Response to Stephane Renaud et al.
Source:Radiotherapy and Oncology
Author(s): Wen-Chi Yang, Jin-Yuan Shih, Chao-Chi Ho, Feng-Ming Hsu
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Tarsometatarsal joint communication during fluoroscopy-guided therapeutic joint injections and relationship with patient age and degree of osteoarthritis
Although the tarsometatarsal joints are separated into three distinct synovial compartments, communications between adjacent compartments are often noted during image-guided injections. This study aims to determine whether abnormal inter-compartment tarsometatarsal joint communication is associated with patient age or degree of tarsometatarsal osteoarthritis.
One hundred forty tarsometatarsal injections were retrospectively reviewed by two radiologists. Extent of inter-compartment communication and degree of osteoarthritis were independently scored. Univariate and multivariable analyses were performed to assess whether the presence of and number of abnormal joint communications were related to age and degree of osteoarthritis.
Forty out of 140 tarsometatarsal joints showed abnormal communication with a separate synovial compartment, and 3 of the 40 showed abnormal communication with two separate compartments. On univariate analysis, higher grade osteoarthritis (p < 0.001) and older age (p = 0.014) were associated with an increased likelihood of abnormal inter-compartment tarsometatarsal communication and a greater number of these abnormal communications. On multivariate analysis, the degree of osteoarthritis remained a significant predictor of the presence of (p < 0.001) and number of (p < 0.001) abnormal communications, while the association of age was not statistically significant. There was significant correlation between age and degree of osteoarthritis (p < 0.001).
Higher grade osteoarthritis increases the likelihood of abnormal inter-compartment tarsometatarsal joint communication and is associated with a greater number of abnormal communications. Diagnostic injection to localize a symptomatic tarsometatarsal joint may be less reliable in the setting of advanced osteoarthritis.
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Reduction of artifacts caused by orthopedic hardware in the spine in spectral detector CT examinations using virtual monoenergetic image reconstructions and metal-artifact-reduction algorithms
Aim of this study was to assess the artifact reduction in patients with orthopedic hardware in the spine as provided by (1) metal-artifact-reduction algorithms (O-MAR) and (2) virtual monoenergetic images (MonoE) as provided by spectral detector CT (SDCT) compared to conventional iterative reconstruction (CI).
In all, 28 consecutive patients with orthopedic hardware in the spine who underwent SDCT-examinations were included. CI, O-MAR and MonoE (40–200 keV) images were reconstructed. Attenuation (HU) and noise (SD) were measured in order to calculate signal-to-noise ratio (SNR) of paravertebral muscle and spinal canal. Subjective image quality was assessed by two radiologists in terms of image quality and extent of artifact reduction.
O-MAR and high-keV MonoE showed significant decrease of hypodense artifacts in terms of higher attenuation as compared to CI (CI vs O-MAR, 200 keV MonoE: −396.5HU vs. –115.2HU, −48.1HU; both p ≤ 0.001). Further, artifacts as depicted by noise were reduced in O-MAR and high-keV MonoE as compared to CI in (1) paravertebral muscle and (2) spinal canal—CI vs. O-MAR/200 keV: (1) 34.7 ± 19.0 HU vs. 26.4 ± 14.4 HU, p ≤ 0.05/27.4 ± 16.1, n.s.; (2) 103.4 ± 61.3 HU vs. 72.6 ± 62.6 HU/60.9 ± 40.1 HU, both p ≤ 0.001. Subjectively both O-MAR and high-keV images yielded an artifact reduction in up to 24/28 patients.
Both, O-MAR and high-keV MonoE reconstructions as provided by SDCT lead to objective and subjective artifact reduction, thus the combination of O-MAR and MonoE seems promising for further reduction.
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Progressive loss of supination of the wrist
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Scapulothoracic pathology: review of anatomy, pathophysiology, imaging findings, and an approach to management
Symptomatic scapulothoracic disorders, including scapulothoracic crepitus and scapulothoracic bursitis are uncommon disorders involving the scapulothoracic articulation that have the potential to cause significant patient morbidity. Scapulothoracic crepitus is the presence of a grinding or popping sound with movement of the scapula that may or may not be symptomatic, while scapulothoracic bursitis refers to inflammation of bursa within the scapulothoracic articulation. Both entities may occur either concomitantly or independently. Nonetheless, the constellation of symptoms manifested by both entities has been referred to as the snapping scapula syndrome. Various causes of scapulothoracic crepitus include bursitis, variable scapular morphology, post-surgical or post-traumatic changes, osseous and soft tissue masses, scapular dyskinesis, and postural defects. Imaging is an important adjunct to the physical examination for accurate diagnosis and appropriate treatment management. Non-operative management such as physical therapy and local injection can be effective for symptoms secondary to scapular dyskinesis or benign, non-osseous lesions. Surgical treatment is utilized for osseous lesions, or if non-operative management for bursitis has failed. Open, arthroscopic, or combined methods have been performed with good clinical outcomes.
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Mesoaxial synostotic syndactyly with phalangeal reduction (MSSD): syndactyly type IX
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Voriconazole-induced periostitis deformans: serial imaging in a patient with ANCA vasculitis
A 61-year-old with acute granulomatosis and polyangiitis developed Aspergillus fumigatus pneumonia after admission to the intensive care unit with a small bowel perforation. This occurred after immunosuppression (intravenous methylprednisolone, intravenous cyclophosphamide, and plasmapheresis) for his initial presentation with stage 3 acute kidney injury.
The mycologist recommended long-term treatment with voriconazole after initial recovery.
After 7 months of treatment, the patient complained of joint pain and swelling in his hands. Radiographs, computed tomography, and single-photon emission computed tomography appearances were consistent with periostitis. A diagnosis of Voriconazole-induced periostitis deformans was made and the voriconazole was stopped. Plasma fluoride level was 278 μg/L (normal range < 50 μg/L). Discontinuation of voriconazole led to clinical improvement.
Periostitis deformans due to fluorosis is a rare complication of voriconazole treatment. The imaging in our case is unusually dramatic. We were able to track the evolution of periosteal reactions over serial imaging.
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MRI findings associated with microscopic residual tumor following unplanned excision of soft tissue sarcomas in the extremities
MRI is often used to determine the presence of residual disease following unplanned excisions (UPE) of soft tissue sarcomas (STS). We sought to identify MRI features associated with histologic evidence of residual disease after TBE.
This was an IRB-approved retrospective review of 27 patients with R1-type UPE of STS over a 32-month period, with subsequent MRI and TBE. MRI studies were retrospectively evaluated to determine depth of tissue involvement, presence of nodular enhancement, and maximum length of soft tissue edema normalized to extremity size. MRI findings were correlated with histology from unplanned excision and TBE.
Among the 21 subjects, there were 13 males and 8 females, mean age 58. Eighteen of 21 STS were grade 2 or 3. Deep compartments were involved in 5/21 cases. Original margins were positive in 17/21 UPE, with inadequate margin assessment in the remaining 4 cases. Residual tumor was present at TBE in 11/21 cases; it was found in 4/6 cases with nodular enhancement and 7/15 cases without nodular enhancement (sensitivity = 0.36; specificity = 0.80; PPV = 0.67; NPV = 0.53). Increased extent of soft tissue edema increased the likelihood of residual tumor at TBE (OR = 35.0; 95% CI = 1.6 to 752.7; p = 0.023).
Nodular enhancement is neither sensitive nor specific in predicting residual microscopic tumor in TBE following UPE. Extensive soft tissue edema on MRI after UPE increases the likelihood of finding a residual microscopic tumor, justifying ample margins at TBE and consideration of adjuvant therapy.
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Detection of femoroplasty on pre- and post-arthroscopic comparison radiographs following treatment of femoroacetabular impingement syndrome: multi-reader accuracy and agreement study
To assess diagnostic accuracy and agreement among radiologists in detecting femoroplasty on pre- and post-arthroscopic comparison frog lateral and anteroposterior (AP) pelvic radiographs after treatment of femoroacetabular impingement (FAI) syndrome.
In this retrospective, cross-sectional study, 86 patients underwent hip arthroscopy (52 with and 34 without femoroplasty) for treatment of FAI syndrome. Three radiologists blinded to clinical data and chronological order of the pre- and post-arthroscopic comparison radiographs independently examined AP pelvis and frog lateral radiographs to detect femoroplasty changes. Statistical analysis outputs included diagnostic accuracy parameters and inter- and intra-observer agreement.
Identification of femoroplasty in the frog lateral projection has mean sensitivity 70%, specificity 82%, inter-observer agreement κ 0.74–0.76 and intra-observer agreement κ 0.72–0.85. Using the AP pelvis projection to detect femoroplasty has mean sensitivity 32%, specificity 71%, inter-observer agreement κ 0.47–0.65, and intra-observer agreement κ, 0.56–0.84.
Radiologists are only moderately sensitive, though more specific, in femoroplasty detection in the frog lateral projection. The AP pelvis projection yields lower sensitivity and specificity. Both projections have moderate inter- and intra-observer agreement.
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Giant angioleiomyoma of the sacral foramina: an unusual location
Angioleiomyoma is a benign, vascular smooth muscle tumor originating from the tunica media of the vessel wall. In general, it typically arises in the cutaneous, subcutaneous tissue or fascia of the lower extremities in middle-aged women and is less than 2 cm in diameter. We report an unusual case of an angioleiomyoma of the sacral foramina in an 82-year-old man. MRI revealed a well-defined irregular-shaped deep-seated mass in the sacral foramina, showing branching pattern of growth associated with pressure bony erosion of the adjacent bones, with isointense to hypointense signal on T2-weighted images. Surgical excision was performed and the mass was diagnosed as angioleiomyoma on pathological examination. To the best of our knowledge, there has been no report of an angioleiomyoma involving the sacral foramina.
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Clinical efficacy of transforaminal epidural injection for management of zoster-associated pain: a retrospective analysis
Transforaminal epidural injection (TFEI) has superior accessibility to the dorsal root ganglion, which is an essential location of pain signaling in herpes zoster. However, the effectiveness of TFEI for herpes zoster patients has not previously been studied. We retrospectively analyzed the efficacy of TFEI for pain control and prevention of PHN in patients with acute and subacute herpes zoster.
Medical records of 137 patients who underwent TFEI for zoster-associated pain (ZAP) were reviewed. The participants were divided into two groups: acute TFEI group (TFEI within 30 days after zoster) and subacute TEEI group (TFEI between 30 and 90 days). The efficacy of TFEI was assessed by a numerical rating scale (NRS), doses of medications, and time to relief of ZAP. Incidence of PHN at 1 week to 6 months after TFEI was evaluated.
Time to ZAP relief was significantly shorter and the incidence of PHN was significantly lower in the acute TFEI group than in the subacute TFEI group. Rate of medication discontinuation was significantly higher in the acute TFEI group than in the subacute TFEI group.
Early application of TFEI in the acute phase of zoster can be a useful option for ZAP control and prevention of chronic neuropathic pain such as PHN.
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T2 signal intensity as an imaging biomarker for patients with superficial Fibromatoses of the hands (Dupuytren's disease) and feet (Ledderhose disease) undergoing definitive electron beam irradiation
Electron beam therapy is a definitive radiation treatment option for superficial fibromatoses of the hands and feet. Because objective criteria for treatment response remain poorly defined, we sought to describe changes in electron beam treated lesions on MRI.
The study included 1 male and 9 female patients with a total of 37 superficial fibromatoses; average age was 60.7 years. Standard 6 MeV electron beam treatment included 3 Gy per fraction for 10 or 12 treatments using split-course with 3-month halfway break. Pre- and post-treatment MRIs were evaluated to determine lesion size (cm3), T2 signal intensity and contrast enhancement (5-point ordinal scales) by a fellowship trained musculoskeletal radiologist. MRI findings were correlated with clinical response using a composite 1–5 ordinal scale, Karnofsky Performance Scale and patient-reported 10-point visual analog scale for pain.
Mean volume decreased from 1.5 to 1.2 cm3 (p = 0.01, paired t-test). Mean T2 hyperintensity score decreased from 3.0 to 2.1 (p < 0.0001, Wilcoxon signed-rank). Mean enhancement score available for 22 lesions decreased from 3.8 to 3.0 (p < 0.0001, Wilcoxon signed-rank). Performance scores improved from 78.9 ± 13.7 to 84.6 ± 6.9 (p = 0.007, paired t-test). Pain scores decreased from 3.0 ± 3.3 to 1.1 ± 2.0 (p = 0.0001, paired t-test). Post-treatment T2 signal correlated weakly with performance and pain (Spearman's ρ = −0.37 and 0.16, respectively).
MRI is valuable for evaluating patients undergoing electron beam therapy for superficial fibromatoses: higher pretreatment T2 intensity may predict benefit from radiotherapy. T2 hypointensity may be a better marker than size for therapeutic effect.
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Society of Skeletal Radiology 2017 annual meeting summary
Peer-reviewed abstracts presented at the 2017 Society of Skeletal Radiology (SSR) Annual Meeting were reviewed following oral presentation. Topics felt to be of potential interest to musculoskeletal (MSK) investigators and practicing clinicians are highlighted in this compilation and analysis of the meeting. New concepts regarding MSK imaging and intervention, MSK protocols and techniques and quality improvement are included. ePoster highlights are also presented.
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Dose reduction for fluoroscopically guided injections: phantom simulation and patient procedures
To demonstrate fluoroscopy dose reduction through both simulated injections on a phantom and patient injections.
Our study was IRB-approved and HIPAA-compliant. Simulation on a phantom was used to estimate effective dose, entrance dose, and organ doses for hip joint injections without and with dose minimization technique (DMT). Additionally, 1,094 joint, bursae, and tendon sheath injections performed by three operators in the same fluoroscopy suite were evaluated both before and after application of DMT. Fluoroscopy time (FT), dose, and dose area product (DAP) of injections were compared using unpaired t-tests with P > 0.05 considered statistically significant.
For the phantom simulation comparing injections without DMT and with DMT, the total DAP was 191.7 vs 18.7 μGy·m2, and the entrance dose was 10.2 vs 3.6 mGy, respectively. For both men and women, DMT reduces effective dose and organ doses.
For all injections, the FT (0.7 to 0.2 min), dose (5.6 to 1.9 mGy), and DAP (56.9 to 19.1 μGy·m2) for all three operators decreased with DMT and remained statistically significant when stratified by the two most common injections, glenohumeral and hip joint injections (P < 0.05).
FT, effective dose, entrance dose, and DAP can be reduced with the use of simple easy-to-learn techniques, which will benefit both the patient and the radiologist.
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Hyperextension injuries of the knee: do patterns of bone bruising predict soft tissue injury?
To establish whether patterns of soft tissue injury following knee hyperextension are associated with post-traumatic 'bone bruise' distribution.
Patients with a knee MRI within one year of hyperextension injury were identified at our institution over a 7 year period. MRIs, plain radiographs and clinical details of these patients were reviewed.
Twenty-five patients were identified (median time from injury to MRI = 24 days). The most common sites of bone bruising were the anteromedial tibial plateau (48%) and anterolateral tibial plateau (44%). There were high rates of injury to the posterior capsule (52%), ACL (40%) and PCL (40%) but lower rates of injury to the menisci (20%), medial and lateral collateral ligaments (16%) and posterolateral corner (16%). Anterior tibial plateau oedema and rupture of the posterior capsule predicted cruciate ligament injury [OR = 10.5 (p = 0.02) and 24.0 (p = 0.001) respectively]. Whilst anterolateral tibial plateau oedema strongly predicted PCL injury [OR = 26.0, p = 0.003], ACL injury was associated with a variable pattern of bone bruising. Meniscal injury was unrelated to the extent or pattern of bone bruising. 5 out of 8 patients with a 'double sulcus' on the lateral radiograph had ACL injury. The presence of a double sulcus showed significant association with anteromedial kissing contusions (OR = 7.8, p = 0.03).
Following knee hyperextension, bone bruising patterns may be associated with cruciate ligament injury. Other structures are injured less frequently and have weaker associations with bone bruise distribution. The double sulcus sign is a radiographic marker that confers a high probability of ACL injury.
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Highlights of the 44th Annual Scientific Congress of the International Skeletal Society (ISS) 2017, New York, New York
This paper summarizes the highlights of the Special Scientific Sessions of the 44th Annual Scientific Meeting of the International Skeletal Society (ISS), which was hosted in New York, NY, in August 2017.
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Safety of omitting routine bleeding tests prior to image-guided musculoskeletal core needle biopsy
To evaluate the safety of withholding preprocedure international normalized ratio (INR) and platelet testing in patients undergoing musculoskeletal (MSK) core needle biopsy (CNB).
Initially, a retrospective review of 1,162 consecutive patients undergoing MSK CNB with preprocedural INR and platelet testing was performed. Clinical (age, gender, bleeding disorder, liver disease, anticoagulation use, INR > 2, platelet count <50,000/ul) and biopsy factors (imaging modality, lesion type, biopsy needle gauge, number biopsy samples) were tested for association with bleeding complications. During the second phase, an additional 188 biopsies performed without preprocedural coagulation testing were studied. Categorical variables were compared using Chi-squared or Fisher's exact tests, continuous variables with a student t-test. Multivariate analysis was performed using logistic regression.
In the first phase, there was a complication rate of 2.6%, 30/1162. Of the 11 clinical and biopsy factors, soft tissue lesions (p = 0.029) and lesions biopsied under ultrasound (p = 0.048) had a higher rate of bleeding than bone lesions or lesions biopsied under CT, respectively. Only three patients had an INR >2, 0.3% (3/1162) and only four patients had platelet count <50,000/ul, 0.3% (4/1162). No patient with a bleeding complication had an abnormal preprocedure bleeding test. In the second phase, there was a bleeding complication rate of 1.1% (2/188).
Bleeding complications from MSK biopsy are low, even when preprocedure coagulation testing is omitted.
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Frequency of inflammatory-like MR imaging findings in asymptomatic fingers of healthy volunteers
To describe the frequency of inflammatory-like findings on MR imaging in asymptomatic volunteers and compare them with patients with known rheumatoid arthritis and psoriatic arthritis.
MR images of fingers in 42 asymptomatic volunteers and 33 patients with rheumatoid/psoriatic arthritis were analyzed. The Outcome Measures in Rheumatology Clinical Trials (OMERACT) Rheumatoid/Psoriatic Arthritis MRI Scoring System (RAMRIS/PsAMRIS) and tenosynovitis scoring system were used to assess: bone marrow edema (BME), erosions, tendon sheath fluid/tenosynovitis, joint effusion, and soft-tissue edema. Findings and scores were compared between volunteers and patients. Inter-reader agreement was calculated (intraclass correlation coefficients, ICC).
In volunteers, tendon sheath fluid was very common in at least one location (42/42 volunteers for reader 1, 34/42 volunteers for reader 2). BME, erosions, joint effusion, and soft-tissue edema were absent (except one BME in the 3rd proximal phalanx for reader 1). Tendon sheath fluid scores in volunteers and tenosynovitis scores in patients were high (reader 1, 7.17 and 5.39; reader 2, 2.31 and 5.45). Overall, inter-reader agreement was substantial (ICC = 0.696–0.844), except for tendon sheath fluid (ICC = 0.258).
Fluid in the finger flexor tendon sheaths may be a normal finding and without gadolinium administration should not be interpreted as tenosynovitis. Bone marrow edema, erosions, joint effusion, and soft-tissue edema in the fingers most likely reflect pathology if present.
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Assessment of the zonal variation of perfusion parameters in the femoral head: a 3-T dynamic contrast-enhanced MRI pilot study
The objective was to describe MR perfusion characteristics of the femoral head, with a focus on the subchondral bone.
This prospective monocentric study was approved by our local Ethics Committee. Written informed consent was obtained from all subjects. Dynamic contrast-enhanced MRI of the right hip was performed in 59 adults with suspected spondyloarthritis (32 women, 28 men). Mean age was 37.5 (±12.5) years. Regions of interest were drawn in the femoral head epiphysis, in the subchondral areas the most exposed to mechanical load (superolateral, anterosuperior, and posterior zones) and in areas less exposed to mechanical load (inferior subchondral zone and center of the femoral head). Semi-quantitative and pharmacokinetic parameters were calculated using the Tofts model. Statistical analysis was performed with a linear mixed model to compare the perfusion parameters in the different femoral head zones.
Extravascular extracellular volume and area under the curve were lower in the superolateral zone than in the inferior zone (p = 0.0135 and p < 0.0001 respectively) and the central zone (p = 0.007 and p = 0.0134 respectively). Extravascular extracellular volume and rate constant were lower in the anterosuperior zone than in the inferior zones (p = 0.011 and p = 0.029). In the anterosuperior zone, extravascular extracellular volume was lower, and time to peak was higher than in the central zones (p = 0.0056 and p = 0.0013 respectively). No significant differences were found for any values between other paired zones.
The perfusion of femoral head subchondral bone assessed with dynamic contrast-enhanced magnetic resonance imaging is not homogeneous: the areas exposed to more mechanical loading are less perfused.
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We appreciate the comments in the letter to the editor. The letter addressed that specific KRAS mutation in non-small cell lung cancer (NSCLC) patients with brain metastases is associated with worse response to radiotherapy [1], and it might cause bias in our results from a retrospective cohort.
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A case of radiation-induced bullous morphea/lichen sclerosus overlap in a breast cancer patient
Publication date: January–February 2018
Source:Reports of Practical Oncology & Radiotherapy, Volume 23, Issue 1
Author(s): Erik Petersen, Laila Yazdani, Sharon R. Hymes
Radiation induced morphea (RIM) is an increasingly common complication of radiation treatment for malignancy as early detection has made more patients eligible for non-surgical treatment options. In many cases, the radiation oncologist is the first person to learn of the initial skin changes, often months before a dermatologist sees them. In this paper we present a breast cancer patient who developed a rare bullous variant of RIM, which delayed her diagnosis and subsequent treatment. It is imperative to diagnose RIM early as it carries significant morbidity and permanent deformity if left untreated. The lesions typically present within 1 year of radiation therapy and extend beyond the radiated field. RIM is often mistaken for radiation dermatitis or cellulitis. Bullae, when present, are often hemorrhagic in appearance, which can serve as another clinical clue. It is important to refer these patients for a full gynecologic exam as there can be concurrent anogenital lichen sclerosus et atrophicus which is both debilitating and carries a long term risk for squamous cell carcinoma. Treatment with systemic agents is often necessary, and can be managed by a dermatologist. The most proven regimen in the literature appears to be methotrexate, with our without concurrent narrow band UVB phototherapy.
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Dysplasia and overgrowth: magnetic resonance imaging of pediatric brain abnormalities secondary to alterations in the mechanistic target of rapamycin pathway
The current classification of malformations of cortical development is based on the type of disrupted embryological process (cell proliferation, migration, or cortical organization/post-migrational development) and the resulting morphological anomalous pattern of findings. An ideal classification would include knowledge of biological pathways. It has recently been demonstrated that alterations affecting the mechanistic target of rapamycin (mTOR) signaling pathway result in diverse abnormalities such as dysplastic megalencephaly, hemimegalencephaly, ganglioglioma, dysplastic cerebellar gangliocytoma, focal cortical dysplasia type IIb, and brain lesions associated with tuberous sclerosis. We review the neuroimaging findings in brain abnormalities related to alterations in the mTOR pathway, following the emerging trend from morphology towards genetics in the classification of malformations of cortical development. This approach improves the understanding of anomalous brain development and allows precise diagnosis and potentially targeted therapies that may regulate mTOR pathway function.
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Diagnostic accuracy of 11 C-methionine PET in detecting neuropathologically confirmed recurrent brain tumor after radiation therapy
This study aims to determine the diagnostic test accuracy (DTA) of 11C-methionine (MET) PET in the discrimination between recurrent tumor and radiation-induced injury in neuropathologically confirmed cases.
A retrospective cohort of 30 patients with previously irradiated intracranial tumors (23 gliomas, 6 metastases, and 1 meningioma) was included. All patients underwent a preoperative MET PET and postoperative neuropathological analysis. Maximum and mean standardized uptake values (SUV) were obtained in the lesion, in the contralateral mirror region, and in the contralateral frontal cortex. Lesion-to-background SUV ratios (SUR mirror and SUR cortex) were then calculated. The Mann–Whitney U test was used to evaluate differences in SUV ratios between confirmed recurrent tumor and radiation injury. DTA was determined through receiver operating characteristic (ROC) analysis.
Twenty-one patients had recurrent tumor and nine had radiation injury. The area under the ROC curve (AUC) was 0.89 for SURmaxmirror and 0.88 for SURmaxcortex. The mean (SD) of SURmaxmirror was 2.37 (0.58) in tumor recurrence and 1.57 (0.40) in radiation necrosis (P ≤ 0.001). The corresponding values for SURmaxcortex were 2.13 (0.50) and 1.45 (0.37) (P = 0.001). Clinically relevant cutoffs were SURmaxmirror ≥ 1.99 giving a specificity of 100% for tumor recurrence with a sensitivity of 76% and SURmaxcortex ≥ 1.58 giving a sensitivity and specificity of 90 and 78%, respectively.
Based on neuropathologically confirmed cases, the DTA of SURmaxmirror and SURmaxcortex from 11C-methionine PET was high when discriminating recurrent tumor from radiation injury.
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Impact of omalizumab on treatment of severe allergic asthma in UK clinical practice: a UK multicentre observational study (the APEX II study).
BMJ Open. 2016 Aug 09;6(8):e011857
Authors: Niven RM, Saralaya D, Chaudhuri R, Masoli M, Clifton I, Mansur AH, Hacking V, McLain-Smith S, Menzies-Gow A
OBJECTIVE: To describe the impact of omalizumab on asthma management in patients treated as part of normal clinical practice in the UK National Health Service (NHS).
DESIGN: A non-interventional, mixed methodology study, combining retrospective and prospective data collection for 12 months pre-omalizumab and post-omalizumab initiation, respectively.
SETTING: Data were collected in 22 UK NHS centres, including specialist centres and district general hospitals in the UK.
PARTICIPANTS: 258 adult patients (aged ≥16 years; 65% women) with severe persistent allergic asthma treated with omalizumab were recruited, of whom 218 (84.5%) completed the study.
PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was change in mean daily dose of oral corticosteroids (OCS) between the 12-month pre-omalizumab and post-omalizumab initiation periods. A priori secondary outcome measures included response to treatment, changes in OCS dosing, asthma exacerbations, lung function, employment/education, patient-reported outcomes and hospital resource utilisation.
RESULTS: The response rate to omalizumab at 16 weeks was 82.4%. Comparing pre-omalizumab and post-omalizumab periods, the mean (95% CIs) daily dose of OCS decreased by 1.61 (-2.41 to -0.80) mg/patient/day (p<0.001) and hospital exacerbations decreased by 0.97 (-1.19 to -0.75) exacerbations/patient (p<0.001). Compared with baseline, lung function, assessed by percentage of forced expiratory volume in 1 s, improved by 4.5 (2.7 to 6.3)% at 16 weeks (p<0.001; maintained at 12 months) and patient quality of life (Asthma Quality of Life Questionnaire) improved by 1.38 (1.18 to 1.58) points at 16 weeks (p<0.001, maintained at 12 months). 21/162 patients with complete employment data gained employment and 6 patients lost employment in the 12-month post-omalizumab period. The mean number of A&E visits, inpatient hospitalisations, outpatient visits (excluding for omalizumab) and number of bed days/patient decreased significantly (p<0.001) in the 12-month post-omalizumab period.
CONCLUSIONS: These data support the beneficial effects of omalizumab on asthma-related outcomes, quality of life and resource utilisation in unselected patients treated in 'real-world' clinical practice.
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Comparative evaluation of MicroDTTect device and flocked swabs in the diagnosis of prosthetic and orthopaedic infections.
Injury. 2016 Oct;47 Suppl 4:S17-S21
Authors: Calori GM, Colombo M, Navone P, Nobile M, Auxilia F, Toscano M, Drago L
The evolution of new prosthetic and osteosynthetic devices has led to more surgical indications, and this is accompanied by an increased incidence of septic complications in orthopaedic and trauma surgery in the general population. The strategy for choosing surgical or therapeutic (conservative) treatment is based on the identification of the pathogen: knowledge of the aetiological agents is an essential element in the decision-making process to ensure the most effective treatment is administered. The pathogen also needs to be considered in the challenging case of doubtful infection, where perhaps the only sign is inflammation, for a more accurate prediction of progression to either sepsis or healing. Biofilm-related infections and low-grade infections may fall into this category. Biofilm slows the metabolism of microorganisms and prolongs their survival, which renders them resistant to antibiotics. Moreover, when microorganisms are embedded in the biofilm they are poorly recognised by the immune system and the infection becomes chronic. As recently demonstrated, isolation and identification of bacteria in biofilm is difficult as the bacteria are concealed. The development of an effective means of sample collection and laboratory methods that can dislodge bacteria from prosthetic surfaces has therefore become necessary. The primary aim of the study was to evaluate the reliability of an innovative technology (MicroDTTect), specifically applied to collect and transport explanted samples (prostheses, osteosynthetic devices, biological tissues), and compare with flocked swabs. The MicroDTTect system is quick and simple to use and, most importantly, is a closed system that is totally sterile and safe for the patient being treated. It contains a specific concentration of dithiotreitol (DTT) that can dislodge bacteria from the biofilm adhering to prosthetic surfaces. The numbers of positive and negative samples were measured to compare the MicroDTTect methodology with swab collection in 30 procedures. The results showed that MicroDTTect had a higher sensitivity compared to swabs (77% and 46%, respectively), and was associated with more positive results than swabs (35% and 20%, respectively). These preliminary results show that MicroDTTect is superior to swab collection for bacterial identification in orthopaedic surgery. The early identification of microorganisms that cause sepsis may help improve treatment strategies and the efficacy of therapy, which will lead to an increased healing rate, reduced severity of sequelae and improved quality of life.
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Study design for a randomised controlled trial to explore the modality and mechanism of Tai Chi in the pulmonary rehabilitation of chronic obstructive pulmonary disease.
Authors: Fu JJ, Min J, Yu PM, McDonald VM, Mao B
INTRODUCTION: Although pulmonary rehabilitation (PR) is associated with significant clinical benefits in chronic obstructive pulmonary disease (COPD) and has been recommended by guidelines, PR with conventional exercise training has not been widely applied in the clinic because of its inherent limitations. Alternative exercise such as Tai Chi has been investigated and the results are promising. However, the strengths and weaknesses of the exercise modality of Tai Chi, conventional PR and a combination of Tai Chi and conventional PR and the possible mechanisms underlying Tai Chi exercise remain unclear. This study aims to address the above research gaps in a well-designed clinical trial.
METHODS AND ANALYSIS: This study is a single-blind, randomised controlled trial. Participants with stable COPD will be recruited and randomly assigned to one of four groups receiving Tai Chi exercise, conventional PR using a total body recumbent stepper (TBRS), combined Tai Chi and TBRS, or usual care (control) in a 1:1:1:1 ratio. Participants will perform 30 min of supervised exercise three times a week for 8 weeks; they will receive sequential follow-ups until 12 months after recruitment. The primary outcome will be health-related quality of life as measured by the St George's Respiratory Questionnaire. Secondary outcomes will include 6 min walking distance, pulmonary function, the modified Medical Research Council Dyspnoea Scale, the COPD Assessment Test, the Hospital Anxiety and Depression Scale, the Berg Balance Scale, exacerbation frequency during the study period, and systemic inflammatory and immune markers.
ETHICS AND DISSEMINATION: Ethics approval has been granted by the Clinical Trial and Biomedical Ethics Committee of West China Hospital of Sichuan University (No TCM-2015-82). Written informed consent will be obtained from each participant before any procedures are performed. The study findings will be published in peer-reviewed journals and presented at national and international conferences.
TRIAL REGISTRATION NUMBER: ChiCTR-IOR-15006874; Pre-results.
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Bright light and oxygen therapies decrease delirium risk in critically ill surgical patients by targeting sleep and acid-base disturbances.
Psychiatry Res. 2017 Dec 18;261:21-27
Authors: Potharajaroen S, Tangwongchai S, Tayjasanant T, Thawitsri T, Anderson G, Maes M
This study examined the effects of bright light therapy (BLT) on the incidence of delirium in post-operative patients admitted to a surgical intensive care unit (SICU) and delineates risk and protective factors. We included 62 patients in a single-blind, randomized controlled study. The intervention group was treated with care as usual plus BLT for three consecutive days. Delirium was diagnosed by DSM-5 criteria with the Confusion Assessment Method-Intensive Care Unit (CAM-ICU). Risk factors for delirium were measured, including the APACHE II score, Insomnia Severity Index (ISI), as well as hematocrit and bicarbonate levels. Results were adjusted for treatment with nasal cannula oxygen and medications. Thirteen patients developed delirium within the three days following surgery. Generalized estimating equations analysis showed a significant preventive effect of BLT on delirium, which was independent of risk or treatment factors. Higher APACHE-II and ISI scores, lower hematocrit and lower bicarbonate levels increased the risk of developing delirium. BLT plus nasal cannula oxygen significantly reduced the likelihood of delirium. BLT significantly lowered ISI scores, while nasal cannula oxygen significantly enhanced bicarbonate levels. The results indicate that BLT and supplementary oxygen therapy may protect against delirium by targeting sleep-wake and deficits in the bicarbonate buffer system.
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Media use and insomnia after terror attacks in France.
J Psychiatr Res. 2017 Dec 16;98:47-50
Authors: Goodwin R, Lemola S, Ben-Ezra M
Direct exposure to traumatic events often precipitates sleep disorders. Sleep disturbance has also been observed amongst those indirectly exposed to trauma, via mass media. However, previous work has focused on traditional media use, rather than contemporary social media. We tested associations between both traditional and social media consumption and insomnia symptoms following 2015 terror attacks in Paris France, controlling for location and post-traumatic symptomology. 1878 respondents, selected to represent the national French population, completed an internet survey a month after the Bataclan attacks (response rate 72%). Respondents indicated different media use, post-traumatic stress and insomnia. Controlling for demographics, location and PTSD, insomnia was associated with both traditional (β 0.10, P = .001) and social media use (β 0.12, P = .001). Associations between social media and insomnia were independent of traditional media use. Interventions targeted at social media may be particularly important following mass trauma.
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Mycobacterium abscessus disease in lung transplant recipients: Diagnosis and management.
J Clin Tuberc Other Mycobact Dis. 2017 Dec;9:10-18
Authors: Chandrashekaran S, Escalante P, Kennedy CC
Mycobacterium abscessus complex (MAbsC ) disease in lung transplant recipients is increasingly being recognized as an important cause of graft function decline and suboptimal outcomes. Lung transplant recipients appear to be at the highest risk of MAbsC among solid organ transplant recipients, as they have more intense immunosuppression, and the organisms preferentially inhabit the lungs. MAbsC is the most resistant species of rapidly growing mycobacteria and difficult to treat, causing considerable mortality and morbidity in immunocompetent and immunosuppressed patients. Herein we describe the risk factors, epidemiology, clinical features, diagnostics, and treatment strategies of MAbsC in lung transplant recipients.
PMID: 29276785 [PubMed]
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Association between Sleep Patterns and Health in Families with Exceptional Longevity.
Front Med (Lausanne). 2017;4:214
Authors: Klein L, Gao T, Barzilai N, Milman S
Background: Sleep patterns such as longer sleep duration or napping are associated with poor health outcomes. Although centenarians and their offspring demonstrate a delayed onset of age-related diseases, it is not known whether they have healthier sleep patterns or are protected against the negative effects of sleep disturbances.
Methods: Data on sleep patterns and health history were collected from Ashkenazi Jewish subjects of the Longevity Genes Project using standardized questionnaires. Participants included individuals with exceptional longevity (centenarians) with preserved cognition (n = 348, median age 97 years), their offspring (n = 513, median age 69 years), and controls (n = 199) age-matched to the offspring. Centenarians reported on their sleep patterns at age 70, while the offspring and controls on their current sleep patterns. Biochemical parameters were measured at baseline. Models were adjusted for age, sex, BMI, and use of sleep medication.
Results: The offspring and controls reported similar sleep patterns, with 33% sleeping ≥8 h and 17% napping in each group. At age 70, centenarians were more likely to have slept ≥8 h (55%) and to have napped (28%) compared with offspring and controls, p < 0.01. Among centenarians, no association was noted between sleep patterns and health outcomes. Sleeping for ≥8 h was associated with lower high-density lipoprotein cholesterol levels in the offspring and controls, and with insulin resistance in the offspring, but not with diabetes. Napping was associated with insulin resistance among the controls (p < 0.01), but not the offspring. Controls, but not offspring, who napped were 2.79 times more likely to have one or more of the following diseases: hypertension, myocardial infarction, stroke, or diabetes (OR 2.79, 95% CI 1.08-7.21, p = 0.04).
Conclusion: Despite being more likely to exhibit risky sleep patterns at age 70 compared with the offspring and controls, the centenarians were protected from age-related morbidities. The offspring of centenarians did exhibit metabolic disturbances in association with less healthy sleep patterns; however, unlike the controls, they were much less likely to manifest age-related diseases. This suggests that offspring may have inherited resilience genotypes from their centenarian parents that protect them against the harmful effects of sleep disturbances.
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Insights since FDA Approval of Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea.
Curr Sleep Med Rep. 2017 Sep;3(3):133-141
Authors: Strohl MM, Yamauchi M, Peng Z, Strohl KP
Purpose: The literature on hypoglossal nerve stimulation (HNS) for the treatment of moderate-to-severe obstructive sleep apnea (OSA) was reviewed from 2014, the time of FDA approval for the Inspire Systems device, to 2017 for themes that might be useful conceptually and practically in the consideration of this new non-anatomic surgical therapy.
Recent Findings: there are now further follow-up articles since the 12-month results for Apnea Reduction (STAR) trial of the Inspire device, and post-approval publications which report similar and/0r improved AHI outcomes. Other emerging themes include drug-induced sedation endoscopy (DISE) as a tool in assessment of eligibility and a more detailed understanding of mechanisms for an HNS effects.
Summary: The post-STAR literature provides guidelines for an integrated coordination of medicine and surgery to appropriately screen and manage patients.
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Association between sleep difficulties as well as duration and hypertension: is BMI a mediator?
Glob Health Epidemiol Genom. 2017;2:e12
Authors: Carrillo-Larco RM, Bernabe-Ortiz A, Sacksteder KA, Diez-Canseco F, Cárdenas MK, Gilman RH, Miranda JJ
Sleep difficulties and short sleep duration have been associated with hypertension. Though body mass index (BMI) may be a mediator variable, the mediation effect has not been defined. We aimed to assess the association between sleep duration and sleep difficulties with hypertension, to determine if BMI is a mediator variable, and to quantify the mediation effect. We conducted a mediation analysis and calculated prevalence ratios with 95% confidence intervals. The exposure variables were sleep duration and sleep difficulties, and the outcome was hypertension. Sleep difficulties were statistically significantly associated with a 43% higher prevalence of hypertension in multivariable analyses; results were not statistically significant for sleep duration. In these analyses, and in sex-specific subgroup analyses, we found no strong evidence that BMI mediated the association between sleep indices and risk of hypertension. Our findings suggest that BMI does not appear to mediate the association between sleep patterns and hypertension. These results highlight the need to further study the mechanisms underlying the relationship between sleep patterns and cardiovascular risk factors.
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Is 8:30 a.m. Still Too Early to Start School? A 10:00 a.m. School Start Time Improves Health and Performance of Students Aged 13-16.
Front Hum Neurosci. 2017;11:588
Authors: Kelley P, Lockley SW, Kelley J, Evans MDR
While many studies have shown the benefits of later school starts, including better student attendance, higher test scores, and improved sleep duration, few have used starting times later than 9:00 a.m. Here we report on the implementation and impact of a 10 a.m. school start time for 13 to 16-year-old students. A 4-year observational study using a before-after-before (A-B-A) design was carried out in an English state-funded high school. School start times were changed from 8:50 a.m. in study year 0, to 10 a.m. in years 1-2, and then back to 8:50 a.m. in year 3. Measures of student health (absence due to illness) and academic performance (national examination results) were used for all students. Implementing a 10 a.m. start saw a decrease in student illness after 2 years of over 50% (p < 0.0005 and effect size: Cohen's d = 1.07), and reverting to an 8:50 a.m. start reversed this improvement, leading to an increase of 30% in student illness (p < 0.0005 and Cohen's d = 0.47). The 10:00 a.m. start was associated with a 12% increase in the value-added number of students making good academic progress (in standard national examinations) that was significant (<0.0005) and equivalent to 20% of the national benchmark. These results show that changing to a 10:00 a.m. high school start time can greatly reduce illness and improve academic performance. Implementing school start times later than 8:30 a.m., which may address the circadian delay in adolescents' sleep rhythms more effectively for evening chronotypes, appears to have few costs and substantial benefits.
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Lessons From Unilateral Loss of Cilia: Early Nasal Nitric Oxide Gas Mixing and the Role of Sinus Patency in Determining Nasal Nitric Oxide.
Clin Med Insights Ear Nose Throat. 2017;10:1179550617746361
Authors: Rodriguez K, Gaston B, Wasman J, Marozkina N
Nasal nitric oxide (nNO) measurement is a diagnostic test for primary ciliary dyskinesia (PCD). Here, we have shown the development of unilateral PCD-like symptoms associated with low nNO. A 60-year-old man had been previously healthy but developed unilateral, severe pansinusitis. He required surgical drainage of all left sinuses, and biopsies showed loss of the ciliated epithelium. At 4 weeks, he had unilateral (left-sided), profuse, clear rhinorrhea characteristic of PCD, and his surgical ostia were all patent endoscopically. His left-sided nNO was less than the right side by 37 ± 1.2 nL/min; this difference decreased to 18 ± 0.87 nL/min at 5 weeks and was gone by 6 weeks when his symptoms resolved. Measurements of 2- and 10-second measurements, in addition to standard nNO measurements, identified this discordance. We conclude that nNO reflects, in part, the production of NO by the ciliated epithelium, not just in the absence or occlusion of sinuses. Early (nasal/sinus volume) measures may be better for diagnosing PCD in than standard, steady-state assays in certain populations.
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Interstitial Pneumonia with Autoimmune Features: Overview of proposed criteria and recent cohort characterization.
Clin Pulm Med. 2017 Sep;24(5):191-196
Authors: Lee CT, Oldham JM
The accurate diagnosis of interstitial lung disease (ILD) is essential for optimal prognostication and management. While connective tissue disease (CTD) is among the most common causes of ILD, some patients have features suggestive of autoimmunity without meeting criteria for a specific CTD. To help define and study this disease entity more uniformly, a 2015 research statement proposed consensus-based criteria and coined the term "interstitial pneumonia with autoimmune features" (IPAF). In this review, we summarize and compare previously proposed criteria to characterize these patients, provide an overview of the IPAF criteria and highlight recent investigations aimed at characterizing IPAF cohorts. We then call attention to questions that have arisen with the application of the IPAF criteria and discuss future areas of study.
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Rhesus macaques (Macaca mulatta) displaying self-injurious behavior show more sleep disruption than controls.
Appl Anim Behav Sci. 2017 Dec;197:62-67
Authors: Stanwicks LL, Hamel AF, Novak MA
Self-injurious behavior (SIB) is a pathology observed in both humans and animals. In humans, SIB has been linked to various mental health conditions that are also associated with significant sleep disruption. In rhesus macaques, SIB consists of self-directed biting which can range from mild skin abrasions to wounds requiring veterinary care. However, only one study suggests possible sleep disruption in macaques with SIB. We evaluated sleep disruption using a noninvasive system (infra-red camera and a video surveillance program) which created videos for every movement over the nighttime hours. Nighttime activity was examined in 13 macaques (three females) of which six were classified as having SIB (one female). Each monkey was studied for a total of 6 nights spanning a period of 4 months. Measures included total movement time (TMT), time moving in the first hour (HR1), time moving in the last hour (HR11), and number of videos <10 secs, ≥10 secs, and ≥30 secs in length. Overall, SIB monkeys had higher TMT (p < 0.01), higher HR1 (p<0.001), and generated more videos ≥10 secs (p < 0.01) and ≥30 secs (p < 0.01). Thus, SIB monkeys showed significant sleep disruption. A four-fold difference between SIB and control monkeys in the ≥30 secs videos revealed many more significant awakenings in the SIB group. Overall higher nighttime activity, in the first hour but not in the last hour, is consistent with sleep-onset insomnia in humans. Whether increased nighttime activity contributes to the SIB condition during the day or, conversely, SIB causes higher nighttime activity remains undetermined.
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BMAL1 Deficiency Contributes to Mandibular Dysplasia by Upregulating MMP3.
Stem Cell Reports. 2017 Dec 14;:
Authors: Zhao J, Zhou X, Tang Q, Yu R, Yu S, Long Y, Cao C, Han J, Shi A, Mao JJ, Chen X, Chen L
Skeletal mandibular hypoplasia (SMH), one of the common types of craniofacial deformities, seriously affects appearance, chewing, pronunciation, and breathing. Moreover, SMH is prone to inducing obstructive sleep apnea syndrome. We found that brain and muscle ARNT-like 1 (BMAL1), the core component of the molecular circadian oscillator, was significantly decreased in mandibles of juvenile SMH patients. Accordingly, SMH was observed in circadian-rhythm-disrupted or BMAL1-deficient mice. RNA sequencing and protein chip analyses suggested that matrix metallopeptidase 3 (MMP3) is the potential target of BMAL1. Interestingly, in juvenile SMH patients, we observed that MMP3 was obviously increased. Consistently, MMP3 was upregulated during the whole growth period of 3-10 weeks in Bmal1-/- mice. Given these findings, we set out to characterize the underlying mechanism and found BMAL1 deficiency enhanced Mmp3 transcription through activating p65 phosphorylation. Together, our results provide insight into the mechanism by which BMAL1 is implicated in the pathogenesis of SMH.
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Corrigendum to "Regular treadmill exercise prevents sleep deprivation-induced disruption of synaptic plasticity and associated signaling cascade in the dentate gyrus" [Mol. Cell Neurosci. 56 (2013 Sep) 375-83].
Mol Cell Neurosci. 2017 Dec 22;:
Authors: Zagaar M, Dao A, Alhaider I, Alkadhi K
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Response to "Prognosis in patients with obstructive sleep apnea with special reference to comorbidities and treatment of positive airway pressure".
Sleep Med. 2017 Sep 05;:
Authors: Jennum PJ
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A standardized test to document cataplexy.
Sleep Med. 2017 Oct 09;:
Authors: Vandi S, Pizza F, Antelmi E, Neccia G, Iloti M, Mazzoni A, Avoni P, Plazzi G
OBJECTIVE/BACKGROUND: Cataplexy is the pathognomonic symptom of narcolepsy type 1 (NT1). Since it is considered difficult to be directly observed or documented by clinicians, its diagnosis relies mainly on history taking. Our study aimed at testing the feasibility of a standardized video recording procedure under emotional stimulation to document cataplexy in the diagnostic work-up of suspected hypersomnia of central origin.
PATIENTS/METHODS: Two-hundred-eight consecutive patients underwent the diagnostic work-up and reached the final diagnosis of NT1 (n = 133), idiopathic hypersomnia or narcolepsy type 2 (IH/NT2 group, n = 33), or subjective excessive daytime sleepiness (sEDS group, n = 42). All subjects underwent a standardized video recording procedure while watching funny movies selected according to individual preferences, and a technician blind to clinical features reviewed the recordings to identify hypotonic phenomena that were finally confirmed by patients.
RESULTS: The video recording under emotional stimulation captured hypotonic phenomena in 72.2%, 9.1% and 4.8% of NT1, IH/NT2, and sEDS subjects (p < 0.0001), respectively. When tested against CSF hypocretin deficiency, the documentation of a hypotonic episode at the test showed an area under the ROC curve of 0.823 ± 0.033 (p < 0.0001). NT1 patients under anticataplectic medications showed less frequently hypotonic episodes than untreated ones (48.0% vs 77.8%, p = 0.003).
CONCLUSIONS: A standardized video recording procedure under emotional stimulation can help in the characterization of suspected hypersomnia of central origin. Further multi-center studies are warranted to extend the present findings and integrate a shared procedure for the laboratory work-up of narcolepsy.
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Food allergy: Children's symptom levels are associated with mothers' psycho-socio-economic variables.
J Psychosom Res. 2018 Jan;104:48-54
Authors: Cortes A, Castillo A, Sciaraffia A
BACKGROUND: Allergies affect children's health as well as their quality of life, stress levels, and family budget. The available literature suggests that family, social and psychological factors are affected by allergic pathologies such as rhinitis, asthma and atopic dermatitis. However, few studies have focused on quantifying such association in child food allergy. This study aims to enhance the understanding of the associations between caregiver variables and children's Food Allergy (FA).
METHODS: The study involved 206 participants: 103 mothers plus 103 children with IgE mediated FA. The analyses excluded two outliers comprising 101 subjects. For statistical analyses, each dyad -mother/child- was considered to be one subject unity. A between-subjects one-way ANOVA determined the association of children's cutaneous, gastric and respiratory symptoms with anxiety, depression, perceived social support and socioeconomic factors in the mothers.
RESULTS: There are significant associations between children's allergic symptoms (gastric and cutaneous) and mothers' psychological state (anxiety and depression); family budget; social interactions (with friends, family and partner); understanding of health care required by their child; and sleep disorders. Respiratory symptoms did not show any significant associations with the dependent variables.
CONCLUSION: FA is a process in which children's symptoms are significantly associated with socioeconomic and psychological variables of the mothers. The presence or absence of some specific symptoms is directly associated with specific impacts on the mothers. An understanding of such dynamics supports the consideration of a comprehensive and multidisciplinary therapeutic approach to offer more ecological healthcare for "families living with FA."
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Psychiatric comorbidities in patients with Atypical Odontalgia.
Authors: Miura A, Tu TTH, Shinohara Y, Mikuzuki L, Kawasaki K, Sugawara S, Suga T, Watanabe T, Watanabe M, Umezaki Y, Yoshikawa T, Motomura H, Takenoshita M, Maeda H, Toyofuku A
OBJECTIVE: Atypical Odontalgia (AO) is a condition characterized by tooth pain with no apparent cause. Although psychiatric comorbidity seems to be very common, it has rarely been studied. To clarify the influence of psychiatric comorbidity on the clinical features in patients with AO, we retrospectively evaluated their examination records.
METHODS: Clinical features and psychiatric diagnoses of 383 patients with AO were investigated by reviewing patients' medical records and referral letters. Psychiatric diagnoses were categorized according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). We also analyzed visual analogue scale (VAS), self-rating depression scale (SDS), and the short-form McGill pain questionnaire (SF-MPQ) scores.
RESULTS: Of the 383 patients with AO, 177 (46.2%) had comorbid psychiatric disorders. The most common were depressive disorders (15.4%) and anxiety disorders (10.1%). Serious psychotic disorders such as bipolar disorder (3.0%) and schizophrenia (1.8%) were rare. Dental trigger of AO was reported in 217 (56.7%) patients. There were no significant correlations between psychiatric comorbidities and most of the demographic features. Higher VAS and SDS scores, higher frequency of sleep disturbance, and higher ratings of "Fearful" and "Punishing-cruel" descriptors of the SF-MPQ were found in patients with psychiatric comorbidity.
CONCLUSIONS: About half of AO patients had comorbid psychiatric disorders. Dental procedures are not necessarily causative factors of AO. In AO patients with comorbid psychiatric disorders, pain might have a larger emotional component than a sensory one. VAS, SDS, and SF-MPQ scores might aid in the noticing of underlying comorbid psychiatric disorders in AO patients.
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Chronic fatigue syndrome (CFS/ME) symptom-based phenotypes and 1-year treatment outcomes in two clinical cohorts of adult patients in the UK and The Netherlands.
Authors: Collin SM, Heron J, Nikolaus S, Knoop H, Crawley E
OBJECTIVE: We previously described symptom-based chronic fatigue syndrome (CFS/ME) phenotypes in clinical assessment data from 7041 UK and 1392 Dutch adult CFS/ME patients. Here we aim to replicate these phenotypes in a more recent UK patient cohort, and investigate whether phenotypes are associated with 1-year treatment outcome.
METHODS: 12 specialist CFS/ME services (11 UK, 1 NL) recorded the presence/absence of 5 symptoms (muscle pain, joint pain, headache, sore throat, and painful lymph nodes) which can occur in addition to the 3 symptoms (post-exertional malaise, cognitive dysfunction, and disturbed/unrefreshing sleep) that are present for almost all patients. Latent Class Analysis (LCA) was used to assign symptom profiles (phenotypes). Multinomial logistic regression models were fitted to quantify associations between phenotypes and overall change in health 1year after the start of treatment.
RESULTS: Baseline data were available for N=918 UK and N=1392 Dutch patients, of whom 416 (45.3%) and 912 (65.5%) had 1-year follow-up data, respectively. 3- and 4-class phenotypes identified in the previous UK patient cohort were replicated in the new UK cohort. UK patients who presented with 'polysymptomatic' and 'pain-only' phenotypes were 57% and 67% less likely (multinomial odds ratio (MOR) 0.43 (95% CI 0.19-0.94) and 0.33 (95% CI 0.13-0.84)) to report that their health was "very much better" or "much better" than patients who presented with an 'oligosymptomatic' phenotype. For Dutch patients, polysymptomatic and pain-only phenotypes were associated with 72% and 55% lower odds of improvement (MOR 0.28 (95% CI 0.11, 0.69) and 0.45 (95% CI 0.21, 0.99)) compared with oligosymptomatic patients.
CONCLUSIONS: Adult CFS/ME patients with multiple symptoms or pain symptoms who present for specialist treatment are much less likely to report favourable treatment outcomes than patients who present with few symptoms.
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Impact of UGT1A1 gene polymorphisms on plasma dolutegravir trough concentrations and neuropsychiatric adverse events in Japanese individuals infected with HIV-1.
BMC Infect Dis. 2017 Sep 16;17(1):622
Authors: Yagura H, Watanabe D, Kushida H, Tomishima K, Togami H, Hirano A, Takahashi M, Hirota K, Ikuma M, Kasai D, Nishida Y, Yoshino M, Yamazaki K, Uehira T, Shirasaka T
BACKGROUND: Dolutegravir (DTG) is metabolized mainly by uridine diphosphate (UDP)-glucuronosyltransferase 1A1 (UGT1A1), and partly by cytochrome P450 3A (CYP3A). Therefore, we focused on UGT1A1 gene polymorphisms (*6 and *28) in Japanese individuals infected with human immunodeficiency virus (HIV)-1 to examine the relationship between their plasma trough concentration of DTG and gene polymorphisms. Recently, neuropsychiatric adverse events (NP-AEs) after the use of DTG have become a concern, so the association between UGT1A1 gene polymorphisms and selected NP-AEs was also investigated.
METHODS: The study subjects were 107 Japanese patients with HIV-1 infections who were receiving DTG. Five symptoms (dizziness, headache, insomnia, restlessness, and anxiety) were selected as NP-AEs. The subjects were classified by their UGT1A1 gene polymorphisms for the group comparison of DTG trough concentration and the presence or absence of NP-AEs.
RESULTS: The subjects consisted of eight (7%) *6 homozygotes, three (3%) *28 homozygotes, four (4%) for *6/*28 compound heterozygotes, 23 (21%) *6 heterozygotes, 18 (17%) *28 heterozygotes, and 51 (48%) patients carrying the normal allele. The plasma DTG trough concentration of the *6 homozygous patients was significantly higher than that of the patients carrying the normal allele (median, 1.43 and 0.82 μg/mL, respectively, p = 0.0054). The *6 and *28 heterozygous patients also showed significantly higher values than those shown by patients with the normal allele. Multivariate analysis revealed that carrying one or two UGT1A1*6 gene polymorphisms, one UGT1A1*28 polymorphism, and age of < 40 years were independent factors associated with high DTG trough concentrations. The median DTG trough concentration was significantly higher in the patients with NP-AEs (1.31 μg/mL) than in those without NP-AEs (1.01 μg/mL). Consistent with these results, subjects carrying UGT1A1*6, UGT1A1*28, or both alleles showed a higher cumulative incidence of having selected NP-AEs than those carrying the normal alleles (p = 0.0454).
CONCLUSION: In addition to younger age, carrying UGT1A1*6 and/or UGT1A1*28 was demonstrated to be a factor associated with high DTG trough concentrations. Our results also suggest a relationship between plasma DTG trough concentrations and NP-AEs, and that carrying UGT1A1*6 and/or UGT1A1*28 alleles might be a risk factor for NP-AEs.
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Biological rationale and potential clinical use of gabapentin and pregabalin in bipolar disorder, insomnia and anxiety: protocol for a systematic review and meta-analysis.
BMJ Open. 2017 Mar 27;7(3):e013433
Authors: Houghton KT, Forrest A, Awad A, Atkinson LZ, Stockton S, Harrison PJ, Geddes JR, Cipriani A
INTRODUCTION: Gabapentin has been extensively prescribed off-label for psychiatric indications, with little established evidence of efficacy. Gabapentin and pregabalin, a very similar drug with the same mechanism of action, bind to a subunit of voltage-dependent calcium channels which are implicated in the aetiopathogenesis of bipolar disorder, anxiety and insomnia. This systematic review and meta-analysis aims to collect and critically appraise all the available evidence about the efficacy and tolerability of gabapentin and pregabalin in the treatment of bipolar disorder, insomnia and anxiety.
METHODS AND ANALYSIS: We will include all randomised controlled trials (RCTs) reported as double-blind and comparing gabapentin or pregabalin with placebo or any other active pharmacological treatment (any preparation, dose, frequency, route of delivery or setting) in patients with bipolar disorder, anxiety or insomnia. For consideration of adverse effects (tolerability), single-blind or open-label RCTs and non-randomised evidence will also be summarised. The main outcomes will be efficacy (measured as dichotomous and continuous outcome) and acceptability (proportion of patients who dropped out of the allocated treatment). Published and unpublished studies will be sought through relevant database searches, trial registries and websites; all reference selection and data extraction will be conducted by at least 2 independent reviewers. We will conduct a random-effects meta-analysis to synthesise all evidence for each outcome. Heterogeneity between studies will be investigated by the I2 statistic. Data from included studies will be entered into a funnel plot for investigation of small-study effects. No subgroup analysis will be undertaken, but we will carry out sensitivity analyses about combination treatment, psychiatric comorbidity, use of rescue medications and fixed versus random-effects model.
ETHICS AND DISSEMINATION: This review does not require ethical approval. This protocol has been registered on PROSPERO (CRD42016041802). The results of the systematic review will be disseminated via publication in a peer-reviewed journal.
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Patient-reported experiences on supportive care strategies following the introduction of the first Swedish national cancer strategy and in accordance with the new patient act.
Acta Oncol. 2017 Dec 25;:1-11
Authors: Westman B, Kirkpatrick L, Ebrahim F, Henriksson R, Sharp L
INTRODUCTION: Several supportive care strategies are described in Swedish legislation and policy documents, such as the National Cancer Strategy and the Patient act. No previous systematic evaluation from a patient perspective has been performed. The aim of this study was to evaluate how these supportive care strategies are experienced by patients treated for cancer in the Stockholm-Gotland region.
MATERIAL AND METHODS: In this cross-sectional study, we identified patients (diagnosed with gynaecological, haematological, upper gastrointestinal and head and neck cancer during 2014) from the Swedish Cancer Register. The European Organization of Research and Treatment of Cancer, EORTC, Quality of Life Questionnaires, QLQ-C30, Information QLQ-INFO25 and a study-specific questionnaire was used to collect data during follow-up after cancer treatment. We collected data on 869 cancer patients' perception of availability and access to supportive care strategies and how they were experienced.
RESULTS: Among the supportive care strategies suggested in the legislation and policy documents, just over half of the patients (n = 393, 53%) reported that they had access to a contact nurse, while 43% (n = 312) had received an individual written care plan and 16% (n= 137) had been referred to palliative care. Only 29% (n = 218) of the patients reported that they had received information about patient advocacy groups and 8% (n= 62) on medical second opinions from their cancer care team.
DISCUSSION: The supportive care strategies suggested in Swedish legislation and policy documents may be useful but are only available for some patients. The implementation goals for the National Cancer Strategy and the Swedish Patient act have not been reached.
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Recurrent post-tonsillectomy bleeding due to an iatrogenic facial artery pseudoaneurysm.
Acta Otolaryngol Case Rep. 2017;2(1):103-106
Authors: Choi KJ, Cheng T, Cobb MI, Sajisevi MB, Gonzalez LF, Ryan MA
This is a report of an illustrative case of recurrent post-tonsillectomy bleeding that was caused by an iatrogenic facial artery pseudoaneurysm and controlled by endovascular embolization. A 37 year-old female who underwent bilateral tonsillectomy for chronic tonsillitis had recurrent secondary hemorrhage despite multiple operative interventions to control the bleeding. Because of the recurrent nature of the bleeding, an angiography of the external carotid artery was performed demonstrating a pseudoaneurysm of the left facial artery with active extravasation. This was successfully embolized with ethylene vinyl alcohol copolymer and the bleeding did not recur. Most post-operative bleeds can be managed with bedside or intraoperative interventions. However, pseudoaneurysms should be considered in the differential diagnosis of recurrent bleeds refractory to surgical control.
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Pyridostigmine for the Reversal of Severe Adverse Reactions to Botulinum Toxin in Children.
J Pediatr. 2017 Dec 22;:
Authors: Boerner RM, Young DL, Gnagi SH, White DR, Halstead LA
Therapeutic botulinum toxin injections are commonly performed in pediatric otolaryngology. Aerodigestive complications from botulinum toxin injections, although rare, may be serious. Oral pyridostigmine is effective in the symptomatic treatment of these complications. We report 2 cases of aerodigestive complications arising from injection of botulinum toxin that were successfully treated with pyridostigmine.
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[Advances in the management of cervical lymphadenopathies of unknown primary; advances in diagnostic imaging and surgical modalities and new international staging system].
Bull Cancer. 2017 Dec 21;:
Authors: Troussier I, Klausner G, Morinière S, Blais E, Jean-Christophe Faivre, Champion A, Geoffrois L, Pflumio C, Babin E, Maingon P, Thariat J
INTRODUCTION: Cervical lymphadenopathies of unknown primary represent 3 % of head and neck cancers. Their diagnostic work up has largely changed in recent years. This review provides an update on diagnostic developments and their potential therapeutic impact.
MATERIALS AND METHODS: This is a systematic review of the literature.
RESULTS: In recent years, changes in epidemiology-based prognostic factors such as human papilloma virus (HPV) cancers, advances in imaging and minimally invasive surgery have been integrated in the management of cervical lymphadenopathies of unknown primary. In particular, systematic use of PET scanner and increasing practice of robotic or laser surgery have contributed to increasing detection rate of primary cancers. These allow more adapted and personalized treatments. The impact of changes in the eighth TNM staging system is discussed.
CONCLUSION: The management of cervical lymphadenopathies of unknown primary cancer has changed significantly in the last 10 years. On the other hand, practice changes will have to be assessed.
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[Epidemiological investigation on 2 133 hospitalized patients with electrical burns].
Zhonghua Shao Shang Za Zhi. 2017 Dec 20;33(12):732-737
Authors: Jiang MJ, Li Z, Xie WG
Objective: To analyze the epidemiological characteristics of the hospitalized patients with electrical burns in Institute of Burns of Tongren Hospital of Wuhan University & Wuhan Third Hospital (hereinafter referred to as Institute of Burns of Wuhan Third Hospital), so as to provide reference for the prevention and treatment of electrical burns. Methods: Medical records of all hospitalized burn patients in Institute of Burns of Wuhan Third Hospital from January 2004 to December 2016 were collected. Genders, ages, social categories, seasons of injury, total burn areas, depths of wounds, electrical voltages of injury, sites of wound, treatment methods, amputation rates, lengths of hospital stay, operation costs, hospitalization costs, and treatment outcomes of the electrical burn patients were collected. Treatment methods, lengths of hospital stay, operation costs, and hospitalization costs of the thermal burn patients were collected and compared with those of the electrical burn patients. Electrical voltages of injury, amputation rates, operation costs, hospitalization costs, and treatment outcomes were compared and analyzed between the electrical contact burn patients and the electrical arc burn patients. Data were processed with Chi-square test and Wilcoxon rank-sum test. Results: During the 13 years, 23 534 burn patients were admitted to Institute of Burns of Wuhan Third Hospital, among whom 2 133 (9.1%) were with electrical burns, without obvious variation in admission number of electrical burn patients every year. There were 1 418 patients (66.5%) with electrical contact burns and 715 patients (33.5%) with electrical arc burns. The ratio of male to female was 11.2∶1.0 among the electrical burn patients with known genders. The proportions of three age groups of more than 20 years old and less than or equal to 30 years old, more than 30 years old and less than or equal to 40 years old, and more than 40 years old and less than or equal to 50 years old were relatively higher, which were 18.3% (391/2 133), 22.1% (471/2 133), and 24.6% (525/2 133), respectively. The first three social category groups in proportions were workers, peasants, and preschool children, which were 57.9% (1 235/2 133), 14.6% (311/2 133), and 6.0% (128/2 133), respectively. Among the electrical burn patients with known seasons of injury, most cases were injured in summer (659 cases, accounting for 34.1%), obviously more than the proportions in autumn (537 cases, accounting for 27.8%), spring (455 cases, accounting for 23.5%), and winter (283 cases, accounting for 14.6%), with χ(2) values from 8.414 to 149.573, P values below 0.01. The group of patients with total burn areas less than 10% total body surface area (TBSA) occupied the highest proportion (1 603 cases, accounting for 75.15%), among whom 229 (10.74%) were with scattered small wounds which were less than 1% TBSA. The percentage of electrical contact burn patients with deep wounds was 79.1% (1 122/1 418), which was obviously higher than 2.5% (18/715) of the electrical arc burn patients (χ(2)=381.741, P<0.001). Among the patients with known electrical voltages of injury, patients injured by high voltage among the electrical contact burn patients accounted for 78.4% (469/598), which was obviously higher than 8.7% (11/127) of the electrical arc burn patients (χ(2)=227.893, P<0.001). The most common wound site of the electrical burn patients was upper limbs (1 650 cases, accounting for 63.2%), followed by lower limbs (382 cases, accounting for 14.6%), head and neck (292 cases, accounting for 11.2%), trunk (247 cases, accounting for 9.5%), and hip and perineum (40 cases, accounting for 1.5%). The operation rate of electrical burn patients was 32.4% (691/2 133), obviously higher than 19.1% (3 860/20 209)of the thermal burn patients during the same period (χ(2)=210.255, P<0.001). Wounds of 116 electrical contact burn patients were repaired with free flap by vascular anastomosis, of which 9 (7.8%) failed. The length of hospital stay, the operation cost, and the hospitalization cost of electrical burn patients were (28±29) d, (9 534±16 935) and (44 258±93 012) Yuan, respectively, obviously longer or higher than those of the thermal burn patients during the same period [(17±19) d, (2 990±8 916) and (23 291±88 340) Yuan, respectively, with Z values from -21.323 to -10.996, P values below 0.001]. The amputation rate and the death rate of electrical burn patients were 3.8% (82/2 133) and 0.8% (16/2 133) respectively. Compared with those of electrical arc burn patients, the amputation rate and the operation cost of electrical contact burn patients were obviously higher (χ(2)=36.970, Z=-11.351, P values below 0.001), and the length of hospital stay of electrical contact burn patients was obviously longer (Z=-5.181, P<0.001). There were no significant differences in hospitalization cost and treatment outcome between the electrical contact burn patients and the electrical arc burn patients (Z=-1.461, χ(2)=1.673, P values above 0.05). Conclusions: The number and the proportion of hospitalized electrical burn patients in Institute of Burns of Wuhan Third Hospital were relatively high, indicating a hard task of prevention for electrical burns in Wuhan area. Working-age workers and farmers, and preschool children were the key groups in prevention from electrical burns. The length of hospital stay, the operation cost, and the hospitalization cost of electrical burn patients were obviously higher than those of thermal burn patients. The amputation rate and the operation cost of electrical contact burn patients were obviously higher than those of electrical arc burn patients, but there were no obvious differences in hospitalization cost or treatment outcome between them. Actively using tissue flaps including free flap to repair of wounds may be helpful to reduce the amputation rate, improve the results, and shorten the time of treatment.
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[Expression of integrin αvβ3, CXC chemokine receptor 4 and CXC chemokine receptor 7 and their relationship with lymph node metastasis in squamous cell carcinoma of head and neck].
Zhonghua Kou Qiang Yi Xue Za Zhi. 2017 Dec 09;52(12):723-729
Authors: Li P, Li WL, Qi JX
Objective: To investigate the expression of integrin αvβ3, CXC chemokine receptor (CXCR)4 and CXCR7 and their relationship with lymph node metastasis in squamous cell carcinoma of head and neck (SCCHN). Methods: The expression of integrin αvβ3, CXCR4 and CXCR7 was detected by immunohistochemistry SABC in 92 cases of primary SCCHN, metastatic lymph node, normal oral mucosa tissues and normal lymph nodes. Results: The positive rate of the expression of integrin αvβ3, CXCR4 and CXCR7 was 75% (69/92), 81%(75/92) and 76%(70/92), respectively in primary SCCHN, and was 82%(75/92), 76%(70/92) and 65%(60/92), respectively in metastatic lymph node. The expression of integrin αvβ3 and CXCR4 in primary SCCHN (r=0.813, P<0.05) and lymph node metastasis (r=0.541, P<0.05) was positively correlated. Integrin αvβ3 and CXCR7 expression in primary SCCHN (r=0.683, P<0.05) and lymph node metastasis (r=0.708, P<0.05) was positively correlated. CXCR4 and CXCR7 expression in primary SCCHN (r=0.644, P<0.05) and lymph node metastasis (r=0.707, P<0.05) had a positive correlation. The expression level was associated with tumor size (P=0.040, 0.001, 0.009), lymph node metastasis (P=0.001, 0.000, 0.000) and surrounding tissue invasion (P=0.046, 0.002, 0.001), but not related to age (P=0.097, 0.274, 0.162), gender (P=0.103, 0.309, 0.187). Conclusions: The overexpression of integrin αvβ3, CXCR4 and CXCR7 in primary head and neck squamous carcinoma and metastatic lymph nodes was related to lymph node metastasis. The co-expression of integrin αvβ3, CXCR4 and CXCR7 may play a synergistic role in lymphatic metastasis of SCCHN.
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Antibiotic Prophylaxis in Endoscopic Endonasal Pituitary and Skull Base Surgery.
World Neurosurg. 2017 Oct;106:912-918
Authors: Milanese L, Zoli M, Sollini G, Martone C, Zenesini C, Sturiale C, Farneti P, Frank G, Pasquini E, Mazzatenta D
OBJECTIVE: Postoperative infection is a potentially dramatic consequence in endoscopic endonasal surgery. The aim of this study was to assess the efficacy of our intraoperative antibiotic prophylaxis by analyzing the risk factors of postoperative meningitis in our series.
METHODS: Each endoscopic endonasal procedure performed since 1998 in patients with no preoperative infections and a follow-up longer than 30 days were included and retrospectively reviewed. Antibiotic protocol consisted in single antibiotic administration of ampicillin/sulbactam 3 g or cefazolin 2 g on induction; no postoperative administrations were performed after 2005. All cases of cerebrospinal fluid (CSF) leak, meningitis, and systemic infection were recorded.
RESULTS: Two thousand thirty-two procedures matched the inclusion criteria (median age 50 years; range: 1-89 years, male/female ratio: 1:1.12). Intraoperative CSF leak occurred in 32.8% of the cases and postoperative CSF leak in 3.4%. The rate of meningitis was 0.69%; other systemic infections were observed in 0.44% of cases. Meningitis was statistically associated with intra- and postoperative CSF leak (P < 0.001). Other risk factors were the intradural extension of the tumors and their malignant histology. Extended approaches producing wide osteodural defects were correlated with a greater risk of meningitis (P < 0.001).
CONCLUSIONS: All surgical maneuvers to prevent, detect, and quickly repair intra- and postoperative CSF leak are crucial to avoid postoperative meningitis. The proposed prophylaxis protocol is comparable in safety to those recommended in literature as assessed by the low rate of meningitis.
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Microsurgical Bypass Training Rat Model: Part 2-Anastomosis Configurations.
World Neurosurg. 2017 Nov;107:935-943
Authors: Tayebi Meybodi A, Lawton MT, Yousef S, Mokhtari P, Gandhi S, Benet A
BACKGROUND: Mastery of microsurgical anastomosis is key to achieving good outcomes in cerebrovascular bypass procedures. Animal models (especially rodents) provide an optimal preclinical bypass training platform. However, the existing models for practicing different anastomosis configurations have several limitations.
OBJECTIVE: We sought to optimize the use of the rat's abdominal aorta and common iliac arteries (CIA) for practicing the 3 main anastomosis configurations commonly used in cerebrovascular surgery.
METHODS: Thirteen male Sprague-Dawley rats underwent inhalant anesthesia. The abdominal aorta and the CIAs were exposed. The distances between the major branches of the aorta were measured to find the optimal location for an end-to-end anastomosis. Also, the feasibility of performing side-to-side and end-to-side anastomoses between the CIAs was assessed.
RESULTS: All bypass configurations could be performed between the left renal artery and the CIA bifurcation. The longest segments of the aorta without major branches were 1) between the left renal and left iliolumbar arteries (16.9 mm ± 4.6), and 2) between the right iliolumbar artery and the aortic bifurcation (9.7 mm ± 4.7). The CIAs could be juxtaposed for an average length of 7.6 mm ± 1.3, for a side-to-side anastomosis. The left CIA could be successfully reimplanted on to the right CIA at an average distance of 9.1 mm ± 1.6 from the aortic bifurcation.
CONCLUSIONS: Our results show that rat's abdominal aorta and CIAs may be effectively used for all the anastomosis configurations used in cerebral revascularization procedures. We also provide technical nuances and anatomic descriptions to plan for practicing each bypass configuration.
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New Scientist 2017 holiday quiz
Fingers on buzzers! University Challenge stars Monkman and Seagull are here to test your scientific smarts, from narwhals to supercomputers
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