Fluoroscopy- and CT-Guided Gold Fiducial Marker Placement for Intraoperative Localization during Spinal Surgery: Review of 179 Cases at a Single Institution-Technique and Safety Profile.

BACKGROUND AND PURPOSE: Wrong-level spinal surgery, especially in the thoracic spine, remains a challenge for a variety of reasons related to visualization, such as osteopenia, large body habitus, severe kyphosis, radiographic misinterpretation, or anatomic variation. Preoperative fiducial marker placement performed in a dedicated imaging suite has been proposed to facilitate identification of thoracic spine vertebral levels. In this current study, we report our experience using image-guided percutaneous gold fiducial marker placement to enhance the accuracy and safety of thoracic spinal surgical procedures. MATERIALS AND METHODS: A retrospective review was performed of all fluoroscopy- or CT-guided gold fiducial markers placed at our institution between January 3, 2019, and March 16, 2022. A chart review of 179 patients was performed detailing the procedural approach and clinical information. In addition, the method of gold fiducial marker placement (fluoroscopy/CT), procedure duration, spinal level of the gold fiducial marker, radiation dose, fluoroscopy time, surgery date, and complications (including whether wrong-level surgery occurred) were recorded. RESULTS: A total of 179 patients (104 female) underwent gold fiducial marker placement. The mean age was 57 years (range, 12-96 years). Fiducial marker placement was performed by 13 different neuroradiologists. All placements were technically successful without complications. All 179 (100%) operations were performed at the correct level. Most fiducial markers (143) were placed with fluoroscopy with the most common location at T6-T8. The most common location for placement in CT was at T3 and T4. CONCLUSIONS: All operations guided with gold fiducial markers were performed at the correct level. There were no complications of fiducial marker placement.

Percutaneous CT-Guided Core Needle Biopsies of Head and Neck Masses: Review of 184 Cases at a Single Academic Institution, Common and Special Techniques, Diagnostic Yield, and Safety.

BACKGROUND AND PURPOSE: Percutaneous CT-guided core needle biopsies of head and neck lesions can be safely performed with vigilant planning. This largest-to-date single-center retrospective study evaluates multiple approaches with consideration of special techniques and examines the histopathologic yield. MATERIALS AND METHODS: Retrospective review of CT-guided core biopsies of head and neck lesions from January 1, 2010, to October 30, 2020, was performed. We recorded the following: patient demographics, sedation details, biopsy needle type and size, lesion location and size, approach, patient positioning, preprocedural intravenous contrast, proceduralists' years of experience, complications, and pathology results. RESULTS: One hundred eighty-four CT-guided core biopsies were evaluated. The initial diagnostic yield was 93% (171/184). However, of 43/184 (23%) originally "negative for malignancy" biopsies, 4 were eventually positive for malignancy via rebiopsy/excision, resulting in a 2% false-negative rate and an adjusted total diagnostic yield of 167/184 (91%). Biopsies were performed by 16 neuroradiologists with variable experience. The diagnostic yield was essentially the same: 91% (64/70) for proceduralists with ≤3 years' experience, and 90% (103/114) with >3 years' experience. The diagnostic yield was 93% (155/166) for lesions of >10 mm. The diagnostic yield per biopsy needle gauge was the following: 20 ga, 81% (13/16); 18 ga, 93% (70/75); 16 ga, 90% (64/71); and 14 ga, 91% (20/22). There were 4 asymptomatic hematomas, with none requiring intervention. CONCLUSIONS: Percutaneous CT-guided core needle biopsies are safe procedures for superficial and deep head and neck lesions with a high diagnostic yield. Careful planning and special techniques may increase the number of lesions accessible percutaneously while minimizing the risk of complications.

Defining a study population using enhanced reporting of Aboriginality and the effects on study outcomes.

INTRODUCTION: The under-reporting of Aboriginal and Torres Strait Islander people on routinely collected health datasets has important implications for understanding the health of this population. By pooling available information on individuals' Aboriginal or Torres Strait Islander status from probabilistically linked datasets, methods have been developed to adjust for this under-reporting. OBJECTIVES: To explore different algorithms that enhance reporting of Aboriginal status in birth data to define a cohort of Aboriginal women, examine any differences between women recorded as Aboriginal and those assigned enhanced Aboriginal status, and assess the effects of using different reported populations to estimate within-group comparisons for Aboriginal people. METHODS: Three algorithms, with different levels of inclusiveness, were used to establish different study populations all of which aimed to include all singleton babies born to Aboriginal or Torres Strait Islander women residing in New South Wales, Australia between 2010 and 2014 and their mothers. The demographics of the four study populations were described and compared using frequencies and percentages. In order to assess the impact on research outcomes and conclusions of using study populations derived from different algorithms, estimates of the associations between smoking during pregnancy and selected perinatal outcomes were compared using rates and relative risks. RESULTS: Women included in the study population through enhanced reporting were older, less disadvantaged and more commonly resided in urban areas than those recorded as Aboriginal in the birth data. Although rates of smoking and some perinatal outcomes differed between the different study populations, the relative risks of each outcome comparing smoking and non-smoking Aboriginal mothers were very similar when estimated from each of the study populations. CONCLUSIONS: This work provides evidence that estimates of within-group relative risks are reliable regardless of the assumptions made for establishing the study population through the enhanced reporting of indigenous peoples.

Time to Resolution of Inadvertent Subdural Contrast Injection during a Myelogram: When Can the Study Be Reattempted?

BACKGROUND AND PURPOSE: Inadvertent subdural contrast injections can occur during any myelogram. Currently, there are no guidelines defining when residual subdural iodinated contrast will be cleared and no longer interfere with subsequent procedure and imaging. We investigated the time to resolution of subdural contrast using a 2-day lateral decubitus digital subtraction myelogram and associated CT myelogram data in patients undergoing evaluation for spontaneous intracranial hypotension. MATERIALS AND METHODS: Retrospective review of 63 patients with lateral decubitus digital subtraction myelograms from September 4, 2018, to October 1, 2019, was performed. Patients with 2-day lateral decubitus digital subtraction myelograms on 2 consecutive days, with or without a same-day CT myelogram on day 1 and with a same-day CT myelogram on day 2, were included. Patients with next-day CT covering at least the abdomen and pelvis after either-day injection were also included. In cases of subdural injection, next-day CT scans were evaluated for residual subdural contrast. RESULTS: Of 49 included patients, 5 had subdural injection on day 1, with the second-day CT myelogram available for review. One of these 5 patients had subdural injections on 2 different days and subsequently had chest/abdomen/pelvis CTA a day after the second subdural injection. In all 6 cases of subdural injections, there was complete resolution of subdural contrast on the next-day CT, with the shortest time to resolution of approximately 20.5 hours (range, 20.5-28.5 hours). CONCLUSIONS: Our study suggests that resolution of inadvertently injected subdural contrast occurs within 1 day, and the myelogram can be reattempted as early as the next day.

Lateral Decubitus Digital Subtraction Myelography: Tips, Tricks, and Pitfalls.

Digital subtraction myelography is a valuable diagnostic technique to detect the exact location of CSF leaks in the spine to facilitate appropriate diagnosis and treatment of spontaneous spinal CSF leaks. Digital subtraction myelography is an excellent diagnostic tool for assessment of various types of CSF leaks, and lateral decubitus digital subtraction myelography is increasingly being used to diagnose CSF-venous fistulas. Lateral decubitus digital subtraction myelography differs from typical CT and fluoroscopy-guided myelograms in many ways, including equipment, supplies, and injection and image-acquisition techniques. Operators should be familiar with techniques, common pitfalls, and artifacts to improve diagnostic yield and prevent nondiagnostic examinations.

Regulation of biosimilar medicines and current perspectives on interchangeability and policy.

Competition arising from the increasing availability of biosimilar medicines has resulted in healthcare savings and has provided greater patient access to high cost therapeutics in Europe. The biosimilar market in the USA is relatively new so the full impact of biosimilar availability remains to be seen. Educational initiatives relating to the use of biosimilar medicines are currently being undertaken by regulators, policy makers and industry. The debate on biosimilars has moved on from the appropriateness of the regulatory framework which governs their approval, to the practice of interchangeability. Interchangeability is an important issue for healthcare professionals but different definitions and regulatory frameworks exist in the USA and Europe. In the USA, an interchangeable biological product is a biosimilar which may be substituted by a pharmacist, subject to local State policies. The interchangeability of a biosimilar with its reference medicine will be evaluated by the United States Food and Drug Administration (FDA) in cases where approval as an 'interchangeable product' is sought. In contrast, the European Medicines Agency (EMA) does not assess or make recommendations on interchangeability, therefore, in Europe, interchangeability does not mean substitution but is generally physician-led or driven by national policy. This paper provides an overview of the regulation of biosimilar medicines. Challenges associated with the demonstration of interchangeability and practical considerations relating to switching are also discussed. Finally, we present policies that have been adopted to date in several European countries, the USA and Australia, which aim to promote the use of biosimilar medicines.

Dilated Vein of the Filum Terminale on MRI: A Marker for Deep Lumbar and Sacral Dural and Epidural Arteriovenous Fistulas.

BACKGROUND AND PURPOSE: Conventional MR imaging can provide important clues regarding the location of a spinal vascular malformation. We hypothesized that a dilated vein of the filum terminale, identified as a curvilinear flow void on T2WI, could be an imaging marker for a lower lumbar (L3-L5) or sacral fistula. MATERIALS AND METHODS: We retrospectively identified all spinal dural and spinal epidural arteriovenous fistulas from 2 large tertiary referral centers from 2005 to 2018. All patients had a lumbar spinal MR imaging and a conventional spinal angiography. Images were reviewed by 2 neuroradiologists who categorized the level of the arterial feeder to the fistula and the presence or absence of a dilated vein of the filum terminale on T2WI and T1 postcontrast images. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the presence of a dilated filum terminale vein for a deep lumbar or sacral fistula. RESULTS: One hundred sixty-two patients were included. An enlarged filum terminale vein was identified in 39 patients. Sensitivity, specificity, positive predictive value, and negative predictive value of the presence of a dilated filum terminale vein for a deep lumbar or sacral fistula were 86%, 98.3%, 94.9%, and 95.1%, respectively. CONCLUSIONS: The presence of a dilated vein of the filum terminale can accurately localize a spinal dural arteriovenous fistula/spinal epidural arteriovenous fistula to the lower lumbar or sacral spine in patients being evaluated for such lesions. This finding can be used to facilitate both noninvasive and conventional spinal angiography.

Knowledge of Adverse Drug Reaction Reporting and the Pharmacovigilance of Biological Medicines: A Survey of Healthcare Professionals in Ireland.

BACKGROUND: In Europe, changes to pharmacovigilance legislation, which include additional monitoring of medicines, aim to optimise adverse drug reaction (ADR) reporting systems. The legislation also makes provisions related to the traceability of biological medicines. OBJECTIVE: The objective of this study was to assess (i) knowledge and general experience of ADR reporting, (ii) knowledge, behaviours, and attitudes related to the pharmacovigilance of biologicals, and (iii) awareness of additional monitoring among healthcare professionals (HCPs) in Ireland. METHODS: Hospital doctors (n = 88), general practitioners (GPs) (n = 197), nurses (n = 104) and pharmacists (n = 309) completed an online questionnaire. RESULTS: There were differences in mean knowledge scores relating to ADR reporting and the pharmacovigilance of biologicals among the HCP groups. The majority of HCPs who use biological medicines in their practice generally record biologicals by brand name but practice behaviours relating to batch number recording differed between some professions. HCPs consider batch number recording to be valuable but also regard it as being more difficult than brand name recording. Most respondents were aware of the concept of additional monitoring but awareness rates differed between some groups. Among those who knew about additional monitoring, there was higher awareness of the inverted black triangle symbol among pharmacists (> 86.4%) compared with hospital doctors (35.1%), GPs (35.6%), and nurses (14.9%). Hospital pharmacists had more experience and knowledge of ADR reporting than other practising HCPs. CONCLUSION: This study highlights the important role hospital pharmacists play in post-marketing surveillance. There is a need to increase pharmacovigilance awareness of biological medicines and improve systems to support their batch traceability.

Childhood outcomes following preterm prelabor rupture of the membranes (PPROM): a population-based record linkage cohort study.

OBJECTIVE: The objective of this study is to determine child health, development and educational outcomes for infants born following preterm prelabor rupture of the membrane (PPROM). STUDY DESIGN: Population-based record linkage cohort study using data from NSW, Australia, 2001 to 2014. RESULTS: Of 121 822 births at 20 to 37 weeks, 18 799 (15%) followed PPROM, 56 406 (46%) followed spontaneous labor and 46 617 (38%) were planned. Compared with infants of a similar gestational age born following spontaneous labor or planned delivery, exposure to PPROM did not increase the risk of childhood mortality, childhood hospitalization, developmentally vulnerable at school entry, low reading or numeracy scores. Median latency ranged from 12 days (interquartile range 3 to 37 days) at 25 weeks to 1 day (0 to 2 days) at 36 weeks. Longer latency and more advanced gestational age at birth were associated with better outcomes. CONCLUSION: Infants born following PPROM are at no greater risk of adverse child health, development and education outcomes than those of similar gestational age born without PPROM.

An economic evaluation of planned immediate versus delayed birth for preterm prelabour rupture of membranes: findings from the PPROMT randomised controlled trial.

OBJECTIVE: This study is an economic evaluation of immediate birth compared with expectant management in women with preterm prelabour rupture of the membranes near term (PPROMT). DESIGN: A cost-effectiveness analysis alongside the PPROMT randomised controlled trial. SETTING: Obstetric departments in 65 hospitals across 11 countries. POPULATION: Women with a singleton pregnancy with ruptured membranes between 34+0 and 36+6 weeks gestation. METHODS: Women were randomly allocated to immediate birth or expectant management. Costs to the health system were identified and valued. National hospital costing data from both the UK and Australia were used. Average cost per recruit in each arm was calculated and 95% confidence intervals were estimated using bootstrap re-sampling. Averages costs during antenatal care, delivery and postnatal care, and by country were estimated. MAIN OUTCOMES MEASURES: Total mean cost difference between immediate birth and expectant management arms of the trial. RESULTS: From 11 countries 923 women were randomised to immediate birth and 912 were randomised to expectant management. Total mean costs per recruit were £8852 for immediate birth and £8740 for expectant delivery resulting in a mean difference in costs of £112 (95% CI: -431 to 662). The expectant management arm had significantly higher antenatal costs, whereas the immediate birth arm had significantly higher delivery and neonatal costs. There was large variation between total mean costs by country. CONCLUSION: This economic evaluation found no evidence that expectant management was more or less costly than immediate birth. Outpatient management may offer opportunities for cost savings for those women with delayed delivery. TWEETABLE ABSTRACT: For women with preterm prelabour rupture of the membranes, the relative benefits and harms of immediate and expectant management should inform counselling as costs are similar.

Association between interpregnancy interval and the risk of recurrent loss after a midtrimester loss.

STUDY QUESTION: After an initial midtrimester loss, is the interval to the next conception associated with the risk of a recurrent loss? SUMMARY ANSWER: Among women who had a pregnancy loss at 14-19 weeks gestation, conception at least 3 months after this initial loss was associated with a reduced risk of a recurrent loss. WHAT IS KNOWN ALREADY: A short interpregnancy interval (IPI) has been thought to increase risk but recent studies of pregnancy after a loss have found no effect; however, these studies have been based almost entirely on an initial first trimester (<14 weeks) loss. STUDY DESIGN, SIZE, DURATION: A retrospective cohort study drawing on over 997 000 linked birth and hospital records from New South Wales, Australia for 2003-2011. Index pregnancies were those of women who had a first recorded pregnancy loss of 14-23 weeks gestation (miscarriage, termination and perinatal death). The study population was 4290 women who conceived again within 2 years. PARTICIPANTS/MATERIALS, SETTING, METHODS: The index loss was categorized by subgroups: 14-19 weeks gestation versus 20-23 weeks, and by whether spontaneous or a termination. The primary outcome was any loss or perinatal death before 24 weeks in the subsequent pregnancy. MAIN RESULTS AND THE ROLE OF CHANCE: After a 14-19 weeks index loss, an IPI of ≤3 months had an increased rate of recurrent loss compared with an IPI of >9-12 months: 21.9% versus 11.3% (adjusted relative risk (aRR) = 2.02, 95% CI 1.44-2.83). For women who had a spontaneous index loss of 20-23 weeks, there was no evidence that a short IPI increased or decreased the risk of recurrent loss. For any gestational age group of index losses, an IPI of >18-24 months increased the risk of a recurrent loss; the risk was highest after a 20-23 weeks index loss (aRR = 2.15, 95% CI 1.18-3.91). LIMITATIONS, REASONS FOR CAUTION: We do not know how many cycles were required to achieve conception. Pregnancies resulting in early first trimester losses are unlikely to have resulted in hospitalization so would not have been identified. WIDER IMPLICATIONS OF THE FINDINGS: The risk of recurrent loss after an initial midtrimester loss may differ from the risk after an initial first trimester loss. STUDY FUNDING/COMPETING INTERESTS: This work was supported by an Australian National Health and Medical Research Council (NHMRC) Centre for Research Excellence Grant (1001066). C.L.R. is supported by an NHMRC Senior Research Fellowship (#APP1021025). J.B.F. is supported by an ARC Future Fellowship (#120100069). The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Lethal and sub-lethal effects of Deepwater Horizon slick oil and dispersant on oyster (Crassostrea virginica) larvae.

In April 2010, crude oil was spilled from the Deepwater Horizon (DWH) oil platform for 87 days, coincident with the spawning season and recruitment of the oyster, Crassostrea virginica, in the Gulf of Mexico. Impacts of acute exposures to surface-collected DWH oil (HEWAF), dispersed oil (CEWAF) and dispersant alone (Corexit 9500A(®)) on planktonic larval stages of C. virginica (veliger, umbo and pediveliger) were tested in the laboratory. Exposures to HEWAF, CEWAF and dispersant were toxic to larvae impairing growth, settlement success and ultimately survival. Larval growth and settlement were reduced at concentrations of tPAH50 ranging from 1.7 to 106 µg L(-1) for HEWAF and 1.1-35 µg L(-1) for CEWAF, concentrations well within the range of water sampled during the DWH oil spill. Sublethal effects induced by oil and dispersant could have significant ecological implications on oyster populations and on the whole estuarine ecosystem.

SAPHO Syndrome: Imaging Findings of Vertebral Involvement.

BACKGROUND AND PURPOSE: Imaging findings in patients with a combination of synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) are often misinterpreted as discitis/osteomyelitis or metastases, resulting in multiple biopsies and delayed diagnosis. We have incidentally noted a semicircular morphology in vertebral body imaging in several cases of SAPHO syndrome with vertebral involvement. Our goal was to evaluate the prevalence of this distinctive morphology in these patients. MATERIALS AND METHODS: A retrospective review of patients with SAPHO syndrome diagnosed between July 1998 and August 2013 was conducted. A descriptive analysis of MR imaging, CT, radiography, bone scanning, and PET imaging was performed for the presence and distribution of vertebral body signal intensity or attenuation changes and/or enhancement; contiguous vertebral body involvement; vertebral body collapse; endplate irregularity; disc space, facet, and spinous process involvement; subligamentous thickening; and paraspinal soft-tissue involvement. RESULTS: Eighteen patients (16 women [89%]; mean age, 52.9 years) with SAPHO and spine involvement were included. Contiguous involvement of ≥2 vertebral bodies was found in 16 patients (89%), with a curvilinear or "semicircular" pattern involving portions of adjacent vertebral bodies in 10 (63%, P = .14). Most intervertebral discs demonstrated absence of abnormal T2 hyperintensity (73%) and enhancement (89%). Subligamentous thickening was present in 12 (67%). Paraspinal soft-tissue involvement was present in 6 (33%). CONCLUSIONS: SAPHO syndrome should be included in the differential diagnosis in a patient with a curvilinear or semicircular pattern of vertebral involvement, contiguous vertebral body involvement, and absence of intervertebral disc edema and enhancement.

High maternal iron status, dietary iron intake and iron supplement use in pregnancy and risk of gestational diabetes mellitus: a prospective study and systematic review.

AIM: High iron measured using dietary intake and biomarkers is associated with Type 2 diabetes. It is uncertain whether a similar association exists for gestational diabetes mellitus. The aim of this systematic review was to conduct a cohort study examining first trimester body iron stores and subsequent risk of gestational diabetes, and to include these findings in a systematic review of all studies examining the association between maternal iron status, iron intake (dietary and supplemental) and the risk of gestational diabetes. METHODS: Serum samples from women with first trimester screening were linked to birth and hospital records for data on maternal characteristics and gestational diabetes diagnosis. Blood was analysed for ferritin, soluble transferrin receptor and C-reactive protein. Associations between iron biomarkers and gestational diabetes were assessed using multivariate logistic regression. A systematic review and meta-analysis, registered with PROSPERO (CRD42014013663) included studies of all designs published in English from January 1995 to July 2015 that examined the association between iron and gestational diabetes and included an appropriate comparison group. RESULTS: Of 3776 women, 3.4% subsequently developed gestational diabetes. Adjusted analyses found increased odds of gestational diabetes for ferritin (OR 1.41; 95% CI 1.11, 1.78), but not for soluble transferrin receptor (OR 1.00; 95% CI 0.97, 1.03) per unit increase of the biomarker. Two trials of iron supplementation found no association with gestational diabetes. Increased risk of gestational diabetes was associated with higher levels of ferritin and serum iron and dietary haem iron intakes. CONCLUSIONS: Increased risk of gestational diabetes among women with high serum ferritin and iron levels and dietary haem iron intakes warrants further investigation.

Fluoroscopically guided transforaminal epidural steroid injections at a quaternary-care teaching institution: effect of trainee involvement and patient body mass index on fluoroscopy time and patient dose.

AIM: To investigate whether there are differences in fluoroscopy time and patient dose for fluoroscopically guided lumbar transforaminal epidural steroid injections (TFESIs) performed by staff radiologists versus with trainees and to evaluate the effect of patient body mass index (BMI) on fluoroscopy time and patient dose, including their interactions with other variables. MATERIALS AND METHODS: Single-level lumbar TFESIs (n=1844) between 1 January 2011 and 31 December 2013 were reviewed. Fluoroscopy time, reference point air kerma (Ka,r), and kerma area product (KAP) were recorded. BMI and trainee involvement were examined as predictors of fluoroscopy time, Ka,r, and KAP in models adjusted for age and gender in multivariable linear models. Stratified models of BMI groups by trainee presence were performed. RESULTS: Increased age was the only significant predictor of increased fluoroscopy time (p<0.0001). Ka,r and KAP were significantly higher in patients with a higher BMI (p<0.0001 and p=0.0009). When stratified by BMI, longer fluoroscopy time predicted increased Ka,r and KAP in all groups (p<0.0001). Trainee involvement was not a statistically significant predictor of fluoroscopy time or Ka,r in any BMI category. KAP was lower with trainees in the overweight group (p=0.0009) and higher in male patients for all BMI categories (p<0.02). CONCLUSION: Trainee involvement did not result in increased fluoroscopy time or patient dose. BMI did not affect fluoroscopy time; however, overweight and obese patients received significantly higher Ka,r and KAP. Male patients received a higher KAP in all BMI categories. Limiting fluoroscopy time and good collimation practices should be reinforced in these patients.

Predicting High-Flow Spinal CSF Leaks in Spontaneous Intracranial Hypotension Using a Spinal MRI-Based Algorithm: Have Repeat CT Myelograms Been Reduced?

BACKGROUND AND PURPOSE: We adopted an imaging algorithm in 2011 in which extradural fluid on spinal MR imaging directs dynamic CT myelography. We assessed algorithm compliance and its effectiveness in reducing repeat or unnecessary dynamic CT myelograms. MATERIALS AND METHODS: CT myelograms for CSF leaks from January 2011 to September 2014 were reviewed. Patients with iatrogenic leaks, traumatic brachial plexus injuries, or prior CT myelography within 2 years were excluded. Completion and results of spinal MR imaging, CT myelographic technique, and the need for repeat CT myelography or unnecessary dynamic CT myelograms were recorded. RESULTS: The algorithm was followed in 102 (79%) of 129 patients. No extradural fluid was detected in 75 (74%), of whom 70 (93%) had no leak, 4 (5%) had a slow leak, and 1 (1%) had a fast leak. Extradural fluid was detected in 27 (26%): 24 (89%) fast leaks, 1 (4%) slow leak, and 2 (7%) with no leaks. When the algorithm was followed, 1 (1%) required repeat CT myelography and 3 (3%) had unnecessary dynamic CT myelograms. The algorithm was breached in 27 (21%) cases, including no pre-CT myelogram MR imaging in 11 (41%), performing conventional CT myelography when extradural fluid was present in 13 (48%), and performing dynamic CT myelography when extradural fluid was absent in 3 (11%). Algorithm breaches resulted in 4 (15%) repeat CT myelograms and 3 (12%) unnecessary dynamic CT myelograms, both higher than with algorithm compliance. CONCLUSIONS: Using spinal MR imaging to direct CT myelography resulted in significant reduction in repeat CT myelograms to localize fast leaks with minimal unnecessary dynamic CT myelograms.

Iron deficiency in early pregnancy using serum ferritin and soluble transferrin receptor concentrations are associated with pregnancy and birth outcomes.

BACKGROUND/OBJECTIVES: There are several biomarkers for measuring iron deficiency (ID) in pregnancy, but the prevalence of ID and its association with inflammation and adverse pregnancy outcomes is inconclusive. The aim of this work was to describe the prevalence and determinants of first trimester ID and associations with pregnancy and birth outcomes. SUBJECTS/METHODS: A record-linkage cohort study of archived serum samples of women attending first trimester screening and birth and hospital data to ascertain maternal characteristics and pregnancy outcomes. Sera were analysed for iron stores (ferritin; µg/l), lack of iron in the tissues (soluble transferrin receptor (sTfR); nmol/l) and inflammatory (C-reactive protein (CRP); mg/dl) biomarkers. Total body iron (TBI) was calculated from serum ferritin (SF) and sTfR concentrations. Multivariate logistic regression analysed risk factors and pregnancy outcomes associated with ID using the definitions: SF<12 µg/l, TfR ⩾ 21.0 nmol/l, and TBI<0 mg/kg. RESULTS: Of the 4420 women, the prevalence of ID based on ferritin, sTfR and TBI was 19.6, 15.3 and 15.7%, respectively. Risk factors of ID varied depending on which iron parameter was used and included maternal age <25 years, multiparity, socioeconomic disadvantage, high maternal body weight and inflammation. ID, defined by SF and TBI but not TfR, was associated with reduced risk of gestational diabetes mellitus (GDM). ID defined using TBI only was associated with increased risk of large-for-gestation-age (LGA) infants. CONCLUSIONS: Nearly one in five Australian women begin pregnancy with ID. Further investigation of excess maternal weight and inflammation in the relationships between ID and GDM and LGA infants is needed.