Characterization of clinical human prostate cancer lesions using 3.0-T sodium MRI registered to Gleason-graded whole-mount histopathology.

BACKGROUND: Overtreatment of prostate cancer (PCa) is a healthcare issue. Development of noninvasive imaging tools for improved characterization of prostate lesions might reduce overtreatment. PURPOSE: To measure the distribution of tissue sodium concentration (TSC), proton T2 -weighted signal, and apparent diffusion coefficient (ADC) values in human PCa and to test the presence of a correlation between regional differences in imaging metrics and the Gleason grade of lesions determined from histopathology. STUDY TYPE: Cross-sectional. SUBJECTS: Ten men with biopsy-proven PCa. SEQUENCES/FIELD STRENGTH: Sodium, proton T2 -weighted, and diffusion-weighted MRI data were acquired using Broad-Band 3D-Fast-Gradient-Recalled, 3D Cube (Isotropic 3D-Fast-Turbo-Spin-Echo acquisition) and 2D Spin-Echo sequences, respectively, with a 3.0T MR scanner. ASSESSMENT: All imaging data were coregistered to Gleason-graded postprostatectomy histology, as the standard for prostate cancer lesion characterization. Regional TSC and T2 data were assessed using percent changes from healthy tissue of the same patient (denoted ΔTSC, ΔT2 ). STATISTICS: Differences in ΔTSC, ADC, and ΔT2 as a function of Gleason score were analyzed for each imaging contrast using a one-way analysis of variance or a nonparametric t-test. Correlations between imaging data measures and Gleason score were assessed using a Spearman's ranked correlation. RESULTS: Evaluation of the correlation of ΔTSC, ADC, and ΔT2 datasets with Gleason scoring revealed that only the correlation between ΔTSC and Gleason score was statistically significant (rs = 0.791, p < 0.01), whereas the correlations of ADC and ΔT2 with Gleason score were not (rs = -0.306, p = 0.079 and r s = -0.069, p = 0.699, respectively). In addition, all individual patients showed monotonically increasing ΔTSC with Gleason score. DATA CONCLUSION: The results of this preliminary study suggest that changes in TSC, assessed by sodium MRI, has utility as a noninvasive imaging assay to accurately characterize PCa lesions. Sodium MRI may provide useful complementary information on mpMRI, which may assist the decision-making of men choosing either active surveillance or treatment. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:1409-1419.

Utilizing health records to characterize obesity, comorbidities, and health-care services in one human service agency in the United States.

US surveys report higher prevalence of obesity in adults with intellectual disability. Health records of 40 adults with intellectual disability were retrospectively reviewed for data on health status, problem lists with International Classification of Diseases, Ninth Revision codes, medication lists, and health encounters over 18 months. Mean age was 49.5 years, 53% were males. Prevalence of overweight, obese, and morbidly obese was 28%, 58%, and 23%, respectively. Primary diagnosis was intellectual disability (50% mild, 33% moderate, 10% severe, and 8% profound), 85% had mental health disorders (67.5% with affective or mood and 42.5% had anxiety disorders). On average, residents consumed 2.63 psychotropic medications daily with additional 5.75 medications for axis 3 diagnoses and made 39.2 health visits over past 18 months. Our analysis supports increased prevalence of overweight/obesity, higher comorbidities, dual psychiatric diagnosis, substantial medication consumption, and higher utilization of health-care services in adults with intellectual disabilities. Targeted health interventions are therefore essential to improve their health and quality of life.

Unshielded asymmetric transmit-only and endorectal receive-only radiofrequency coil for (23) Na MRI of the prostate at 3 tesla.

BACKGROUND: To develop and optimize radiofrequency (RF) hardware for the detection of endogenous sodium ((23) Na) by 3.0 Tesla (T) MRI in the human prostate. METHODS: A transmit-only receive-only (TORO) RF system of resonators consisting of an unshielded, asymmetric, quadrature birdcage (transmit), and an endorectal (ER), linear, surface (receive) coil were developed and tested on a 3T MRI scanner. Two different ER receivers were constructed; a single-tuned ((23) Na) and a dual-tuned ((1) H/(23) Na). Both receivers were evaluated by the measurements of signal-to-noise ratio (SNR) and B1 homogeneity. For tissue sodium concentration (TSC) quantification, vials containing known sodium concentrations were incorporated into the ER. The system was used to measure the prostate TSC of three men (age 55 ± 5 years) with biopsy-proven prostate cancer. RESULTS: B1 field inhomogeneity of the asymmetric transmitter was estimated to be less than 5%. The mean SNR measured in a region of interest within the prostate using the single-tuned ER coil was 54.0 ± 4.6. The mean TSC in the central gland was 60.2 ± 5.7 mmol/L and in the peripheral gland was 70.5 ± 9.0 mmol/L. CONCLUSION: A TORO system was developed and optimized for (23) Na MRI of the human prostate which showed good sensitivity throughout the prostate for quantitative measurement of TSC.

Validation of the ASSIST for Detecting Unhealthy Alcohol Use and Alcohol Use Disorders in Urgent Care Patients.

BACKGROUND: Screening and brief intervention (SBI) is effective in reducing alcohol use, particularly among moderate risk patients. Results of SBI are inconsistent among patients with alcohol use disorders (AUDs). The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) is used as a screening tool in many existing SBI programs. ASSIST validation studies have identified risk level cutoff scores using criteria for AUD and have not included a criterion measure for at-risk drinking (ARD), the group for whom SBI is most effective. This study examines the ability of the ASSIST to identify unhealthy alcohol use (ARD or AUD) and AUD in patients presenting to urgent care. METHODS: Data were obtained from interviews with 442 adult drinkers presenting to 1 of 3 urgent care clinics. Subjects completed the ASSIST, a 90-day timeline follow-back interview to detect ARD, and a modified Diagnostic Interview Schedule to identify AUD. Validity measures compared the specificity and sensitivity of cutoff scores for the ASSIST in detecting unhealthy alcohol use and AUDs. RESULTS: The optimal ASSIST score for detecting unhealthy alcohol use is 6+ for males (sensitivity and specificity 68 and 66%, respectively) and 5+ for females (62%/70%). Sensitivity, specificity, and receiver operating characteristic values were lower than those previously reported for the Alcohol Use Disorders Identification Test (AUDIT). For AUD, the optimal ASSIST cutoff scores are 10+ for males (63%/85%) and 9+ for females (63%/85%). While higher scores provided increased specificity, thereby reducing the percentage of false positives, sensitivity dropped sharply as scores increased. CONCLUSIONS: Optimal ASSIST cutoff scores for unhealthy alcohol use are lower than those commonly used in many SBI programs. Use of lower ASSIST cutoff scores may increase detection of unhealthy alcohol use and increase the numbers served by SBI programs.

The modern use of the extended humeral head (cuff tear arthropathy) hemiarthroplasty.

Today, the treatment of osteoarthritis in the rotator cuff-deficient population is largely dominated by reverse shoulder arthroplasty (RSA). Despite the popularity of and increased familiarity with this procedure, the complication rate of RSA remains significant. An extended humeral head hemiarthroplasty may provide a less invasive alternative for select patients with cuff tear arthropathy (CTA) and preserved glenohumeral active elevation. With the indications for reverse arthroplasty expanding to younger patients, there are concerns about the longevity of this implant, as well as the associated revision burden. In the setting of failed RSA, the bone stock available for glenosphere baseplate fixation can be inadequate for reimplantation. The treatment strategies for complex shoulder deformities and failed RSA are limited by patient-specific issues, such as anatomy and risk factors. In this review, we discuss the potential role of extended humeral head hemiarthroplasty (CTA hemiarthroplasty) as a primary surgical option in select patients (1) who have preserved elevation > 90°, (2) who have maintained stability (intact coracoacromial ligament), and (3) who desire to circumvent the complications associated with RSA. Furthermore, CTA hemiarthroplasty may be used for severe glenoid erosion, for a fragmented acromion, and in the revision setting for failed RSA aimed at a reliable salvage procedure.

Common Complications of Sickle Cell Disease: A Simulation-Based Curriculum.

Introduction: Sickle cell disease (SCD), the most common autosomal recessive genetic disorder worldwide, affects nearly every organ of the body and results in accelerated mortality. Nationally, internal medicine physicians lack a complete understanding of morbidity and mortality in this population leading to health care disparities. Methods: We created a 2-hour curriculum consisting of three SCD case vignettes representing common disease complications (acute stroke, acute chest syndrome, and septic shock) with the goal to increase medicine house staff knowledge and confidence in patient management. Residents completed a pretest to assess baseline knowledge and were divided into groups of four to five. Three simulation cases were completed by each group; learners needed to work through a differential diagnosis and describe key management steps. Each group was graded on achieving the 10 critical actions for each case. Following each case, there was a faculty-led debriefing session. Residents repeated the pretest 30 days after completion of the curriculum (posttest). Results: Thirty-six second year internal medicine residents participated in this curriculum. After completing this curriculum, residents improved their test score from 33% (SD = 12%) to 57% (SD = 18%) (p < .0001). Additionally, self-reported confidence in management scores increased from 2.6 (SD = 0.8) in the pretest to 3.5 (SD = 0.4) in the posttest (p = .02) on a 5-point Likert scale (1 = not very confident, 5 = very confident). Discussion: Use of a simulation curriculum increased knowledge and confidence of internal medicine residents in the management of critical illness in patients with SCD.

The Flexion Initiation Test and an Evidence-Based Diagnostic Algorithm for Distal Biceps Tendon Tears.

PURPOSE: The purpose of this study was (1) to assess the flexion initiation test's (FIT) ability to detect distal biceps tendon tears (DBTT) in a cohort of consecutive patients presenting with elbow pain and (2) to generate a reliable evidence-based diagnostic algorithm using a combination of both the FIT and hook tests. METHODS: We performed a retrospective review of 125 consecutive patients who presented with elbow pain, all of which had the FIT and hook test performed prior to imaging/further intervention. The integrity of the tendon was determined during surgery or by magnetic resonance imaging. Sensitivity, specificity, positive predictive value, and negative predictive value were determined for the FIT and hook test. RESULTS: Our evidence-based diagnostic algorithm showed that when both test results are in agreement, there is a 100% diagnostic accuracy for detecting what prior authors have termed surgically indicated tears (complete ruptures and high-grade partial tears) and biceps pathology that can be treated with nonoperative management. The FIT demonstrated 100% sensitivity for surgically indicated tears. The hook test demonstrated 100% sensitivity for complete ruptures, but 18% sensitivity for diagnosing partial tears. CONCLUSIONS: The FIT, which is aimed at improving diagnostic acuity of high-grade partial thickness tears, demonstrated a 93% sensitivity and 96% specificity overall and a 100% sensitivity for complete ruptures and high-grade partial tears. The evidence-based diagnostic algorithm using the combination of the FIT and hook test demonstrates high accuracy for the diagnosis of both complete and high-grade partial DBTTs. The methodology may help to prevent diagnosis delays, improve patient education, and preserve the option for timely primary surgical repair in the treatment of DBTTs. LEVEL OF EVIDENCE: Level IV, diagnostic.

Design and construction of a gradient coil for high resolution marmoset imaging.

A gradient coil with integrated second and third order shims has been designed and constructed for use inside an actively shielded 310 mm horizontal bore 9.4 T small animal MRI. An extension of the boundary element method, to minimise the power deposited in conducting surfaces, was used to design the gradients, and a boundary element method with a constraint on mutual inductance was used to design the shims. The gradient coil allows for improved imaging performance and was optimized for an imaging region appropriate for marmoset imaging studies. Efficiencies of 1.5 mT m-1 A-1 were achieved in a 15 cm wide bore while maintaining gradient uniformity ≤5% over the 8 cm region of interest. Two new cooling methods were implemented which allowed the gradient coil to operate at 100 A RMS, 25 % of max current with a temperature rise below 30 C.

Stereotactic Body Radiotherapy for Large (> 5 cm) Non-Small-Cell Lung Cancer.

BACKGROUND: Stereotactic body radiotherapy (SBRT) is a well-established treatment option for early stage non-small-cell lung cancer (NSCLC) tumors < 5 cm. There is limited information on tumors > 5 cm. PATIENTS AND METHODS: We performed retrospective data collection of patients enrolled onto a prospective SBRT registry study. Eligible patients for this study had node-negative NSCLC measuring > 5 cm in any dimension. Data from 41 patients were analyzed. Median patient age was 75 years, and median tumor size was 5.6 cm (range, 5.0-12.2 cm). Sixteen patients had squamous disease, 20 patients adenocarcinoma, and 1 mixed tumor; 4 patients had no biopsy. Median radiation dose per fraction was 50 Gy in 5 fractions. Radiation was prescribed to isodose line, median 66% (range, 50%-84%). RESULTS: Before SBRT, 6 patients had previous chemotherapy and 7 patients had previous radiation. Median follow-up for all patients was 15.2 months (range, 0.56-48.1 months). At last follow-up, 16 patients were still alive, with a median follow-up of 16.1 months for surviving patients. The median survival was 17.5 months with 1- and 2-year survivals of 65% and 34%. Two patients (4.8%) had local failure, and 13 patients (31%) had distant failure. Four patients (9.8%) had acute toxicity, and 7 patients (17.1%) had late toxicity, including 2 (4.8%) grade 3 late toxicities. CONCLUSION: SBRT for tumors > 5 cm is effective, with good local control rates and acceptable toxicity. The main pattern of failure is distant, suggesting a possible role for systemic chemotherapy in these patients.

Identifying state resources and support programs on e-government websites for persons with intellectual and developmental disabilities.

This descriptive cross-sectional study identified resources and programs that are available nationwide on the Internet to support individuals and families with intellectual and developmental disabilities (I/DD), with a focus on intellectual disability. This evaluation included easily identifiable information on specific resources and highlighted unique programs found in individual states that were linked from e-government websites. Researchers documented the ease of access and available information for all 50 states and the District of Columbia. A number of disparities and areas for improvement were recorded for states and I/DD websites. The researchers conclude that a number of additional health and support services will be needed to address the growing needs of this vulnerable population.

Effect of glucose or fat challenge on aspirin resistance in diabetes.

Aspirin has lower antiplatelet activity in diabetic patients. Our aim is to study the roles of acute hyperglycemia and hyperlipidemia on aspirin function in diabetic subjects with and without cardiovascular disease. Using urine thromboxane (pg/mg creatinine) and VerifyNow (Aspirin Resistance Measures-ARU), we investigated diabetic subjects during a 2-hour glucose challenge (n = 49) or a 4-hour fat challenge (n = 11). All subjects were currently taking aspirin (81 or 325 mg). After fat ingestion, urine thromboxane increased in all subjects (Mean ± SE before: after) (1209 ± 336: 1552 ± 371, P = .01), while we noted a trend increase in VerifyNow measures (408 ± 8: 431 ± 18, P = .1). The response to glucose ingestion was variable. Diabetic subjects with cardiac disease and dyslipidemia increased thromboxane (1693 ± 364: 2799 ± 513, P < .05) and VerifyNow (457.6 ± 22.3: 527.1 ± 25.8, P < .05) measures after glucose. We conclude that saturated fat ingestion increases in vivo thromboxane production despite aspirin therapy.

Clinical determinants of aspirin resistance in diabetes.

Recent studies indicate that not all diabetic subjects benefit from aspirin therapy. Our objective is to characterize diabetic subjects with aspirin resistance using urine thromboxane, and VerifyNow measures. Our results suggest that cardiovascular disease, microalbuminuria, poor diabetes control, and increased waist circumference help identify aspirin resistance in diabetes.