Non-EPI versus Multishot EPI DWI in Cholesteatoma Detection: Correlation with Operative Findings

BACKGROUND AND PURPOSE:Although multishot EPI (readout-segmented EPI) has been touted as a robust DWI sequence for cholesteatoma evaluation, its efficacy in disease detection compared with a non-EPI (eg, HASTE) technique is unknown. This study sought to compare the accuracy of readout-segmented EPI with that of HASTE DWI in cholesteatoma detection.MATERIALS AND METHODS:A retrospective review was completed of consecutive patients who underwent MR imaging for the evaluation of suspected primary or recurrent/residual cholesteatomas. Included patients had MR imaging examinations that included both HASTE and readout-segmented EPI sequences and confirmed cholesteatomas on a subsequent operation. Two neuroradiologist reviewers assessed all images, with discrepancies resolved by consensus. The ratio of signal intensity between the cerebellum and any observed lesion was noted.RESULTS:Of 23 included patients, 12 (52.2%) were women (average age, 47.8 [SD, 25.2] years). All patients had surgically confirmed cholesteatomas: Six (26.1%) were primary and 17 (73.9%) were recidivistic. HASTE images correctly identified cholesteatomas in 100.0% of patients. On readout-segmented EPI sequences, 16 (69.6%) were positive, 5 (21.7%) were equivocal, and 2 (8.7%) were falsely negative. Excellent interobserver agreement was noted between reviews on both HASTE (κ = 1.0) and readout-segmented EPI (κ = 0.9) sequences. The average signal intensity ratio was significantly higher on HASTE than in readout-segmented EPI, facilitating enhanced detection (mean difference 0.5; 95% CI, 0.3–0.8; P = .003).CONCLUSIONS:HASTE outperforms readout-segmented EPI in the detection of primary cholesteatoma and disease recidivism.

Middle ear cholesteatomas are ectopic, keratinizing squamous epithelium, which may be acquired or, much less commonly, congenital.^1,2 Although not considered a true neoplasm, cholesteatomas are locally destructive and have a high propensity for recurrence following surgical removal. As they gradually expand, cholesteatomas erode the osseous structures within and adjacent to the middle ear cavity, including the ossicles, labyrinth, fallopian canal, and middle fossa bone plate.³ Current mainstay therapy includes microsurgical extirpation, with the chief goal of complete disease removal and prevention of intratemporal and intracranial complications.⁴ The most common microsurgical approach for cholesteatoma is an canal wall up tympanomastoidectomy, in which the posterior bony ear canal is left intact and the tympanic membrane is reconstructed. Depending on the extent of disease at surgery, a planned second-look procedure may be performed approximately 1 year after the initial operation to evaluate residual disease and potentially reconstruct the ossicular chain when indicated. Nevertheless, residual and/or recurrent (ie, recidivism) disease occurs in up to 30% of cases. Imaging is crucial in cholesteatoma management; it aids in the initial diagnosis and may obviate the need for second-look surgery.^5,6During the past decade, DWI has emerged as a powerful diagnostic tool for detection of both primary and residual or recurrent cholesteatomas.^7-9 Cholesteatomas demonstrate marked hyperintensity on DWI , likely related to either T2 shinethrough or intralesional restricted diffusion related to keratin debris.¹⁰ Across the years, there have been many iterations of DWI optimization for cholesteatoma identification. The EPI trajectory used by conventional DWI makes such sequences prone to substantial susceptibility artifacts, and single-shot EPI sequences were found to be poor at identifying lesions of <4–5 mm.^11-13 Consequently, non-EPI DWI techniques began to be favored; such algorithms minimize susceptibility artifacts and geometric distortion related to the skull base and are able to detect lesions as small as 2 mm.^14,15 BLADE (Siemens) and other such PROPELLER sequences are subtypes of non-EPI techniques that minimize susceptibility artifacts and geometric distortions by sampling k-space in a rotating fashion.^16,17More recently, HASTE DWI (Siemens) has emerged as a particularly effective sequence, which is relatively insensitive to motion and has been shown in prior studies to detect cholesteatomas with promising accuracy.^18,19 Although traditional EPI techniques have been largely abandoned in the setting of cholesteatoma detection, readout-segmented EPI (RESOLVE; Siemens) DWI is a relatively new technique that has been promoted as a possible alternative diffusion sequence. RESOLVE is a multishot (MS) EPI sequence that is able to reduce geometric distortions at the expense of longer imaging time. Recent reports have indicated that RESOLVE may be a useful sequence in cases of suspected cholesteatoma.^7,20Despite its proposed efficacy in cholesteatoma imaging, the diagnostic utility of RESOLVE sequences has yet to be robustly evaluated against non-EPI DWI, the current criterion standard. Thus, this study was conceived with the chief goal of assessing the accuracy of RESOLVE in the detection of cholesteatomas and comparing the ability of RESOLVE with that of HASTE sequences in this context.     

Manejo de la enfermedad de Parkinson y otros trastornos del movimiento en mujeres en edad fértil: Parte 1

IntroductionThe main challenge of Parkinson's disease in women of childbearing age is managing symptoms and drugs during pregnancy and breastfeeding. The increase in the age at which women are having children makes it likely that these pregnancies will become more common in future.ObjectivesThis study aims to define the clinical characteristics of women of childbearing age with Parkinson's disease and the factors affecting their lives, and to establish a series of guidelines for managing pregnancy in these patients.ResultsThis consensus document was developed through an exhaustive literature search and a discussion of the available evidence by a group of movement disorder experts from the Spanish Society of Neurology.ConclusionsParkinson's disease affects all aspects of sexual and reproductive health in women of childbearing age. Pregnancy should be well planned to minimise teratogenic risk. A multidisciplinary approach should be adopted in the management of these patients in order to take all relevant considerations into account.     

Association of Multiple Plasma Biomarker Concentrations with Progression of Prevalent Diabetic Kidney Disease: Findings from the Chronic Renal Insufficiency Cohort (CRIC) Study

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Radiotherapy-specific interprofessional learning through simulation

IntroductionInterprofessional learning (IPL) is a vital aspect of training in radiation oncology professions, yet is rarely delivered to those professionals who work most closely together in clinical practice. Scenario-based learning using simulation facilities provides a unique opportunity to facilitate this learning and this project aimed to determine the impact and value of this initiative.MethodsSmall groups comprising post-graduate diploma pre-registration therapeutic radiographers, medical physics trainees and radiation oncology registrars were challenged with 4 plausible and challenging radiotherapy scenarios within an academic simulation centre. Pre- and post-event completion of the “Readiness for Interprofessional Learning Scale” measured impact and a Likert-style survey gathered feedback from participants.ResultsThe session increased participants' teamwork and collaboration skills as well as strengthening professional identities. Participants reported high levels of enjoyment related to collaborative working, communication and observing other professionals deploying their technical skills and specialist knowledge.ConclusionAlthough beneficial, simulated scenarios offering equal opportunities for engagement across the professions are challenging to plan and timetabling issues between the 3 groups present significant difficulties. The safe environment and unique opportunity for these groups to learn together was particularly well received and future oncology-specific simulated scenario sessions are planned with larger cohorts.Implications for practiceSimulated scenario training can be used to improve team working across the radiotherapy interprofessional team and may have wider use in other specialist interdisciplinary team development.     

Clot Burden Score and Collateral Status and Their Impact on Functional Outcome in Acute Ischemic Stroke

BACKGROUND AND PURPOSE:Collateral status and thrombus length have been independently associated with functional outcome in patients with acute ischemic stroke. It has been suggested that thrombus length would influence functional outcome via interaction with the collateral circulation. We investigated the individual and combined effects of thrombus length assessed by the clot burden score and collateral status assessed by a FLAIR vascular hyperintensity–ASPECTS rating system on functional outcome (mRS).MATERIALS AND METHODS:Patients with anterior circulation acute ischemic stroke due to large-vessel occlusion from the ASTER and THRACE trials treated with endovascular thrombectomy were pooled. The clot burden score and FLAIR vascular hyperintensity score were determined on MR imaging obtained before endovascular thrombectomy. Favorable outcome was defined as an mRS score of 0–2 at 90 days. Association of the clot burden score and the FLAIR vascular hyperintensity score with favorable outcome (individual effect and interaction) was examined using logistic regression models.RESULTS:Of the 326 patients treated by endovascular thrombectomy with both the clot burden score and FLAIR vascular hyperintensity assessment, favorable outcome was observed in 165 (51%). The rate of favorable outcome increased with clot burden score (smaller clots) and FLAIR vascular hyperintensity (better collaterals) values. The association between clot burden score and functional outcome was significantly modified by the FLAIR vascular hyperintensity score, and this association was stronger in patients with good collaterals, with an adjusted OR = 6.15 (95% CI, 1.03–36.81).CONCLUSIONS:The association between the clot burden score and functional outcome varied for different collateral scores. The FLAIR vascular hyperintensity score might be a valuable prognostic factor, especially when contrast-based vascular imaging is not available.

Therapeutic reperfusion with endovascular thrombectomy (EVT) is consistently associated with a better long-term functional outcome in anterior circulation acute ischemic stroke (AIS).¹ Early reperfusion is the mainstay of therapy because it strongly predicts functional outcome.² Many factors impact clinical outcomes, including the extent of clot and collateral supply.^3–7The clot burden score (CBS) assessed by the T2* MR imaging sequence (T2*-CBS), which was adapted from the CTA-CBS,⁸ has been used to assess the extent of the clot⁹ and has been independently associated with functional outcome in patients undergoing EVT.¹⁰Good collaterals have been related to better clinical outcome through 2 distinct mechanisms. First, collaterals are thought to contribute to prolonged penumbra sustenance.^11,12 Second, good retrograde collateral filling beyond the occlusion could promote successful reperfusion by providing more access to thrombolytics at the distal end of the clot and robust collaterals dissolving clot fragments in the distal vasculature.^13,14 The Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration analysis suggested a benefit with EVT across all strata of collateral circulation status;¹⁵ however, patients with poor collaterals are less likely to benefit from EVT than those with better collaterals.Most interesting, FLAIR vascular hyperintensity (FVH) on baseline MR imaging could indicate the formation of a leptomeningeal collateral circulation and serve as a prognostic marker for patients with AIS.^16-18 Both collaterals and the CBS were separately associated with functional outcome in patients undergoing EVT,^10,16 but their combined effect regarding clinical outcome is still poorly understood and has been assessed and quantified only with CTA or contrast-enhanced MRA in patients with AIS.^14,15 Furthermore, the lack of adjustment for possible confounders because of the small number of patients with very low collateral scores might also have influenced results in these studies.The purpose of this study was to determine whether there is an association between the CBS and FVH score and whether the association between the CBS and functional outcome is modified by the FVH score for patients who were treated by EVT for large-vessel occlusion within the framework of the Contact Aspiration versus Stent Retriever for Successful Revascularization (ASTER) and the THRombectomie des Artères CErebrales (THRACE) randomized trials.^19,20     

Prognostic tools for hypertrophic scar formation based on fundamental differences in systemic immunity

Unpredictable hypertrophic scarring (HS) occurs after approximately 35% of all surgical procedures and causes significant physical and psychological complaints. Parallel to the need to understanding the mechanisms underlying HS formation, a prognostic tool is needed. The objective was to determine whether (systemic) immunological differences exist between patients who develop HS and those who develop normotrophic scars (NS) and to assess whether those differences can be used to identify patients prone to developing HS. A prospective cohort study with NS and HS groups in which (a) cytokine release by peripheral blood mononuclear cells (PBMC) and (b) the irritation threshold (IT) after an irritant (sodium lauryl sulphate) patch test was evaluated. Univariate regression analysis of PBMC cytokine secretion showed that low MCP‐1, IL‐8, IL‐18 and IL‐23 levels have a strong correlation with HS (P < .010‐0.004; AUC = 0.790‐0.883). Notably, combinations of two or three cytokines (TNF‐a, MCP‐1 and IL‐23; AUC: 0.942, Nagelkerke R²: 0.727) showed an improved AUC indicating a better correlation with HS than single cytokine analysis. These combination models produce good prognostic results over a broad probability range (sensitivity: 93.8%, specificity 86.7%, accuracy 90,25% between probability 0.3 and 0.7). Furthermore, the HS group had a lower IT than the NS group and an accuracy of 68%. In conclusion, very fundamental immunological differences exist between individuals who develop HS and those who do not, whereas the cytokine assay forms the basis of a predictive prognostic test for HS formation, the less invasive, easily performed irritant skin patch test is more accessible for daily practice.     

Epilepsy and pregnancy: What should the neurologists do?

Epilepsy is one of the most common chronic disorders affecting women of childbearing age. Unfortunately, many women with epilepsy (WWE) still report not receiving key information about pregnancy. They obviously need information about epilepsy and pregnancy prior to conception with a particular emphasis on effective birth control (i.e. contraception), necessity to plan pregnancy, antiepileptic drugs optimization, and folate supplementation. The risks associated with use of antiepileptic drugs during pregnancy have to be balanced against fetal and maternal risks associated with uncontrolled seizures. This report reviews evidence-based counseling and management strategies concerning maternal and fetal risks associated with seizures, teratogenic risks associated with antiepileptic drug exposure with a special emphasis on developmental and behavioural outcomes of children exposed to intra utero antiepileptic drugs.     

Conserving resources in the diagnosis of intraoral fibroepithelial polyps

Fibroepithelial polyps (FEPs) are common, benign intraoral lesions that tend to develop slowly at predictable sites, often in response to local irritation or trauma. Historical precedent often results in referral to oral and maxillofacial surgery (OMFS) departments for biopsy, often irrespective of symptoms, and histological assessment. OMFS and pathology services are struggling to cope with an increasing workload that will potentially lead to widespread delays to diagnosis and treatment. Over the past 20 years, clinical pathways and guidance have been developed to ensure that healthcare interventions, such as the removal of third molars, tonsils, skin tags, and benign moles, are evidence-based, have a net patient benefit, and ensure the best use of finite NHS resources. However, no such guidance exists for intraoral lesions and we regard this as an oversight. We analysed the removal of 682 FEPs over a seven-year period and report sensitivities of 92.4% for a “confirmed clinical suspicion of an FEP” and 99.7% for a “confirmed clinical suspicion of a benign diagnosis”. The incidence of non-benign disease was 0.3%. Primary care dentists should be able to diagnose and monitor FEPs and refer only if symptoms are serious or in high-risk patients or sites. Adopting this practice across the UK could free up to 1825 four-hour OMFS clinics, 405 hours of consultant histopathologists’ time, and recurring savings to the NHS estimated to be in the region of £620 000/annum. We believe that the removal of FEPs should be reclassified as an “intervention not normally funded”, and the time and resources put to better use treating patients with lesions of questionable pathology.     

Patients’ narratives of orthognathic treatment for facial asymmetry: a qualitative study

To explore patients’ experiences of orthognathic treatment for facial asymmetry and their adaptation to facial changes after surgery, we did a qualitative, cross-sectional study of patients after treatment for non-cleft asymmetry at two UK sites. A total of 15 patients aged 19-40 years were approached after being identified using patient databases and clinical notes. Individual and photo-elicitation interviews were conducted covering experiences prior to treatment, during treatment, and after surgery. Interviews were transcribed and thematic narrative analysis undertaken. Participants were largely positive about their orthognathic treatment. The following themes were identified: preoperative (becoming aware, negative impacts of asymmetry, committing to treatment, establishing expectations), pre-surgery orthodontics and inpatient experiences (challenges and coping strategies, preparedness, support, and shared experiences); and postoperative (surgery as ‘worth it’, positive impacts of treatment, adapting to facial change). Undergoing orthognathic surgery was portrayed as a journey involving recognisable narratives (treatment unfinished, threat of liminality, treatment as resolution, and treatment as transformation). Patients’ experiences of facial asymmetry are associated with feeling ‘abnormal’, and negative impacts, and orthognathic treatment for facial asymmetry is worthwhile. Having the feeling that something is ‘wrong’ legitimised by clinicians allows patients access to a recognisable treatment narrative (resolution). Orthognathic treatment is also described as transformation from ‘normal abnormality’ to being ‘normal’. Nevertheless, the associated challenges can be frustrating, particularly if resolution is hard to envisage. Further psychological input could help patients cope with these challenges and the complex process of adapting to facial change.     

Antibiotics in orthognathic surgery: a retrospective analysis and identification of risk factors for postoperative infection

This study was undertaken to evaluate the infection rate following orthognathic surgery and to identify possible risk factors. A retrospective study was conducted. Patients undergoing orthognathic surgery from August 1, 2017 to July 31, 2018 were included. The outcome variable was surgical site infection (SSI). All data were analysed with respect to demographics and procedure specifications. A total of 137 patients (mean age 28.5 ± 12.69 years) were included in this study, of whom 20 (14.6%) developed a SSI. The only risk factor identified was the type of surgery: those undergoing mandibular osteotomies (in bilateral sagittal split osteotomy (BSSO) or bimaxillary osteotomies) were far more likely to develop infections. Third molar teeth were removed during orthognathic surgery in 28.5% of the procedures, and a genioplasty was performed in 10.9%. Removal of osteosynthesis material because of infectious reasons was necessary in 10.2% of patients, with a strong association to previous SSI. In conclusion, this study showed an infection rate of 14.6% with no link to any demographic risk factor. Neither the simultaneous removal of third molar teeth nor genioplasty was found to be a risk factor for SSI. For literature comparison purposes, there is a clear need for the international guidelines defining SSI to be used.