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Background: The utilization and cost-effectiveness of stress testing before abdominal aortic aneurysm (AAA) repair remains insufficiently studied. We examined the variation and financial implications of stress testing, and their association with major adverse cardiovascular events (MACE). Methods: We studied patients who underwent elective endovascular (EVAR) or open AAA repair (OAR) at Vascular Quality Initiative centers from 2015 to 2019. We grouped centers into quintiles of preoperative stress testing frequency. We calculated the risk of postoperative MACE, a composite of in-hospital myocardial infarction, heart failure, or death, for each center-quintile. We obtained charges for stress tests locally and applied these to the cohort to estimate charges per 1000 patients. Results: We studied 32,459 patients (EVAR: 27,978; OAR: 4481; 283 centers). Stress test utilization varied across quintiles from 13.0% to 68.6% (median: 36.8%) before EVAR and 15.9% to 85.0% (median: 59.4%) before OAR. The risk of MACE was 1.4% after EVAR and 10.2% after OAR. There was a trend towards more common MACE after EVAR among centers with higher utilization of stress testing: 0.9% among centers in the lowest quintile, versus 1.7% in the highest quintile ( p-trend = 0.068). There was no association between MACE and stress testing frequency for OAR ( p-trend = 0.223). The estimated financial charges for stress testing before EVAR ranged from $125,806 per 1000 patients at 1st-quintile centers, to $665,975 at 5th-quintile centers. Charges before OAR ranged from $153,861 at 1st-quintile centers, to $825,473 at 5th-quintile centers. Conclusion: Stress test use before AAA repair is highly variable and associated with substantial cost, with an unclear association with postoperative MACE. This highlights the need for improved stress testing paradigms prior to surgery.

Our study aimed to (1) examine the effect of adjunctive high-definition transcranial direct current stimulation (HD-tDCS) in craving and withdrawal among patients with opioid use disorder on buprenorphine-naloxone, and (2) examine effect of HD-tDCS changes in glutamate-glutamine and γ-aminobutyric acid (GABA) at the left dorsolateral prefrontal cortex (DLPFC) among patients with opioid use disorder on buprenorphine-naloxone.This was a pilot randomized double-blind, sham-controlled parallel-group study. A total of 28 patients on buprenorphine-naloxone (6/1.5 mg/d) were randomly allocated into 2 groups for active and sham HD-tDCS stimulation. High-definition transcranial direct current stimulation was administered twice daily for consecutive 5 days, from days 2 to 6. The Clinical Opiate Withdrawal Scale (COWS), the Desire for Drug Questionnaire (DDQ), the Obsessive-Compulsive Drug Use Scale (OCDUS), and glutamate-glutamine and GABA at DLPFC via proton magnetic resonance spectroscopy were measured at baseline and on day 7.Both active and sham groups had comparable changes in DDQ, OCDUS (except 2 subcomponents), COWS, and glutamate-glutamine and GABA at DLPFC. In the active HD-tDCS group, statistically significant reductions were observed in DDQ, OCDUS, and COWS but not in glutamate-glutamine and GABA.The adjunctive active HD-tDCS group showed comparable changes in craving and withdrawal, and glutamate-glutamine and GABA at DLPFC compared with sham HD-tDCS. Craving and withdrawal but not glutamate-glutamine and GABA at DLPFC decreased significantly with adjunctive HD-tDCS. Future studies with larger sample size and online assessment of glutamate-glutamine and GABA would enhance our knowledge.

Background Endovascular therapy for chronic mesenteric ischemia (CMI) is the mainstay of treatment. Duplex velocity criteria within stented mesenteric vessels are not well established. We describe single-center outcomes of mesenteric stenting for CMI and analyze duplex velocities associated with in-stent restenosis (ISR). Methods We performed a single-center retrospective review of patients undergoing mesenteric stenting for CMI (2012-2018). Primary outcome was reintervention for recurrence of CMI symptoms. Secondary outcomes were occlusion or bypass grafting. Duplex velocities in those with recurrent symptoms, corresponding with clinically significant ISR, were identified. Receiver operating characteristic (ROC) curves were created to identify velocity thresholds for ISR. Results Mesenteric stents were placed in 61 patients (71 arteries). Mean age was 72 years (range, 49-92), and the majority were female (55%). Thirty-two (45%) celiac (CA) stents and 39 (55%) superior mesenteric artery (SMA) stents were placed. Ten patients had SMA and CA stents placed. Twenty-five stents were covered (35%). Freedom from reintervention at 1, 2, and 3 years was 83%, 73%, and 60%. Freedom from occlusion or bypass grafting at 1, 2, and 3 years was 100%, 86%, and 86%. No significant difference in patency was seen between covered and bare-metal stents (OR 0.45; 95% CI: 0.15–1.33; P = 0.1383). Median survival was 6.1 years. For CA stents, a peak systolic velocity (PSV) of 440 cm/s corresponded with clinically significant ISR with 100% sensitivity and 86% specificity. For SMA stents, a PSV of 341 cm/s corresponded with clinically significant ISR with only 80% sensitivity and 52% specificity. Conclusions A PSV of 440 cm/s for CA stents was indicative of clinically significant ISR with excellent sensitivity and specificity. This should be used in conjunction with clinical findings to identify patients that may benefit from repeat intervention. A similar threshold could not be identified for SMA stents and warrants further collaborative investigation.

Type 2 diabetes mellitus (T2DM) is an emerging epidemic in Asian countries, especially in India. With the advent of the SGLT2 inhibitor class of drugs demonstrating benefits beyond glycemic control, viz. weight loss, blood pressure reduction, and cardiovascular and renal protection, the management of T2DM has taken a quantum leap. Remogliflozin etabonate (RE) is the latest addition to the SGLT2 inhibitor class of drugs that have been recently approved in India for the management of T2DM. RE is a potent and selective inhibitor of SGLT2 with the unique distinction of being administered as a prodrug, existence of active metabolites, and short half-life necessitating twice-daily dosing. The Phase III study of RE demonstrated it to be an efficacious and safe agent and non-inferior to the currently available SGLT2 inhibitors. This paper reviews not only the pharmacokinetics, pharmacodynamics, clinical efficacy, and safety profile of RE but also its molecular and clinical development program. This review has taken into consideration all available published as well as unpublished literature on RE and discusses the individual studies performed during its development for characterization of pharmacological profile.

We analysed quantitative biomarkers derived from both baseline whole-body imaging and blood serum to identify prognostic markers in patients treated within the lutetium-177 prostate-specific membrane antigen (LuPSMA) phase 2 trial. PET image analysis was carried out using whole-body segmentation quantifying molecular tumour volume (SUV > 3 threshold for PSMA, SUV > liver+2sd for fluorodeoxyglucose (FDG) including SUVmax and SUVmean. For baseline bone scans, EXINI bone scan index (BSI) was used to calculate the percentage of involved bone. Baseline alkaline phosphatase (ALP), lactate dehydrogenase (LDH), prostate specific antigen (PSA) and PSA doubling time were also used in this analysis. We used univariate cox regression analysis and log-rank comparison with optimised cut-offs to find suitable biomarkers prognostic of overall survival from time of enrolment. This analysis identified FDG-positive tumour volume (FDGvol; HR 2.6; 95% CI, 1.4–4.8), mean intensity of PSMA-avid tumour uptake (PSMAmean; HR 0.89; 95% CI, 0.8–0.98), bone scan index (BSI; HR 2.3; 95% CI, 1.2–4.4), ALP (HR 1.1; 95% CI, 1–1.2) and LDH (HR 1.2; 95% CI, 1–1.5) as biomarkers prognostic of overall survival. In addition to established biomarkers, both FDG and PSMA PET/CT parameters have prognostic significance for survival in men undergoing LuPSMA therapy.

PURPOSE: Prostate specific membrane antigen (PSMA) targeting radioligands deliver radiation to PSMA expressing cells. However, the relationship between PSMA levels and intra-lesion heterogeneity of PSMA expression, and cytotoxic radiation by radioligand therapy (RLT) is unknown. Here we investigate RLT efficacy as function of PSMA levels/cell, and the fraction of PSMA-positive cells in a tumor. EXPERIMENTAL DESIGN: RM1 cells expressing different levels of PSMA (PSMA-, PSMA(+), PSMA(++), PSMA(+++); study 1) or a mix of PSMA-positive and -negative RM1 (study 2, 4) or PC-3/PC-3-PIP (study 3) cells at various ratios were injected into mice. Mice received (177)Lu- (studies 1–3) or (225)Ac- (study 4) PSMA617. Tumor growth was monitored. Two days post-RLT, tumors were resected in a subset of mice. Radioligand uptake and DNA damage were quantified. RESULTS: (177)Lu-PSMA617 efficacy increased with increasing PSMA levels (study 1) and fractions of PSMA positive cells (studies 2, 3) in both, the RM1 and PC-3-PIP models. In tumors resected two days post-RLT, PSMA expression correlated with (177)Lu-PSMA617 uptake and the degree of DNA damage. Compared to (177)Lu-PSMA617, (225)Ac-PSMA617 improved overall anti-tumor effectiveness and tended to enhance the differences in therapeutic efficacy between experimental groups. CONCLUSION: In the current models both the degree of PSMA expression and the fraction of PSMA-positive cells correlate with (177)Lu-/(225)Ac-PSMA617 tumor uptake and DNA damage, and thus, RLT efficacy. Low or heterogeneous PSMA expression represents a resistance mechanism to RLT.

Non-melanomatous skin cancer (NMSC) generally refers to basal cell and squamous cell carcinoma of the skin. The majority of patients are curatively treated with simple excision. Only few present with locally advanced disease or have evidence of high-risk features, placing them at an elevated risk of relapse. In such cases, further investigations may guide the multidisciplinary management plan. There are no universally agreed on indications for recommending additional staging investigations, due to a lack of prospective data reporting their impact on patient outcomes. Some generally agreed upon indications are discussed in this review article. Most commonly, computed tomography (CT) and magnetic resonance imaging (MR) are used in cases of locally advanced NMSC for staging purposes and surgical planning. While Positron Emission Tomography (PET)/CT and sentinel lymph node biopsy have shown utility, data is lacking to establish their roles in the staging algorithm. An updated NMSC system was included in The American Joint Committee for Cancer eighth edition staging manual (AJCC8). Under AJCC8 the majority of patients with regional disease are upstaged by the presence of extranodal extension, however, this updated system appears to provide limited prognostic discrimination between the nodal categories and the overall TNM stages. This review article will explore the contemporary role of staging investigations, including evolving technologies, and review the changes implemented in AJCC8. It will also discuss the implications of the AJCC8 decision to assign patients with p16-positive cervical nodal SCC with an unknown primary to the oropharyngeal staging system, with particular relevance to clinicians working in areas of high NMSC incidence.

Peptide receptor radionuclide/chemoradionuclide therapy (PRRT/PRCRT) is an effective therapy for metastatic neuroendocrine neoplasia (NEN), but therapy-related myeloid neoplasms (t-MN) remain of concern. The study reviewed the clinicopathological features and outcomes of patients who developed t-MN. Retrospective analysis of all patients diagnosed with t-MN by 2016 WHO classification, from a cohort of 521 patients who received PRRT/PRCRT over a 12-year period. Molecular next-generation sequencing using an in-house 26-gene panel was performed. Twenty-five of 521 (4.8%) patients were diagnosed with t-MN, including six acute myeloid leukaemia (AML) and 19 myelodysplastic syndrome (MDS). The median time from first cycle PRRT/PRCRT to diagnosis of t-MN was 26 months (range 4–91). Twenty-two of 25 (88%) patients had grade 1–2 pancreatic or small bowel NEN with moderate metastatic liver burden. Six patients (24%) had prior chemotherapy. Median number of PRRT cycles = 5 (22/25 (88%) with concomitant radiosensitising chemotherapy). All 25 patients achieved disease stabilisation (68%) or partial response (32%) on RECIST 1.1 at 3 months post-PRRT. At t-MN diagnosis, all patients presented with thrombocytopenia (median nadir 33 × 109/L, range 3–75) and 17 (68%) remained NEN progression-free. Marrow genetic analysis revealed unfavourable karyotype in 16/25 (66%) patients with tumour protein 53 (TP53) mutation in nine (36%). Azacitidine therapy was utilised in ten eligible patients, while four received induction chemotherapy for AML. The median overall survival from first PRRT was 62 months (19–94), but from t-MN diagnosis was only 13 months (1–56), with death due primarily to haematological disease progression. The diagnosis of t-MN after PRRT/PRCRT is an infrequent but serious complication with poor overall survival. Most patients present with thrombocytopenia; unfavourable genetic mutations have a poor response to t-MN treatment. Prospective data are needed to explore potential pre-existing genetic factors and predictive biomarkers to minimise the risk of t-MN.

Hypothesis Ciprofloxacin-resistant pathogens are inhibited by high concentrations of ciprofloxacin found in commercially-available ototopical solutions. Background Ciprofloxacin-resistant pathogens in otitis media are currently treated with ototopical ciprofloxacin suspensions. This is done irrespective of laboratory-reported ciprofloxacin susceptibility, under the assumption that the high concentration of ciprofloxacin applied topically is sufficient to overcome antimicrobial resistance. Methods We evaluated 34 ciprofloxacin-resistant isolates consisting of Staphylococcus aureus, Pseudomonas aeruginosa, Corynebacterium spp., and Turicella otitidis. Ciprofloxacin minimum inhibitory concentration (MIC) assays and clinical ototopical solution minimum bactericidal concentration (CMBC) assays were performed. Results Amongst the ciprofloxacin-resistant isolates, ciprofloxacin MICs ranged from 8 to 256 mcg/ml (mean: 87.1 mcg/ml) and CMBCs ranged from 23.4 to 1500 mcg/ml (mean: 237.0 mcg/ml). There were no significant differences with respect to MIC in comparing P. aeruginosa versus Corynebacterium spp. (mean: 53.3 versus 55.2, p = 0.86), S. aureus versus P. aeruginosa (mean: 128.0 versus 53.3, p = 0.34), and S. aureus versus Corynebacterium spp. (mean: 128.0 versus 55.2, p = 0.09). The correlation between ciprofloxacin MIC and CMBC was poor (Pearson's r = -0.08, p = 0.75). Conclusions Ciprofloxacin-resistant pathogens commonly recovered from otitis media exhibit highly variable ciprofloxacin MIC and CMBC levels. Ciprofloxacin was able to inhibit growth in all isolates tested at MIC levels less than or equal to 256 mcg/ml; however, CMBC's up to 1500 mcg/ml were observed within that same group. The clinical relevance of these in vitro MICs is unclear due in part to higher bactericidal concentrations (CMBC) in several strains. Our results suggest that treatment failures may be due to a combination of factors rather than high-level resistance alone.

Molecular imaging with PET/CT targeting the prostate-specific membrane antigen (PSMA) receptor is increasingly utilized in men with prostate cancer (PCa), with clinical indications now expanding beyond biochemical recurrence. PSMA PET/CT often detects sub-centimetre size pathologic nodes and low-volume bone marrow disease that are occult on conventional imaging when the lesion does not cause sclerosis or osteoblastic reaction in surrounding bone. This review focuses on recent evidence for PSMA PET/CT in initial disease staging.Several recent studies including a large randomized trial have evaluated the clinical impact of PSMA PET/CT in initial staging of PCa. PSMA PET/CT is more sensitive and accurate than the conventional imaging standard of CT and bone scan. Change in treatment plan or modality of therapy occurs frequently when PSMA PET/CT forms part of the diagnostic algorithm. Hybrid PET/MRI also has potential utility, particularly in evaluating pelvic disease, but evidence base remains very limited.PSMA PET/CT has emerged as a new standard in primary staging of PCa. Reimbursement by national funding bodies and incorporation into international clinical guidelines is anticipated within the next few years.

Adenoid cystic carcinoma is a rare disease and characterised by slow but unrelenting local progression and risk of haematogenous metastases. We present a case of locally unresectable disease where PSMA PET/CT provided complementary staging and early treatment response assessment.

Objectives: The aim of this study was to describe the cytological features of patients with significant occupational dust exposure presenting with benign bilateral mediastinal and hilar lymphadenopathy (BHL). Methods: A retrospective cohort study including patients undergoing EBUS-TBNA for investigation of benign BHL. Patient characteristics, dust exposure history, radiology, and cytology samples from EBUS-TBNA were assessed. Results: EBUS-TBNA cytology in patients with exposure showed a significant increase in the presence of birefringent fibers (60.7% vs 19.2%, P=0.001) and intracellular carbon pigment (75.0% vs 28.9%, P=0.001) compared with patients without exposure. The presence of these two features together yielded a sensitivity of 53.6% and a specificity of 88.5%. Conclusion: In patients with BHL and a history of occupational dust exposure, the presence of birefringent fibers and intracellular carbon pigment in EBUS-TBNA cytology samples may assist in a diagnosis of lymphadenopathy due to occupational dust exposure.

The effectiveness of rotational atherectomy in the treatment of complex superficial femoral artery (SFA) lesions remains poorly defined. Outcomes of SFA lesions treated with rotational atherectomy were analyzed.This retrospective review assessed all patients who underwent rotational atherectomy of the SFA at a single institution between 2015 and 2018. The data of all patients were deidentified, and the study was approved by the Institutional Review Board. Informed consent was not obtained for this retrospective analysis. Main outcomes were Kaplan-Meier primary patency rate, freedom from major amputation, and 2-year survival rate. The effect of drug-coated balloon angioplasty (DCBA) on patency and time to death was investigated with univariate regression. The safety profile for atherectomy and DCBA was assessed by the 30-day incidence of major amputation and all-cause mortality.Fifty-three patients (mean age, 70.2 ± 9.8 years; 73% male; 65% critical limb-threatening ischemia; 47 [90%] current or former smokers; seven [13%] with prior failed ipsilateral endovascular intervention) underwent rotational atherectomy (Jetstream; Boston Scientific, Marlborough, Mass) with mean follow-up of 543 days. Forty-six (87%) patients underwent DCBA (Lutonix; BD Bard, Covington, Ga) after atherectomy. Mean lesion length was 13.2 ± 9.0 cm. Thirty-one (58%) lesions were TransAtlantic Inter-Society Consensus C or D class. At 1-month follow-up, 39 of 45 (87%) patients experienced improvement in symptoms and Rutherford class. An improvement in ankle-brachial index was also noted in 13% of patients without improvement of symptoms, with no patients progressing to surgical bypass or major amputation. Mean ankle-brachial index increased from 0.54 ± 0.035 to 0.90 ± 0.031 at 1 month after intervention (P .001) and remained constant out to 18 months. Mean toe pressure increased from 36 ± 3.8 mm Hg to 67 ± 4.5 mm Hg at 1 month after intervention (P .001) and remained constant out to 18 months. Kaplan-Meier primary patency rate was 75% (95% confidence interval, 61%-85%) at 12 months and 65% (51%-77%) at 24 months. There was a trend toward improved primary patency after adjunctive DCBA compared with plain balloon angioplasty at 1 year (75% vs 43%; P = .1082). There was no significant difference in mortality between adjunctive DCBA and plain balloon angioplasty at 2 years (11% vs 0%). The 2-year incidence of major amputation in critical limb-threatening ischemia patients was 3.9% (1.2%-6.5%). One patient died and none underwent amputation within 30 days.Rotational atherectomy with adjunctive DCBA of long SFA lesions has excellent long-term patency. Two-year major amputation and mortality rates are low, and the technique has an exceptional safety profile.

Esthesioneuroblastoma is rare, with limited therapeutic options when unresectable or metastatic; however, expression of somatostatin receptors qualifies it for peptide receptor radionuclide therapy (PRRT). We report outcomes of PRRT in esthesioneuroblastoma from 2 referral centers. Methods: Using PRRT databases at 2 European Neuroendocrine Tumor Society Centers of Excellence, cases were sought between 2004 and 2018 of patients who had PRRT with recurrent or metastatic esthesioneuroblastoma deemed unsuitable for further conventional therapies. Evaluations of survival and of response using a composite reference standard were performed. Results: Of 7 patients, 4 had partial response, 2 had disease stabilization, and one had early progression. Possible side effects include worsening cerebrospinal fluid leaks. Median progression-free survival was 17 mo (range, 0-30 mo), and median overall survival was 32 mo (range, 4-53 mo). Conclusion: PRRT shows promising efficacy and moderate survival duration in unresectable locally advanced or metastatic esthesioneuroblastoma warranting larger cohort studies incorporating measures of quality of life.

Background: Some patients with metastatic differentiated thyroid cancer (DTC) lack iodine avidity and are therefore unsuitable for radioactive iodine (RAI) therapy. Limited experience suggests that single-agent selective mitogen-activated protein kinase (MAPK) pathway inhibitors can restore expression of the sodium-iodide symporter rendering RAI refractory (RAIR) DTC patients amenable to RAI therapy. The aim of this study was to assess the feasibility of mutation-guided MAPK-pathway blockade combined with thyroid hormone withdrawal (THW) for redifferentiation. Methods: This is a retrospective review of metastatic RAIR DTC and driver mutation in MAPK pathway, treated on a redifferentiation protocol. All patients had metastatic disease that had never been RAI-avid and/or imaging and biochemical progression despite treatment with RAI within the past 12 months. Patients with tumors harboring an NRAS mutation were treated with an MEK inhibitor (trametinib), and tumors with a BRAFV600E mutation with combined BRAF and MEK inhibition (dabrafenib and trametinib; or vemurafenib and cobimetinib) for four weeks. Thyrotropin stimulation was performed by THW for four weeks. Restoration of RAI uptake was determined by 124I positron emission tomography/computed tomography imaging. The response was assessed at least three months post-RAI. Results: From 2015 to 2017, six patients (age 45-70, four females) received redifferentiation therapy. Three patients had an NRAS mutation; two with follicular thyroid carcinoma (FTC) and one with a poorly differentiated thyroid carcinoma (PDTC); and three patients had a BRAFV600E mutation and papillary thyroid carcinoma (PTC). One NRAS and all BRAFV600E mutation cases demonstrated restoration of RAI uptake and proceeded to RAI therapy with a median follow-up of 16.6 months (range 13.5-42.3 months). The patient with an NRAS mutation and two of three patients with a BRAFV600E demonstrated partial imaging response beyond a three-month follow-up. Grade 3 adverse events (acneiform rash) were observed in two patients with NRAS mutations. Conclusions: Mutation-guided MAPK pathway inhibition with MEK inhibitor or a combination of BRAF inhibitor and MEK inhibitor under concurrent THW is a feasible and a promising strategy to redifferentiate RAIR DTC, thereby rendering them suitable for RAI therapy with satisfactory retention following treatment.

Purpose Recent data have provided evidence of systemic inflammatory markers playing an important role in determining the disease-free survival (DFS) and overall survival (OS) of patients with oral squamous cell carcinoma (OSCC). The aim of the present study was to determine the prognosis of OSCC using the preoperative neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR). Patients and Methods We enrolled 130 patients with OSCC who received treatment in the present retrospective study. Both PLR and NLR correlated with the demographic data, tumor characteristics, and prognosis. The optimal cutoff for PLR and NLR was determined by receiver operating characteristic curve analysis and was 142 and 3.1 for PLR and NLR, respectively. The prognostic significance of both markers was determined by univariate and multivariate analysis. Survival curves were plotted using the Kaplan-Meier method. Results The clinicopathologic variables correlated with cumulative survival on univariate analysis. Advanced clinical lymph node stage (P = .001), pathologic lymph node stage (P = .001), pathologic tumor stage (P = .049), pathologic TNM stage (P = .006), receipt of multimodality treatment (P = .013), and high PLRs (P = .001) and NLRs (P = .002) showed a statistically significant association with shorter DFS. A multivariate Cox proportional hazard regression model demonstrated that a high PLR (hazard ratio [HR], 2.998; 95% confidence interval [CI], 1.128 to 7.968; P = .028) and patient age (HR, 1.100; 95% CI, 0.750 to 1.613; P = .025) were independent factors for determining DFS and OS. Conclusions We observed that high PLRs and NLRs were significant in determining the prognosis. The PLR was superior to the NLR in determining DFS and OS and can be used as an independent prognostic indicator in patients with OSCC.

Purpose Germline succinate dehydrogenase (SDHx) mutation carriers, especially SDHB, are at increased risk for malignancy and require life-long surveillance. Current guidelines recommend periodic whole-body MRI imaging. We assessed the incremental value of 68Ga-DOTA-octreotate (GaTate) positron emission tomography (PET)/CT compared with conventional imaging in such patients. Methods SDHx mutation carriers who had GaTate PET/CT were retrospectively reviewed. Detection of lesions were compared with MRI or CT on a per-patient and per-lesion basis. Proof of lesions were based on histopathology or clinical/imaging follow-up. Results Twenty consecutive patients (median age, 46 years; 10 males) were reviewed. Fourteen patients had SDHB, four, SDHD, one SDHC, and one SDHA mutation. Fifteen had prior surgery and/or radiotherapy. Indications for PET/CT were as follows: 7 patients for surveillance for previously treated disease, 9 residual disease, 2 asymptomatic mutation carriers, and 2 for elevated catecholamines. Median time between modalities was 1.5 months. GaTate PET/CT had higher sensitivity and specificity than conventional imaging. On a per-patient basis: PET/CT sensitivity 100%, specificity 100%; MRI/CT 85% and 50%. Per-lesion basis: PET/CT sensitivity 100%, specificity 75%; MRI/CT 80% and 25%. PET/CT correctly identified additional small nodal and osseous lesions. MRI/CT had more false-positive findings. Change of management resulted in 40% (8/20 patients): 3 received localized treatment instead of observation, 1 changed to observation given extra disease detected, 4 with metastases had radionuclide therapy. Conclusions GaTate PET/CT provided incremental diagnostic information with consequent management impact in SDHx-pheochromocytoma and paraganglioma. Incorporating this modality as part of a surveillance program seems prudent. Further research is needed to define the optimal surveillance strategy including use of MRI.

BACKGROUND: Data are lacking on the long-term effect on cardiovascular events of adding sitagliptin, a dipeptidyl peptidase 4 inhibitor, to usual care in patients with type 2 diabetes and cardiovascular disease. METHODS: In this randomized, double-blind study, we assigned 14,671 patients to add either sitagliptin or placebo to their existing therapy. Open-label use of antihyperglycemic therapy was encouraged as required, aimed at reaching individually appropriate glycemic targets in all patients. To determine whether sitagliptin was noninferior to placebo, we used a relative risk of 1.3 as the marginal upper boundary. The primary cardiovascular outcome was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina. RESULTS: During a median follow-up of 3.0 years, there was a small difference in glycated hemoglobin levels (least-squares mean difference for sitagliptin vs. placebo, -0.29 percentage points; 95% confidence interval [CI], -0.32 to-0.27). Overall, the primary outcome occurred in 839 patients in the sitagliptin group (11.4%; 4.06 per 100 person-years) and 851 patients in the placebo group (11.6%; 4.17 per 100 person-years). Sitagliptin was noninferior to placebo for the primary composite cardiovascular outcome (hazard ratio, 0.98; 95% CI, 0.88 to 1.09; P

Recurrent aphthous ulcers are the most prevalent oral mucosal disease, but the subset major aphthous ulcer is a less frequent type. These ulcers are refractory, may persist for several weeks to months, and interfere with the normal state of health. The aetiology is multifactorial and so is the treatment. We present a case of an adolescent male patient reported with multiple oral ulcers. He developed three ulcers simultaneously and suffered for 10 months despite using topical medications prescribed by different dental practitioners. We executed a multidisciplinary treatment approach that resulted in a long-term disease-free state. The treatment methods followed in our case could be a successful model to implement by medical practitioners and oral physicians when the situation demands.

BACKGROUND: Empagliflozin slowed the progression of CKD in patients with type 2 diabetes and cardiovascular disease in the EMPA-REG OUTCOME Trial. In a prespecified statistical approach, we assessed treatment differences in kidney function by analyzing slopes of eGFR changes.METHODS: Participants (n=7020) were randomized (1:1:1) to empagliflozin 10 mg/d, empagliflozin 25 mg/d, or placebo added to standard of care. We calculated eGFR slopes using random-intercept/random-coefficient models for prespecified study periods: treatment initiation (baseline to week 4), chronic maintenance treatment (week 4 to last value on treatment), and post-treatment (last value on treatment to follow-up).RESULTS: Compared with placebo, empagliflozin was associated with uniform shifts in individual eGFR slopes across all periods. On treatment initiation, adjusted mean slope (eGFR change per week, ml/min per 1.73 m2) decreased with empagliflozin (-0.77; 95% confidence interval, -0.83 to -0.71; placebo: 0.01; 95% confidence interval, -0.08 to 0.10; PCONCLUSIONS: The hemodynamic effects of empagliflozin, associated with reduction in intraglomerular pressure, may contribute to long-term preservation of kidney function.

Purpose: There is evidence that the status of human papilloma virus subtype 16 (HPV-p16) alters the prognosis of patients with oropharyngeal squamous cell cancer (OSCC). We sought to establish whether there is a relationship between HPV-p16 status and F-FDG uptake in the prognosis of OSCC. Materials and methods: Patients with newly diagnosed OSCC at our institution between June 2011 and June 2012 were retrospectively evaluated. All patients underwent a baseline F-FDG PET/computed tomographic scan and HPV-p16 testing. Tumour maximum standardized uptake value (SUV), mean standardized uptake value (SUV) and total glycolytic activity (TGA) [defined as metabolic tumour volume (MTV) multiplied by SUV] were measured. All PET/computed tomographic scans were reviewed on a Siemens Syngo.via (version VA11B-HF03) workstation. A designated operator defined the region of the primary tumour with the MTV segmented by 40% of the SUV fixed threshold method. Results: Seventy-nine patients aged 27-84 years met the criteria for inclusion in the study. The types of primary tumour were tonsillar squamous cell carcinoma in 48% and base of tongue squamous cell carcinoma in 29%. The mean SUV was 17.5 and 17.7 in HPV-p16-positive and HPV-p16-negative groups, respectively (P=0.90). The mean MTV was 8.36 and 7.07 ml in HPV-p16-positive and HPVp16- negative patients, respectively (P=0.42). The mean TGA values were 96.3 and 82.5 g among the HPVp16- positive and HPV-p16-negative patients (P=0.54). There was no significant difference between HPV-p16 status and tumour grading for any of the imaging markers. Conclusion: There were no statistically significant differences between HPV-p16-positive and HPVp16- negative OSCC for any of the metabolic imaging markers (SUV, SUV, MTV and TGA) measured in this study.

Focal myositis is a rare benign inflammatory pseudotumor that can mimic malignancy, clinically and on imaging. A 34-year-old man presented with a 3-week history of sudden-onset, nontender, left upper neck mass that was nonresolving with antibiotics. Anatomical imaging was concerning for a sarcoma of the sternocleidomastoid muscle with possible regional nodal metastases and surrounding inflammatory change. F-FDG PET/CT showed marked FDG uptake extending around the anterior border of the sternocleidomastoid muscle with no FDG-avid local nodal disease. Core biopsy of the sternocleidomastoid muscle and adjacent node revealed inflammatory changes. A diagnosis of focal inflammatory myositis was made.

Objectives Surgery is the primary treatment modality for node-positive cutaneous squamous cell carcinoma of the head and neck with no distant disease (HNcSCC-M0). The role of preoperative positron emission tomography/computed tomography (PET/CT) scan for these patients is unclear. We compared preoperative PET/CT with final histopathology among patients undergoing lymphadenectomy and/or parotidectomy for HNcSCC-M0. Study Design Case series with chart review. Setting Single Australian center. Subjects and Methods Investigation included disease parameters and preoperative CT and PET/CT findings of 64 patients with node-positive HNcSCC without distant metastatic disease. Fisher's exact test was used to test for a difference in the proportion of patients with chronic lymphocytic leukemia between the false- and true-negative PET/CT subgroups. Results Of 64 patients who underwent PET/CT prior to surgery for node-positive HNcSCC-M0, 56 underwent a neck dissection and 30, a parotidectomy. Of these, 13 neck dissections and 2 parotidectomies were performed in the absence of FDG-avid (18F-fludeoxyglucose) nodes in these nodal fields. The PET/CT positive predictive value of the neck was 91.1%. The negative predictive values in the neck and parotid regions were 60%. Of the false-negative subgroup, 66.7% had chronic lymphocytic leukemia, compared with 11.1% of the true-negative subgroup ( P = .09). Based on PET/CT findings, surgical plans according to preoperative CT were changed for 6.25% of patients. Conclusion Use of PET/CT for surgical candidates with node-positive HNcSCC-M0 has high specificity and positive predictive value with relatively low sensitivity and negative predictive value. A statistical trend toward a higher rate of chronic lymphocytic leukemia among patients with false-negative results is suggested.

BK channels are dually regulated by voltage and Ca

Supplemental Digital Content is available in the text., Background and Purpose— In the EMPA-REG OUTCOME trial (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients), empagliflozin added to standard of care in patients with type 2 diabetes mellitus and high cardiovascular risk reduced the risk of 3-point major adverse cardiovascular events, driven by a reduction in cardiovascular mortality, with no significant difference between empagliflozin and placebo in risk of myocardial infarction or stroke. In a modified intent-to-treat analysis, the hazard ratio for stroke was 1.18 (95% confidence interval, 0.89–1.56; P=0.26). We further investigated cerebrovascular events. Methods— Patients were randomized to empagliflozin 10 mg, empagliflozin 25 mg, or placebo; 7020 patients were treated. Median observation time was 3.1 years. Results— The numeric difference in stroke between empagliflozin and placebo in the modified intent-to-treat analysis was primarily because of 18 patients in the empagliflozin group with a first event >90 days after last intake of study drug (versus 3 on placebo). In a sensitivity analysis based on events during treatment or ≤90 days after last dose of drug, the hazard ratio for stroke with empagliflozin versus placebo was 1.08 (95% confidence interval, 0.81–1.45; P=0.60). There were no differences in risk of recurrent, fatal, or disabling strokes, or transient ischemic attack, with empagliflozin versus placebo. Patients with the largest increases in hematocrit or largest decreases in systolic blood pressure did not have an increased risk of stroke. Conclusions— In patients with type 2 diabetes mellitus and high cardiovascular risk, there was no significant difference in the risk of cerebrovascular events with empagliflozin versus placebo. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01131676.

Cerebral perfusion single photon emission computer tomography (SPECT) can be used to identify epileptogenic foci. A (99m)Tc ethyl cysteinate dimer SPECT of the brain showed clinically evident differences in uptake between the CT attenuation corrected image and the Chang attenuation corrected image. The upper right hemisphere of the brain showed apparent diffuse hyperperfusion in the CT attenuation corrected image while the Chang attenuation corrected image, after reconstruction that appears to average projections, showed symmetrical cerebral perfusion. On review of archived patient data, this artefact was also observed in multiple previous cerebral SPECT studies undertaken on the same camera. Phantom investigation was used to identify the cause of the artefact as a difference in relative head sensitivity. The investigation also characterised the extent and nature of this artefact for CT attenuation corrected images, Chang attenuation corrected images and non-attenuation corrected images.

Stiffness following total knee arthroplasty is a disabling complication. One of the management options of stiffness includes manipulation under anaesthesia, but no real consensus exist on appropriate timing of intervention, and the timing and results of the manipulation under anaesthesia (MUA) are under debate in the literature. Our aim was to determine the efficacy of single and multiple manipulations under anaesthesia following total knee arthroplasty and to determine the most appropriate timing for manipulation. We retrospectively reviewed 86 patients who underwent manipulation for stiffness following primary total knee replacement with at least 1-year follow-up. Range of motion before surgery, at the time of the MUA, immediately after MUA and at 6 weeks and 1 year post-MUA were recorded. At the end of 1 year post-manipulation, manipulations performed at less than 20 weeks, following primary total knee arthroplasty, showed 31° of flexion gain as compared to only 1.5° of flexion gain when manipulation was undertaken after 20 weeks. Of the 86 patients, 21 had multiple manipulations with no significant difference in flexion gain after the second manipulation. Patients on warfarin (26%) had an increased incidence of stiffness and poor flexion gain. This study showed that better results were achieved when manipulation was performed at less than 20 weeks (particularly between 12 and 14 weeks) from primary surgery with no added benefit from re-manipulations.

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IntroductionFailure of acetabular components frequently leads to bone loss with extensive elongated defects in the surrounding bone. In these cases the use of an oblong cup has been described as an option for acetabular reconstruction. We report the longest follow up results obtained with this implant to date.Materials and MethodsA prospective study was conducted to evaluate the results of the BOFOR oblong revision cup. Between 2001 and 2006, 15 acetabular revisions were performed for aseptic loosening of the acetabular cup. The acetabular defects were classified as type 2A to 3A, according to Paprosky's criteria. No allografts were used in any of the cases. The mean follow-up was 90 months (range 60–120 months).ResultsClinical assessment at follow-up showed a significantly improved mean Harris Hip Score from 39 points preoperatively to 84 points postoperatively and a mean Oxford Hip Score from 55 points preoperatively to 22 points postoperatively. Only one case underwent re-revision due to aseptic loosening in a patient with severe ankylosing spondylitis. There were no cases of dislocation or infection. One patient had a sciatic nerve neurapraxia. After an average follow up of 7.5 years, 93% of the investigated implants remained in-situ without further revision.ConclusionThis study shows that the BOFOR cup provided good clinical results and showed satisfactory stability at early to midterm follow-up.

INTRODUCTION Objective measures can be impractical in some settings, because they are time consuming and require face-to-face contact. More recently, there is an increasing trend towards the use of subjective outcome measures. Hence, in this article, five common subjective shoulder outcome measures are critically appraised in terms of their development, validity, relia-lity, responsiveness and clinical application. MATERIALS AND METHODS Following an extensive literature search, five common shoulder patient-based scores were identified: Disability of Arm, Shoulder and Hand (DASH), Oxford Shoulder Score (OSS), Shoulder Disability Questionnaire (SDQ-UK), Shoulder Pain and Disability Index (SPADI), and the Shoulder Rating Questionnaire (SRQ). These questionnaires were then critically appraised in terms of their development process, validity, reliability, responsiveness, and clinical application. RESULTS The SDQ-UK has shown good construct validity but there is no data available regarding internal consistency, reliability and responsiveness. The SPADI has good internal consistency, fair reliability with adequate criterion and construct validity. The DASH has shown to have good construct validity, excellent test–re-test reliability and responsiveness to change. The OSS has good sensitivity, validity and responsiveness. Though SRQ has good internal consistency, its reproducibility and responsiveness are poor. CONCLUSIONS Based on this critical appraisal, the DASH received the best ratings for its clinimetric properties followed by the OSS.

BACKGROUND: Unexpected focal colorectal fluorodeoxyglucose (FDG) uptake is becoming a common clinical dilemma with the increasing utilization of positron emission tomography (PET). These findings may subsequently reveal malignant or premalignant pathology. AIM: In addition to reporting the prevalence of clinically significant colonic pathology associated with unexpected focal FDG uptake, this study analysed the correlation between pathological colonic segments with those reported on the FDG-PET scan. METHODS: The reports of 2071 consecutive PET-computed tomography (PET-CT) scans performed in a calendar year were reviewed. Information regarding subsequent patient investigation and management was collected from medical records. The segments harbouring foci of unexpected bowel FDG uptake were compared against the eventual outcome(s) of the endoscopic and pathological investigations. RESULTS: Among the 62 individual patients represented, 37 (60%) were investigated further. Clinically unsuspected neoplasms were found in 68% of those investigated, including 10 diagnosed with carcinoma. In addition, an unknown bowel lymphoma and 19 colonic adenomas were discovered. The positive predictive value for pathology was higher in the proximal colon than the distal colon. The segments in which the pathological findings were identified correlated well with those reported as abnormal on PET-CT. CONCLUSION: Unexpected bowel FDG uptake on PET-CT is associated with a high incidence of neoplastic pathology. In particular, focal FDG uptake in the proximal colon is associated with a high positive predictive value for neoplasm. The location of pathology is strongly concordant with endoscopic findings.

SummaryObjectivesBecause of the suboptimal recovery rate of brucellae from blood, it has been proposed that cultures of bone marrow, liver tissue, and lymph nodes may improve the recovery rate of the organism. Data in support of these recommendations are limited and not clearly convincing, especially that of bone marrow culture. The main purpose of this work was to evaluate the roles of blood, bone marrow, liver, and lymph node cultures in the diagnosis of human brucellosis.MethodsBlood and bone marrow cultures were evaluated in parallel in 103 cases of human brucellosis using Castaneda's biphasic technique. Simultaneous cultures of blood, bone marrow, liver, and lymph node aspirates were also carried out for 13 of these 103 cases.ResultsBlood culture identified 47 (45.6%) cases and bone marrow culture identified 85 (82.5%) cases. Faster recovery of Brucella spp was accomplished with the bone marrow culture (2.8±0.7 days, p

There is widespread adoption of FDG-PET/CT in staging of lung cancer, but no universally accepted criteria for classifying thoracic nodes as malignant. Previous studies show high negative predictive values, but reporting criteria and positive predictive values varies. Using Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) results as gold standard, we evaluated objective FDG-PET/CT criteria for interpreting mediastinal and hilar nodes and compared this to expert visual interpretation (EVI).A retrospective review of all patients with lung cancer who had both FDG-PET/CT and EBUS-TBNA from 2008 to 2010 was performed. Scan interpretation was blinded to histology. Patients from 2008/2009 were used for the prediction set. The validation set analysed patients from 2010. Objective FDG-PET/CT criteria were SUVmax lymph node (SUVmaxLN), ratio SUVmaxLN/SUVmax primary lung malignancy, ratio SUVmaxLN/SUVaverage liver, ratio SUVmaxLN/SUVmax liver and ratio SUVmaxLN/SUVmax blood pool. A nuclear medicine physician reviewed all scans and classified nodal stations as benign or malignant.Eighty-seven malignant lymph nodes and 41 benign nodes were in the prediction set. All objective FDG-PET/CT criteria analysed were significantly higher in the malignant group (P0.0001). EVI correctly classified 122/128 nodes (95.3%). Thirty-four malignant nodes and 19 benign nodes were in the validation set. The new proposed cut-off values of the objective criteria from the prediction set correctly classified 44/53 (83.0%) nodes: 28/34 (82.4%) malignant nodes and 16/19 (84.2%) benign nodes. EVI had 91% accuracy: 33/34 (97.1%) malignant nodes and 15/19 (79.0%) benign nodes.Objective analysis of 18-F FDG PET/CT can differentiate between malignant and benign nodes but is not superior to EVI.

A previously well 48-year-old male patient presented with several months of weight loss, fever, massive hepatosplenomegaly, and pancytopenia. A provisional diagnosis of lymphoma could not be confirmed on blind lymph node or bone marrow biopsies. Referral for 18F-FDG PET was made to identify an appropriate biopsy site. Focal uptake in multiple splenic lesions was seen, with normal FDG uptake elsewhere in the body. Splenectomy was then performed and histology revealed leishmaniasis, with no evidence of lymphoma. Focally FDG avid splenic deposits have never been reported in leishmaniasis and were likely due to nodular red pulp expansion.

A 76-year-old man was incidentally diagnosed with prostate lymphoma following transurethral resection of the prostate for prostatism. Staging F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) revealed markedly increased FDG uptake in the prostate, with no evidence of other disease. Following combination chemotherapy, restaging FDG-PET/CT demonstrated a complete metabolic response. The patient subsequently achieved prolonged remission on follow-up. Because of its rarity, FDG-PET in predicting outcome after therapy has not been validated for primary prostate lymphoma. This case highlights the potential of FDG-PET/CT in not only evaluation of disease extent but also prognostication of primary lymphoma of the prostate.

A 46-year-old woman with known Graves' disease underwent a Tc-99m tetrofosmin myocardial perfusion scan (MPS) for investigation of chest pain. The study showed a mildly dilated left ventricle but no evidence of myocardial ischemia. Routine planar images of the thorax showed prominent, diffu

Enhancing the deposition and permeation of 5-fluorouracil across human epidermis assisted by appropriately charged and well-defined peptide dendrimers was investigated. Peptide dendrimers with arginine as the terminal amino acid and having a range of terminal positive charges (4(+), 8(+) and 16(+)) were synthesized by solid phase peptide synthesis. Various parameters including effect of peptide dendrimers on the solubility and partition coefficient of 5-FU, degradation of drug in skin as well as deposition and permeation of 5-FU in/through skin were studied. All the tested dendrimers increased the aqueous solubility and partition coefficient of 5-FU with each also significantly (p 0.05) enhancing the deposition and permeation of 5-FU in/across human epidermis in a concentration-dependent manner. Of the three peptide dendrimers examined, R8 dendrimer (bearing 8(+) charge derived from four terminal arginines and MW of ≈1000 Da) showed greatest values for flux, Q(48) (cumulative amount of drug permeated at the end of 48 h) and amount of drug retained in human skin. Furthermore, this study also scrutinized and reports on the likely mechanisms by which peptide dendrimers act as transdermal permeation enhancers.

Group B streptococci (GBS) birth canal colonisation in pregnant women and women of child-bearing age is well known. The recognition and incidence of infections caused by these organisms in non-pregnant and elderly adults are increasing. Clinical manifestations of GBS infections can range from simple skin and soft tissue infections to fatal meningitis in newborns. GBS as a cause of septic arthritis of the hip associated with pregnancy is previously unreported. We report a case of septic arthritis of the hip joint caused by GBS in a 30-year-old woman with a history of recent childbirth. Delay in recognition and lack of timely appropriate treatment of this condition henceforth led to severe destruction of the joint, requiring ultimate reconstruction of the joint with cemented total hip arthroplasty. This case report highlights the atypical presentation and rapidly destructive nature of this infection with catastrophic consequences.

A 56-year-old patient was referred for FDG PET/CT with a right preauricular lymph node fine-needle biopsy, suggesting poorly differentiated carcinoma and no obvious primary lesion. There was intense FDG uptake in the right preauricular nodule. The node was excised, and formal histology demonstrated a benign pilomatricoma rather than malignancy. Pilomatricoma is uncommon in adults and an unusual cause for marked FDG uptake, likely due to foreign body inflammation. Pilomatricoma can be either benign or malignant. The marked FDG uptake demonstrated in our patient with benign pilomatricoma also suggests that FDG PET cannot reliably grade this rare condition.

BACKGROUND: Fluorine-18 fluorodeoxyglucose PET/computed tomography (CT) is now routinely used for staging and monitoring treatment response in head and neck squamous cell carcinoma (HNSCC). Although most patients with HSNCC have locoregional disease, distant metastases are relatively uncommon and occur predominantly in the lungs. AIM: To explore the potential of a limited scan range from the skull vertex to lung bases, viz. an 'above diaphragm' scan, as an adequate examination for assessment of disease following chemoradiotherapy. METHODS: A retrospective review of 240 patients with HNSCC both staged and monitored after therapy with F-fluorodeoxyglucose PET/CT was conducted. Patients with previous HNSCC, unknown primary and known distant metastatic disease were excluded. Patients with positive PET/CT findings below the neck on the posttherapy study were confirmed on either follow-up clinical or radiological findings. RESULTS: A total of 196 (81.7%) patients had nodal disease at PET/CT staging. Unrelated findings were present in 50 (20.8%) patients, including five colonic neoplasms and two second malignancies. After an average of 6.4 months after staging, 13 patients (5.4%) demonstrated progression to distant metastases on the posttherapy PET/CT. All patients demonstrated intrapulmonary metastases. Two patients had additional liver metastases, which would not have impacted on the overall management. No patient demonstrated isolated disease below the diaphragm. CONCLUSION: A limited 'above-diaphragm' scan for early assessment following chemoradiotherapy may be safely considered. The benefits of this tailored approach flow onto both the health system and the patients as it can improve resource allocation by increasing scanner availability and patient throughput and reduces cumulative patient radiation exposure.

The aim of this study is to assess the comparability and interchangeability of the radionuclide glomerular filtration rate (GFR) using different published techniques, and propose normative data for paediatrics.A total of 476 paediatric oncology patients aged 2-17 years, referred between January 2001 and December 2008 for GFR estimation, were reviewed for any potential cause of renal impairment. Sixty-nine patients met the stringent inclusion criteria, and were included in the study. GFR estimation was carried out using either technetium-99m diethylene triamine penta-acetic acid (⁹⁹mTc-DTPA) or chromium-51 EDTA (⁵¹Cr-EDTA). Multiple GFR results were calculated from the same blood sample data (counts/min/ml), according to previously published GFR estimation techniques using one to three blood samples. These techniques were slope-intercept, slope-only and half life. For slope-intercept techniques, GFR was normalized to body surface area or extracellular fluid volume.The GFR values obtained using different techniques were highly variant. The intraclass correlation (ICC) for different methods was moderate (ICC=0.56-0.66). A reliable empiric formula to allow conversion of GFR values from one technique to another could not be derived because of this variability, with some exceptions. ⁵¹Cr-EDTA yielded the same or lower variability than ⁹⁹mTc-DTPA. The British Nuclear Medicine Society-recommended method had the lowest coefficient of variation, with a mean value of 116 (SD 22) normalized to 1.73 m² for ⁵¹Cr-EDTA using two samples.The GFR values obtained from different calculation techniques are not readily interchangeable or comparable, with some exceptions. For both ⁹⁹mTc-DTPA and ⁵¹Cr-EDTA, the British Nuclear Medicine Society-recommended technique appears to be the most robust, with the least coefficient of variation.

Morphologic and sonographic features of endobronchial ultrasound (EBUS) convex probe images are helpful in predicting metastatic lymph nodes. Grey scale texture analysis is a well-established methodology that has been applied to ultrasound images in other fields of medicine. The aim of this study was to determine if this methodology could differentiate between benign and malignant lymphadenopathy of EBUS images.Lymph nodes from digital images of EBUS procedures were manually mapped to obtain a region of interest and were analyzed in a prediction set. The regions of interest were analyzed for the following grey scale texture features in MATLAB (version 7.8.0.347 [R2009a]): mean pixel value, difference between maximal and minimal pixel value, SEM pixel value, entropy, correlation, energy, and homogeneity. Significant grey scale texture features were used to assess a validation set compared with fluoro-D-glucose (FDG)-PET-CT scan findings where available.Fifty-two malignant nodes and 48 benign nodes were in the prediction set. Malignant nodes had a greater difference in the maximal and minimal pixel values, SEM pixel value, entropy, and correlation, and a lower energy (P.0001 for all values). Fifty-one lymph nodes were in the validation set; 44 of 51 (86.3%) were classified correctly. Eighteen of these lymph nodes also had FDG-PET-CT scan assessment, which correctly classified 14 of 18 nodes (77.8%), compared with grey scale texture analysis, which correctly classified 16 of 18 nodes (88.9%).Grey scale texture analysis of EBUS convex probe images can be used to differentiate malignant and benign lymphadenopathy. Preliminary results are comparable to FDG-PET-CT scan.

A 29-year-old woman presented with a new right supraclavicular mass on a background of resection of a malignant melanoma from her right shoulder before 4 years. F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) imaging revealed uptake in a right supraclavicular node and the inferior pole of the left lobe of the thyroid gland. Subsequent resection and histology of the right supraclavicular node and the left lobe of the thyroid gland demonstrated metastatic melanoma and palpation thyroiditis, respectively. A number of malignant and benign pathologies of the thyroid demonstrate FDG uptake, with 75% being benign. To our knowledge, the findings of palpation thyroiditis on FDG PET/CT have never been previously described.

We aimed to assess the radiological and functional outcome of total hip arthroplasty performed using a simple technique for intra-operative leg length assessment. The comparative group was made up of patients receiving total hip arthroplasty prior to introduction of the technique. Fifty patients were studied in each group. The pre- and 3 month post-operative leg length difference (LLD) was measured radiologically along with pre- and 12 months post-operative Oxford hip scores (OHS) and University of California Los Angeles (UCLA) activity scores. There were no statistically significant differences in pre-operative parameters between the two groups. The mean LLD in the new technique group was 0.46mm which was significantly less than in the control group (p< 0.001). Post operative OHS values were worse when shortening or lengthening was >5mm in both groups. UCLA activity scores were significantly better in the new technique group than in the control group (p< 0.001). The overall radiological and functional outcome of the patients was better in the new technique group. Functional outcome is related to small differences in leg length and our simple new technique can be used to control leg length intraoperatively.

Steroid injection into the arthritic joint is a well-known treatment. Its efficacy is well documented. An increase in the incidence of infection secondary to steroid injection has been reported in recent literature. Based on the current literature we carried out a retrospective study to evaluate the incidence of infection in primary total knee arthroplasty as a result of previous steroid infiltration into the knee joint. In our study, 440 patients underwent total knee replacement between 1997 and 2005. Only 90 patients had intraarticular steroid injection prior to surgery, of which 45 patients had injection within 1 year prior to surgery. A matched cohort of 180 patients who had total knee replacement without steroid injection was used as control group to compare the infection rate. All patients had at least 1 year follow up. Two cases of superficial infection were noted in the study group and five cases of superficial infection in the control group. No cases of deep infection were noted in either group. Statistical analysis showed no significant difference in incidence of infection in either group (P value 1.0). This study showed no increase in the incidence of infection in patients with total knee arthroplasty with prior steroid injection.

Culture of blood is the most frequent, accurate means of diagnosing bacteremia in enteric fever and brucellosis. However, conventional blood culturing is slow in isolating bacteria causing these diseases. In this work, we evaluated the performance of blood clot culture and conventional whole blood cultures in the accurate diagnosis of enteric fever (253 cases) and human brucellosis (71cases). The blood clot culture was found to be much more sensitive for both Salmonella (more by 34.4%, P0.001) and Brucella (more by 22.6%, P0.001) than whole blood culture. Bacterial growth was significantly faster in cultures of blood clot compared to whole blood (1.1 versus 2.6 days for Salmonella, 3.1 versus 8.2 days for Brucella melitensis, respectively). The rapid confirmation of the etiological agent would facilitate an early institution of appropriate antimicrobial therapy, thereby reducing clinical morbidity especially in an endemic population. It is worthwile practicing blood clot culture for the accurate diagnosis of enteric fever and brucellosis in developing countries where diagnostic facilities by advanced technologies like automated culture systems and PCR are not available.

Rib and sternal fractures are relatively common following conventional cardiopulmonary resuscitation (CPR). This case demonstrates the 18F-FDG PET/CT appearances of typical CPR-related multiple rib and sternal fractures in a 55-year-old man with suspected cardiac sarcoidosis. The PET/CT scan was performed to assess disease activity of cardiac sarcoidosis, and no active cardiac inflammation was detected. The patient initially presented with an out-of-hospital cardiac arrest and successfully received bystander CPR.