Evaluation of acute cervical spine imaging based on ACR Appropriateness Criteria®.

The objectives of this study were to determine the rate of acute blunt cervical spine injury at an academic urban level 1 trauma center and to evaluate the utilization of cervical spine imaging based on the established American College of Radiology (ACR) Appropriateness Criteria®. We retrospectively reviewed all radiography and CT imaging of the cervical spine performed over a year period in adult patients presenting with acute blunt cervical spine trauma. Exclusion criteria were children ≤17 years, non-acute trauma of ≥72 h, and penetrating trauma. Any fracture, dislocation, or ligamentous instability demonstrated by diagnostic imaging and requiring stabilization or specialized follow-up was defined as clinically significant cervical spine injury. A total of 1,325 cervical spine studies were reviewed in 1,245 patients; 32.7% (433/1,325) were cervical spine radiographs and 67.3% (892/1,325) were CT examinations. Approximately 1.5% (19/1,245) of the patients demonstrated clinically significant acute cervical spine injury. There were 6.4% (80/1,245) patients who received both cervical spine radiographs and CT as imaging evaluation. Based on the ACR Appropriateness Criteria®, all of the cervical spine radiographs performed (433) were determined to be "inappropriate" imaging in the setting of acute cervical spine injury.

Clinical assessment of tumor regression grade systems in gastroesophageal adenocarcinoma following neoadjuvant chemotherapy.

BACKGROUND: The standard treatment for gastroesophageal cancer is neoadjuvant chemotherapy, followed by surgery, which has been shown to increase survival compared with surgery alone. Evidence is mounting that characterization of the oncologically induced tumor regression is of prognostic importance. However, no consensus regarding the optimal system for describing tumor regression exists. Thus, this study aims to explore three validated/promising tumor regression systems with a focus on their interobserver reliability and usability. METHODS: We included 100 consecutive patients with gastroesophageal adenocarcinoma who had undergone neoadjuvant oncological treatment followed by surgery. The tumors underwent tumor regression grade (TRG) assessment according to the Standard Mandard-, Modified Mandard-, and Becker systems to assess the interobserver reliability between two consultant pathologists. The interobserver reliability was determined by both Fleiss kappa and weighted kappa metrics. Besides, a semi-quantitative usability questionary was completed and it was expanded with usability comments. RESULTS: The Fleiss kappa interobserver agreement was 0.67 [95% CI, 0.55-0.79], 0.88 [95% CI, 0.73-1.00], and 0.88 [95% CI, 0.73-1.00] for Standard Mandard-, Modified Mandard-, and the Becker systems, respectively. The weighted kappa (linear) was 0.80 [95% CI, 0.72-0.89], 0.91 [95% CI, 0.84-0.98], and 0.91 [95% CI, 0.84-0.98] for the Standard Mandard-, Modified Mandard-, and the Becker systems, respectively. The usability was scored on a scale of 8-24 by both raters. The systems were scored accordingly: 47 (Modified Mandard system), 43 (Becker system), and 37 (Standard Mandard system). CONCLUSION: The Modified Mandard- and Becker systems had excellent interobserver reliability and usability. However, the systems could be improved by a better characterization of the different tiers and tumor morphology.

Feasibility of superficial temporal artery as the input artery for cerebral perfusion CT.

OBJECTIVE: The purpose of this study was to determine whether the superficial temporal artery as a surrogate arterial input function, compared with the anterior cerebral artery as the arterial input function, generates accurate perfusion CT maps with significant correlates for cerebral blood flow, cerebral blood volume, and mean transit time. MATERIALS AND METHODS: One hundred perfusion CT examinations performed on 90 patients (51 women and girls, 39 men and boys) were retrospectively reviewed and postprocessed by one investigator using CT perfusion software at a workstation. Color-coded cerebral blood flow, cerebral blood volume, and mean transit time maps were constructed with the superficial temporal artery as a surrogate arterial input function and the anterior cerebral artery as the arterial input function. The effect of input artery choice on mean cerebral blood flow, cerebral blood volume, and mean transit time values in six regions of interest (one region of interest in each anterior cerebral artery, middle cerebral artery, and posterior cerebral artery territory) was assessed. RESULTS: All graphs of correlation between the anterior cerebral artery as the arterial input function and the superficial temporal artery as a surrogate arterial input function produced significant results (p < 0.0001). Excellent correlation existed between the cerebral blood flow (r = 0.96 [Pearson correlation coefficient]; rho(c) = 0.96 [concordance correlation coefficient]), cerebral blood volume (r = 0.97; rho(c) = 0.97), and mean transit time (r = 0.97; rho(c) = 0.97) values obtained with the anterior cerebral artery and the values obtained with the superficial temporal artery. Linear regression lines produced strong agreement between use of the anterior cerebral artery and use of the superficial temporal artery (cerebral blood flow, y = 1.03x + 0.65; cerebral blood volume, y = 1.05x - 0.09; mean transit time, y = 0.92x + 0.21). CONCLUSION: The preliminary results show that using an extracranial vessel such as the superficial temporal artery as a surrogate input artery can generate perfusion maps comparable with those generated with an intracranial vessel such as the anterior cerebral artery. This knowledge can be useful if the proximal intracranial vessels typically used for arterial input are not visible owing to diffuse disease, such as diffuse vasospasm and atherosclerosis, or are not included in the field of view of perfusion CT.

Autonomic dysfunction in obstructive sleep apnea is associated with impaired glucose regulation.

INTRODUCTION: Autonomic dysfunction has been theorized to be responsible for the increased risk of cardiovascular disease in obstructive sleep apnea (OSA). Previous studies did not control for the presence of impaired glucose regulation (IGR, comprising impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and diabetes) which is also associated with abnormalities in autonomic function. METHODS: Thirty-two patients were recruited for the study. Patients underwent autonomic testing consisting of heart rate response to deep breathing, valsalva maneuver, tilt-up, and quantitative sudomotor axon reflex testing. Polysomnography (PSG) and a 2-h oral glucose tolerance test were performed. Results were analyzed with logistic regression, with age, race, body mass index (BMI), and gender as covariates. RESULTS: Nineteen of 24 patients with OSA had abnormal glucose (79%, p=0.04) compared to two of nine patients without OSA. The correlation between IGR, OSA and total autonomic dysfunction was similar (p=.10 for IGR, p=0.06 for OSA). However, cardiac autonomic function was more strongly associated with IGR than OSA (p=.10 vs. 0.50). Age was a significant confounder, as glucose correlated with adrenergic autonomic dysfunction significantly when age was removed from the model (p=0.006). CONCLUSIONS: The presence of IGR may be a confounding factor in studies of autonomic function in OSA. Larger studies are needed to delineate whether OSA is directly associated with autonomic dysfunction or whether the previously described association between dysautonomia and OSA may have been due to glucose dysregulation.

[Fatal neutropenic enterocolitis in a patient with castration-resistant prostate cancer treated with first-line chemotherapy]. / Fatal neutropen enterokolitis hos en patient i kemoterapi med kastrationsresistent prostatacancer.

Neutropenic enterocolitis (NE) is a possible life-threatening complication to chemotherapy. The pathogenesis is multi-factorial with mucosal injury and impaired mucosal defence as contributing factors. Histopathological findings are heterogeneous. Clinical presentation includes neutropenia, fever and abdominal pain. Treatment is not clearly defined. We present a fatal case of NE in a patient with prostate cancer treated with first-line chemotherapy, docetaxel 75 mg/m2 every three weeks and prednisolone 5 mg × 2 daily. The post-mortem examination confirmed NE with prostate cancer cells in bowel wall.

Reliability of quantitative sudomotor axon reflex testing and quantitative sensory testing in neuropathy of impaired glucose regulation.

Reproducible neurophysiologic testing paradigms are critical for multicenter studies of neuropathy associated with impaired glucose regulation (IGR), yet the best methodologies and endpoints remain to be established. This study evaluates the reproducibility of neurophysiologic tests within a multicenter research setting. Twenty-three participants with neuropathy and IGR were recruited from two study sites. The reproducibility of quantitative sudomotor axon reflex test (QSART) and quantitative sensory test (QST) (using the CASE IV system) was determined in a subset of patients at two sessions, and it was calculated from intraclass correlation coefficients (ICCs). QST (cold detection threshold: ICC=0.80; vibration detection threshold: ICC=0.75) was more reproducible than QSART (ICC foot=0.52). The performance of multiple tests in one setting did not improve reproducibility of QST. QST reproducibility in our IGR patients was similar to reports of other studies. QSART reproducibility was significantly lower than QST. In this group of patients, the reproducibility of QSART was unacceptable for use as a secondary endpoint measure in clinical research trials.