Utility of whole-body (head-to-toe) PET/CT in the evaluation of melanoma and sarcoma patients.

OBJECTIVE: The aim of this study was to assess the added benefit of whole-body (head-to-toes) PET/CT versus routine 'eyes-to-thighs' PET/CT of melanoma and sarcoma patients. PATIENTS AND METHODS: We performed a retrospective review of consecutive whole-body PET/CT scans from January 2006 through December 2010 in patients with melanoma or sarcoma. PET abnormalities in the brain, distal thighs, and legs were recorded and clinical significance was assessed on the basis of pathology, imaging studies, and clinical follow-up. Patients with known primary lesions distal to the proximal femora were excluded as these patients would routinely undergo 'head-to-toe' PET/CT. RESULTS: We reviewed reports from 352 PET/CT examinations in 194 patients with melanoma and 75 PET/CT examinations in 44 patients with sarcoma. Melanoma: 13 patients had brain metastases on PET. In five of these patients, lesions were unknown, but all were in the setting of other metastatic disease. Twenty-seven patients had lower extremity metastases, all in the setting of other metastatic disease. No lower extremity metastases were found in the remaining 167 patients. Sarcoma: one patient had an isolated, unexpected brain metastasis. Six patients had leg metastases, but none were isolated. No lower extremity metastases were found in the remaining 38 patients. CONCLUSION: In patients with melanoma and sarcoma, inclusion of entire lower extremities adds little additional clinical value as detection of isolated, unexpected metastasis is rare. Brain imaging may add value as the presence of brain metastases alters clinical management. Overall, in patients with melanoma or sarcoma, whole-brain PET/CT imaging may be of value, but routine inclusion of the entire lower extremities adds little additional value.

Incidence and Duration of Continuously Measured Oxygen Desaturation During Emergency Department Intubation.

STUDY OBJECTIVE: Desaturation during intubation has been associated with serious complications, including dysrhythmias, hemodynamic decompensation, hypoxic brain injury, and cardiac arrest. We seek to determine the incidence and duration of oxygen desaturation during emergency department (ED) rapid sequence intubation. METHODS: This study included adult rapid sequence intubation cases conducted between September 2011 and July 2012 in an urban, academic, Level I trauma center ED. We obtained continuous vital signs with BedMasterEX data acquisition software. Start and completion times of rapid sequence intubation originated from nursing records. We defined oxygen desaturation as (1) cases exhibiting SpO2 reduction to less than 90% if the starting SpO2 was greater than or equal to 90%, or (2) a further reduction in SpO2 in cases in which starting SpO2 was less than 90%. We used multivariable logistic regression to predict oxygen desaturation during rapid sequence intubation. RESULTS: During the study period, there were 265 rapid sequence intubation cases. The study excluded 99 cases for failure of electronic data acquisition, inadequate documentation, or poor SpO2 waveform during rapid sequence intubation, and excluded cases managed by anesthesia providers, leaving 166 patients in the analysis. After preoxygenation, starting SpO2 was greater than 93% in 124 of 166 cases (75%) and SpO2 was less than 93% in the remaining 46 cases. Oxygen desaturation occurred in 59 patients (35.5%). The median duration of desaturation was 80 seconds (interquartile range 40, 155). Multivariable analysis demonstrated that oxygen desaturation was associated with preintubation SpO2 less than 93% (odds ratio [OR] 5.1; 95% confidence interval (CI) 2.3 to 11.0), multiple intubation attempts (>1 attempt) (OR 3.4; 95% CI 1.4 to 6.1), and rapid sequence intubation duration greater than 3 minutes (OR 2.7; 95% CI 1.2 to 6.1). CONCLUSION: In this series, 1 in 3 patients undergoing ED rapid sequence intubation experienced oxygen desaturation for a median duration of 80 seconds. Preintubation saturation less than 93%, multiple intubation attempts, and prolonged intubation time are independently associated with oxygen desaturation. Clinicians should use strategies to prevent oxygen desaturation during ED rapid sequence intubation.

Calcaneal osteochondroma.

Osteochondromas are essentially the most common primary bone tumors. These benign cartilage producing neoplasms are generally asymptomatic and have a relatively small potential for adverse effects. HME, the familial form of this tumor, is associated with a greater incidence of complications, the most significant of which is sarcomatous degeneration to secondary chondrosarcomas. Various imaging techniques can be used to characterize these lesions, but in the absence of symptoms or signs of complications, plain-film radiography is usually sufficient for diagnosis as this tumor has a characteristic radiographic appearance. Once this benign tumor is identified and more serious forms of tumor are ruled out, treatment is generally not needed. If a malignancy is suspected, however, complete surgical excision is the preferred treatment as this usually ensures long term survival.

Milk-alkali syndrome: a historical review and description of the modern version of the syndrome.

Formerly recognized primarily for its historic interest as a disorder found in those taking milk and bicarbonate for peptide ulcer disease, milk-alkali syndrome (MAS) is experiencing a resurgence in its incidence largely due to the increased usage of calcium carbonate. The modern version of MAS affects a different patient population and has a different etiologic basis than was characterized in the original descriptions of the syndrome. Advances in parathyroid hormone measurement have allowed for improved diagnostic separation between MAS and hyperparathyroidism and have further explained some of the physiologic responses in the resolution of hypercalcemia. We have reviewed the reasons for the increasing incidence of MAS, described the typical patient with the modern form of the syndrome, and further elaborated on the pathophysiology of MAS, as it is currently understood. MAS is an important diagnostic consideration in the patient with hypercalcemia because the syndrome is now common and prompt diagnosis limits permanent kidney function impairment but depends strongly on considering the diagnosis as well as obtaining an over-the-counter medication history.

Hemophilic pseudotumor.

Bleeding diatheses are a hallmark of hemophilia. Hemophilic pseudotumor results from multiple episodes of hemorrhage into bones or soft tissue spaces. It is uncommon and is seen in severe cases of hemophilia only 1-2% of the time. Complications and symptoms arise due to pain and/or compression of surrounding structures. Pathologic fractures can be associated with intraosseous lesions and can result from bone destruction or resorption due to the chronic pressure of an osseous hemorrhage. Radiographs may demonstrate expansile lesions of the bones or increased soft tissue density that may be associated with extra osseous lesions. Bleeding may also occur within the joint space. These intra-articular hemorrhages can, over time, result in hemophilic arthropathy. The following case report demonstrates both an expansile lesion of a metacarpal as well as hemophilic knee arthropathy in an 11 year old.

Pubic symphyseal width in pediatric patients.

Traditionally, there has been no readily available and statistically sound method for evaluating the normal pubic symphyseal width in children. Normal values for the width of the pubic symphysis in the pediatric population are useful for determining pathologic widening, either congenital or posttraumatic. This investigation was directed at determining a reference range for the normal pubic symphyseal width according to age, age group, gender, and when combining these variables. Overall, the study found that the normal measurement for pediatric pubic symphyseal width ranges from 0.52 to 0.84 cm. The data also showed that the mean pubic symphyseal width for all variables combined was 0.68 cm (standard deviation of 0.16 cm and a 95% confidence interval of 0.668 to 0.690) and that anything greater than 0.84 cm needs further evaluation for pathology. The interclass correlation coefficient, test of interrater reliability, yielded moderate reliability of measurements between physicians.