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In the Andes, ancient peoples would bury human sacrifices throughout the high peaks in a sacred ritual called Capacocha (Wilson et al. The best-preserved mummy to date is called the "Maiden" or "Sarita" because she was found at the summit of Sara Sara Volcano. Her remains are over 500 years old, but she still looks like the 15-year-old girl she was at the time of her death, as if she had slept for 500 years. Finally, arid environments can also contribute to the preservation of organic remains. As discussed with waterlogged sites, much of the bacteria that is active in breaking down bodies is already present in our gut and begins the putrefaction process shortly after death. Arid environments deplete organic material of the moisture that putrefactive bacteria need to function (Booth et al. It is similar to the way a food dehydrator works to preserve meat, fruit, and vegetables for longterm storage. It would be impossible to calculate the exact amount, but the vast majority of animals that once lived do not make it into the fossil record. The reason for such a small number is that it is extremely difficult for an organism to become a fossil. There are many stages involved and if the process is disturbed at any of the stages, the organism will fail to become a fossil. Bacteria, insects, scavengers, weather, and environment all aid in the process that breaks down organisms so their nutrients, molecules, and elements can be returned to Earth to maintain ecosystems (Stodder 2008). Fossilization, therefore, is the preservation of an organism against these natural decay processes (Figure 7. Understanding the Fossil Context 241 For fossilization to occur, several important things must happen. First, the organism must be protected from things like bacterial activity, scavengers, and temperature and moisture fluctuations. Since soft tissue like organs, muscle, and skin are more easily broken down in the decay process, they are less likely to be preserved except in rare circumstances. Bones and teeth, however, last much longer and are more likely to be preserved in the fossil record (Williams 2004, 207). They, along with water, provide the minerals that will eventually become the fossil (Williams 2004, 31). Sediment accumulation also provides the pressure needed for mineralization to take place. Lithification is when the weight and pressure of the sediments squeeze out extra fluids and replace the voids, that appear in the remains as they decay, with minerals from the surrounding sediments. One of the most common plants existing today, the fern, has been found in fossilized form many times. Other plants that no longer exist or the early ancestors of modern plants come in fossilized forms as well. It is through these fossils that we can discover how plants evolved and learn about the climate of Earth over different periods of time. This fossil is created when actual pieces of wood-such as the trunk of a tree-mineralize and turn into rock. Petrified wood is a combination of silica, calcite, and quartz, and it is both heavy and brittle. There are a number of places all over the world where petrified wood "forests" can be found, but there is an excellent assemblage in Arizona, at the Petrified Forest National Park. At this site, evidence relating to the environment of the area some 225 mya is on display. However, there are a number of fossilized hominin remains that provide a picture of the fossil record over the course of our evolution from primates. The term hominins includes all human ancestors who existed after the evolutionary split from chimpanzees and bonobos, some six to seven mya. Modern humans are Homo sapiens, but hominins can include much earlier versions of humans. Until recently, Lucy was the most complete and oldest hominin fossil, with 40% of her skeleton preserved (see Chapter 9 for more information about Lucy). In 1994, an Australopithecus fossil nicknamed "Little Foot" (Stw 573) was located in the World Heritage Site at Sterkfontein Caves ("the Cradle of Humankind") in South Africa. Little Foot is more complete than Lucy and possibly the oldest fossil that has so far been found, dating to at least 3. Through tedious excavation, the specific ankle bones of the fossil were extricated from the matrix of concrete-like rock, revealing that the bones of the ankles and feet indicate bipedalism (University of Witwatersrand 2017). The oldest hominin fossil is a fragmentary skull named Sahelanthropus tchadensis, found in Northern Chad and dating to circa seven mya (Lebatard et al. It is through the discovery, dating, and study of primate and early hominin fossils that we find physical evidence of the evolutionary timeline of humans. Without a complete cranium (or other fossilized remains), it is difficult to tell exactly what was going on in the fossil record. Furthermore, it is reasonable to assume that of the existing fossilized remains, many remain hidden in glaciated rock, in caves, or in the ground. Sometimes pieces of amber contain inclusions such as air bubbles or insects that become trapped in the sap (Figure 7. This beautiful fossil comes in a variety of colors from light gold to orange red to even green. For this reason, amber is frequently polished to a high luster and used in jewelry (Figure 7. The notoriety of amber increased significantly when it was featured in the highly fictionalized Understanding the Fossil Context 243 Jurassic Park film franchise. Rest assured, at the time of this writing, amber is not being used as the genetic basis for the regeneration of extinct dinosaurs, although the recent discovery of a tick that fed off of dinosaur blood that is trapped in amber has renewed interest in the idea (Pickrell 2017). Asphalt is commonly referred to in error as tar because of its viscous nature and dark color. A famous fossil site from California is La Brea Tar Pits in downtown Los Angeles (Figure 7. In the middle of the busy city on Wilshire Boulevard, asphalt (not tar) bubbles up through seeps (cracks) in the sidewalk. These animals became entrapped in the asphalt during the Pleistocene and perished in place. Ongoing excavations have yielded millions of fossils, including megafauna such as American mastodons and incomplete skeletons of extinct species of dire wolves, Canis dirus, and the saber-toothed cat, Smilodon fatalis (Figures 7. Between the fossils of animals and those of plants, paleontologists have a good idea of the way the Los Angeles Basin looked and the climate in the area many thousands of years ago. It is rare for fossils to survive molten lava, and it is estimated that only 2% of all fossils have been found in igneous rock (Ingber 2012). Trace Fossils Depending on the specific circumstances of weather and time, even footprints can become fossilized. Footprints fall into the category of trace fossils, which includes other evidence of biological activity such as nests, burrows, tooth marks, shells. When you consider how quickly our footprints on the ground or in sand disappear, you must also realize how rare it is that footprints can become fossilized. A well-known example of trace fossils are the Laetoli footprints in Tanzania (Figure 7. At Pech Merle cave in the Dordogne region of France, archaeologists discovered two fossilized footprints. They then brought in indigenous trackers from Namibia to look for other footprints. The approach worked as many other footprints belonging to as many as five individuals were discovered with the expert eyes of the trackers (Pastoors et al. These footprints date back 12,000 years (Granger Historical Picture Archive 2018).
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It is in fact a resistance index, which increases as renal function deteriorates and decreases as renal perfusion improves. A transplant uptake that appears more intense than that of the iliac artery is considered to be associated with good early perfusion. If the transplant and the iliac artery have the same activity, this demonstrates moderate early perfusion, while a transplant with lower uptake than the iliac vessel demonstrates poor perfusion. Good and moderate perfusion are usually seen in acute tubular necrosis, whereas moderate to poor early perfusion is seen in established rejection. Lack of urinary activity in the first 30 min is typical of acute tubular necrosis, and as the kidney recovers the time to urinary activity shortens. Native kidneys can occasionally be seen according to pre-transplant functional status. Serial perfusion index determinations show a gradual reduction of the number towards 100%. Any superimposed adverse event such as rejection, septicaemia or Cyclosporin toxicity will have a negative effect on the improvement of the perfusion index. Rejection usually has its onset at about 7 days and is characterized by a reduction of uptake on the early image, moving from moderate to poor early perfusion. In adults with normal renal function, final distribution is attained after two hours and the excretion can then be described by a monoexponential function. Clinical indications the clinical indications for measuring the glomerular filtration rate are: (a) (b) (c) (d) (e) Investigation and evaluation of chronic nephro-urological diseases; In conjunction with renography before surgery on the kidneys and/or the urinary tract; Evaluation in association with transplantation; Monitoring of renal function during treatment with potentially nephrotoxic pharmaceuticals; For dose calculation of potentially toxic pharmaceuticals that are mainly excreted by the kidneys. Its use, however, requires standardization, since the amount of protein binding varies among different manufactures. Iodine-125 iothalamate can be used but it is a high-osmolar ionic contrast agent whose intravenous administration some countries no longer endorse. It is desirable for children to come to the laboratory with an intravenous route already established. For reasons of feasibility, the blood sample needed for the determination of serum creatinine can be taken together with the blood sample that is taken for determination of background activity immediately before injection of the radiopharmaceutical. Urine sampling should always be included in the procedure for patients with oedema and ascites. Formulas for calculation according to the single sample and multisample methods are presented in Appendix 1 to this section. Correction for the time delay due to the transport of urine from the kidneys to the bladder in the well hydrated patient can be made as follows: Time delay (min) = 3. Procedural issues concerning preparation of standards, injection of radiopharmaceutical, drawing of blood samples and centrifugation are described in Appendix 2 to this section. Interpretation Interpretation should be made with reference to a set of normal values. Children aged 2 years and above should have a kidney function corresponding to that of a 20 year old, provided the result is normalized to a body surface area of 1. It is, however, only necessary to determine the slow exponential component, since the contribution of the fast component to the total area under the curve is small and can be corrected for. The first step of the multisample method is to calculate a preliminary clearance, Clp, as Clp = Q0 /(A/b) where Q0 is the injected amount of radioactivity, b is the slope of the slow component, as determined from one blood sample drawn at the beginning and another drawn at the end of the recommended time interval for drawing of the blood samples, and A is the intercept of the extrapolated slow component with the y axis. In adults the final clearance, Clf, can then be obtained by insertion of Clp into: 2 Clf = 0. A substantial variation in counts between standards indicates a pipetting error and new standards should be prepared. Inject approximately 5 mL of heparinized saline to clear out the stopcock and the tubing. Introduction Radionuclide methods are available for the study of lung ventilation and perfusion. Other indications are for assessment of residual lung function if surgery is planned for lung tumours, ventilation scans to assess alveolar capillary permeability in smoke inhalation injuries and studies of mucociliary clearance (tracheobronchial clearance). Technegas, a vaporized 99mTc-carbide from a special device, has a particle size of less than 0. Perfusion lung imaging permits an evaluation of the pulmonary arterial blood flow. Clinical indications the most common indication for lung scintigraphy is to confirm or exclude pulmonary embolism. Thrombi, usually from the deep venous system of the lower extremities, and globules of fat and particulate amniotic fluid can embolize the pulmonary arteries and produce acute pulmonary hypertension. A ventilation study, performed in conjunction with the lung perfusion images, improves the sensitivity of the lung perfusion image up to 90%. As a general rule, normal ventilation is found in regions of pulmonary embolization. Clinical suspicion of pulmonary embolism should lead to immediate heparinization (unless there is a contraindication), with a lung study conducted at the same time or on the following day in order to confirm or exclude pulmonary embolism. Less common indications include the evaluation of lung function preoperatively, alveolar capillary permeability after smoke inhalation injury, mucociliary function and lung transplant evaluation. Lung perfusion imaging in conjunction with ventilation imaging has added a non-invasive component to the proper evaluation of patients with bronchitis or obstructive forms of chronic pulmonary disease. Bronchogenic carcinoma, the most common form of lung carcinoma, causes a decrease or absence of pulmonary blood flow to the affected bronchial segment. Lung perfusion images can provide a direct quantitative estimate of the amount of perfusion remaining in the total lung field, to enable a prediction as to whether or not the patient will become respiratorily disabled if the portion of the lung involved in the malignant process is surgically removed. Albumin microspheres, although less available, give a more homogeneous particle size. The minimum number of particles necessary to obtain an even distribution of radioactivity in the vascular bed is 60 000; hence it is reasonable to use about 100 000 particles, which will transiently occlude one in 1500 arterioles of the lung. Since both agents are labelled with 99mTc, it is extremely important for the count rate of the second study to be at least four times that of the first study. The radioactive gases 133Xe or 81mKr are unavailable in many countries so that radioaerosols are preferred. In patients who have no changes in signs or symptoms, a chest radiograph within one day of scintigraphy is adequate. A more recent radiograph (preferably within 1 hour) is necessary in patients with evolving clinical status. Before intravenous administration of the pulmonary perfusion radiopharmaceutical, the patient should be instructed to cough and to take several deep breaths. The patient should be in a supine position during injection or, in the case of a patient with orthopnea, as close to the supine position as possible, since particle distribution is affected by gravity. For example, half the usual activity may be used for the perfusion study and the ventilation study is omitted if possible. The pertinent clinical history should include details on: - Right-to-left shunt(s); - Severe pulmonary hypertension; - Chest pain; - Dyspnea; - Haemoptysis; - Syncope; - Symptoms of deep venous thrombosis; - Oral contraceptive use; - Recent surgery; - Prior pulmonary embolism(s); - Cancer; - Congestive heart failure; - Underlying or previous diseases; - Smoking; - Intravenous drug abuse; - Long air flights. Other factors may also be relevant; a physical examination includes vital signs, chest cardiac examination and leg findings, among other aspects. Treatment with anticoagulants or thrombolytic therapy should be noted, as should the results of tests for deep venous thrombosis, for example compression ultrasonography. In adults, the number may be reduced to between 100 000 and 200 000 particles without significantly altering the quality of the images for detection of perfusion defects.
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Where vessels are present, they can be visualized by iris angiography after intravenous injection of fluorescein sodium dye. Defects in the pigmented layer of the iris appear red under retroillumination with a slit lamp (see. Slit lamp biomicroscopy visualizes individual cells such as melanin cells at 40-power magnification. Opacification of the aqueous humor by proteins may be observed with the aid of a slit lamp when the eye is illuminated with a lateral focal beam of light (Tyndall effect). This method can also be used to diagnose cells in the anterior chamber in the presence of inflammation. Direct inspection of the root of the iris is not possible because it does not lie within the line of sight. Inspection of the posterior portion of the pars plana requires a threemirror lens. The globe is also indented with a metal rod to permit visualization of this part of the ciliary body (for example in the presence of a suspected malignant melanoma of the ciliary body). The pigmented epithelium of the retina permits only limited evaluation of the choroid by ophthalmoscopy and fluorescein angiography or indocyanine green angiography. Changes in the choroid such as tumors or hemangiomas can be visualized by ultrasound examination. After administration of topical anesthesia, a fiberoptic light source is placed on the eyeball to visualize the shadow of the tumor on the red of the fundus. This generally bilateral condition is transmitted as an autosomal dominant trait or occurs sporadically. However, peripheral remnants of the iris are usually still present so that ciliary villi and zonule fibers will be visualized under slit-lamp examination. The disorder is frequently associated with nystagmus, amblyopia, buphthalmos, and cataract. Involvement of the choroid and optic nerve frequently leads to reduced visual acuity. Surgical iris colobomas in cataract and glaucoma surgery are usually opened superiorly. In this manner, they are covered by the upper eyelid so the patient will not usually experience blinding glare. Isolated heterochromia is not necessarily clinically significant (simple heterochromia), yet it can be a sign of abnormal changes. This disorder is often associated with complicated cataract and increased intraocular pressure (glaucoma). O Sympathetic heterochromia: In unilateral impairment of the sympathetic nerve supply, the affected iris is significantly lighter. Heterochromia with unilaterally lighter pigmentation of the iris also occurs in iridocyclitis, acute glaucoma, and anterior chamber hemorrhage (hyphema). Aside from the difference in coloration between the two irises, neither sympathetic heterochromia nor melanosis leads to further symptoms. The following types are differentiated: O ocular albinism (involving only the eyes) and O oculocutaneous albinism (involving the eyes, skin, and hair). In albinism the iris is light blue because of the melanin deficiency resulting from impaired melanin synthesis. Under slit-lamp retroillumination, the iris appears reddish due to fundus reflex. Associated foveal aplasia results in significant reduction in visual acuity and nystagmus. Most patients are also photophobic because of the missing filter function of the pigmented layer of the iris. However, some inflammations involve the middle portions of the uveal tract such as iridocyclitis (inflammation of the iris and ciliary body) or panuveitis (inflammation involving all segments). Etiology: Iridocyclitis is frequently attributable to immunologic causes such as allergic or hyperergic reaction to bacterial toxins. Infections are less frequent and occur secondary to penetrating trauma or sepsis (bacteria, viruses, mycosis, or parasites). Phacogenic inflammation, possibly with glaucoma, can result when the lens becomes involved. Symptoms: Patients report dull pain in the eye or forehead accompanied by impaired vision, photophobia, and excessive tearing (epiphora). In contrast to choroiditis, acute iritis or iridocyclitis is painful because of the involvement of the ciliary nerves. Diagnostic considerations: Typical signs include: O Ciliary injection: the episcleral and perilimbal vessels may appear blue and red. Vision is impaired because of cellular infiltration of the anterior chamber and protein or fibrin accumulation (visible as a Tyndall effect). Exudate accumulation on the floor of the anterior chamber is referred to as hypopyon. Viral infections may be accompanied by bleeding into the anterior chamber (hyphema;. Corneal edemas and Tyndall effects (accumulations of protein in the anterior chamber) can be diagnosed when the eye is illuminated with a lateral beam of light from a focused light or slit lamp. In acute iritis, the depth of the anterior chamber is normal and reactive miosis is present. In contrast, in acute glaucoma the anterior chamber is shallow and the pupil is dilated (Table 8. O Adhesions between the iris and posterior surface of the cornea (anterior synechiae). Treatment: Topical and, in appropriate cases, systemic antibiotic or antiviral therapy is indicated for iridocyclitis due to a pathogen (with a corneal ulcer, penetrating trauma, or sepsis). Antibiotic therapy should begin immediately as microbiological identification of the pathogen is not always successful. Therapeutic mydriasis in combination with steroid therapy is indicated to minimize the risk of synechiae. Where no pathogen can be identified, high-dose topical steroid therapy (prednisolone eyedrops every hour in combination with subconjunctival injections of soluble dexamethasone) is administered. To minimize the risk of posterior synechiae, the pupil must be maximally dilated (atropine, scopolamine, cyclopentolate, and possibly epinephrine and epinephrine eyedrops). This may necessitate the use of longer-acting medications such as atropine, which may have to be applied several times daily. Occasionally it is possible to break off existing synechiae in this manner, and patches of iris tissue will remain on the anterior surface of the lens. Secondary open angle glaucoma is treated by administering beta blockers in eyedrop form and, in applicable cases, carbonic anhydrase inhibitors (acetazolamide; see Table 10. Prognosis: Symptoms usually improve within a few days when proper therapy is initiated. Differential diagnosis: the disorder should be distinguished from acute glaucoma, conjunctivitis, and keratitis. Complications: Total obliteration of the pupil by posterior synechiae is referred to a pupillary block. This can lead to the development of posterior subcapsular opacities in the lens (secondary cataract). In the presence of a secondary cataract, a cataract extraction may be performed when the inflammation has abated. Prognosis: Because of the chronic recurrent course of the disorder, it frequently involves complications such as synechiae or cataract that may progress to blindness from shrinkage of the eyeball. Symptoms: Patients are free of pain, although they report blurred vision and floaters. Diagnostic considerations: Ophthalmoscopy reveals isolated or multiple choroiditis foci. Once scarring has occurred the foci are sharply demarcated with a yellowish-brown color.
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Limiting balance to an ankle strategy, obese individuals have increased body weight, which increases the gravitational moment about the ankles. This increased gravitational moment would require larger ankle plantar flexor torque to recover from a perturbation , making balance recovery more physically demanding. At the same time, obese individuals have an increased mass moment of inertia about the ankles. The increased inertia in the obese may be beneficial in resisting an increase in velocity from a perturbation, making balance recovery less physically demanding. Because of this ambiguity, the purpose of this study was to investigate the effects of obesity on balance recovery using an ankle strategy. This study was approved by the Virginia Tech Institutional Review Board, and written consent was obtained from all participants. Three types of perturbations were used because the effects of obesity may be perturbation dependent. The first type involved releasing subjects from a static forward lean (lean trials) to impose an initial angular displacement from vertical with no initial angular velocity. Body angle relative to vertical was increased until the subject could no longer recover (return to upright stance). The second type of perturbation involved applying a forwarddirected force impulse to the upper back with a ballistic pendulum while subjects stood comfortably (free perturbation trials). The third type of perturbation involved applying a forward-directed force impulse to the upper back with a ballistic pendulum, but while subjects leaned against a rigid stop (lean perturbation trials) to impose an initial angular velocity at a controlled body angle. Initial angular velocity was increased until the subject could no longer recover for both free perturbation and lean perturbation trials. During all trials, subjects were harnessed to a backboard to limit balance recovery to an ankle strategy for all trials (contraction of only the muscles spanning the ankle and returning to an upright posture while keeping the body straight and not stepping). Balance recovery capability was quantified by maximum lean angle (max) for lean trials. For free perturbation trials and lean perturbation trials, balance recovery capability was quantified by the & maximum angular velocity (max) at the body angle at the end of the force perturbation (0). Body angle was low- pass filtered at 20 Hz (eighth order zero-phase-shift Butterworth filter). In particular, increased inertia may be beneficial for recovery after perturbations in which there is limited or no initial velocity because the increased inertia would resist changes in velocity, and therefore would accelerate slower. Theoretically, as initial velocity increases, increased inertia would become detrimental because that increased mass is already moving. For the lean trials, max was not significantly different between normal-weight and obese subjects & (p=0. These results indicate that obese subjects had impaired balance recovery when perturbations involved an initial angular velocity, but not when perturbations involved only an initial angular displacement. The differences between perturbation types may be explained by a possible benefit of In conclusion, obese subjects were unable to recover balance using an ankle strategy as well as normal weight subjects when perturbations involved an initial angular velocity. No differences between obese and normal-weight subjects were found when perturbations only involved an initial angular displacement. Future studies should investigate less constrained tasks of balance recovery, such as slipping and tripping, to gain more insight on the source of the increased risk of falls in the obese. Several researchers, over the past few decades, have successfully quantified different gait parameters pertaining to the biomechanics of slips and falls in an effort to help reduce the incidence of slip and fall accidents. However, a comprehensive understanding of mechanisms including strategies used by individuals for recovery during a slip perturbation is lacking. Numerous researchers [1, 3, 4] have explored different proactive and reactive strategies that individuals have used to reduce their slip potential when they walk over known and unknown slippery surfaces. Only recently  has the upper body response to a slip been explored to any extent, and the effects of load carriage on this response is unknown. This study investigates upper body response strategies, related to head and arm (hand) motion, in young and elderly subjects during a slip perturbation while carrying a load. Twenty-eight subjects (14 young, 14 elderly with equal numbers of males and females) participated in the study. All were in good health and passed the screening procedures required for participation. It should be pointed out that data from only four subjects are included in this paper as data analysis is still in its infancy. Gait trials were performed on a circular track equipped with a fall arrest rig system. Twenty-four (24) reflective markers were used to create a whole body biomechanical model in order to determine the motion of different body segments and the whole body as each subject walked over dry, known and unknown slippery surfaces. The box was carried in front of the body with elbow(s) at approximately 90, and in the right hand for single arm load. Resultant velocities for the head and wrist were calculated using 3D positional data. Peak (max) velocities were determined from coordinate data for head, left wrist and right wrist over one stride (heel contact to heel contact of same foot). Examination of the coordinated response of the upper and lower extremities to slip, and the influence of load carriage on this coordinated response is forthcoming. Considering many people, young and old, carry objects while walking on somewhat unpredictable surfaces. Preliminary results demonstrate that upper body strategy is affected by load carriage, and that the method of load carriage (1-hand versus 2) further influences the velocity of head and arm motion in slip recovery. Slip conditions resulted in greater head and arm velocities compared with non-slip, and these velocities tended to be greater in males than females. The 2-handed load carriage resulted in more constrained arm and head velocities compared with the single-hand load-carriage conditions. The no load condition did not consistently produce the highest arm or head velocities as might be expected. Many of these efforts, such as targeted physical therapy and balance retraining, are most effective and feasible when catered to the population at highest risk of falling . One of the risk factors that can help identify these individuals is balance impairment; however, many of the clinical tests used to measure balance are too long to administer or too subjective in scoring to be used as a reliable screening tool [1,2]. Posturography, the use of a force plate to measure center of pressure, has the potential to overcome these limitations. Recently, we presented preliminary results demonstrating the potential of logistic regression modeling to differentiate recurrent fallers from non-recurrent fallers . The current work further develops these findings to demonstrate clinical utility by calculating sensitivity and specificity of the developed models. A secondary aim was to determine future sample size necessary for followup work based on these findings. Subjects were classified as either recurrent or non-recurrent fallers, with recurrent falls being at least two falls in the past year. Twenty-one subjects classified as recurrent fallers (13 females, 8 males; mean age: 83. Exclusion criteria was minimal to represent the diverse population that would need to be screened using this tool. Individuals who could not stand independently, who had undergone physical therapy focused on balance in the last 6 months, or who lived in assisted living or nursing care facilities were excluded. These randomized tasks were each 60 seconds long and included: eyes open, comfortable stance; eyes closed, comfortable stance; eyes open, narrow stance (heels and toes touching); and eyes closed, narrow stance. Center of pressure data for the anterior-posterior (A/P) and medial-lateral (M/L) direction was collected at 1000 Hz. For those trials where the subject lost balance, no further analysis was performed on the data for that trial. From the center of pressure data A/P Sway Range, M/L Sway Range, Mean Sway Velocity, Root Mean Square Displacement, 95% Confidence Ellipse Area, Angular Deviation from A/P, Mean Frequency, and M/L Sway Velocity were calculated. Detrended Fluctuation Analysis was performed and two scaling regions emerged, providing a Short-Term -Scaling Exponent, a Long-Term -Scaling Exponent, and a Crossover Point for each the A/P and M/L sway directions. For each testing condition, stepwise logistic binary regression with forward selection (=0.
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Subjects were instructed to place each heel on the respective virtual lines at the instant of heel-contact. During the No Arms condition, subjects crossed their arms in front of their chest. Step width variability was defined as the standard deviation about the average step width . An increase in step width variability signified a decrease in lateral balance while running. The net rate of O2 consumption (ml/kg/min) was calculated by subtracting the average standing rate of O2 consumption from the total rate of O2 consumption during the last 3 minutes of each running condition. To compare between Arms and No Arms, we used paired t-tests with statistical significance set an! When arm swing was eliminated, the rate of O2 consumption was 8% greater than running with normal arm swing (p <. Mean step width variability at the 0% target step width was 7% greater than the Arms condition but the difference was not statistically significant (p =. In general, running with step widths other than preferred or without arm swing decreased lateral balance as indicated by an increase in step width variability. Despite the prevalence of this disorder, the specific cause of pain remains unclear. One possible mechanism of pain is elevated subchondral bone stress at the patellofemoral joint. These techniques can detect alterations in tissue metabolism that may accompany or precede pathological changes in tissue structure. Bone scans have revealed increased bone activity in 52% of patients with patellofemoral pain ; however, because it is difficult to quantify bone activity in specific regions of the joint using this technique, the relationship between bone metabolic activity and pain remains unclear. In this technique, the tracer, 18F NaF, becomes incorporated into the bone at sites of bone remodeling with high metabolic activity. The goal of this study was to characterize regions of increased bone metabolic activity in patients with patellofemoral pain and to evaluate whether metabolic activity correlates with pain. Subjects were between 20-42 years of age, had no prior knee surgery, injury, or other knee joint pathology. To minimize the effects of physical activity and blood flow on tracer distribution, subjects rested in a seated position for 30 minutes prior to tracer injection and for 60 minutes between the tracer injection and the scan. During the scan, subjects lay in a supine position with their legs secured by straps around the ankles. Since all subjects were free of tibial pathology, an axial slice through the tibial epiphysis, just proximal to the tibial tuberosity, was chosen to be representative of background tracer uptake. The maximum pain experienced during the previous year was recorded on a scale from 0-10 and the location of pain (medial/lateral facet, etc) was assessed during the clinical exam. The lateral patellar facet was the most common location of tracer uptake (10 knees). There were 15 subjects with increased uptake who could localize pain to either the medial or lateral side of the joint. In 11 of the 15 subjects, the side of maximum pain was consistent with the side of peak tracer uptake. One possible explanation for this relationship could be related to the fact that areas of mineralized bone with high metabolic activity receive rich sensory innervation . While the increase in bone metabolic activity might be due to elevated mechanical stress in the tissue, a study investigating this relationship is needed. This information could guide treatment decisions by identifying the affected regions of the joint. Furthermore, treatments that reduce bone metabolic activity in the joint may alleviate pain in some patients. Virtual Pre-Operative Reconstruction Planning for Comminuted Articular Fractures Thaddeus P. Successful clinical outcomes are most likely when the anatomy is precisely restored. Virtual pre-operative reconstruction planning using three-dimensional (3D) puzzle solving methods offers new capabilities for achieving this objective with less surgical insult. Accurate fracture reconstructions were obtained by interactively matching native fragment surfaces to an intact template. While successfully piloted in a clinical case, more automated methods will be required in order for this approach to be practical in a clinical setting . Additional complexity is present in vivo, as the structure of peri-articular bone makes it more susceptible to plastic deformations. The objective of the present study was to develop and apply new automated bone segmentation and 3D puzzle solving algorithms to obtain fracture reconstructions in a clinical series of highly comminuted tibial plafond fractures. A modified 3D watershed segmentation algorithm that iteratively propagated regions from cortical seeds into cancellous bone regions was implemented in Figure 1. Propagation speed was controlled by a combined image intensity and distance transform function. Whereas prior methods required 8-10 hours per case, this new method enabled the processing of each case in < 20 minutes with minimal user guidance. Each tibia was then methodically reconstructed by matching fragment native (periosteal and articular) surfaces to an intact template that was created from a mirror image of the healthy contralateral limb. Fragment native surfaces were identified using a region-growing algorithm that propagated discrete surface patches to boundaries of high curvature . Reconstruction started by aligning the intact template to the intact diaphyseal segment of the fractured tibia. Since the articular surface is the most important to precisely restore to forestall joint degeneration, it was isolated from the periosteal surface and separately compared to the intact anatomy. To illustrate the clinical utility of 3D puzzle solving, virtual reconstructions were compared to those achieved in surgery. Virtual pre-operative reconstruction planning holds great potential for improving articular fracture treatment. Provided this blueprint for restoring the original anatomy, the surgeon can minimize surgical insult while still achieving accurate fracture reconstructions. Furthermore, the ideal reconstruction can be used to plan for intraoperative complexities in order to avoid further complications. Knowledge of the puzzle solution could have enabled the surgeon to better restore anatomic limb length. While perfectly repairing that defect is unlikely given the plastic deformation, its detection could have allowed for the pre-operative preparation of biological interventions or engineered tissues to mitigate the incongruity. This structural instability could have been recognized virtually, giving the surgeon the opportunity to have either planned an alternate fragment configuration, a different fixation technique, or a tissue grafting solution. Unfortunately, the outcome was less than ideal, A B C Puzzle Solution Articular Defect Void Restored Anatomy Surgical Results Articular Defect Collapse Shortening Figure 2. Particularly, clinical execution of a planned reconstruction needs to respect broader anatomic constraints: the surgical access site, the presence of nearby neurovascular structures, the sequence in which fragments can be optimally reduced, etc. Despite such limitations, the results from this study suggest that 3D puzzle solving methods offer a powerful new tool for enhancing the surgical reconstruction of complex peri-articular fractures. A computational/experimental platform for investigating three-dimensional puzzle solving of comminuted articular fractures. Adaptation and form of the unconstrained lateral compensatory stepping response 1 Christopher P. If this relationship is disrupted a compensatory step may be required to re-establish stability. It should be noted however that in this study subjects were instructed to resist stepping and were discouraged from using their arms to aid in their recovery. The purpose of this study was to characterize the unconstrained stepping response to unpredictable lateral disturbances in younger adults. We were also interested in understanding how subjects adapted their stepping response to repeated exposures of the same disturbance. The disturbance waveform comprised a 240 ms approximately square-wave acceleration pulse followed by a 240 ms deceleration pulse. The difference between the minimum and maximum values of trunk lateral flexion was used to calculate trunk excursion.
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Little is known about the range of residual limb muscle activation patterns during locomotion. Foot marker trajectories in combination with ground reaction forces were used to determine gait cycle events. Prosthetic ankles lack the ability to modulate these functions due to loss of musculoskeletal structures. The commercial prosthesis market is dominated by passive devices that have fixed mechanical properties. Advances have been made in powered prosthesis control for upper extremity devices; however, little has been achieved in creating a powered prosthesis for the lower extremity. Currently available computerized prostheses rely on manual adjustment to change the state of the device . However, new innovations include a device that assists in the transition from level-ground to stair descent and back to levelground using activation of the Gastrocnemius and Tibialis Anterior as on/off triggers for switching mode . Although this allows for more diverse state control than the traditional passive devices, it is not fluid and may be dangerous in some cases. Several problems in utilizing a powered prosthesis stem from lack of fluid, on-line control. However, residual limb muscles do not activate as is expected from the natural limb. The signal was then further processed to calculate linear envelopes for each signal, using the following steps: 1) full-wave rectification, and 2) a low-pass 4th order Butterworth filter with cutoff frequency of 8Hz. Furthermore, the observation that the co-contraction index is relatively independent of walking speed should increase the potential for development of proportional control algorithms based on signal magnitude and phased timing. Preliminary observations have also revealed an occasional co-contraction pattern during the toe-off stage of the gait cycle (50-70%). Clinically, there are several factors that should be studied regarding the magnitude and timing of residual limb muscle activation. These include time since amputation, activity level, type of amputation, and age of amputee. This observation appears to be unique to the residual limb of trans-tibial amputees and independent of walking speed. Response to Tripping Perturbations in Transfemoral Amputees 1 Fabian Sierra, 1Fan Zhang, 1He (Helen) Huang and 2,3Susan E. In the latter, these types of falls may not only cause physical harm, but also can affect their balance confidence and increase fear of falling, resulting in further gait irregularities. If an able bodied person encounters unexpected perturbations during normal walking, it is possible to implement stabilizing strategies to recover from the stumble; however, for lower extremity amputees, the implementation of these strategies can prove difficult. Therefore, the goal of this study is to compare and analyze the reaction strategies of able bodied and lower extremity amputees in an effort to better understand how to assist amputee patients to recover from gait perturbations while maintaining the dynamic walking stability. They had no known prior history of neurological or orthopedic abnormalities that would hinder their normal gait during the experiment. When the perturbation is initiated with the foot in contact with the treadmill, the initial response is passive and mechanical as evidenced by the immediate change in the force profile after the trip is initiated. Conversely, when the treadmill belt is accelerated with the limb in swing, the neurological response corresponding to the increase in muscle activation of the thigh muscles is the early response. Each subject was required to perform 26 trials, two sets of 13 trials (including 5 tripping, 5 slipping, and 3 undisturbed walking tasks). A six-degree of freedom load cell was incorporated into the pylon of amputee subjects. Our data are consistent with the findings that the activity of the thigh muscles is a key factor in regaining balance after a gait perturbation, controlled largely by the knee motion. These data provide a baseline by which to compare recovery between groups from stumbling. Continuing work will focus on determining the contribution of the individual muscles to the recovery, isolating recovery patterns and using these signals to design a stumble recovery algorithm. Understanding of the mechanisms underlying stumbling and recovery during walking is important for developing these strategies and improving the quality of life for patients with lower-limb amputations. Vertical dashed lines represent significant changes in measured signals affecting the recovery of the individual. Since rear foot motion during running is often cited as a contributing factor to overuse injuries, any prospective screening should include a measure of rear foot movement. While tracking markers can be placed directly on the shoe, bone pin studies have indicated that shoe motion is not the same as true rear foot motion . As a solution some authors have advocated the use of windows in the shoe heel counter with markers attached directly to the foot for tracking rear foot motion during running . However, to date, no study has used a three dimensional (3D) analysis to evaluate differences in rear foot motion when measured by placing markers directly on the shoes or by using heel windows. Additionally, most studies on running injuries use a group design where the average performance of an injured group is compared to the average performance of a non-injured group. However, the performance of any one individual rarely, if ever, matches the average group performance . This is especially true in assessing injury risk, when it is deficits or changes in a single individual that are of concern, not how they compare to an average group performance . In these situations a single subject analysis might yield insights which are masked during a traditional group analysis. Therefore, the purposes of this study were to use a 3D analysis to compare differences in rear foot motion between markers placed on the shoes and markers placed directly on the rear foot using heel windows. A second purpose was to determine the influence of group verse single subject analysis on any kinematic differences. The shoe markers consisted of two markers along the vertical bisection of the heel counter with a third marker on the lateral side of the shoe. The heel windows markers were placed in the same locations, with marker bases attached directly to the rear foot and extending through holes cut in the heel counter. For each condition, subjects ran approximately 40 laps around a 25 meter track in the laboratory with data being collected over a 5 meter segment of each lap. For the group analysis, 10 trials were used to create an average profile for each subject. Variables of interest included rear foot eversion excursion, percent stance at maximal eversion, maximal instantaneous eversion velocity, and maximal instantaneous vertical loading rate. Significant differences between conditions were evaluated with a dependent observations t test, with set to 0. Significant differences between trials under both conditions were evaluated on an 1 individual subject basis with both an independent observations t test and a statistical method called Model Statistics . These results suggest placing the markers on the shoe artificially reduces the variability in the measured movement patterns. Similar individualized response patterns were observed for the other variables of interest. However, some of the changes were up to 40% in magnitude, suggesting there were differences between conditions; they were just not identified by the group analysis. Both the t test and Model Statistics results indicated that individuals who demonstrated large percent changes in the group analysis did in fact have significant differences between the two marker conditions. Table 2 shows the number of feet with significant differences between conditions under the single subject analysis. Overall the results of this study suggest joint kinematics and kinetics, as well as the variability in movement patterns of the rear foot, are different when measured with shoe based or heel windows markers. However, given the individualized responses observed in this study, these differences only become evident when the data is analyzed on an individual subject basis, a fact which has important implications for addressing prospective injury risk in runners. A 10-fold cross-validation was employed to assess the generalizability of the classifier scheme. In addition, a forward feature selection  was used to determine the minimum number of features necessary to achieve the best performance of the classifier. The 2D scatter-plot in Figure 1 allows an easy geometric interpretation of the data where we see a line, which represents the hyperplane in a high-dimensional space, separating groups based in these features.
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Female baboons have a strong dominance hierarchy, and the distance they travel each day increases with group size. Patas monkeys have a weak dominance hierarchy, and when group size increases, individuals spread out while feeding and daily travel distance does not increase. Community Ecology In addition to interactions with other members of their own group and other groups of conspecifics (members of the same species), primates are members composed species Figure 6. Some habitats support highly diverse primate communities consisting of 10 or more species (Figure 6. Observations of one species displacing another at a food site is a sign of competition between the two species. When this happens, usually it is the largebodied species that supplants the small-bodied species. The exception is when the smallbodied species significantly outnumbers the larger-bodied Figure 6. The competitive exclusion principle states that two species that compete for the exact same resources cannot coexist. This means that two species cannot occupy the same niche-cannot seek to meet their needs for food and shelter in the exact same way. Because tropical rainforests are highly variable, with many habitats and many sources of food and shelter, there are many different niches for multiple species Figure 6. Regardless of habitat type, sympatric species avoid competition through niche partitioning (using the environment differently). Niche partitioning includes differences in diet, ranging behavior, and habitat use. In Laikipia, Kenya, bush babies reduce competition with vervets by feeding more heavily on insects. Predation An important aspect of primate communities is the predators that also occupy them. In this section, we will limit our discussion to predation of and by vertebrates (animals with an internal spinal column or backbone). Often, predation by primates is opportunistic, occurring because the prey happen to be in the right place at the right time. In some parts of their range (including Gombe Stream National Park and Mahale Mountain National Park, both in Tanzania), chimpanzees are described as opportunistic hunters, with the vast majority of hunts occurring after a chance encounter with prey (Figure 6. Other primates are more deliberate predators, and some even work together to increase their chances of success. Cooperative hunting has been observed in white-faced capuchins and some chimpanzee populations. White-faced capuchins hunt more often during the dry season, when other food is scarce, and sometimes work together to chase, surround, and capture small mammals like young squirrels or coatis (Fedigan 1990). All primates are susceptible to predation by mammalian carnivores (animals whose diet consists primarily of animal tissue) (Figures 6. Smaller primates fall prey to a wider range of predators than larger primates, and some habitats contain a greater diversity of predators. Perhaps the best way to avoid predation is to avoid being detected by predators in the first place, and some primates use crypsis to great effect. Nocturnal and solitary, the slow loris moves slowly (as its name suggests) and quietly as its primary strategy to avoid predation (Wiens and Zitzmann 2003). If detected, however, the slow loris will attempt to escape by releasing its grip and falling off the branch or biting in defense. The venom is formed when the slow loris combines oil from a gland on its arm with its saliva (Nekaris et al. It can either apply the venom to its head for protection or store it in the mouth to deliver through a bite. Indeed, anti-predator behavior, including vigilance, alarm calling, and mobbing, may be one of the primary benefits primates get from living in groups; we will discuss these behaviors in a later section, entitled "Why do Primates Live in Groups? While there are many threats to primates, habitat destruction and hunting are the leading causes of population decline (Figure 6. Primate populations have withstood small-scale forest clearing and low levels of hunting by local human groups for hundreds of years. However, the recent, intense pressure of expanding human populations on many primate habitats is resulting in rapid population declines for many species. Between 1973 and 2010, almost 100,000 km2 of orangutan habitat was cleared for palm oil plantations in Borneo (Figure 6. During this same time, the orangutan population decreased from almost 300,000 to 100,000, an average loss of more than 5,000 orangutans every year. If this rate of loss is not curtailed, the Bornean orangutan will go extinct in less than 15 years. Survey work has revealed that the Grauer gorilla population has declined significantly since the 1990s, due almost entirely to illegal hunting. As consumers and concerned citizens, all of us are learning how to use our wallets to combat habitat and species loss. We do not buy palm oil or products made with palm oil in an effort to save orangutans. We donate to conservation organizations doing important on-the-ground work in Democratic Republic of Congo and other conservation hot-spots. We educate ourselves as well as our friends, families, and communities about the plight of endangered primates. Current and future primatologists have the opportunity to affect real change in primate conservation (Chapman and Peres 2001). Whether understanding the mechanisms that determine species abundance, predicting the effects of human activity on species survival, documenting patterns of environmental change, understanding the effects of species removal in broader contexts, or evaluating different approaches to conservation, information gained from 200 Primate Ecology and Behavior primate studies offers some of the best hope we have for a future that continues to include our closest living relatives. Gibbons and siamangs of Southeast Asia and titi monkeys of South America form long-term pair bonds with groups consisting of an adult male and female with their dependent young. Ukaris of South America and ring-tailed lemurs of Madagascar both live in groups of up to 35 individuals containing multiple adult males and females, juveniles, and infants. Gorilla troops typically number between eight and 10 individuals, consisting of multiple females, juveniles, and infants but only one adult male, the silverback. Some primate groups (like gorillas, ukaris, and ring-tailed lemurs) are stable and cohesive over long periods, except for the dispersal of some individuals who leave the group. Others, like chimpanzees and spider monkeys, have more fluid social systems, called fission-fusion, where groups break up and reunite based on differences in food availability throughout the year. Because group living is relatively unusual among mammals but quite common among primates, a central question for primatologists is: Why do primates live in groups? The answer is that primates live in groups when the benefits of feeding competition and/or predation avoidance exceed the costs. Feeding Competition As discussed in the previous section, when species feed on high-quality, scarce food (like fruit), larger groups mean there are more individuals competing for access to the resource. The result of this competition takes the form of dominance hierarchies and increased day-range length. A dominance hierarchy is the result of aggressive and submissive interactions, but once established, a dominance hierarchy functions to reduce levels of aggression because all individuals "know their place. Dominant (high-ranking) females spend more time feeding and eat more ripe fruit than subordinates (lowranking), so they consume more nutrients. Dominants weigh more, start reproducing earlier, and produce more offspring than subordinates do. The answer is that larger groups are more successful in competition with other groups. Females in larger groups had shorter interbirth intervals (the average length of time between one birth and the next) and higher average infant and female survival rates than the smallest group. In terms of competition for resources, the benefits of being a member of a larger vervet group (even a low-ranking member) outweigh the costs (Cheney and Seyfarth 1987). Seyfarth (1987) found that larger vervet groups had higher average infant and female survival rates, causes of mortality differed based on group size. Unlike the small group, mortality in larger groups was almost entirely due to predation, and this highlights another set of costs and benefits of group living. This is one of the reasons that primates who rely on crypsis to avoid predation (like the slow loris; Figure 6. However, some anti-predator behaviors, like shared vigilance duties, alarm calling, and mobbing, are responses to predators that are only available to group-living species (like Hanuman langurs; Figure 6.
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These characteristics have enabled its price to fall to a reasonable level in most parts of the world. Gallium-67 decays by emission of four gamma rays at 93, 184, 296 and 388 keV; the first three peaks being used for imaging. Lung carcinomas: - Evaluation of mediastinal nodal enlargement (if the scan is positive bilaterally, mediastinoscopy could be avoided). Sarcoidosis: - Evaluation of the extent of the disease at the time of initial diagnosis. Patient preparation the following procedure should be followed: (a) Before injection of radiopharmaceuticals: - A full clinical examination and the information gathered from laboratory tests and other sources of morphological imaging are needed. In such cases, gallium will be mainly taken up by the bone marrow, with less uptake in the liver and pathological sites; the sensitivity of the test will be low. After injection of the radiopharmaceutical: - Bowel activity presents a problem for the recognition of abnormal abdominal areas. Bowel cleansing with a mild laxative such as magnesia milk or a washing enema is recommended. When imaging malignant diseases, the problem of bowel activity can be resolved by delayed imaging up to seven days following intravenous injection. The study may be repeated at variable times, in accordance with department protocol, if there is bowel activity. Procedure and equipment the following procedures and items of equipment are required: (a) (b) A medium energy, parallel hole collimator (high energy collimators are also used). The cut-off frequency or power of the filters should be adjusted according to the total counts acquired. Alternatively, an iterative reconstruction method should be used if one is available. An attenuation correction should be considered for deep structures (especially the abdomen). Mechanism of uptake: Gallium-67 binds to plasma proteins, especially transferrin, lactoferrin and ferritin at the iron binding sites, competing with iron. The labelled plasma proteins cross the target cellular membrane to intracytoplasmic liposomes or stick to the binding sites on the cellular membrane. Conditions that saturate iron binding sites in the plasma interfere with the biodistribution of 67Ga, which remains in the blood pool and has more bone uptake, thus decreasing its sensitivity. Interpretation (a) Patterns of gallium uptake Normally, one third of the dose will be in the liver, one third in the bone marrow and spleen, and one third excreted in the urine and by the bowels. Hyperplastic breasts, secondary to oral contraceptives, also can have bilateral increased uptake. It has been successful for diagnosing more than 80% of cases of breast cancer at an early stage. As a consequence, patients are being treated at an earlier phase of their disease and their prognosis has improved. Mammography, more than any other procedure, has contributed to the more successful care of breast cancer and survival rates. Because of the non-specificity of the findings that differentiate between benign and malignant lesions, many patients are biopsied for benign lesions. Mammography is not sensitive in dense breasts, or in breasts that have been deformed as a result of a previous biopsy, treatment of previous malignancy by lumpectomy, radiotherapy either of the whole breast or locally 342 5. Similar problems are also encountered in patients with fibrocystic disease of the breast. There have been various attempts to reduce the number of biopsies for benign lesions in order to save costs and to avoid the psychological impact on those patients who are left with a scar following lumpectomy. All such attempts failed to demonstrate major clinical value because the sensitivity of mammography for small lesions under 2 cm is less than 70%. Therefore, it is very difficult to substitute for a biopsy whenever there is suspicion of malignancy in the mammogram. Once the diagnosis of malignancy has been established, the next step is determining the stage of the disease in order to decide on the best treatment for the patient. Eighty per cent of breast cancers are discovered at an early state and are operable. The most important staging criterion in these patients is the status of axillary node involvement by malignant cells. Until recently, total axillary node dissection with histological examination was the only way for axillary staging. Axillary dissection requires longer hospitalization and is followed by complications in more than 30% of patients due to infection, pain, oedema of the arm and limitation of movements. This is a high price to pay, since in the majority of patients the pathological examination of the axillary specimen shows no evidence of metastatic spread. The new approach to localize the sentinel node, either by methylene blue or by radionuclide techniques, represents a major development. It is considered the second most important milestone for the treatment of breast cancer following the changes from the mutilating radical or modified radical mastectomy to the more conservative approach of lumpectomy and postoperative radiotherapy. Sentinel node localization is successful and accurate in more than 98% of patients. Patients who have metastatic disease to the sentinel nodes require dissection of all the axillary nodes. Protocols are currently under evaluation in order to determine the prognostic impact of these findings. The sentinel node approach has a negative predictive value of more than 99% in T-1 lesions, which constitutes the most significant feature of this approach. Patient selection Nothing else is as effective as a biopsy whenever a malignant lesion is suspected. A biopsy, however, is only appropriate for those patients for whom the results of a mammography are inconclusive, namely under the following conditions: - Dense breasts, when there is clinical suspicion of a mass that cannot be detected in the mammogram. Patient preparation the procedure, its benefits and the time needed to perform it should be explained to the patient when obtaining her consent. Radiopharmaceuticals Technetium-99m sestamibi is preferred to 201Tl-chloride because of the higher injected dose and greater photon flux, as well as data from tissue culture experimental work that show a higher uptake of 99mTc-sestamibi than 201Tlchloride in breast cancer cells. Route of injection: -An intravenous injection should not be given in the arm on the side of the suspicious breast mass. Any extravasation will lead to lymphatic permeation and uptake by the lymph nodes in the axilla that could be misleading for the interpretation of axillary metastasis. Waiting time: -Although imaging can be started 15 min after injection, longer periods of up to two hours are indicated in patients with suspected inflammatory lesions. It is known that both thallium (201Tl) and 99mTcsestamibi wash out with time in benign lesions. In most malignant lesions, the washout is usually slower than in benign inflammatory lesions. Procedure and equipment the following procedure and items of equipment are recommended: (a) Patient positioning and views to be acquired: -The patient should lie face down with the affected breast resting on a foam lined aperture on the imaging table. The patient should be in the prone position and with the breast hanging, relaxing the pectoralis muscle and allowing separation of the breast tissue from the chest wall muscles and from cardiac and liver activity. In the anterior projections, both breasts, the axillae and supraclavicular regions should be included so magnification is not critical. Interpretation the interpretation should be made in steps, firstly blind to other data and then with all the information available from the clinical examination, mammography and any previous interventions. Malignant tumours show up as areas of focal increased uptake that can be graded in different ways according to the intensity and distribution of the uptake. Lymph node metastases should be checked in the axillae, supraclavicular, infraclavicular and internal mammary regions. Although no special processing is needed, reporting directly from the computer screen with threshold enhancement and background subtraction is recommended.