The intrinsic apoptotic pathway lies upstream of reactive species production in cortical neurons and age-related oxidative stress in the brain.

A BAX- and mitochondria-dependent production of reactive oxygen species (ROS) and reactive species (reactive nitrogen species, RNS) lying downstream of these ROS occurs in apoptotic and nonapoptotic mouse sympathetic neurons and cerebellar granule cells in cell culture. These ROS have been shown to lie downstream of caspase 3 in mouse sympathetic neurons. Here we show that BAX is necessary for similar ROS production in apoptotic and nonapoptotic mouse cortical neurons in cell culture and that it also positively regulates oxidative stress in the brains of mice of different ages. Brains from mice with genetically reduced levels of mitochondrial superoxide dismutase 2 (SOD2) exhibited elevated levels of DNA strand breaks consistent with oxidative damage. Lipid peroxides were also elevated at some ages in comparison to the brains of wild type animals. BAX deletion in these mice reduced both brain DNA strand breaks and lipid peroxide levels to well below those of wild type animals. Deletion of caspase 3 greatly reduced age-augmented levels of brain oxidative stress markers including lipid peroxides, oxidized DNA, and nitrosylated proteins. These findings indicate that BAX contributes to ROS production in mouse cortical neurons, to oxidative stress their brains, and that this effect is likely mediated via caspase 3 activity.

Polyps seen but not removed during index colonoscopy: an underestimated inefficiency in endoscopy practice.

BACKGROUND AND AIMS: In the United Kingdom endoscopists are certified for independent practice once competent in the removal of polyps up to 20 mm in size. Where polyps are detected but not removed during the index colonoscopy, a repeat procedure is required. The aim of this study was to identify the proportion of polyps <20 mm that were not removed at the time of diagnosis. METHODS: Polyps identified at colonoscopy during a 12-month period in a single institution were included in this study. All polyps were categorized according to the reported size and complexity per the size, morphology, site, access (SMSA) classification. In cases where polyps ≤20 mm were not removed, patient records and endoscopy reports were interrogated to ascertain the reasons for this. RESULTS: Across 1444 patients, 2442 polyps <20 mm in size were diagnosed. Removal at the time of the index procedure occurred in 1158 patients (80.2%). Nonremoval for a predefined acceptable reason, such as concomitant anticoagulation therapy, accounted for 174 cases (12.0%). Nonremoval without contraindication was noted in 112 cases (7.8%). The mean polypectomy complexity as determined by the SMSA score of these polyps was lower than level 2, denoting low complexity. The requirement for unnecessary repeat procedures equated to 9.3 days of endoscopy capacity per year. CONCLUSIONS: This study demonstrates that a small but significant proportion of small colorectal polyps are not removed at the time of diagnosis. This practice has implications for both patients and service provision.

A Hippocratic Oath for Mathematicians? Mapping the Landscape of Ethics in Mathematics.

While the consequences of mathematically-based software, algorithms and strategies have become ever wider and better appreciated, ethical reflection on mathematics has remained primitive. We review the somewhat disconnected suggestions of commentators in recent decades with a view to piecing together a coherent approach to ethics in mathematics. Calls for a Hippocratic Oath for mathematicians are examined and it is concluded that while lessons can be learned from the medical profession, the relation of mathematicians to those affected by their work is significantly different. There is something to be learned also from the codes of conduct of cognate but professionalised quantitative disciplines such as engineering and accountancy, as well as from legal principles bearing on professional work. We conclude with recommendations that professional societies in mathematics should sponsor an (international) code of ethics, institutional mission statements for mathematicians and syllabuses of ethics courses for incorporation into mathematics degrees.

Long-term nitrogen addition does not sustain host tree stem radial growth but doubles the abundance of high-biomass ectomycorrhizal fungi.

Global change has altered nitrogen availability in boreal forest soils. As ectomycorrhizal fungi play critical ecological functions, shifts in their abundance and community composition must be considered in the response of forests to changes in nitrogen availability. Furthermore, ectomycorrhizas are symbiotic, so the response of ectomycorrhizal fungi to nitrogen cannot be understood in isolation of their plant partners. Most previous studies, however, neglect to measure the response of host trees to nitrogen addition simultaneously with that of fungal communities. In addition to being one-sided, most of these studies have also been conducted in coniferous forests. Deciduous and "dual-mycorrhizal" tree species, namely those that form ecto- and arbuscular mycorrhizas, have received little attention despite being widespread in the boreal forest. We applied nitrogen (30 kg ha-1  year-1 ) for 13 years to stands dominated by aspen (Populus tremuloides Michx.) and hypothesized that tree stem radial growth would increase, ectomycorrhizal fungal biomass would decrease, ectomycorrhizal fungal community composition would shift, and the abundance of arbuscular mycorrhizal (AM) fungi would increase. Nitrogen addition initially increased stem radial growth of aspen, but it was not sustained at the time we characterized their mycorrhizas. After 13 years, the abundance of fungi possessing extramatrical hyphae, or "high-biomass" ectomycorrhizas, doubled. No changes occurred in ectomycorrhizal and AM fungal community composition, or in ecto- and AM abundance measured as root colonization. This dual-mycorrhizal tree species did not shift away from ectomycorrhizal fungal dominance with long-term nitrogen input. The unexpected increase in high-biomass ectomycorrhizal fungi with nitrogen addition may be due to increased carbon allocation to their fungal partners by growth-limited trees. Given the focus on conifers in past studies, reconciling results of plant-mycorrhizal fungal relationships in stands of deciduous trees may demand a broader view on the impacts of nitrogen addition on the structure and function of boreal forests.

Assessing the dual-mycorrhizal status of a widespread tree species as a model for studies on stand biogeochemistry.

Viewing plant species by their mycorrhizal type has explained a range of ecosystem processes. However, mycorrhizal type is confounded with plant phylogeny and the environments in which mycorrhizal partners occur. To circumvent these confounding effects, "dual-mycorrhizal" plant species may be potential models for testing the influence of mycorrhizal type on stand biogeochemistry. To assess their use as models, duality in mycorrhizas within a single host species must be confirmed and factors underlying their variation understood. We surveyed roots, soils, and leaves of mature aspen (Populus tremuloides) across 27 stands in western Canada spanning two biomes: boreal forest and parklands. Aspen roots were mostly ectomycorrhizal with sporadic and rare occurrences of arbuscular mycorrhizas. We further tested whether a climate moisture index predicted abundance of ectomycorrhizal roots (number of ectomycorrhizal root tips m-1 root length) surveyed at two depths (0-20 cm and 20-40 cm) and found that ectomycorrhizal root abundance in subsoils (20-40 cm) was positively related to the index. We subsequently examined the relationships between ectomycorrhizal root abundance, leaf traits, and slow and fast pools of soil organic carbon and nitrogen. The ratio of leaf lignin:N, but not its components, increased along with ectomycorrhizal root abundance in subsoils. Soil carbon and nitrogen pools were independent of ectomycorrhizal root abundance. Our results suggest that (1) categorizing aspen as dual-mycorrhizal may overstate the functional importance of arbuscular mycorrhizas in this species and life stage, (2) water availability influences ectomycorrhizal root abundance, and (3) ectomycorrhizal root abundance coincides with leaf quality.

Population-level variation in host plant response to multiple microbial mutualists.

PREMISE: Multipartite mutualisms are widespread in nature, but population-level variation in these interactions is rarely quantified. In the model multipartite mutualism between legumes, arbuscular mycorrhizal (AM) fungi and rhizobia bacteria, host responses to microbial partners are expected to be synergistic because the nutrients provided by each microbe colimit plant growth, but tests of this prediction have not been done in multiple host populations. METHODS: To test whether plant response to associations with AM fungi and rhizobia varies among host populations and whether synergistic responses to microbial mutualists are common, we grew 34 Medicago truncatula populations in a factorial experiment that manipulated the presence or absence of each mutualist. RESULTS: Plant growth increased in response to each mutualist, but there were no synergistic effects. Instead, plant response to inoculation with AM fungi was an order of magnitude higher than with rhizobia. Plant response to AM fungi varied among populations, whereas responses to rhizobia were relatively uniform. There was a positive correlation between plant host response to each mutualist but no correlation between AM fungal colonization and rhizobia nodulation of plant roots. CONCLUSIONS: The greater population divergence in host response to AM fungi relative to rhizobia, weak correlation in host response to each microbial mutualist, and the absence of a correlation between measures of AM fungal and rhizobia performance suggests that each plant-microbe mutualism evolved independently among M. truncatula populations.

The mitochondria-targeted antioxidant MitoQ inhibits memory loss, neuropathology, and extends lifespan in aged 3xTg-AD mice.

Oxidative stress, likely stemming from dysfunctional mitochondria, occurs before major cognitive deficits and neuropathologies become apparent in Alzheimer's disease (AD) patients and in mouse models of the disease. We previously reported that treating 2- to 7-month-old 3xTg-AD mice with the mitochondria-targeted antioxidant MitoQ (mitoquinone mesylate: [10-(4,5-Dimethoxy-2-methyl-3,6-dioxo-1,4-cyclohexadien-1-yl)decyl](triphenyl)phosphonium methanesulfonate), a period when AD-like pathologies first manifest in them, prevents AD-like symptoms from developing. To elucidate further a role for mitochondria-derived oxidative stress in AD progression, we examined the ability of MitoQ to inhibit AD-like pathologies in these mice at an age in which cognitive and neuropathological symptoms have fully developed. 3xTg-AD female mice received MitoQ in their drinking water for five months beginning at twelve months after birth. Untreated 18-month-old 3xTg-AD mice exhibited significant learning deficits and extensive AD-like neuropathologies. MitoQ-treated mice showed improved memory retention compared to untreated 3xTg-AD mice as well as reduced brain oxidative stress, synapse loss, astrogliosis, microglial cell proliferation, Aß accumulation, caspase activation, and tau hyperphosphorylation. Additionally, MitoQ treatment significantly increased the abbreviated lifespan of the 3xTg-AD mice. These findings support a role for the involvement of mitochondria-derived oxidative stress in the etiology of AD and suggest that mitochondria-targeted antioxidants may lessen symptoms in AD patients.

An Argument Against Drug Testing Welfare Recipients.

Programs of drug testing welfare recipients are increasingly common in US states and have been considered elsewhere. Though often intensely debated, such programs are complicated to evaluate because their aims are ambiguous-aims like saving money may be in tension with aims like referring people to treatment. We assess such programs using a proportionality approach, which requires that for ethical acceptability a practice must be reasonably likely to meet its aims, sufficiently important in purpose as to outweigh harms incurred, and lower in costs than feasible alternatives. In the light of empirical findings, we argue that the programs fail the three requirements. Pursuing recreational drug users is not important in the light of costs incurred, while dependent users who may require referral are usually identifiable without testing and typically need a broader approach than one focussing on drugs. Drug testing of welfare recipients is therefore not ethically acceptable policy.

Executive summary and goals and objectives of the U.S. National Postvention Guidelines.

This preparatory article to a special issue of Death Studies on Responding to Grief, Trauma and Distress After a Suicide: U.S. National Guidelines reproduces the document's Executive Summary and Goals and Objectives.

Key concepts in the national guidelines: "Suicide exposure" and "levels of care".

This article is an extended excerpt from the document Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines, rewritten to emphasize, expand upon, and clarify two key, interrelated concepts introduced in the Guidelines. First, everyone exposed to a suicide fatality, regardless of their relationship to the deceased, may require support services to ameliorate the effects of that exposure. Second, a systemic response to suicide ought to be organized around three levels of care, designed and implemented strategically to meet people's immediate needs, their need for ongoing support, and any clinical treatment needs that arise from their exposure to the fatality.

Evidence- and practice-informed approach to implementing peer grief support after suicide systematically in the USA.

The landmark report, Responding to Grief, Trauma, and Distress After a Suicide: U.S. National Guidelines, identifies the suicide bereaved as an underserved population and recommends systematic development of peer grief support to help meet the needs of survivors of suicide loss. A widespread array of peer grief support after suicide (PGSS) services exists nationally, but only as a decentralized network of autonomous programs. Some research indicates that peer support is generally helpful to the suicide bereaved, a finding that is reinforced by a large body of emerging research showing that peer support is effective in mental illness and substance abuse recovery. The practice, study, growth, and refinement of peer support in those fields have generated viable ideas about the elements and principles of effective peer support-for individual practitioners and for programs and organizations-that could be used to guide the systematic implementation of PGSS. In addition, a comprehensive PGSS program (Tragedy Assistance Program for Survivors) that currently serves a large population-survivors of suicide in the military-could be a model for national PGSS systems development. Finally, there are several frameworks for systems development-zero suicide, consumer-operated services, recovery-oriented systems of care, and the consumer action research model-that could guide the expansion and increased effectiveness of PGSS in keeping with the Guidelines' recommendation.

Imaging oligometastatic cancer before local treatment.

With the advent of novel treatment strategies to help widen the therapeutic window for patients with oligometastatic cancer, improved biomarkers are needed to reliably define patients who can benefit from these treatments. Multimodal imaging is one such option and should be optimised to comprehensively assess metastatic sites, disease burden, and response to neoadjuvant treatment in each disease setting. These features will probably remain important prognostic biomarkers, and are crucial in planning multidisciplinary treatment. There are opportunities to extract additional phenotypic information from conventional imaging, while novel imaging techniques can also reveal specific aspects of tumour biology. Imaging can both characterise and localise the phenotypic heterogeneity of multiple tumour sites. Novel approaches to existing imaging datasets and correlation with tumour biology will be important in realising the potential of imaging to guide treatment in the oligometastatic setting. In this Personal View, we discuss the current status and future directions of imaging before treatment in patients with extracranial oligometastases.

Restaging oesophageal cancer after neoadjuvant therapy with (18)F-FDG PET-CT: identifying interval metastases and predicting incurable disease at surgery.

OBJECTIVES: It is unknown whether restaging oesophageal cancer after neoadjuvant therapy with positron emission tomography-computed tomography (PET-CT) is more sensitive than contrast-enhanced CT for disease progression. We aimed to determine this and stratify risk. METHODS: This was a retrospective study of patients staged before neoadjuvant chemotherapy (NAC) by (18)F-FDG PET-CT and restaged with CT or PET-CT in a single centre (2006-2014). RESULTS: Three hundred and eighty-three patients were restaged (103 CT, 280 PET-CT). Incurable disease was detected by CT in 3 (2.91 %) and PET-CT in 17 (6.07 %). Despite restaging unsuspected incurable disease was encountered at surgery in 34/336 patients (10.1 %). PET-CT was more sensitive than CT (p = 0.005, McNemar's test). A new classification of FDG-avid nodal stage (mN) before NAC (plus tumour FDG-avid length) predicted subsequent progression, independent of conventional nodal stage. The presence of FDG-avid nodes after NAC and an impassable tumour stratified risk of incurable disease at surgery into high (75.0 %; both risk factors), medium (22.4 %; either), and low risk (3.87 %; neither) groups (p < 0.001). Decision theory supported restaging PET-CT. CONCLUSIONS: PET-CT is more sensitive than CT for detecting interval progression; however, it is insufficient in at least higher risk patients. mN stage and response (mNR) plus primary tumour characteristics can stratify this risk simply. KEY POINTS: • Restaging (18) F-FDG-PET-CT after neoadjuvant chemotherapy identifies metastases in 6 % of patients • Restaging (18) F-FDG-PET-CT is more sensitive than CT for detecting interval progression • Despite this, at surgery 10 % of patients had unsuspected incurable disease • New concepts (FDG-avid nodal stage and response) plus tumour impassability stratify risk • Higher risk (if not all) patients may benefit from additional restaging modalities.

Mitochondria-derived reactive oxygen species mediate caspase-dependent and -independent neuronal deaths.

Mitochondrial dysfunction and oxidative stress are implicated in many neurodegenerative diseases. Mitochondria-targeted drugs that effectively decrease oxidative stress, protect mitochondrial energetics, and prevent neuronal loss may therefore lend therapeutic benefit to these currently incurable diseases. To investigate the efficacy of such drugs, we examined the effects of mitochondria-targeted antioxidants MitoQ10 and MitoE2 on neuronal death induced by neurotrophin deficiency. Our results indicate that MitoQ10 blocked apoptosis by preventing increased mitochondria-derived reactive oxygen species (ROS) and subsequent cytochrome c release, caspase activation, and mitochondrial damage in nerve growth factor (NGF)-deprived sympathetic neurons, while MitoE2 was largely ineffective. In this paradigm, the most proximal point of divergence was the ability of MitoQ10 to scavenge mitochondrial superoxide (O2(-)). MitoQ10 also prevented caspase-independent neuronal death in these cells demonstrating that the mitochondrial redox state significantly influences both apoptotic and nonapoptotic pathways leading to neuronal death. We suggest that mitochondria-targeted antioxidants may provide tools for delineating the role and significance of mitochondrial ROS in neuronal death and provide a new therapeutic approach for neurodegenerative conditions involving trophic factor deficits and multiple modes of cell death.

Cancer Precision-Prevention trial of Metformin in adults with Li Fraumeni syndrome (MILI) undergoing yearly MRI surveillance: a randomised controlled trial protocol.

BACKGROUND: Li-Fraumeni syndrome (LFS) is a rare autosomal dominant disease caused by inherited or de novo germline pathogenic variants in TP53. Individuals with LFS have a 70-100% lifetime risk of developing cancer. The current standard of care involves annual surveillance with whole-body and brain MRI (WB-MRI) and clinical review; however, there are no chemoprevention agents licensed for individuals with LFS. Preclinical studies in LFS murine models show that the anti-diabetic drug metformin is chemopreventive and, in a pilot intervention trial, short-term use of metformin was well-tolerated in adults with LFS. However, metformin's mechanism of anticancer activity in this context is unclear. METHODS: Metformin in adults with Li-Fraumeni syndrome (MILI) is a Precision-Prevention phase II open-labelled unblinded randomised clinical trial in which 224 adults aged ≥ 16 years with LFS are randomised 1:1 to oral metformin (up to 2 mg daily) plus annual MRI surveillance or annual MRI surveillance alone for up to 5 years. The primary endpoint is to compare cumulative cancer-free survival up to 5 years (60 months) from randomisation between the intervention (metformin) and control (no metformin) arms. Secondary endpoints include a comparison of cumulative tumour-free survival at 5 years, overall survival at 5 years and clinical characteristics of emerging cancers between trial arms. Safety, toxicity and acceptability of metformin; impact of metformin on quality of life; and impact of baseline lifestyle risk factors on cancer incidence will be assessed. Exploratory end-points will evaluate the mechanism of action of metformin as a cancer preventative, identify biomarkers of response or carcinogenesis and assess WB-MRI performance as a diagnostic tool for detecting cancers in participants with LFS by assessing yield and diagnostic accuracy of WB-MRI. DISCUSSION: Alongside a parallel MILI study being conducted by collaborators at the National Cancer Institute (NCI), MILI is the first prevention trial to be conducted in this high-risk group. The MILI study provides a unique opportunity to evaluate the efficacy of metformin as a chemopreventive alongside exploring its mechanism of anticancer action and the biological process of mutated P53-driven tumourigenesis. TRIAL REGISTRATION: ISRCTN16699730. Registered on 28 November 2022. URL: https://www.isrctn.com/ EudraCT/CTIS number 2022-000165-41.

Outcomes of National Survey of the Practice of Hepatocellular Carcinoma Surveillance.

Background & Aim: HCC has significantly improved outcomes when detected early. Guidelines recommend biannual surveillance with ultrasound (US) and/or AFP in at-risk individuals. This survey aimed to describe HCC surveillance adherence/practices amongst the NHS hospitals in the UK. Methods: An electronic survey was sent to 79 NHS hospitals via the British Association for the Study of the Liver distribution list. The responses were captured from July 2021 to January 2022. Centres were divided into hepato-pancreato-biliary (HPB) and non-HPB centres, depending on whether the hospital undertakes major liver surgeries. Results: A total of 39 (49.3%) centres responded: 15 HPB and 24 non-HPB centres from across the UK. HCC surveillance eligibility criteria were universally applied, but heterogeneous approaches occur outside these criteria. Eighty per cent of patients undergoing surveillance were estimated to have cirrhosis. Eighty-five per cent of centres do 6-monthly US and AFP requested by clinicians and liver clinical nurse specialists. Compliance was estimated at 80% but not routinely audited. In most centres, general sonographers and/or radiologists perform surveillance US scans without a standard reporting template, although structured reporting was viewed as desirable by the majority. Poor views on US are approached heterogeneously, with patients variably offered ongoing US, CT, or MRI with different protocols. Conclusion: Most responding NHS hospitals follow 6-monthly HCC surveillance guidance. Data recording is variable, with limited routine data collection regarding compliance, yield, and quality. Surveillance US is mostly performed by non-HPB specialists without standardised reporting. There is an inconsistent approach to poor views with US surveillance. Even in a universal healthcare system such as NHS, which is free at the point of care, delivery of HCC surveillance has not improved over the last decade and remains variable.

The mitochondria-targeted antioxidant MitoQ prevents loss of spatial memory retention and early neuropathology in a transgenic mouse model of Alzheimer's disease.

Considerable evidence suggests that mitochondrial dysfunction and oxidative stress contribute to the progression of Alzheimer's disease (AD). We examined the ability of the novel mitochondria-targeted antioxidant MitoQ (mitoquinone mesylate: [10-(4,5-dimethoxy-2-methyl-3,6-dioxo-1,4-cycloheexadienl-yl) decyl triphenylphosphonium methanesulfonate]) to prevent AD-like pathology in mouse cortical neurons in cell culture and in a triple transgenic mouse model of AD (3xTg-AD). MitoQ attenuated ß-amyloid (Aß)-induced neurotoxicity in cortical neurons and also prevented increased production of reactive species and loss of mitochondrial membrane potential (Δψ(m)) in them. To determine whether the mitochondrial protection conferred by MitoQ was sufficient to prevent the emergence of AD-like neuropathology in vivo, we treated young female 3xTg-AD mice with MitoQ for 5 months and analyzed the effect on the progression of AD-like pathologies. Our results show that MitoQ prevented cognitive decline in these mice as well as oxidative stress, Aß accumulation, astrogliosis, synaptic loss, and caspase activation in their brains. The work presented herein suggests a central role for mitochondria in neurodegeneration and provides evidence supporting the use of mitochondria-targeted therapeutics in diseases involving oxidative stress and metabolic failure, namely AD.

Modeling extreme risks in ecology.

Extreme risks in ecology are typified by circumstances in which data are sporadic or unavailable, understanding is poor, and decisions are urgently needed. Expert judgments are pervasive and disagreements among experts are commonplace. We outline approaches to evaluating extreme risks in ecology that rely on stochastic simulation, with a particular focus on methods to evaluate the likelihood of extinction and quasi-extinction of threatened species, and the likelihood of establishment and spread of invasive pests. We evaluate the importance of assumptions in these assessments and the potential of some new approaches to account for these uncertainties, including hierarchical estimation procedures and generalized extreme value distributions. We conclude by examining the treatment of consequences in extreme risk analysis in ecology and how expert judgment may better be harnessed to evaluate extreme risks.

Bax regulates production of superoxide in both apoptotic and nonapoptotic neurons: role of caspases.

A Bax- and, apparently, mitochondria-dependent increase in superoxide (O(2)(·-)) and other reactive oxygen species (ROS) occurs in apoptotic superior cervical ganglion (SCG) and cerebellar granule (CG) neurons. Here we show that Bax also lies upstream of ROS produced in nonapoptotic neurons and present evidence that caspases partially mediate the pro-oxidant effect of Bax. We used the O(2)(·-)-sensitive dye MitoSOX to monitor O(2)(·-) in neurons expressing different levels of Bax and mitochondrial superoxide dismutase (SOD2). Basal and apoptotic O(2)(·-) levels in both SCG and CG neurons were reduced in SOD2 wild-type (WT) cells having lower Bax concentrations. Apoptotic and nonapoptotic neurons from Bax-WT/SOD2-null but not Bax-null/SOD2-null mice had increased O(2)(·-) levels. A caspase inhibitor inhibited O(2)(·-) in both apoptotic and nonapoptotic SCG neurons. O(2)(·-) production increased when WT, but not Bax-null, SCG neurons were permeabilized and treated with active caspase 3. There was no apoptosis and little increase in O(2)(·-) in SCG neurons from caspase 3-null mice exposed to an apoptotic stimulus. O(2)(·-) levels in nonapoptotic caspase 3-null SCG neurons were lower than in WT cells but not as low as in caspase inhibitor-treated cells. These data indicate that Bax lies upstream of most O(2)(·-) produced in neurons, that caspase 3 is required for increased O(2)(·-) production during neuronal apoptosis, that caspase 3 is partially involved in O(2)(·-) production in nonapoptotic neurons, and that other caspases may also be involved in Bax-dependent O(2)(·-) production in nonapoptotic cells.

The clinician's response to a report of an incidental pulmonary embolism detected on multidetector CT.

BACKGROUND: The prevalence of incidental pulmonary emboli (PE) detected on contrast enhanced CT performed for other reasons is approximately 2.5%. The treatment decisions based upon the discovery of incidental PE have been less well reported. The purpose of this study was to report the clinician's response to, and consequences of, the finding of incidental PE on contrast enhanced CT. METHODS: Retrospective cohort study. Patients with incidental PE detected on a contrast enhanced CT were retrospectively identified at a single institution between 1 January 2009 and 31 December 2009. Case note review was performed to assess clinicians' responses to this finding. Patients with synchronous venous thromboembolism, unrecognised symptoms or factors preventing response assessment were excluded from this analysis. Patient and PE characteristics, treatment, and outcomes related to treatment and non-treatment were recorded. RESULTS: There were 73 patients with incidental PE: 52 were in the proximal pulmonary arteries and 21 were distal. 16 patients were excluded from the treatment analysis. 52 of 57 (91.2%) patients were treated with therapeutic anticoagulation. There were 2 (3.8%) serious adverse events related to treatment. 5 (8.8%) patients were not treated; 2 (40%) developed recurrent venous thromboembolism. Treatment of incidental PE was not significantly associated with patient age, PE risk factors or PE location. A smaller proportion of single incidental PE were treated than multiple incidental PE (p=0.047). CONCLUSION: There is morbidity associated with both treatment and non-treatment of incidental PE. However, despite the uncertainty about the natural history and clinical significance of incidental PE, the majority of patients at the authors' institution received prompt anticoagulation.