Investigation of patterns of nodal metastases in BRAF mutant lung cancer.

Axillary lymph nodes (axLN) are a rare site of nodal metastases in patients with lung cancer. BRAF mutated lung cancer is a genetically distinct subtype that occurs in 2-5% of non-small cell lung carcinomas (NSCLC). A recent study identified a highly unusual pattern of metastatic spread to axLN in patients with BRAF mutated colorectal cancer (CRC). The purpose of the study is to assess the incidence of axLN metastases in BRAF mutated NSCLC. Baseline computed tomography (CT) imaging at diagnosis and all follow up CTs of patients with BRAF mutated NSCLC treated at our institution were retrospectively reviewed by two radiologists for evidence of axLN metastases. Positron emission tomography (PET)/CT was reviewed when available. A control group of patients with non-BRAF mutated NSCLC was assessed. Three criteria were used for the diagnosis of a metastatic node; pathologic confirmation, radiologic size greater ≥1.5cm in short axis diameter or fluorodeoxyglucose avidity on PET/CT and radiologic size ≥1.0cm in short axis diameter. Forty-six patients with BRAF mutated NSCLC and CT images on the institutional PACS were identified. 7 (15%) patients with BRAF mutated NSCLC had axLN metastases using the proposed diagnostic criteria. One patient had a pathologic proven axLN metastasis, 3 had axLNs measuring ≥1.5cm in short axis, and 3 had nodes which were FDG avid on PET/CT and measured ≥1.0cm in short axis. By comparison, 1 of 46 (2%) control patients with non-BRAF mutated NSCLC had axLN metastases. Previous series have reported the prevalence of axLN metastases in patients with NSCLC as 0.61-0.75%. We have found a higher incidence of axLN metastases in BRAF mutated NSCLC patients than described in non-BRAF mutated NSCLC patients. Examination of the axilla should be a routine part of physical examination in this genetically distinct subgroup of lung cancer patients.

Which is the best current guideline for the diagnosis and management of cystic pancreatic neoplasms? An appraisal using evidence-based practice methods.

BACKGROUND AND AIM: Cystic pancreatic neoplasms (CPNs) are an increasingly diagnosed entity. Their heterogeneity poses complex diagnostic and management challenges. Despite frequently encountering these entities, particularly in the context of the increased imaging of patients in modern medicine, doctors have to rely on incomplete and ambiguous published literature. The aim of this project was to review the guidelines relating to CPNs using evidence-based practice (EBP) methods. METHODS: A search of both the primary and secondary literature was performed. Five sets of guidelines were identified which were then methodologically appraised by the AGREE II instrument, a validated and widely utilised tool for guideline development assessment. RESULTS: The 2014 'Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms' were found to be the most methodologically sound guidelines, on the basis of both the overall score and average weighted domain score. CONCLUSIONS: The current best guidelines were identified. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument can be used for retrospective review of published guidelines or as a roadmap for guideline-writing groups. All guidelines found were methodologically limited. Further longitudinal/prospective studies are required to improve the level of evidence. KEY POINTS: • Cystic pancreatic neoplasms (CPNs) are an increasingly encountered entity in modern medicine. • Clinical uncertainty remains with regard to optimal diagnostic and management strategies. • The Italian consensus guidelines for cystic pancreatic neoplasms are currently the best guidelines.

Haemangioma, an uncommon cause of an extradural or intradural extramedullary mass: case series with radiological pathological correlation.

UNLABELLED: Haemangiomas of the vertebrae, usually regarded as having little or no consequence, may display aggressive features, including extension into the extradural space, and cause significant neurological symptoms and signs necessitating treatment. Extraosseous haemangiomas in an extradural or intradural extramedullary location are a rare entity. Here we review our radiologic and pathologic experience of osseous haemangiomas with extradural extension and primary extradural and intradural extramedullary haemangiomas. Magnetic resonance imaging plays a pivotal role in the characterisation of spinal haemangiomas, with typical imaging features including T1 and T2 signal hyperintensity. Atypical and aggressive imaging features are also described. Spinal angiography may be required to differentiate haemangiomas from non-vascular lesions. This is a rare and unusual entity, and should be considered as a differential diagnosis for some extramedullary masses. TEACHING POINTS: • Osseous haemangiomas can display aggressive features and cause neurologic symptoms needing treatment. • Haemangioma extension into the extradural space is an imaging feature of aggressiveness. • Extraosseous haemangiomas are a rare but important differential diagnosis for extramedullary masses. • Extraosseous extramedullary haemangiomas most frequently present with progressive myelopathy. • MRI is pivitol in characterising spinal haemangiomas; imaging characteristics can vary.

Subclassification of small bowel Crohn's disease using magnetic resonance enterography: a review using evidence-based medicine methodology.

Magnetic resonance enterography (MRE) has a growing role in imaging small bowel Crohn's disease (SBCD), both in diagnosis and assessment of treatment response. Certain SBCD phenotypes respond well to biologic therapy and others require surgery; MRE has an expanding role in triaging these patients. In this review, we evaluate the MRE signs that subclassify SBCD using evidence-based medicine (EBM) methodology and provide a structured approach to MRE interpretation.

Should abdominal sequences be included in prostate cancer MR staging studies?

OBJECTIVES: Prostate cancer staging MR examinations commonly include abdominal sequences to assess for non-regional (common iliac or para-aortic) nodal metastasis. In our experience the diagnostic yield of this is limited, but incidental findings are frequent, often necessitating further investigations. The aim of this study is to assess the diagnostic utility of abdominal sequences in routine prostate cancer MR staging studies. METHODS: Findings on abdominal sequences of consecutive MRI prostate studies performed for staging newly diagnosed prostate cancer between September 2011 and September 2013 were reviewed with respect to adenopathy and additional incidental findings. Results were correlated with Gleason grade and serum prostate-specific antigen (PSA) level in each case. RESULTS: 355 MRI prostate examinations were reviewed. 4 (1.1%) showed enlarged non-regional lymph nodes. Incidental findings were found in 82(23.1%) cases, neccessitating further investigation in 45 (12.7%) cases. Enlarged non-regional nodes were associated with higher PSA level and Gleason grade (p=0.007, p=0.005 respectively). With a combined threshold of PSA > 20 ng/mL and/or Gleason grade ≥ 8 the sensitivity, specificity, PPV and NPV were 100, 60, 3 and 100% respectively for predicting the presence of non-regional adenopathy. CONCLUSIONS: Routine abdominal sequences are of very low yield in routine prostate cancer MR staging, frequently resulting in incidental findings requiring further work-up and should be reserved for high-risk cases. Our experience supports the use of an abdominal staging sequence in high-risk cases only.

Pancreaticoduodenectomy: expected post-operative anatomy and complications.

Pancreaticoduodenectomy is a complex, high-risk surgical procedure performed for tumours of the pancreatic head and other periampullary structures. The rate of perioperative mortality has decreased in the past number of years but perioperative morbidity remains high. This pictorial review illustrates expected findings in early and late post-operative periods, including mimickers of pathology. It aims to familiarize radiologists with the imaging appearances of common and unusual post-operative complications. These are classified into early non-vascular complications such as delayed gastric emptying, post-operative collections, pancreatic fistulae and bilomas; late non-vascular complications, for example, biliary strictures and hepatic abscesses; and vascular complications including haemorrhage and ischaemia. Options for minimally invasive image-guided management of vascular and non-vascular complications are discussed. Familiarity with normal anatomic findings is essential in order to distinguish expected post-operative change from surgical complications or recurrent disease. This review summarizes the normal and abnormal radiological findings following pancreaticoduodenectomy.

Impact of Lepeophtheirus salmonis infestations on migrating Atlantic salmon , Salmo salar L., smolts at eight locations in Ireland with an analysis of lice-induced marine mortality.

Sea lice infestation as a source of marine mortality of outwardly migrating Atlantic salmon smolts has been investigated by treating groups of ranched salmon, prior to release, with a prophylactic sea lice treatment conferring protection from sea lice infestation. A number of studies have been carried out in Ireland using both established ranched populations and groups of hatchery reared fish imprinted for 5-8 weeks in the sites of experimental releases. In this study, data on 352 142 migrating salmon from twenty-eight releases, at eight locations along Ireland's South and West coasts covering a 9-year period (2001 to 2009) are reviewed. Both published and new data are presented including a previously unpublished time series. The results of a meta-analysis of the combined data suggest that while sea lice-induced mortality on outwardly migrating smolts can be significant, it is a minor and irregular component of marine mortality in the stocks studied and is unlikely to be a significant factor influencing conservation status of salmon stocks.

Scoliosis secondary to an unusual rib lesion.

Tumours of the chest wall are uncommon and are usually malignant. A bone haemangioma is a rare benign vascular neoplasm, which more commonly occurs in middle-aged patients. We present the case of a scoliosis caused by a rib haemangioma in an adolescent male. Other causes of scoliosis secondary to rib lesions are discussed.

Nutritional practices in full-day-care pre-schools.

BACKGROUND: Full-day-care pre-schools contribute significantly to the nutritional intake and acquisition of dietary habits of the pre-school child. The present study investigated nutritional practices in full-day-care pre-schools in Dublin, Ireland, aiming to determine the nutritional support that pre-school managers deem necessary, thereby facilitating the amelioration of existing pre-school nutritional training and practices. METHODS: A telephone questionnaire completed by pre-school managers (n=54) examined pre-school dietary practices, food provision and the association between these and pre-school size, nutritional training attendance, possession of the Food and Nutrition Guidelines for Pre-school Services and having a healthy eating policy. Nutritional training needs were also investigated. RESULTS: Twenty-five pre-schools provided all food for attending children; parents were sole providers in six. Thirty-four pre-schools had a written healthy eating policy. Attendance at nutritional training was reported by 40. Possession of the Guidelines (n=40) did not consistently result in their use. Poor parental and staff involvement in policy and menu development was cited. Although the delayed introduction of iron-containing foods and a feeding beaker in infants was clearly evident, inappropriate beverages and snacks were served to children aged 1-5 years in 43 and 37 pre-schools, respectively. Training priorities cited by managers included parental education and the provision of information regarding menu planning and healthy food choices. CONCLUSIONS: Nutritional training should advocate whole staff familiarity with and use of current guidelines, in addition to encouraging nutritional policy development and enforcement. Parental education is warranted. Dietary education should focus specifically on appropriate weaning practices, healthy beverage and snack provision and menu planning.

A review of the imaging and intervention of liver transplant complications.

Liver transplantation has become a successful surgical solution to a variety of medical and oncological parenchymal liver diseases. As a result, these patients are being encountered more frequently within diagnostic imaging departments which may be remote from the transplant centre. Radiologists must therefore be proficient in identifying normal post-transplant anatomy which involves the anastomosis of four structures between the donor and recipient, namely the hepatic artery, the main portal vein, the retro-hepatic inferior vena cava and the extra-hepatic bile ducts. A number of potential complications can arise involving any or all of these structures, which can be potentially devastating and lead to graft failure. Radiologists must familiarise themselves with the normal post-operative appearances of liver transplantation and become competent in diagnosing post-transplant complications. Where possible, complications should be treated using interventional radiological techniques, thus avoiding the need for repeat surgical intervention or retransplantation.

International albumin use: 1995 to 2006.

Over the last ten years more reliable information regarding the risks and benefits of the use of albumin for fluid resuscitation has emerged. To determine what influence this has had on clinical practice, we sought to document albumin use (from mass of albumin supplied to hospitals) in 16 industrialised countries between 1995 and 2006. Data on national albumin and synthetic colloid use was sought from independent intensive care researchers and albumin issuers. The mass of albumin supplied per 10,000 persons on an annual basis by country and aggregated across the study countries was calculated. Volumes of synthetic colloid supplied per 10,000 persons were calculated. Data were obtained for 15 countries. Albumin use varied significantly between countries and throughout the observation period. Overall, aggregate albumin use decreased from a peak of 2.54 kg per 10,000 persons in 1995 to 1.40 kg per 10,000 persons in 1999; use has remained relatively constant since. Data on supply of synthetic colloids was available in only three countries and varied from 11.7 litres per 10,000 persons in Canada in 1995, to 231.8 litres per 10,000 persons in Denmark in 2004. Between 1995 and 1999 albumin use decreased and has been materially constant since; where data were available, use of synthetic colloids increased. Whether these practice changes have resulted in a net health gain or in harm requires further research.

Anisakid larvae in Atlantic salmon (Salmo salar L.) grilse and post-smolts: molecular identification and histopathology.

The molecular identification and histopathology are described for the parasitic larvae of a nematode species present in the abdominal cavity of Atlantic salmon ( Salmo salar ) grilse caught in fish traps on their natal river in the west of Ireland and post-smolts collected during experimental trawls on the continental shelf edge of the northeast Atlantic Ocean. Larvae in the adult and juvenile salmon were identified as Anisakis simplex sensu stricto by PCR amplification and RFLP and sequencing of the ITS gene and PCR amplification and sequencing of the cox2 gene. Parasitic nematode larvae in the grilse were either encapsulated in the abdominal mesentery associated with the pyloric ceca or on the serosal surface of the liver and in the vent region. In some fish, larvae were found in the parenchyma of the liver and muscularis circularis of the intestine. In general, the larvae induced a limited cellular response apart from the occurrence of focal melanin macrophage aggregates and individual eosinophilic granular cells in the connective tissue capsule. Melanin macrophage aggregates were also present among the hepatocytes adjacent to encapsulated larvae in the liver. The reaction to the parasites was more severe in the wall of the intestine. Encapsulated nematode larvae caused displacement, vacuolation, and necrosis of the circular muscle fibers. The stratum compactum was also disrupted with focal areas of degeneration. Overall, the intestinal wall had a hypercellular appearance with extensive cellular infiltration comprising eosinophilic granular cells, macrophages, lymphocytes, and fibrocytes. The post-smolts were caught in May during the early oceanic phase of their life cycle. In these fish, A. simplex sensu stricto larvae were found lying free on the serosal surface of the intestine and liver without any apparent histologic changes. This is the earliest in the marine migration of Atlantic salmon that A. simplex sensu stricto infection has been recorded.

Co-ordinated approach to healthcare worker influenza vaccination in an area health service.

To increase local influenza vaccination uptake among healthcare workers (HCWs), a co-ordinated, area-wide influenza vaccination campaign was undertaken in 2008 for five hospitals in the South Metropolitan Area Health Service of Perth, Western Australia (WA). The programme included standardised marketing and data collection, with a consent form completed by each recipient. Denominator data were obtained from the WA Department of Health's staff database. Vaccination coverage at each hospital was calculated and compared with that of 2007, with predictors for vaccination determined using a follow-up cross-sectional survey. A total of 6387 influenza vaccinations were administered. The coverage rate was above 55% in all but one hospital (range: 48.8-76.5%) whereas in 2007 no hospital achieved 55% (range: 29-51%). Allied health professionals attained the highest coverage (57.7%), followed by doctors (51.9%), nurses (49.6%) and patient support staff (48.6%). Of HCWs who worked half-time or more, 58.8% were vaccinated. The main reasons for vaccination were to prevent influenza, limit spread, and the programme's availability. The survey revealed that HCWs who perceived that they were susceptible to influenza, that it was a serious disease and that immunisation was effective and important were significantly more likely to be vaccinated. An area-wide approach to HCW influenza vaccination can substantially improve uptake. Regular working party meetings, consistent marketing, standardised data collection and analysis, and senior management support were key elements and could be used by others to attain good vaccination coverage among HCWs.

Purulent pericarditis.

BACKGROUND: Bacterial pericarditis has become a clinical rarity since the onset of antimicrobial therapy, yet remains fatal in a large majority of cases. AIM: We present the case of a 57-year-old male, admitted with a short history of pleuritic chest pain and dyspnoea. Investigations led to diagnosis of pyopericardium, most likely secondary to fistulating thoracic malignancy. Despite maximum medical treatment this condition proved fatal. CONCLUSION: This case highlights the still unfortunately poor prognosis of purulent pericarditis in the antibiotic era. Underlying aetiological factors should be searched for and eliminated where possible when a diagnosis of purulent pericarditis is made.

Five-year survival from breast cancer in Western Australia over a decade.

The aim of the present study was to investigate whether 5-year survival of patients with breast cancer in Western Australia has improved over time. We used a population-based study conducted in the State of Western Australia, to identify all cases of invasive breast cancer cases diagnosed in 1989, 1994 and 1999. Information on presentation, investigation and management was extracted from medical records of each case and status at 5 years after date of diagnosis was determined. Comparison of 5-year overall survival for women diagnosed in the three calendar years, and hazard ratios for survival calculated for prognostic variables were measured. We found that survival from breast cancer has improved in Western Australia since 1989. Earlier diagnosis, living in the Perth metropolitan area and use of breast-conserving surgery are associated with better survival, irrespective of year of diagnosis. Further research needs to be carried out to determine the reason for this improvement.

The impact of driver distraction on road safety: results from a representative survey in two Australian states.

OBJECTIVE: To quantify the prevalence and effects of distracting activities while driving. DESIGN: Cross sectional driver survey. SETTING: New South Wales and Western Australia, Australia. PARTICIPANTS: 1347 licensed drivers aged between 18 and 65 years. Data were weighted to reflect the corresponding driving population. MAIN OUTCOME MEASURES: Prevalence of distracting activities while driving; perceived risks and adverse outcomes due to distractions. RESULTS: The most common distracting activities during the most recent driving trip were lack of concentration (weighted percentage (standard error, SE) 71.8% (1.4%) of drivers); adjusting in-vehicle equipment (68.7% (1.5%)); outside people, objects or events (57.8% (1.6%)); and talking to passengers (39.8% (1.6%)). On average, a driver engaged in a distracting activity once every six minutes. One in five crashes (21%) during the last three years, involving one in 20 drivers (5.0% (0.7%)), was attributed to driver distraction based on self-report. In the population under study, this equated to 242,188 (SE 34,417) drivers. Younger drivers (18-30 years) were significantly more likely to report distracting activities, to perceive distracting activities as less dangerous, and to have crashed as a result. CONCLUSIONS: Distracting activities while driving are common and can result in driving errors. Driver distraction is an important cause of crashes. Further research is needed to estimate the risk conferred by different distracting activities and the circumstances during which activities pose greatest risk. These results suggest that a strategy to minimize distracting activities while driving, with a focus on young drivers, is indicated.

Rural-urban differences in the presentation, management and survival of breast cancer in Western Australia.

From all women diagnosed with invasive breast cancer in 1999 in Western Australia, rural and urban women were compared with regard to mode of detection, tumour characteristics at presentation, diagnostic investigations, treatment and survival. Women from rural areas with breast cancer (n=206, 23%) were less likely to have open biopsy with frozen section (P<0.001), breast-conserving surgery (P<0.001), adjuvant radiotherapy (P=0.004) and hormonal therapy (P=0.03), and were less likely to be treated by a high caseload breast cancer surgeon (P<0.001). Adjusting for age and tumour characteristics, rural women had an increased likelihood of death within 5 years of breast cancer diagnosis (HR 1.62, 95% CI 1.10-2.38). This difference was not significant after adjustment for treatment factors (HR 1.36, 95% CI 0.90-2.04).