Association of Computed Tomography Measures of Muscle and Adipose Tissue and Progressive Changes throughout Treatment with Clinical Endpoints in Patients with Advanced Lung Cancer Treated with Immune Checkpoint Inhibitors.

To investigate the association between skeletal muscle mass and adiposity measures with disease-free progression (DFS) and overall survival (OS) in patients with advanced lung cancer receiving immunotherapy, we retrospectively analysed 97 patients (age: 67.5 ± 10.2 years) with lung cancer who were treated with immunotherapy between March 2014 and June 2019. From computed tomography scans, we assessed the radiological measures of skeletal muscle mass, and intramuscular, subcutaneous and visceral adipose tissue at the third lumbar vertebra. Patients were divided into two groups based on specific or median values at baseline and changes throughout treatment. A total number of 96 patients (99.0%) had disease progression (median of 11.3 months) and died (median of 15.4 months) during follow-up. Increases of 10% in intramuscular adipose tissue were significantly associated with DFS (HR: 0.60, 95% CI: 0.38 to 0.95) and OS (HR: 0.60, 95% CI: 0.37 to 0.95), while increases of 10% in subcutaneous adipose tissue were associated with DFS (HR: 0.59, 95% CI: 0.36 to 0.95). These results indicate that, although muscle mass and visceral adipose tissue were not associated with DFS or OS, changes in intramuscular and subcutaneous adipose tissue can predict immunotherapy clinical outcomes in patients with advanced lung cancer.

Muscle B mode ultrasound and shear-wave elastography in idiopathic inflammatory myopathies (SWIM): criterion validation against MRI and muscle biopsy findings in an incident patient cohort.

BACKGROUND: B mode ultrasound (US) and shear wave elastography (SWE) are easily accessible imaging tools for idiopathic inflammatory myopathies (IIM) but require further validation against standard diagnostic procedures such as MRI and muscle biopsy. METHODS: In this prospective cross-sectional study we compared US findings to MRI and muscle biopsy findings in a group of 18 patients (11 F, 7 M) with active IIM (dermatomyositis 6, necrotising autoimmune myopathy 7, inclusion body myositis 4, overlap myositis 1) who had one or both procedures on the same muscle. US domains (echogenicity, fascial thickness, muscle bulk, shear wave speed and power doppler) in the deltoid and vastus lateralis were compared to MRI domains (muscle oedema, fatty infiltration/atrophy) and muscle biopsy findings (lymphocytic inflammation, myonecrosis, atrophy and fibro-fatty infiltration). A composite index score (1-4) was also used as an arbitrary indicator of overall muscle pathology in biopsies. RESULTS: Increased echogenicity correlated with the presence of fatty infiltration/atrophy on MRI (p = 0.047) in the vastus lateralis, and showed a non-significant association with muscle inflammation, myonecrosis, fibrosis and fatty infiltration/atrophy (p > 0.333) Severe echogenicity also had a non-significant association with higher composite biopsy index score in the vastus lateralis (p = 0.380). SWS and US measures of fascial thickness and muscle bulk showed poor discrimination in differentiating between pathologies on MRI or muscle biopsy. Power Doppler measures of vascularity correlated poorly with the presence of oedema on MRI, or with inflammation or fatty infiltration on biopsy. Overall, US was sensitive in detecting the presence of muscle pathology shown on MRI (67-100%) but showed poorer specificity (13-100%). Increased echogenicity showed good sensitivity when detecting muscle pathology (100%) but lacked specificity in differentiating muscle pathologies (0%). Most study participants rated US as the preferred imaging modality. CONCLUSIONS: Our findings show that US, in particular muscle echogenicity, has a high sensitivity, but low specificity, for detecting muscle pathology in IIM. Traditional visual grading scores are not IIM-specific and require further modification and validation. Future studies should continue to focus on developing a feasible scoring system, which is reliable and allows translation to clinical practice.

The Association Between Different Trajectories of Low Back Pain and Degenerative Imaging Findings in Young Adult Participants Within The Raine Study.

STUDY DESIGN: Case-control study. OBJECTIVE: Investigate the association between lumbar spine magnetic resonance imaging (MRI) findings and 5-year trajectories of low back pain (LBP) in young Australian adults. SUMMARY OF BACKGROUND DATA: The association between lumbar spine imaging findings and LBP remains unclear due to important limitations of previous research, such as a lack of clearly defined LBP phenotypes and inadequate controlling for age, which may substantially affect the association. METHODS: Seventy-eight "case" participants with a previously identified "consistent high disabling LBP" trajectory from age 17 to 22 years and 78 "control" participants from a trajectory with consistently low LBP over the same time period, matched for sex, body mass index, physical activity levels, and work physical demands, were identified from Gen2 Raine Study participants. At age 27, participants underwent a standardized lumbar MRI scan, from which 14 specific MRI phenotypes were identified. Primary analyses used unconditional logistic regression, adjusting for covariates used in the matching process, to investigate the relationship between presence of each imaging finding and being a case or control. Secondary analyses explored those relationships based on the number of spinal levels with each MRI finding. RESULTS: The odds for being a case compared with a control were higher in those with disc degeneration (Pfirrmann grade ≥ 3; OR = 3.21, 95% CI: 1.60-6.44; P = 0.001) or those with a herniation (OR = 1.90, 95% CI: 0.96-3.74; P - 0.065). We also found that the association became substantially stronger when either disc degeneration or herniation was present at two or more spinal levels (OR = 5.56, 95% CI: 1.97-15.70; P = 0.001, and OR = 5.85, 95% CI: 1.54-22.25; P = 0.009, respectively). The other investigated MRI findings were not associated with greater odds of being a case. CONCLUSION: Lumbar disc degeneration and herniation may be important contributors to disabling LBP in young adults. Further investigation of their potential prognostic and causal roles is indicated.Level of Evidence: 4.

False-negative contrast-enhanced spectral mammography: use of more than one imaging modality and application of the triple test avoids misdiagnosis.

A 50-year-old woman presented with chest tenderness. On examination, both breasts were lumpy. Bilateral mammography showed heterogeneously dense parenchyma, with possible stromal distortion laterally on the right at the 0900 position. On ultrasound (US), a corresponding 13×9×10 mm irregular hypoechoic mass with internal vascularity was noted and both breasts had a complex heterogeneous fibroglandular background pattern. US-guided core biopsy with marker clip insertion was performed with the diagnosis of a grade 2 invasive ductal carcinoma (IDC). In view of the parenchymal pattern on mammography and US, contrast-enhanced spectral mammography (CESM) was performed for local staging. Mild background enhancement was noted, but there was no enhancement at the lesion site. The patient elected to have bilateral mastectomies and sentinel node biopsies. Final histopathology showed a node negative 11 mm grade 2 oestrogen and progesterone receptor positive, IDC.

Access to reliable information about long-term prognosis influences clinical opinion on use of lifesaving intervention.

BACKGROUND: Decompressive craniectomy has been traditionally used as a lifesaving rescue treatment in severe traumatic brain injury (TBI). This study assessed whether objective information on long-term prognosis would influence healthcare workers' opinion about using decompressive craniectomy as a lifesaving procedure for patients with severe TBI. METHOD: A two-part structured interview was used to assess the participants' opinion to perform decompressive craniectomy for three patients who had very severe TBI. Their opinion was assessed before and after knowing the predicted and observed risks of an unfavourable long-term neurological outcome in various scenarios. RESULTS: Five hundred healthcare workers with a wide variety of clinical backgrounds participated. The participants were significantly more likely to recommend decompressive craniectomy for their patients than for themselves (mean difference in visual analogue scale [VAS] -1.5, 95% confidence interval -1.3 to -1.6), especially when the next of kin of the patients requested intervention. Patients' preferences were more similar to patients who had advance directives. The participants' preferences to perform the procedure for themselves and their patients both significantly reduced after knowing the predicted risks of unfavourable outcomes, and the changes in attitude were consistent across different specialties, amount of experience in caring for similar patients, religious backgrounds, and positions in the specialty of the participants. CONCLUSIONS: Access to objective information on risk of an unfavourable long-term outcome influenced healthcare workers' decision to recommend decompressive craniectomy, considered as a lifesaving procedure, for patients with very severe TBI.

Medial thigh abscess mimicking septic arthritis of the knee: a report of two cases.

BACKGROUND: Septic arthritis of the knee joint requires prompt diagnosis and treatment for optimal outcomes. Pyomyositis with abscess formation is uncommon but may present with similar symptoms in the vicinity of a joint. OBJECTIVE: This report describes two cases of medial thigh abscess initially diagnosed and treated as septic arthritis, and highlights the need to make an accurate diagnosis. CASE REPORT: Two patients presenting with knee pain secondary to pyomyositis and abscess formation in the medial thigh were investigated with aspiration and treated subsequently with knee surgery, resulting in contamination of the knee joint in one case and delayed diagnosis with significant morbidity in both. CONCLUSION: Failure to identify a soft tissue infection may lead to delayed diagnosis, misdirected treatment, and contamination of a normal joint. Diagnosis is best confirmed with thorough physical examination and specific imaging where available.

Decompressive craniectomy for severe head injury: does an outcome prediction model influence clinical decision-making?

The use of a prognostic model to aid clinician decision-making with regard to decompressive craniectomy for patients with severe neurotrauma has not been examined. Thus in this study we assessed whether an internationally validated prediction model would influence clinician decision-making about craniectomy. A two-part structured interview, given before and after knowing the predicted risks of unfavorable neurological outcomes at 6 months, was used to assess the participants' recommendations about performing decompressive craniectomy in three patients with severe traumatic brain injury. The participants rated their preferences when there was no surrogate decision maker available, when the next of kin requested surgical intervention, when the patient had an advance directive, and when the participant was the injured party. A visual analogue scale (1-10) was used to assess the strength of their opinions. A total of 50 neurosurgeons and intensive care physicians participated in this study. The participants were significantly more likely to recommend decompressive craniectomy for their patients than for themselves, especially when the next of kin of the patient demanded the procedure, and were more similar in their own preferences to patients who had advance directives. Clinicians' preferences to perform the procedure for both themselves and their patients was significantly reduced after knowing the predicted risks of unfavorable outcomes, and these changes in attitude were consistent across those with different specialties, regardless of the amount of experience caring for similar patients, or religious background. In conclusion, the predicted risks of unfavorable outcomes influenced clinician decision-making about recommending decompressive craniectomy for patients with very severe neurotrauma.