Diagnostic accuracy of virtual non-contrast enhanced dual-energy CT for diagnosis of adrenal adenoma: A systematic review and meta-analysis.

OBJECTIVE: To compare the diagnostic accuracy of dual-energy (DE) virtual non-contrast computed tomography (vNCT) to non-contrast CT (NCT) for the diagnosis of adrenal adenomas. METHODS: Search of multiple databases and grey literature was performed. Two reviewers independently applied inclusion criteria and extracted data. Risk of bias was assessed using QUADAS-2. Summary estimates of diagnostic accuracy were generated and sources of heterogeneity were assessed. RESULTS: Five studies (170 patients; 192 adrenal masses) were included for diagnostic accuracy assessment; all used dual-source dual-energy CT. Pooled sensitivity for adrenal adenoma on vNCT was 54% (95% CI: 47-62%). Pooled sensitivity for NCT was 57% (95% CI: 45-69%). Pooling of specificity was not performed since no false positives were reported. There was a trend for overestimation of HU density on vNCT as compared to NCT which appeared related to contrast timing. Potential sources of bias were seen regarding the index test and reference standard for the included studies. Potential sources of heterogeneity between studies were seen in adenoma prevalence and intravenous contrast timing. CONCLUSIONS: vNCT images generated from dual-energy CT demonstrated comparable sensitivity to NCT for the diagnosis of adenomas; however the included studies are heterogeneous and at high risk for some types of bias. KEY POINTS: • Similar sensitivity of vNCT to NCT for diagnosis of adenoma • Heterogeneity could be related to vNCT from early (<=60 sec) CECT studies • Could not pool specificity as there were no false positives • Small number of heterogeneous studies at high risk of bias.

Randomized Trial Comparing the Primary Patency following Cutting Versus High-Pressure Balloon Angioplasty for Treatment of de Novo Venous Stenoses in Hemodialysis Arteriovenous Fistulae.

PURPOSE: A single-center randomized clinical trial was performed to compare postinterventional primary patency rates achieved by cutting balloon angioplasty and high-pressure balloon angioplasty in the treatment of de novo stenoses within autogenous arteriovenous (AV) fistulae for hemodialysis. MATERIALS AND METHODS: Forty-eight patients undergoing their first angioplasty were prospectively randomized to undergo angioplasty with a cutting balloon or high-pressure balloon 4-8 mm in diameter because cutting balloons larger than 8 mm are not available. Nine patients were excluded after angiography, with seven requiring balloons larger than 8 mm. In the remaining 39 patients, there were 42 stenoses in the following regions: juxtaanastomotic (38%), perianstomotic (38%), midcephalic (9%), and cephalic arch (14%). Patients in the cutting balloon group were younger (mean age difference, 9 y; P = .04), but other demographic variables were comparable (range, P = .08-.89). The mean follow-up period was 8.5 mo (range, 24 d to 32 mo). Kaplan-Meier analysis was used to compare duration of patency. Mann-Whitney rank-sum t test and χ2/Fisher exact tests were used to compare continuous and categoric variables, respectively. RESULTS: Technical success was achieved in all 39 patients. At 3, 6, and 12 months, the postinterventional primary patency rates for the cutting balloon group were 61.1% (95% confidence interval [CI], 35.75%-82.70%), 27.7% (95% CI, 9.69%-53.48%), and 11.1% (95% CI, 1.38%-34.71%), respectively, compared with 70.0% (95% CI, 45.72%-88.11%), 42.1% (95% CI, 20.25%-66.50%), and 26.3% (95% CI, 9.15%-51.20%), respectively, for the high-pressure balloon group (P < .3 at each interval). CONCLUSIONS: Compared with high-pressure balloon angioplasty, cutting balloon angioplasty does not improve postinterventional primary patency of de novo stenotic lesions in autogenous arteriovenous fistulae.

Health service support in the future operating environment 2035.

The period to 2035 is likely to be characterised by instability between states and in relations between groups within states. It is predicted to include climate change, rapid population growth, resource scarcity, resurgence in ideology, and shifts in power from west to east. Many of these changes are likely to have an impact on the health of civil societies and those military personnel deployed by states to counter these challenges. This paper considers the potential impact of emerging global strategic trends on health service support (HSS) in the Future Operating Environment 2035. Global Strategic Trends-Out to 2040, The Future Character of Conflict and NATO Strategic Foresight Analysis Report 2013 provide the foundations of the paper. The study concludes that future impacts on HSS are neither completely predictable nor predetermined, and there is always a possibility of a strategic shock. Knowledge of vulnerability, however, allows an informed approach to the development and evaluation of adaptive strategies to lessen risks to health.

Stress-induced elevation of oxytocin in maltreated children: evolution, neurodevelopment, and social behavior.

Child maltreatment often has a negative impact on the development of social behavior and health. The biobehavioral mechanisms through which these adverse outcomes emerge, however, are not clear. To better understand the ways in which early life adversity affects subsequent social behavior, changes in the neuropeptide oxytocin (OT) in children (n = 73) aged 8.1-11.5 years following a laboratory stressor were examined. Girls with histories of physical abuse have higher levels of urinary OT and lower levels of salivary cortisol following the stressor when compared to controls. Abused and control boys, however, do not differ in their hormonal responses. These data suggest that early adversity may disrupt the development of the stress regulation system in girls by middle childhood.

Repeat prostate biopsy accuracy: simulator-based comparison of two- and three-dimensional transrectal US modalities.

PURPOSE: To compare the accuracy of biopsy with two-dimensional (2D) transrectal ultrasonography (US) with that of biopsy with conventional three-dimensional (3D) transrectal US and biopsy with guided 3D transrectal US in the guidance of repeat prostate biopsy procedures in a prostate biopsy simulator. MATERIALS AND METHODS: The institutional review board approved this retrospective study. Five residents and five experts performed repeat biopsies with a biopsy simulator that contained the transrectal US prostate images of 10 patients who had undergone biopsy. Simulated repeat biopsies were performed with 2D transrectal US, conventional 3D transrectal US, and guided 3D transrectal US (an extension of 3D transrectal US that enables active display of biopsy targets). The modalities were compared on the basis of time per biopsy and how accurately simulated repeat biopsies could be guided to specific targets. The probability for successful biopsy of a repeat target was calculated for each modality. RESULTS: Guided 3D transrectal US was significantly (P < .01) more accurate for simulated biopsy of repeat targets than was 2D or 3D transrectal US, with a biopsy accuracy of 0.86 mm +/- 0.47 (standard deviation), 3.68 mm +/- 2.60, and 3.60 mm +/- 2.57, respectively. Experts had a 70% probability of sampling a prior biopsy target volume of 0.5 cm(3) with 2D transrectal US; however, the probability approached 100% with guided 3D transrectal US. Biopsy accuracy was not significantly different between experts and residents for any modality; however, experts were significantly (P < .05) faster than residents with each modality. CONCLUSION: Repeat biopsy of the prostate with 2D transrectal US has limited accuracy. Compared with 2D transrectal US, the biopsy accuracy of both experts and residents improved with guided 3D transrectal US but did not improve with conventional 3D transrectal US.

Ectopic Parathyroid Adenoma in Piriform Sinus: Case Report and Review of the Literature.

During routine blood work, a 53-year-old female patient was noted to have asymptomatic hypercalcemia and subsequently found to have hyperparathyroidism. Localization studies for a suspected parathyroid adenoma included 99mTc Sestamibi scintigraphy, Single Photon Emission Computed Tomography (SPECT)/computed tomography (CT) study, and ultrasound of the neck, which were initially read as negative for parathyroid adenoma. A contrast-enhanced CT scan of the neck was performed to locate the suspected parathyroid adenoma and demonstrated a soft tissue lesion within the right piriform sinus. Flexible fiber optic nasolaryngoscopy revealed a submucosal lesion in the right piriform sinus. Following these findings, the initial 99mTc Sestamibi scintigraphy and SPECT/CT were reviewed with confirmation of a focal area of increased activity superior to the right thyroid lobe, corresponding to a nodule in the right piriform sinus that demonstrated increased activity on SPECT/CT. The patient was brought to the operating room for surgical management where a laryngoscope and operating microscope were utilized. The encapsulated lesion was dissected and excised in total. The parathyroid hormone and ionized calcium levels normalized postoperatively. Pathology confirmed a parathyroid adenoma. Parathyroid adenomas are the most common cause of primary hyperparathyroidism. Sixteen percent of parathyroid adenomas can be situated in an ectopic location. Ectopic parathyroid adenomas in the piriform sinus are rare with only a few previously documented cases. We document a rare case of ectopic parathyroid adenoma in the piriform sinus overlooked on initial imaging studies. These lesions can be challenging to localize, however, an understanding of embryology, close scrutiny of possible ectopic locations, and the application of complementary imaging techniques may prove useful for surgeons and clinicians.