Imaging in myeloma: a Royal College of Radiologists national survey of current imaging practice.

AIMS: To evaluate current national imaging practice in myeloma with reference to National Institute for Health and Care Excellence (NICE) guidelines (NG35, 2016) and compare results with an initial survey conducted in 2017 (61 participating sites). MATERIALS AND METHODS: All UK radiology departments treating myeloma patients and with a Royal College of Radiologists (RCR) Audit Lead were invited to participate. Data were collected using an online questionnaire. Descriptive statistics were performed. RESULTS: One hundred and fourteen hospitals supplied data (54% return rate). Skeletal survey (SS) remains the most-commonly performed first-line imaging test for suspected/confirmed myeloma or plasmacytoma (39%, 45/114 hospitals), followed by whole-body magnetic resonance imaging (WBMRI) (27%, 31/114) and whole-body computed tomography (WBCT) (19%, 22/114). Integrated positron-emission tomography/CT (PET/CT) was first-line in 14% (16/114). The NICE recommended initial investigation, WBMRI, is currently offered in 27% of surveyed hospitals (<10% in 2017). Ongoing challenges to implementing WBMRI include scanner availability, financial constraints, reporting time, and radiologist training. CONCLUSION: Despite NICE recommendations regarding WBMRI in diagnosis/follow-up of myeloma, SS (poor sensitivity and specificity) remains the most commonly performed first-line test. Radiologists, haematologists, and patients should continue to emphasise the superiority and benefit of modern and more accurate imaging, such that they are prioritised in clinical service planning.

Does efavirenz replacement improve neurological function in treated HIV infection?

OBJECTIVES: The contribution of specific antiretroviral drugs to cognitive function in HIV-infected people remains poorly understood. Efavirenz (EFV) may plausibly cause cognitive impairment. The objective of this study was therefore to determine whether chronic EFV therapy is a modifier of neurocognitive and neurometabolic function in the setting of suppressive highly active antiretroviral therapy. METHODS: We performed an open-label phase IV controlled trial. Adult subjects who were stable on suppressive EFV therapy for at least 6 months were switched to ritonavir-boosted lopinavir (LPV/r) with no change in the nucleoside reverse transcriptase inhibitor (NRTI) backbone. The following parameters were assessed before and 10 weeks after therapy switch: cognitive function (by CogState® computerized battery); brain metabolites (by proton magnetic resonance spectroscopy); brain activity [by attentional processing task-based functional magnetic resonance imaging]; and sleep quantity and quality [by sleep diary, Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale]. RESULTS: Sixteen subjects completed the study. Despite most subjects (81%) self-reporting memory problems at baseline, cognitive function, brain metabolites, and brain activity showed no change at 10 weeks after switch. Sleep quality improved on switch off EFV [mean PSQI (standard deviation): EFV, 8.5 (6.5); LPV/r, 5.8 (5.5); mean difference -0.4; 95% confidence interval -6.0 to -0.7]. CONCLUSIONS: This is the first study to assess the effects of chronic EFV therapy on neurological function in a controlled setting. We conclude that EFV withdrawal is unlikely to result in significant modification of neurocognitive function in otherwise stable HIV-infected people.

Prospective assessment of MRI for imaging retroperitoneal metastases from testicular germ cell tumours.

AIM: To determine the sensitivity of magnetic resonance imaging (MRI) in the detection of retroperitoneal lymph nodes in patients with testicular germ cell tumours (TGCT). METHODS AND MATERIALS: A prospective study of 52 patients (mean age 34 years, range 18-54 years) was performed. Imaging of the retroperitoneum was performed using multidetector computed tomography (CT) and 1.5 T MRI systems. The CT and MRI images were read independently by three observers. The number, size, and site of enlarged nodes (> or =10 mm maximum short axis diameter) were recorded. Retroperitoneal nodal detection on MRI was compared to CT. RESULTS: Twenty-two (42%) of the 52 patients had no retroperitoneal disease; in remaining 30 patients 51 enlarged nodes were identified. On a per patient basis readers 1, 2, and 3 identified nodal disease in 28 of 29, 29 of 30, and 24 of 30 patients, respectively, using MRI compared to CT. Thus for experienced radiologists (readers 1 and 2) MRI is comparable to CT for nodal detection (i.e., this study excludes MRI being inferior to CT with 80% power and 5% type 1 error). CONCLUSION: MRI offers an alternative method for staging the retroperitoneum in young patients being followed for TGCT and has the major advantage of avoiding exposure to ionizing radiation.

Clinical optoacoustic imaging combined with ultrasound for coregistered functional and anatomical mapping of breast tumors.

Optoacoustic imaging, based on the differences in optical contrast of blood hemoglobin and oxyhemoglobin, is uniquely suited for the detection of breast vasculature and tumor microvasculature with the inherent capability to differentiate hypoxic from the normally oxygenated tissue. We describe technological details of the clinical ultrasound (US) system with optoacoustic (OA) imaging capabilities developed specifically for diagnostic imaging of breast cancer. The combined OA/US system provides co-registered and fused images of breast morphology based upon gray scale US with the functional parameters of total hemoglobin and blood oxygen saturation in the tumor angiogenesis related microvasculature based upon OA images. The system component that enabled clinical utility of functional OA imaging is the hand-held probe that utilizes a linear array of ultrasonic transducers sensitive within an ultrawide-band of acoustic frequencies from 0.1 MHz to 12 MHz when loaded to the high-impedance input of the low-noise analog preamplifier. The fiberoptic light delivery system integrated into a dual modality probe through a patented design allowed acquisition of OA images while minimizing typical artefacts associated with pulsed laser illumination of skin and the probe components in the US detection path. We report technical advances of the OA/US imaging system that enabled its demonstrated clinical viability. The prototype system performance was validated in well-defined tissue phantoms. Then a commercial prototype system named Imagio™ was produced and tested in a multicenter clinical trial termed PIONEER. We present examples of clinical images which demonstrate that the spatio-temporal co-registration of functional and anatomical images permit radiological assessment of the vascular pattern around tumors, microvascular density of tumors as well as the relative values of the total hemoglobin [tHb] and blood oxygen saturation [sO2] in tumors relative to adjacent normal breast tissues. The co-registration technology enables increased accuracy of radiologist assessment of malignancy by confirming, upgrading and/or downgrading US categorization of breast tumors according to Breast Imaging Reporting And Data System (BI-RADS). Microscopic histologic examinations on the biopsied tissue of the imaged tumors served as a gold standard in verifying the functional and anatomic interpretations of the OA/US image feature analysis.

Cardiopulmonary resuscitation in intensive care unit and non-intensive care unit patients. Immediate and long-term survival.

OBJECTIVE: To determine the effect of location within the hospital and preexisting electrocardiographic rhythm on the outcome of cardiopulmonary resuscitation, the cardiopulmonary resuscitation records for a 3-year period, including 668 hospitalized patients, were retrospectively reviewed. RESULTS: Resuscitation was successful in only 12 patients in the intensive care unit (3.3%) and 43 patients not in the intensive care unit (14.0%), 20 of whom were on a telemetry unit. Patients who survived to discharge had similar 1-year survival rates regardless of initial hospital location, although intensive care unit patients had the best 3-year survival rate, and there were no survivors at 3-years in the group that received cardiopulmonary resuscitation in the nonmonitored hospital bed. Survival was best with an initial cardiac rhythm of ventricular tachycardia or fibrillation, but all non-ventricular tachyarrhythmias were associated with survival. Age was not an apparent factor, while survival to hospital discharge favored whites over blacks. CONCLUSIONS: Futile resuscitative efforts are routinely performed in part because physicians and patients are unaware of outcome results and factors that influence survival. A wider recognition of the limitations of cardiopulmonary resuscitation should lead to advanced directives that reflect this awareness, with substantially more patients choosing not to have cardiopulmonary resuscitation.

Determination of nicotine and cotinine in tobacco harvesters' urine by solid-phase extraction and liquid chromatography.

A solid-phase extraction method using Drug Test-1 column containing chemically modified silica as a solid support for sample clean up and reversed phase ion-paired high-pressure liquid chromatography method have been developed for the simultaneous determination of nicotine and its metabolite cotinine from the urine samples. Mobile phase was consisted of acetate buffer (containing 0.03 M sodium acetate and 0.1 M acetic acid) pH 3.1 and acetonitrile (78:22% (v/v)) containing 0.02 M sodium octanosulfonate as an ion pair agent. pH of the mobile phase was adjusted to 3.6 with triethylamine for better resolution and to prevent peak tailing. The linearity was obtained in the range of 0.5-10 microg/ml concentrations of nicotine and cotinine standards. The correlation coefficients were 0.998 for cotinine and 0.999 for nicotine. The recoveries were obtained in the range of 79-97% with average value of 85% for nicotine and in the range of 82-98% with average value of 88% for cotinine. The limit of detection was 2 ng/ml for cotinine and 5 ng/ml for nicotine with 2 ml urine for extraction, calculated by taking signal to noise ratio 10:3. The intra-day co-efficient of variation (CV) were <4 and 7% and inter-day CV were <9 and 7% for nicotine and cotinine, respectively. The method was applied to the urine samples of tobacco harvesters, who suffer from green tobacco sickness (GTS) to check the absorption of nicotine through dermal route during the various processes of tobacco cultivation due to its good reproducibility and sensitivity.

Pulsed Doppler derived indices in predicting noninvasively, pulmonary arterial pressures.

The pulsed doppler (P.D.) signals obtained in RVOT just below the pulmonary leaflets were used to calculate acceleration time (AcT), pre-ejection period (PEP) and their ratios. These indices were correlated in 31 patients (2 1/2-49 yrs. age) having varying cardiac lesions to Pulmonary arterial pressure (P.A.P) measured during cardiac catheterisation. The mean values of AcT for those with normal PAP was 137 +/- 19.9ms, as compared to 105 +/- 37 ms in those in whom PAP greater than 20mm of Hg. (t = 3.0.p less than .01). The P value was less than 0.001 when comparison was between normal PAP and severe PH. The ratios of PEP upon AcT was 0.87 +/- 0.18 for normal PAP, as compared to 1.39 +/- 0.74 in those with PH (t = 0.31, p less than 0.01). The PEP/AcT predicted systolic PAP 35.49 PEP/AcT + 3.22 (r = 0.77, p less than 0.001). The mean PAP was best predicted by 23.94 PEP/AcT + 2.44 (r = 0.75, p less than 0.001). The quantitative assessment showed presence of presystolic 'a' wave in all with normal PAP; this was absent in all the 9 patients with severe PH (MAPA greater than 40mm of Hg.). We conclude that noninvasively obtained P.D. derived indices can help accurately to predict PAP.

Coronary arteriographic findings soon after non Q wave myocardial infarction.

We performed early coronary arteriography in 27 patients (23 males, 4 females) having non Q wave MI. Infarct related vessel (IRV) was totally blocked in 25.9%, whereas 66.7% had severe residual stenosis (greater than or equal to 70%). Left main was involved in 7.5%, and at least 2 major coronary arteries were involved in 51.8%. Visible collaterals were seen in 11%. We feel, as compared to transmural MI, where total occlusion of IRV is common, the higher incidence of subtotal occlusion of IRV with severe residual stenosis, poor collaterals and significant involvement of at least one other major coronary artery may be responsible for observation of early recurrent ischemic episodes in non Q wave MI.

Comparison of clinical outcome of fixed-dose subcutaneous low molecular weight heparin (tinzaparin) with conventional heparin in unstable angina: a pilot study.

Forty patients who were hospitalized for unstable angina were randomized to receive treatment with either regular heparin (Group I) in conventional dose as continuous infusion for 5 days or fixed-dose low molecular weight heparin (LMWH) (Group II), 3500 units subcutaneous twice daily for a period of 5 days. Both the groups were evenly matched with regard to age, sex presence of risk factors and adjunctive drug therapy. The clinical endpoints at the end of 5 day therapy were: recurrence of angina, occurrence of myocardial infarction and need for urgent revascularization. In Group I, 6 out of 20 patients had recurrence of angina, of whom 3 required urgent coronary angiography and revascularization. In Group II, 4 out of 20 patients had recurrence of angina, of whom one patient required urgent angiography and angioplasty. There were no bleeding complications in either of the groups. The recurrent anginal episodes in the conventional heparin group correlated with low aPTT values at the time of angina. Thus, this pilot study suggests that LMWH is equally effective in the treatment of unstable angina, the advantage of LMWH being the ease of administration and no need for monitoring aPTT levels during therapy.

Occupational health problems among tobacco processing workers: a preliminary study.

Occupational health problems among 100 tobacco processing workers were investigated. Symptoms, including vomiting, giddiness, headache, etc. were found among 69 exposed subjects. It was also observed that the excretion rate of nicotine and cotinine increased among exposed subjects. Biochemical parameters were found to be within the normal range. Electrocardiographic findings were non-specific and clinically there was no evidence of hypertension or ischemic heart disease. Therefore, the symptoms in tobacco processing workers might possibly result from mild nicotine toxicity.

Intervention studies against "green symptoms" among Indian tobacco harvesters.

The use of rubber gloves reduced nicotine and cotinine absorption among 29 tobacco harvesters, as evidenced by the urinary excretion rate of nicotine and cotinine. Approximately 20% (n = 6) of the subjects reported that symptoms disappeared when they used gloves, but the remaining 23 workers complained of an occasional headache even when using gloves. Wearing of boots and socks as well as gloves prevented the symptoms and significantly decreased nicotine and cotinine excretion. This suggests that nicotine is absorbed through the feet.

Changes in serum hexachlorocyclohexane (HCH) residues in malaria spraymen after short-term occupational exposure.

The use of organochlorine insecticides for public health programs is indisputably necessary in developing countries. Thus, there is a need to evaluate human response to these chemicals under local field conditions. The effects of a short-term, 16-wk exposure to hexachlorocyclohexane has been evaluated and compared in malaria spraymen with and without any previous occupational exposure to this insecticide by measuring the pre- and post-exposure serum hexachlorocyclohexane concentration. A significant increase in original serum hexachlorocyclohexane concentration. A significant increase in original serum hexachlorocyclohexane concentration was observed in subjects on their first occupational exposure (5X), compared to those with previous exposure (3X). All workers reached approximately the same serum levels within 16 wk, regardless of their history of previous exposure.

Protection against "green symptoms" from tobacco in Indian harvesters: a preliminary intervention study.

Two types of gloves were provided to 85 non-Virginia tobacco harvesters who complained of having "green symptoms." Results show that the use of gloves causes a significant reduction in nicotine absorption as reflected by the nicotine and cotinine excretion rates and also the reduction in the prevalence of "green symptoms," since contact with the leaves and leaf-sap and the abrasions of the palms was avoided by their use. It was found that the use of rubber gloves afforded protection among 93% of the subjects, while with cotton gloves the proportion was somewhat less (78.5%). Cotton gloves were more comfortable but nondurable while the rubber ones were durable but not so comfortable.

Prognostic significance of predischarge 2D-echocardiography after first transmural myocardial infarction.

Predischarge two dimensional echocardiography (2D Echo) was performed in 45 survivors of first transmural myocardial infarction to assess its value in predicting major cardiac complications (MCC) during convalescence. Wall motion score was derived for each patient by analysing endocardial motion in 11 left ventricular segments. In 18 months follow up 11 of 14 patients (78%) who had major cardiac complications had wall motion score of at least 5. Wall motion score of less than 5 was present in 29 of the 31 (94%) of patients in asymptomatic group. Non-invasively obtained wall motion score helps in risk stratification of survivors of AMI. Wall motion score at predischarge 2D Echo or more identifies high risk cases from a relatively asymptomatic group (Killip Class I & II).

Percutaneous transluminal coronary angioplasty (PTCA) in unstable angina.

We performed percutaneous transluminal coronary angioplasty in 33 highly selected patients of unstable angina, a majority of whom were initially stabilized by medical therapy. All these patients had single vessel disease with type A lesion. The initial success rate was 91% with recurrence of 17% at the end of 1 year.

Interhemispheric empyema. An unusual form of subdural empyema.

A 16 year old male was admitted with a clinical picture suggesting an intracranial pyogenic infection. He also has focal convulsions and left abducens palsy. CT scan showed a subdural empyema with interhemispheric extension. Since the patient was improving clinically, neurosurgical intervention was deferred. Spontaneous interhemispheric empyema is an uncommon condition. In our case conservative management was curative in what is considered a neurosurgical emergency.

Rectal tumour volume (GTV) delineation using T2-weighted and diffusion-weighted MRI: Implications for radiotherapy planning.

PURPOSE: To compare the rectal tumour gross target volume (GTV) delineated on T2 weighted (T2W MRI) and diffusion weighted MRI (DWI) images by two different observers and to assess if agreement is improved by DWI. MATERIAL AND METHODS: 27 consecutive patients (15 male, range 27.1-88.8 years, mean 66.9 years) underwent 1.5T MRI prior to chemoradiation (45Gy in 25 fractions; oral capecitabine 850mg/m(2)), including axial T2W MRI (TR=6600ms, TE=90ms) and DWI (TR=3000ms, TE=77ms, b=0, 100, 800s/mm(2)). 3D tumour volume (cm(3)) was measured by volume of interest (VOI) analysis by two independent readers for the T2W MRI and b800 DWI axial images, and the T2W MRI and DWI volumes compared using Mann-Whitney test. Observer agreement was assessed using Bland-Altman statistics. Significance was at 5%. RESULTS: Artefacts precluded DWI analysis in 1 patient. In the remaining 26 patients evaluated, median (range) T2W MRI MRI and DWI (b=800s/mm(2)) 3D GTVin cm(3) were 33.97 (4.44-199.8) and 31.38 (2.43-228), respectively, for Reader One and 43.78 (7.57-267.7) and 42.45 (3.68-251) for Reader Two. T2W MRI GTVs were slightly larger but not statistically different from DWI volumes: p=0.52 Reader One; p=0.92 Reader Two. Interobserver mean difference (95% limits of agreement) for T2W MRI and DWI GTVs were -9.84 (-54.96 to +35.28) cm(3) and -14.79 (-54.01 to +24.43) cm(3) respectively. CONCLUSION: Smaller DWI volumes may result from better tumour conspicuity but overall observer agreement is not improved by DWI.

Does preoperative cross-sectional imaging accurately predict main duct involvement in intraductal papillary mucinous neoplasm?

Main pancreatic duct (MPD) involvement is a well-demonstrated risk factor for malignancy in intraductal papillary mucinous neoplasm (IPMN). Preoperative radiographic determination of IPMN type is heavily relied upon in oncologic risk stratification. We hypothesized that radiographic assessment of MPD involvement in IPMN is an accurate predictor of pathological MPD involvement. Data regarding all patients undergoing resection for IPMN at a single academic institution between 1992 and 2012 were gathered prospectively. Retrospective analysis of imaging and pathologic data was undertaken. Preoperative classification of IPMN type was based on cross-sectional imaging (MRI/magnetic resonance cholangiopancreatography (MRCP) and/or CT). Three hundred sixty-two patients underwent resection for IPMN. Of these, 334 had complete data for analysis. Of 164 suspected branch duct (BD) IPMN, 34 (20.7%) demonstrated MPD involvement on final pathology. Of 170 patients with suspicion of MPD involvement, 50 (29.4%) demonstrated no MPD involvement. Of 34 patients with suspected BD-IPMN who were found to have MPD involvement on pathology, 10 (29.4%) had invasive carcinoma. Alternatively, 2/50 (4%) of the patients with suspected MPD involvement who ultimately had isolated BD-IPMN demonstrated invasive carcinoma. Preoperative radiographic IPMN type did not correlate with final pathology in 25% of the patients. In addition, risk of invasive carcinoma correlates with pathologic presence of MPD involvement.

Coal fly ash basins as an attractive nuisance to birds: parental provisioning exposes nestlings to harmful trace elements.

Birds attracted to nest around coal ash settling basins may expose their young to contaminants by provisioning them with contaminated food. Diet and tissues of Common Grackle (Quiscalus quiscala) nestlings were analyzed for trace elements to determine if nestlings were accumulating elements via dietary exposure and if feather growth limits elemental accumulation in other tissues. Arsenic, cadmium, and selenium concentrations in ash basin diets were 5× higher than reference diets. Arsenic, cadmium, and selenium concentrations were elevated in feather, liver, and carcass, but only liver Se concentrations approached levels of concern. Approximately 15% of the total body burden of Se, As, and Cd was sequestered in feathers of older (>5 days) nestlings, whereas only 1% of the total body burden of Sr was sequestered in feathers. Feather concentrations of only three elements (As, Se, and Sr) were correlated with liver concentrations, indicating their value as non-lethal indicators of exposure.