lhcqf logo 2016


Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


In developing the emergency medical plan proven azilect 0.5 mg, it is important to buy azilect 0.5 mg low price recognize that in any given situation buy generic azilect 1 mg line, the members of the emergency response team can vary. For example, a physician may or may not be on-site, the athletic trainer may be working alone or part of an on-site staff, and emergency medical technicians may be present at an event or available only if summoned. The following questions should be addressed relative to each event: I What emergency equipment must be available I Who will be responsible for ensuring that the emergency equipment is operational I If a physician is present, what are the responsibilities of other medical personnel. I If a physician is not present and the athletic trainer is evaluating the situation, what are the responsibilities of emergency medical technicians responding to the situation I If it becomes necessary to stabilize and transport an individual to a medical facility, who will direct the stabilization, and what protocol will be followed for the removal of protective equipment I Who will supervise other participants if the athletic trainer is assessing and providing care to an injured individual I Who will be responsible for the proper disposal of items and equipment exposed to blood or other bodily fluids Field Strategy: Developing A written emergency plan should be developed for each activity site to address these an Emergency Care Plan, questions. The use of interactive or marizes several important simulation practice exercises can better prepare individuals to assume their roles issues in developing an emergency medical plan. You also will find a checklist for materials and supplies While the condition of the gymnast may eventually warrant activation of that should be included in the institution’s emergency medical plan, there is not sufficient informa an athletic training medical tion at this point to activate the plan. It is important that the athletic trainer kit and in the emergency assess the athlete’s condition to determine whether activation of the emergency crash kit. In responding to an on-field or on-site injury, the initial assessment performed by the athletic trainer is intended to rule out any life-threatening conditions. The primary survey determines level of responsiveness and assesses airway, breathing, and circulation. If at any time during the assessment conditions exist that are an immediate threat to life, or if “red flags” are noted (Box 5. Triage refers to the rapid assessment of all injured individuals followed by return to the most seriously injured to provide immediate treatment. Once it has determined that a life-threatening condition does not exist, a secondary survey is performed to identify the type and extent of any injury and the immediate disposition of the con dition. During an on-field (on-site) assessment, the athletic trainer should assume a position close to the injured individual. One hand should be placed on the forehead of the injured individual to stabilize the head and neck and prevent any unnecessary movement. The history of the injury can be obtained from the individual or, if the individual is unconscious, from bystanders who may have witnessed the injury. Questions should be open-ended to allow the per son to provide as much information as possible about the injury. The athletic trainer should listen attentively for clues that may indicate the nature of the injury. On-site history taking should be relatively brief as compared to a more comprehensive clinical evaluation. The site of the injury should be identified; it is important to be aware that several areas may be injured. The position of the injured body part at the point of impact and the direction of force should be identified. If no response, rap the sternum more forcibly with a knuckle, or pinch the soft tissue in the armpit (axillary fold). If you did not see what happened, question other players, supervisors, officials, and bystanders. Note if the individual is alert and aware of his or her surroundings or has any short or long-term memory loss. If the individual is lying down, determine if the person was knocked down, fell, or rolled voluntarily into that position. Instead, the individual should be encouraged to describe what happened, and the examiner should listen attentively for clues to the nature of the injury. A report of hearing a “snap” or a “pop” may indicate a fracture or rupture of a ligament or tendon. Any preexisting condition or injury may have exacerbated the current injury or may complicate the injury assessment. The history of the evaluation will enable the athletic trainer to determine the possibility of an asso ciated head or spinal injury, to rule out injury to other body areas, and if necessary, to calm the individual. If the individual cannot open the eyes on verbal command or does not demonstrate withdrawal from painful stimulus, a serious “red flag” injury exists. On-Site Observation and Inspection In an on-site evaluation, the initial observation is completed en route to the injured individual and, therefore, occurs prior to the history taking. Any equipment or apparatus that may have contributed to the injury should be noted. In severe brain injuries, a neurologic sign called “posturing” of the extremities can occur (Fig. Decorticate rigidity is characterized by extension of the legs and marked flexion in the elbows, wrists, and fingers. If the individual is not moving or is having a seizure, possible systemic, psychological, or neurologic dysfunction should be suspected.

Annuloplasty alone emitted from the transducer and resulting wave travels through may be adequate over time for control of ischemic mitral regur tissue causing compression cheap azilect 1 mg with visa, refraction and particle movement discount azilect 0.5 mg visa, gitation in some patients buy azilect cheap. There is the potential that ultrasound may both ischemic mitral regurgitation is best managed with techniques ablate and image, thus providing confirmation that the lesion for both abnormalities and recurrence may not be different is transmural. The course of mitral stenosis Percutaneous mitral commissurotomy with the Inoue balloon for severe mitral stenosis during pregnancy. Newer advances in the diagnosis and management of patients with valvular heart disease: Executive treatment of mitral stenosis. Percutaneous Heart Association Task Force on Practice Guidelines (Committee on mitral balloon valvotomy for recurrent mitral stenosis after surgical Management of Patients with Valvular Heart Disease). Predictors of long-term application of transvenous mitral commissurotomy by a new balloon outcome after percutaneous balloon mitral valvuloplasty. Percutaneous balloon assessment of commissural calcium: A simple predictor of outcome valvuloplasty compared with open surgical commissurotomy for after percutaneous mitral balloon valvotomy. Catheter balloon commissurotomy long-term results of mitral valve repair in 254 young patients with for mitral stenosis: Complications and results. Catheter balloon valvuloplasty for severe calcific of chordal preservation versus chordal resection in mitral valve aortic stenosis: A limited role. Comparison of open versus surgical closed and open mitral commissurotomy: Seven-year mitral commissurotomy with mitral valve replacement with or follow-up results of a randomized trial. Mid-term results of mitral valve from the National Heart, Lung, and Blood Institute Balloon replacement combined with chordae tendineae replacement in Valvuloplasty Registry. Prediction of outcome after percutaneous mitral commissurotomy: Six year results of the valve replacement for rheumatic mitral regurgitation in the era of N. Functional results 5 years valvotomy in reducing the severity of associated tricuspid valve after successful percutaneous mitral commissurotomy in a series of regurgitation. A predictive model on a regurgitant lesions of the aortic or mitral valve in advanced left series of 1514 patients. Mechanics of left ventricular contraction in chronic severe mitral Circulation 1992;85:448-61. Cathet Cardiovasc Diagn Determinants of pulmonary hypertension in left ventricular 1998;43:42. Echocardiographic results of balloon valvotomy in mitral stenosis with versus without prediction of left ventricular function after correction of mitral mitral regurgitation. J Am Coll Cardiol ejection fraction on postoperative left ventricular remodeling after 1996;27:1225-31. Am Heart J follow-up of patients undergoing percutaneous mitral balloon 1996;131:974-81. American Society and long-term outcome of percutaneous mitral valvotomy in of Echocardiography. J Thorac preoperative symptoms on survival after surgical correction of Cardiovasc Surg 1998;115:381-8. Cardiol Rev Echocardiographic predictors of survival after surgery for mitral 2001;9:137-43. Surgical treatment of angiographic predictors of operative mortality in patients undergoing asymptomatic and mildly symptomatic mitral regurgitation. Mitral regurgitation hemodynamic effects of the preserved papillary muscles during mitral due to ruptured chordae tendineae: Early and late results of valve valve replacement. Late outcomes of postoperative ventricular performance following valve replacement mitral valve repair for floppy valves: Implications for asymptomatic for chronic mitral regurgitation. Mitral valve replacement with and without chordal preservation in Current concepts of mitral valve reconstruction for mitral patients with chronic mitral regurgitation: Mechanisms for insufficiency. Valve repair improves the outcome of surgery for mitral invasive and conventional mitral valve surgery using premeasured regurgitation. Preoperative left mitral valve reconstruction with mitral valve replacement: ventricular peak systolic pressure/end-systolic volume ratio and Intermediate-term results. Lorusso R, Borghetti V, Totaro P, Parrinello G, Coletti G, mitral valve reconstruction with Carpentier techniques in 148 Minzioni G. Ann Thorac Surg Mechanism of outflow tract obstruction causing failed mitral valve 2001;71:1464-70. Curr Opin without chordal replacement with expanded polytetrafluoroethylene Cardiol 2002;17:179-82. New York: on the surgical treatment of ischemic mitral regurgitation: Operative McGraw Hill, 1997:991-1024. Mitral regurgitation: Basic pathophysiologic J Thorac Cardiovasc Surg 1996;112:287-92. Ischemic mitral regurgitation: Long-term outcome and prognostic Ann Thorac Surg 1999;68:820-4. Leaflet restriction versus coapting force: In vitro the posterior tricuspid leaflet and chordae: Technique and results. Mitral stenosis after mitral valve repair for strategy in mitral valve regurgitation based on echocardiography. Ann Thorac Surg mitral regurgitation due to severe myxomatous disease: Surgical 1998;66:1277-81. The edge-to-edge technique: Intraoperative transesophageal Doppler color flow imaging used to A simplified method to correct mitral insufficiency. Eur J guide patient selection and operative treatment of ischemic mitral Cardiothorac Surg 1998;13:240-6. Effects of valve surgery on left ventricular contractile valve repair for mitral valve prolapse. J Thorac Determinants of the degree of functional mitral regurgitation in Cardiovasc Surg 1991;101:495-501. Incidence, clinical detection, and prognostic the restricted posterior mitral leaflet motion in chronic ischemic implications.

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Historically best 0.5mg azilect, occurred often after exposure to order azilect on line amex thalidomide at 30–40 days of gestation 6 buy azilect 1mg. Skeletal defects – vertebral and rib abnormalities, sacral agenesis, radial abnormalities, talipes equinovarus b. Gastrointestinalanomalies–esophagealatresia,tracheo-esophageal stula, intestinal malrotation, Meckel diverticulum, and anal-rectal atresia c. Most abnormalities are located near the umbilical cord insertion into the abdomen H. Gastroschisis is usually situated to the right of the umbilicus and does not involve the umbilical cord directly. May form vascular compromise of either the umbilical vein or the om phalomesenteric artery. Premature involution of the right umbilical vein, before 28–32 conceptual days, may lead to ischemia and resultant mesodermal and ectodermal defects. Ischemic injury to the region of the superior mesenteric artery may explain high rates of jejunal atresia found in association with gastroschisis 4. Defects are generally small, less than 4 cm in diameter, and bowel loops are often covered by an inammatory exudate a. Be careful in evaluation for omphalocele, as the sac may have rup tured and no longer be evident (obscuring the diagnosis of om phalocele) 5. Many believe that gastroschisis has no apparent association with chromosomal abnormalities b. As previously noted, an omphalocele sac (see below) may no longer beevidentbecauseofrupture. Insuchcases,relianceonthediagnosis of gastroschisis in determining the need for antenatal karyotypic evaluation may yield inaccurate analysis of the likelihood of aneu ploidy. If amniocentesis is not elected, care should be taken to ensure that the observed defect conforms closely to the preceding description. If defects are situated to the left of the midline, are moderate or large in size, involve the liver or other abdominal structures, or if other sonographic ndings are present, the possibility of ruptured omphalocele should be considered and appropriate evaluation con sidered. Ventral wall abnormalities that involve herniations of the peritoneal sac and its contents outside the abdominal wall. The anterior ab dominal wall is formed by fusion of the cephalic fold with the lateral folds; failure of this fusion yields omphalocele with ectopia cordis, diaphragmatic, and sternal defects. Defective fusion of the lateral folds (between the 2nd and 4th conceptual weeks) leads to isolated omphalocele. Intra-abdominalcon tents herniate within the peritoneal sac into the amniotic cavity through the base of the umbilical cord. Bowel loops, stomach, and liver are commonly involved, and the size of the defect ranges from small to sacs containing most of the abdominal contents. Trisomy 13 – cardiac anomalies, midline facial anomalies, mi crocephaly,holoprosencephaly,polydactyly,rocker-bottomfeet, single umbilical artery iv. Trisomy18–cardiacanomalies,growthretardation,cleftlip,sin gle umbilical artery, cystic hygroma, hydrocephaly, overlapping ngers, rocker-bottom feet v. The kidney is formed by an interaction between the ureteric bud and the metanephric blastema (Figures 19. If the ureteric buds are located more medially than normal or if the inducible metanephric blastema is con tinuous at the lower pole, then a fused horseshoe kidney may develop. Its renal pelves are displaced anteriorly and its ureters usually course across the anterior surfaces of the kidney. The ureters may be duplicated or angulated, so that obstruction, which leads to hydronephrosis, occurs. Ectopic Kidney A kidney is ectopic when it is in the pelvis and not in its usual location. Ectopic kidney and ureter duplication usually are not functionally important in the prenatal period. Renal Agenesis In bilateral renal agenesis, both kidneys and ureters are absent (Table 19. May occur with dysplasia as a hereditary syndrome May be isolated Syndromatic Brachio-oto-renal syndrome Bilateralrenalagenesisisrare,occurringin1/3,000to1/4,000liveborns(Fig Goldenhar syndrome, DiGeorge ure 19. Unilateral agenesis occurs in 1/1,000 newborns; it is more common syndrome in males. Aplasia of female genital tract Fraser-cryptophthalmos, syndactyly It is postulated that renal agenesis is caused by the failure of the ureteric bud syndrome to develop. The ureteric bud normally induces the metanephric blastema to Kallmann syndrome Thymic-renal-anal-lung syndrome become a kidney. In some cases, however, it is possible that the mesenchyme is unable to respond to the ureteric bud, which would then degenerate. Oligohydramnios Oligohydramnios is the most serious intrauterine conse quence of bilateral renal agenesis. The lack of amniotic uid interferes with normal lung development even before 20 weeks gestation and results in pulmonary hypoplasia (Fig ures 19. The renal lesion is usually accompanied by congenital hepatic brosis, with dilated intrahepatic bile ducts (Figures 19. Variation within an individual family occurs with variation in the sever ity of renal and hepatic involvement. Hyperplasia and cystic dilation of the renal collecting ducts are attributed to an abnormal differentiation of the interstitial portion of the ureteric bud branches; the nephrons, ampulla, and pelvis are not affected. Fusion of kidneys forming partial Simple renal cysts horseshoe with S-shaped curve in a 17 Acquired renal cystic disease week gestation fetus.

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Candidates must be advised that audio-visual material purchase azilect overnight delivery, text purchase generic azilect from india, graphs cheap azilect 1 mg free shipping, images and/or data published in print or in electronic sources that is not their own must also attribute the source. This section, titled Nature of science, is in the biology, chemistry and physics guides to support teachers in their understanding of what is meant by the nature of science. The “Nature of science” section of the guide provides a comprehensive account of the nature of science in the 21st century. It will not be possible to cover in this document all the themes in detail in the three science courses, either for teaching or assessment. Technology Although this section is about the nature of science, the interpretation of the word technology is important, and the role of technology emerging from and contributing to science needs to be clarified. In today’s world, the words science and technology are often used interchangeably, however historically this is not the case. Technology emerged before science, and materials were used to produce useful and decorative artefacts long before there was an understanding of why materials had different properties that could be used for different purposes. In the modern world the reverse is the case: an understanding of the underlying science is the basis for technological developments. Despite their mutual dependence they are based on different values: science on evidence, rationality and the quest for deeper understanding; technology on the practical, the appropriate and the useful with an increasingly important emphasis on sustainability. The underlying assumption of science is that the universe has an independent, external reality accessible to human senses and amenable to human reason. Pure science aims to come to a common understanding of this external universe; applied science and engineering develop technologies that result in new processes and products. Scientists use a wide variety of methodologies which taken together, make up the process of science. Scientists have used, and do use, different methods at different times to build up their knowledge and ideas but they have a common understanding about what makes them all scientifically valid. This is an exciting and challenging adventure involving much creativity and imagination as well as exacting and detailed thinking and application. Scientists also have to be ready for unplanned, surprising, accidental discoveries. Many scientific discoveries have involved flashes of intuition and many have come from speculation or simple curiosity about particular phenomena. Scientists have a common terminology and a common reasoning process, which involves using deductive and inductive logic through analogies and generalizations. This does not mean that they disbelieve everything, but rather that they suspend judgment until they have a good reason to believe a claim to be true or false. It can be gathered by human senses, primarily sight, but much modern science is carried out using instrumentation and sensors that can gather information remotely and automatically in areas that are too small, or too far away, or otherwise beyond human sense perception. Improved instrumentation and new technology have often been the drivers for new discoveries. Observations followed by analysis and deduction led to the Big Bang theory of the origin of the universe and to the theory of evolution by natural selection. Disciplines such as geology and astronomy rely strongly on collecting data in the field, but all disciplines use observation to collect evidence to some extent. Experimentation in a controlled environment, generally in laboratories, is the other way of obtaining evidence in the form of data, and there are many conventions and understandings as to how this is to be achieved. This evidence is used to develop theories, generalize from data to form laws and propose hypotheses. In this way theories can be supported or opposed and can be modified or replaced by new theories. Models, some simple, some very complex, based on theoretical understanding, are developed to explain processes that may not be observable. Computer-based mathematical models are used to make testable predictions, which can be especially useful when experimentation is not possible. Models tested against experiments or data from observations may prove inadequate, in which case they may be modified or replaced by new models. The outcomes of experiments, the insights provided by modelling and observations of the natural world may be used as further evidence for a claim. Models, usually mathematical, are now used to derive new understandings when no experiments are possible (and sometimes when they are). This dynamic modelling of complex situations involving large amounts of data, a large number of variables and complex and lengthy calculations is only possible as a result of increased computing power. Modelling of the Earth’s climate, for example, is used to predict or make a range of projections of future climatic conditions. A range of different models have been developed in this field and results from different models have been compared to see which models are most accurate. Models can sometimes be tested by using data from the past and used to see if they can predict the present situation. Science is carried out by a community of people from a wide variety of backgrounds and traditions, and this has clearly influenced the way science has proceeded at different times. It is important to understand, however, that to do science is to be involved in a community of inquiry with certain common principles, methodologies, understandings and processes. Though these concepts are connected, there is no progression from one to the other. These words have a special meaning in science and it is important to distinguish these from their everyday use.

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Most major anomalies can be detected at 18–20 weeks of gestation by a specialized (or targeted) ultrasound examination that includes a carefully performed assess ment of fetal cardiac structure purchase generic azilect canada, including the great vessels purchase azilect in india. Antepartum Management the management of diabetes in pregnancy must focus on excellent glucose con trol achieved using a careful combination of diet generic 1 mg azilect otc, exercise, and insulin therapy. Patients may need to be seen every 1–2 weeks during the first two trimesters and weekly after 28–30 weeks of gestation. A registered dietitian may be of value in providing an individualized nutrition program. Pregnancy is characterized by increased insulin resistance and reduced sen sitivity to insulin action. Insulin requirements will increase throughout preg Obstetric and Medical Complications 221 nancy, most markedly in the period between 28–32 weeks of gestation. Short-acting or rapid-acting insulins are administered before meals to reduce glucose elevations associated with eating. Longer acting insu lins are used to restrain hepatic glucose production between meals and in the fasting state. Frequent self-monitoring of blood glucose is essential to achieve euglycemia without significant hypoglycemia during pregnancy. Early delivery may be indicated in some patients with vasculopathy, nephropathy, poor glucose control, or a prior stillbirth. During induction of labor, maternal glycemia can be controlled with an intravenous infusion of regular insulin titrated to maintain hourly readings of blood glucose levels less than 110 mg/dL. Avoiding intrapartum maternal hyperglycemia may prevent fetal hyperglycemia and reduce the likelihood of subsequent neonatal hypoglycemia. One half of the pre delivery dose may be reinstituted after starting regular food intake. Thyroid Disease Because thyroid disease is the second most common endocrine disease that affects women of reproductive age, obstetricians often care for patients in whom alterations in thyroid gland function have been previously diagnosed. However, there are gestational age-specific nomograms and thresholds for evaluating thyroid status during pregnancy. The presence of maternal thyroid disease is important information for the pediatrician to have at the time of delivery. Thyroid Function Testing Thyroid testing in pregnancy should be performed on symptomatic women and women with a personal history of thyroid disease or other medical conditions associated with thyroid disease (eg, type 1 diabetes mellitus). Development of a signifi cant goiter or distinct nodules should be evaluated as in any patient. Women with established overt thyroid disease (hyperthyroidism or hypothyroidism) should be appropriately treated to maintain a euthyroid state throughout preg nancy and during the postpartum period. Compared with controlled maternal hyperthyroidism, inadequately treated maternal hyperthyroidism is associated with a greater risk of preterm deliv ery, severe preeclampsia, and heart failure and with an increase in medically indicated preterm deliveries, low birth weight infants, and possibly fetal loss. The goal of management of hyperthyroidism in pregnancy is to maintain the free thyroxine or free thyroxine index in the high normal range using the lowest possible dosage of thioamides to minimize fetal exposure to thioamides. Hemoglobin and Hct levels are lower in African American women compared with white women. Antepartum Management the initial evaluation of pregnant women with mild to moderate anemia may include a medical history, physical examination, and red blood cell indices, serum iron levels, and ferritin levels. Using biochemical tests, iron deficiency anemia is defined by results of abnormal values for levels of serum ferritin, transferrin saturation, and levels of free erythrocyte protoporphyrin, along with low Hgb or Hct levels. Failure to respond to iron therapy should prompt further investigation and may suggest an incorrect diagnosis, coexisting disease, malabsorption (sometimes caused by the use of Table 7-1. Patients with anemia other than iron deficiency anemia should be further evaluated (see also “Hemoglobinopathies” in this chapter). Intrapartum Management Iron supplementation decreases the prevalence of maternal anemia at delivery. Transfusions of red cells seldom are indicated unless hypovolemia from blood loss coexists or an operative delivery must be performed on a patient with ane mia. Severe anemia with maternal Hgb levels less than 6 g/dL has been associ ated with abnormal fetal oxygenation, resulting in nonreassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilatation, and fetal death. Venous thromboembolism accounts for approximately 9% of all maternal deaths in the United States. Evaluation and Diagnosis Women with a history of thrombosis who have not had a complete evaluation of possible underlying etiologies should be tested for both antiphospholipid antibodies and for inherited thrombophilias. Additional measures should be considered for certain women at particularly high risk of thrombosis at the time of delivery. Women who have antithrom bin deficiency may be candidates for antithrombin concentrates peripartum. Most patients who receive thromboprophylaxis during pregnancy will benefit from thromboprophylaxis postpartum, but the dose and route will vary by indication. When reinstitution of anticoagulation is planned postpartum, pneumatic compression devices should be left in place until the patient is ambulatory and until antico agulation is restarted. Women who require more than 6 weeks of anticoagula tion may be bridged to warfarin. Gestational Diabetes Mellitus Diagnosis and Management ^117^219^240 Gestational diabetes mellitus is defined as carbohydrate intolerance that begins or is first recognized during pregnancy. This condition is associated with increased risks for the fetus and newborn, including macrosomia, shoulder dystocia, birth injuries, hyperbilirubinemia, hypoglycemia, respiratory distress syndrome, and childhood obesity.

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T1 relaxation time without contrast enhancement has also been shown to purchase generic azilect pills correlate with cartilage water 43 content order azilect with amex. Magnetic field strength is the main determinant of image contrast and image 44 45 resolution 0.5 mg azilect overnight delivery. Depending on the field strength, rated in tesla, magnets are divided into low (0. The disadvantages of a lower strength magnet include decreased signal to noise ratio, thicker images slices, longer scanning times and patient motion ending in inferior 45,46 image resolution and quality compared to higher strength magnets. Superficial erosions and fibrillations of the articular cartilage have been unreliably detected in low-field systems 10 in cadaver limbs, whereas experimentally created full thickness erosions (8 mm in 10 diameter) were always detected using T1 weighted gradient-recalled echo sequences. Non-structural (early) 48 cartilage alterations were limited in this joint in the examined technique. The reliability of both low and high field systems for the detection of cartilage and bone lesions has been 49 investigated in the equine proximal metacarpo/metatarso phalangeal joint. It was found that there was a high likelihood of false positive results using both low or high-field systems for the detection of cartilage lesions and a moderate to high likelihood for false positive 49 results when detecting subchondral bone lesions compared to histopathology. Despite using high-field systems evaluation of the thin equine articular cartilage still remains a challenge. This however depends on the joint itself, the location within the joint, the individual’s age and whether the joint is under load or not. Abrupt thinning of the articular cartilage was noted at the most abaxial palmar aspects of the distal phalanx and should not be confused with cartilage erosions in this particular region. This implies that cartilage 55 damage can and does progress while no clinical signs such as lameness are yet apparent, therefore it is imperative to use modalities that can detect cartilage injury early, enabling pathologic conditions to be addressed before they have progressed and allowing timely therapy to be instigated. In humans more is known about imaging articular cartilage than horses or small animals. Such morphological changes are preceded by biochemical and structural changes in the extracellular cartilage matrix, which can be evaluated by parametric mapping of cartilage. To obtain relaxation time maps several images of one area are acquired, whereby a certain sequence parameter is varied. The change of image intensity as a function of this sequence parameter is fitted pixel by pixel into mono-exponential equations, resulting in 58, a a relaxation time value for each pixel. In vitro studies have investigated the relationship between T2 measurements and the biochemical composition of cartilage showing that increased T2 values correlated with histologically present degeneration, both in tissue 61-66 samples and in animal models (rats and rhesus macaque). In vivo studies have been 67,68-72 73,74 75 conducted in the human knee joint, the human hip joint, the human ankle, and 76 the human proximal interphalangeal joint of the hands. In T2 mapping cartilage stratification (tangential zone, transitional zone, radiate zone) has been well visualized. It has been recognized that superficial cartilage has significantly longer T2 relaxation time values 70,63 than deeper cartilage. Studies have explored the relationship between cartilage biomechanics and T2 values. A strong relationship between the change in collagen fiber orientation and T2 values was 78-80 81 noted: T2 values decreased under static compression of the cartilage. Similarly after running T2 values were found 82 lower, suspected to correspond with loss of cartilage water due to cartilage compression. T2 mapping has also been used to evaluate cartilage repair techniques and study results show that it is a useful technique in post-operative evaluation of repaired articular 58 cartilage. Following autologous chondrocyte implantation with a fibrin-based scaffold in the human knee T2 mapping showed that the spatial variation of the T2 values was similar in 83 84 repaired and in normal articular cartilage. The spatial variation of T2 values was similar in normal articular cartilage and in the repaired articular cartilage, making T2 mapping a promising tool in the 18 Introduction 84 assessment of articular cartilage ultrastructure following cartilage repair techniques. T1 mapping can then be used to quantify the amount of cartilage 55,58 degeneration in the joint. Similar T1Gd relaxation times were noted in repaired cartilage and normal 93 cartilage. Vascular distribution and the thickness of the articular cartilage affect the rate of equilibration between the articular cartilage and 55 the contrast media. The delineation of the cartilage in the human hip joint and 89 in the canine stifle joint was superior using a direct intraarticular administration versus an intravenous administration. The authors showed that it is a feasible technique to map T1 relaxation times in the equine distal third metacarpal/metatarsal bone articular cartilage with recommendations to delay scanning 60 120 minutes following intraarticular contrast administration. These investigations were limited by the thin cartilage of the distal third metacarpal/metatarsal bone and the low magnet strength (1. Quantitative mapping techniques in the horse T2 mapping of experimentally made defects in articular cartilage of equine stifles using a 1. T2 mapping of full-thickness cartilage defects repaired with concentrated bone marrow aspirate versus microfracture indicated that treatment with bone marrow aspirate resulted in increased fill of the defects and improved integration of 104 repair tissue into surrounding normal cartilage. Similar to humans these reports are promising and clearly show the benefits of a non-invasive tool to determine the biological consequence of an intervention. Joint disease state and site within the joint will have a significant effect on cartilage thickness measurements. Contribution: Study design, study execution, shared contribution to data collection, shared contribution to data analysis, shared contribution to data interpretation, shared contribution to manuscript writing, arrangement and formatting. The effects of cartilage health and site within the joint ((condylar, intercondylar) (dorsal, central, palmar)) on cartilage thickness were analysed using generalized linear mixed models. However, the correlation between the T1 measurements and the histological measurements was superior to the correlation of the T2 measurements to the histological measurements.


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