Comparison of breast density assessment between human eye and automated software on digital and synthetic mammography: Impact on breast cancer risk

PurposeTo evaluate the agreement between automatic assessment software of breast density based on artificial intelligence (AI) and visual assessment by a senior and a junior radiologist, as well as the impact on the assessment of breast cancer risk (BCR) at 5 years.Materials and methodsWe retrospectively included 311 consecutive women (mean age, 55.6 ± 8.5 [SD]; range: 40–74 years) without a personal history of breast cancer who underwent routine mammography between January 1, 2019 and February 28, 2019. Mammographic breast density (MBD) was independently evaluated by a junior and a senior reader on digital mammography (DM) and synthetic mammography (SM) using BI-RADS (5th edition) and by an AI software. For each MBD, BCR at 5 years was estimated per woman by the AI software. Interobserver agreement for MBD between the two readers and the AI software were evaluated by quadratic κ coefficients. Reproducibility of BCR was assessed by intraclass correlation coefficient (ICC).ResultsAgreement for MBD assessment on DM and SM was almost perfect between senior and junior radiologists (κ = 0.88 [95% CI: 0.84–0.92] and κ = 0.86 [95% CI: 0.82–0.90], respectively) and substantial between the senior radiologist and AI (κ = 0.79; 95% CI: 0.73–0.84). There was substantial agreement between DM and SM for the senior radiologist (κ = 0.79; 95% CI: 0.74–0.84). BCR evaluation at 5 years was highly reproducible between the two radiologists on DM and SM (ICC = 0.98 [95% CI: 0.97–0.98] for both), between BCR evaluation based on DM and SM evaluated by the senior (ICC = 0.96; 95% CI: 0.95–0.97) or junior radiologist (ICC = 0.97; 95% CI: 0.96–0.98) and between the senior radiologist and AI (ICC = 0.96; 95% CI: 0.95–0.97).ConclusionThis preliminary study demonstrates a very good agreement for BCR evaluation based on the evaluation of MBD by a senior radiologist, junior radiologist and AI software.     

Determination of the appropriate catheter length and place for needle thoracostomy by using computed tomography scans of pneumothorax patients

Introduction

The primary goal of this study was to compare the chest wall thicknesses (CWT) at the 2nd intercostal space (ICS) at the mid-clavicular line (MCL) and 5th ICS at the mid-axillary line (MAL) in a population of patients with a CT confirmed pneumothorax (PTX). This result will help physicians to determine the optimum needle thoracostomy (NT) puncture site in patients with a PTX.

Materials and methods

All trauma patients who presented consecutively to A&E over a 12-month period were included. Among all the trauma patients with a chest CT (4204 patients), 160 were included in the final analysis. CWTs were measured at both sides and were compared in all subgroup of patients.

Results

The average CWT for men on the 2nd ICS-MCL was 38 mm and for women was 52 mm; on the other hand, on the 5th ICS-MAL was 33 mm for men and 38 mm for women. On the 2nd ICS-MCL 17% of men and 48% of women; on the 5th ICS-MAL 13% of men and 33% of women would be inaccessible with a routine 5-cm catheter. Patients with trauma, subcutaneous emphysema and multiple rib fractures would have thicker CWT on the 2nd ICS-MCL. Patients with trauma, lung contusion, sternum fracture, subcutaneous emphysema and multiple rib fractures would have thicker CWT on the 5th ICS-MAL.

Conclusions

This study confirms that a 5.0-cm catheter would be unlikely to access the pleural space in at least 1/3 of female and 1/10 of male Turkish trauma patients, regardless of the puncture site. If NT is needed, the 5th ICS-MAL is a better option for a puncture site with thinner CWT.     

Effective volumes of 1.5% mepivacaine with different sodium concentration for ultrasound guided popliteal block

Study objectiveTo determine if a solution of 1.5% mepivacaine diluted with 5% dextrose, which decreases the sodium concentration by 30%, results in reduced volume requirements for a complete sensory block, in the case of an ultrasound guided popliteal nerve block.DesignA randomized controlled study.SettingOperating room.PatientsWe included seventy ASA 1–3 patients, undergoing unilateral “hallux valgus” repair under ultrasound guided popliteal nerve block.InterventionsAn ultrasound guided popliteal nerve block was performed on all patients, with 1.5% mepivacaine using the normal dilution (ND group, thirty-five patients) or the 5% dextrose dilution (D5 group, thirty-five patients). Starting with 25 ml in each group, increasing or decreasing it by 1 ml on subsequent patients, depending on the success or failure in the previous one (Dixon's “up-and-down” sequential allocation).MeasurementsEffective dose in 50, 90, and 95% of patients (ED50, ED90, and ED95) of 1.5% mepivacaine in both groups. Onset time and duration of the blocks, side effects, and neurological complications.Main resultsThere were no statistically significant differences between ED50 in ND group (6.2 ml; 95% confidence interval, 5.2–7.5), and D5 group (5.8 ml; 95% CI, 5.1–7). Also no statistically significant differences in ED90 (7.7 ml, 95% CI 6.9–8.1 in the D5 group; 7.8 ml, 95% CI 7–8.1 in the ND) or in ED95 (7.9 ml, 95% CI 7.1–8.2 in the D5 group; 8 ml, 95% CI 7.2–8.2 in the ND) were found. Onset time for a complete sensory block in D5 group was 14 min (95% CI, 12–17) and 15 min in ND (95% CI, 13–18), p = 0.66. Neither severe side effects, nor neurological complications were reported.ConclusionsA dilution of 1.5% mepivacaine with 30% less sodium concentration does not decrease volume requirement for ultrasound guided sciatic nerve block at popliteal level.     

Endovascular stenting for chronic femoro-iliac venous obstructive disease: Clinical efficacy and short-term outcomes

PurposeTo report the clinical efficacy and mid-term outcomes of endovascular treatment in patients with chronic, symptomatic, post-thrombotic femoro-iliac venous obstruction.Materials and methodsForty-two patients with post-thrombotic syndrome (PTS) presenting with femoro-iliac venous obstructive lesions treated in our institution by endovascular approach between March 2012 and October 2017 were retrospectively included. There were 27 women and 15 men with a mean age of 47.3 ± 17 (SD) years (range: 22–86 years). Procedure included first venous recanalization, then pre-dilatation and self-expandable metallic stenting of the narrowed or occluded iliac and/or femoral veins. Severity of PTS and quality of life were assessed at baseline and 3 months after the intervention respectively, using Villalta score and Chronic Venous Insufficiency Questionnaire (CIVIQ-20) scale. Imaging follow-up evaluation of stent patency was based on the results of duplex Doppler ultrasound and computed tomography.ResultsImmediate technical success was achieved in 41/42 (97.6%) patients, without any major complications. Primary patency, primary assisted patency and secondary patency at the end of the median imaging follow-up of 18.1 months (IQR, 9.7–34.4) were achieved in 29/42 (66.7%) patients, 33/42 (78.6%) patients and 37/42 (88.1%) patients, respectively. Median Villalta and CIVIQ-20 scores decreased from 14 (IQR, 10–19) and 57 (IQR, 39–72) at baseline, respectively, to 5 (IQR, 2–9) and 30 (IQR, 24–50) 3 months after the procedure, respectively (P < 0.0001), showing significant decrease in the severity of PTS and improvement in the quality of life. The multiple linear regression model showed that both baseline Villalta and CIVIQ-20 scores ([95% CI: −7.80–3.79; P < 0.0001] and [95% CI: 0.07–0.20; P < 0.0001], respectively), age (95% CI: 0.04–0.19; P = 0.002) and stenting expanse (95% CI: 0.97–5.65; P = 0.006) were independent variables related to Villalta gain. Baseline Villalta (95% CI: 0.89–2.23; P < 0.0001) was the single independent variable related to CIVIQ-20 gain.ConclusionThis study confirms the high clinical efficacy and favorable mid-term outcomes of endovascular stenting in patients with chronic symptomatic femoro-iliac venous obstructive lesions.     

Arterial endofibrosis in endurance athletes: Prospective comparison of the diagnostic accuracy of intra-arterial digital subtraction angiography and computed tomography angiography

PurposeTo prospectively compare the diagnostic capabilities of computed tomography angiography (CTA) to those of digital subtraction angiography (DSA) in endurance athletes with suspicion of arterial endofibrosis.Materials and methodsForty-five athletes (39 men, 6 women; median age: 30 years, interquartile range: 23–42 years) prospectively underwent DSA and CTA without (n = 5) or with (n = 40) electrocardiogram gating. DSA was interpreted by a single expert (experience of 15 years). CTA was independently interpreted by three other readers (experience of 5–8 years). Readers assessed the presence and degree of stenoses on iliac and femoral arteries and the overall diagnosis (negative, uncertain, positive) of endofibrosis at the limb level. Sensitivities and specificities of DSA and CTA were estimated at the limb level using histological findings and long-term follow-up as reference, and compared using the McNemar test.ResultsFor diagnosing and quantifying stenoses, concordance between DSA and CTA was moderate-to-good for common and external iliac arteries, moderate for lateral circumflex arteries and poor-to-moderate for the other branches of the deep femoral artery. It was good for all readers for the overall diagnosis of endofibrosis. After long-term follow-up (median, 95 months; interquartile range: 7–109 months), DSA sensitivity and specificity were respectively 88.6% (39/44; 95% confidence interval [CI]: 76–95%) and 75% (24/32; 95% CI: 57.9–86.7%); CTA sensitivity and specificity were respectively 88.6% (39/44; 95% CI: 76–95%; P > 0.99) and 84.4% (27/32; 95% CI: 68.2–93.1%; P = 0.51), 86.3% (38/44; 95% CI: 73.3–93.6%; P > 0.99) and 75% (24/32; 95% CI: 57.9–86.7%; P > 0.99), and 84.1% (37/44; 95% CI: 70.6–92.1%; P = 0.68) and 75% (24/32; 95% CI: 57.9–86.7%; P > 0.99) for the three readers.ConclusionCTA shows performances similar to those of DSA in predicting the long-term diagnosis of endofibrosis in endurance athletes with suggestive symptoms.     

Texture analysis of apparent diffusion coefficient (ADC) map for glioma grading: Analysis of whole tumoral and peri-tumoral tissue

PurposeTo prospectively investigate the capabilities of texture analysis (TA) based on apparent diffusion coefficient (ADC) map of the entire tumor volume and the whole volume of peri-tumoral edema, in discriminating between high-grade glioma (HGG) and low-grade glioma (LGG).Materials and methodsA total of 33 patients with histopathological proven glioma were prospectively included. There were 20 men and 13 women with a mean age of 54.5 ± 14.7 (standard deviation [SD]) years (range: 34–75 years). TA parameters of whole tumor and peri-tumoral edema were extracted from the ADC map obtained with diffusion-weighted spin-echo echo-planar magnetic resonance imaging at 1.5–T. TA variables of HGG were compared to those of LGG. The optimum cut-off values of TA variables and their corresponding sensitivity, specificity and accuracy for differentiating between LGG and HGG were calculated using receiver operating characteristic curve analysis.ResultsMean and median tumoral ADC of HGG were significantly lower than those of LGG, at 1.23 × 10^?3 mm²/s and 1.21 × 10^?3 mm²/s cut-off values, yielding 70% sensitivity each (95% CI: 59–82% and 61–80%, respectively), 80% (95% CI: 79–98%) and 90% (95% CI: 82–97%) specificity, and 73% (95% CI: 66–91%) and 76% (95% CI: 72–90%) accuracy, respectively. Significant differences in tumoral and peri-tumoral kurtosis were found between HGG and LGG at 1.60 and 0.314 cut-off values yielding sensitivities of 74% (95% CI: 58–83%) and 70% (95% CI: 59–84%), specificities of 90% (95% CI: 80–95%) and 70% (95% CI: 64–83%) and accuracies of 79% (95% CI: 69–89%) and 70% (95% CI: 64–77%), respectively.ConclusionMeasurements of whole tumoral and peri-tumoral TA, based on ADC maps, provide useful information that helps distinguish between HGG and LGG.     

Glioma-grade diagnosis using in-phase and out-of-phase T1-weighted magnetic resonance imaging: A prospective study

PurposeThe purpose of this prospective study was to determine whether chemical shift gradient-echo magnetic resonance imaging (MRI) could predict glioma grade.Materials and methodsA total of 69 patients with 69 gliomas were prospectively included. There were 41 men and 28 women with a mean age of 50 ± (SD) years (range: 16–82 years). All patients had MRI of the brain including chemical shift gradient-echo sequence, further referred to as in- and out-of phase sequence (IP/OP). Intravoxel fat content was estimated by signal loss ratio (SLR = [IP-OP]/2IP), between in- and out-of-phase images, using a region of interest placed on the viable portion of the gliomas. Association between SLR and glioma grade was searched for using Wilcoxon and Mann–Whitney U tests and diagnostic capabilities using area under the receiver operating characteristic (AUROC) curves.ResultsA significant association was found between SLR value and glioma grade (P < 0.0001). SLR > 9‰ allowed complete discrimination between grade III and grade II glioma with 100% specificity (95% CI: 85–100%), 100% sensitivity (95% CI: 78–100%) and 100% accuracy (95% CI: 90–100%) (AUROC = 1). A SLR > 20‰ allowed discriminating between grade IV and grade III glioma with 75% specificity (95% CI: 57–89%), 73% sensitivity (95% CI: 45–92%) and 72% accuracy (95% CI: 57–84%) (AUC = 0.825, 95% CI: 0.702–0.948). The AUROC for the diagnosis of high-grade glioma (grade III and IV vs. grade II) was 1.ConclusionChemical shift gradient echo MRI provides accurate grading of gliomas. This simple method should be used as a biomarker to predict glioma grade.     

Diagnosis of postoperative recurrence of Crohn disease with MR-enterography: Value of diffusion-weighted imaging

PurposeTo compare the diagnostic capabilities of MR enterography (MRE) using contrast-enhanced (CE) sequences with those of MRE using diffusion-weighted (DW) imaging for the diagnosis of postoperative recurrence at the neo-terminal ileum and/or anastomosis after ileocolonic resection in patients with Crohn disease (CD), and to clarify the role of additional DW imaging to CE-MRE in this context.Material and methodsForty patients who underwent ileal resection for CD, and both endoscopy and MRE within the first year after surgery were included. There were 21 men and 19 women, with a mean age of 38 years ± 12 (SD) years (range: 18–67 years). MRE examinations were blindly analyzed independently by one senior (R1) and one junior (R2) radiologist for the presence of small bowel postoperative recurrence at the anastomotic site. During a first reading session, T2-, steady-state- and DW-MRE were reviewed (DW-MRE or set 1). During a separate distant session, T2-, steady-state- and CE-MRE were reviewed (CE-MRE or set 2). Lastly, all sequences were analyzed altogether (set 3). Performances of each reader for the diagnosis of postoperative recurrence were evaluated using endoscopic findings as the standard of reference (Rutgeerts score ≥ i2b).ResultsFifteen patients out of 40 (37.5%) had endoscopic postoperative recurrence at the anastomotic site. Sensitivity for the diagnosis of postoperative recurrence was 73% (95% CI: 51–96%) for R1 and 67% (95% CI: 43–91%) for R2 using set 1, and 80% (95% CI: 60–100%) for both readers using set 2. There was no significant differences in sensitivity between reading set 1 and reading set 2, for either R1 or R2 (R1, P  > 0.99; R2, P = 0.48). Specificity was 96% (95% CI: 88–100%) for both readers using set 1 or using set 2. Reading set 3 yielded an area under the ROC curve (AUC) of 0.93 (95% CI: 0.84–1) versus 0.89 (95% CI: 0.75–1) with set 1 (P = 0.18) and versus 0.89 (95% CI: 0.78–1) with set 2 (P = 0.21). No significant differences in AUC were found between set 1 or 2 and set 3 (P = 0.18), nor between set 1 and 2 (P = 0.76). Accuracies were 88% (95% CI: 74–95%) and 85% (95% CI: 71–93%) for DW-MRE for R1 and R2, respectively; 90% (95% CI: 77–96%) for CE-MRE for both readers; and 93% (95% CI: 80–97%) and 88% (95% CI: 74–95%) for R1 and R2 with set 3, respectively.ConclusionDW-MRE has diagnostic capabilities similar to those of CE-MRE for the diagnosis of postoperative recurrence of CD at the anastomotic site.     

MRI combined with PSA density in detecting clinically significant prostate cancer in patients with PSA serum levels of 4∼10 ng/mL: Biparametric versus multiparametric MRI

PurposeTo compare the performance of biparametric magnetic resonance imaging (bpMRI) to that of multiparametric MRI (mpMRI) in combination with prostate-specific antigen density (PSAD) in detecting clinically significant prostate cancer (csPCa) in patients with PSA serum levels of 4∼10 ng/mL.Materials and methodsA total of 123 men (mean age, 66.3 ± 8.9 [SD]; range: 42–83 years) with PSA serum levels of 4∼10 ng/mL with suspected csPCa were included. All patients underwent mpMRI at 3 Tesla and transrectal ultrasound-guided prostate biopsy in their clinical workup and were followed-up for >1 year when no csPCa was found at initial biopsy. The mpMRI images were reinterpreted according to the Prostate Imaging Reporting and Data System (PI-RADS, v2.1) twice in two different sessions using either mpMRI sequences or bpMRI sequences. The patients were divided into 2 groups according to whether csPCa was detected. The PI-RADS (mpMRI or bpMRI) categories and PSAD were used in combination to detect csPCa. Receiver operating characteristic (ROC) curve and decision curve analyses were performed to compare the efficacy of the different models (mpMRI, bpMRI, PSAD, mpMRI + PSAD and bpMRI + PSAD).ResultsThirty-seven patients (30.1%, 37/123) had csPCa. ROC analysis showed that bpMRI (AUC = 0.884 [95% confidence interval (CI): 0.814–0.935]) outperformed mpMRI (AUC = 0.867 [95% CI: 0.794–0.921]) (P = 0.035) and that bpMRI and mpMRI performed better than PSAD (0.682 [95% CI: 0.592–0.763]) in detecting csPCa; bpMRI + PSAD (AUC = 0.907 [95% CI: 0.841–0.952]) performed similarly to mpMRI + PSAD (AUC = 0.896 [95% CI: 0.828–0.944]) (P = 0.151) and bpMRI (P = 0.224). The sensitivity and specificity were 81.1% (95% CI: 64.8–92.0%) and 88.4% (95% CI: 79.7–94.3%), respectively for bpMRI, and 83.8% (95% CI: 68.0–93.8%) and 80.2% (95% CI: 70.2–88.0%), respectively for mpMRI (P > 0.999 for sensitivity and P = 0.016 for specificity). Among the 5 decision models, the decision curve analysis showed that all models (except for PSAD) achieved a high net benefit.ConclusionIn patients with PSA serum levels of 4∼10 ng/mL, bpMRI and bpMRI combined with PSAD achieve better performance than mpMRI in detecting csPCa; bpMRI has a higher specificity than mpMRI, which could decrease unnecessary biopsy, and may serve as a potential alternative to mpMRI to optimize clinical workup.     

Association between common risk factors and molecular subtypes in breast cancer patients

BackgroundBreast cancer is the most commonly diagnosed cancer in women worldwide and characterized its by molecular and clinical heterogeneity. Gene expression profiling studies have classified breast cancers into five subtypes: luminal A, luminal B, HER-2 overexpressing, basal-like, and normal breast-like. Although clinical differences between subtypes have been well described in the literature, etiologic heterogeneity have not been fully studied. The aim of this study was to assess the associations between several hormonal and nonhormonal risk factors and molecular subtypes of breast cancer.MethodsThis cross-sectional study consisted of 1884 invasive breast cancer cases. Variables studied included family history, age at first full-term pregnancy, number of children, duration of lactation, menstruation history, menopausal status, blood type, smoking, obesity, oral contraceptive use, hormone replacement therapy and in vitro fertilization. The odds ratios (OR) and 95% confidence intervals (CI) were estimated using multivariate logistic regression analysis.ResultsThousand two-hundred and forty nine patients had luminal A, 234 had luminal B, 169 had HER-2 overexpressing and 232 had triple negative breast cancer. The age of ≥40 years was found to be a risk factor for luminal A (OR 1.41 95% CI 1.15–1.74; p = 0.001) and HER-2 overexpressing subtype (OR: 1.51, 95% CI: 1.01–2.25; p = 0.04). Women who were nulliparous (OR 1.48, 95% CI 1.03–2.13; p = 0.03) or who had their first full-term pregnancy at age 30 years or older (OR 1.25 95% CI 0.83–1.88; p = 0.04) were at increased risk of luminal breast cancer, whereas women with more than two children had a decreased risk (OR 0.68, 95% CI 0.47–0.97; p = 0.03). Breast-feeding was also a protective factor for luminal subtype (OR 0.74, 95% CI 0.53–1.04; p = 0.04) when compared to non-luminal breast cancer. We found increased risks for postmenopausal women with HER-2 overexpressing (OR 2.20, 95% CI 0.93–5.17; p = 0.04) and luminal A (OR 1.87, 95% CI 0.93–3.90, p = 0.02) breast cancers, who used hormone replacement therapy for 5 years or more. Overweight and obesity significantly increased the risk of triple negative subtype (OR 1.89 95% CI 1.06–3.37; p = 0.04 and OR 1.90 95% CI 1.00–3.61; p = 0.03), on the contrary, decreased the risk of luminal breast cancer (OR 0.63 95% CI 0.43–0.95; p = 0.02 and OR 0.50 95% CI 0.32–0.76; p = 0.002, respectively) in premenopausal women. There were no significant differences between risk of breast cancer subtypes and early menarche, late menopause, family history, postmenopausal obesity, oral contraseptive use, smoking, in vitro fertilization, blood groups and use of hands.ConclusionsReproductive and hormonal characteristics (breastfeeding, parity, age at first full-term birth, hormone replacement therapy) were associated with luminal subtype, compared to non-luminal breast cancer, as consistent with previous studies. Obesity and overweight increased the risk of triple negative subtype, particularly in premenopausal women. Older age and use of hormone replacement therapy were related to the risk of HER-2 overexpressing breast cancer. Our data suggest a significant heterogeneity in association of traditional breast cancer risk factors and tumor subtypes.     

Vertebral fracture risk factors in postmenopausal women over 50 in Valencia,Spain. A population-based cross-sectional study

PurposeThis study aims to estimate the prevalence of risk factors for osteoporotic vertebral fracture and analyze the possible associations between these factors and the presence of densitometric osteoporosis and prevalent morphometric vertebral fracture.MethodsData from a population-based cross-sectional sample of 804 postmenopausal women over the age of 50 years old living in the city of Valencia (Spain) were used. The women were interviewed to identify the prevalence of osteoporotic fracture risk factors and underwent a densitometry and a dorsolumbar spine X-ray.ResultsThe most prevalent risk factors were densitometric osteoporosis (31.7%), history of parental hip fracture (19.4%), hypoestrogenism (19%), and body mass index (BMI) ≥ 30 kg/m² (35.2%). After adjusting for all covariables, densitometric osteoporosis was associated with increased age [odds ratio (OR)_{65–69 years}: 2.84, 95% confidence interval (CI): 1.75–4.61; OR_{70–74 years}: 4.01, 95% CI: 2.47–6.52; OR_75 + years: 5.96, 95% CI: 3.27–10.87] and inversely associated with high BMI (OR_25.0–29.9: 0.51, 95% CI: 0.34–0.76; OR_≥ 30: 0.30, 95% CI: 0.19–0.46). Morphometric vertebral fracture was associated with age (OR_{65–69 years}: 2.04, 95% CI: 1.03–4.05; OR_{70–74 years}: 4.05, 95% CI: 2.11–7.77; OR_75 + years: 8.43, 95% CI: 3.97–17.93), poor educational level (OR: 1.70, 95% CI: 1.06–2.72) and with densitometric osteoporosis and BMI ≥ 30 kg/m² (OR: 3.35, 95% CI: 1.85–6.07).ConclusionsThe most prevalent osteoporotic fracture risk factors were having a high BMI and the presence of densitometric osteoporosis. A higher risk of morphometric vertebral fracture in women with both low bone mineral density and high BMI was found. This association, if confirmed, has important implications for clinical practice and fracture risk tools. We also found a higher risk in women with a poor educational level. More attention should be addressed to these populations in order to control modifiable risk factors.     

Oncological outcomes of laparoscopic nephroureterectomy with pluck method for distal ureter resection

ObjectiveTo report the oncologic outcomes of upper tract urothelial carcinoma treated with laparoscopic nephroureterectomy and pluck method for distal ureter resection.Materials and methodsBetween May 2004 and November 2015, 118 patients with upper urinary tract urothelial carcinoma received laparoscopic radical nephroureterectomy with endoscopic bladder cuff excision at our institution. The medical records were reviewed retrospectively for clinical and pathological results. Cox regression analyses were performed on factors related to oncological outcomes.ResultsThe median follow-up was 26 months. Bladder recurrence was found in 27 patients (22.9%), extravesical retroperitoneal recurrence in four patients (3.4%), and metastases in 17 patients (14.4%). Multivariate analyses showed that male sex was associated with higher bladder recurrence [odds ratio (OR) = 2.2; 95% confidence interval (CI), 1.02–4.78; p = 0.045)], tumor size had significant correlation with locoregional recurrence (OR = 1.29; 95% CI, 1.07–3.43; p = 0.029), tumor stage was significantly correlated with subsequent metastasis (OR = 2.08; 95% CI, 1.21–3.56; p = 0.008) and overall survival (OR = 1.84; 95% CI, 1.06–3.22 ; p = 0.031), and tumor size correlated significantly with cancer-specific survival (OR = 2.57; 95% CI, 1.16–5.72; p = 0.021).ConclusionsTumor size and tumor stage were significantly associated with survival (cancer-specific and overall survival) in patients receiving nephroureterectomy with pluck method.     

Prevalence and risk factors of osteoporosis in Korea: A community-based cohort study with lumbar spine and hip bone mineral density

PurposeTo investigate bone mineral density (BMD) profiles, osteoporosis prevalence and risk factors in a community-based cohort in Korea.MethodsThe present study is a cross-sectional study. The study population consisted of 1,547 men and 1991 women aged 40 years and older with BMD measurements using central dual energy X-ray absorptiometry from a prospective community-based cohort. The data were compared with other ethnic groups. Risk factors related to osteoporosis were analyzed.ResultsCrude prevalence of osteoporosis in the whole subjects (40–79 years old) was 13.1% for men and 24.3% for women by WHO criteria, at any site among lumbar spine, femoral neck or total hip. Standardized prevalence of osteoporosis between age of 50 and 79 at lumbar spine, femoral neck and total hip was 12.9%, 1.3% and 0.7% in men and 24.0%, 5.7% and 5.6% in women, respectively. The mean BMD of studied female subjects after age of 50 was not significantly different from that of Chinese but significantly lower than that of Japanese, non-Hispanic whites, non-Hispanic blacks and Mexican Americans. Risk of osteoporosis was significantly associated with the presence of past fracture history (OR, 1.45; 95% CI, 1.08–1.94), smoking ≥ 1 pack/day (OR, 1.63; 95% CI, 1.01–2.62), menarche after age of 16 (OR, 1.46; 95% CI, 1.14–1.87), last delivery after age of 30 (OR, 1.58; 95% CI, 1.20–2.09), more than three offspring (OR, 1.42; 95% CI, 1.07–1.89), post-menopause status (OR, 7.32; 95% CI, 3.05–17.6), more than 17 years since menopause (OR, 1.53; 95% CI, 1.10–2.14), regular exercise of two to three times per week (OR, 0.40; 95% CI, 0.18–0.89), monthly income above 500,000 won per household (OR, 0.64; 95% CI, 0.45–0.92), college graduate (OR, 0.29; 95% CI, 0.13–0.63) and calcium intake ≥ 627.5 mg/day (OR, 0.65; 95% CI, 0.43–0.98) after adjusting for age and BMI.ConclusionThe BMD and osteoporosis prevalence of Koreans are presented. Risk of osteoporosis was significantly associated with fracture history, smoking, reproductive history, regular exercise, income level, education background and calcium intake.     

Evaluation of Monaldi’s approach with regard to needle decompression of the tension pneumothorax—A cadaver study

BackgroundAlthough needle decompression of tension pneumothorax through the second intercostal space in the midclavicular line (Monaldi’s approach) is a life-saving procedure, severe complications have been reported after its implementation. We evaluated the procedure by comparing how it was performed on cadavers by study participants with different training levels.MethodsSix participants including one thoracic surgeon performed bilateral thoracic drainage after Monaldi on 82 torsos. After the thoraces were opened, the distances from the internal thoracic artery (A), the site of the puncture (B) and the midclavicular line (C) were measured bilaterally with reference to the median of the sternum. Further, it was determined whether the participants had correctly identified the second intercostal space. The differences between B-A and C-B were analysed.ResultsThe needle was placed in the second intercostal space in 136 hemithoraces (83%). The thoracic surgeon showed a hit rate of 0% laceration of adjacent vessels. All the other participants had hit rates between 10% and 15%. The interval B-A ranged from 2.88 to 5.06 cm in right and from 3.00 to 5.00 cm in left hemithoraces. The distance C-B lay between 1.03 cm and 1.87 cm (right side), and 0.84 cm and 2.02 cm (left side).ConclusionIn our collective, the main problem was failure to assess correctly the lateral extension of the clavicle. If this fact is emphasized during training, Monaldi’s approach is a safe method for needle decompression of pneumothorax.     

Burn induced nervous system morbidity among burn and non-burn trauma patients compared with non-injured people

ObjectiveBurns cause acute damage to the peripheral nervous system with published reports identifying that neurological changes after injury remain for a prolonged period. To shed some light on potential mechanisms, we assessed injury etiology and patterns of nervous system morbidity after injury by comparing long-term hospital admissions data of burns patients and other non-burn trauma patients with uninjured people.MethodsLinked hospital and death data of a burn patient cohort (n = 30,997) in Western Australia during the period 1980–2012 were analysed along with two age and gender frequency matched comparison cohorts: non-burn trauma patients (n = 28,647) and; non-injured people (n = 123,399). The number of annual NS disease admissions and length of stay (LOS) were used as outcome measures. Multivariable negative binomial regression modelling was used to derive adjusted incidence rate ratios and 95% confidence intervals (IRR, 95% CI) and adjusted Cox regression models and hazard ratios (HR) were used to examine time to first nervous system admission after burn and incident admission rates.ResultsThe most common peripheral nervous system condition identified in each cohort (burn, non-burn trauma, uninjured) were episodic and paroxysmal disorders followed by nerve root and plexus disorders and polyneuropathies/peripheral NS conditions. Significantly elevated admission rates for NS conditions (IRR, 95% CI) were found for the burn (2.20, 1.86–2.61) and non-burn trauma (1.85, 1.51–2.27), compared to uninjured. Peripheral nervous system admission rates after injury (IRR, 95% CI) were significantly higher regardless of age at time of injury for the burn (<15years: 1.97, 1.49–2.61; 15–45: 2.70, 2.016–3.55; ≥45 year: 1.62, 1.33–1.97) and non-burn trauma cohorts (<15years: 1.91, 1.55–2.35; 15–45: 1.94, 1.51–2.49; ≥45 year: 1.42, 1.18–1.72), when compared to the uninjured. Significantly higher rates of incident NS hospitalisations were found for the burn cohort vs. uninjured cohort for a period of 15-years after discharge (0–5 years: HR, 95% CI: 1.97, 1.75–2.22; 5–15 years; HR, 95% CI: 1.44, 1.28–1.63). The non-burn trauma cohort had significantly higher incident nervous system admissions for 10 years after discharge (0–30 days: HR, 95% CI: 4.75, 2.44–9.23; 30 days to 1-year HR, 95% CI: 2.95, 2.34–3.74; 1–5 years; HR, 95% CI: 1.47, 1.26–1.70; 5–10 years; HR, 95% CI: 1.34, 1.13–1.58).ConclusionsResults suggest that injury patients are at increased risk of peripheral nervous system morbidity after discharge for a prolonged period of time. The time patterns associated with incident nervous system conditions suggest possible differences in underlying pathology and long-term patient care needs. Further research is needed to elucidate the underlying neuropathology.     

Predictors of response to anti-TNF therapy in RA patients with moderate or high DAS28 scores

ObjectivesTo identify the clinical factors predicting a good clinical response to anti-TNF therapy in rheumatoid arthritis (RA) patients entered in the LORHEN registry after 5 years of treatment with anti-TNF agents and divided into two groups on the basis of their baseline DAS28 scores (moderate > 3.2–5.1 [MDA] and high > 5.1 [HDA]).MethodsDisease activity at baseline and after 12 months was assessed using the DAS28, and response was evaluated using the EULAR improvement criteria.ResultsThe study involved 1300 patients with established RA: 975 with HDA and 325 with MDA. After a mean 36-month, 29.6% of the patients had a DAS28 score of less or equal to 2.6 (HDA 25.8% vs. MDA 43.0%; P < 0.001) and were considered to be in remission. A higher probability of a good EULAR response in patients with HDA was associated with male gender (F vs. M – OR 0.45, 95% CI 0.26–0.78; P: 0.004), lower age at the start of treatment (OR 0.98, 95% CI 0.96–0.99; P: 0.002), the absence of comorbidities (OR 0.18, 95% CI 0.06–0.52; P: 0.002) or no previous use of corticosteroids (OR 1.92, 95% CI 1.14–3.22; P: 0.015) and the use of adalimumab vs. infliximab (OR 2.21, 95% CI 1.37–3.57; P 0.001); in patients with MDA, the probability of a good EULAR response was associated with male gender (F vs. M – OR 0.39, 95% CI 0.17–0.90; P: 0.027).ConclusionsWith the exception of male gender, the factors predicting a good EULAR response are different in patients with MDA and those with HDA.     

Detection of secondary causes of spontaneous pneumothorax: Comparison between computed tomography and chest X-ray

PurposeThe aim of this study was to compare the effectiveness of chest X-ray to that of thoracic computed tomography (CT) for the detection of the causes of secondary spontaneous pneumothorax (SP).MethodsA prospective cohort of patients with SP was studied. All chest X-ray and CT examinations of the patients were reviewed retrospectively by an expert radiologist blinded to clinical data. The concordance between the CT examination and chest X-ray was assessed using the Cohen Kappa coefficient (κ), based on a bootstrap resampling method.ResultsA total of 105 patients with SP were included. There were 78 men and 27 women, with a mean age of 34.5 years ± 14.2 (SD) (range: 16–87 years). Of these, 44/105 (41%) patients had primary SP and 61/105 (59%) had secondary SP due to emphysema (47/61; 77%), tuberculosis (3/61, 5%), lymphangioleiomyomatosis (3/61; 5%), lung cancer (2/61, 3%) or other causes (6/61; 10%). Apart from pneumothorax, CT showed abnormal findings in 85/105 (81%) patients and chest X-ray in 29/105 (28%). Clinically relevant abnormalities were detected on 62/105 (59%) CT examinations. The concordance between chest X-ray and CT was fair for detecting emphysema (κ = 0.39; 95% CI: 0.2420–0.55), moderate for a mass or nodule (κ = 0.60; 95% CI: 0.28–0.90), fair for alveolar opacities (κ = 0.39; 95% CI: −0.02–1.00), and slight for interstitial syndrome (κ = 0.20; 95% CI: −0.02–0.85).ConclusionChest X-ray is not sufficient for detecting the cause of secondary SP. As the detection of the cause of secondary SP may alter the therapeutic approach and long-term follow-up in patients with SP, the usefulness of a systematic CT examination should be assessed in a prospective trial.     

Instability of the extensor digitorum tendons in Jaccoud arthropathy assessed by semi-dynamic MRI of the metacarpophalangeal joints

PurposeThe purpose of this study was to test the hypothesis that Jaccoud arthropathy (JA) in patients with systemic lupus erythematosus (SLE) is associated with instability of the extensor digitorum (ED) tendons during flexion of the metacarpophalangeal (MCP) joints by comparing the position of the ED tendons between SLE patients with JA and control subjects on hand MRI obtained with flexed and extended MCP joints.Materials and methodsThirty-two hands of SLE patients with JA (13 women and 3 men; mean age, 50.0 ± 12.2 [SD] years; age range: 26–68 years) and 24 hands of sex- and age-matched control subjects (20 women and 4 men; mean age, 50.1 ± 13.0 [SD] years; age range: 24–68 years) were included in the study. Axial spin echo T1-weighted MRI images of the second to fifth MCP joints in flexion and in extension were obtained. Two radiologists (R1 and R2) separately measured the amplitude and assessed the direction of the displacement of the ED tendons with respect to the midline at the level of each MCP joint. Statistical analysis included two-way ANOVA with random effects to assess differences in amplitude and Fisher–Freeman–Halton exact test to assess differences in direction with P-values < 0.0083 and < 0.0063 considered as statistically significant respectively.ResultsAmplitude of the displacement of the ED tendons was statistically significantly greater in SLE patients with JA than in control subjects in flexion for both readers (median 58°, 95% confidence interval [CI]: 50°–65° vs. 20°, 95% CI: 16°–24°; P < 0.0001 for R1 and 54°, 95% CI: 47°–61° vs. 25°, 95% CI: 22°–28°; P < 0.0001 for R2) and in extension for one reader (17°, 95% CI: 15°–20° vs. 14°, 95% CI: 11°–16°; P = 0.0048 for R1 and 20°, 95% CI: 15°–25° vs. 16°, 95% CI: 12°–18°; P = 0.0292 for R2). Ulnar deviation of the ED tendons was statistically significantly more frequent in SLE patients with JA than in control subjects in flexion and in extension for both readers (P < 0.0001).ConclusionJA is associated with instability of the ED tendons in patients with SLE best depicted when MCP joints are flexed.     

Early PSA level decline is an independent predictor of biochemical and clinical control for salvage postprostatectomy radiotherapy

BackgroundTo improve the early detection of responders to salvage external beam radiotherapy (RT) after radical prostatectomy (RP).MethodsBetween 2002 and 2007, in a single institution, 136 consecutive patients received salvage RT to a dose of 66 Gy without androgen-deprivation therapy after RP for a rising prostate-specific antigen (PSA) level. PSA measurements were systematically performed before RT (PSA_RT), at the fifth week of RT (PSA5), and in the follow-up at least twice a year (every 6 mo). The PSA level decline during RT was expressed as PSA ratio (PSA5/PSA_RT). Two different definitions of biochemical failure after salvage RT were considered: PSA level>0.4 ng/ml and PSA>PSA nadir post-RT +0.4 ng/ml. Statistical analyses included univariate and multivariate Cox regression models.ResultsThe median follow-up was 60 months. The 5-year freedom from biochemical and clinical failure rates were 57% (95% CI: 48%–66%) and 92% (95% CI: 87%–97%), respectively. The mean PSA5 was 0.61 ng/ml (range: 0–7) and the mean PSA ratio was 0.67 (0–1.7). A PSA ratio<1 was a significant prognostic factor in multivariate analysis for both definitions of biochemical failure (P = 0.01 for both) and for clinical failure (P = 0.005).ConclusionsFor patients undergoing salvage RT after RP for a rising PSA level, the absence of PSA level decline during RT is predictive of biochemical and clinical failure and may be used to rapidly identify poor responders.