Evaluation of 18 F-fluorodeoxyglucose positron emission tomography and computed tomography with histopathologic correlation in the initial staging of head and neck cancer

OBJECTIVE: To prospectively evaluate the use of 18F-Fluorodeoxyglucose positron emission tomography (FDG-PET) in the initial staging of squamous cell head and neck carcinoma. SUMMARY BACKGROUND DATA: The status of cervical lymph nodes is an important prognostic factor and determinant of management approach in squamous cell head and neck cancer. METHODS: FDG-PET findings were compared with those of computed tomography (CT) before removal of the primary tumor and/or neck dissection. Histopathologic analysis was used as the gold standard for assessment of the sensitivity and specificity of these modalities. RESULTS: FDG-PET correctly identified the primary tumor in 35 of 40 patients in whom the site of the primary was known clinically and still present (sensitivity 88%). None of four unknown primaries were detected. Tumors not detected by FDG-PET were generally superficial, with depths of less than 4 mm. CT correctly identified 18 of the 35 primary tumors (sensitivity 51%). Eleven of 17 CT false-negative tumors were detected by FDG-PET. The sensitivity and specificity for the presence of metastatic neck disease on FDG-PET were 82% and 100%, respectively; those for CT were 81% and 81%, respectively. FDG-PET was true positive for metastatic neck disease in two of the three CT false-negative patients. CONCLUSIONS: FDG-PET shows promise in the initial staging of head and neck cancer and provides additional accuracy to a conventional staging process using CT.     

Mycophenolic acid concentrations in long-term heart transplant patients: relationship with calcineurin antagonists and acute rejection

BACKGROUND: When used in conjunction with steroids and cyclosporin, mycophenolate mofetil (MMF) has been shown to significantly reduce mortality and incidence of rejection in the first year after heart transplantation. It also appears that in this early post-transplantation period, the monitoring of immunosuppressive therapies may be warranted. The current study was undertaken to determine if such monitoring is still useful more than 1 yr after heart transplantation. METHODS: Twenty-six patients who had survived the first year after orthotopic heart transplantation and had been on MMF therapy for more than 3 months were prospectively followed. At the time of their routine endomyocardial biopsy blood samples were taken to monitor immunosuppressive therapy. Most patients had two samples taken, on average 109 d apart. RESULTS: There were 22 episodes of asymptomatic rejection documented on a total of 48 biopsies. Of these, only two were of ISHLT (International Society for Heart and Lung Transplantation) grade 3A the remainder being of ISHLT grades 1 or 2. There was no relation between immunosuppressive regimen (tacrolimus and MMF or cyclosporin and MMF) and rejection. There was no relation between monitored immunosuppressive levels and rejection. Patients with the combination of MMF and tacrolimus had significantly higher plasma mycophenolic acid levels despite significantly lower daily MMF dose. CONCLUSION: There does not appear to be a benefit in continued monitoring of plasma mycophenolic acid levels beyond the first year of heart transplantation. There were significant differences in plasma mycophenolic acid levels depending on the type of calcineurin inhibitor concomitantly used.     

Chronic histological changes in deceased donor kidneys at implantation do not predict graft survival: a single‐centre retrospective analysis

The use of preimplantation kidney biopsies (PIKBs) to aid deceased donor kidney utilization decisions is controversial. Outcomes of transplants that had been biopsied after the decision had been made to implant were analysed, in order to determine the association between chronic histological changes at implantation and graft outcomes. A retrospective analysis of transplants between the year range 2006–2015 was performed. Karpinski scores on biopsies were collected, and graft outcomes were analysed using univariate and multivariable techniques. Also, Karpinski scores from single and dual kidney transplants from older donors were examined to determine if knowledge of the score preoperatively would have altered utilization. Four hundred and eight single kidneys were transplanted. Although kidneys with scores >4 had lower 1‐ and 3‐year median (IQR) estimated glomerular filtration rates (eGFRs) than those scoring 0–4 (51 (37–66) vs. 35 (26–52) ml/min/1.73 m², P < 0.001, and 52 (34–64) vs. 35 (24–52) ml/min/1.73 m², P < 0.001, respectively), there was no significant association between Karpinski score and death‐censored graft survival on univariate or multivariable analyses. The utilization analysis (75 single and 25 dual kidney transplant recipients) suggested that systematic use of PIKBs would have resulted in 29% fewer patients being transplanted. This analysis does not support the systematic use of PIKBs to determine deceased donor kidney utilization.     

Use of intubation introducers through a supraglottic airway to facilitate tracheal intubation: a brief review

Purpose

This article is a narrative review regarding the usage and effectiveness of introducers or catheters to facilitate tracheal intubation through a supraglottic airway (SGA) as an alternative intubation technique in normal and difficult airway management.

Sources

Relevant articles were obtained through Medline (1948-July 2011). The articles were subsequently cross-referenced for additional literature, and only articles published in English were included.

Principal findings

In this review, we consider 32 reports using the LMA Classic?, LMA Unique?, LMA ProSeal?, LMA Supreme?, AuraOnce?, and i-gel? as SGA conduits for intubation. In 13 articles, the use of an Aintree Intubation Catheter was described as an intubation introducer and resulted in high success rates in both elective and emergent situations. Eight studies used a guidewire exchange catheter technique. Although blind intubation using a guidewire resulted in a high failure rate, these studies found that using a bronchoscope improved successful intubation. Ten studies showed that insertion of a gum elastic bougie with a bronchoscope as an intubation introducer has high success rates compared with blind bougie insertion. One article described the use of a small endotracheal tube as an intermediary for tracheal intubation.

Conclusions

In failed intubation scenarios, supraglottic airways, such as the LMA Classic? or LMA ProSeal? can serve as a conduit for tracheal intubation. A number of techniques using introducers or catheters can facilitate the insertion of an adequately sized endotracheal tube, particularly guided by a bronchoscope. Usage of introducers or catheters through a supraglottic airway may be a useful alternative intubation technique in difficult airway management.     

Are Instrumented Knee Forces Representative of a Larger Population of Cruciate-Retaining Total Knee Arthroplasties?

Background

It is not known if the loads and motions reported for instrumented knees are generalizable to a larger population of total knee arthroplasty (TKA) patients. The purpose of this study is to (1) report axial implant force data for chair and stair activities for a population of cruciate-retaining TKA patients and (2) compare the population forces to those measured with instrumented TKAs.

Increased prevalence of gastrointestinal symptoms in patients with allergic disease

Background

Children with allergic diseases such as asthma and atopic dermatitis experience increased gastrointestinal symptoms. Further, physiological and histological abnormalities of the gastrointestinal tract in patients with allergic diseases have been reported. It is not certain whether adult patients experience increased gastrointestinal symptoms.

Methods

A retrospective, case–control study of 7235 adult (⩾20 years old) primary care patients was conducted. A general practitioner diagnosis of irritable bowel syndrome was used to serve as a marker of lower gastrointestinal symptoms. The prevalence of lower gastrointestinal symptoms was calculated in patients with asthma or allergic rhinitis and compared with that in patients with other chronic diseases (insulin‐dependent diabetes mellitus, osteoarthritis and rheumatoid arthritis) and with the remaining population.

Results

Gastrointestinal symptoms were significantly more common in patients with asthma (9.9%) as compared with patients with chronic diseases (4.9%; odds ratio (OR) 2.13, 95% confidence interval (CI) 1.39 to 2.56; p<0.002) or the remaining non‐asthmatic population (5.5%; OR 1.89, 95% CI 1.39 to 2.56; p<0.001). Gastrointestinal symptoms were also significantly more common in patients with allergic rhinitis (7.9%) as compared with patients with chronic diseases (4.9%; OR 1.66, 95% CI 1.02 to 2.7; p<0.05) and the remaining population (5.5%; OR 1.47, 95% CI 1.04 to 2.1; p<0.02). This phenomenon was independent of age, sex and inhaled asthma therapy in the case of patients with asthma.

Conclusions

Our findings support the hypothesis that lower gastrointestinal symptoms are more common in patients with allergic diseases such as asthma and allergic rhinitis.Lower gastrointestinal symptoms such as diarrhoea and abdominal pain are common in children with allergic diseases such as asthma¹ and atopic dermatitis.² Although food allergies and rare organic gastrointestinal diseases such as eosinophilic gastroenteropathy are associated with atopic disease, it is unlikely that they alone would account for such symptoms. Histological abnormalities of the gastrointestinal tract in patients with allergic airway diseases have also been reported. Small bowel biopsy specimens from patients with asthma and allergic rhinitis show features in common with the inflammatory reaction observed in the airways, with accumulation of eosinophils, T cells, mast cells, macrophages and increased expression of proallergic cytokines, such as interleukin (IL)4 and IL5.^3,4 Accumulation of eosinophils in the oesophageal mucosa has also been reported in patients with allergic rhinitis and asthma compared with controls.⁵ It is yet to be established whether these microscopic inflammatory changes influence gastrointestinal function. Interestingly, absorption studies with chromium 51‐labelled EDTA suggest a permeability defect of the gastrointestinal tract in patients with asthma.⁶We hypothesised that lower gastrointestinal symptoms would be more prevalent in patients with asthma and allergic rhinitis. We conducted a retrospective, case–control study of community‐based patients by evaluating computerised records of patients from a large primary healthcare centre in the UK. This strategy allowed us to identify large numbers of patients with asthma and allergic rhinitis through specific diagnostic codes (James Read codes). We used a general practitioner diagnosis of irritable bowel syndrome (IBS) to serve as a marker for lower gastrointestinal symptoms. IBS has no specific features, and, typically, diagnosis depends on the presence of lower gastrointestinal tract symptoms in the absence of organic bowel disorders. Although criteria‐based definitions of IBS have been developed,^7,8 it was not deemed necessary to use them strictly in this study, as we were simply using the diagnostic label to indicate the presence of lower gastrointestinal symptoms without an obvious organic cause.     

Renal artery stenosis: a disease worth pursuing

Consider renovascular hypertension (HT) when: Newly diagnosed hypertension presents with features that are atypical of essential hypertension; Resistant hypertension is associated with risk factors for atheroma; or Angiotensin-converting enzyme (ACE) inhibitor or angiotensin-II-receptor antagonist therapy is associated with increasing plasma creatinine levels. Atheromatous renovascular HT can often be managed medically, which includes intensive correction of cardiovascular risk factors. ACE inhibitors are probably second-line antihypertensives for patients with unilateral renal artery stenosis and two kidneys. First-line antihypertensives are diuretics, beta-blockers and calcium-channel blockers. Bilateral renal artery stenosis, or a unilateral stenosis in a patient with only one kidney, is an absolute contraindication to ACE inhibition.     

Sexual Assault,Posttraumatic Stress Symptoms,and Indices of Aggression Among Women

Sexual assault is associated with many adverse outcomes, including a higher risk for developing posttraumatic stress symptoms (PTSS). Although nonsexual trauma exposure has been linked to aggression, the associations between sexual assault and aggression are understudied. Further, the DSM-5 conceptualization of posttraumatic stress disorder (PTSD) includes a symptom related to aggression, and associations between symptom clusters and aggression with regard to the new criteria are underexplored. The present study aimed to (a) examine the relations between sexual assault and indices of aggression (i.e., physical/verbal aggression, anger, and hostility) after accounting for PTSS and (b) investigate PTSD symptom clusters in relation to aggression among 263 women (M_age = 29.03 years, SD = 11.71; 67.6% white). Path analysis revealed that sexual assault was unrelated to indices of aggression, βs = .003–.08; however, PTSS was consistently linked with increased aggression, βs = .22–.49. Results indicated specificity in the associations between the symptom clusters and aspects of aggression. Negative alterations in cognitions and mood corresponded with increased physical aggression, β = .28, and hostility, β = .38, and avoidance was related to verbal aggression, β = .19. Hyperarousal was also tied to higher levels of anger, hostility, and verbal aggression, βs = .21–.33. Nonetheless, lower levels of intrusion symptoms were associated with increased anger and hostility, β = -.26. With regard to understanding women's risk for aggression, PTSS may be more relevant than sexual assault. Further, there may be specificity related to the type of PTSD symptoms and aspects of aggression.