CT-derived textural analysis parameters discriminate high-attenuation renal cysts from solid renal neoplasms.

AIM: To assess the utility of textural features on computed tomography (CT) to differentiate high-attenuation cysts from solid renal neoplasms among indeterminate renal lesions detected incidentally on CT. MATERIALS AND METHODS: Patients were included if they had an indeterminate renal lesion on CT that was subsequently characterised on ultrasound or magnetic resonance imaging (MRI). Up to three lesions per patient were included if they had a size ≥10 mm and density of 20-70 HU on unenhanced CT or any single phase of contrast-enhanced CT. Cases were categorised as benign or most likely benign cysts (Bosniak II and IIF) versus indeterminate (Bosniak III), mixed solid and cystic (Bosniak IV), or solid renal lesions. A random forest model was generated using 95 textural parameters and four clinical parameters for each lesion. RESULTS: Two hundred and thirty-four patients were included who had a total of 278 lesions. Of these, 193 (69%) were benign or most likely benign cysts and 85 (31%) were indeterminate, mixed cystic and solid, or solid renal lesions. The random forest model had an area under the curve of 0.71 (95% confidence interval [CI]: 0.65, 0.78), with a sensitivity and specificity of 81.2% and 38.9%, respectively. CONCLUSION: A multivariate model including textural and clinical parameters had moderate overall performance for discriminating benign or likely benign cysts from indeterminate, mixed solid and cystic, or solid renal lesions. This study serves as a proof of concept and may reduce the need for further follow-up by characterising a significant portion of indeterminate lesions on CT as benign.

Molecular imaging for cancer immunotherapy.

Immunotherapy has changed the treatment landscape for many cancers; however, not all patients treated have a favorable response and others can develop immune-related adverse events. A method to predict the treatment response to immunotherapeutic agents could allow for improved selection of patients more likely to benefit from treatment while sparing those who would suffer serious complications. While this has been an active area of research and has resulted in significant insights, current proposed mechanisms do not fully explain responses to therapy. One problem is that our understanding relies mostly on tumor biopsy samples that do not account for the complex spatiotemporal heterogeneity of cancers and their microenvironment. Radiolabeled probes targeting immune biomarkers and imaged using positron emission tomography with computed tomography could provide in vivo, real-time and non-invasive imaging of these biomarkers. Here we review the current field of functional nuclear imaging agents in immuno-oncology including antibodies and small molecule tracers to image PD-1, PD-L1, CTLA-4, T-cell markers and other targets being studied for potential therapies.

Curvilinear, three-dimensional motion of chromatin domains and nucleoli in neuronal interphase nuclei.

The term "nuclear rotation" refers to a motion of nucleoli within interphase nuclei of several cell types. No mechanism or function has been ascribed to this phenomenon, and it was unknown whether nuclear structures in addition to nucleoli participate in this motion. Moreover, it was unclear whether nuclear rotation occurs independent of concurrent motion of juxtanuclear cytoplasm. The work reported here presents quantitative evidence, for three-dimensional intranuclear, tandem motion of fluorescently labeled chromatin domains associated with nucleoli and those remote from nucleoli. The results show that such motion is curvilinear, that it is not restricted to nucleoli, and, moreover, that it occurs independently of motion of juxtanuclear, cytoplasmic structures. These results suggest that this motion represents karyoplasmic streaming and its function is to transpose to nuclear pores those chromatin domains actively transcribed.

Gender differences in how physicians access and process information.

There is an absence of information on how physicians make surgical decisions, and on the effect of gender on the processing of information. A novel web based decision-matrix software was designed to trace experimentally the process of decision making in medical situations. The scenarios included a crisis and non-crisis simulation for endometrial cancer surgery. Gynecologic oncologists, fellows, and residents (42 male and 42 female) in Canada participated in this experiment. Overall, male physicians used more heuristics, whereas female physicians were more comprehensive in accessing clinical information (p < 0.03), utilized alternative-based acquisition processes in the non-crisis scenario (p = 0.01), were less likely to consider procedure-related costs (p = 0.04), and overall allocated more time to evaluate the information (p < 0.01). Further experiments leading to a better understanding of the cognitive processes involved in medical decision making could influence education and training and impact on patient outcome.

[Attachment process between an infant and his/her mother: the first year]. / Développement du processus d'attachement entre un bébé et sa mère.

Attachment theory is focused upon the development of the attachment process organized jointly by the child and the environmental factors which contribute to the development of the feeling of security. The authors focus on the mother-baby relationships and describe the normative process of attachment relationships during the first year of life. The ethologic perspective of this development is also summarized. The steps of the developing attachment relationship are described. The description of motherhood is focused on the bonding process, which is a more immediate and biologically based process and on caregiving which is a symmetrical motivational system as complex as the attachment one. The main factors known as having an impact on the two processes are described.

Management of single brain metastasis: a practice guideline.

QUESTIONS: Should patients with confirmed single brain metastasis undergo surgical resection? Should patients with single brain metastasis undergoing surgical resection receive adjuvant whole-brain radiation therapy (wbrt)? What is the role of stereotactic radiosurgery (srs) in the management of patients with single brain metastasis? PERSPECTIVES: Approximately 15%-30% of patients with cancer will develop cerebral metastases over the course of their disease. Patients identified as having single brain metastasis generally undergo more aggressive treatment than do those with multiple metastases; however, in the province of Ontario, management of patients with single brain metastasis varies. Given that conflicting evidence has been reported, the Neuro-oncology Disease Site Group (dsg) of the Cancer Care Ontario Program in Evidence-based Care felt that a systematic review of the evidence and a practice guideline were warranted. OUTCOMES: Outcomes of interest were survival, local control of disease, quality of life, and adverse effects. METHODOLOGY: The medline, cancerlit, embase, and Cochrane Library databases and abstracts published in the proceedings of the annual meetings of the American Society of Clinical Oncology (1997-2005) and American Society for Therapeutic Radiology and Oncology (1998-2004) were systematically searched for relevant evidence. The review included fully published reports or abstracts of randomized controlled trials (rcts), nonrandomized prospective studies, and retrospective studies. The present systematic review and practice guideline has been reviewed and approved by the Neuro-oncology dsg, which comprises medical and radiation oncologists, surgeons, neurologists, a nurse, and a patient representative. External review by Ontario practitioners was obtained through an electronic survey. Final approval of the guideline report was obtained from the Report Approval Panel and the Neuro-oncology dsg. QUALITY OF EVIDENCE: The literature search found three rcts that compared surgical resection plus wbrt with wbrt alone. In addition, a Cochrane review, including a meta-analysis of published data from those three rcts, was obtained. One rct compared surgical resection plus wbrt with surgical resection alone. One rct compared wbrt plus srs with wbrt alone. Evidence comparing srs with surgical resection or examining srs with or without wbrt was limited to prospective case series and retrospective studies. BENEFITS: Two of three rcts reported a significant survival benefit for patients who underwent surgical resection as compared with those who received wbrt alone. Pooled results of the three rcts indicated no significant difference in survival or likelihood of dying from neurologic causes; however, significant heterogeneity was detected between the trials. The rct that compared surgical resection plus wbrt with surgical resection alone reported no significant difference in overall survival or length of functional independence; however, tumour recurrence at the site of the metastasis and anywhere in the brain was less frequent in patients who received wbrt as compared with patients in the observation group. In addition, patients who received wbrt were less likely to die from neurologic causes. Results of the rct that compared wbrt plus srs with wbrt alone indicated a significant improvement in median survival in patients who received srs. No quality evidence compares the efficacy of srs with surgical resection or examines the question of whether patients who receive srs should also receive wbrt. HARMS: Pooled results of the three rcts that examined surgical resection indicated no significant difference in adverse effects between groups. Postoperative complications included respiratory problems, intracerebral hemorrhage, and infection. One rct reported no significant difference in adverse effects between patients who received wbrt plus srs and those who received wbrt alone. TARGET POPULATION: The recommendations that follow apply to adults with confirmed cancer and a single brain metastasis. This practice guideline does not apply to patients with metastatic lymphoma, small-cell lung cancer, germ-cell tumour, leukemia, or sarcoma. RECOMMENDATIONS: Surgical excision should be considered for patients with good performance status, minimal or no evidence of extracranial disease, and a surgically accessible single brain metastasis amenable to complete excision. Because treatment in cases of single brain metastasis is considered palliative, invasive local treatments must be individualized. Patients with lesions requiring emergency decompression because of intracranial hypertension were excluded from the rcts, but should be considered candidates for surgery. To reduce the risk of tumour recurrence for patients who have undergone resection of a single brain metastasis, postoperative wbrt should be considered. The optimal dose and fractionation schedule for wbrt is 3000 cGy in 10 fractions or 2000 cGy in 5 fractions. As an alternative to surgical resection, wbrt followed by srs boost should be considered for patients with single brain metastasis. The evidence is insufficient to recommend srs alone as a single-modality therapy. QUALIFYING STATEMENTS: No high-quality data are available regarding the choice of surgery versus radiosurgery for single brain metastasis. In general, the size and location of the metastasis determine the optimal approach. The standard wbrt regimen for management of patients with single brain metastasis in the United States is 3000 cGy in 10 fractions, and this treatment is usually the standard arm in randomized studies of radiation in patients with brain metastases. Based solely on evidence, the understanding that no reason exists to choose 3000 cGy in 10 fractions over 2000 cGy in 5 fractions is correct; however, fraction size is believed to be important, and therefore 300 cGy daily (3000/10) is believed to be associated with fewer long-term neurocognitive effects than 400 cGy daily (2000/5) in the occasional long-term survivor. For that reason, many radiation oncologists in Ontario prefer 3000 cGy in 10 fractions. No data exist to either support or refute that preference; therefore, finding a resolution to this issue is not currently possible. The Neuro-oncology dsg will update the recommendations as new evidence becomes available.

Patellar resurfacing in total knee replacement: a ten-year randomised prospective trial.

A series of 100 consecutive osteoarthritic patients was randomised to undergo total knee replacement using a Miller-Galante II prosthesis, with or without a cemented polyethylene patellar component. Knee function was evaluated using the American Knee Society score, Western Ontario and McMaster University Osteoarthritis index, specific patellofemoral-related questions and radiographic evaluation until the fourth post-operative year, then via questionnaire until ten years post-operatively. A ten-point difference in the American Knee Society score between the two groups was considered a significant change in knee performance, with alpha and beta levels of 0.05. The mean age of the patients in the resurfaced group was 71 years (53 to 88) and in the non-resurfaced group was 73 years (54 to 86). After ten years 22 patients had died, seven were suffering from dementia, three declined further participation and ten were lost to follow-up. Two patients in the non-resurfaced group subsequently had their patellae resurfaced. In the resurfaced group one patient had an arthroscopic lateral release. There was no significant difference between the two treatment groups: both had a similar deterioration of scores with time, and no further patellofemoral complications were observed in either group. We are unable to recommend routine patellar resurfacing in osteoarthritic patients undergoing total knee replacement on the basis of our findings.

Preoperative and postoperative levels of interleukin-6 in patients with acute appendicitis: comparison between open and laparoscopic appendectomy.

BACKGROUND: Cytokine interleukin-6 (IL-6) is an early marker of systemic inflammatory response and tissue damage. This study aimed to evaluate the levels of IL-6 after open and laparoscopic appendectomy to compare the degree of surgical stress associated with these procedures. METHODS: The levels of IL-6 were measured pre- and postoperatively in the plasma of 37 consecutive patients with a diagnosis of acute appendicitis. After preoperative randomization, 22 patients underwent open appendectomy, and 15 patients underwent laparoscopic appendectomy. RESULTS: The preoperative concentrations of IL-6 were 7.2 +/- 5.6 pg/ml in the open appendectomy group, as compared with 12.1 +/- 9.7 pg/ml in the laparoscopic appendectomy group (p < 0.05). The postoperative levels were 16.9 +/- 15.7 and 23.2 +/- 19.4 pg/ml, respectively. The mean postoperative to preoperative ratio of IL-6 was slightly higher for open (2.7 +/- 2.4) than for laparoscopic (2.3 +/- 1.6) appendectomy, but the difference did not reach statistical significance. CONCLUSION: The operative stress in open as compared with laparoscopic appendectomy is not reflected by circulating levels of IL-6.

A ten-year assessment of methicillin-associated side effects.

The exact incidence and importance of side effects associated with methicillin therapy in children is unknown. During the ten-year period from 1964 to 1974 approximately 3,000 Houston children who received methicillin were observed for side effects. The great majority of these patients received the drug for less than ten days; however, side effects were more common in patients receiving long-term therapy. In order to assess these side effects, experiences with 124 children who received methicillin for ten days or longer were reviewed in depth. The average dose of methicillin was 200 mg/kg/day and the average duration was 22 days. In this highly selected group there were no adverse side effects in 54.8% and only eosinophilia in an additional 13%. Leukopenia occurred in 16%, microscopic hematuria in 8%, gross hematuria in 4%, skin rash in 6%, and "drug fever" in 6%. In many instances several of these side effects occurred within a single patient so that the total number of patients with definite side effects was 39 of 124 (31.5%). The true incidence figure of overall side effects is much lower than 31.5%. Corrected incidence rates based on a conservative figure of 3,000 methicillin-treated children are less than 1.5% for all side effects. In some patients the mechanism producing the adverse reactions seemed to be chemical irritation or toxicity and in others hypersensitivity. In nine of the 39 patients follow-up studies were not optimal. In the other 30 patients all side effects were reversible.

Schwannoma associated with anomalous division of the median nerve: case report.

The authors present a case of a schwannoma associated with high division of the median nerve in a patient who had previously had a diagnosis of a ganglion. The case is presented and the literature concerning these 2 conditions is reviewed.

Multiple peripheral aneurysms of the posterior inferior cerebellar artery associated with a cerebellar arteriovenous malformation: case report.

The authors describe a rare case of multiple peripheral aneurysms of the posterior inferior cerebellar artery found in association with a midline cerebellar arteriovenous malformation. Successful trapping of the aneurysms and excision of the arteriovenous malformation was accomplished with an excellent clinical result. The literature concerning aneurysms of the posterior inferior cerebellar artery, cerebellar arteriovenous malformations, and combined intracranial vascular abnormalities is discussed.

A comparison of plain and fluoroscopically guided radiographs in the assessment of arthroplasty of the knee.

A cadaver model was used to compare the sensitivity of fluoroscopically guided radiographs with that of plain radiographs in revealing lucent lines beneath the tibial component of an uncemented total knee arthroplasty and subsidence of the component. Fluoroscopically guided radiographs allowed accurate measurement of a lucent line that was one millimeter wide. Plain radiographs were inadequate for the detection and measurement of these lucent lines, leading to inaccuracy. Fluoroscopically guided radiographs also allowed measurement of the distance between the tibial component and radiopaque markers in the proximal part of the tibial metaphysis that was reproducible to within one-half millimeter. Plain radiographs did not provide a reproducible measurement of this distance. The relatively simple technique of fluoroscopically guided radiography is recommended to detect the presence and progression of radiolucent lines and the subsidence of uncemented tibial components after total knee arthroplasty.

Diagnosis and treatment of respiratory symptoms of initially unsuspected gastroesophageal reflux in infants.

Gastroesophageal reflux (GER) in infants is most commonly thought of as repeated excessive vomiting and failure to thrive, with most infants responding favorably to medical therapy. However, GER may also manifest exclusively with a variety of respiratory symptoms that, if not detected and treated early, may lead to life-threatening complications. During the period of 1987 to 1992, 39 neonates and infants underwent Nissen fundoplication for the treatment of respiratory symptoms attributed to GER. Symptoms included apnea and bradycardia (64%), pneumonia (31%), cyanosis (28%), cough (18%), and stridor (15%). Most patients were ascribed at least one incorrect diagnosis to explain respiratory symptoms. These include apnea of prematurity (38%), bronchopulmonary dysplasia (31%), asthma (8%), and subglottic stenosis (8%). All patients underwent a variety of investigations and medical treatments without noticeable clinical improvement. These included bronchoscopy, esophagoscopy, and polysomnograms. Treatment such as antibiotics, theophylline, bronchodilators, steroids, and oxygen were directed at presumed primary respiratory disease. On the other hand, H2 blockers, metoclopramide, positioning, and thickened feeds were prescribed to treat GER without objective evidence of disease. Ultimately, GER was demonstrated by upper gastrointestinal series in 64%, pH probe in 61%, and both studies in 38%. All patients underwent Nissen fundoplication after failed attempts at medical therapy. A total of 95% of patients had resolution or substantial improvement of respiratory symptoms postoperatively. Preoperative hospitalization averaged 37.0 days, and postoperative stay averaged only 14.2 days. We present a series of patients with GER, all of whom presented with respiratory symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Focal gastrointestinal perforations not associated with necrotizing enterocolitis in very low birth weight neonates.

Nine very low birth weight (VLBW) neonates (< 1,000 g) undergoing abdominal exploration for peritonitis were found to have focal perforations of the gastrointestinal (GI) tract and no clinical or histologic evidence of necrotizing enterocolitis (NEC) or other mechanical cause. Although most patients presented initially with clinical findings suggestive of NEC, none developed the traditional clinical or radiographic findings associated with this diagnosis. Most patients initially had normal bowel gas patterns or transient bowel distension on abdominal x-ray, followed within hours by a paucity of bowel gas or a totally gasless abdomen. Paracentesis was positive in 7 patients. A blue, purplish, or dusky discoloration of the abdomen was described in 7 patients prior to surgery. Surgery was performed at an average age of 16.7 days. In all, the bowel appeared grossly normal with the exception of a 0.3- to 1-cm focal perforation of the small intestine or colon. One patient had an additional similar perforation of the stomach. Treatment in most was simple exteriorization of the perforation. The one gastric perforation was oversewn. Biopsy specimens at the site of perforation from 4 patients were described as having focal necrosis without intrinsic bowel disease. Two were noted to have Candida invading the bowel wall. Unlike the typical bowel flora found on culture in infants with perforations due to NEC, these patients had cultures and histological specimens positive for Candida and/or Staphylococcus epidermidis. We conclude that focal GI perforations occurring in the VLBW infant represent a clinically distinct phenomenon and that the traditionally accepted diagnostic criteria for bowel perforation due to NEC are unreliable in this condition.(ABSTRACT TRUNCATED AT 250 WORDS)

The incidence of mucogingival defects: report of case.

The term true mucogingival defects has been used to denote a complete absence of attached gingiva. This study attempted to establish how often true mucogingival defects occur in a random population sample. Of the 1,302 teeth studied, 13 teeth (1%) had a mucogingival defect, indicating that the true mucogingival defect is not a common occurrence.

Duodenal hematoma. A mechanical cause for enterogastric reflux in cholescintigraphy.

Enterogastric reflux occurs in normal and abnormal conditions. When pronounced, it is a nonspecific indicator of pathology. There are relatively few published reports discussing enterogastric reflux as a prominent finding on cholescintigraphy. A unique case of pronounced enterogastric reflux from an obstructing duodenal hematoma is presented.

Buccal separators for relief of TMJ pain and symptoms.

A case report and extended discussion of a simple technique that is effective in relieving TMJ symptoms in some cases. The many questions raised by the clinical response to insertion of separators between some buccal teeth demonstrate the complexity of TMJ problems and the limitations of present understanding.

Re-irradiation with radiosurgery for recurrent glioblastoma multiforme.

Local tumor control remains a significant challenge in patients with glioblastoma multiforme (GBM). Despite aggressive radiation therapy approaches, most recurrences are within the high-dose field, limiting the ability to safely re-irradiate recurrence using conventional techniques. Fractionated stereotactic radiosurgery (fSRS) is a technique whose properties make it useful for re-irradiation. We retrospectively reviewed the charts of 14 patients with recurrent GBM treated with salvage radiosurgery. Seven patients were male and seven were female with a median age of 58 (range: 39-76). All patients had prior cranial radiation therapy to a median dose of 60 Gy (58-69). There were 18 lesions treated with a median tumor volume of 6.97 cm3 (0.54-50.0 cm3). fSRS was delivered in 1-3 fractions to a median dose of 24 Gy (18-30 Gy). Median follow-up for the cohort was 8 months (3-22 months). On follow-up MRI, 8 of 18 lesions had a radiographic response. The median time-to-progression following primary irradiation was 8 months (1-28 months) while the median time-to-progression (TTP) following fSRS was 5 months (1-16 months). Median local control following re-irradiation was 5 months and actuarial local control was 21% at 1-year. Overall survival following primary irradiation was 79% at 12 months and 46% at 2 years. Overall survival following re-irradiation was 79% at 6 months and 30% at 1 year. No significant treatment-related toxicity was seen in follow-up. These results indicate that re-irradiation for recurrent GBM using fSRS is well-tolerated and can offer a benefit in terms of progression-free survival (PFS).