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Dearomatisation reactions of (hetero)arenes have been widely employed as efficient methods to obtain highly substituted saturated cyclic compounds for over a century. In recent years, research in this area has shifted towards effecting additional C-C bond formation during the overall dearomative process. Moving away from classical hydrogenation-based strategies a wide range of reagents were found to be capable of initiating dearomatisation through nucleophilic addition (typically a reduction) or photochemically induced radical addition. The dearomatisation process gives rise to reactive intermediates which can be intercepted in an intra- or intermolecular fashion to deliver products with significantly increased molecular complexity when compared to simple dearomatisation. In this Perspective recent examples and strategies for the dearomative functionalisation of heteroaromatic systems will be discussed.

Purpose The purpose of the study is to determine if a combination of dermal thickening and subcutaneous fluid honeycombing on non-contrast MRI, termed the dermal rim sign (DRS), can be diagnostically analogous to dermal backflow seen on lymphoscintigraphy in patients with secondary upper extremity lymphedema. Materials and methods Upper extremity MRI and lymphoscintigraphy were performed on patients referred to a multidisciplinary lymphedema clinic for suspicion of secondary lymphedema. Sensitivity, specificity, and positive and negative predictive values of DRS on MRI in detecting dermal backflow on lymphoscintigraphy and the correlation between DRS, Indocyanine Green (ICG) lymphography, bioimpedence L-Dex® ratio and MRI Lymphedema Staging were calculated. Weighted interobserver agreements on the presence and location of DRS on MRI were calculated. Results Of the 45 patients in the study, 91.1% (41/45) of patients had history of breast cancer. The average age was 58.4 ± 10.5 years, with a mean symptom duration of 4.7 ± 4.4 years. The mean BMI was 30.5 ± 7.0 kg/m2. Interobserver agreement on the presence and the extent of DRS on MRI was 0.93 [95% confidence-interval: 0.80–1]. DRS was present in 97% (32/33) of patients who demonstrated dermal backflow on lymphoscintigraphy. Sensitivity, specificity, PPV, and NPV of DRS were 96.6% [81.7%–99.9%], and 75.0% [47.6%–92.7%], 87.5% [74.9%–94.3%], and 92.3% [63.1%–98.8%]. DRS was associated with severity on ICG lymphography and bioimpedance (both p Conclusions DRS on non-contrast MRI is highly predictive of dermal backflow and correlates with clinical measures of lymphedema severity. DRS may be used as an independent diagnostic biomarker to identify patients who would benefit from dedicated exams.

The use of benzylic and allylic alcohols in HFIP solvent together with Ti(OiPr)4 has been shown to trigger a highly stereoselective polyene cyclisation cascade. Three new carbon-carbon bonds are made during the process and complete stereocontrol of up to five new stereogenic centers is observed. The reaction is efficient, has high functional group tolerance and is atom-economic generating water as a stoichiometric by-product. A new polyene substrate-class is employed, and subsequent mechanistic studies indicate a stereoconvergent mechanism. The products of this reaction can be used to synthesize steroid-analogues in a single step.

In this work an approach for the synthesis of furanocembranoid natural products containing the C-7,8-diol moiety is disclosed. This culminated in the first total synthesis of the natural product molestin E, together with ent-sinulacembranolide A and ent-sinumaximol A as well as a thorough exploration of their chemistry. Late-stage ring-closure of the C-7,8-diols to the corresponding epoxides was also demonstrated. Key features of this synthetic strategy include a stereoselective Baylis-Hillman reaction, ring-closing metathesis and Shiina macrolactonisation. Chiral-pool materials were deployed to ensure the desired absolute stereochemistry which was confirmed by late-stage single crystal X-ray diffraction.

The total synthesis of (–)-γ-lycorane (10 steps) and synthesis of (±)- γ-lycorane (8 steps) was completed from cyclohexenone. A new two step hydrogen borrowing alkylation of an aziridinyl alcohol, coupled with a Ph* deprotection/cyclisation procedure was developed for de novo formation of the fused 6,5 heterocyclic ring. This work is one of the first examples of hydrogen borrowing C-C bond formation being used as a key step in a total synthesis project.

For the first time we have been able to employ enantiopure 1,2‐amino alcohols derived from abundant amino acids in C−C bond‐forming hydrogen‐borrowing alkylation reactions. These reactions are facilitated by the use of the aryl ketone Ph*COMe. Racemisation of the amine stereocentre during alkylation can be prevented by the use of sub‐stoichiometric base and protection of the nitrogen with a sterically hindered triphenylmethane (trityl) or benzyl group. The Ph* and trityl groups are readily cleaved in one pot to give γ‐aminobutyric acid (GABA) products as their HCl salts without further purification. Both steps may be performed in sequence without isolation of the hydrogen‐borrowing intermediate, removing the need for column chromatography., The scope of carbon–carbon bond‐forming hydrogen‐borrowing reactions has been expanded to include 1,2‐amino alcohols derived from both natural and unnatural amino acids. The vulnerable amine stereocentre is preserved in the reaction by the use of a bulky nitrogen protecting group (trityl or benzyl), with the products being readily cleaved under acidic conditions to the corresponding γ‐aminobutyric acids without further purification.

Herein we disclose a mild protocol for the reductive functionalisation of quinolinium and isoquinolinium salts. The reaction proceeds under transition-metal-free conditions as well as under rhodium catalysis with very low catalyst loadings (0.01 mol %) and uses inexpensive formic acid as the terminal reductant. A wide range of electrophiles, including enones, imides, unsaturated esters and sulfones, β-nitro styrenes and aldehydes are intercepted by the in situ formed enamine species forming a large variety of substituted tetrahydro(iso)quinolines. Electrophiles are incorporated at the C-3 and C-4 position for quinolines and isoquinolines respectively, providing access to substitution patterns which are not favoured in electrophilic or nucleophilic aromatic substitution. Finally, this reactivity was exploited to facilitate three types of annulation reactions, giving rise to complex polycyclic products of a formal [3+3] or [4+2] cycloaddition.

A Ti(Oi-Pr)4 promoted 5 or 6-endo-trig cyclisation to make nitrogen heterocycles is presented. The utilisation of HFIP as a key solvent enables the stereoselective preparation of di- & tri-substituted pyrrolidines and piperidines while forming a new C-C bond at the same time. The process is triggered by a cationic intermediate generated from an allylic or benzylic alcohol and leads to the simultaneous generation of both a C-C and a C-N bond in a single step. Notably, either 2,3-trans or 2,3-cis substituted heterocycles can be obtained by using a nucleophilic amine bearing different substituents. Lastly, the stereoselective synthesis of enantiopure products was achieved by using readily available enantiopure acyclic starting materials.

The survival of incident dialysis patients’ end-stage kidney disease in some European and American has been reported to improve in modern era compared to earlier periods. However, in Ireland, this has not been well documented. To investigate the survival outcomes of incident end-stage kidney failure dialysis patients in a tertiary center over a 24-year period, 1993–2017. A retrospective analysis was carried out utilizing the Beaumont Hospital Renal Database. Consecutive adults with incident dialysis were analyzed. Kaplan-Meier methods and the estimated mean survival times were used to evaluate survival at successive 4-year periods of time. In total, 2106 patients were included, of whom 830 underwent subsequent renal transplantation during follow-up. During the study period, from 1993 up to 2017, the mean patients’ age increased from 56.3 ± 17.4 in 1993–1996 to 60.6 ± 18.3 in 2014–2017. There was an overall decrement in mortality over successive time intervals which were mirrored by the improvements in median survival after commencement of dialysis treatment from 6.14 years during 1993–1996 to 8.01 years during 2009–2012. Patients’ survival has steadily improved, with the 5-year survival has risen over time, by almost 15%. This positive signal persisted and became more pronounced after adjusting Kaplan-Meier curve to age, where the 5-year survival estimates were exceeding 80% in 2014–2017. Survival rates among incident dialysis patients have improved progressively between 1993 and 2017 in Beaumont Hospital in Dublin, Ireland. The factors which led to this improvement are not entirely clear, but likely to be multifactorial.

Through the use of model studies, an approach was conceived towards the synthesis of the taiwanschirin family of natural products. These are structurally complex compounds which represent highly challenging and biologically active targets for total synthesis. This work describes a successful synthesis of the complex taiwanschirin fused [8,6,5] core through a novel alkynylation reaction coupled with an intramolecular Heck reaction used to construct the 8-membered ring., Key enolate alkynylation and ring closing Heck reactions have been used to make the core of the taiwanschirin natural products.

OBJECTIVE To implement and evaluate outcomes from a comprehensive, multi-disciplinary debulking program in the United States. SUMMARY BACKGROUND DATA Interest in and access to surgical treatment for chronic lymphedema (LE) in the United States have increased in recent years, yet there remains little attention on liposuction, or debulking, as an effective treatment option. In some other countries, debulking is a common procedure for the surgical treatment of LE, is covered by insurance, and has demonstrated excellent, reproducible outcomes. In this study we describe our experience implementing a debulking technique from Sweden in the United States. METHODS Patients who presented with chronic lymphedema followed a systematic multi-disciplinary work-up. For debulking with power assisted liposuction, the surgical protocol was modeled after that developed by Hakan Brorson. A retrospective review of consecutive patients who underwent debulking at our institution was conducted. RESULTS Between December 2017 and January 2020, 39 patients underwent 41 debulking procedures with power assisted liposuction, including 23 upper and 18 lower extremities. Mean patient age was 58 years and 85% of patients had LE secondary to cancer, the majority of which (64%) was breast cancer. Patients experienced excess volume reductions of 111% and 115% in the upper and lower extremities, respectively, at one year post-operatively. Overall quality of life (LYMQOL) improved by a mean of 33%. Finally, patients reported a decreased incidence of cellulitis and decreased reliance on conservative therapy modalities post-operatively. CONCLUSIONS Debulking with power assisted liposuction is an effective treatment for patients with chronic extremity lymphedema. The operation addresses patient goals and improves quality of life, and additionally reduces extremity volumes, infection rates and reliance on outpatient therapy. A comprehensive, multi-disciplinary debulking program can be successfully implemented in the United States healthcare system.

Hydrogen‐borrowing catalysis represents a powerful method for the alkylation of amine or enolate nucleophiles with non‐activated alcohols. This approach relies upon a catalyst that can mediate a strategic series of redox events, enabling the formation of C−C and C−N bonds and producing water as the sole by‐product. In the majority of cases these reactions have been employed to target achiral or racemic products. In contrast, the focus of this Minireview is upon hydrogen‐borrowing‐catalysed reactions in which the absolute stereochemical outcome of the process can be controlled. Asymmetric hydrogen‐borrowing catalysis is rapidly emerging as a powerful approach for the synthesis of enantioenriched amine and carbonyl containing products and examples involving both C−N and C−C bond formation are presented. A variety of different approaches are discussed including use of chiral auxiliaries, asymmetric catalysis and enantiospecific processes., Borrowing hydrogen: This Minireview summarizes the rapidly developing area of transition‐metal‐catalysed asymmetric hydrogen‐borrowing catalysis. A range of enantioselective processes involving alkylation of both amines and enolates are presented. A wide variety of strategies have been employed to induce asymmetry in these reactions including asymmetric reduction, dynamic kinetic asymmetric transformation and incorporation of chiral auxiliaries.

A vinyl cyclopropane rearrangement embedded in an iridium‐catalyzed hydrogen borrowing reaction enabled the formation of substituted stereo‐defined cyclopentanes from Ph* methyl ketone and cyclopropyl alcohols. Mechanistic studies provide evidence for the ring‐expansion reaction being the result of a cascade based on oxidation of the cyclopropyl alcohols, followed by aldol condensation with the pentamethyl phenyl‐substituted ketone to form an enone containing the vinyl cyclopropane. Subsequent single electron transfer (SET) to this system initiates a rearrangement, and the catalytic cycle is completed by reduction of the new enone. This process allows for the efficient formation of diversely substituted cyclopentanes as well as the construction of complex bicyclic carbon skeletons containing up to four contiguous stereocentres, all with high diastereoselectivity., A vinyl cyclopropane/cyclopentene rearrangement process has been embedded in an iridium‐catalyzed hydrogen borrowing reaction, enabling the formation of substituted, stereo‐defined cyclopentanes containing up to four contiguous stereogenic centres—all from reaction of pentamethylphenyl (Ph*) methylketone and a variety of cyclopropyl alcohols.

Staging of upper extremity lymphedema is needed to guide surgical management, but is not standardized due to lack of accessible, quantitative, or precise measures. Here, we established an MRI-based staging system for lymphedema and validate it against existing clinical measures. Bilateral upper extremity MRI and lymphoscintigraphy were performed on 45 patients with unilateral secondary lymphedema, due to surgical intervention, who were referred to our multidisciplinary lymphedema clinic between March 2017 and October 2018. MRI short-tau inversion recovery (STIR) images were retrospectively reviewed. A grading system was established based on the cross-sectional circumferential extent of subcutaneous fluid infiltration at three locations, labeled MRI stage 0–3, and was compared to L-Dex®, ICG lymphography, volume, lymphedema quality of life (LYMQOL), International Society of Lymphology (ISL) stage, and lymphoscintigraphy. Linear weighted Cohen’s kappa was calculated to compare MRI staging by two readers. STIR images on MRI revealed a predictable pattern of fluid infiltration centered on the elbow and extending along the posterior aspect of the upper arm and the ulnar side of the forearm. Patients with higher MRI stage were more likely to be in ISL stage 2 (p = 0.002) or to demonstrate dermal backflow on lymphoscintigraphy (p = 0.0002). No correlation was found between MRI stages and LYMQOL. Higher MRI stage correlated with abnormal ICG lymphography pattern (rs = 0.63, p

An atom-economical methodology to access substituted acyl-cyclohexenes from pentamethylacetophenone and 1,5-diols is described. This process is catalyzed by an iridium(I) catalyst in conjunction with a bulky electron rich phosphine ligand (CataCXium A) which favors acceptorless dehydrogenation over conjugate reduction to the corresponding cyclohexane. The reaction produces water and hydrogen gas as the sole byproducts and a wide range of functionalized acyl-cyclohexene products can be synthesized using this method in very high yields. A series of control experiments were carried out, which revealed that the process is initiated by acceptorless dehydrogenation of the diol followed by a redox-neutral cascade process, which is independent of the iridium catalyst. Deuterium labeling studies established that the key step of this cascade involves a novel base-mediated [1,5]-hydride shift. The cyclohexenyl ketone products could readily be cleaved under mildly acidic conditions to access a range of valuable substituted cyclohexene derivatives.

An iridium catalyzed method for the synthesis of saturated aza-heterocycles from amines and diols is reported. A wide range of substituted heterocycles can be obtained using this approach including products bearing substituents at the C2, C3 and C4 positions. Employing water as the solvent, enantiopure diols could undergo annulation with minimal racemization, enabling the synthesis of valuable enantioenriched C3 and C4-substituted saturated aza-heterocycles.

Hydrogen borrowing catalysis serves as a powerful alternative to enolate alkylation, enabling the direct coupling of ketones with unactivated alcohols. However, to date, methods that enable control over the absolute stereochemical outcome of such a process have remained elusive. Here we report a catalytic asymmetric method for the synthesis of enantioenriched cyclohexanes from 1,5‐diols via hydrogen borrowing catalysis. This reaction is mediated by the addition of a chiral iridium(I) complex, which is able to impart high levels of enantioselectivity upon the process. A series of enantioenriched cyclohexanes have been prepared and the mode of enantioinduction has been probed by a combination of experimental and DFT studies.

The Society of Nuclear Medicine and Molecular Imaging (SNMMI) continues to develop clinical guidance documents to synthesize and disseminate clinical information for optimal patient care. Clinical guidelines help standardize delivery of care and improve quality. Chronology of SNMMI efforts in the development of nuclear medicine procedure standards (PS) and appropriate use criteria (AUC) is reviewed. Historically, the Society has focused its efforts on developing PS describing the accepted methodology for performing nuclear medicine procedures. However, legislative mandates and lack of existing evidence-based documents prompted SNMMI to take a lead in developing AUC for high-value nuclear medicine procedures. AUC presents common clinical scenarios where the use of nuclear medicine procedures is or is not appropriate. Methodology used by SNMMI for the development of PS and AUC is described. Following a multidisciplinary, transparent, and widely acceptable process can result in the development of widely acceptable clinical guidance documents that can standardize best practices, improve quality, and result in effective and efficient patient care. The Society has been developing and/or revising new PS and AUC documents for high-value nuclear medicine procedures. Updated real-time information on these clinical guidelines can be found at www.snmmi.org/ps and www.snmmi.org/auc.

Pentamethylphenyl (Ph*) ketones are rapidly emerging as versatile and useful building blocks for organic synthesis. The ortho-methyl substituents force the aromatic ring to twist out of planarity with the carbonyl, and consequently these molecules display a unique pattern of reactivity which is completely distinct to that of traditional aromatic ketones. The primary aim of this Digest is to highlight examples where new chemical reactivity is unlocked through the use of Ph* ketones, and a wide range of examples are presented including hydrogen borrowing catalysis, aldol addition and organocatalysis. Finally, methods to cleave the Ph* group to a range of other functionality are surveyed.

The alkylation of a variety of ketones using 1° or 2° alcohols under hydrogen borrowing catalysis is described. Initial research focused on the α-alkylation of cyclopropyl ketones with higher 1° alcohols (i.e. larger than MeOH), leading to the formation of α-branched products. Our search for additional substrates with which to explore this chemistry led us to discover that di-ortho-substituted aryl ketones were also privileged scaffolds, with Ph∗ (C6Me5) ketones being the optimal choice. Further investigations revealed that this motif was crucial for alkylation with 2° alcohols forming β-branched products, which also provided an opportunity to study diastereoselective and intramolecular hydrogen borrowing processes.

The single point activation of pyridines, using an electron-deficient benzyl group, facilitates the ruthenium-catalysed dearomative functionalisation of a range of electronically diverse pyridine derivatives. This transformation delivers hydroxymethylated piperidines in good yields, allowing rapid access to medicinally relevant small heterocycles. A noteworthy feature of this work is that paraformaldehyde acts as both a hydride donor and an electrophile in the reaction, enabling the use of cheap and readily available feedstock chemicals. Removal of the activating group can be achieved readily, furnishing the free NH compound in only 2 steps. The synthetic utility of the method was illustrated with a synthesis of (±)-Paroxetine., Pyridines can be activated at a single point with a new benzyl group, followed by dearomative functionalisation at C3 using formaldehyde.

A study of acyl protecting groups derived from the Ph* motif is reported. While initial studies indicated that a variety of functional groups were not compatible with the Br2-mediated cleavage conditions required to release the Ph* group, strategies involving the use of different reagents or a modification of Ph* itself (Ph*OH) were investigated to solve this problem.

Youth and young adults living with HIV (YYALH) are less likely to be engaged in HIV care, adhere to their medications, and achieve viral suppression compared to older adult populations. In the United States, the majority of YYALH belong to racial/ethnic, sexual, and gender minority groups. HIV care interventions are needed that specifically target YYALH and that exploit the use of social media and mobile technology (SMMT) platforms, where youth and young adults have a ubiquitous presence. We conducted a qualitative evaluation of SMMT interventions included in a Health Resources and Services Administration Special Projects of National Significance initiative designed to improve medical care engagement, retention, and medication adherence to achieve viral suppression among YYALH. However, in this study, only young adults living with HIV (YALH) ages 18 to 34 years participated. A total of 48 YALH were interviewed. The data were analyzed using thematic analysis and revealed three main themes supporting the usefulness of the SMMT interventions, which included (1) acceptability of SMMT interventions in managing HIV care with subthemes of medical information accessibility, reminders, and self-efficacy; (2) feelings of support and personal connection afforded by SMMT interventions; and (3) SMMT interventions help to alleviate negative feelings about status and mitigate HIV-related stigma. A few participants identified problems with using their respective intervention, primarily related to the functionality of the technologies. Overall, findings from our qualitative evaluation suggest that SMMT-based interventions have the potential to increase engagement and retention in care, support YALH in adhering to medication, and help them adjust to their diagnosis.

A route to prepare functionalized quinolines based on a Heck reaction/UV-induced alkene isomerization sequence is described. The method allows for the preparation of quinolines under mild and neutral conditions and has broad functional group tolerance. Acid-sensitive functional groups that would not be tolerated under previous approaches can be included and a one-pot quinoline forming procedure is also reported.

The emergence of new methods for the stereoselective synthesis of strained carbocycles is a challenging but worthwhile endeavour. Cyclobutanes, in particular, have attracted the attention of both medicinal chemists and material scientists for their unique properties. Herein, we present a new method that allows access to highly functionalized cyclobutanes with complementary all-trans and trans–cis–trans relative stereochemistry, that could not be accessed before. This approach consists of an intramolecular dimerisation of non-conjugated dienes using an oxidative single electron transfer (SET) process, and is initiated by catalytic amounts of hypervalent iodine reagents. The potential uses of these cyclobutanes is demonstrated with selective functionalization, including the formation of diols and carboxylic acids.

Transcranial magnetic stimulation (TMS) reveals decreased efficacy of long-term potentiation-like (LTP-like) neuroplastic mechanisms in Alzheimer's disease (AD). However, it is not yet known whether LTP-like plasticity is also impaired in prodromal AD, or how abnormal TMS measures are related to established AD biomarkers. Here, we investigated the LTP-like response to intermittent theta-burst stimulation in 17 amyloid-positive participants with amnestic mild cognitive impairment (MCI) and 10 cognitively unimpaired controls. Our results showed a lack of LTP-like neuromodulation in MCI compared with controls that was unrelated to quantitative amyloid-beta burden on positron emission tomography. Surprisingly, greater LTP-like response was related to worse memory function in the MCI group, highlighting the complex role of neuroplasticity in the prodromal stages of AD. Overall, our results demonstrate abnormal LTP-like plasticity using intermittent theta-burst stimulation assessment in amyloid-positive participants with MCI. These findings support the potential for development of TMS measures as prognostic markers or therapeutic targets in early-stage symptomatic AD.

An enantioconvergent method for the alkylation of o-disubstituted aryl ketones with racemic secondary alcohols is described. This process is mediated by a commercially available iridium catalyst and proceeds via hydrogen borrowing catalysis. The highly enantioenriched β-substituted ketone products were readily cleaved to a wide range of functional groups via retro-Friedel–Crafts acylation.

Catalytic oxidative cyclisation reactions have been employed for the synthesis of the E and F rings of the complex natural product target pectenotoxin 4. The choice of metal catalyst (cobalt- or osmium-based) allowed for the formation of THF rings with either trans or cis stereoselectivity. Fragment union using a modified Julia reaction then enabled the synthesis of an advanced synthetic intermediate containing the EF and G rings of the target.

Synthesis of substituted β-carbolines was accomplished by utilizing the catalytic enolate arylation reaction of ketones in conjunction with several 3-bromoindole derivatives. Quenching of the arylation reaction in situ with an electrophile allowed ready incorporation of functionality at the carboline C-4 position in an efficient one-pot protocol.

Pyridines are ubiquitous aromatic rings used in organic chemistry and are crucial elements of the drug discovery process. Herein we describe a new catalytic method that directly introduces a methyl group onto the aromatic ring; this new reaction is related to hydrogen borrowing, and is notable for its use of the feedstock chemicals methanol and formaldehyde as the key reagents. Conceptually, the C-3/5 methylation of pyridines was accomplished by exploiting the interface between aromatic and non-aromatic compounds, and this allows an oscillating reactivity pattern to emerge whereby normally electrophilic aromatic compounds become nucleophilic in the reaction after activation by reduction. Thus, a set of C-4 functionalised pyridines can be mono or doubly methylated at the C-3/5 positions., Electron poor pyridines can be activated by reduction and then methylated at C3/5 using formaldehyde.

The aim of this systematic review was to evaluate the surgical, radiological, and functional outcomes of posterior-only versus combined anterior-posterior approaches in patients with traumatic thoracolumbar burst fractures. The ideal approach (anterior-only, posterior-only, or combined anterior-posterior) for the surgical management of thoracolumbar burst fracture remains controversial, with each approach having its advantages and disadvantages. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed (registration no., CRD42018115120). The authors reviewed comparative studies evaluating posterior-only approach compared with combined anterior-posterior approaches with respect to clinical, surgical, radiographic, and functional outcome measures. Five retrospective cohort studies were included. Postoperative neurological deterioration was not reported in either group. Operative time, estimated blood loss, and postoperative length of stay were increased among patients in the combined anterior-posterior group in one study and equivalent between groups in another study. No significant difference was observed between the two approaches with regards to long-term postoperative Cobb angle (mean difference, −0.2; 95% confidence interval, −5.2 to 4.8; p =0.936). Moreover, no significant difference in functional patient outcomes was observed in the 36item Short-Form Health Survey, Visual Analog Scale, and return-to-work rates between the two groups. The available evidence does not indicate improved clinical, radiologic (including kyphotic deformity), and functional outcomes in the combined anterior-posterior and posterior-only approaches in the management of traumatic thoracolumbar burst fractures. Further studies are required to ascertain if a subset of patients will benefit from a combined anterior-posterior approach.

Staging of upper extremity lymphedema is needed to guide surgical management, but is not standardized due to lack of accessible, quantitative, or precise measures. Here, we established an MRI-based staging system for lymphedema and validate it against existing clinical measures.Bilateral upper extremity MRI and lymphoscintigraphy were performed on 45 patients with unilateral secondary lymphedema, due to surgical intervention, who were referred to our multidisciplinary lymphedema clinic between March 2017 and October 2018. MRI short-tau inversion recovery (STIR) images were retrospectively reviewed. A grading system was established based on the cross-sectional circumferential extent of subcutaneous fluid infiltration at three locations, labeled MRI stage 0-3, and was compared to L-Dex®, ICG lymphography, volume, lymphedema quality of life (LYMQOL), International Society of Lymphology (ISL) stage, and lymphoscintigraphy. Linear weighted Cohen's kappa was calculated to compare MRI staging by two readers.STIR images on MRI revealed a predictable pattern of fluid infiltration centered on the elbow and extending along the posterior aspect of the upper arm and the ulnar side of the forearm. Patients with higher MRI stage were more likely to be in ISL stage 2 (p = 0.002) or to demonstrate dermal backflow on lymphoscintigraphy (p = 0.0002). No correlation was found between MRI stages and LYMQOL. Higher MRI stage correlated with abnormal ICG lymphography pattern (rAn MRI staging system for upper extremity lymphedema offers an improved non-invasive precision marker for lymphedema for therapeutic planning.• Diagnosis and staging of patients with secondary upper extremity lymphedema may be performed with non-contrast MRI, which is non-invasive and more readily accessible compared to lymphoscintigraphy and evaluation by lymphedema specialists. • MRI-based staging of secondary upper extremity lymphedema is highly reproducible and could be used for long-term follow-up of patients. • In patients with borderline clinical measurements, MRI can be used to identify patients with early-stage lymphedema.

Nuclear medicine is an essential tool in the delivery of high-quality medical care, going beyond simple anatomic imaging to the use of physiologic processes for both imaging and therapy. One of the first uses of nuclear medicine techniques occurred in the 1930s to demonstrate the physiology of

Introduction Breathlessness is a subjective feeling of breathing discomfort, a symptom that is common and can be chronic and distressing for the individual experiencing it. Patients with chronic respiratory disease can experience significantly worse dyspnoea than patients with end stage lung cancer. 25% of all emergency admissions in the UK require treatment for dyspnoea. Despite this burden treatment and management of dyspnoea remains variable. Method A pilot was carried out in the Merseyside region offering patients and family/careers access to a specialist community Breathlessness Management (BM) group. Patients who were under the care of a community respiratory service and highlighted as struggling with BM were offered a referral. The group was run by a respiratory physiotherapist with a specialist interest in palliative care, a respiratory counsellor and an assistant practitioner. The group ran for 5 weeks and offered educational and practical components including advanced care planning (ACP), relaxation, anxiety management and energy conservation. Results 15 patients plus family members have been through the programme. Feedback was collated for patients and family to review suitability and acceptability of the group and attendance rates were reviewed. Discussion The BM group was viewed as highly valued and informative by patients and family members suggesting the group were able to improve self-management ability of dyspnoea over a short space of time. Including family was invaluable as it gave them coping strategies on how to support the individual suffering with episodes of dyspnoea. The MDT approach of the group was key in improving dyspnoea management and future groups should ensure this approach. The inclusion of ACP sessions can help to prevent unnecessary crisis admissions if patients are moving towards end of life. Small groups were felt to be more effective, as patients could learn from each other, and felt comfortable to ask questions. This pilot demonstrated developing a specialist BM groups is feasible, effective and well-liked by patients. It’s an effective addition to respiratory services and can be delivered in community settings ensuring easy access for the target group. Follow up is required to assess the long term impact of this intervention.