Case Start Time Affects Intraoperative Transfusion Rates in Adult Cardiac Surgery: A Single-Center Retrospective Analysis.

OBJECTIVE: The goal of the study was to investigate the role time of day plays in perioperative outcomes. The authors examined intraoperative transfusion rates throughout the day in adult cardiac surgery patients. They hypothesized that the rate of transfusion changes with later case start times in scheduled cardiac surgery. DESIGN: Retrospective observational study. SETTING: Single academic medical center. PARTICIPANTS: Adults undergoing cardiac surgery involving cardiopulmonary bypass. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite variable of transfusion. The association between the time of day and the rate of transfusion was explored with a multivariate logistic regression to fit the effect of starting time as a cubic spline. There were 1,421 cases that met inclusion criteria. There were 1,220 cases that were matched for modeling. The estimated probability of a patient receiving a transfusion changed significantly with later case start times in the multivariable model after adjusting for initial hemoglobin, age, sex, height, ideal body weight, diabetes, peripheral vascular disease, stroke, chronic kidney disease, chronic obstructive pulmonary disease, duration of cardiopulmonary bypass, aortic cross clamp time, attending surgeon, and attending anesthesiologist (p = 0.032, C-statistic = 0.807, n = 1220). The estimated probability of receiving an intraoperative red blood cell transfusion increased with later case start times in the multivariable model (p = 0.027, C-statistic = 0.902, n = 1220). There was no difference in the probability of transfusion for plasma, cryoprecipitate, or platelets. CONCLUSIONS: The observed rate of intraoperative blood product transfusion changed with later case start times in a multivariable model of scheduled cardiac surgery.

Nuclear Medicine and Resources for Patients: How Complex Are Online Patient Educational Materials?

The Internet is a major source of health care information for patients. The American Medical Association and the National Institutes of Health recommend that consumer health care websites be written at a third- to seventh-grade level. The purpose of this study was to evaluate the level of readability of patient education websites pertaining to nuclear medicine. Methods: We searched for 10 terms on Google, collected the top 10 links for each term, and analyzed their level of readability using 10 well-established readability scales. Results: Collectively, the 99 articles were written at a grade level of 11.8 (SD, 3.4). Only 5 of the 99 articles were written at the third- to seventh-grade level recommended by the National Institutes of Health and the American Medical Association. Conclusion: There is a clear discordance between the readability level of nuclear medicine-related imaging terms and the National Institutes of Health and American Medical Association guidelines. This discordance may have a negative impact on patient understanding, contributing to poor health outcomes.

X-linked Charcot-Marie-Tooth disease type 6 (CMTX6) patients with a p.R158H mutation in the pyruvate dehydrogenase kinase isoenzyme 3 gene.

Charcot-Marie-Tooth disease (CMT) is the most common inherited peripheral neuropathy. Mutations in the pyruvate dehydrogenase kinase isoenzyme 3 (PDK3) gene have been found to cause X-linked dominant CMT type 6 (CMTX6). This study identified the p.R158H PDK3 mutation after screening 67 probable X-linked CMT families. The mutation fully segregated with the phenotype, and genotyping the family indicated the mutation arose on a different haplotype compared with the original Australian CMTX6 family. Results of bisulphite sequencing suggest that methylated deamination of a CpG dinucleotide may cause the recurrent p.R158H mutation. The frequency of the p.R158H PDK3 mutation in Koreans is very rare. Magnetic resonance imaging revealed fatty infiltration involving distal muscles in the lower extremities. In addition, fatty infiltrations were predominantly observed in the soleus muscles, with a lesser extent in tibialis anterior muscles. This differs from demyelinating CMT1A patients and is similar to axonal CMT2A patients. The clinical, neuroimaging, and electrophysiological findings from a second CMTX6 family with the p.R158H PDK3 mutation were similar to the axonal neuropathy reported in the Australian family.

Provider Distribution Changes in Dual-Energy X-Ray Absorptiometry in the Medicare Population Over the Past Decade.

Both radiologists as well as nonimaging physicians perform dual-energy X-ray absorptiometry (DXA) imaging in the United States. This study aims to compare provider distribution between these physician groups on the Medicare population, which is the predominant age group of patients evaluated by this imaging procedure. Using the 2 relevant Current Procedural Terminology, Fourth Edition codes for DXA scans, source data were obtained from the CMS Physician Supplier Procedure Summary Master Files from 2003 through 2013. DXA scan procedure volumes for radiologists and nonradiologists on Medicare patients were tabulated. Utilization rates were calculated. From 2003 to 2013, the total number of DXA scans performed on Medicare patients decreased by 2%. However, over the same period, the number of scans performed by radiologists had increased by 25% over nonimaging specialists, whose utilization had declined by approximately the same amount. From 2003 to 2013, the rate of utilization of DXA scans in the Medicare fee-for-service population declined somewhat. However, radiologists continue to gain market share from other specialists and now predominate in this type of imaging by a substantial margin.

The effects of resource improvement on decision-to-delivery times for cesarean deliveries in a Ghanaian regional hospital.

OBJECTIVE: To evaluate the effects of having a dedicated obstetric operating room (OR) on the decision-to-delivery interval (DDI) in a large referral hospital in Ghana. METHODS: An observational study was undertaken of all patients undergoing cesarean delivery at Ridge Regional Hospital, Accra, before (pre-OR; August-September 2011) and after (post-OR; August-September 2012) introduction of an obstetric OR. The primary outcome was the DDI. RESULTS: In total, 581 cesareans were performed in the pre-OR period and 574 in the post-OR period. Overall, the median DDI decreased from 259 min (interquartile range [IQR] 161-432) in the pre-OR period to 195 min (IQR 138-319) in the post-OR period (P<0.001). DDI was lower in the post-OR period than in the pre-OR period for both emergency (175 min [IQR 126-241] vs 220 min [IQR 146-315]; P<0.001) and elective (1828 min [IQR 1432-2985] vs 4291 min [IQR 2992-5862]; P<0.001) cesarean deliveries. Only one emergency cesarean-in the post-OR period-was conducted within the recommended 30-minute timeframe. CONCLUSION: An obstetric OR lowered the DDI for cesarean delivery; however, a realistic timeframe for emergency cesareans in low-income countries remains to be determined.

Somatostatin receptor scintigraphy in patients with metastatic uveal melanoma.

As uveal melanoma originates in the neural crest, we aimed to explore whether somatostatin receptor (SSTR) expression is present and plays any role in these patients. Heavily pretreated metastatic uveal melanoma patients were tested with somatostatin receptor scintigraphy (SRS). Planar images of the whole body complemented by single-photon emission computed tomography on suspected sites were acquired between 4 and 24 h after an intravenous administration of 185-222 MBq (5-6 mCi) of indium-octeotride. SSTR expression in metastatic tissues was confirmed by immunohistochemistry. In seven patients, sandostatin LAR was used with therapeutic intention. Thirty white patients were tested. All had extensive metastatic disease and the median number of previous treatments was three. SRS was found to be positive in 14 (46%) of the patients, but was not related to sex, type of previous treatments, tumor site, or histological type. In 10 patients, sufficient tumor specimens were available to perform immunohistochemical staining for SSTR. All cases with positive SSTR-2A staining were also positive by SRS. Two of the seven patients who received sandostatin LAR died within a month after receiving the first dose, whereas another two (28.5%) had stable disease for more than 5 months. The median time to progression after starting sandostatin was 2.1 months (range: 0.2-5.5 months). Approximately 50% of the uveal melanoma patients with extensive metastatic disease were positive for SSR, which was consistent with immunohistochemical staining for SSTR-2A. Therapeutic approaches targeting SSTR might be beneficial in patients with metastatic uveal melanoma.

Imaging of the thyroid in benign and malignant disease.

The thyroid gland was one of the first organs imaged in nuclear medicine, beginning in the 1940s. Thyroid scintigraphy is based on a specific phase or prelude to thyroid hormone synthesis, namely trapping of iodide or iodide analogues (ie, Tc99m pertechnetate), and in the case of radioactive iodine, eventual incorporation into thyroid hormone synthesis within the thyroid follicle. Moreover, thyroid scintigraphy is a reflection of the functional state of the gland, as well as the physiological state of any structure (ie, nodule) within the gland. Scintigraphy, therefore, provides information that anatomical imaging (ie, ultrasound, computed tomography [CT], magnetic resonance imaging) lacks. Thyroid scintigraphy plays an essential role in the management of patients with benign or malignant thyroid disease. In the former, the structure or architecture of the gland is best demonstrated by anatomical or cross-sectional imaging, such as ultrasound, CT, or even magnetic resonance imaging. The role of scintigraphy, however, is to display the functional state of the thyroid gland or that of a clinically palpable nodule within the gland. Such information is most useful in (1) patients with thyrotoxicosis, and (2) those patients whose thyroid nodules would not require tissue sampling if their nodules are hyperfunctioning. In neoplastic thyroid disease, thyroid scintigraphy is often standard of care for postthyroidectomy remnant evaluation and in subsequent thyroid cancer surveillance. Planar radioiodine imaging, in the form of the whole-body scan (WBS) and posttherapy scan (PTS), is a fundamental tool in differentiated thyroid cancer management. Continued controversy remains over the utility of WBS in a variety of patient risk groups and clinical scenarios. Proponents on both sides of the arguments compare WBS with PTS, thyroglobulin, and other imaging modalities with differing results. The paucity of large, randomized, prospective studies results in dependence on consensus expert opinion and retrospective analysis with inherent bias. With a growing trend not to ablate low-risk patients, so that a PTS cannot be performed, some thyroid carcinoma patients may never have radioiodine imaging. In routine clinical practice, however, imaging plays a critical role in patient management both before and after treatment. Moreover, as evidenced by the robust flow of publications concerning WBS and PTS, planar imaging of thyroid carcinoma remains a topic of great interest in this modern age of rapidly advancing cross sectional and hybrid imaging with single-photon emission computed tomography, single-photon emission computed tomography/CT, and positron emission tomography/CT.

Subclinical hyperthyroidism: current concepts and scintigraphic imaging.

Subclinical hyperthyroidism is defined as normal serum free thyroxine and a free triiodothyronine level, with a thyroid-stimulating hormone level suppressed below the normal range and is usually undetectable. Although patients with this diagnosis have no or few signs and symptoms of overt thyrotoxicosis, there is sufficient evidence that it is associated with a relatively higher risk of supraventricular arrhythmias as well as the acceleration or the development of osteoporosis. Consequently, the approach to the patient with subclinical hyperthyroidism is controversial, that is, therapeutic intervention versus watchful waiting. Regardless, it is imperative for the referring physician to identify the causative thyroid disorder. This is optimally accomplished by a functional study, namely scintigraphy. Recognition of the scan findings of the various causes of subclinical hyperthyroidism enables the imaging specialist to help in diagnosing the underlying condition causing thyroid-stimulating hormone suppression thereby facilitating the workup and management of this thyroid disorder.

Terrabacter carboxydivorans sp. nov., a carbon monoxide-oxidizing actinomycete.

A bacterial strain, PY2(T), capable of oxidizing carbon monoxide, was isolated from a soil sample collected from a roadside at Yonsei University, Seoul, Korea. On the basis of 16S rRNA gene sequence analysis, strain PY2(T) was shown to belong to the genus Terrabacter and was most closely related to Terrabacter lapilli LR-26(T) (99.1 % similarity). Strain PY2(T) was characterized chemotaxonomically as having iso-C(15 : 0) as the predominant fatty acid, MK-8(H(4)) as the major menaquinone, ll-diaminopimelic acid as the diagnostic diamino acid of the cell wall, as possessing a polar lipid profile that included diphosphatidylglycerol, phosphatidylethanolamine, phosphatidylglycerol, phosphatidylinositol and unknown amino-containing phosphoglycolipids, and having a DNA G+C content of 75.6 mol%. DNA-DNA relatedness values between strain PY2(T) and the type strains of T. lapilli, Terrabacter tumescens, Terrabacter terrae and Terrabacter aerolatus were 20.0 %, 22.9 %, 35.9 % and 64.5 %, respectively. Based on the combined evidence from the phylogenetic analyses, chemotaxonomic data and DNA-DNA hybridization experiments, it is proposed that strain PY2(T) represents a novel species for which the name Terrabacter carboxydivorans sp. nov. is proposed. The type strain is PY2(T) (=KCCM 42922(T)=JCM 16259(T)).

Impedance changes according to the degree of atopi dermatitis in mice.

Variations in electrical impedance over frequency might be used to distinguish the degree of atopic dermatitis (AD), even if the mechanisms of the skin barrier impairment due to AD are still unknown. We observed the skin bioimpedance of normal mice and of abnormal mice having atopic with instrument measuring electrical impedance. Electrical impedance was measured from 20 Hz to 1 MHz at many frequencies and normalized with several indices such as IMP, PIX, IMIX, RIX, and et al. to reduce variation in subjects. The results showed the high relationship between subjective score and indices, especially, the capacitance change and impedance ratio, abs(Z(1 kHz))/abs(Z(10 kHz)). These results indicate electrical impedance may be a promising clinical diagnostic tool to monitor prognosis of skin care for atopic dermatitis. Using developed software application we easily acquired complex impedance data from the instrument and got the analysis results for very kinds of frequency. This may be useful in various bioimpedance studies such as skin cancer assessment or body composition analysis, or etc.

Lymphoscintigraphy in cutaneous melanoma: an updated total body atlas of sentinel node mapping.

Lymphoscintigraphy has become part of the standard of care for patients with a new or recurrent diagnosis of melanoma, in helping determine the status of regional lymph nodes. Correct identification of sentinel lymph nodes enables the surgeon to further delineate the extent of malignancy by allowing sampling of the appropriate nodal group. Performing the lymphoscintigraphy prior to the planned operation allows limited surgery with less extensive postoperative morbidity. For this reason, a thorough knowledge of the lymph node drainage patterns from the different primary tumor locations, as well as of proper lymphoscintigraphic techniques and radiopharmaceuticals, constitutes an important armamentarium in the hands of surgeons, radiologists, and nuclear medicine physicians.

Tsukamurella carboxydivorans sp. nov., a carbon monoxide-oxidizing actinomycete.

A Gram-positive, slightly acid-alcohol-fast, carbon monoxide-oxidizing bacterium, strain Y2(T), was isolated from a soil sample collected from a roadside in Seoul, Korea. On the basis of 16S rRNA gene sequence comparative analyses, strain Y2(T) was shown to belong to the genus Tsukamurella and was most closely related to Tsukamurella tyrosinosolvens DSM 44234(T) (GenBank accession no. AY238514; 99.8 %). The predominant fatty acids were C(18 : 1)omega9c and C(16 : 0). The cell-wall peptidoglycan of strain Y2(T) contained meso-diaminopimelic acid as the diagnostic diamino acid. Strain Y2(T) contained galactose and arabinose as the whole cell sugars. The DNA G+C content was 77 mol%. The DNA-DNA relatedness value between strain Y2(T) and T. tyrosinosolvens DSM 44234(T) was 62.7 %. Based on the combination of the carbon source utilization pattern, fatty acid profile, cell-wall chemotype, DNA G+C content and DNA-DNA hybridization experiments, it is proposed that strain Y2(T) (=KCCM 42885(T)=JCM 15482(T)) represents the type strain of a novel species, Tsukamurella carboxydivorans sp. nov.

Scintigraphic imaging of body neuroendocrine tumors.

Radionuclide imaging is often used in the diagnosis and work-up of a wide range of neoplasms, on the basis of the biologic behavior of the tumor. Neuroendocrine tumors are a subgroup of neoplasms that are generally small and slow growing, and consequently their identification with conventional anatomic imaging can be difficult. Depending on the physiologic properties of the tumor, functional images obtained with radionuclides are often complementary to anatomic images, not only in the localization of the tumor and its metastases, but also in the assessment of prognosis and response to therapy. Familiarity with the choice of the appropriate radiopharmaceutical, proper imaging protocols, and the wide range of imaging patterns will enable the radiologist to guide the clinician in case management.

Pulmonary lymphangitic carcinomatosis (PLC): spectrum of FDG-PET findings.

The lungs are among the most common sites for metastases from a multitude of cancers. The majority of pulmonary metastases appear nodular on radiologic images. Interstitial spread of tumor through pulmonary lymphatics, also known as pulmonary lymphangitic carcinomatosis (PLC), is not uncommon and constitutes approximately 7% of pulmonary metastases. PLC is most often seen with adenocarcinoma of a variety of histologies such as thyroid carcinoma, and melanoma. It is usually noted in late stages of malignancy and therefore is indicative of a poor prognosis. Diagnosis of PLC is usually based on a combination of clinical and radiologic findings. However, the diagnosis is difficult when patients have limited clinical findings or have a history of or the possibility of other interstitial lung diseases. High-resolution computed tomography (HRCT) has been the modality of choice in the radiologic diagnosis of PLC. Imaging features of PLC on HRCT include thickening of interlobular septa, fissures, and bronchovascular bundles. Distribution of PLC may be focal or diffuse, unilateral or bilateral, and symmetric or asymmetric. Although FDG-PET has been extensively used in primary or secondary lung malignancies, its role and appearance in PLC have not been well determined in the literature. In this communication, we describe a spectrum of FDG-PET and CT findings in 5 cases with PLC. Similar to CT, the distribution of PLC can be extensive or limited on the FDG-PET. Diffuse, lobar, or segmental FDG uptake in the lungs is seen in extensive PLC. In limited PLC, a linear or a hazy area of FDG uptake extending from the tumor can be seen. Recognition of various patterns related to PLC on FDG-PET may allow accurate diagnosis of disease and could potentially influence the management of these patients.

The role of nuclear medicine in the evaluation of complex regional pain syndrome type I.

Chronic pain resulting from complex regional pain syndrome type I (CRPS I), formerly referred to as the reflex sympathetic dystrophy syndrome (RSDS), is a diagnostic challenge to the clinician. It involves multiple organ systems, namely peripheral as well as central nervous, vascular, soft tissue, and skeletal. It usually develops as a consequence of trauma, without nerve injury. Signs and symptoms vary depending on the time since the initiating event, and there is no confirmatory histopathologic diagnosis. This article summarizes the current consensus on the classification, pathophysiology, and diagnostic approaches, emphasizing the role of scintigraphy in the management of this multisystem disorder.

131I therapeutic efficacy is not influenced by stunning after diagnostic whole-body scanning.

PURPOSE: To determine if stunning can be seen with a 185-MBq (5-mCi) dose of iodine 131 (131I) at diagnostic whole-body scanning and, if stunning is seen, determine if there is any 131I therapeutic efficacy. MATERIALS AND METHODS: A retrospective review of findings involving 166 patients who underwent thyroidectomy for differentiated thyroid carcinoma was performed. Diagnostic 131I scans were compared with postablation scans for evidence of stunning. Stunning was defined when the diagnostic scan showed activity that was subsequently decreased on the postablation scan. The sample population was divided into two groups: group NS, patients with no stunning, and group S, patients with stunning. Patients were considered successfully treated if no functioning thyroid tissue and/or metastases were seen on follow-up diagnostic scans. Fisher exact and Student t tests were used to evaluate the statistical significance of therapy success rates, clinical characteristics, and scanning parameters between the two groups. RESULTS: Group NS included 135 (81.3%) of 166 patients, with 36 (26.7%) of 135 lost to follow-up. Group S included 31 (18.7%) of 166 patients, with eight (26%) of 31 patients lost to follow-up. There was no significant difference (P =.61) in treatment success rates between group NS (87 of 99, 88%) and group S (21 of 23, 91%). The treatment success rates for thyroid remnants were 87% (48 of 55) for group NS and 91% (10 of 11) for group S (P =.63). Treatment success rates for metastases (mostly lymph nodes) were 89% (39 of 44) for group NS and 83% (10 of 12) for group S (P =.55). CONCLUSION: Thyroid stunning can occur with 185 MBq of 131I in diagnostic imaging. However, data did not show any effect of stunning on the efficacy of 131I therapy for differentiated thyroid carcinoma.

Scintigraphic manifestations of thyrotoxicosis.

The term thyrotoxicosis refers to the clinical syndrome of increased systemic metabolism that results when the serum concentrations of free thyroxine, free triiodothyronine, or both are elevated. The term hyperthyroidism refers to overactivity of the thyroid gland with a resultant increase in thyroid hormone synthesis and release into the systemic circulation. These terms are not interchangeable, since thyrotoxicosis can develop in thyroid conditions that are not associated with increased thyroid function, such as thyroiditis, or in so-called factitious hyperthyroidism. The clinical signs and symptoms of thyrotoxicosis are virtually identical regardless of the cause. However, in a given patient, every attempt should be made to determine the exact cause of the thyrotoxicosis, as this in turn determines the prognosis and treatment. Since thyroid scintigraphy demonstrates the functional state of the thyroid gland, it should be used, in conjunction with determination of radioactive iodine uptake, as the imaging modality of choice for diagnosis of thyrotoxicosis. Although the scintigraphic features of several of the thyroid disorders that cause thyrotoxicosis may overlap, their recognition helps narrow the differential diagnosis, thereby guiding the referring physician in the work-up and management of this disorder.

Fractionated stereotactic radiotherapy for the treatment of optic nerve sheath meningiomas: preliminary observations of 33 optic nerves in 30 patients with historical comparison to observation with or without prior surgery.

OBJECTIVE: We investigated the safety and efficacy of stereotactic radiotherapy as an alternative therapy to surgical resection for optic nerve sheath meningiomas (ONSMs). METHODS: Thirty patients and 33 optic nerves with ONSMs were treated with conventional fractionated stereotactic radiotherapy treatment (CF-SRT) between July 1996 and May 2001 with the use of a 6-MeV LINAC designed for and dedicated to radiosurgery. The LINAC technique involved daily CF-SRT involving a relocatable frame, an average of three isocenters, and high-radiation dose conformality established by noncoplanar arc beam shaping and differential beam weighting. The patients who were treated with CF-SRT were followed clinically with serial visual fields and radiographically with both magnetic resonance imaging and functional (111)In-octreotide single-photon emission computed tomography. The results of treatment were compared with a historical control group of ONSM patients who were either observed or treated surgically and then observed. RESULTS: Our study population comprised 18 women and 12 men with a median age of 44 years (age range, 20-76 yr). The median isosurface radiation dose was 51 Gy (dose range, 50-54.0 Gy), and the median clinical follow-up time was 89 weeks (range, 9-284 wk). Of 22 optic nerves with vision before CF-SRT, 20 nerves (92%) demonstrated preserved vision, and 42% manifested improvement in visual acuity and/or visual field at follow-up. Comparison of our patients with a historical control group revealed preserved vision in only 16% of patients in a comparable period of observation, along with a 150% greater probability of visual improvement. Four patients (13%) had posttreatment morbidities, including visual loss (two patients), optic neuritis (one patient), and transient orbital pain (one patient). On magnetic resonance imaging studies, there was no evidence of tumor progression or recurrence in all patients, including tumor volume reductions noted in four patients. All six patients monitored with (111)In-octreotide scintigraphy demonstrated significant decreases in tumor activity after CF-SRT. CONCLUSION: To date, this article describes the largest reported series of ONSMs. Although longer follow-up is necessary, we think that CF-SRT represents a safe alternative to surgery and offers a higher likelihood of preserved or improved vision in patients with ONSM. Our analysis suggests that CF-SRT is also preferable to observation. Functional (111)In-octreotide single-photon emission computed tomographic scintigraphy provides a useful technique for the assessment of tumor control that complements serial posttreatment magnetic resonance imaging in patients with ONSMs.