Advances in computer-assisted single-photon emission computed tomography (SPECT) for epilepsy surgery in children

Epilepsy surgery has emerged as an important option in the treatment of children with epilepsy that is refractory to antiepileptic drug management. The cornerstone of successful surgery is accurate localization of the brain region of seizure onset. Traditional techniques of seizure onset localization, e.g. surface electroencephalography (EEG) recording and magnetic resonance imaging (MRI), allow accurate localization in a significant number of patients. When the focus of seizure onset is not apparent from these non-invasive techniques, other methods of localization, e.g. intracranial EEG recording, may be needed before resection of the focus. Single-photon emission computed tomography (SPECT) is a nuclear medicine blood-flow technique that has been used to identify a region of epileptogenic brain associated with low blood flow in the resting state (interictal SPECT) or increased blood flow at the time of seizure activity (ictal SPECT). This report describes the validation and utility of a computer-assisted method of subtracting the interictal from the ictal SPECT scans and co-registering the difference image on the MRI. This method, called subtraction ictal SPECT co-registered on MRI (SISCOM), is used in guiding the location and the extent of intracranial electrode implantation, or in obviating the need for the implantation in some cases.     

肠易激综合征和胶原性结肠炎患者粪便中炎性标志物的检测

目的：与腹痛及腹部不适症状相关的排便习惯改变的长期反复发作是肠易激综合征（IBS）和胶原性结肠炎（CC）的共有症状。该研究旨在明确IBS和CC患排泄物中能否检测到炎性标志物，并探讨此种检测能否作为一种无创性方式用于这些功能紊乱性疾病的鉴别。材料与方法：采集18例CC患、46例IBS患和20例健康对照（HC）的粪便，经处理后留取上清液，采用免疫法测定嗜酸粒细胞蛋白X（EPX）、髓过氧化物酶（MPO）、纤维蛋白溶酶、白介素-1β（IL-1β）和肿瘤坏死因子-α（TNF-α）水平。结果：与IBS组（中位数0．44μg／g，95％CI0．25～1．8；P〈0．001）和HC组（中位数0．46μg／g，95％CI0．21～1．3；P〈0．001）相比，EPX水平在CC组中有所增加（中位数3．81μg／g，95％CI0．47～16．2）。另外，MPO水平在CC组中也有所增加（中位数11．7μg／g，95％CI2．0～124），显高于IBS患组（中位数1．7μg／g，95％CI0．81～5．2；P〈0．01）和HC组（中位数2．5μg／g，95％CI1．1～6．3；P〈0．05）。     

Human values in the care of the surgical patient

Viewing ethics in surgical practice as applying critical thinking to issues of human values leads to 4 levels of consideration: the individual patient, the surgeon, surgical research and education, and surgical organizations. This perspective starts with quantitative and qualitative feedback from patients, studies of the process of surgical decision making, and understanding how surgeons matter in preoperative counseling and postoperative recovery. Surgeons should become as active in research on the psychosocial aspects of surgical care as they are in research on the biological. Based on this information, surgical training should become explicit in preparing surgeons for patient-centered management of surgical care. Finally, surgical organizations can help by recognizing research in the human values domain, setting standards that recognize feedback from patients, and addressing more formally the needs of underserved populations. This approach fails to give the basis for clear answers but gives priority to more understanding of the moral dilemmas faced by patients and their surgeons.     

Treatment of relapsed chronic lymphocytic leukemia by 72-hour continuous infusion or 1-hour bolus infusion of flavopiridol: results from Cancer and Leukemia Group B study 19805.

PURPOSE: Flavopiridol has in vitro activity in chronic lymphocytic leukemia (CLL) and promotes apoptosis independent of p53 function or prior fludarabine exposure. We sought to determine if flavopiridol has activity in previously treated CLL using two schedules of administration. PATIENTS AND METHODS: Patients with previously treated CLL were enrolled in two sequentially done phase II studies. Patients in the first trial received flavopiridol (50 mg/m(2)/d) as a continuous infusion (CI) for 72 hours every 2 weeks. Patients in the second trial received flavopiridol 50 mg/m(2) as a 1-hour bolus (IVB) daily for 3 days repeated every 3 weeks. Patients received up to 12 (CI cohort) or 8 (IVB cohort) cycles of therapy. RESULTS: Fifteen patients were enrolled in the 72-hour CI phase II trial; 6 (40%) had intermediate-risk (Rai stage I or II) and 9 (60%) had high-risk (Rai stage III and IV) stages. No responses were noted in this group; 27% had stable disease and 73% had progressive disease. Thirty-six patients were enrolled in the second IVB trial, with 13 (36%) having intermediate and 23 (64%) having high-risk disease. Four patients (11%) had partial responses, 19 (53%) had stable disease, and 13 (36%) had progressive disease. The progression-free survival for responders in the IVB trial was 3, 3, 9, and 19 months. The median progression-free survival was 2 months [95% confidence interval (95% CI), 1.8-3.8] for patients in the CI trial and 3 months (95% CI, 2.5-7.4) for the IVB trial. The median overall survival was 27 months (95% CI, 20-42) for the CI trial and 24 months (95% CI, 18-31) for the IVB trial. Toxicity was manageable and included mainly myelosuppression, infections, diarrhea, and fatigue. CONCLUSIONS: Flavopiridol has modest, schedule-dependent clinical activity in relapsed CLL and warrants future investigation utilizing alternative schedules of administration.     

Pneumatic compression hemodynamics in total hip arthroplasty

A crossover study was performed to evaluate the effect of several pneumatic compression devices and active dorsoplantar flexion in 10 patients who underwent total hip arthroplasty. Using the Acuson 128XP/10 duplex ultrasound unit with a 5-MHz linear array probe, peak venous velocity and venous volume were assessed above and below the greater saphenous vein and common femoral vein junction. A computer generated randomization table was used to determine the order of the test conditions. The pneumatic compression devices evaluated included two foot pumps, one foot and calf pump, one calf pump, and three calf and thigh pumps. Statistical analyses included analysis of variance and analysis of variance with covariance between devices and patients. The covariates tested were the baseline measurements and the order in which the devices were tested. Differences between devices relate in part to the frequency and rate of inflation and the location and type of compression. Pulsatile calf and foot and calf pneumatic compression with a rapid inflation time produced the greatest increase in peak venous velocity, whereas compression of the calf and thigh showed the greatest increase in venous volume. Because patient and nursing compliance is essential to the success of mechanical prophylaxis for thromboembolic disease, the more simple, yet efficacious, devices that are easier to apply and less cumbersome appear to have a greater likelihood of success. In the active and alert patient, active dorsoplantar flexion should be encouraged.     

Infant brain imaging using magnetoencephalography: Challenges,solutions, and best practices

The excellent temporal resolution and advanced spatial resolution of magnetoencephalography (MEG) makes it an excellent tool to study the neural dynamics underlying cognitive processes in the developing brain. Nonetheless, a number of challenges exist when using MEG to image infant populations. There is a persistent belief that collecting MEG data with infants presents a number of limitations and challenges that are difficult to overcome. Due to this notion, many researchers either avoid conducting infant MEG research or believe that, in order to collect high‐quality data, they must impose limiting restrictions on the infant or the experimental paradigm. In this article, we discuss the various challenges unique to imaging awake infants and young children with MEG, and share general best‐practice guidelines and recommendations for data collection, acquisition, preprocessing, and analysis. The current article is focused on methodology that allows investigators to test the sensory, perceptual, and cognitive capacities of awake and moving infants. We believe that such methodology opens the pathway for using MEG to provide mechanistic explanations for the complex behavior observed in awake, sentient, and dynamically interacting infants, thus addressing core topics in developmental cognitive neuroscience.     

REACT: Rapid Evaluation Assessment of Clinical Reasoning Tool

IntroductionClinical reasoning encompasses the process of data collection, synthesis, and interpretation to generate a working diagnosis and make management decisions. Situated cognition theory suggests that knowledge is relative to contextual factors, and clinical reasoning in urgent situations is framed by pressure of consequential, time-sensitive decision-making for diagnosis and management. These unique aspects of urgent clinical care may limit the effectiveness of traditional tools to assess, teach, and remediate clinical reasoning.MethodsUsing two validated frameworks, a multidisciplinary group of clinicians trained to remediate clinical reasoning and with experience in urgent clinical care encounters designed the novel Rapid Evaluation Assessment of Clinical Reasoning Tool (REACT). REACT is a behaviorally anchored assessment tool scoring five domains used to provide formative feedback to learners evaluating patients during urgent clinical situations. A pilot study was performed to assess fourth-year medical students during simulated urgent clinical scenarios. Learners were scored using REACT by a separate, multidisciplinary group of clinician educators with no additional training in the clinical reasoning process. REACT scores were analyzed for internal consistency across raters and observations.ResultsOverall internal consistency for the 41 patient simulations as measured by Cronbach’s alpha was 0.86. A weighted kappa statistic was used to assess the overall score inter-rater reliability. Moderate reliability was observed at 0.56.DiscussionTo our knowledge, REACT is the first tool designed specifically for formative assessment of a learner’s clinical reasoning performance during simulated urgent clinical situations. With evidence of reliability and content validity, this tool guides feedback to learners during high-risk urgent clinical scenarios, with the goal of reducing diagnostic and management errors to limit patient harm.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07513-5.