Differences in cardiac testing resource utilization using two different risk stratification schemes.

OBJECTIVE: Assess whether changing an emergency department (ED) chest pain pathway from utilizing the Thrombolysis in Myocardial Infarction (TIMI) score for risk stratification to an approach utilizing the History, EKG, Age, Risk, Troponin (HEART) score was associated with reductions in healthcare resource utilization. METHODS: A retrospective, quasi-experimental study using difference-in-differences and interrupted time series specifications evaluated all ED patients with a chest pain encounter from 8/2015 to 7/2019 at a large academic medical center. We included patients age ≥ 18 with negative troponin testing discharged from the ED. Our standardized care pathway utilized TIMI for risk stratification until 09/2017 and HEART thereafter. We evaluated patients undergoing hospital-based cardiac diagnostic testing (CDT), length of stay (LOS), and 30-day Major Adverse Cardiovascular Events (MACE) at the intervention site before and after the pathway change and compared these outcomes to a similar control site within the health system for the difference-in-differences specification. RESULTS: During the study period, 6.3% (450 of 7117) of patients in the TIMI cohort and 7.2% (546 of 7623) in the HEART cohort among 400,965 total ED visits underwent CDT. In a multivariable analysis, transition to the HEART pathway was associated with greater odds of receiving CDT (odds ratio 2.88 [95% CI 1.21 to 6.86]), a reduction in LOS of 34 min (95% CI 2.2 to 67.6), and no significant difference in 30-day MACE. CONCLUSION: The transition from TIMI to HEART was associated with mixed consequences for healthcare resource utilization, including increased CDT but reduced length of stay.

Interscalene Brachial Plexus Block with Liposomal Bupivacaine versus Standard Bupivacaine with Perineural Dexamethasone: A Noninferiority Trial.

BACKGROUND: The interscalene nerve block provides analgesia for shoulder surgery. To extend block duration, provide adequate analgesia, and minimize opioid consumption, the use of adjuvants such as dexamethasone as well as the application of perineural liposomal bupivacaine have been proposed. This randomized, double-blinded, noninferiority trial hypothesized that perineural liposomal bupivacaine is noninferior to standard bupivacaine with perineural dexamethasone in respect to average pain scores in the first 72 h after surgery. METHODS: A total of 112 patients undergoing ambulatory shoulder surgery were randomized into two groups. The liposomal bupivacaine group received a 15-ml premixed admixture of 10 ml of 133 mg liposomal bupivacaine and 5 ml of 0.5% bupivacaine (n = 55), while the bupivacaine with dexamethasone group received an admixture of 15 ml of 0.5% standard bupivacaine with 4 mg dexamethasone (n = 56), respectively. The primary outcome was the average numerical rating scale pain scores at rest over 72 h. The mean difference between the two groups was compared against a noninferiority margin of 1.3. Secondary outcomes were analgesic block duration, motor and sensory resolution, opioid consumption, numerical rating scale pain scores at rest and movement on postoperative days 1 to 4 and again on postoperative day 7, patient satisfaction, readiness for postanesthesia care unit discharge, and adverse events. RESULTS: A liposomal bupivacaine group average numerical rating scale pain score over 72 h was not inferior to the bupivacaine with dexamethasone group (mean [SD], 2.4 [1.9] vs. 3.4 [1.9]; mean difference [95% CI], -1.1 [-1.8, -0.4]; P < 0.001 for noninferiority). There was no significant difference in duration of analgesia between the groups (26 [20, 42] h vs. 27 [20, 39] h; P = 0.851). Motor and sensory resolutions were similar in both groups: 27 (21, 48) h versus 27 (19, 40) h (P = 0.436) and 27 [21, 44] h versus 31 (20, 42) h (P = 0.862), respectively. There was no difference in opioid consumption, readiness for postanesthesia care unit discharge, or adverse events. CONCLUSIONS: Interscalene nerve blocks with perineural liposomal bupivacaine provided effective analgesia similar to the perineural standard bupivacaine with dexamethasone. The results show that bupivacaine with dexamethasone can be used interchangeably with liposomal bupivacaine for analgesia after shoulder surgery.

Comparison of electrodiagnosis, neurosonography and MR neurography in localization of ulnar neuropathy at the elbow.

INTRODUCTION: In patients with ulnar neuropathy at the elbow (UNE) the precise determination of the site of lesion is important for subsequent differential diagnostic considerations and therapeutic management. Due to a paucity of comparable data, to better define the role of different diagnostic tests, we performed the first prospective study comparing the diagnostic accuracy of short segment nerve stimulation, nerve ultrasonography, MR neurography (MRN), and diffusion tensor imaging (DTI) in patients with UNE. METHODS: UNE was clinically diagnosed in 17 patients with 18 affected elbows. For all 18 affected elbows in patients and 20 elbows in 10 healthy volunteers, measurements of all different diagnostic tests were performed at six anatomical positions across the elbow with measuring points from distal (D4) to proximal (P6) in relation to the medial epicondyle (P0). Additional qualitative assessment regarding structural changes of surrounding nerve anatomy was conducted. RESULTS: The difference between affected arms of patients and healthy control arms were most frequently the largest at measure intervals D2 to P0 and P0 to P2 for electrophysiological testing, or measure points P0 and P2 for all other devices, respectively. At both levels P0 and at P2, T2 contrast-to-noise ratio (CNR) of MRN and mean diffusivity (MD) of DTI-based MRN showed best accuracies. DISCUSSION: This study revealed differences in diagnostic performance of tests concerning a specific location of UNE, with better results for T2 contrast to noise ratio (CNR) in MRN and mean diffusivity of DTI-based MRN. Additional testing with MRN and nerve ultrasonography is recommended to uncover anatomical changes.

Improving quality of life through the routine use of the patient concerns inventory for head and neck cancer patients: main results of a cluster preference randomised controlled trial.

PURPOSE: The patient concerns inventory (PCI) is a prompt list allowing head and neck cancer (HNC) patients to discuss issues that otherwise might be overlooked. This trial evaluated the effectiveness of using the PCI at routine outpatient clinics for one year after treatment on health-related QOL (HRQOL). METHODS: A pragmatic cluster preference randomised control trial with 15 consultants, 8 'using' and 7 'not using' the PCI intervention. Patients treated with curative intent (all sites, disease stages, treatments) were eligible. RESULTS: Consultants saw a median (inter-quartile range) 16 (13-26) patients, with 140 PCI and 148 control patients. Of the pre-specified outcomes, the 12-month results for the mean University of Washington Quality of Life (UW-QOLv4) social-emotional subscale score suggested a small clinical effect of intervention of 4.6 units (95% CI 0.2, 9.0), p = 0.04 after full adjustment for pre-stated case-mix. Results for UW-QOLv4 overall quality of life being less than good at 12 months (primary outcome) also favoured the PCI with a risk ratio of 0.83 (95% CI 0.66, 1.06) and absolute risk 4.8% (- 2.9%, 12.9%) but without achieving statistical significance. Other non-a-priori analyses, including all 12 UWQOL domains and at consultant level also suggested better HRQOL with PCI. Consultation times were unaffected and the number of items selected decreased over time. CONCLUSION: This novel trial supports the integration of the PCI approach into routine consultations as a simple low-cost means of benefiting HNC patients. It adds to a growing body of evidence supporting the use of patient prompt lists more generally.

Improving quality of life through the routine use of the patient concerns inventory for head and neck cancer patients: baseline results in a cluster preference randomised controlled trial.

PURPOSE: The main aim of this paper is to present baseline demographic and clinical characteristics and HRQOL in the two groups of the Patient Concerns Inventory (PCI) trial. The baseline PCI data will also be described. METHODS: This is a pragmatic cluster preference randomised control trial with 15 consultant clusters from two sites either 'using' (n = 8) or 'not using' (n = 7) the PCI at a clinic for all of their trial patients. The PCI is a 56-item prompt list that helps patients raise concerns that otherwise might be missed. Eligibility was head and neck cancer patients treated with curative intent (all sites, stage of disease, treatments). RESULTS: From 511 patients first identified as eligible when screening for the multi-disciplinary tumour board meetings, 288 attended a first routine outpatient baseline study clinic after completion of their treatment, median (IQR) of 103 (71-162) days. At baseline, the two trial groups were similar in demographic and clinical characteristics as well as in HRQOL measures apart from differences in tumour location, tumour staging and mode of treatment. These exceptions were cluster (consultant) related to Maxillofacial and ENT consultants seeing different types of cases. Consultation times were similar, with PCI group times taking about 1 min longer on average (95% CL for the difference between means was from - 0.7 to + 2.2 min). CONCLUSION: Using the PCI in routine post-treatment head and neck cancer clinics do not elongate consultations. Recruitment has finished but 12-month follow-up is still ongoing.

Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block: A Randomized Controlled Trial.

BACKGROUND: Interscalene nerve blockade remains one of the most commonly used anesthetic and analgesic approaches for shoulder surgery. The high incidence of hemidiaphragmatic paralysis associated with the block, however, precludes its use among patients with compromised pulmonary function. To address this issue, recent studies have investigated phrenic-sparing alternatives that provide analgesia. None, however, have been able to reliably demonstrate surgical anesthesia without significant risk for hemidiaphragmatic paralysis. The utility of the superior trunk block has yet to be studied. The hypothesis was that compared with the interscalene block, the superior trunk block will provide noninferior surgical anesthesia and analgesia while sparing the phrenic nerve. METHODS: This randomized controlled trial included 126 patients undergoing arthroscopic ambulatory shoulder surgery. Patients either received a superior trunk block (n = 63) or an interscalene block (n = 63). The primary outcomes were the incidence of hemidiaphragmatic paralysis and worst pain score in the recovery room. Ultrasound was used to assess for hemidiaphragmatic paralysis. Secondary outcomes included noninvasively measured parameters of respiratory function, opioid consumption, handgrip strength, adverse effects, and patient satisfaction. RESULTS: The superior trunk group had a significantly lower incidence of hemidiaphragmatic paralysis compared with the interscalene group (3 of 62 [4.8%] vs. 45 of 63 [71.4%]; P < 0.001, adjusted odds ratio 0.02 [95% CI, 0.01, 0.07]), whereas the worst pain scores in the recovery room were noninferior (0 [0, 2] vs. 0 [0, 3]; P = 0.951). The superior trunk group were more satisfied, had unaffected respiratory parameters, and had a lower incidence of hoarseness. No difference in handgrip strength or opioid consumption were detected. Superior trunk block was associated with lower worst pain scores on postoperative day 1. CONCLUSIONS: Compared with the interscalene block, the superior trunk block provides noninferior surgical anesthesia while preserving diaphragmatic function. The superior trunk block may therefore be considered an alternative to traditional interscalene block for shoulder surgery.

Early Clinical Exposure to Geriatric Psychiatry and Medical Students' Interest in Caring for Older Adults: A Randomized Controlled Trial.

OBJECTIVE: In the next 25 years, the population aged 65 and older will nearly double in many countries, with few new doctors wishing to care for older adults. The authors hypothesize that early clinical exposure to elderly patient care could increase student interest in caring for older adults during their future career. METHODS: The authors conducted a pragmatic medical education randomized controlled trial (RCT) at the Jewish General Hospital and the Douglas Mental Health Institute, McGill University, in Montreal, Canada. Third-year medical students undergoing their mandatory 16-week half-time clerkship rotation in psychiatry were randomly assigned to the equivalent of 2-4 weeks of full-time exposure to clinical geriatric psychiatry (n = 84). RESULTS: Being randomly assigned to geriatric psychiatry exposure (n = 44 of 84) was associated with increased "comfort in working with geriatric patients and their families" at 16-week follow-up (59.1% versus 37.5%, χ2 (1) = 3.9; p = 0.05). However, there was no significant association found between geriatric psychiatry exposure and change "in interest in caring for older adults," or change in "interest in becoming a geriatric psychiatrist." CONCLUSION: The results of this pragmatic education RCT suggest that exposing third-year medical students to 2-4 weeks of geriatric psychiatry did not increase their interest to care for older adults or become a geriatric psychiatrist. However, it did increase their comfort level in working with older adults and their families. However, more research is necessary to identify potential interventions that could inspire and increase medical student interest in caring for older adults as part of their future careers.

Pre-procedural CT angiography inferior vena cava measurements: a predictor of mortality in patients undergoing transcatheter aortic valve implantation.

OBJECTIVES: To assess the value of pre-procedural computed tomography angiography (CTA) measurements of the suprahepatic inferior vena cava (IVC) to detect elevated central venous pressure (CVP) assessed by right heart catheterisation (RHC), and to predict post-procedural 1-year mortality in a cohort of patients undergoing transcatheter aortic valve implantation (TAVI). METHODS: We retrospectively evaluated 408 consecutive patients undergoing CTA before TAVI between January 2011 and December 2014. Two hundred and five patients were included in the RHC cohort, who underwent RHC and CTA within ≤1 day prior to TAVI. Two hundred and three patients not fulfilling this requirement were included in the validation cohort. Measurements of the IVC were performed between diaphragm and right atrium on axial slices. Receiver operating characteristic (ROC) analyses, Kaplan-Meier analyses and Cox regression analyses were performed. RESULTS: In the RHC cohort, ROC curve analyses for IVC area measurements indicated an AUC of 0.77 (p < 0.001) to detect CVP ≥10mmHg and an area under the ROC curve (AUC) of 0.72 (p < 0.001) to predict 1-year mortality. An IVC area cut-off of ≥665 mm2 predicted 1-year mortality with a specificity of 84% and a sensitivity of 63%. Kaplan-Meier analysis showed that patients with an IVC area ≥665 mm2 had a significantly higher post-procedural 1-year mortality (38% versus 7%, log-rank p < 0.001) with a hazard ratio of 5.5 (95% CI, 2.2-13.6; p < 0.001). Applying this cut-off value to the validation cohort confirmed a significantly higher 1-year mortality after TAVI (34% versus 11%; log-rank p = 0.004) for patients with an IVC area ≥665 mm2. CONCLUSIONS: Pre-procedural enlargement of the suprahepatic IVC is a predictor of post-procedural 1-year mortality in patients evaluated for TAVI. KEY POINTS: • IVC measurements are moderate predictors of an elevated CVP in TAVI patients. • Pre-procedural IVC enlargement is a predictor of 1-year mortality after TAVI. • IVC enlargement is associated with right heart dysfunction in TAVI patients.

Patterns of utilization and effects of hospital-specific factors on physical, occupational, and speech therapy for critically ill patients with acute respiratory failure in the USA: results of a 5-year sample.

BACKGROUND: Timely initiation of physical, occupational, and speech therapy in critically ill patients is crucial to reduce morbidity and improve outcomes. Over a 5-year time interval, we sought to determine the utilization of these rehabilitation therapies in the USA. METHODS: We performed a retrospective cohort study utilizing a large, national administrative database including ICU patients from 591 hospitals. Patients over 18 years of age with acute respiratory failure requiring invasive mechanical ventilation within the first 2 days of hospitalization and for a duration of at least 48 h were included. RESULTS: A total of 264,137 patients received invasive mechanical ventilation for a median of 4.0 [2.0-8.0] days. Overall, patients spent a median of 5.0 [3.0-10.0] days in the ICU and 10.0 [7.0-16.0] days in the hospital. During their hospitalization, 66.5%, 41.0%, and 33.2% (95% CI = 66.3-66.7%, 40.8-41.2%, 33.0-33.4%, respectively) received physical, occupational, and speech therapy. While on mechanical ventilation, 36.2%, 29.7%, and 29.9% (95% CI = 36.0-36.4%, 29.5-29.9%, 29.7-30.1%) received physical, occupational, and speech therapy. In patients receiving therapy, their first physical therapy session occurred on hospital day 5 [3.0-8.0] and hospital day 6 [4.0-10.0] for occupational and speech therapy. Of all patients, 28.6% (95% CI = 28.4-28.8%) did not receive physical, occupational, or speech therapy during their hospitalization. In a multivariate analysis, patients cared for in the Midwest and at teaching hospitals were more likely to receive physical, occupational, and speech therapy (all P < 0.05). Of patients with identical covariates receiving therapy, there was a median of 61%, 187%, and 70% greater odds of receiving physical, occupational, and speech therapy, respectively, at one randomly selected hospital compared with another (median odds ratio 1.61, 2.87, 1.70, respectively). CONCLUSIONS: Physical, occupational, and speech therapy are not routinely delivered to critically ill patients, particularly while on mechanical ventilation in the USA. The utilization of these therapies varies according to insurance coverage, geography, and hospital teaching status, and at a hospital level.

Utility of prehospital electrocardiogram characteristics as prognostic markers in out-of-hospital pulseless electrical activity arrests.

BACKGROUND: It is unclear if there are predictors of survival, including ECG characteristics, that can guide resuscitative efforts in pulseless electrical activity (PEA) cardiac arrests. We studied the predictive potential of presenting prehospital ECGs on survival for patients with out-of-hospital cardiac arrest (OHCA) with PEA. METHODS: We studied prehospital ECGs of patients with OHCA prospectively enrolled between June 2007 and November 2009 at the Ottawa/OPALS (Ontario Prehospital Advanced Life Support Study) site of the Resuscitation Outcomes Consortium PRIMED study (Prehospital Resuscitation using an IMpedance valve and Early versus Delayed analysis). We included adult non-traumatic OHCA with PEA rhythm where resuscitation was attempted. We measured HR, QRS interval and presence of P waves, and determined their impact on return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD) using multivariate regression analysis. RESULTS: The demographic characteristics of the 332 included cases were the following: mean age 71.8, male 58.4%, SHD 5.4% and ROSC at ED arrival 26.5%. Survivors had similar HR (56.8 vs 52.0 beats per minute (bpm), p=0.53) and QRS intervals (128.7 vs 129.6 ms, p=0.95) compared with non-survivors. Prehospital ECG characteristics did not predict SHD or ROSC on multivariate analyses. Patients with initial HR <30 bpm had a 3.8% survival rate; those with both HR <30 bpm and QRS≥120 ms had a 3.7% survival rate. Location of arrest predicted SHD (adjusted OR (AdjOR)=1.49, 1.11 to 1.99; p=0.007). Atropine use negatively predicted SHD (AdjOR=0.06, 0.02 to 0.22; p<0.001). Predictors of ROSC ALS paramedic on scene (AdjOR=8.90, 1.11 to 71.41; p=0.04) and successful intubation (AdjOR=3.35, 1.75 to 6.39; p<0.001). Atropine use negatively predicted ROSC (AdjOR=0.27, 0.14 to 0.50; p<0.001). CONCLUSIONS: Presenting prehospital ECG characteristics did not predict SHD or ROSC in OHCA PEA victims and should not be used to guide termination of resuscitation. Location of arrest was a positive predictor for SHD; atropine use was a negative predictor. ALS paramedic on scene and successful intubation were positive predictors of ROSC; atropine use was a negative predictor. TRIAL REGISTRATION NUMBER: NCT00394706; post-results.

Effects of kneeling posture on chest compression during cardiopulmonary resuscitation in males.

AIMS AND OBJECTIVES: To study the effects of kneeling posture on chest compression during cardiopulmonary resuscitation (CPR) in males. BACKGROUND: Efficiency of chest compression during CPR affected millions of victims over the world. There are still no clear guidelines on kneeling posture that a rescuer should adopt in performing CPR. DESIGN: A self-controlled repeated-measures design was applied in this study. The efficiency of chest compression on a mannequin when three kneeling postures were adopted (farthest, self-adjusted and nearest) was analysed. METHODS: Eighteen participants with qualified first-aid certificate were recruited. Each participant had to perform three sessions of CPR, using one of the three different kneeling postures (i.e., farthest, self-adjusted and nearest) in each. They were performed in a random order chosen by drawing lots. Each session consisted of five cycles of CPR in each kneeling posture. Each cycle consisted of 30 strokes of chest compression performed within 18 s with a 4-s pause between consecutive cycles. Each session lasted for 2 min. The participants were allowed to rest for 10 min on a chair between sessions. Efficiency of chest compression was quantified by compression force, joint angle, heart rate and energy expenditure. After each session of CPR, the participants were surveyed about their rate of perceived exertion. RESULTS: Efficiency of chest compression in self-adjusted and nearest kneeling postures was significantly better than that of the farthest one. While the self-adjusted and nearest postures had the similar effect, most of the participants preferred self-adjusted kneeling posture because of lower rate of perceived exertion. CONCLUSION: The use of the self-adjusted and nearest kneeling postures during CPR in males resulted in more effective chest compression with lower perceived exertion, compared with the farthest kneeling posture. Both these positions can be objectively recommended to enhance the efficiency of chest compression and thereby increase the cardiac arrest survival rate. RELEVANCE TO CLINICAL PRACTICE: More consistent force and higher endurance could be achieved by performing CPR at self-adjusted kneeling posture.

Simultaneous multislice readout-segmented echo planar imaging for accelerated diffusion tensor imaging of the mandibular nerve: A feasibility study.

PURPOSE: To assess the feasibility of diffusion tensor imaging (DTI) using simultaneous multislice (SMS) acquisition with blipped controlled aliasing in parallel imaging (CAIPI) for accelerated readout-segmented echo planar imaging (rs-EPI) of the mandibular nerves. DTI of the mandibular nerves using EPI is challenging due to susceptibility artifacts. Rs-EPI is less prone to artifacts but associated with longer scan durations. MATERIALS AND METHODS: Eight asymptomatic volunteers were imaged at 3T using a 64-channel head/neck coil. Conventional, 2-fold (2xSMS) and 3-fold (3xSMS) slice-accelerated rs-EPI sequences were acquired. Tractography of the mandibular nerves was performed. Signal-to-noise ratio (SNR), fractional anisotropy (FA), mean diffusivity (MD), and number of tracts were calculated. Artifacts were evaluated qualitatively on Likert scales. Parameters were compared statistically. Clinical feasibility of 2xSMS rs-EPI was tested in four patients. RESULTS: SNR was similar for conventional (mean ± SD; 8.55 ± 3.90) and 2xSMS rs-EPI (7.83 ± 3.15) but lower for 3xSMS rs-EPI (5.42 ± 2.93; analysis of variance, P = 0.004). FA was similar for all sequences (rs-EPI, 0.42 ± 0.08; 2xSMS rs-EPI, 0.43 ± 0.08; 3xSMS rs-EPI, 0.44 ± 0.06), while 3xSMS rs-EPI showed lower MD (rs-EPI, 0.0015 ± 0.0003; 2xSMS rs-EPI, 0.0014 ± 0.0001; 3xSMS rs-EPI, 0.0013 ± 0.0003) and lower number of tracts (rs-EPI, 66.56 ± 51.31; 2xSMS rs-EPI, 65.75 ± 55.40; 3xSMS rs-EPI, 37.93 ± 52.42) compared to rs-EPI and 2xSMS rs-EPI. Additionally, 2xSMS rs-EPI was feasible in four clinical patients and provided robust imaging results. CONCLUSION: 2xSMS rs-EPI yielded similar SNR, FA, and MD values compared to conventional rs-EPI at reduced scan time and is feasible in clinical patients. These findings suggest the potential clinical applicability of rs-EPI for DTI of the mandibular nerve. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 1 J. MAGN. RESON. IMAGING 2017;46:663-677.

CDC Grand Rounds: Improving Medication Adherence for Chronic Disease Management - Innovations and Opportunities.

Adherence to prescribed medications is associated with improved clinical outcomes for chronic disease management and reduced mortality from chronic conditions (1). Conversely, nonadherence is associated with higher rates of hospital admissions, suboptimal health outcomes, increased morbidity and mortality, and increased health care costs (2). In the United States, 3.8 billion prescriptions are written annually (3). Approximately one in five new prescriptions are never filled, and among those filled, approximately 50% are taken incorrectly, particularly with regard to timing, dosage, frequency, and duration (4). Whereas rates of nonadherence across the United States have remained relatively stable, direct health care costs associated with nonadherence have grown to approximately $100-$300 billion of U.S. health care dollars spent annually (5,6). Improving medication adherence is a public health priority and could reduce the economic and health burdens of many diseases and chronic conditions (7).

Magnetic Resonance Neurographic and Clinical Long-Term Results After Oberlin's Transfer for Adult Brachial Plexus Injuries.

The primary goal of the surgical treatment of upper brachial plexus injuries is to restore active elbow flexion. Accordingly, Oberlin's transfer has been frequently performed since 1994 and has influenced the development of other nerve transfers. However, the window of opportunity for nerve transfers remains a subject of controversy. The objective of this study was to assess magnetic resonance (MR) neurographic, clinical and electrophysiological long-term results after Oberlin's transfer. For this purpose, we performed a retrospective follow-up study. Six patients with upper brachial plexus or musculocutaneous nerve injuries were assessed; 2 were iatrogenic nerve injuries following shoulder arthroscopy or neurofibroma resection. Direct and indirect signs of neuropathy were objectified with MR neurography. Moreover, clinical and electrodiagnostic follow-up was performed and all patients completed the Disabilities of Arm, Shoulder and Hand score. Mean follow-up was 48 ± 21.9 (range, 20-73) months. Mean age was 40 ± 11.3 years and mean delay to surgery was 9 ± 3.2 months. All patients were satisfied with the functional results and the median Disabilities of Arm, Shoulder and Hand score was 21 (range, 1-57). Biceps strength was improved in 5 patients from Medical Research Council grade M0 to M4-5 and in one patient to M2-3. The donor nerve showed normal motor and sensory action potentials. Follow-up MR neurography demonstrated biceps reinnervation. Taken together, this study reports good long-term results after Oberlin's transfer. MR neurography represents an excellent, noninvasive preoperative planning tool and can be of high value in selected postoperative cases. The combined evaluation of nerves and muscles may help to indicate nerve transfers in delayed cases.

[Tumors of peripheral nerves]. / Tumoren der peripheren Nerven.

BACKGROUND: Differentiation between malignant and benign tumors of peripheral nerves in the early stages is challenging; however, due to the unfavorable prognosis of malignant tumors early identification is required. OBJECTIVES: To show the possibilities for detection, differential diagnosis and clinical management of peripheral nerve tumors by imaging appearance in magnetic resonance (MR) neurography. MATERIAL AND METHODS: Review of current literature available in PubMed and MEDLINE, supplemented by the authors' own observations in clinical practice. RESULTS: Although not pathognomonic, several imaging features have been reported for a differentiation between distinct peripheral nerve tumors. CONCLUSION: The use of MR neurography enables detection and initial differential diagnosis in tumors of peripheral nerves. Furthermore, it plays an important role in clinical follow-up, targeted biopsy and surgical planning.

A new classification for mandibular defects after oncological resection.

No universally accepted classification system exists for mandibular defects after oncological resection. Here, we discuss the scientific literature on classifications for mandibular defects that are sufficiently presented either pictorially or descriptively, and propose a new classification system based on these findings. Of 167 studies included in the data analysis, 49 of these reports sufficiently described the defect for analysis. These reports were analysed for classification, reconstruction, size of defect, number of osteotomies needed, and complications. On the basis of these findings, a new classification is proposed based on the four corners of the mandible (two angles and two canines): class I (lateral), class II (hemimandibulectomy), class III (anterior), and class IV (extensive). Further classes (Ic, IIc, and IVc) include condylectomy. The increasing defect class relates to the size of the defect, osteotomy rate, and functional and aesthetic outcome, and could guide the method of reconstruction.

MR neurographic orthopantomogram: Ultrashort echo-time imaging of mandibular bone and teeth complemented with high-resolution morphological and functional MR neurography.

PURPOSE: Panoramical radiographs or cone-beam computed tomography (CT) are the standard-of-care in dental imaging to assess teeth, mandible, and mandibular canal pathologies, but do not allow assessment of the inferior alveolar nerve itself nor of its branches. We propose a new technique for "MR neurographic orthopantomograms" exploiting ultrashort echo-time (UTE) imaging of bone and teeth complemented with high-resolution morphological and functional MR neurography. MATERIALS AND METHODS: The Institutional Review Board approved the study in 10 healthy volunteers. Imaging of the subjects mandibles at 3.0T (Magnetom Skyra, Siemens-Healthcare) using a 64-channel head coil with isotropic spatial resolution for subsequent multiplanar reformatting, was performed. Bone images were acquired using a 3D PETRA sequence (TE, 0.07 msec). Morphological nerve imaging was performed using a dedicated 3D PSIF and 3D SPACE STIR sequence. Functional MR neurography was accomplished using a new accelerated diffusion-tensor-imaging (DTI) prototype sequence (2D SMS-accelerated RESOLVE). Qualitative and quantitative image analysis was performed and descriptive statistics are provided. RESULTS: Image acquisition and subsequent postprocessing into the MR neurographic orthopantomogram by overlay of morphological and functional images were feasible in all 10 volunteers without artifacts. All mandibular bones and mandibular nerves were assessable and considered normal. Fiber tractography with quantitative evaluation of physiological diffusion properties of mandibular nerves yielded the following mean ± SD values: fractional anisotropy, 0.43 ± 0.07; mean diffusivity (mm(2) /s), 0.0014 ± 0.0002; axial diffusivity, 0.0020 ± 0.0002, and radial diffusivity, 0.0011 ± 0.0001. CONCLUSION: The proposed technique of MR neurographic orthopantomogram exploiting UTE imaging complemented with high-resolution morphological and functional MR neurography was feasible and allowed comprehensive assessment of osseous texture and neural microarchitecture in a single examination. J. Magn. Reson. Imaging 2016;44:393-400.

Application of a Colored Multiexposure High Dynamic Range Technique to Radiographic Imaging: An Experimental Trial to Show Feasibility.

PURPOSE: The aim of this study was to evaluate the feasibility of applying the high dynamic range (HDR) technique to radiographic imaging to expand the dynamic range of conventional radiographic images using a colored multiexposure approach. MATERIAL AND METHODS: An appropriate study object was repeatedly imaged using a range of different imaging parameters using a standard clinical x-ray unit. An underexposed image (acquired at 80 keV), an intermediate exposed image (110 keV), and an overexposed image (140 keV) were chosen and combined to a 32-bit colored HDR image. To display the resulting HDR image on a regular color display with typically 8 bits per channel, the Reinhard tone mapping algorithm was applied. The source images and the resulting HDR image were qualitatively evaluated by 5 independent radiologists with regard to the visibility of the different anatomic structures using a Likert scale (1, not visible, to 5, excellent visibility). Data were presented descriptively. RESULTS: High dynamic range postprocessing was possible without malalignment or image distortion. Application of the Reinhardt algorithm did not cause visible artifacts. Overall, postprocessing time was 7 minutes 10 seconds for the whole process. Visibility of anatomic structure was rated between 1 and 5, depending on the anatomic structure of interest. Most authors rated the HDR image best before individual source images. CONCLUSIONS: This experimental trial showed the feasibility of applying the HDR technique to radiographic imaging to expand the dynamic range of conventional radiographic images using a colored multiexposure approach.

Mutism Caused by Severe Demyelination in a Patient With Marchiafava-Bignami Disease.

BACKGROUND: Marchiafava-Bignami (MB) disease is a rare disorder that causes primary degeneration of the corpus callosum. It is associated with chronic alcohol consumption caused by either a toxic or nutritional etiology. CASE REPORT: We report a case of a 54-year-old woman who presented to our emergency department with complete mutism caused by MB disease that completely resolved with intravenous thiamine and dextrose therapy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians frequently encounter patients with alcohol abuse and its complications. We report a rare presentation of a potential alcohol-related spectrum disease that may be encountered by an emergency physician. Early diagnosis and prompt management are critical to potentially reversing the disease, and this case shows the importance of including this disease in the differential diagnosis in patients with speech difficulty and alcohol abuse.

Prognostic value of the Index of Microcirculatory Resistance measured after primary percutaneous coronary intervention.

BACKGROUND: Most methods for assessing microvascular function are not readily available in the cardiac catheterization laboratory. The aim of this study is to determine whether the Index of Microcirculatory Resistance (IMR), measured at the time of primary percutaneous coronary intervention, is predictive of death and rehospitalization for heart failure. METHODS AND RESULTS: IMR was measured immediately after primary percutaneous coronary intervention in 253 patients from 3 institutions with the use of a pressure-temperature sensor wire. The primary end point was the rate of death or rehospitalization for heart failure. The prognostic value of IMR was compared with coronary flow reserve, TIMI myocardial perfusion grade, and clinical variables. The mean IMR was 40.3±32.5. Patients with an IMR >40 had a higher rate of the primary end point at 1 year than patients with an IMR ≤40 (17.1% versus 6.6%; P=0.027). During a median follow-up period of 2.8 years, 13.8% experienced the primary end point and 4.3% died. An IMR >40 was associated with an increased risk of death or rehospitalization for heart failure (hazard ratio [HR], 2.1; P=0.034) and of death alone (HR, 3.95; P=0.028). On multivariable analysis, independent predictors of death or rehospitalization for heart failure included IMR >40 (HR, 2.2; P=0.026), fractional flow reserve ≤0.8 (HR, 3.24; P=0.008), and diabetes mellitus (HR, 4.4; P<0.001). An IMR >40 was the only independent predictor of death alone (HR, 4.3; P=0.02). CONCLUSIONS: An elevated IMR at the time of primary percutaneous coronary intervention predicts poor long-term outcomes.