The Fundamentals of Courage

AUTHOR: Tom Heston, MD

"You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You must do the thing which you think you cannot do." - Eleanor Roosevelt

Eleanor Roosevelt faced many challenges during her life. She married Franklin Delano Roosevelt at age 20, then around age 30 she discovered that FDR was having an affair with her own secretary. Shortly thereafter, FDR became paralyzed, and her campaigning on his behalf played a huge role in him winning election to the Presidency of the U.S. Through her fearless and direct actions, she was able to make the most of things, and ultimately became one of the ten most widely admired people of the 20th century according a poll of the American people. She knew that positive thinking was not courage. Talking to her friends about plans for the future is not courage. Courage is an action.

It takes action to overcome a fear, and only through taking action does one become more bold and courageous.Through action directed at fear, the fear is overcome and courage is strengthened. So, in order to become more courageous, it is necessary to embrace the first fundamental element of courage- action.

"Conscience is the root of all true courage; if a man would be brave let him obey his conscience." - James Freeman Clarke

James Clarke was an early 19th century theologian and author. A graduate of Harvard College in 1829, he then became a minister for the Unitarian church in Louisville, Kentucky. At the time, Kentucky was a slave state, but James Clark stood up against his state's government and advocated strongly for the abolition of slavery. This strength of conviction, coupled with action, made Clarke a courageous person others could follow and respect. Courage comes from this strength to follow one's conscience, even if it goes against popular opinion or as in the case of Clarke, the government. This is the second fundamental principle of courage. When actions become aligned with the conscience, courage grows and is strengthened.

Taking positive action that is in alignment with the conscience is a simple concept. To strengthen courage, one must act upon the things known to be true, just, and right.

Is there something the community needs to be improved? What can be done to help? Is there something in the family that can improve? What are some simple actions that will help make things better? Is there something that should be confronted, but fear is getting in the way of acting?

REFERENCES

Gallup News Service. Mother Teresa Voted by American People as Most Admired Person of the Century. 31-Dec-1999. Retrieved 24-Feb-2012.Eleanor Roosevelt was #9 on this list.

Heston T (ed). Courage Builder. Internet Medical Association, Las Vegas, 2011.

Can We Skip the Autopsy?

AUTHOR: Tom Heston, MD

The postmortem autopsy is considered the gold standard in the determination of the cause of death. Newer imaging technologies, however, including high resolution computed tomography (CT) and magnetic resonance imaging (MRI), may allow in some cases a virtual autopsy instead, that utilizes medical imaging alone. The benefits of a virtual, imaging autopsy include the potential for conducting more autopsies which could lead to more accurate mortality statistics, and reduced costs. The virtual autopsy may also be more widely accepted by families and religions.

A study published in the January 14^th, 2012 issue of the Lancet compared traditional autopsy results with virtual autopsy by both CT and MRI. They randomly enrolled 182 cases that underwent both virtual and full conventional autopsy. The CT and MRI scans were independently interpreted for cause of death, then a combined report was created from both imaging modalities. The radiologists also indicated how confident they were in their diagnosis, which was based entirely upon the scan images. The cases were then dividing into two groups: those with a definite imaging diagnosis, and those without a definite imaging diagnosis.
The researchers found that overall, about 1 in 3 virtual autopsies contained a major discrepancy when compared with the full, traditional autopsy. Radiologists considered the imaging diagnosis for cause of death to be definite in about half of the cases. In these cases where the imaging results were considered definite, the major discrepancy rate with full autopsy was about 1 in 6. The researchers also found that CT was more accurate than MRI when using a conventional autopsy as the gold standard. Major common sources of error were when the cause of death was coronary heart disease, pulmonary embolism, bronchopneumonia, and intestinal infarction. As the study progressed, the radiologists improved their interpretation accuracy, however, major discrepancies continued to exist.

The researchers concluded that when conducting a virtual autopsy, CT imaging was better than MRI scanning in providing an accurate cause of death. When the findings on virtual autopsy were considered definite, the major discrepancy rate with full autopsy was 16%.

COMMENT: This is a new, emerging application of medical imaging that has tremendous potential. The authors note that when the imaging diagnosis was considered definite, the error rate was comparable to the error rate of a conventional, full autopsy. As physician experience with this relatively new application of medical imaging improves, it is likely that the accuracy will significantly rise. Because of the relatively low cost and ease of conducting a virtual autopsy, it is likely to become fully integrated into and a routine part of postmortem investigation.

REFERENCE

Roberts IS, Benamore RE, Benbow EW et al. Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study. Lancet. 2012 Jan 14;379(9811):136-42

Stress-only Nuclear Myocardial Perfusion Imaging

Author: Tom Heston, MD

Inducible myocardial ischemia from coronary artery disease is diagnosed when blood flow to the heart at stress is significantly less than blood flow at rest. The identification of inducible ischemia is important in people with chest pain, because with proper treatment the risk of a major adverse cardiac event is greatly reduced. Many different conditions can cause chest pain, most of which are benign and non-life threatening. However, inducible ischemia can be life threatening, and when left untreated the consequences are severe.

One of the best and most thoroughly validated method of testing for inducible ischemia is stress-rest myocardial perfusion gated SPECT imaging. This involves injecting a patient with a radiotracer at rest and during peak stress. The radiotracer is primarily designed to map blood flow to the heart. However, using a gated SPECT protocol also allows determination of left ventricular size, wall motion, and ejection fraction. Inducible ischemia is suggested by abnormalities in any of these imaging variables at stress, that are not present at rest. Because the objective is to identify abnormalities at stress that are not present at rest, current utilization guidelines for myocardial perfusion gated SPECT recommend imaging both at rest and immediately post-stress.

Newer research in myocardial perfusion imaging has looked at the possibility of imaging patients only post-stress, and omitting the rest scan. The reasoning for this is that if the stress scan is normal, then the rest scan is medically unnecessary, financially costly, and exposes patients to excess radiation. Although not yet widely validated, stress-only imaging may be reasonable in low-risk patients as long as any abnormal stress study is followed-up with a rest scan. Nevertheless, at the current time, clinical practice guidelines have not fully addressed or endorsed stress-only imaging, and nearly all nuclear cardiology clinics continue to perform stress-rest imaging.

There are several reasons for continuing the practice of stress-rest imaging until more research is done. One reason is that myocardial perfusion imaging is not indicated in low-risk patients, so the research doesn't apply to clinical medicine. The research protocols for stress-only imaging typically involved attenuation correction SPECT, a technique that has not been widely accepted due to a relative lack of solid evidence supporting its use. Another reason is that risk stratification prior to imaging is often inexact, so it is medically safer to assume at least an intermediate risk and perform a stress-rest study. Finally, the goal of myocardial perfusion imaging is to maximize sensitivity, since the consequences of failing to identify inducible ischemia can be severe. Stress-only imaging is not thought to be as sensitive as stress-rest imaging.

The current prevailing medical practice to perform stress-rest imaging as a routine appears to be clinically appropriate, with a recent clinical update (2009) from the American Society of Nuclear Cardiology concluding that a stress-only strategy "does not yet have sufficient data to support a widespread utilization." Nevertheless, the research supporting stress-only imaging continues to grow, with one recent paper finding its use even in high-risk patients to be appropriate in some circumstances.

REFERENCES

Heller G, Hendel R. Nuclear Cardiology: Practical Applications, Second Edition [2010].

A Case Report: Treatment of a medial condylar humeral fracture in an adult with osteopetrosis - (author: Calvin Chien)

Authors: Dr Calvin CHIEN, MBBS
Dr Rajesh BEDI, DNB (Ortho)
Dr Richard D. LAWSON, FRACS (Ortho)

Abstract:

Patients with osteopetrosis often present with orthopaedic problems such as frequent fractures. Management of fractures with open reduction and internal fixation is difficult but possible. We report on a 22 year old patient with a medial humeral condyle fracture treated successfully with internal fixation using a pre-contoured plate.

Introduction:

In 1904 Albers-Schoenberg described a condition characterised by marked radiographic density of the bones (1). Despite the sclerotic radiographic appearance of the thickened cortices and its material hardness, osteopetrotic bone is weak, brittle and prone to fracture after minor trauma (1). Most literature regarding treatment of osteopetrotic patients with fractures concentrates on paediatric patients or on the difficulty of operative intervention in adults (2). We report the case of an adult patient with osteopetrosis and a low medial column fracture (Milch Type I (1)) of the distal humerus after minor trauma. The fracture was treated operatively utilising internal fixation with a pre-contoured peri-articular plate.

Case:

A 22 year old female with known osteopetrosis presented with an elbow injury after bracing herself with the right arm after a fall. The mechanism described suggested a valgus injury to the right elbow resulting in a Milch Type I (3) low medial column fracture of the distal humerus (Fig. 1). There were no neurological deficits. As an adolescent she had previous injuries including one to the radius of the same side limiting elbow extension by twenty degrees. She was also partially blind and was receiving psychiatric treatment for depression.

Two days later, open reduction of the right distal humerus was performed with internal fixation using a pre-contoured medial condylar locking plate (Fig 2). This was done through a posterior approach after identifying the ulnar nerve. Anterior transposition of the ulnar nerve was done before closure. The patient was discharged two days later in a plaster-of-paris back slab with outpatient follow-up. After two weeks the arm was placed in a range of movement elbow brace with unrestricted range of motion. Serial radiographs were performed at four-weekly intervals and complete bony union with disappearance of the fracture line was evident on the radiographs taken at fourteen weeks (Fig 3). Outpatient as well as a home-based physiotherapy program was arranged and full pre-injury range of motion was achieved by ten weeks.

Discussion:
Osteopetrosis is a rare hereditary disease of the osteoclasts first described by Albers-Schönberg, a German radiologist, in 1904. Defective osteoclastic activity or a reduced number of osteoclasts results in a failure of bone remodelling (4). This is manifested on radiographs as an increase in bone mass and osteosclerotic changes (4).



Osteopetrosis can be classified into three main forms: a malignant autosomal recessive, intermediate autosomal recessive and benign autosomal dominant form; the vast majority of these cases are the benign autosomal dominant form. The malignant autosomal recessive type, also known as infantile, is characterised by growth retardation, failure to thrive and cranial nerve palsies manifesting as proptosis, deafness and blindness. In addition, pancytopenia and thrombocytopenia may result from bone marrow failure. Many features of the intermediate form of osteopetrosis are similar to those of the malignant form but the intermediate form is less severe and later in onset. It is often diagnosed after a fracture, usually occurring in the first decade. Benign osteopetrosis has been further subdivided into types I and II. However, recent genetic studies have shown that autosomal-dominant osteopetrosis type I is caused by an increase in osteoblastic activity rather than osteoclastic dysfunction. In this case osteoblasts deposit excessive amounts of bone matrix (4). Type II autosomal dominant osteopetrosis is the form Albers-Schönberg first described and so is often named after him. The onset is in later childhood and is usually diagnosed incidentally during a radiographic examination (4). It is also associated with increased fracture frequency. Other manifestations include coxa vara, osteoarthritis, spondylolysis, back pain, osteomyelitis and cranial nerve palsies. Radiographic features include skull-base thickening, vertebral end-plate thickening and endobone appearance (4).

Isolated medial condylar fractures of the humerus in adults are uncommon and we have not discovered a report of this fracture in an osteopetrotic patient. Medial condylar fractures are intra-articular and like lateral condylar fractures are prone to non-union (1). Usually, the mechanism for this fracture is through a valgus force on an extended elbow where the force is transmitted via the olecranon or coronoid process into the medial condyle (3). The fracture can also arise from an avulsion injury of the condyle through forceful contraction of the forearm flexors. With minimally displaced fractures of the medial humeral condyle, good fracture healing and functional outcomes can be expected with non-surgical treatment consisting of immobilisation in a splint and a gradually increasing permissible range of motion (7). On the other hand, studies specifically examining displaced medial humeral condylar fractures treated by open reduction internal fixation reported good or excellent outcome in 86% of patients (2). As mentioned earlier, patients with osteopetrosis are prone to infections and the reported incidence of post-operative infection is 12% (2). Furthermore, some authors have reported delayed and non-union following fractures in osteopetrotic patients (2). A study has shown fracture healing time in osteopetrotic mice to be more than twice as long (2).

Despite the difficulties of surgery, the risk of infection, and the higher incidence of delayed and non-union, the patient achieved an excellent functional outcome with no surgical complications. Open reduction and internal fixation to a fractured medial humeral condyle in a young osteopetrotic patient is certainly an option.

REFERENCES

1. Albers-Schönberg H. Roentgenbilder einer seltenen Knochennerkrankung. Munch Med Wochenschr 1904;51:365.

2. Armstrong DG, Newfield JT, Gillespie R. Orthopedic management of osteopetrosis: results of a survey and review of the literature. J Pediatr Orthop 1999;19:122–132.

3. Milch H. Fractures and fracture dislocations of the humeral condyles. J Trauma 1964;15:592-607.

4. Tolar J, Teitelbaum SL, Orchard PJ. Osteopetrosis. N Engl J Med 2004; 351:2839-2849.

5. Abe S, Watanabe H, Hirayama A, Shibuya E, Hashimoto M, Ide Y. Morphological study of the femur in osteopetrotic (op/op) mice using microcomputed tomography. Br J Radiol 2000;73:1078-82.

6. Bollerslev J, Mosekilde L. Autosomal dominant osteopetrosis. Clin Orthop Relat Res. 1993;294:45-51.

7. El Ghawabi MH. Fracture of the medial condyle of the humerus. J Bone Joint Surg Am 1975;57:677-80.

8. Jupiter JB, Neff U, Regazzoni P, Allgower M. Unicondylar fractures of the distal humerus: an operative approach. J Orthop Trauma 1988;2:102-109.

9. Shapiro F. Osteopetrosis: Current clinical considerations. Clin Orthop Relat Res 1993;294:34-44.

10. Marks SC Jr, Schmidt CJ. Bone Remodeling as an Expression of Altered Phenotype: Studies of Fracture Healing in Untreated and Cured Osteopetrotic Rats. Clin Orthop Relat Res 1970;137:259-264.

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