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O. Baldar, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.

Deputy Director, Indiana Wesleyan University

Proposals for non-commercial reproductions and translations are welcomed and considered on a case-by-case basis. Although there is academic proof of these benefits, there was initial clinical scepticism from both the radiological and nuclear medicine fields concerning the combination of two complementary imaging modalities. However, it is now widely accepted that combining the advantages of both radiology and nuclear medicine leads to an improved diagnosis and better outcome. There is great interest in imaging that can provide support regarding the decision making process for referring physicians in order to improve patient management and care. In many institutions, however, it is not yet a routine component of nuclear medicine procedures. Close collaboration between nuclear medicine physicians and radiologists would be very beneficial. It does not address questions of responsibility, legal or otherwise, for acts or omissions on the part of any person. There are numerous advantages of an integrated, functional and morphological imaging device: (a) (b) (c) A single examination can provide comprehensive functional and anatomical information on the state of a disease. Experts in radiology and nuclear medicine can review the complementary image sets together and integrate their interpretation into a single report. However, there is still a significant amount of oncology work which can be done with many different tracers, too. The technology has matured, and more data are available to appraise its clinical role. Previous topics in musculoskeletal imaging have already covered the appropriate use of bone scintigraphy in adults and in paediatric patients. In addition, this atlas provides information on the usefulness of several sets of specific indications. The cases present the typical pattern of the spread of disease, the possible pitfalls and various teaching points. The structure of this publication is adapted to the anatomical areas of the skeleton: cervical spine, thoracic spine, lumbar spine, pelvis and extremities. Furthermore, there are two extra-anatomical categories: musculoskeletal metastatic disease and paediatric cases. An additional structure within these categories is given as types of studies and can be found in the Study type of each case (Orthopaedics, Traumatology, Oncology, Infection, Rheumatology, Degenerative and Paediatric). In this way, the cases can be found by anatomy and also by different indication, key words and results. The readers will find a short clinical history, imaging descriptions as well as the immediate impact on the clinical course based on the imaging findings. Findings Planar bone scan (A): Shows focal uptake in the right lateral cervical spine. Differential diagnosis facet joint arthritis or bone metastases in the right paedicle. No metastatic disease detected within the vertebral body or the right paedicle of C4. Outcome and teaching point Metastatic disease was ruled out and treatment started as planned. Note the lateral uptake in the cervical spine has the typical appearance for facet joint arthritis. Findings Planar image (A, B): Heterogeneous uptake by the cervical spine, increased uptake in both acromioclavicular joints (R > L). Outcome Conservative treatment of the osteoarthritis, which led to improved clinical condition. Findings Planar bone scan (A): Shows foci with increased bone metabolism in right temporal bone (large arrow). Additional findings (small arrows): Increased bone metabolism due to degenerative disease in the C5 facet joint and in the body of T5 likely due to osteoporotic fracture. As an incidental finding, a focal uptake at the top of the skull was seen (long black arrows).

A larva that is 1/4 inch or greater in length is considered to have survived or "escaped" the toxin. During the blooming period, bollworms can sometimes cause economic damage to Bt cotton. Twice a week scouting and closer examination within the plant canopy may be necessary to locate and determine bollworm survival before making a treatment decision. The Bt toxin should be given an opportunity to work; therefore, treatment based just on the presence of eggs is not usually recommended. However, insecticide treatments may still be needed if sufficient pest pressure occurs, particularly for bollworm or fall armyworm. Bt cotton does not control tarnished plant bugs, stink bugs or other non-caterpillar pests. A refuge is not required for Bt cotton varieties, but planting a refuge is still a potentially valuable resistance management strategy. Planting non-Bt cotton will provide a source of susceptible moths for mating with resistant moths that survive in Bt cotton. Bt Cotton Management Bt cotton varieties, which produce toxins from the bacterium Bacillus thuringiensis, are widely used in Tennessee. The use of Bt cotton is recommended in areas with high occurrence of tobacco budworm and bollworm. Tobacco budworm should not cause economic damage to Bt cotton at any time during the season, and damaging infestations of bollworm are uncommon prior to bloom. Prior to bloom, concentrate efforts in Bt cotton on monitoring square retention and scouting for pests such as plant bugs. However, fields should be checked for the presence of surviving larvae if a bollworm egg lay occurs. Larvae must feed on plant tissue to ingest a toxic dose of Bt Boll Weevil the boll weevil has been successfully eradicated from Tennessee. Post-eradication pheromone trapping will continue in order to detect reinfestations that may occur. Evidence of boll weevil infestations should be reported immediately to boll weevil eradication officials. Stage of Plant Development Emergence to first square First square to first bloom After first bloom Common Pests Thrips Plant bugs Bollworm, Tobacco budworm, Plant bugs, Stink bugs Occasional Pests Aphids, Cutworms, Plant bugs, Spider mites Aphids, Spider mites, Bollworm, Tobacco budworm Aphids, Loopers, Fall and Beet armyworm, Spider mites, Whiteflies Cutworms Cutworm damage occurs most frequently following legume cover crops or in reduced tillage systems. Cutworms may become established on existing vegetation and move to emerging cotton once this vegetation has been killed. Destroying all green vegetation 21 days prior to planting reduces the likelihood of cutworm attack. Treat when cutworms are damaging stand and plant population is less than three plants per row foot. Infestations may be spotty within a field and only require treatment where damage and live cutworms are found. At-planting insecticides applied in a band (no less than 10 inches) may be justified if vegetation has not been burned down at least 21 days prior to planting. Do not expect Bt cotton to provide adequate control of cutworms, although it provides some protection against small larvae or low infestation levels. Under adverse growing conditions, a foliar treatment may be needed even when preventative controls were used. Foliar applications, when needed, typically provide the most benefit when applied before the third true leaf has emerged. Under conditions of slow emergence and seedling growth, consider applying a foliar insecticide at the first or second leaf stage when the emerging leaf shows signs of thrips injury and especially if immature thrips are present. Two foliar insecticide applications are rarely justified if at-planting treatments were used. Plant Bugs the tarnished plant bug and clouded plant bug are the predominant species. The sweep net is a very effective tool for monitoring adult plant bugs and detecting movement into the field. The presence of nymphs indicates reproduction is occurring, and they generally are more common after first bloom. Visual sampling should include examining terminals for adults and nymphs, and checking inside squares, blooms and small bolls for nymphs. Distinguishing plant bug damage from stink bug based on external symptoms is difficult.

When inflammatory activity in the scalp subsides and hair regrows, nails usually revert to normal within another 6 months. It primarily affects children from 2 to 8 years of age and is more common among Japanese or children of Asian descent. These include desquamation of the palmar and plantar skin that begins with separation at the distal-free edges of the nails (Figure 8. A golden brown chromonychia of the nail plates is rarely observed within a few weeks after the onset of the illness. Some investigators believe that these conditions differ in their pathophysiology while others contend that they are the same disease on a spectrum of extent and severity. Photo-onycholysis Phototoxicity from ingestion of medications is a distinctive, frightening, and painful condition that rarely occurs in children. It is most commonly seen in teenagers being treated with doxycycline for acne (Figure 8. It has also been reported in immunosuppressed children on voriconizole12 and in one patient on griseofulvin. There may or may not be evidence of sunburn on the dorsum of the fingers and hands. Pain may be followed by subungual ecchymoses and then separation of the nail plate from the nail bed. The condition is transient and nails grow out normally once the offending agent is discontinued. It may involve all or a portion of the nail matrix, the nail bed, or the entire nail unit. When the proximal nail matrix is solely involved, the nails have the appearance of trachyonychia (Figure 8. The plates have a dull, lusterless color from small confluent pits or longitudinal striations that result in a sandpaperlike texture. As more of the nail matrix is involved, the plates become thinner and more ridged. Pterygium of the proximal nail fold is a sign of atrophy and may progress to total anonychia. Longitudinal erythronychia can be observed with distal matrix and nail bed involvement. However, if distal chipping is a problem, several coats of clear nail hardener may be applied as needed. In young children, a 6- to 12-week trial of high potency topical steroid can be tried first. Fortunately, it is non-scarring and gradually resolves along with the selflimited skin rash. There is also a high spontaneous mutation rate and mosaic or localized forms are reported. Acral involvement including nail disease may be the first manifestation during childhood. The nails display longitudinal red and white bands that extend through the nail bed from the distal matrix. The plates are thin and will frequently be fissured with "v" shaped notches at the distal-free edge (Figure 8. Greasy flat-topped warty papules are seen on the dorsum of the hands, but they become much more confluent in the seborrhea areas of the chest and back in older teens and adults. Most desquamating vesicular lesions are in the flexures and can spread by a positive Nikolsky sign.

It is impossible to recommend specifications for specific types of microorganisms in raw materials as these will very much depend on how they are processed and how they are to be used in the final product. For instance, for a pasteurized juice it is important to control levels of heatresistant moulds in raw materials whereas in a product preserved by the use of chemical preservatives it is more important to know the level of preservative-resistant microbes. Thus, Gluconobacter and related bacteria such as Acetobacter are important spoilage organisms in products that contain benzoate and/or sorbate and are distributed in plastic containers. If the differentiation of these organisms is important, the method described by Cirigliano (1982) may be used. Although routine microbiological testing of end-products is not useful for the direct control of manufacturing operations it may provide useful trend data on the performance of a particular operation over a period of time. For this purpose, once a production line has been established to perform to within commercially acceptable spoilage levels, the numbers of containers that should be examined from a production plant on a daily basis should be between 0. Unless prior knowledge indicates that sampling of containers should be concentrated on particular parts of a production period. Samples should be incubated appropriately and examined for evidence of microbial spoilage. In most products simple visual inspection for haze, sediment, gas, or mould clumps will suffice. If microbiological examinations are made, the methods used should be the most suitable for the likely spoilage organisms. Most spoilage problems result from the growth of yeasts (principally Saccharomyces, but often Brettanomyces in carbonated beverages) and/or acid-tolerant bacteria such as Acetobacter, Gluconobacter, Lactobacillus, and Leuconostoc. The complete identification of spoilage organisms is often useful in identifying the cause of a particular microbiological problem. A selective medium for the isolation and differentiation of Gluconobacter and Acetobacter. Diacetyl test as a quality control tool in processing frozen concentrated orange juice. There are many cereal-based products and a wide variety of confectionery and bakery products with a cereal as a main component. Some of these products are potential microbial foodborne disease risks by virtue of their cereal components but many more may be risks because of the various animal and other vegetable components they contain. Those products for which the use of microbiological criteria would appear to be of value are listed in Table 29. Protein-rich oil seeds, such as soya beans, and the flours and protein isolates and concentrates derived from them are included in this chapter as their storage, handling, and use pose risks that are somewhat similar to those of cereal grains. Grains, provided they are harvested when in good condition and rapidly dried to a water activity level preventing microbial growth, and then stored under conditions such that the excessive ingress or movement of water is avoided, have virtually no microbiological risks. However, in practice, these conditions are not always met and mould growth may result. Many of the field and storage fungi found on grains and in flours derived from them are capable of producing Reprinted from: Microorganisms in Foods 2. Their control should be principally at source, that is, by controlling conditions during and after harvesting. It is not recommended that these products be routinely monitored for mycotoxins because routine analytical methods for most mycotoxins are not available. Levels of mould propagules found in food-quality grains and flours vary between approximately 102 and 105 per gram depending on the type of grain and the growing, harvesting, drying, and storage conditions (including time of storage). Grains and flours may be variously treated, and this circumstance will affect the levels of moulds found on examination. Thus grains may be washed in chlorinated waters and flours may be heat-treated to change functional properties or treated with a bleaching agent such as chlorine dioxide. All these treatments will reduce mould levels, although none will have a significant effect on mycotoxins, if present. Patent flours, made from part of the endosperm of the grain, will generally contain only low levels of moulds. Wholemeal flours will often contain much higher levels as these include the surface layers of the grain, which are those parts principally contaminated with moulds. Thus when deciding on an acceptable limit for moulds it is necessary to know the conditions to which the flour or grain has been subjected prior to sampling.