Non-contrast computed tomography characteristics in a large cohort of cystinuria patients.

PURPOSE: Cystine stones are widely considered hard and difficult to treat. Hounsfield Units (HU) are used in other stone types to estimate 'hardness' and treatments based on that finding. Our objective was to report mean HU of cystine stones in vivo in a large case series of cystinuria patients and assess for differences in genotype. METHODS: A prospective case series of cystinuria patients referred to a specialist centre was analysed. CT imaging was assessed by two independent radiologists to determine in vivo attenuation of cystine calculi. Mean HU was compared for both cystinuria genes (SLC3A1 and SLC7A9) using an independent t-test. RESULTS: 164 adult cystinuric patients were identified (55% male), median age 43 years (range 18-80). Median follow up was 31 months (IQR 10-62). Genetic data available for 153/164 (93%) demonstrated 97 SLC3A1 (63%) and 55 (36%) SLC7A9 mutations (39 homozygous, 16 heterozygous) and one heterozygous for both SLC3A1/SLC7A9. 107 patients had CT images available demonstrating calculi. Median HU across the cohort was 633 (5th to 95th centile 328-780). There was no difference in mean HU between SLC3A1 and SLC7A9 genotypes (p = 0.68) or homo and heterozygous SLC7A9 (p = 0.70). Mean HU correlated with stone size (Pearson correlation coefficient = 0.51, p < 0.001). CONCLUSION: In this large single centre cystinuria cohort, mean HU was low for stones that are difficult to treat. Calculi of < 800 HU should prompt consideration of a cystinuria diagnosis. Attenuation was not associated with genotype, and distinct 'smooth' and 'rough' stones were not observed. Calculi with HU > 1000 are unlikely pure cystine, and in a known cystinuric would suggest conversion to another stone type.

MRI features to aid the identification of lateral temporal bone cephaloceles.

OBJECTIVES: To evaluate ancillary MRI features which may aid the identification of lateral temporal bone cephaloceles (LTBCs). METHODS: A retrospective cohort study analysed patients with MRI evidence of surgically confirmed spontaneous LTBCs as defined by intracranial contents traversing the tegmen tympani or mastoideum. Cases were identified from radiology and surgical databases. Two observers analysed three-dimensional T 2W temporal bone and whole brain imaging according to a priori criteria by consensus, with emphasis on the relationship of any adjacent cerebrospinal fluid (CSF) cleft to the defect. The contents, location, and clinical features of the LTBCs were recorded. RESULTS: Eighteen patients (11 female, 7 male; mean age 59.3 years, age range 42-86 years) with 20 surgically confirmed spontaneous LTBCs (2 bilateral;16 unilateral) were evaluated. A temporal lobe sulcus or other CSF cleft extending to or traversing the defect was identified in 19/20 (95%) cases. Isointense CSF tympanomastoid signal was present in 41.2% cases, whilst superior semi-circular canal dehiscence was found in 40% of cephaloceles. At least two MRI features of idiopathic intracranial hypertension were seen in 38.9% patients. Cephaloceles were most commonly centred on the tegmen tympani (55%). Meningoencephaloceles were present in 95% cases. CONCLUSION: A temporal lobe sulcus or CSF cleft extending to or traversing the defect may aid the identification of LTBCs. Isointense CSF tympanomastoid signal, superior semi-circular canal dehiscence and MRI features of idiopathic intracranial hypertension are only present in under half of LTBCs. ADVANCES IN KNOWLEDGE: The study details novel ancillary MRI features of LTBCs which may aid their identification.

The role of [18F]FDG-PET/CT in gram-positive and gram-negative bacteraemia: A systematic review.

Objectives: Bacteraemia is associated with significant morbidity and mortality. [18F]FDG-PET/CT is increasingly used to detect infectious metastatic foci, however there remains international variation in its use. We performed a systematic review assessing the impact of [18F]FDG-PET/CT in adult inpatients with gram-positive and Gram-negative bacteraemia. Design: The systematic review was performed according to PRISMA guidelines. Studies published between 2009 and December 2021 were searched in MEDLINE, EMBASE and Cochrane clinical trials database. Data extraction and quality assessment was performed using ROBINS-I and GRADE. Setting: Eligible study designs included randomised-controlled trials, clinically-controlled trials, prospective trials, retrospective trials, case-control studies, and non-controlled studies. Participants: Studies solely assessing adult inpatients with blood-culture confirmed bacteraemia with one cohort of patients receiving [18F]FDG-PET/CT were included. Main outcome measures: primary outcomes were mortality, identification of metastatic foci and relapse rate. Studies not examining any of the pre-specified outcomes were excluded. Results: Ten studies were included, of which five had a non-PET/CT control arm. Overall, there was low quality of evidence that [18F]FDG-PET/CT is associated with reduced mortality, improved identification of metastatic foci and reduced relapse rate. Six studies assessed Staphylococcus aureus bacteraemia (SAB) only; nine studies included Gram-positive bacteraemia only, and one study included data from Gram-negative bacteraemia. Two studies compared outcomes between patients with different types of bacteraemia. Four studies identified a statistically significant difference in mortality in [18F]FDG-PET/CT recipients and controls. Relapse rate was significantly reduced in patients with SAB who received [18F]FDG-PET/CT. Studies identified significantly higher detection of metastatic foci in [18F]FDG-PET/CT recipients compared to controls. [18F]FDG-PET/CT was the first to identify an infectious site in 35.5% to 67.2% of overall foci identified. Conclusions: Further research is required to establish the role of [18F]FDG-PET/CT in bacteraemia, and its impact on management and mortality.

Factors Predicting Outcomes of Supine Percutaneous Nephrolithotomy: Large Single-Centre Experience.

Objective: Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large renal calculi. The prone position has been considered the preferred position to obtain renal access. However, the supine position has recently gained popularity, which confers several potential advantages. The current study analyses the prognostic factors for successful supine PCNL procedures in a larger tertiary centre. Subjects: Prospective data were collected from all patients undergoing PCNL in the Galdako modified Valdivia position at our institution between February-2007 and September-2020. Surgical outcomes variables collected included: the rate of Endoscopic-combined intra-renal surgery (ECIRS), operative times, surgical effectiveness (no residuals <2 mm stone fragments) and complications. Results: A total of 592 patients underwent PCNL with a median age of 56 years (IQR: 42−67). The median stone size was 17 mm (IQR: 13−23). Of those, 79% of patients had an effective procedure. Stone size (p < 0.001), location (p < 0.001) and Guys-Stone Score (GSS) (p < 0.001) were associated with effectiveness. A Percutaneous nephrostomy tube was sited at the completion of the procedure in 97.3% of patients and a simultaneous double-J stent in 45.3%. Stent insertion was associated with larger stones (p < 0.001), the performance of ECIRS (p < 0.001) and higher GSS (p < 0.001). The overall complication rate was 21.7%. The main type of complication was an infection in 26.2 of the cases followed by the need for repeated nephrostogram in 12.7%. Conclusions: We demonstrate that PCNL in a high-volume centre is safe and efficacious in the Galdalko modified Valdivia position. Patients with smaller stones in the renal pelvis and a low GSS have the highest chance of a successful procedure.

Attitudes and perceptions of UK medical students towards artificial intelligence and radiology: a multicentre survey.

OBJECTIVES: To explore the attitudes of United Kingdom (UK) medical students regarding artificial intelligence (AI), their understanding, and career intention towards radiology. We also examine the state of education relating to AI amongst this cohort. METHODS: UK medical students were invited to complete an anonymous electronic survey consisting of Likert and dichotomous questions. RESULTS: Four hundred eighty-four responses were received from 19 UK medical schools. Eighty-eight percent of students believed that AI will play an important role in healthcare, and 49% reported they were less likely to consider a career in radiology due to AI. Eighty-nine percent of students believed that teaching in AI would be beneficial for their careers, and 78% agreed that students should receive training in AI as part of their medical degree. Only 45 students received any teaching on AI; none of the students received such teaching as part of their compulsory curriculum. Statistically, students that did receive teaching in AI were more likely to consider radiology (p = 0.01) and rated more positively to the questions relating to the perceived competence in the post-graduation use of AI (p = 0.01-0.04); despite this, a large proportion of students in the taught group reported a lack of confidence and understanding required for the critical use of healthcare AI tools. CONCLUSIONS: UK medical students understand the importance of AI and are keen to engage. Medical school training on AI should be expanded and improved. Realistic use cases and limitations of AI must be presented to students so they will not feel discouraged from pursuing radiology.

Management of Abdomino-scrotal hydrocele (ASH)/Scrotal-inguino-retroperitoneal (SIR) hydrocele in a renal transplant patient.

Abdomino-scrotal hydrocele (ASH) is a very rare clinical entity. It is an unusual condition, in which there is an hourglass communication between a large hydrocele and the retroperitoneal space, through the inguinal canal. First described by Dupuytren in 1834 and defined by Bickle in 1919, the condition is rarely seen. Surgical management usually involves excision of the sac as the definitive treatment option. The pathogenesis of ASH remains unclear and numerous theories have been postulated. We favour the term scrotal-inguino-retroperitoneal (SIR) hydrocele as a more accurate description. The paper presents a unique case of a 24-year-old gentleman, with a functioning kidney transplant, who developed a large ASH/SIR hydrocele that required a midline laparotomy to fenestrate the sac.

Supine Percutaneous Nephrolithotomy in the Galdako-Modified Valdivia Position: A High-Volume Single Center Experience.

OBJECTIVE: To describe the technique and outcomes of supine percutaneous nephrolithotomy (PCNL) in the Galdako-modified Valdivia position. MATERIALS AND METHODS: Prospective data were collected from 303 patients undergoing PCNL in the Galdako-modified Valdivia position at our institution between 2007 and 2015. We report our technique with outcomes of operative times, stone-free rate (SFR), and complications. RESULTS: A total of 202 solitary stones with a mean size of 17.19 ± 5.82 mm, 42 stones in multiple calices, and 57 staghorns were treated. Mean operative time was 79.79 ± 35.72 minutes. A total of 244/303 (80.5%) patients had clearance or <2 mm stone on postoperative CT. Minor complications (Clavien-Dindo Classification [CDC] 1-2) occurred in 59 (19.5%) cases and major complications (CDC ≥3) occurred in 22 (7.3%) cases. Five (1.7%) cases required postoperative blood transfusion for bleeding complications. CONCLUSION: We demonstrate that PCNL in a high-volume center to be safe and efficacious in the Galdalko-modified Valdivia position. We show equivalent SFR and complication rates to large studies of prone PCNL, with potential to decrease operative time. In particular, supine position is optimum for obese or high-risk patients with complex stone disease, because of ease of positioning and lower theoretical risk of anesthetic complications.

Nutritional status of tribal children and adolescents in rural south India: the effect of an NGO delivered nutritional programme.

OBJECTIVES: To investigate the prevalence of malnutrition using anthropometric measures in a cohort of tribal students attending a school in rural south India. Children attending the school were offered three meals a day during attendance. Analysis of anthropometric data obtained aimed to determine the nutritional effect of the food provided. METHODS: The nutritional status of 409 students were assessed by comparing anthropometric measurements to reference values according to WHO/NCHS guidelines. Height for age <3rd percentile was defined as stunting. BMI for age <5th percentile was defined as thinness. 'New' students were defined as attending the school for <1 y. 'Old' students were defined as being in attendance for ≥ 1 y. Comparison of thinness and stunting prevalence in these groups enabled evaluation of the meals provided by the organisation. RESULTS: Four hundred and nine students were included for analysis in the study. The prevalence of thinness was 39.4 %. 59.5 % of 'new' and 52.9 % of 'old' students at the school demonstrated thinness. 59.4 % of students were classified as stunted. 73.8 % of 'new' students and 52.9 % of 'old' students demonstrated stunting (p 0.091). Significantly (p 0.010) more 'new' female students had stunted growth. CONCLUSIONS: Acute and chronic measures of malnutrition were high amongst adolescent students attending the school. Comparison of 'new' and 'old' adolescent pupils at the school hints that the 'old' students were less malnourished than their 'new' counterparts. This study demonstrates the importance for NGOs to develop their nutritional programmes with a special focus on adolescents.

Escalating regulation of 5T4-specific IFN-γ+ CD4+ T cells distinguishes colorectal cancer patients from healthy controls and provides a target for in vivo therapy.

The relationship between the adaptive CD4+ T cell response and human cancer is unclear. The oncofetal antigen 5T4 is expressed on many human carcinomas, including colorectal cancer (CRC) cells, but has limited expression on normal tissues. We previously identified anti-5T4 CD4+ T cells in a proportion of CRC patients, and we extended this study to examine whether the quality or quantity of the T cell response reflects tumor stage. An overlapping peptide library spanning 5T4 was used as a target to enumerate cognate IFN-γ+CD4+ T-cells (measured as spot forming cells [SFC]/105 cultured T cells) in peripheral blood-derived lymphocytes following a 12-day in vitro culture period comparing patients pre-operatively (n = 27) to healthy controls (n = 17). Robust 5T4-specific T cell responses were present in 100% of healthy donors. There was a steady loss of T cell responses with advancing tumors with a significant negative correlation from stage I to III (P = 0.008). The predictability of the decline meant < 200 SFC/105 was only found in subjects with stage III CRC. The mechanism of loss of T cell response is independent of HLA-DR type or patient age, but does correspond to increases in Foxp3+ regulatory T cells (Tregs). Using low-dose cyclophosphamide to reduce the proportion of Tregs in vivo resulted in increased anti-5T4 T cell responses in CRC patients. The selective loss of 5T4-specific IFN-γ+CD4+ T cell responses implies a link between tumor stage and antitumor Th1 effector function; depleting Tregs can enhance such responses.