal deformity correction was conducted to evaluate performance under realistic clinical imaging conditions. KC-MAR demonstrated reduction in artifacts (standard deviation in voxel values) across a range of component types and dose levels, reducing the artifact to 5-10 HU. Accurate component delineation was demonstrated for rigid (screw) and deformable (rod) models with sub-mm registration errors, and a single-pixel dilation of the projected components was found to compensate for partial-volume effects. Artifacts associated with spine screws and rods were reduced by 40%-80% in cadaver studies, and the resulting images demonstrated markedly improved visualization of instrumentation (e.g. screw threads) within cortical margins. The KC-MAR algorithm combines knowledge of surgical instrumentation with 3D image reconstruction in a manner that overcomes potential pitfalls of segmentation. The approach is compatible with FBP-thereby maintaining simplicity in a manner that is consistent with surgical workflow-or more sophisticated model-based reconstruction methods that could further improve image quality and/or help reduce radiation dose.

3D-2D Image Registration in Virtual Long-Film Imaging: Application to Spinal Deformity Correction

PURPOSE

Intraoperative 2D virtual long-film (VLF) imaging is investigated for 3D guidance and confirmation of the surgical product in spinal deformity correction. Multi-slot-scan geometry (rather than a single-slot "topogram") is exploited to produce parallax views of the scene for accurate 3D colocalization from a single radiograph.

METHODS

The multi-slot approach uses additional angled collimator apertures to form fan-beams with disparate views (parallax) of anatomy and instrumentation and to extend field-of-view beyond the linear motion limits. Combined with a knowledge of surgical implants (pedicle screws and/or spinal rods modeled as "known components"), 3D-2D image registration is used to solve for pose estimates via optimization of image gradient correlation. Experiments were conducted in cadaver studies emulating the system geometry of the O-arm (Medtronic, Minneapolis MN).

RESULTS

Experiments demonstrated feasibility of multi-slot VLF and quantified the geometric accuracy of 3D-2D registration using VLF acquisitions. Registration of pedicle screws from a single VLF yielded mean target registration error of (2.0±0.7) mm, comparable to the accuracy of surgical trackers and registration using multiple radiographs (e.g., AP and LAT).

CONCLUSIONS

3D-2D registration in a single VLF image offers a promising new solution for image guidance in spinal deformity correction. The ability to accurately resolve pose from a single view absolves workflow challenges of multiple-view registration and suggests application beyond spine surgery, such as reduction of long-bone fractures.

Image quality and dose characteristics for an O-arm intraoperative imaging system with model-based image reconstruction

PURPOSE

To assess the imaging performance and radiation dose characteristics of the O-arm CBCT imaging system (Medtronic Inc., Littleton MA) and demonstrate the potential for improved image quality and reduced dose via model-based image reconstruction (MBIR).

METHODS

Two main studies were performed to investigate previously unreported characteristics of the O-arm system. First is an investigation of dose and 3D image quality achieved with filtered back-projection (FBP) - including enhancements in geometric calibration, handling of lateral truncation and detector saturation, and incorporation of an isotropic apodization filter. Second is implementation of an MBIR algorithm based on Huber-penalized likelihood estimation (PLH) and investigation of image quality improvement at reduced dose. Each study involved measurements in quantitative phantoms as a basis for analysis of contrast-to-noise ratio and spatial resolution as well as imaging of a human cadaver to test the findings under realistic imaging conditions.

RESULTS

View-dependent calibration of system geometry improved the accuracy of reconstruction as quantified by the full-width at half maximum of the point-spread function - from 0.80 to 0.65 mm - and yielded subtle but perceptible improvement in high-contrast detail of bone (e.g., temporal bone). Standard technique protocols for the head and body imparted absorbed dose of 16 and 18 mGy, respectively. For low-to-medium contrast (<100 HU) imaging at fixed spatial resolution (1.3 mm edge-spread function) and fixed dose (6.7 mGy), PLH improved CNR over FBP by +48% in the head and +35% in the body. Evaluation at different dose levels demonstrated 30% increase in CNR at 62% of the dose in the head and 90% increase in CNR at 50% dose in the body.

CONCLUSIONS

A variety of improvements in FBP implementation (geometric calibration, truncation and saturation effects, and isotropic apodization) offer the potential for improved image quality and reduced radiation dose on the O-arm system. Further gains are possible with MBIR, including improved soft-tissue visualization, low-dose imaging protocols, and extension to methods that naturally incorporate prior information of patient anatomy and/or surgical instrumentation.

Hexachlorocyclohexanes in the Canadian archipelago. 1. Spatial distribution and pathways of alpha-, beta- and gamma-HCHS in surface water

Hexachlorocyclohexanes (HCHs) in the surface water of the Canadian Archipelago and south Beaufort Sea were measured in summer, 1999. Overall concentrations of HCH isomers were in order of abundance: alpha-HCH (3.5 +/- 1.2 ng L(-1)) > gamma-HCH (0.31 +/- 0.07 ng L(-1)) > beta-HCH (0.10 +/- 0.03 ng L(-1)). Concentrations and ratios of alpha-HCH/gamma-HCH decreased significantly (p < 0.001 to 0.003) from west to east, but there was no significant variation in alpha-HCH/ beta-HCH. The (+) enantiomer of alpha-HCH was preferentially degraded, with enantiomer fractions (EFs) ranging from 0.432-0.463 and increasing significantly (p < 0.001) from west to east. Concentrations also varied latitudinally for alpha-HCH and gamma-HCH (p < 0.002) but not for beta-HCH. Principal component analysis with variables alpha-HCH and gamma-HCH concentrations, EF, latitude, and longitude accounted for 71% (PC 1) and 16% (PC 2) of the variance. Mixing in the eastern Archipelago was modeled by assuming three end members with characteristic concentrations of alpha-HCH and gamma-HCH. The model accounted for the observed concentrations and higher EFs of alpha-HCH at the eastern stations.

Persistent organic pollutants and mercury in marine biota of the Canadian Arctic: an overview of spatial and temporal trends

This review summarizes and synthesizes the significant amount of data which was generated on mercury (Hg) and persistent organic pollutants (POPs) in Canadian Arctic marine biota since the first Canadian Arctic Contaminants Assessment Report (CACAR) was published in 1997. This recent body of work has led to a better understanding of the current levels and spatial and temporal trends of contaminants in biota, including the marine food species that northern peoples traditionally consume. Compared to other circumpolar countries, concentrations of many organochlorines (OCs) in Canadian Arctic marine biota are generally lower than in the European Arctic and eastern Greenland but are higher than in Alaska, whereas Hg concentrations are substantially higher in Canada than elsewhere. Spatial coverage of OCs in ringed seals, beluga and seabirds remains a strength of the Arctic contaminant data set for Canada. Concentrations of OCs in marine mammals and seabirds remain fairly consistent across the Canadian Arctic although subtle differences from west to east and south to north are found in the proportions of various chemicals. The most significant development since 1997 is improvement in the temporal trend data sets, thanks to the use of archived tissue samples from the 1970s and 1980s, long-term studies using archeological material, as well as the continuation of sampling. These data cover a range of species and chemicals and also include retrospective studies on new chemicals such as polybrominated diphenyl ethers. There is solid evidence in a few species (beluga, polar bear, blue mussels) that Hg at some locations has significantly increased from pre-industrial times to the present; however, the temporal trends of Hg over the past 20-30 years are inconsistent. Some animal populations exhibited significant increases in Hg whereas others did not. Therefore, it is currently not possible to determine if anthropogenic Hg is generally increasing in Canadian Arctic biota. It is also not yet possible to evaluate whether the recent Hg increases observed in some biota may be due solely to increased anthropogenic inputs or are in part the product of environmental change, e.g., climate warming. Concentrations of most "legacy" OCs (PCBs, DDT, etc.) significantly declined in Canadian Arctic biota from the 1970s to the late 1990s, and today are generally less than half the levels of the 1970s, particularly in seabirds and ringed seals. Chlorobenzenes and endosulfan were among the few OCs to show increases during this period while summation operatorHCH remained relatively constant in most species. A suite of new-use chemicals previously unreported in Arctic biota (e.g., polybrominated diphenyl ethers (PBDEs), short chain chlorinated paraffins (SCCPs), polychlorinated naphthalenes (PCNs), perfluoro-octane sulfonic acid (PFOS) and perfluorocarboxylic acids (PFCAs)) has recently been found, but there is insufficient information to assess species differences, spatial patterns or food web dynamics for these compounds. Concentrations of these new chemicals are generally lower than legacy OCs, but there is concern because some are rapidly increasing in concentration (e.g., PBDEs), while others such as PFOS have unique toxicological properties, and some were not expected to be found in the Arctic because of their supposedly low potential for long-range transport. Continuing temporal monitoring of POPs and Hg in a variety of marine biota must be a priority.

Modern and historical fluxes of halogenated organic contaminants to a lake in the Canadian arctic, as determined from annually laminated sediment cores

Two annually laminated cores collected from Lake DV09 on Devon Island in May 1999 were dated using 210Pb and 137Cs, and analyzed for a variety of halogenated organic contaminants (HOCs), including polychlorinated biphenyls (PCBs), organochlorine pesticides, short-chain polychlorinated n-alkanes (sPCAs), polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs), and polybrominated diphenyl ethers (PBDEs). Dry weight HOC concentrations in Lake DV09 sediments were generally similar to other remote Arctic lakes. Maximum HOC fluxes often agreed well with production maxima, although many compound groups exhibited maxima at or near the sediment surface, much later than peak production. The lower than expected HOC concentrations in older sediment slices may be due to anaerobic degradation and possibly to dilution resulting from a temporary increase in sedimentation rate observed between the mid-1960s and 1970s. Indeed, temporal trends were more readily apparent for those compound classes when anaerobic metabolites were also analyzed, such as for DDT and toxaphene. However, it is postulated here for the first time that the maximum or increasing HOC surface fluxes observed for many of the major compound classes in DV09 sediments may be influenced by climate variation and the resulting increase in algal primary productivity which could drive an increasing rate of HOC scavenging from the water column. Both the fraction (F(TC)) and enantiomer fraction (EF) of trans-chlordane (TC) decreased significantly between 1957 and 1997, suggesting that recent inputs to the lake are from weathered chlordane sources. PCDD/Fs showed a change in sources from pentachlorophenol (PeCP) in the 1950s and 1960s to combustion sources into the 1990s. Improvements in combustion technology may be responsible for the reducing the proportion of TCDF relative to OCDD in the most recent slice.

Temporal and spatial variabilities of atmospheric polychlorinated biphenyls (PCBs), organochlorine (OC) pesticides and polycyclic aromatic hydrocarbons (PAHs) in the Canadian Arctic: results from a decade of monitoring

The Northern Contaminants Program (NCP) baseline monitoring project was established in 1992 to monitor for persistent organic pollutants (POPs) in Arctic air. Under this project, weekly samples of air were collected at four Canadian and two Russian arctic sites, namely Alert, Nunavut; Tagish, Yukon; Little Fox Lake, Yukon; Kinngait, Nunavut; Dunai Island, Russia and Amderma, Russia. Selected POPs, including polycyclic aromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs) and organochlorine (OC) pesticides, were analyzed in both the gas and particulate phases. This paper summarizes results obtained from this project in the past 5 years. Temporal trends were developed for atmospheric PCBs and OCs observed at Alert using a digital filtration (DF) technique. It was found that trends developed with 5 years of data (1993-1997) did not differ significantly from those determined with 7 years of data (1993-1999). This implies that with the DF technique, long-term trends can still be developed with less than 10 years of data. An acceleration in decline of OC and PCB air concentrations was noted in 1999 for some compounds, although the reason is unknown. Monitoring efforts must continue to assess the effect of this decline on the long-term trends of POPs in the Canadian Arctic. Occasional high trans-/cis-chlordane ratios and heptachlor air concentrations measured at Alert between 1995 and 1997 suggests sporadic fresh usage of chlordane-based pesticides. However, significant decreasing trends of chlordanes along with their chemical signatures has provided evidence that emission of old soil residues is replacing new usage as an important source to the atmosphere. Measurements of OC air concentrations conducted at Kinngait in 1994-1995 and 2000-2001 indicated faster OC removal at this location than at Alert. This may be attributed to the proximity of Kinngait to temperate regions where both biotic and abiotic degradation rates are faster. The PAH concentrations observed at Alert mimic those at mid-latitudes and are consistent with long-range transport to the Arctic, particularly for the lighter PAHs. A decline in particulate PAH was observed, similar to atmospheric sulphate aerosol and can be attributed to the collapse of industrial activity in the former Soviet Union between 1991 and 1995. Spatial comparisons of OC seasonality at Alert, Tagish, Dunai and Kinngait show elevated air concentrations of some compounds in spring. However, elevated spring concentrations were observed for different compounds at different sites. Potential causes are discussed. Further investigation in the atmospheric flow pattern in spring which is responsible for the transport of POPs into the Arctic is required. OC and PCB air concentrations at Alert were found to be influenced by two climate variation patterns, the North Atlantic Oscillation (NAO) and the Pacific North American (PNA) pattern. Planetary atmospheric patterns must be taken into account in the global prediction and modelling of POPs in the future.

Factors affecting the occurrence and enantiomeric degradation of hexachlorocyclohexane isomers in northern and temperate aquatic systems

Concentrations of (alpha- and gamma-hexachlorocyclohexane (HCH), alpha/gamma-HCH ratios, and enantiomer ratios (ER) of alpha-HCH were measured in lakes in the arctic, subarctic, Great Lakes, Canada, and temperate regions, and temperate and arctic wetlands and streams. The highest concentrations of alpha-HCH were found in cold, large, and oligotrophic lakes such as those in the arctic, subarctic, and the upper Great Lakes, which is attributed to greater inputs from atmospheric deposition and slower loss rates relative to warmer, temperate lakes. High alpha/gamma-HCH ratios in northern systems indicate aged HCH that has undergone long-range transport to high latitude areas, whereas low ratios in the lower Great Lakes and small temperate systems indicate recent gamma-HCH usage and residual alpha-HCH concentrations. Enantioselective degradation (ERs ranged from 0.31 to 0.7) was greatest in small, high arctic lakes and streams and in large lakes in the subarctic in which alpha-HCH concentrations and contact time between chemical and sediments are highest and nutrient concentrations are lowest. Low ERs were found in wetlands and streams in which contact between chemical and sediments was greatest. Conversely, minimal enantioselective degradation occurred in temperate small lakes and wetlands (ERs ranging from 0.77 to 1.06), despite the warmer temperatures, greater microbial populations, and nutrient availability. The results suggest that enantioselective degradation is optimized by maximal contact between chemical and sediment substrates in nutrient-poor waters in which, it is hypothesized, oligotrophic bacteria may act as biofilms.

Polychlorinated naphthalenes in U.K. soils: time trends, markers of source, and equilibrium status

Polychlorinated naphthalenes (PCNs) have been analyzed in archived soil from the U.K. to investigate historical trends. Samples were obtained from the Broadbalk experiment plots (1944-1986) and Luddington experiment station (1968-1990). Luddington samples also include a set of soils that received a one-time sludge treatment in 1968, and duplicate samples of this archived sludge were also analyzed. Peak residues of sumPCN (sum of all PCN congeners quantified) were approximately 9000 pg g(-1) dry weight in 1956, declining to approximately 300 pg g(-1) in contemporary soils. The one-time sludge application resulted in elevated soil residues that were 1.5-6 times higher than the control plot over the time series. This increase is consistent with the known application rate and the amount of sumPCN in the applied sludge (approximately 250,000 pg g(-1) dry wt). Half-lives forthe Luddington control soil and the sludge-amended soil for the period 1972-1990 were 5.3 and 9.9 years, respectively. Investigation of time trends revealed differences between homologue groups with the higher molecular weight congeners peaking earlier in the time series (pre-1950) and the lower molecular weight congeners peaking later, ca. 1970. Time trends of individual congeners were investigated in terms of their relative mass percent contribution to the sum of their homologue group. Significant (p < 0.05) increasing trends were observed for several congeners associated with combustion sources (CN-29, -51, -52/60, -54, and -66/67) suggesting that combustion related sources are more important now than they were in the past. However, no decreasing trend was observed for congeners that were thought to be susceptible to degradation by photolysis suggesting that this may not be a key elimination pathway of PCNs in the environment. A simple calculation of the fugacity status of PCNs in air and soil showed that the tri-CNs are exhibiting net outgassing, while the penta-CNs are still being deposited to soil. Interestingly, the penta-CNs associated with combustion show the largest gradient for air-to-soil transfer, supporting the notion that combustion sources are important contributors to contemporary air burdens of these congeners.

Accuracy of registration methods in frameless stereotaxis

The accuracy of image to patient registration is a critical issue in the intraoperative use of frameless stereotaxic instruments for surgical guidance. This study was performed to assess the accuracy of image to head phantom registration using several standard registration techniques and a clinical frameless stereotaxic instrument. Two types of radioopaque fiducial markers were fixed to a plastic head phantom, and a computed tomography scan of the phantom was performed in the routine fashion. Image to phantom registration was carried out using fiducial markers, fiducial markers plus surface fit, anatomic landmarks, and anatomic landmarks plus surface fit. After each registration, linear inaccuracy measurements were performed for each of 32 markers. Each registration was performed 10 times, and the overall mean error measurements and anterior and posterior error were computed and compared. The overall mean error was smallest for the fiducial registration alone (2.07 mm). The magnitude of error increased significantly for posterior locations for all other registration techniques, but it was not significantly increased for the fiducial registration method. For this hardware configuration, registration with surface-applied fiducial markers is measurably more accurate than registration with surface anatomic landmarks. The addition of surface points to the fiducial registration does not increase the registration accuracy but, in fact, increases the degree of error.

Contribution of abnormal sarcoplasmic reticulum ATPase activity to systolic and diastolic dysfunction in human heart failure

Two of the most significant characteristics of failing human myocardium are an increased diastolic [Ca2+]i and a prolonged diastolic relaxation. These abnormalities are more pronounced at higher frequencies of stimulation and may be caused by an altered Ca2+ resequestration into the sarcoplasmic reticulum (SR). The force-frequency relationship was determined in multicellular preparations obtained from non-failing (n=6) and failing human myocardium (n=11). The active force in non-failing tissue increased as a function of the frequency of stimulation. In failing myocardium, an increase in frequency of stimulation (>1 Hz) was accompanied by a decrease in active force. Changes in the frequency of stimulation and active force were also associated with changes in intracellular calcium concentrations. The diastolic force in failing myocardium was augmented following an increase in frequency of stimulation, whereas in non-failing tissue, no increase in diastolic force was observed. Associated with the increase in diastolic force was an increase in intracellular diastolic calcium concentrations. The SR Ca2+ ATPase activity was reduced in failing compared to non-failing myocardium. SR Ca2+ ATPase was positively correlated with diastolic force in non-failing myocardium. The relationship between Ca2+ ATPase activity at 1 micromol/l [Ca2+] and active force between 0.5 and 2.0 Hz was different between failing and non-failing myocardium. The diastolic force demonstrate an inverse relationship with the SR Ca2+ ATPase activity in failing myocardium. These data suggest that a reduction in SR Ca2+ ATPase activity contributes to the impairment in both systolic and diastolic function of failing human hearts.

Gait pattern alteration by functional sensory substitution in healthy subjects and in diabetic subjects with peripheral neuropathy

OBJECTIVE

To evaluate the ability of diabetic and nondiabetic individuals to learn to use a lower extremity sensory substitution device to cue gait pattern changes.

DESIGN

Case-control study.

SETTING

Gait laboratory.

PARTICIPANTS

Thirty diabetic persons and 20 age- and education-matched nondiabetic controls responded to advertisements for study participation.

INTERVENTION

Participants walked on a treadmill at three speeds (1, 2, and 2.5mph) with auditory sensory feedback to cue ground contact greater than 80% duration of baseline.

MAIN OUTCOME MEASUREMENTS

The variables measured included gait cycle (steps per minute) and number of times per minute that any step during a trial exceeded 80% duration of ground contacted compared with a measured baseline step length for each speed.

RESULTS

Persons in both groups were able to rapidly and significantly alter their gait patterns in response to signals from the sensory substitution device, by changing their gait cycles (nondiabetic group, F(17,124) = 5.27, p < .001; diabetic group, F(5,172) = 3.45, p < .001). Post hoc analyses showed early gait cycle modification and error reduction among both groups. The nondiabetic group learned to use the device significantly more quickly than the diabetic group during the slow (1mph, t = 3.57, p < .001) and average (2mph, t = 2.97, p < .05) trials. By the fast (2.5mph) ambulation trial, both groups were performing equally, suggesting a rapid rate of adjustment to the device. No technical failures from gait trainer malfunction occurred during the study.

CONCLUSIONS

Diabetic persons with neuropathy effectively used lower extremity sensory substitution, and the technology is now available to manufacture a durable, effective lower extremity sensory substitution system.

Is contractility depressed in the failing human heart?

Is contractility depressed in the failing human heart? The question must be approached in a stringent manner. Myocardium from failing human hearts has been shown to generate normal physiological force under the ideal conditions of low stimulation and an adequate energy supply. Nevertheless, even when subjected to physiologically conducive conditions, failing myocardium experiences a slowed relaxation, adversely affecting the diastolic properties of the heart. In addition, experiments have shown that increasing the contraction rates of failing hearts clearly results in lowered force and pressure evolution. This information indicates a decrease in contractile reserve in both a systolic and diastolic sense. Not surprisingly, the term end-stage heart failure becomes questionable when applied to myocardium obtained from patients undergoing cardiac transplantation. A number of studies involve such myocardium from feasible regions of the heart perfused within ideal physiological conditions yielding, at times, nonfailing performance. Therefore, it becomes imperative to bear in mind the role of such myocardium within the framework of the entire diseased heart.

Total-contact casting, sandals, and insoles. Construction and applications in a total foot-care program

It must be stressed that these tools do not exist in a vacuum and that no single tool is particularly useful unless it is a part of a comprehensive, lifelong foot-care program. A partnership between the health care provider and the patient is essential in making any of these techniques useful. On the positive side, a program incorporating these techniques can be very successful with even the most difficult population. The very successful Parkland Memorial Hospital program provides care for a county hospital population that is often difficult in terms of compliance. Without question, the reasons for incorporating such a program in a public facility are sound. Amputations are avoided; and patients remain or become more functional, thus decreasing hospital cost and patient morbidity and mortality and increasing the patient's potential for contributing to society. Similarly, in private facilities, once the program is established, costs need not run high and considerable amounts can be saved by helping heal and/or prevent the horrendous sequelae of diabetic neuropathies.

[Ca2+]i in human heart failure: a review and discussion of current areas of controversy

Multiple abnormalities have been reported in the setting of human heart failure. It is unclear whether detected changes reflect adaptive alterations in myocardium subjected to increased and sustained hemodynamic overload or are pathogenic to the disease process. As a result of the observation that the primary defect in heart failure is decreased pump function, investigators have concentrated their efforts on determining systolic [Ca2+]i as a logical corollary and a causative mechanism for contractile dysfunction. A simple cause and effect relationship has therefore been proposed with regard to contractile dysfunction and [Ca2+]i. Yet some investigators have found no difference in peak systolic [Ca2+]i between failing and non-failing human myocardium, whereas others have found peak [Ca2+]i to be significantly reduced in failing hearts. Resting calcium concentrations have been reported either to be elevated in failing human myocardium or not different from non-failing human myocardium. Investigators should now appreciate that the force-calcium relationship is not a simple relationship. One must take into account the prolonged time course and slowed mobilization of [Ca2+]i as opposed to simply peak [Ca2+]i. When put in perspective of mechanisms and determinants of the Ca(2+)-force relationship, we begin to realize that failing human myocardium has the "potential" to generate normal levels of force. Only when stressed by [Ca2+]i overload and/or frequency perturbation does myocardium from patients with end-stage heart disease demonstrate contractile failure. Although [Ca2+]i availability and mobilization are likely to play a role in the systolic as well as diastolic dysfunction reported in human heart failure, it is likely that other mechanisms are involved as well (e.g., myocardial energetics). Myocardial energetics is directly related to [Ca2+]i and mobilization in failing human myocardium, because metabolites, e.g., ADP, inhibit pumps, such as sarcoplasmic reticulum Ca2+ ATPase activity. We therefore conclude that there is a role for intracellular calcium mobilization and myocardial energetics for systolic and diastolic dysfunction seen in human heart failure.

The status of burn rehabilitation services in the United States: results of a national survey

A survey to determine the status of burn rehabilitation services in the United States was developed and sent to 186 burn treatment facilities. The facilities were divided into four groups based upon number of admissions per year (0 to 80, 81 to 120, 121 to 200, and 200+). Completed surveys were received from 114 facilities. Results indicated that burn facilities of different sizes were consistent with respect to the severity of burn injuries treated, the length of hospitalization for acute injuries, and the duration of physician follow-up after discharge. Burn facilities with more admissions were more likely to report (1) organized outpatient burn rehabilitation programs, (2) available specialized burn rehabilitation personnel, (3) regular interdisciplinary inpatient staffing conferences and outpatient clinics, and (4) structured educational activities for staff and Full-time equivalent burn rehabilitation personnel were equally represented across facilities of different sizes. The overall results suggest that there have been substantial improvements in the comprehensiveness of burn rehabilitation care since a previous survey in 1983. Minimum guidelines for burn rehabilitation are suggested based upon the relative consistency between burn facilities indicated by the survey results.

Burn rehabilitation: dimensions of the problem

Recent improvements in the mortality rates of burned patients are attributed to the expansion of specialized burn centers. Satellite treatment areas with trained personnel need to be developed, located away from the burn center, and efforts should be made to increase the number of patient programs at existing burn centers. In addition, studies need to be conducted on cost consequences, hypertrophic scarring, peripheral and central nervous system involvement, musculoskeletal changes, sleep deprivation, and the comparison of various treatment techniques to determine what protocols provide the best treatment outcome.

Return to work after burn injury

The research literature suggests but does not test the hypothesis that differential factors determine when a patient will return to work after serious burn injury. In this study, factors influencing time before return to work after serious burn injury were investigated prospectively as part of a large burn research project. Sixty-five patients with burns who had returned to work were followed. Several variables were examined, including percent total body surface area burned, total percent of partial-thickness burn, total percent of full-thickness burn, duration of treatment, payment source for treatment, sex, race, type of burn, and age. The most significant predictor of time before return to work was percent total body surface area burned, followed by percent body surface area with full-thickness burns, percent body surface area with partial-thickness burns, and number of weeks of treatment, respectively. Sufficient data were available to develop a regression equation to specifically predict time before return to work. The data presented here are useful in informing patients, families, employers, and health-funding agencies as to the probable delay before return to work that can be expected after serious burn injury. In particular, predictability refinements are possible with the regression equation developed in this study.

Recurrence of neuropathic ulceration following healing in a total contact cast

Total contact casting has been clearly shown to be an effective technique in the healing of diabetic neuropathic foot ulcerations. The purpose of this study was twofold: (1) to determine the rate of ulcer recurrence in a large population of patients whose ulcerations had healed in a total contact cast, and (2) to determine the reason for which ulcerations had recurred. A random sample of 102 patients was taken from a much larger population, all of whom had healed in a total contact cast. There were 54 men and 48 women, all of whom were diabetics, averaging 50.5 years of age. These patients had an average wound size of 2.6cm by 1.9cm prior to casting and an average healing time of 33.9 days. At the time the sample was drawn, it had been an average of 25 months since casting for this group. Twenty (19.6%) of the 102 patients had ulcer recurrences since initially healing in a cast. Causes of ulcer recurrence were failure to comply with follow-up foot-wear/foot-care protocol (n = 8), biomechanical faults (n = 5), osteophyte or bone fragment (n = 4), osteomyelitis (n = 5), and Charcot joint (n = 4). Some patients had multiple etiologies.

Range of motion of the shoulder performed while patient is anesthetized

Significant loss of shoulder range of motion (ROM) in the early stages of burn recovery is a common and frustrating complication of burn injury. Pain is a primary reason for decreased motion: it prevents the patient from cooperating in an aggressive therapy program that could minimize contracture formation. To combat loss of movement without inflicting severe pain, the performance of ROM exercises and gentle passive stretching while patients were anesthetized was used as a treatment. A total of 59 treatments were performed on 14 patients who had limited unilateral or bilateral shoulder motion. A significant gain in shoulder ROM was attained when this treatment was performed and resulted in an increase in shoulder ROM when the patient was alert after anesthesia compared with preanesthesia measurements.

The problem of Social Security disability determination for the burn patient. A report from the Committee on Rehabilitation of the American Burn Association (ABA)

The ABA Rehabilitation Committee has developed a form to be included in the hospital record at discharge that should facilitate the Social Security disability determination process for the burn patient. This form should aid in the disability determination process by guiding the Social Security disability examiner to the pertinent evidence of limitation and chronicity in the often cumbersome medical record and by emphasizing the multiple body system nature of the severe burn injury.

New bone formation at amputation sites in electrically burn-injured patients

Sixty-one amputation sites in 43 electrically injured men were examined for significant new bone formation. Twenty-eight amputations were classified as long bone (6 above knee, 4 below knee, 4 above elbow, 14 below elbow); 28 small bone (9 hand or finger and 19 foot or toe); and 5 disarticulations. Significant new bone formation occurred at the amputation site in 23 (82%) of the 28 long bone cases, but none occurred in the small bone or disarticulation cases. This difference was significant at the 0.0001 level (chi square = 40.53, 2 df). Fourteen (78%) of upper and nine (90%) of lower extremity sites had significant new bone formation. The average time from amputation to diagnosis of new bone was 38 weeks, range from 5 to 110 weeks. Eight of these 23 patients required surgical revision of the stump and/or revision or reconstruction of their prosthesis. Clearly, the ability to predict new bone formation in electrical burn amputees has important clinical and economic applications.

Total contact casting and chronic diabetic neuropathic foot ulcerations: healing rates by wound location

This study investigated healing rates of chronic diabetic neuropathic foot ulcerations located on the plantar surface of the forefoot (n = 30) versus those located on other parts of the foot (n = 25). Each type of ulceration was treated with total contact casting. Ulcerations in the first group were located on the metatarsal heads and toes, while ulcerations in the second group were located on the dorsum of the foot, heel, plantar arch, ankle, medial aspect of foot, and toe or transmetatarsal amputation sites. Successfully healed diabetic neuropathic foot ulcerations treated with total contact casting were rated according to patient age, ethnic origin, sex, patient weight, ulcer size, ulcer location, duration of ulcer prior to casting, and ulcer grade. Analysis of variance and posthoc analyses demonstrated that (1) total contact casting was a highly effective method of treatment regardless of ulcer location (forefoot ulcer healing time mean = 30.6 days; nonforefoot ulcer healing time mean = 42.1 days) and (2) forefoot ulcerations healed significantly faster than ulcerations located on other parts of the foot. Complex correlational relationships were explored in this study, and multiple regression equations were developed for each location grouping.

Return to work following hand burns

Time to return to work following hand burns was studied in 70 patients in relation to several variables: 1. total body surface area (TBSA) burned; 2. hand burned; 3. grafting; 4. patient age; 5. occupational category. Return to work data were also compared by meta-analysis to data in prior reports on return to work in nonburn hand injuries. Patients were evaluated during their hospital stay on all independent variables, and at 8 months following discharge as to the date of return to work. Of the 70 patients selected for the study, 52 (74%) had returned to work at the 8-month assessment. The best predictor of time to return to work was TBSA burned, followed by "grafting" and "hand burned." No significant differences or predictors were found for patient age, occupational category, or between nonburn hand trauma patients in prior reports. Conclusions are drawn concerning the usefulness of these results in terms of case management and economic impact in hand-burn injuries.

Neuromuscular problems in the burn patient: cause and prevention

Neuromuscular complications of the burn patient that occur during hospitalization frequently are overlooked. Eighty-eight patients with signs of weakness or complaints of easy fatigability were examined clinically and electrodiagnostically. The most frequently diagnosed neuromuscular abnormality in this study was generalized peripheral neuropathy. Other specific neuromuscular problems, in order of frequency of occurrence, were found to involve the deltoid muscle, peroneal nerve, ulnar nerve, median nerve, and brachial plexus. These lesions are found to be commonly due to (1) poor positioning, both in bed and in the operating room, and (2) heavy bulky dressings over superficial nerves. Thus, it is concluded that many of these injuries offer a significant potential for prevention through attention to physiologic positioning and meticulous patient care.

Total contact casting in diabetic patients with neuropathic foot ulcerations

This study investigated total contact casting in the treatment of diabetic foot ulcerations and factors affecting the rate of ulcer healing. Twenty-two diabetic patients with foot ulcerations were rated on the basis of age, weight, ulcer size, and ulcer grade. After treatment with total contact casting, 16 patients (72.7%) healed in an average of 38.3 days, 3 refused treatment, 1 developed a small tibial ulceration, and the remainder were discontinued due to excessive edema. A significant (p less than 0.01) t test for differences between means was calculated comparing ulcer duration prior to casting to healing rate during casting. All patient variables were intercorrelated, and significant (p less than 0.01) intercorrelations among patient variables were as follows: age with grade, 0.58; grade with healing time, 0.49; size with healing time, 0.50; age with ulcer size, 0.36; weight with ulcer size, 0.37; age with healing time, 0.32. A multiple correlation of 0.69 (p less than 0.01) was found for age, grade, size, and weight with healing time. Ulcer grade and size contributed most directly to the total multiple correlation; age contributed equally to size, grade, and healing time; and weight contributed primarily to ulcer size. These results suggest the following: 1) total contact casting is an extremely valuable method of treatment for diabetic foot ulcerations, and 2) when using this treatment technique associated factors (ulcer size, ulcer grade, patient age, patient weight) may be utilized to help predict patient healing.

Burn injury: rehabilitation management in 1982

Coincident with the recent development of more effective acute care of burn injured patients, has been the growth of dynamic, integrated rehabilitative efforts. The physical, emotional, and social problems that face the thermally injured patient must be solved in a constructive, coordinated manner within the matrix of total patient care. Most burns are minor burns, which may be optimally treated on an outpatient basis in a physical medicine department. Hospitalized patients, with more extensive and severe burns, should have the benefit of rehabilitative team efforts immediately after injury. We describe a comprehensive approach to the rehabilitative care of the thermally injured, including the techniques of wound management, positioning, splinting, and exercise at all chronologic phases of care. The psychosocial component of patient care is also discussed and the importance of counseling and relaxation methods addressed. Specialized problems and therapeutic techniques associated with hand burns are explained and appropriate splinting methods are illustrated.

Lymphedema incidence after specific postmastectomy therapy

In a retrospective study the incidence of lymphedema was analyzed in 58 women, ages 35 to 81 years, who had received a specific treatment program after radical or modified radical mastectomy for breast carcinoma in a county hospital. Thirty-nine percent (23 patients) had cobalt treatment and 48% (28 patients) had delayed wound healing. Circumferential measurements of both upper limbs were obtained at specific corresponding sites. At the end of the 12 months, 69% of the patients had no lymphedema, 22.4% had slight lymphedema, 5.2% had moderate lymphedema and 3.4% had severe lymphedema. The benefits of close follow-up and specific treatment of mastectomized patients are evidenced in this study by the relatively large group of patients which was free of lymphedema over an extended period of time in spite of wound healing complications.

Burn rehabilitation-a team approach

The team concept in the treatment of burned patients is an effective approach in caring for the physical, psychological, and social needs of the patient. Through the initiation of early rehabilitation services, long-term problems can be prevented and a quicker return to a meaningful life style is possible.