Yield and utility of radiographic “shunt series” in the evaluation of ventriculo-peritoneal shunt malfunction in adult emergency patients

We examined the yield and utility of shunt series (SS) performed for suspected shunt malfunction and whether an abnormal SS lead to shunt revision when head computed tomography (CT) was normal or unchanged. We reviewed medical records for all adult emergency patients over a 34-month period with suspected shunt malfunction imaged with both SS and head CT to determine whether a shunt revision was performed contemporaneous with imaging. Nine (3.4%) abnormal SS were identified among 263 studies performed. Among the 192 cases in which CT was normal or unchanged, two patients with abnormal SS underwent contemporaneous shunt revision. Yield of SS is very low, and in the presence of a normal or unchanged head CT, SS provides the imaging basis for contemporaneous shunt revision in 1% (2/192) of cases.     

Gait kinetics of total hip replacement patients—A large scale,long-term follow-up study

BackgroundIt is not known if lower limb gait kinetics of total hip replacement (THR) patients reach normal levels at long term follow-up post-operatively.MethodsThree-dimensional gait analysis was performed on 134 THR patients with identical implants 10-years post-operatively. Lower limb moments and powers were compared between different age strata (54–64 years, 65–69 years, 70–74 years, 75–79 years and over 80 years) and a normal elderly control group.ResultsHip extensor moment and hip power generation were significantly reduced in all age groups compared to normal. External hip rotation moment was significantly reduced in all age groups, apart from the youngest group, compared to normal. However, in contrast to previous short term follow-up studies there was no significant difference in hip abduction moment between any of the age groups and the normal group.ConclusionThis large cohort study shows that, at long term follow-up following THR, some hip joint kinetics (hip extensor and external rotation moments and hip power generation) do not reach normal levels, but that peak abduction moment is preserved. THR patients recovery could potentially benefit from intensive rehabilitation focusing on hip extension and external rotation in the post-operative, and perhaps preoperative, period.     

Can hip impingement be mistaken for tendon pain in the groin? A long-term follow-up of tenotomy for groin pain in athletes

Purpose

There are several reports on the association between pubalgia and intra-articular hip disorders. The purpose of this study was to evaluate the long-term outcome in athletes who underwent tenotomy due to long-standing groin pain. A secondary purpose was evaluating the frequency of femoro-acetabular impingement (FAI) and its impact on the long-term outcome.

Methods

Thirty-two high-level male athletes treated with adductor tenotomy, rectus abdominis tenotomy or both were included. At a median follow-up time of 6 years after the tenotomy, the subjects underwent standardised clinical examination, plain radiographs, completed web-based health-related patient-reported outcomes, including iHOT12, HAGOS (six subscales), EQ-5D (two subscales), HSAS for physical activity level and a VAS for overall hip function. Furthermore, patient satisfaction and return to sports were documented.

Results

Twenty-four of the 32 (75 %) athletes were satisfied with the outcome of the tenotomy, and 22 of the athletes (69 %) were able to return to their pre-injury sport. Before the long-term follow-up, two of these satisfied athletes had undergone repeat surgery (one hip arthroscopy due to FAI and one repeat tenotomy). Of the 24 satisfied athletes, eight (33 %) had a positive hip impingement test at the follow-up. Of the remaining eight athletes not satisfied with the outcome, only one returned to their pre-injury sport and three had undergone hip arthroscopy prior to follow-up. Five had positive hip impingement tests which was significantly more frequently than in the satisfied group (p = 0.008). The group with a positive hip impingement test reported significantly more pain and symptoms, more hip problems during sports and physical activity, as well as lower hip-related quality of life according to the HAGOS scores (p < 0.05), at follow-up.

Conclusion

Tenotomy for pubalgia yielded a satisfactory long-term outcome, with three of four athletes being able to return to their pre-injury sport. The athletes that did not return to their pre-injury sport had higher frequency of positive hip impingement test and inferior functional outcome compared with the athletes that did return to their pre-injury sport. It is therefore recommended that the hip should be carefully evaluated for hip impingement before tenotomy is considered as treatment for athletes with pubalgia.

Level of evidence

Retrospective case series, Level IV.     

Safe in our hands?: A study of suicide and self-harm in asylum seekers

This study examined the incidence of suicide and self-harm in asylum seekers in the UK, both those in detention and in the community. The investigation revealed that data recording is seriously flawed or sometimes non-existent. However, the scanty data those were available from Immigration Removal Centres, coroners’ records and Prison Ombudsman’s reports showed high levels of self-harm and suicide for detained asylum seekers as compared with the United Kingdom prison population. It is suggested that this could be attributed to routine failure to observe and mitigate risk factors. The author makes the following recommendations: coroners should record asylum seeker status and ethnicity of deceased, self-harm monitoring in the community should record asylum seeker status and ethnicity, health care in immigration removal centres should meet the same standards as UK prisons as a minimum, allegation of torture by immigration detainees should trigger a case management review and risk assessment for continued detention, and this process should be open to audit, and interpreters should be used for mental state examinations unless their English has been shown to the fluent.     

Interstitial pulsed-dose-rate brachytherapy for head and neck cancer—Single-institution long-term results of 385 patients

PurposeTo assess the long-term results of protocol-based pulsed-dose-rate (PDR) interstitial brachytherapy (iBT) in 385 patients with head and neck cancer who underwent PDR-iBT preferably after minimal, nonmutilating surgery.Methods and MaterialsFrom 1997 to 2009, a total of 385 patients received protocol-based PDR-iBT for head and neck cancer. Brachytherapy was preceded by surgery in most of our patients (326/385, 84.7%). Altogether, 246 of 385 patients (63.9%) received iBT alone and 135 of 385 patients (36.1%) in combination with external beam radiation therapy. The analysis was done after a median followup of 63 months.ResultsThe 5-, 10-, and 15-year local relapse-free survival rates according to Kaplan–Meier test for all analyzed patients were 85.8%, 83.1%, and 80.2%, respectively. The 5-, 10-, and 15-year overall survival and disease-free survival rates were 68.9%, 52.2%, and 44.1%, and 81.3%, 79.3%, and 76.3%, respectively. For N0-/N1- vs. N2-patients, we observed significantly different 5-year local recurrence-free survival rates with values of 92.3% and 73.7%, respectively (p = 0.007). No other patient or treatment-related parameters had a significant influence on treatment results. Serious late side effects, such as soft tissue or bone necrosis, were observed in 39 of 385 patients (10.2%) and 18 of 385 patients (4.9%), respectively.ConclusionsThe PDR-iBT with 0.4–0.7 Gy each hour, 24 h per day for patients with head and neck cancer is a proven, effective, and safe treatment method with excellent long-term data.     

Structural and neurochemical evaluation of the brain and pons in patients with Wilson’s disease

Purpose  

The aim of this study was to examine the structural-neurochemical abnormalities of the frontal white matter (FWM), deep gray matter nuclei, and pons in patients with Wilson’s disease (WD) using proton magnetic resonance spectroscopy (MRS) and diffusion-weighted imaging (DWI).     

3 T DCE-MRI assessment of synovitis of the interphalangeal joints in patients with erosive osteoarthritis for treatment response monitoring

Objective

To study the value of 3 T dynamic contrast-enhanced (DCE)-MRI for assessment of synovitis of the interphalangeal joints in patients with erosive osteoarthritis (EOA) for treatment response monitoring.

Materials and methods

The interphalangeal joints of fingers two to five were examined at 3 T MRI in nine patients with EOA. Two musculoskeletal radiologists recorded erosions, bone marrow oedema (BME), synovitis and osteophytes. Interobserver reliability was calculated using κ statistics. In six patients, DCE-MRI time intensity curves of synovitis in two affected joints were analysed. The maximum upslope, absolute and relative enhancement of synovitis were compared with MRI after 12 months of anti-tumour necrosis factor treatment. Intraobserver reproducibility was calculated using intra-class correlation coefficient.

Results

Interobserver reliability was ‘good’ for detection of erosions (κ?=?0.70), BME (κ?=?0.77) and synovitis (κ?=?0.77), but ‘poor’ for osteophytes (κ?=?0.12). Post-treatment DCE-MRI showed decreasing maximum upslope (p?=?0.002) and absolute (p?=?0.002) and relative (p?=?0.01) enhancement compared to the initial scan. Intraobserver reproducibility of DCE-MRI was ‘almost perfect’ or ‘strong’ for all parameters.

Conclusions

3 T DCE-MRI demonstrates changes in time intensity curves of synovitis in EOA of the interphalangeal joints in a longitudinal study, indicating this technique is promising for monitoring therapy response.     

Quantitative evaluation of knee cartilage and meniscus destruction in patients with rheumatoid arthritis using T1ρ and T2 mapping

ObjectiveTo calculate T1ρ and T2 values of articular cartilage and menisci in knee joints of patients with RA, and compare the values between RA patients and healthy volunteers, to gain insight into the pathogenesis of cartilage and meniscus degradation in patients with RA.Materials and methodsNine patients with RA and knee joints symptoms were enrolled in the study, twenty healthy volunteers without knee joint diseases were included as controls. Sagittal fat-saturated T1ρ and T2 mapping images were obtained on a 3T MR scanner (GE750, GE Healthcare, Waukesha, WI), using a dedicated 8-channel knee coil. In the T1rho mapping sequence, the amplitude of the spin-lock pulse was 500 Hz, spin lock durations = 10/20/30/50 ms. In the T2 mapping sequence,TR/TE were 1794/6.5, 13.4, 27, 40.7 ms. Both sequences were performed with the following parameters: flip angle (FA) = 90°, matrix: 320 × 256, FOV: 16 × 16 cm², slice thickness: 3 mm, bandwidth: 62.5 kHZ, and a total scan time of 5:11 min. T1ρ- and T2-mapping images were used for the segmentation of the articular cartilage of the patella, femoral trochlea, medial and lateral femoral condyle, medial and lateral tibial plateau. These images were also used for the segmentation of the anterior and posterior horns of the medial and lateral menisci with livewire semi-automatic segmentation algorithm of MATLAB. A Mann–Whitney U test was performed to compare the T1ρ and T2 values of the above mentioned regions between the two groups.ResultsT1ρ (Z = −3.913 to −2.121, P = 0.000–0.034) and T2 (Z = −3.866 to −2.216, P = 0.000–0.026) values of knee cartilage in patients with RA were higher than that in healthy volunteers, except the cartilage of the patella (T1ρ: Z = −1.273, P = 0.203,T2: Z = −0.236, P = 0.814) and lateral tibial plateau (T1ρ:Z = −1.037, P = 0.317). The T1ρ (Z = −1.462 to 0.572, P = 0.095–0.908) and T2 (Z = −1.461 to 0.278, P = 0.153–0.764) values of medial and lateral menisci showed no difference between the two groups.ConclusionPatients with RA exhibit diffuse knee cartilage destruction in the medial and lateral tibiofemoral joints and in the femoral trochlea. However, we found no increase in T1ρ and T2 values in menisci, this finding warrants further investigation.     

Blunt bowel and mesenteric trauma: role of clinical signs along with CT findings in patients’ management

Background

Bowel and/or mesentery injuries represent the third most common injury among patients with blunt abdominal trauma. Delayed diagnosis increases morbidity and mortality. The aim of our study was to evaluate the role of clinical signs along with CT findings as predictors of early surgical repair.

Material and methods

Between March 2014 and February 2017, charts and CT scans of consecutive patients treated for blunt abdominal trauma in two different trauma centers were reread by two experienced radiologists. We included all adult patients who underwent contrast-enhanced CT of the abdomen and pelvis with CT findings of blunt bowel and/or mesenteric injury (BBMI). We divided CT findings into two groups: the first included three highly specific CT signs and the second included six less specific CT signs indicated as “minor CT findings.” The presence of abdominal guarding and/or abdominal pain was considered as “clinical signs.” Reference standards included surgically proven BBMI and clinical follow-up. Association was evaluated by the chi-square test. A logistic regression model was used to estimate odds ratio (OR) and confidence intervals (CI).

Results

Thirty-four (4.1%) out of 831 patients who sustained blunt abdominal trauma had BBMI at CT. Twenty-one out of thirty-four patients (61.8%) underwent surgical repair; the remaining 13 were treated conservatively. Free fluid had a significant statistical association with surgery (p?=?0.0044). The presence of three or more minor CT findings was statistically associated with surgery (OR?=?8.1; 95% CI, 1.2–53.7). Abdominal guarding along with bowel wall discontinuity and extraluminal air had the highest positive predictive value (100 and 83.3%, respectively).

Conclusion

In patients without solid organ injury (SOI), the presence of free fluid along with abdominal guarding and three or more “minor CT findings” is a significant predictor of early surgical repair. The association of bowel wall discontinuity with extraluminal air warrants exploratory laparotomy.

     

High-resolution MRI of the wrist and finger joints in patients with rheumatoid arthritis: comparison of 1.5 Tesla and 3.0 Tesla

The goal of this study was to compare magnetic resonance (MR) image quality at different field strengths for evaluating lesions in wrist and finger joints of patients with rheumatoid arthritis (RA) in order to determine whether the higher field strength provides diagnostic gain. The hand mainly affected in 17 RA patients was examined at 1.5 Tesla (T) and 3.0 T with comparable MR imaging (MRI) protocols. MR images were reviewed twice by two experienced radiologists using the Rheumatoid Arthritis MRI Scoring System (RAMRIS) of the OMERACT (Outcome Measures in Rheumatoid Arthritis Clinical Trials) group. Image quality was rated on a five-point scale using Friedmann’s test and Kendall’s W-test for statistical analysis. Image comparison revealed better image quality at higher field strength. Image quality of T1-weighted images was rated 14–22% better at 3.0 T compared with 1.5 T by both readers. Moreover, the rating for the T2-weighted-images acquired at 3.0 T was one point better in the five-point scale used. Inter-reader correlation for image quality, bone erosions/defects, edema and synovitis ranged between 0.6 and 0.9 at 3.0 T and between 0.6 and 0.8 at 1.5 T. Intra-reader correlation for these parameters was high at 0.8–1.0. MRI image quality of RA hands is superior at 3.0 T, while an acceptable image quality is achieved at 1.5 T, which improves the evaluation of extent of bone edema, synovitis and identification of small bone erosions.     

Early-stage [123I]β-CIT SPECT and long-term clinical follow-up in patients with an initial diagnosis of Parkinson’s disease

Purpose Previous studies using dopamine transporter single-photon emission computed tomography (SPECT) to try and distinguish between patients with idiopathic Parkinsons disease (IPD) and patients with atypical parkinsonian syndromes (APS) have mainly focussed on patients with an already established clinical diagnosis of several years duration. Differences in the pattern of striatal involvement between IPD and APS have been found in only few studies. We hypothesized that distinguishing SPECT features might be most pronounced at an early disease stage, and the purpose of the present study was to investigate this hypothesis.Methods The study included 72 patients with an initial clinical diagnosis of IPD, supported by decreased striatal [¹²³I]-CIT binding on baseline SPECT. In ten patients, the diagnosis was changed to APS over a mean follow-up period of 62 months. We retrospectively compared the patterns of striatal involvement on the baseline SPECT scans between the group of patients (re)diagnosed with APS and the remaining 62 patients in whom a diagnosis of IPD was maintained.Results In the group of patients with APS, baseline [¹²³I]-CIT binding in both caudate nuclei was lower than in the group of patients with IPD. In addition, putamen to caudate binding ratios were higher in the group of APS patients. In spite of these differences, individual binding values showed considerable overlap between the groups.Conclusion [¹²³I]-CIT SPECT scanning in early-stage, untreated parkinsonian patients revealed a relative sparing of the caudate nucleus in patients with IPD as compared to patients later (re)diagnosed with APS. Nevertheless, the pattern of striatal involvement appears to have little predictive value for a later re-diagnosis of APS in individual cases.     

What is the value of stress 99mTc-tetrofosmin myocardial perfusion imaging for the assessment of very long-term outcome in obese patients?

Objective

There are no data regarding the long-term prognostic value of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in obese patients. The aim of this study was to examine the value of stress ^99mTc-tetrofosmin MPI findings for the prediction of very long-term outcome in obese patients.

Methods

The study population consisted of 261 patients with a body mass index ≥30 kg/m² who underwent exercise or pharmacological stress ^99mTc-tetrofosmin MPI for the assessment of known or suspected coronary artery disease. Endpoints during follow-up were all-cause mortality, cardiac death, nonfatal infarction, and coronary revascularization. Kaplan-Meier survival cures were constructed and univariate and multivariate analyses were performed to identify predictors of very long-term outcome.

Results

The mean age was 59 ± 10 years, 42% of the patients was male, and the body mass index was on average 37 ± 7 kg/m². MPI findings were normal in 109 patients (42%). Myocardial perfusion abnormalities were fixed in 62 patients (24%) and reversible in 90 patients (34%). During a median 12-year follow-up, 91 (35%) patients died, and 27 (10%) had a nonfatal myocardial infarction. Survival curves were compared using the log-rank test at subsequent follow-up durations. Obese patients with a normal stress ^99mTc-tetrofosmin study had a significantly better prognosis as compared with those with an abnormal study, up to 6 years after the test was performed.

Conclusion

Stress ^99mTc-tetrofosmin MPI provides valuable prognostic information for the prediction of outcome in obese patients. Obese patients with a normal stress ^99mTc-tetrofosmin study have a significantly better prognosis as compared with those with an abnormal study, up to 6 years after the test is performed.     

Diagnostic value of (1,3)-β-D-glucan assay and galactomannan test for invasive fungal infection in patients of acute radiation sickness

Objective To investigate the diagnostic values of (1,3)-β-D-glucan (G) and galactomannan (GM) for invasive fungal infection (IFI) in patients of acute radiation sickness (ARS).Methods Samples of periogeral blood,pharyngeal secretion,urine,and feces were collected from 316patients with ARS and suspected to suffer from IFI,192 males and 124 females,aged 60.50(1-96),with the underlying diseases of blood or respiration systems.Platelia Aspergillus EIA kit was used to detect the plasma BG (G test),and ELISA was used to detect the serum GM (GM test).Fungal culture and bacterial culture were performed.Results The positive rates of G test,GM test,and fungal culture were 36.33%,35.84% ,and 34.18% respectively,but the positive rate of fungal culture of blood sample was 1/316 only.Pearson correlation analysis showed that G test,GM test and fungal culture test were positively correlated with IFI clinical diagnosis respectively (x2 = 0.564,0.357,0.727,P ＜ 0.05).Conclusions Easy to operate,rapid,and highly sencitive,G test and GM test can be used as adjunctive methods for early IFI diagnosis in ARS patients.