Opportunistic screening for osteoporosis using routine clinical care computed tomography brain studies.

OBJECTIVE: Osteoporosis and falls are both prevalent in the elderly, and CT brain (CTB) is frequently performed post head-strike. We aim to validate the relationship between frontal bone density (Hounsfield unit) from routine CTB and bone mineral density from dual-energy X-ray absorptiometry (DEXA) scan for opportunistic osteoporosis screening. MATERIALS AND METHODS: Patients who had a non-contrast CTB followed by a DEXA scan in the subsequent year were included in this multi-center retrospective study. The relationship between frontal bone density on CT and femoral neck T-score on DEXA was examined using ANOVA, Pearson's correlation, and receiver operating curve (ROC) analysis. Sensitivity, specificity, negative and positive predictive values, and area under the curve (AUC) were calculated. RESULTS: Three hundred twenty-six patients (205 females and 121 males) were analyzed. ANOVA analysis showed that frontal bone density was lower in patients with DEXA-defined osteoporosis (p < 0.001), while Pearson's correlation analysis demonstrated a fair correlation with femoral neck T-score (r = 0.3, p < 0.001). On subgroup analysis, these were true in females but not in males. On ROC analysis, frontal bone density weakly predicted osteoporosis (AUC 0.6, 95% CI 0.5-0.7) with no optimal threshold identified. HU < 610 was highly specific (87.5%) but poorly sensitive (18.9%). HU > 1200 in females had a strong negative predictive value for osteoporosis (92.6%, 95% CI 87.1-98.1%). CONCLUSION: Frontal bone density from routine CTB is significantly different between females with and without osteoporosis, but not between males. However, frontal bone density was a weak predictor for DEXA-defined osteoporosis. Further research is required to determine the role of CTB in opportunistic osteoporosis screening.

Clinical and financial impacts of abnormal liver biochemistry after liver transplantation.

OBJECTIVE: After liver transplant (LT), many investigations are needed to evaluate abnormal liver function test (LFT), which has poor specificity for graft function and complication. A single center retrospective audit of all adult single organ LT from 1/1/2015 to 31/12/2017 was performed. Demographic, clinical and investigation data from the LT database and electronic medical records and cost data from the hospital's Business Intelligence Unit were analyzed. Patients were classified into uncomplicated or complicated LFT by 2 independent investigators and the number, type, and cost of investigations in the first 30 post-operative days were analyzed. Investigations prior to liver biopsy was sub-analyzed. RESULTS: There was 170 LT with 87 cases of uncomplicated LFT (51.2%) and 83 cases of complicated LFT (48.8%). Most patients with complicated LFT had additional investigations (97.6%), most commonly cholangiogram (55.4%) and liver biopsy (LBx) (50.6%). The additional investigations cost was $1863.3 (95% CI 1289.0-2437.6). Although most LBx (73.8%) showed evidence of rejection, LBx was often not the initial investigation of choice. Current LFT based post-transplant monitoring is inefficient. It remains difficult to determine which patient will benefit from an early invasive procedure like LBx, using LFT alone without further imaging investigations.

Development of a machine learning-based real-time location system to streamline acute endovascular intervention in acute stroke: a proof-of-concept study.

BACKGROUND: Delivery of acute stroke endovascular intervention can be challenging because it requires complex coordination of patient and staff across many different locations. In this proof-of-concept paper we (a) examine whether WiFi fingerprinting is a feasible machine learning (ML)-based real-time location system (RTLS) technology that can provide accurate real-time location information within a hospital setting, and (b) hypothesize its potential application in streamlining acute stroke endovascular intervention. METHODS: We conducted our study in a comprehensive stroke care unit in Melbourne, Australia that offers a 24-hour mechanical thrombectomy service. ML algorithms including K-nearest neighbors, decision tree, random forest, support vector machine and ensemble models were trained and tested on a public WiFi dataset and the study hospital WiFi dataset. The hospital dataset was collected using the WiFi explorer software (version 3.0.2) on a MacBook Pro (AirPort Extreme, Broadcom BCM43x×1.0). Data analysis was implemented in the Python programming environment using the scikit-learn package. The primary statistical measure for algorithm performance was the accuracy of location prediction. RESULTS: ML-based WiFi fingerprinting can accurately predict the different hospital zones relevant in the acute endovascular intervention workflow such as emergency department, CT room and angiography suite. The most accurate algorithms were random forest and support vector machine, both of which were 98% accurate. The algorithms remain robust when new data points, which were distinct from the training dataset, were tested. CONCLUSIONS: ML-based RTLS technology using WiFi fingerprinting has the potential to streamline delivery of acute stroke endovascular intervention by efficiently tracking patient and staff movement during stroke calls.

Retroperitoneal bile leak after laparoscopic cholecystectomy.

Bile duct injury (BDI) is a well-recognised complication of laparoscopic cholecystectomy (LC). Following a BDI, bile usually leaks into the peritoneal space and causes biliary peritonitis. This manifests as non-specific abdominal pain and fever occurring several days after the surgery. It can be managed by laparoscopic washout with or without bile duct repair. We present a rare case of retroperitoneal bile leak post-LC. The mechanism of injury here was likely partial avulsion from excessive traction of the cystic duct during intraoperative cholangiogram. Diagnosing retroperitoneal bile leak can be difficult because it is extremely rare and the presenting symptoms can be similar to an intraperitoneal bile leak. A high index of clinical suspicion is required. In cases of suspected bile leak, any mismatch between the exploratory laparoscopic findings and imaging findings should alert surgeons to consider the rare possibility of a retroperitoneal bile leak.

Juvenile generalized pustular psoriasis is a chronic recalcitrant disease: an analysis of 27 patients seen in a tertiary hospital in Johor, Malaysia.

BACKGROUND: Limited information exists regarding juvenile generalized pustular psoriasis (GPP). We aim to determine the clinical profile and outcome of Malaysians with juvenile GPP. METHODS: Review of hospital case notes on patients with juvenile GPP. RESULTS: Twenty-seven patients with juvenile GPP were identified. Female to male ratio was 1.4:1. The median age at onset of GPP was 6.5 years. Ten patients had prior psoriasis with a median pre-pustular duration of 2.7 years. Onset of GPP was earlier in patients without prior psoriasis (5.1 years vs. 12.0 years, P = 0.002). Precipitating factors identified included stress, upper respiratory tract infection, systemic steroid use, vaccination, and pregnancy. A positive family history of psoriasis and GPP was present in six and one patient(s), respectively. Twenty-one patients had acute, five annular, and one localized variant of GPP. Arthritis was present in 22.2%. Fever, leukocytosis, and transaminitis were mainly seen in patients with acute GPP at 80.9, 72.2, and 11.1%, respectively. Among 20 patients screened, eight carry IL36RN variants and one has CARD14 mutation. IL36RN-positive patients have more severe disease characterized by early onset, low prevalence of prior plaque psoriasis, high prevalence of systemic inflammation, and need for continuous long-term systemic therapy. Acitretin and cyclosporine were effective in aborting acute GPP in 100% of 16 and 66.7% of six patients treated, respectively. However, relapses were common. Only three of the 17 patients whose initial acute GPP was controlled with systemic agents were successfully weaned off treatment. CONCLUSIONS: Juvenile GPP is a chronic recalcitrant disease. IL36RN-positive patients have more severe disease.