CT-like images based on T1-weighted gradient echo MRI sequences for the assessment of fractures of the hand and wrist compared to CT.

OBJECTIVE: To evaluate the performance of a 3D T1-weighted gradient-echo (3D T1GRE) computed tomography (CT)-like magnetic resonance imaging (MRI) sequence for detecting and assessing wrist and hand fractures compared to conventional CT. METHODS: Subjects with acute wrist or hand fracture in CT underwent additional 3 T MRI including a CT-like 3D T1GRE sequence and were compared to patients without fractures. Two radiologists assessed fracture morphology on both modalities according to the Arbeitsgemeinschaft Osteosynthese (AO) and graded image quality and diagnostic confidence on a 5-point Likert scale. Besides diagnostic test evaluation, differences in image quality and diagnostic confidence between CT-like MRI and CT were calculated using the Wilcoxon test. Agreement of AO classification between modalities and readers was assessed using Cohen's Kappa. RESULTS: Twenty-eight patients with 43 fractures and 43 controls were included. Image quality (3D T1GRE 1.19 ± 0.37 vs. CT 1.22 ± 0.42; p = 0.65) and diagnostic confidence (3D T1GRE 1.28 ± 0.53 vs. CT 1.28 ± 0.55; p = 1.00) were rated excellent for both modalities. Regarding the AO classification, intra- (rater 1 and rater 2, κ = 0.89; 95% CI 0.80-0.97) and interrater agreement were excellent (3D T1GRE, κ = 0.82; 95% CI, 0.70-0.93; CT, κ = 0.85; 95% CI, 0.75-0.94). CT-like MRI showed excellent sensitivity, specificity and accuracy for fracture detection (reader 1: 1.00, 0.92, 0.96; reader 2: 0.98, 0.94, 0.96). CONCLUSION: CT-like MRI is a comparable alternative to CT for assessing hand and wrist fractures, offering the advantage of avoiding radiation exposure.

Assuring the Safety of Dental Materials: The Usefulness and Application of Standards.

The formal history of standards and dentistry in the United States goes back to World War I and was prompted by the government's need to buy large quantities of dental materials to treat "an army of teeth in disrepair." This article covers the use of scientific research to establish specifications and standards used to evaluate dental materials and products, and how a practitioner can use these standards to assure the safety and performance of the materials that they use in their everyday practice.

Stenosis of the celiac trunk is associated with anastomotic leak after Ivor-Lewis esophagectomy.

Transthoracic esophagectomy with gastric tube formation is the surgical treatment of choice for esophageal cancer. The surgical reconstruction induces changes of gastric microcirculation, which are recognized as potential risk factors of anastomotic leak. This prospective observational study investigates the association of celiac trunk (TC) stenosis with postoperative anastomotic leak. One hundred fifty-four consecutive patients with esophageal cancer scheduled for Ivor-Lewis esophagectomy were included. Preoperative staging computed tomography (CT) was used to identify TC stenosis. Any narrowing of the lumen due to atherosclerotic changes was classified as stenosis. Percentage of stenotic changes was calculated using the North American Symptomatic Carotid Endarterectomy Trial formula. Multivariable analysis was used to identify possible risk factors for leak. The overall incidence of TC stenosis was 40.9%. Anastomotic leak was identified in 15 patients (9.7%). Incidence of anastomotic leak in patients with stenosis was 19.4% compared to 2.3% in patients without stenosis. Incidence of stenosis in patients with leak was 86.7% (13 of 15 patients) and significantly higher than 38.8% (54 of 139 patients) in patients without leak (P < 0.001). There was a significant difference in median degree of TC stenosis (50.0% vs 39.4%; P = 0.032) in patients with and without leak. In the multivariable model, TC stenosis was an independent risk factor for anastomotic leak (odds ratio: 5.98, 95% CI: 1.58-22.61). TC stenosis is associated with postoperative anastomotic leak after Ivor-Lewis esophagectomy. Routine assessment of TC for possible stenosis is recommended to identify patients at risk.

Degree of conversion and cross-link density within a resin-matrix composite.

The aims of this study were to profile light radiated from two light-curing units (LCUs) and evaluate profile relationship to polymerization patterns within a resin-matrix composite (RMC). Beam profiles of one multiple emission peak light-emitting-diode and one quartz-tungsten-halogen curing-unit were measured using a beam profiler/spectrometer system. A camera-based profiler and an integrating sphere/spectrometer assembly were used to evaluate each LCU beam. Polymerization patterns within a nano-hybrid RMC were investigated using a mapping approach by assessing the degree of conversion utilizing micro-Raman spectroscopy and indirectly estimating cross-link-density by repeated microhardness testing before and after exposure to ethanol (%KH reduction, n = 3). The irradiance received on the top and bottom specimen surfaces from both LCUs was measured using a MARC-RC system. The investigated beam profile area from both LCUs was non-uniform and yielded localized discrepancies in DC (55.7-74.9%) and %KH reduction (26.7-54.1%). The LCU irradiance received at the bottom of the specimens was ∼10% of the top value. This study demonstrated that LCU beam profiles were non-uniform in the area explored. Localized differences in DC and %KH reduction existed throughout the RMC specimens but did not follow a specific pattern. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1496-1504, 2018.

Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery.

This randomised, double-blind, placebo-controlled study compared the effect of perineural with intravenous dexamethasone, both administered concomitantly with interscalene brachial plexus block for shoulder surgery. Patients received 8 mg dexamethasone mixed with ropivacaine in the block injection (n = 42), 8 mg dexamethasone intravenously at the time of the block (n = 37), or intravenous saline (n = 41) at the time of the block. Perineural and intravenous dexamethasone resulted in prolonged mean (SD) duration of block to 16.9 (5.2) h and 18.2 (6.4) h, respectively, compared with 13.8 (3.8) h for saline (p = 0.001). Mean (SD) opioid consumption (morphine equivalents) during the first 24 h after postanaesthesia recovery arrival was 12.2 (9.3) mg in the perineural dexamethasone, 17.1 (15.9) mg in the intravenous dexamethasone and 24.1 (14.3) mg in the saline groups (p = 0.001). Dexamethasone via either route reduced anti-emetic use (p = 0.046). There was no effect on patient satisfaction. These results suggest that both perineural and intravenous dexamethasone are useful adjuncts to ropivacaine interscalene block, with the intravenous route preferred as this avoids the possibility of neural toxicity of dexamethasone.

[Response criteria for malignant melanoma: RECIST and irRC]. / Responsekriterien bei malignem Melanom: RECIST und irRC.

In the field of oncology the response evaluation criteria in solid tumors (RECIST) currently represent the most commonly used and validated radiological response criteria for objective treatment monitoring of conventional chemotherapy. For therapy monitoring of classical cytostatic and cytotoxic tumor therapies RECIST has been tested and successfully validated in many clinical studies. However, with the introduction of novel molecular drugs limitations of these size-based criteria became obvious due to response patterns which are not reflected by RECIST. Thus, for a comprehensive evaluation of modern immunotherapeutic agents new immune-related response criteria (irRC) were developed.This review gives a brief overview of the most important radiological response criteria RECIST 1.0 and 1.1 as well as irRC for malignant melanoma.

Automated cardiopulmonary resuscitation using a load-distributing band external cardiac support device for in-hospital cardiac arrest: a single centre experience of AutoPulse-CPR.

BACKGROUND: Poor quality cardiopulmonary resuscitation (CPR) predicts adverse outcome. During invasive cardiac procedures automated-CPR (A-CPR) may help maintain effective resuscitation. The use of A-CPR following in-hospital cardiac arrest (IHCA) remains poorly described. AIMS & METHODS: Firstly, we aimed to assess the efficiency of healthcare staff using A-CPR in a cardiac arrest scenario at baseline, following re-training and over time (Scenario-based training). Secondly, we studied our clinical experience of A-CPR at our institution over a 2-year period, with particular emphasis on the details of invasive cardiac procedures performed, problems encountered, resuscitation rates and in-hospital outcome (AutoPulse-CPR Registry). RESULTS: Scenario-based training: Forty healthcare professionals were assessed. At baseline, time-to-position device was slow (mean 59 (±24) s (range 15-96s)), with the majority (57%) unable to mode-switch. Following re-training time-to-position reduced (28 (±9) s, p<0.01 vs baseline) with 95% able to mode-switch. This improvement was maintained over time. AutoPulse-CPR Registry: 285 patients suffered IHCA, 25 received A-CPR. Survival to hospital discharge following conventional CPR was 28/260 (11%) and 7/25 (28%) following A-CPR. A-CPR supported invasive procedures in 9 patients, 2 of whom had A-CPR dependant circulation during transfer to the catheter lab. CONCLUSION: A-CPR may provide excellent haemodynamic support and facilitate simultaneous invasive cardiac procedures. A significant learning curve exists when integrating A-CPR into clinical practice. Further studies are required to better define the role and effectiveness of A-CPR following IHCA.

Current role of cardiac and extra-cardiac pathologies in clinically indicated cardiac computed tomography with emphasis on status before pulmonary vein isolation.

PURPOSE: The aim of this study was to assess the incidence of cardiac and significant extra-cardiac findings in clinical computed tomography of the heart in patients with atrial fibrillation before pulmonary vein isolation (PVI). MATERIALS AND METHODS: 224 patients (64 ±â€Š10 years; male 63 %) with atrial fibrillation were examined by cardiac 64-slice multidetector CT before PVI. Extra-cardiac findings were classified as "significant" if they were recommended to additional diagnostics or therapy, and otherwise as "non-significant". Additionally, cardiac findings were documented in detail. RESULTS: A total of 724 cardiac findings were identified in 203 patients (91 % of patients). Additionally, a total of 619 extra-cardiac findings were identified in 179 patients (80 % of patients). Among these extra-cardiac findings 196 (32 %) were "significant", and 423 (68 %) were "non-significant". In 2 patients (1 %) a previously unknown malignancy was detected (esophageal cancer and lung cancer, local stage, no metastasis). 203 additional imaging diagnostics followed to clarify the "significant" findings (124 additional CT, costs 38 314.69 US dollars). Overall, there were 3.2 cardiac and 2.8 extra-cardiac findings per patient. Extra-cardiac findings appear significantly more frequently in patients over 60 years old, in smokers and in patients with a history of cardiac findings (p <0.05). CONCLUSION: Cardiac CT scans before PVI should be screened for extracardiac incidental findings that could have important clinical implications for each patient.

Return of memory and sleep efficiency following moderate to severe closed head injury.

OBJECTIVE: Sleep disturbance is common in the subacute recovery phase following brain injury. A previous study from the authors' group found 68% of patients with closed head injury (CHI) had disrupted sleep on a rehabilitation unit. In the present study, the authors investigated whether improvement in sleep efficiency correlates with duration of posttraumatic amnesia (PTA) after CHI. METHODS: Fourteen CHI patients were enrolled and followed prospectively. Mechanism of injury included motor vehicle accident, fall, and blunt assault. An actigraph was placed on each subject's wrist within 72 hours of admission to the rehabilitation unit and recorded data for the duration of their stay. A minimum of 7 days of continuous actigraphy data was obtained on all subjects. PTA was measured daily using the Orientation Log (O-LOG). RESULTS: Seventy-eight percent of subjects had mean week-1 sleep efficiency scores of < or = 63%. Patients admitted having already cleared PTA had significantly better week-1 sleep efficiency scores than those with ongoing amnesia (P = .032). For those patients admitted with ongoing PTA, each 10-unit increase in sleep efficiency score correlated with 1 unit increase in O-LOG score (P = .056). CONCLUSIONS: Disrupted sleep is common in the postacute stage following CHI. Improved sleep efficiency correlates with resolution of PTA. Decreased sleep efficiency may negatively affect memory return after traumatic brain injury. Actigraphy is uniquely suited to study the sleep patterns of these patients.

Cost savings of patients with a MACIS score lower than 6 when radioactive iodine is not given.

OBJECTIVE: To assess the cost savings if the current policy of treating patients with a MACIS (metastases, age, completeness of resection, invasion, and size) score lower than 6 using radioactive iodine (RAI) was changed to reflect the findings of recent studies. DESIGN: Retrospective medical record review. SETTING: Mount Sinai Hospital, Toronto, Ontario. PATIENTS: Between January 1, 2002, and July 1, 2005, 199 consecutive patients with a MACIS score lower than 6 who received RAI treatment after total thyroidectomy. MAIN OUTCOME MEASURES: Patient demographics were analyzed. Costs for the dose of RAI, hospital stay, and health insurance claims were included in the calculations. RESULTS: For 199 consecutive patients, the cost for sodium iodide 131 treatment totaled Can$161 588, and the required 2-day stay in isolation totaled Can$764 558. The overall cost to the health care system was Can$934 106, which translates into approximately Can$4694 per patient. CONCLUSIONS: By following the recommendations of recent evidence-based studies and by ceasing to treat patients with a MACIS score lower than 6 after total thyroidectomy using RAI, cost savings can be accrued for health care systems involved in the treatment of thyroid cancer. Alternate strategies, such as treating patients who need RAI therapy on an outpatient basis and reducing the dose of RAI, can lower costs as well.

Impact of diabetes on haemoglobin levels in renal disease.

AIMS/HYPOTHESIS: Anaemia is a common complication of renal impairment. It has been suggested that renal failure secondary to diabetes is associated with more severe anaemia, but this has not been clearly substantiated in the published literature. To clarify this, we undertook a single centre, retrospective study to identify the impact of diabetes on anaemia associated with renal impairment. MATERIALS AND METHODS: Information on clinical, biochemical and haematological parameters of 2,052 stable ambulatory patients attending a single tertiary referral renal unit was collected. The impact of diabetic kidney disease on haemoglobin levels at all degrees of renal impairment was studied by comparison with patients with non-diabetic kidney disease after correcting for other commonly associated variables that influence anaemia in patients with renal impairment. RESULTS: Linear regression analysis showed lower haemoglobin in patients with diabetic kidney disease (p < 0.01). At chronic kidney disease (CKD) stages 3, 4 and 5, mean haemoglobin levels in patients with diabetic kidney disease compared with those in patients with non-diabetic kidney disease were 129.5 vs 136.9 g/l (p < 0.001), 120.5 vs 126.9 g/l (p < 0.001) and 107.1 vs 115.9 g/l (p < 0.01), respectively. At CKD stage 4 and 5 the two groups were comparable for ferritin, plasma intact parathyroid hormone levels, ACE inhibitor use and length of follow-up by a nephrologist. CONCLUSIONS/INTERPRETATION: Diabetic kidney disease is associated with lower haemoglobin in comparison with non-diabetic kidney disease, especially at GFR <60 ml/min.

Quality of life in patients undergoing thyroid surgery.

OBJECTIVE: The extent of thyroidectomy in the management of low-risk, well-differentiated thyroid carcinoma (WDTC) has been debated extensively. Our objective was to determine if hemithyroidectomy has a less detrimental effect on quality of life (QOL) than total thyroidectomy. DESIGN: Prospective, nonblinded, nonrandomized, cohort study. SETTING: Tertiary care academic otolaryngology-head and neck surgery practice. METHODS: Using both disease-specific and global QOL instruments, patients treated with either hemi- or total thyroidectomy were prospectively followed. QOL was assessed preoperatively and for 12 months postoperatively. MAIN OUTCOME MEASURES: Scores on the two QOL instruments throughout a 12-month postoperative period. RESULTS: Patients with cancer experienced a greater drop in QOL during the first 6 months following surgery when compared with patients with benign disease (p < .03). Additionally, patients treated with total thyroidectomy did not have a significantly different QOL than patients treated with hemithyroidectomy (p > .2). CONCLUSION: These results suggest that QOL is not significantly impacted by the extent of surgery and that QOL should not be a factor in the decision-making process for the treatment of low-risk WDTC.

An open-label study of escitalopram (Lexapro) for the treatment of 'Depression of Alzheimer's disease' (dAD).

BACKGROUND: Depression is a frequent neuropsychiatric complication of Alzheimer's Disease. METHODS: This study investigated the safety and effectiveness of escitalopram (LEXAPRO) for depression in AD (dAD) as defined by the NIMH consensus criteria in an 8-week, open-label treatment study. CONCLUSION: Escitalopram was efficacious and safe for the treatment of dAD in this study. Larger, controlled studies are warranted to further assess the efficacy for mood and behavioral disturbances in this medically fragile population.

Risk of malignancy in Filipinos with thyroid nodules--a matched pair analysis.

BACKGROUND: Ethnicity is an infrequently cited risk factor for thyroid cancer. This study aims to determine whether patients of Filipino origin assessed at a tertiary referral center are at increased risk of thyroid cancer and to quantify that risk. METHODS: This is a retrospective analysis of 72 Filipino patients with thyroid nodules undergoing thyroidectomy individually matched to 72 controls according to demographics, risk factors, and pre-referral investigations. RESULTS: Thyroid cancer was found in 50 (69.4%) Filipino patients compared with 28 (38.9%) controls. Odds ratio for malignancy in Filipinos was 3.57 (95% confidence interval, 1.79-7.12). Pathologic characteristics of thyroid cancer were not significantly different in the two groups. The median follow-up for Filipino patients was 14.1 months (range, 1.4 months-19.7 years). Recurrence occurred in four Filipino patients, and one patient with anaplastic thyroid cancer died of the disease. CONCLUSIONS: Filipino patients with thyroid nodules are at significantly increased risk of thyroid cancer compared with matched controls, and hence the index of suspicion for malignancy should be high when evaluating these patients.

Clinical course of thyroid carcinoma after neck dissection.

OBJECTIVES/HYPOTHESIS: The objective was to compare the rate and site of recurrences in patients with well-differentiated thyroid carcinoma who underwent a central compartment dissection, a posterolateral neck dissection, or a combination of both procedures. STUDY DESIGN: Retrospective chart review. METHODS: The charts of 522 consecutive patients with well-differentiated thyroid carcinoma were reviewed, and 74 patients who had undergone a neck dissection were identified. The rates of recurrence in three sites were noted: the central compartment nodes (levels VI, superior mediastinum), posterolateral compartment neck nodes (levels II-V), and distant sites. These rates were compared in patients who underwent a central compartment dissection (level VI, superior mediastinum) and in patients who underwent a posterolateral neck dissection (levels II-V). RESULTS: Six patients underwent only a central compartment dissection, 47 patients had only a posterolateral neck dissection, and 21 patients had both a central compartment and a posterolateral neck dissection. In these three groups there were zero, two, and two central compartment node recurrences; two, nine, and seven posterolateral neck recurrences; and zero, two, and three distant recurrences, respectively. There were no significant differences in the rate of recurrence in any of the three sites examined between any of the three treatment groups (Fisher's Exact test, all P values >.20). CONCLUSION: In patients with well-differentiated thyroid carcinoma, dissection of only the central or posterolateral compartments of the neck with clinical or radiographic evidence of disease is advocated.

Predictive value of serum thyroglobulin after surgery for thyroid carcinoma.

OBJECTIVE: To determine the relationship between stimulated serum thyroglobulin levels (taken 3 months after total thyroidectomy) and tumor stage and recurrence in patients with well-differentiated thyroid carcinoma. STUDY DESIGN: Retrospective chart review in a tertiary care institution. METHODS: Two hundred thirteen consecutive patients with well differentiated thyroid carcinoma treated between 1983 and 1998 were identified. Data were collected on clinicopathological variables, stimulated serum thyroglobulin levels obtained 3 months after total thyroidectomy prior to 131I therapy and recurrence. RESULTS: A high postoperative thyroglobulin level was significantly associated with advanced-stage disease at presentation (P =.005, Kruskall-Wallis) but not with any of the other clinicopathological variables. Patients with a thyroglobulin level greater than 20 pmol/L had a significantly increased risk of disease recurrence on univariate analysis (n = 213 [P =.0001, log rank test]), and in the Cox proportional-hazards model, both advanced tumor stage (P =.001, relative hazard, 3.4 [95% confidence interval [CI]: 2.4-4.9]) and a thyroglobulin level greater than 20 pmol/L (P =.001, relative hazard, 5.1 [95% CI: 2.0-13.1]) were significant predictors of recurrence. No other variables significantly altered the hazards model. CONCLUSIONS: Advanced tumor stage at diagnosis and a stimulated thyroglobulin level greater than 20 pmol/L taken 3 months after total thyroidectomy were independent predictors of disease recurrence. Patients with a thyroglobulin level greater than 20 pmol/L are at increased risk of recurrence and may be candidates for more intensive follow-up or additional treatment.