Utility of balanced steady-state field precession sequence in the evaluation of retinal and subdural hemorrhages in patients with abusive head trauma.

Abusive head trauma is the leading cause of physical child abuse deaths in children under 5 years of age in the United States. To evaluate suspected child abuse, radiologic studies are typically the first to identify hallmark findings of abusive head trauma including intracranial hemorrhage, cerebral edema, and ischemic injury. Prompt evaluation and diagnosis are necessary as findings may change rapidly. Current imaging recommendations include brain magnetic resonance imaging with the addition of a susceptibility weighted imaging (SWI) sequence which can detect additional findings that suggest abusive head trauma including cortical venous injury and retinal hemorrhages. However, SWI is limited due to blooming artifacts and artifacts from the adjacent skull vault or retroorbital fat, which can affect the evaluation of retinal, subdural, and subarachnoid hemorrhages. This work explores the utility of the high-resolution, heavily T2 weighted balanced steady-state field precession (bSSFP) sequence to identify and characterize retinal hemorrhage and cerebral cortical venous injury in children with abusive head trauma. The bSSFP sequence provides distinct anatomical images to improve the identification of retinal hemorrhage and cortical venous injury.

New directions in the diagnosis and treatment of pulmonary embolism in pregnancy.

The diagnosis and management of pulmonary embolism in pregnancy is difficult, because diagnostic procedures and the use of anticoagulants potentially can expose mother and fetus to adverse effects. This article reviews evidence for current best practice and emerging novel techniques for the diagnosis of pulmonary embolism in pregnancy and includes clinical prediction models, biomarkers, and diagnostic imaging that may offer improvement in the diagnosis and investigation of pulmonary embolism in pregnancy in the future. The usefulness of new anticoagulant agents (fondaparinux, rivaroxaban, and dabigatran) in managing pulmonary embolism in future pregnancies is also explored.

Single-photon emission computed tomography (SPECT/CT) images of sentinel node distribution in oral cancer.

This audit describes the lymphatic flow from oral tumours seen on single-photon emission computed tomography (SPECT/CT) to help sentinel node (SN) identification. A total of 95 consecutive sentinel node biopsies (SNB) were taken between 2010 and 2019. Eligibility criteria for SNB were patients over 18 years of age with a T1-T2 oral or oropharyngeal squamous cell carcinoma and an N0 neck. SNs collect at high-frequency sites irrespective of the primary tumour (22.7% level Ib; 64.8% levels II/III; and 7.6% level IV), but with individual variation. Radiotracer activity did not influence the number of nodes identified, and metastatic deposits were found in the hottest nodes. SNs occur at the same high-frequency locations in the neck, so familiarity with anatomical detail may reduce false-negative results.

Dramatic response of metastatic cutaneous angiosarcoma to an immune checkpoint inhibitor in a patient with xeroderma pigmentosum: whole-genome sequencing aids treatment decision in end-stage disease.

"Mutational signatures" are patterns of mutations that report DNA damage and subsequent repair processes that have occurred. Whole-genome sequencing (WGS) can provide additional information to standard diagnostic techniques and can identify therapeutic targets. A 32-yr-old male with xeroderma pigmentosum developed metastatic angiosarcoma that was unresponsive to three lines of conventional sarcoma therapies. WGS was performed on his primary cancer revealing a hypermutated tumor, including clonal ultraviolet radiation-induced mutational patterns (Signature 7) and subclonal signatures of mutated DNA polymerase epsilon (POLE) (Signature 10). These signatures are associated with response to immune checkpoint blockade. Immunohistochemistry confirmed high PD-L1 expression in metastatic deposits. The anti-PD-1 monoclonal antibody pembrolizumab was commenced off-label given the POLE mutation and high mutational load. After four cycles, there was a significant reduction in his disease with almost complete resolution of the metastatic deposits. This case highlights the importance of WGS in the analysis, interpretation, and treatment of cancers. We anticipate that as WGS becomes integral to the cancer diagnostic pathway, treatments will be stratified to the individual based on their unique genomic and/or transcriptomic profile, enhancing classical approaches of histologically driven treatment decisions.

Bacteroides-associated pylephlebitis in a patient with strongyloidiasis.

Strongyloidiasis is associated with Gram-negative bacteremia. Septic portal vein thrombosis or pylephlebitis is a rare but serious complication of intra-abdominal infection, and it is often associated with Bacteroides bacteremia. We present the first report of pylephlebitis with Bacteroides bacteremia associated with underlying Strongyloides stercoralis infection and briefly review the management of septic portal vein thrombosis.

The utility of the Wells clinical prediction model and ventilation-perfusion scanning for pulmonary embolism diagnosis in pregnancy.

Pulmonary embolism is one of the leading causes of mortality in pregnancy in the Western world. No clinical prediction models have been validated in pregnancy. As a result, any pregnant woman presenting with signs possibly consistent with pulmonary embolism is investigated radiologically. This study investigates whether using clinical prediction models for pulmonary embolism in pregnancy should be pursued in future prospective trials. The aim of this study was to retrospectively evaluate the Wells clinical prediction model and ventilation-perfusion scanning for pulmonary embolism in pregnancy. A retrospective study was performed on consecutive pregnant women who presented with suspected pulmonary emboli and underwent ventilation perfusion scanning at two tertiary institutions from 2007 until 2010. The clinical pretest probability was determined as likely or unlikely by two independent clinicians retrospectively using Wells-modified criteria. Scans were determined as normal, nondiagnostic or high probability for pulmonary emboli independently by two experienced radiologists. Disagreements were resolved by a third assessor independently. In 183 pregnant women, the pretest probability was determined as 'pulmonary emboli likely' in 76 (42%) and 'pulmonary emboli unlikely' in 107 (58%) of women. Scans were of high probability in four (2%), nondiagnostic in six (3%) and normal in 173 (95%) of women. This gives the pretest probability using Wells-modified criteria a sensitivity of 100% [95% confidence interval (CI) 0.4-1.0] and a negative predictive value of 100% (95% CI 0.96-1.0). A structured clinical model such as modified Wells criteria may be useful in pregnancy, but further prospective evaluation is required.

The role of single-photon emission computed tomography/computed tomography in localizing parathyroid adenoma.

With hybrid imaging playing an increasingly important role in nuclear medicine, this article reviews the literature on single-photon emission computed tomography/computed tomography (SPECT/CT) in parathyroid scintigraphy. An understanding of parathyroid and neck anatomy is important for accurate reporting of these scans, as this can have an impact on the surgical approach used. The contribution of SPECT/CT over and above SPECT alone is greatest in terms of localization, particularly for ectopic tumours. There remains controversy on the role of SPECT/CT in eutopic tumours, especially when considering such factors as imaging time and the additional radiation dose.

Awareness and understanding of nuclear medicine among junior doctors in a district general hospital setting: an audit and personal experiences.

AIM: To discover the level of knowledge and understanding about nuclear medicine techniques among current junior doctors in a hospital setting. METHODS: A questionnaire was sent out to all Foundation Year 1 and Foundation Year 2 doctors at my institution, asking them to list as many nuclear medicine investigations (with relevant indications) as they knew. All known nuclear medicine therapies were also listed. The data from these questionnaires were analysed. The doctors were then given a lecture entitled 'Introduction to Nuclear Medicine'. The questionnaires were then sent out again 1 month later, and the data from them were re-analysed. RESULTS: Each junior doctor, before the lectures, knew a mean of 3.1 investigations and 0.8 therapies. After the lectures, they were able to list a mean of 7.5 investigations and 3.4 therapies. This difference/improvement in knowledge is statistically significant (P<0.001). DISCUSSION: Level of knowledge regarding nuclear medicine is poor among junior doctors. After appropriate education, the audit showed a highly statistically significant improvement in the level of knowledge. A lack of exposure to nuclear medicine, and its low profile in many hospitals, are the likely causes of the initial lack of awareness. It is important to rectify this, not only for improving patient management, but also for the future of the specialty itself.