Analysis of the Accuracy of the Modified CT Severity Index in Predicting Clinical Outcomes in Acute Pancreatitis: A Cross-Sectional Study.

OBJECTIVE: To evaluate the accuracy of the modified CT severity index (MCTSI) in predicting the severity of acute pancreatitis and to prognosticate the clinical outcomes. METHODS AND MATERIALS: The study was conducted at a tertiary health center between January 2021 and June 2023. A total of 150 consecutive patients with clinical/laboratory features suggestive of acute pancreatitis were included in the study and underwent a contrast-enhanced CT scan within 24 hours of admission. Based on their MCTSI score, these patients had conservative or surgical/endoscopic treatment. Clinical outcomes were assessed in terms of recovery, development of complications, or death. The receiver operating characteristic curve and descriptive statistics were computed to determine the sensitivity and specificity. The data were analyzed using SPSS version 16 software (SPSS Inc., Chicago, IL), and an attempt was made to evaluate the accuracy of MCTSI in predicting these clinical outcomes. RESULTS: The mean age of patients in our study was 49.21 ± 11.02 years. Out of the 150 included patients, 103 were men and 47 were women. Compared to 11.68% of severe acute pancreatitis patients who died, 88.32% recovered. The area under the curve was determined as 0.865, based on which the MCTSI score predicted acute pancreatitis clinical outcome with 64% sensitivity and 92% specificity. The MCTSI demonstrated value in predicting clinical outcomes with a p-value of 0.043 ± 0.012 (p < 0.05) in the recovered patients while p = 0.032 ± 0.012 for patients who succumbed. The p-value for MCTSI in predicting complications was p = 0.0012 ± 0.0008 (p < 0.05). CONCLUSION: Our study was able to demonstrate the high level of accuracy of the MCTSI score in predicting complications and clinical outcomes, especially in patients with severe acute pancreatitis. The MCTSI serves as a valuable asset in the preliminary evaluation of acute pancreatitis, thereby facilitating appropriate management.

Epimutation detection in the clinical context: guidelines and a use case from a new Bioconductor package.

Epimutations are rare alterations of the normal DNA methylation pattern at specific loci, which can lead to rare diseases. Methylation microarrays enable genome-wide epimutation detection, but technical limitations prevent their use in clinical settings: methods applied to rare diseases' data cannot be easily incorporated to standard analyses pipelines, while epimutation methods implemented in R packages (ramr) have not been validated for rare diseases. We have developed epimutacions, a Bioconductor package (https://bioconductor.org/packages/release/bioc/html/epimutacions.html). epimutacions implements two previously reported methods and four new statistical approaches to detect epimutations, along with functions to annotate and visualize epimutations. Additionally, we have developed an user-friendly Shiny app to facilitate epimutations detection (https://github.com/isglobal-brge/epimutacionsShiny) to non-bioinformatician users. We first compared the performance of epimutacions and ramr packages using three public datasets with experimentally validated epimutations. Methods in epimutacions had a high performance at low sample sizes and outperformed methods in ramr. Second, we used two general population children cohorts (INMA and HELIX) to determine the technical and biological factors that affect epimutations detection, providing guidelines on how designing the experiments or preprocessing the data. In these cohorts, most epimutations did not correlate with detectable regional gene expression changes. Finally, we exemplified how epimutacions can be used in a clinical context. We run epimutacions in a cohort of children with autism disorder and identified novel recurrent epimutations in candidate genes for autism. Overall, we present epimutacions a new Bioconductor package for incorporating epimutations detection to rare disease diagnosis and provide guidelines for the design and data analyses.

Paediatric Common Infections Pathways: improving antimicrobial stewardship and promoting ambulation for children presenting with common infections to hospitals in the UK and Ireland.

Paediatric common infection pathways have been developed in collaboration between the BSAC and national paediatric groups, addressing the management of cellulitis, lymphadenitis/lymph node abscess, pneumonia/pleural empyema, pyelonephritis, tonsillitis/peritonsillar abscess, otitis media/mastoiditis, pre-septal/post-septal (orbital) cellulitis, and meningitis. Guidance for the management of a child presenting with a petechial/purpuric rash and the infant under 3 months of age with fever is also provided. The aim of these pathways is to support the delivery of high-quality infection management in children presenting to a hospital. The pathways focus on diagnostic approaches, including the recognition of red flags suggesting complex or severe infection requiring urgent intervention, approaches to antimicrobial stewardship (AMS) principles and guidance on safe and timely ambulation aligned with good practice of outpatient parenteral antimicrobial therapy (OPAT).

Ethnic variation in the correlation between waist to height ratio and total daily insulin requirement in children with type 1 diabetes: a cross-sectional study.

INTRODUCTION: Total daily insulin required to achieve glycaemic control in type 1 diabetes (T1D) depends on numerous factors. Correlation of insulin requirement to body mass index and waist circumference has been variably reported in the literature and that of waist-to-height ratio has not been studied. AIMS: To study the correlation between daily insulin requirement [total daily dose (TDD)] and waist-to-height ratio (WHtR) in a multiethnic population. METHODS: A cross-sectional study of children (5-18 years) with T1D attending a diabetes clinic in a multiethnic population in Bradford, UK was conducted. Physical measurements were undertaken in the clinic setting and data collected from case notes and patients/carers. RESULTS: Sixty nine patients with mean age 12.7(±3.1) yr, duration of diabetes 5.4(±3.5) yr and hemoglobin A1c (HbA1c) 80(±18)mmol/mol(9.5 ± 1.6%) were recruited. Nearly 54% (n = 37) were white and 46% were non-white (29 Asian Pakistani; 1 Indian; 2 mixed White Afro-Caribbean). The two groups had similar demographics and disease profiles. Non-whites compared with whites had a higher prevalence of obesity (15 vs 5%, p < 0.01), family history of type 2 diabetes (T2D) (49% vs. 33%), microalbuminuria (22% vs. 11%, p < 0.05) and deprivation (mean index of multiple deprivation score 42 vs. 30, p < 0.001). WHtR and TDD were poorly correlated in the whole group. There was however a significant positive correlation in Caucasians (r = 0.583, N = 37, p < 0.01) and a negative correlation in Asian Pakistanis (r = -0.472, N = 32, p < 0.01); with a significant negative correlation seen in subjects with relatives with T2D (r = -0.86, N = 6, p = 0.02). CONCLUSIONS: The variation in correlations highlights that the two ethnic groups behave differently and should therefore be studied separately with regards to factors influencing insulin requirements with careful consideration to the presence of parental IR. Further prospective studies are required to explore the reasons for these differences.

Workflow efficiency for the treatment planning process in CT-guided high-dose-rate brachytherapy for cervical cancer.

PURPOSE: To investigate process efficiency, we present a prospective investigation of the treatment planning phase of image-guided brachytherapy (BT) for cervical cancer using a specific checklist. METHODS AND MATERIALS: From October 2012 to January 2014, 76 BT procedures were consecutively performed. Prospective data on the CT-based treatment planning process was collected using a specific checklist which details the following steps: (1) dosimetry planning, (2) physician review start, (3) physician review time, (4) dosimetry processing, (5) physics review start, (6) physics review, and (7) procedural pause. Variables examined included the use of a pre-BT MRI, clinic duty conflicts, resident teaching, and the use of specific BT planners. Analysis was performed using descriptive statistics, t-test, and analysis of variance. RESULTS: Seventy-five prospectively gathered checklists comprised this analysis. The mean time for treatment planning was 95 minutes (med 94, std 18). The mean intervals in the above steps were (1) = 42, (2) = 5, (3) = 19, (4) = 10, (5) = 6, (6) = 13, and (7) = 26 minutes. There was no statistical difference in patients who had a pre-BT MRI. Resident teaching did not influence time, p = 0.17. Treatment planning time was decreased with a specific planner, p = 0.0015. CONCLUSIONS: A skillful team approach is required for treatment planning efficiency in image-guided BT. We have found that the specific BT planners can have a significant effect on the overall planning efficiency. We continue to examine clinical and workflow-related factors that will enhance our safety and workflow process with BT.

A failure modes and effects analysis study for gynecologic high-dose-rate brachytherapy.

PURPOSE: To improve the quality of our gynecologic brachytherapy practice and reduce reportable events, we performed a process analysis after the failure modes and effects analysis (FMEA). METHODS AND MATERIALS: The FMEA included a multidisciplinary team specifically targeting the tandem and ring brachytherapy procedure. The treatment process was divided into six subprocesses and failure modes (FMs). A scoring guideline was developed based on published FMEA studies and assigned through team consensus. FMs were ranked according to overall and severity scores. FM ranking >5% of the highest risk priority number (RPN) score was selected for in-depth analysis. The efficiency of each existing quality assurance to detect each FM was analyzed. RESULTS: We identified 170 FMs, and 99 were scored. RPN scores ranged from 1 to 192. Of the 13 highest-ranking FMs with RPN scores >80, half had severity scores of 8 or 9, with no mode having severity of 10. Of these FM, the originating process steps were simulation (5), treatment planning (5), treatment delivery (2), and insertion (1). Our high-ranking FM focused on communication and the potential for applicator movement. Evaluation of the efficiency and the comprehensiveness of our quality assurance program showed coverage of all but three of the top 49 FMs ranked by RPN. CONCLUSIONS: This is the first reported FMEA process for a comprehensive gynecologic brachytherapy procedure overview. We were able to identify FMs that could potentially and severely impact the patient's treatment. We continue to adjust our quality assurance program based on the results of our FMEA analysis.

Implant time and process efficiency for CT-guided high-dose-rate brachytherapy for cervical cancer.

PURPOSE: This investigation details the time and teamwork required for CT-guided tandem and ring high-dose-rate brachytherapy. METHODS AND MATERIALS: From 2010 to 2012, 217 consecutive implantations were identified on 52 patients. We gathered key workflow times: preoperative, applicator insertion, CT image, treatment planning, treatment, patient recovery, and total time in clinic. Linear fixed-effects models were used, and key workflow times were the outcome variables and factors including age, body mass index, stage, outside referral, number of implant per patient, number of implants per day, and year of implantation were examined as fixed effects. RESULTS: Of the 52 patients, 62% of the patients were Fédération Internationale de Gynécologie et d'Obstétrique Stage 2B, 88% were treated with concurrent chemotherapy, and 23% were treated at an outside facility and referred for the procedure. The mean times (minutes) for each step were as follows: preoperative evaluation, 93; insertion, 23; imaging, 45; treatment planning, 137; treatment, removal, and recovery, 115; total clinic time, 401. For the insertion time, the greater implant number per patient was significantly associated with a decreased total insertion time, with and without adjusting for other covariates, p = 0.002 and p = 0.0005, respectively. Treatment planning time was expedited with increasing number of implant per patient and comparing treatment times in 2012 with those in 2010, p = 0.01 and p < 0.0001, respectively. CONCLUSIONS: Gynecologic brachytherapy requires a skillfully coordinated and efficient team approach. Identifying critical components and the time required for each step in the process is needed to improve the safety and efficiency of brachytherapy. Continuous efforts should be made to enhance the optimal treatment delivery in high-dose-rate gynecologic brachytherapy.

Clinical outcomes among patients with head and neck cancer treated by intensity-modulated radiotherapy with and without adaptive replanning.

BACKGROUND: The purpose of this study was to determine the effect of adaptive replanning on clinical outcome among patients treated by intensity-modulated radiotherapy (IMRT) for head and neck cancer. METHODS: Three hundred seventeen patients underwent IMRT with daily image-guidance for newly diagnosed squamous cell carcinoma of the head and neck to a median dose of 66 Gy (range, 60-74 Gy). Of these 317 patients, 51 (16%) underwent adaptive radiotherapy with modification of the original IMRT midway during treatment. RESULTS: The 2-year local-regional control was 88% for patients treated with adaptive replanning compared with 79% for patients treated without (p = .01). The median time to local-regional recurrence for the 4 patients treated by adaptive radiotherapy was 7 months (range, 3-15 months) with all failures occurring within the high-dose planning target volume (PTV). CONCLUSION: Although the use of routine replanning is probably not necessary, our findings do suggest a significant benefit in appropriately selected patients.

Clinical response of pelvic and para-aortic lymphadenopathy to a radiation boost in the definitive management of locally advanced cervical cancer.

PURPOSE: Optimal treatment with radiation for metastatic lymphadenopathy in locally advanced cervical cancer remains controversial. We investigated the clinical dose response threshold for pelvic and para-aortic lymph node boost using radiographic imaging and clinical outcomes. METHODS AND MATERIALS: Between 2007 and 2011, 68 patients were treated for locally advanced cervical cancer; 40 patients had clinically involved pelvic and/or para-aortic lymph nodes. Computed tomography (CT) or 18F-labeled fluorodeoxyglucose-positron emission tomography scans obtained pre- and postchemoradiation for 18 patients were reviewed to assess therapeutic radiographic response of individual lymph nodes. External beam boost doses to involved nodes were compared to treatment response, assessed by change in size of lymph nodes by short axis and change in standard uptake value (SUV). Patterns of failure, time to recurrence, overall survival (OS), and disease-free survival (DFS) were determined. RESULTS: Sixty-four lymph nodes suspicious for metastatic involvement were identified. Radiation boost doses ranged from 0 to 15 Gy, with a mean total dose of 52.3 Gy. Pelvic lymph nodes were treated with a slightly higher dose than para-aortic lymph nodes: mean 55.3 Gy versus 51.7 Gy, respectively. There was no correlation between dose delivered and change in size of lymph nodes along the short axis. All lymph nodes underwent a decrease in SUV with a complete resolution of abnormal uptake observed in 68%. Decrease in SUV was significantly greater for lymph nodes treated with ≥54 Gy compared to those treated with <54 Gy (P=.006). Median follow-up was 18.7 months. At 2 years, OS and DFS for the entire cohort were 78% and 50%, respectively. Locoregional control at 2 years was 84%. CONCLUSIONS: A biologic response, as measured by the change in SUV for metastatic lymph nodes, was observed at a dose threshold of 54 Gy. We recommend that involved lymph nodes be treated to this minimum dose.

Atypical diabetes in children: ketosis-prone type 2 diabetes.

Ketosis-prone type 2 diabetes mellitus also known as atypical or flatbush diabetes is being increasingly recognised worldwide. These patients are typically obese, middle-aged men with a strong family history of type 2 diabetes. The aetiology and pathophysiological mechanism is still unclear but some initial research suggests that patients with ketosis-prone type 2 diabetes have a unique predisposition to glucose desensitisation. These patients have negative autoantibodies typically associated with type 1 diabetes but have shown to have human leucocyte antigen (HLA) positivity. At initial presentation, there is an impairment of both insulin secretion and action. ß Cell function and insulin sensitivity can be markedly improved by initiating aggressive diabetes management to allow for discontinuation of insulin therapy within a few months of treatment. These patients can be maintained on oral hypoglycaemic agents and insulin therapy can be safely discontinued after few months depending on their ß cell function.

Relationship between pelvic organ-at-risk dose and clinical target volume in postprostatectomy patients receiving intensity-modulated radiotherapy.

PURPOSE: To investigate dose-volume consequences of inclusion of the seminal vesicle (SV) bed in the clinical target volume (CTV) for the rectum and bladder using biological response indices in postprostatectomy patients receiving intensity-modulated radiotherapy (IMRT). METHODS AND MATERIALS: We studied 10 consecutive patients who underwent prostatectomy for prostate cancer and subsequently received adjuvant or salvage RT to the prostate fossa. The CTV to planning target volume (PTV) expansion was 7 mm, except posterior expansion, which was 5 mm. Two IMRT plans were generated for each patient, including either the prostate fossa alone or the prostate fossa with the SV bed, but identical in all other aspects. Prescription dose was 68.4 Gy in 1.8-Gy fractions prescribed to ≥95% PTV. RESULTS: With inclusion of the SV bed in the treatment volume, PTV increased and correlated with PTV-bladder and PTV-rectum volume overlap (Spearman ρ 0.91 and 0.86, respectively; p < 0.05). As a result, the dose delivered to the bladder and rectum was higher (p < 0.05): mean bladder dose increased from 11.3 ± 3.5 Gy to 21.2 ± 6.6 Gy, whereas mean rectal dose increased from 25.8 ± 5.5 Gy to 32.3 ± 5.5 Gy. Bladder and rectal equivalent uniform dose correlated with mean bladder and rectal dose. Inclusion of the SV bed in the treatment volume increased rectal normal tissue complication probability from 2.4% to 4.8% (p < 0.01). CONCLUSIONS: Inclusion of the SV bed in the CTV in postprostatectomy patients receiving IMRT increases bladder and rectal dose, as well as rectal normal tissue complication probability. The magnitude of PTV-bladder and PTV-rectal volume overlap and subsequent bladder and rectum dose increase will be higher if larger PTV expansion margins are used.

Validating the RTOG-endorsed brachial plexus contouring atlas: an evaluation of reproducibility among patients treated by intensity-modulated radiotherapy for head-and-neck cancer.

PURPOSE: To evaluate interobserver variability for contouring the brachial plexus as an organ-at-risk (OAR) and to analyze its potential dosimetric consequences in patients treated with intensity-modulated radiotherapy (IMRT) for head-and-neck cancer. METHODS AND MATERIALS: Using the Radiation Therapy Oncology Group (RTOG)-endorsed brachial plexus contouring atlas, three radiation oncologists independently delineated the OAR on treatment planning computed-tomography (CT) axial scans from 5 representative patients undergoing IMRT to a prescribed dose of 70 Gy for head-and-neck cancer. Dose-volume histograms for the brachial plexus were calculated, and interobserver differences were quantified by comparing various dosimetric statistics. Qualitative analysis was performed by visually assessing the overlapping contours on a single beam's eye view. RESULTS: Brachial plexus volumes for the 5 patients across observers were 26 cc (18-35 cc), 25 cc (21-30 cc), 29 cc (28-32 cc), 29 cc (23-38 cc), and 29 cc (23-34 cc). On qualitative analysis, minimal variability existed except at the inferolateral portion of the OAR, where slight discrepancies were noted among the physicians. Maximum doses to the brachial plexus ranged from 71.6 to 72.6 Gy, 75.2 to 75.8 Gy, 69.1 to 71.0 Gy, 76.4 to 76.9 Gy, and 70.6 to 71.4 Gy. Respective volumes receiving doses greater than 60 Gy (V60) were 8.6 to 10.9 cc, 6.2 to 8.1 cc, 8.2 to 11.6 cc, 8.3 to 10.5 cc, and 5.6 to 9.8 cc. CONCLUSION: The RTOG-endorsed brachial plexus atlas provides a consistent set of guidelines for contouring this OAR with essentially no learning curve. Adoption of these contouring guidelines in the clinical setting is encouraged.

Addition of a third field significantly increases dose to the brachial plexus for patients undergoing tangential whole-breast therapy after lumpectomy.

Our goal was to evaluate brachial plexus (BP) dose with and without the use of supraclavicular (SCL) irradiation in patients undergoing breast-conserving therapy with whole-breast radiation therapy (RT) after lumpectomy. Using the standardized Radiation Therapy Oncology Group (RTOG)-endorsed guidelines delineation, we contoured the BP for 10 postlumpectomy breast cancer patients. The radiation dose to the whole breast was 50.4 Gy using tangential fields in 1.8-Gy fractions, followed by a conedown to the operative bed using electrons (10 Gy). The prescription dose to the SCL field was 50.4 Gy, delivered to 3-cm depth. The mean BP volume was 14.5 ± 1.5 cm(3). With tangential fields alone, the median mean dose to the BP was 0.57 Gy, the median maximum dose was 1.93 Gy, and the irradiated volume of the BP receiving 40, 45, and 50 Gy was 0%. When the third (SCL field) was added, the dose to the BP was significantly increased (P = .01): the median mean dose to the BP was 40.60 Gy, and the median maximum dose was 52.22 Gy. With 3-field RT, the median irradiated volume of the BP receiving 40, 45, and 50 Gy was 83.5%, 68.5%, and 24.6%, respectively. The addition of the SCL field significantly increases dose to the BP. The possibility of increasing the risk of BP morbidity should be considered in the context of clinical decision making.

Failure mode and effect analysis for delivery of lung stereotactic body radiation therapy.

PURPOSE: To improve the quality and safety of our practice of stereotactic body radiation therapy (SBRT), we analyzed the process following the failure mode and effects analysis (FMEA) method. METHODS: The FMEA was performed by a multidisciplinary team. For each step in the SBRT delivery process, a potential failure occurrence was derived and three factors were assessed: the probability of each occurrence, the severity if the event occurs, and the probability of detection by the treatment team. A rank of 1 to 10 was assigned to each factor, and then the multiplied ranks yielded the relative risks (risk priority numbers). The failure modes with the highest risk priority numbers were then considered to implement process improvement measures. RESULTS: A total of 28 occurrences were derived, of which nine events scored with significantly high risk priority numbers. The risk priority numbers of the highest ranked events ranged from 20 to 80. These included transcription errors of the stereotactic coordinates and machine failures. CONCLUSION: Several areas of our SBRT delivery were reconsidered in terms of process improvement, and safety measures, including treatment checklists and a surgical time-out, were added for our practice of gantry-based image-guided SBRT. This study serves as a guide for other users of SBRT to perform FMEA of their own practice.

Potential of helical tomotherapy to reduce dose to the ocular structures for patients treated for unresectable sinonasal cancer.

PURPOSE: To compare intensity-modulated radiotherapy (IMRT) treatment plans generated by segmental multileaf collimator (SMLC) and helical tomotherapy (HT) techniques for patients with unresectable sinonasal cancer. METHODS AND MATERIALS: SMLC-IMRT and HT-IMRT plans for 5 patients with cancer of the paranasal sinuses and nasal cavity were independently optimized using the Eclipse treatment planning system (Varian Medial Systems, Palo Alto, CA) and Tomotherapy HI-ART treatment planning system (Tomotherapy, Inc, Madison, WI). The goal was to deliver a prescribed dose of 70 Gy to at least 95% of the planning target volume (PTV) encompassing gross tumor over 35 treatments whereas respecting constraints to organs at risk, notably the ocular structures. RESULTS: HT-IMRT reduced the maximum doses to the optic chiasm, as well as to the ipsilateral optic nerve and retina (P < 0.05, for all). Maximum doses to these structures were reduced by 10%, 16%, and 14%, respectively, using HT-IMRT compared with SMLC-IMRT. Additionally, the mean dose to the ipsilateral lacrimal gland was reduced by 32% using HT-IMRT. With respect to conformality, HT-IMRT improved dose homogeneity by decreasing "hot-spots." The mean percentage of PTV70 receiving greater than 77 Gy (110% of the prescribed dose) was 4.0% for the HT-IMRT plans compared with 17.8% for the SMLC-IMRT plans (P = 0.001). CONCLUSIONS: HT-IMRT has the potential to improve dose homogeneity to PTVs whereas reducing dose to the optic structures. Clinical implications are discussed.

Introducing new technologies into the clinic.

Introducing new technologies into radiation oncology clinical practices poses very specific logistical dilemmas. How do we determine that a new technology's dose distribution is better than the 'standard' and what are the methods that can be applied to easily compare the 'new' with the 'old'? We consider how the benchmark dose-volume histogram (DVH) can serve as a conceptual model to approach these issues. Comparing dosimetric differences using benchmark DVHs helps a 'global' comparison of the area under the curve that is intuitive, relatively efficient and easily implemented. These concepts, applied in prostate cancer in this communication, have wider applications in other disease sites and in the introduction of technologies beyond intensity-modulated radiation therapy.

Characterization of molecular disorder in vapor-deposited thin films of aluminum tris(quinoline-8-olate) by one-dimensional 27Al NMR under magic angle spinning.

Aluminum tris (quinoline-8-olate) (Alq3) is used as an electron-transport layer in organic light-emitting diodes. The material can be obtained in a wide range of different solid phases, both crystalline and amorphous, by deposition from the vapor phase or from solution under controlled conditions. While the structure of the crystalline polymorphs of Alq3 has been investigated thoroughly by x-ray diffraction as well as solid-state NMR, very little information is currently available on the amount of structural disorder in the amorphous forms of Alq3. In the present contribution, we report the use of 27Al NMR spectroscopy in the solid state under magic angle spinning to extract such information from amorphous vapor deposits of Alq3. The NMR spectra obtained from these samples exhibit different degrees of broadening, reflecting distributions of the electric-field gradient tensor at the site of the aluminum ion. These distributions can be obtained from the NMR spectra by solving the corresponding inverse problem. From these results, the magnitude of structural disorder in terms of molecular geometry has been estimated by density-functional theory calculations. It was found that the electric-field gradient anisotropy delta follows a bimodal distribution. Its majority component is centered around delta values comparable to the meridianal alpha crystal polymorph and has a width of about 10%, corresponding to distortions of the molecular geometry of a few degrees in the orientation of the ligands. Alq3 samples obtained at higher deposition rates exhibit higher degrees of disorder. The minor component, present at about 7%, has a much smaller anisotropy, suggesting that it may be due to the facial isomer of Alq3.

Myocardial injury during standard treatment of an adult with status asthmaticus.

Asthma affects 5%-10% of adults in the United States. Older adults (> 65 years) with asthma have higher rates of fatal asthma than younger adults. The occurrence of a respiratory emergency, such as status asthmaticus, would seem likely to create a situation of cardiopulmonary dysfunction conducive to myocardial ischemia. However, multiple studies of fatal or near-fatal asthma have failed to incriminate myocardial infarction as a contributing factor. We report a patient without underlying coronary artery disease who sustained myocardial injury consistent with myocardial ischemia and infarction during status asthmaticus while receiving recommended treatment without intravenous sympathomimetics or theophylline.

Fatal pseudomembranous colitis in a continent urinary neobladder.

Antibiotic-associated colitis is a significant clinical problem, especially in patients hospitalized for longer than three days. Clostridium difficile is now established as the most common nosocomial enteric pathogen causing antibiotic-associated colitis. The condition rarely occurs beyond the boundaries of the large bowel, but can represent significant diagnostic and therapeutic problems if it involves bowel that is used in the creation of a diversionary reservoir such as an ileo-cecal neobladder. We present what we believe to be the first reported case of fatal pseudomembranous colitis occurring in an ileo-cecal neobladder.