An experimental comparison of detector performance for direct and indirect digital radiography systems

Current flat-panel detectors either directly convert x-ray energy to electronic charge or use indirect conversion with an intermediate optical process. The purpose of this work was to compare direct and indirect detectors in terms of their modulation transfer function (MTF), noise power spectrum (NPS), and detective quantum efficiency (DQE). Measurements were made on three flat-panel detectors, Hologic Direct-Ray DR-1000 (DRC), GE Revolution XQ/i (XQ/i), and Philips Digital Diagnost (DiDi) using the IEC-defined RQA5 (approximately 74 kVp, 21 mm Al) and RQA9 (approximately 120 kVp, 40 mm Al) radiographic techniques. The presampled MTFs of the systems were measured using an edge method [Samei et al., Med. Phys. 25, 102 (1998)]. The NPS of the systems were determined for a range of exposure levels by two-dimensional (2D) Fourier analysis of uniformly exposed radiographs [Flynn and Samei, Med. Phys. 26, 1612 (1999)]. The DQEs were assessed from the measured MTF, NPS, exposure, and estimated ideal signal-to-noise ratios. For the direct system, the MTF was found to be significantly higher than that for the indirect systems and very close to an ideal function associated with the detector pixel size. The NPS for the direct system was found to be constant in relation to frequency. For the XQ/i and DRC systems, the DQE results reflected expected differences based on the absorption efficiency of the different detector materials. Using RQA5, the measured DQE values in the diagonal (and axial) direction(s) at spatial frequencies of 0.15 mm(-1) and 2.5 mm(-1) were 64% (64%) and 20% (15%) for the XQ/i system, and 38% (38%) and 20% (20%) for the DRC, respectively. The DQE results of the DiDi system were difficult to interpret due to additional preprocessing steps in that system.     

Object detectability at increased ambient lighting conditions

Under typical dark conditions encountered in diagnostic reading rooms, a reader's pupils will contract and dilate as the visual focus intermittently shifts between the high luminance display and the darker background wall, resulting in increased visual fatigue and the degradation of diagnostic performance. A controlled increase of ambient lighting may, however, reduce the severity of these pupillary adjustments by minimizing the difference between the luminance level to which the eyes adapt while viewing an image (L(adp)) and the luminance level of diffusely reflected light from the area surrounding the display (L(s)). Although ambient lighting in reading rooms has conventionally been kept at a minimum to maintain the perceived contrast of film images, proper Digital Imaging and Communications in Medicine (DICOM) calibration of modern medical-grade liquid crystal displays can compensate for minor lighting increases with very little loss of image contrast. This paper describes two psychophysical studies developed to evaluate and refine optimum reading room ambient lighting conditions through the use of observational tasks intended to simulate real clinical practices. The first study utilized the biologic contrast response of the human visual system to determine a range of representative L(adp) values for typical medical images. Readers identified low contrast horizontal objects in circular foregrounds of uniform luminance (5, 12, 20, and 30 cd/m2) embedded within digitized mammograms. The second study examined the effect of increased ambient lighting on the detection of subtle objects embedded in circular foregrounds of uniform luminance (5, 12, and 35 cd/m2) centered within a constant background of 12 cd/m2 luminance. The images were displayed under a dark room condition (1 lux) and an increased ambient lighting level (50 lux) such that the luminance level of the diffusely reflected light from the background wall was approximately equal to the image L(adp) value of 12 cd/m2. Results from the first study demonstrated that observer true positive and false positive detection rates and true positive detection times were considerably better while viewing foregrounds at 12 and 20 cd/m2 than at the other foreground luminance levels. Results from the second study revealed that under increased room illuminance, the average true positive detection rate improved a statistically significant amount from 39.3% to 55.6% at 5 cd/m2 foreground luminance. Additionally, the true positive rate increased from 46.4% to 56.6% at 35 cd/m2 foreground luminance, and decreased slightly from 90.2% to 87.5% at 12 cd/m2 foreground luminance. False positive rates at all foreground luminance levels remained approximately constant with increased ambient lighting. Furthermore, under increased room illuminance, true positive detection times declined at every foreground luminance level, with the most considerable decrease (approximately 500 ms) at the 5 cd/m2 foreground luminance. The first study suggests that L(adp) of typical mammograms lies between 12 and 20 cd/m2, leading to an optimum reading room illuminance of approximately 50-80 lux. Findings from the second study provide psychophysical evidence that ambient lighting may be increased to a level within this range, potentially improving radiologist comfort, without deleterious effects on diagnostic performance.     

Staging Systems for Newly Diagnosed Myeloma Patients Undergoing Autologous Hematopoietic Cell Transplantation: The Revised International Staging System Shows the Most Differentiation between Groups

The Revised International Staging System (R-ISS) and the International Myeloma Working Group 2014 (IMWG 2014) are newer staging systems used to prognosticate multiple myeloma (MM) outcomes. We hypothesized that these would provide better prognostic differentiation for newly diagnosed multiple myeloma (MM) compared with ISS. We analyzed the Center for International Blood and Marrow Transplant Research database from 2008 to 2014 to compare the 3 systems (N?=?628) among newly diagnosed MM patients undergoing upfront autologous hematopoietic cell transplantation (AHCT). The median follow-up of survivors was 48 (range, 3 to 99) months. The R-ISS provided the greatest differentiation between survival curves for each stage (for overall survival [OS], the differentiation was 1.74 using the R-ISS, 1.58 using ISS, and 1.60 using the IMWG 2014) . Univariate analyses at 3 years for OS showed R-ISS I at 88% (95% confidence interval [CI], 83% to 93%), II at 75% (95% CI, 70% to 80%), and III at 56% (95% CI, 3% to 69%; P < .001). An integrated Brier score function demonstrated the R-ISS had the best prediction for PFS, though all systems had similar prediction for OS. Among available systems, the R-ISS is the most optimal among available prognostic tools for newly diagnosed MM undergoing AHCT. We recommend that serum lactate dehydrogenase and cytogenetic data be performed on every MM patient at diagnosis to allow accurate prognostication.     

Do men with normal testosterone–oestradiol ratios benefit from letrozole for the treatment of male infertility?

Research question

Previous studies of aromatase inhibitors on male infertility have focused on men with low testosterone–oestradiol ratio of less than 10. Can aromatase inhibitors improve spermatogenesis in men with idiopathic male infertility with normal testosterone–oestradiol ratio?

Serum and hair zinc in severely malnourished Bangladeshi children associated with or without acute lower respiratory infection

Objective  To assess the zinc status in Bangladeshi children suffering from severe protein energy malnutrition (severe PEM), acute lower respiratory infection (ALRI), PEM presented with ALRI and to evaluate the relationship of zinc status with aforementioned clinical conditions. Methods  We assessed zinc status by simultaneous estimation of serum and hair zinc of Bangladeshi children less than 5 yr of age suffering from severe PEM, ALRI, severe PEM presented with ALRI and compared them with zinc status of well-nourished healthy children (control) in a hospital based cross sectional four cell study. Zinc concentration was estimated by Flame atomic absorption spectrophotometry. Results  Total one hundred and fifty two children were enrolled and number of children enrolled in severe PEM, ALRI, ALRI with PEM and control were 47, 35, 32 and 38 respectively. Both serum and hair zinc in univariate analysis were found significantly (p<0.05) low in severe PEM, ALRI and severe PEM associated with ALRI. However, in multivariate analysis, when serum and hair zinc were included in the same model, both serum and hair zinc were found to have significant negative association with PEM (p=0.002 & 0.013 respectively) and with ALRI only when ALRI was associated with PEM (p=0.043 and 0.034 respectively). Conclusion  Severe PEM and PEM with ALRI were significantly associated with low zinc status.     

Progressive multifocal leukoencephalopathy in a patient with common variable immunodeficiency and abnormal CD8+ T-cell subset distribution.

BACKGROUND: Patients with primary hypogammaglobulinemia have been reported to have encephalopathy, but progressive multifocal leukoencephalopathy (PML) due to JC virus reactivation is a rare cause. OBJECTIVE: To provide the clinical details and case discussion of a patient diagnosed as having common variable immunodeficiency (CVID) who has progressive neurodegenerative symptoms and was found to have PML and an abnormal CD8+ T-cell subset distribution. METHODS: A detailed case report providing the patient's immunodeficiency history, diagnostic evaluation, and medical management and a review of related literature. RESULTS: Before his neurodegenerative illness, the patient was found to have hypogammaglobulinemia, poor specific antibody responses, low circulating B-cell levels, and abnormal delayed-type hypersensitivity responses; there was no Bruton tyrosine kinase (BTK) mutation. The PML was diagnosed using brain biopsy and was confirmed using a DNA probe specific for JC virus. Peripheral blood flow cytometry at the time of PML diagnosis revealed an accumulation of naive CD8+ T cells (CD3+CD8+CD45RA+) and a deficiency of memory CD8+ T-cell subsets (CD3+CD8+CD45RA- or CD3+CD8+CD45RO+). Despite aggressive treatment with interleukin 2, interferon-gamma, and intravenous cidofovir, the patient died. CONCLUSIONS: JC virus infection should be considered in the differential diagnosis of the patient with CVID and signs and symptoms of encephalopathy. The role of this patient's abnormal CD8' T-cell subset distribution in the development or control of this rare infection is worthy of consideration and has encouraged us to enumerate naive and memory CD4+ and CD8+ T-cell subsets in patients diagnosed as having CVID, even in the absence of neurodegenerative symptoms.     

NOBOX is a strong autosomal candidate gene in Tunisian patients with primary ovarian insufficiency

Premature ovarian insufficiency (POI) affects approximately 1% of women before the age of 40. Genetic contribution is a significant component of POI. In this context, heterozygous mutations in NOBOX, BMP15 and GDF9 have been reported. The objective of our study was to evaluate the prevalence of these genes mutations in 125 unrelated Tunisian patients diagnosed with POI. The screening of NOBOX gene revealed three missense mutations (p.Arg117Trp; p.Gly91Trp and p.Pro619Leu) in eight patients. These mutations were not found in a 200 ethnically matched women without fertility problem. The sequencing of BMP15 and GDF9 gene revealed only previously reported variants. In contrast to previous studies, the prevalence of BMP15 variations is not higher than in the control population. Conversely, 6.4% of the cases present a NOBOX mutations; this high prevalence strengthens the consideration of NOBOX gene as strong autosomal candidate for POI.     

Schistosomal hepatic fibrosis and the interferon gamma receptor: a linkage analysis using single-nucleotide polymorphic markers

A minority of individuals infected with the parasite Schistosoma mansoni develops hepatic fibrosis. HLA studies in Egypt and a candidate gene search in a Sudanese population indicate that the host's genetics contribute to disease susceptibility. In an Egyptian community, 32.7% of individuals 11 years and older had significant fibrosis by WHO ultrasound criteria. Linkage to 10 candidate genes was tested using 89 affected sibling pairs from 40 pedigrees in this community. The candidates included genes that initiate fibrosis, participate in collagen synthesis, or control collagen degradation. Two to four single-nucleotide polymorphisms (SNPs) were genotyped per locus, and 188 individuals were genotyped at 48 markers. Model-free modified Haseman-Elston analysis identified linkage to a SNP in the interferon gamma receptor locus (P=0.000001). There was also weak evidence for linkage to the interleukin 13-4 region and tissue growth factor beta 1.     

Cancer in the oldest old

Our previous work revealed that 88% of centenarians delay or escape the age-related lethal diseases cardiac disease, stroke and diabetes. In the cases of those having a history of cancer we have observed anecdotes of centenarians presenting with large primary tumors that would have otherwise been expected to have metastasized and to have been lethal. However, these tumors were removed without consequence. To better understand the relationship between cancer and exceptional longevity, we quantified age of cancer diagnoses, life-time clinically evident cancer prevalence, tobacco use and family histories through medical record review and interviews. One thousand one hundred and forty-three subjects were studied revealing 20% (N=152) of female and 22% (N=80) of male centenarians with a history of non-skin cancer. The most common cancers were prostate (11.7% of males), breast (8.2% of females), and colon (5.7%). The average age of diagnosis was 80.5 years compared to 63.2 years in the general population according to National Cancer Institute SEER data. Similar delays were noted when age of onset was examined according to specific type of cancer. In conclusion, the age of diagnosis of cancer is relatively delayed in those who live to 100 years. Some cancers are very rare among these individuals suggesting that there are certain cancers that may be incompatible with survival to extreme old age.