Olfactory function in mild cognitive impairment and Alzheimer's disease: A meta‐analysis

Objective

Olfactory function is altered in mild cognitive impairment (MCI) and Alzheimer's disease (AD); therefore, it may serve as a useful tool for the early detection of MCI before its advancement to AD. The aim of this meta‐analysis was to investigate olfactory deficits in patients with MCI and AD.

Study Design

Literature search.

Methods

A search was conducted of the electronic databases PubMed, Embase, and Web of Science from their inception until 2017. We included original articles with adequate data on the identification, threshold, and/or discrimination of olfactory function in MCI or AD. The standard mean difference and 95% confidence interval (CI) were calculated. The studies were weighted according to inverse variance estimates. The effect sizes were categorized as small [Cohen's d = 0.2], medium (d = 0.5), or large (d ≥ 0.8) based on these methods. Subgroup analyses were performed based on mean age and sex differences between the groups.

Results

Twelve articles (reporting 21 effects) examining 563 patients with MCI and 788 patients with AD, were included in the meta‐analysis. Compared to MCI, AD had moderate to large heterogeneous effects on olfactory function (Cohen's d = 0.64, 95% CI: 0.50, 0.78). Olfactory identification tests demonstrated larger effects (d = 0.71, 95% CI: 0.51, 0.91) than did tests of other olfactory domains.

Conclusions

Meta‐analysis results revealed that olfactory identification was more profoundly impaired in patients with AD than in those with MCI. These findings suggest that a simple test of odor identification is valuable in differentiating individuals at a risk of AD.

Level of Evidence

NA Laryngoscope, 2018

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Over–under versus medial tympanoplasty: Comparison of benefit, success, and hearing results

Objectives/Hypothesis

A hybrid variation of a tympanoplasty technique, termed over–under tympanoplasty (OUT), was evaluated to demonstrate the long‐term outcomes and complications compared to medial tympanoplasty.

Study Design

Retrospective review.

Methods

Patients who underwent a tympanoplasty between 2010 and 2015 were included. Primary outcome measures included graft healing at 18 months, change in air‐bone gap (ABG), and change in high‐frequency hearing at 8 kHz. The Shapiro‐Wilk test, Student t test, and nonparametric Mann‐Whitney test were used to compare results. Univariate logistic regression analysis was used to identify potential predictors of surgical success.

Results

One hundred eleven patients were included; 84 underwent the over–under technique and 27 underwent medial tympanoplasty. At the 18‐month follow‐up, 100% of patients in the medial tympanoplasty group had closure of the TM perforation compared to 84% (71/84) in the over–under group. In the over–under group, 12% of patients developed small or pinpoint perforations, and 4% developed larger, recurrent perforations. Mean improvement in ABG was similar between the two groups (11.6 dB for the medial group vs. 11.9 dB for the over–under group, P < .001). No hearing loss was noted in either group. No lateralization of the graft or anterior blunting was noted.

Conclusions

In this series, the OUT technique had a high success rate with TM perforations, including anterior, near total, and total perforations. Hearing loss from dissection on the malleus was not found. This approach blends the advantages and minimizes the disadvantages of the classic techniques and is well suited for all types of tympanic membrane perforations.

Level of Evidence

3b Laryngoscope, 2018

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Novel approach using transoral robotic surgery for resection of cervical spine chordoma

Chordomas are rare, infiltrative neoplasms of notochordal origin that present along the spinal canal; en bloc surgical resection is paramount to successful treatment. Limited visualization and complex anatomy are major challenges to resection of upper cervical spine chordomas and often require invasive surgery. A 27‐year‐old male presented with an incidentally discovered chordoma of the midline second cervical vertebra of the spine. To obtain en bloc resection of the lesion while both overcoming limitations due to access and without introducing morbidity from traditional anterior approaches, we elected using transoral robotic surgery for resection. Due to complete resection, the patient remains disease‐free and was spared adjuvant radiation. Laryngoscope, 2018

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Airway anomalies in patients with craniosynostosis

Objectives

1) Characterize the spectrum of airway anomalies in patients with craniosynostosis, and 2) identify clinical characteristics of these patients that may be associated with the development of airway anomalies.

Methods

This study is a retrospective case series assessing the type and frequency of airway anomalies in all patients with craniosynostosis seen at a tertiary‐care children's hospital between 2000 and 2016. Cohort analyses were then performed to identify differences in airway anomalies dependent on syndromic associations, multisutural fusion, and location of suture fusion. Clinical characteristics examined included demographics and additional neurologic and craniofacial abnormalities.

Results

Four hundred and ninety‐six patients with craniosynostosis (83.5% white, 64.5% male; 33.9% sagittal, 28.8% metopic, 11.5% coronal, 1.2% lambdoid, and 24.6% multisutural) were included. Notable airway anomalies included the following: 13.3% adenotonsillar hypertrophy, 8.9% laryngomalacia, 7.3% tracheomalacia, 7.1% subglottic stenosis, 4.0% bronchomalacia, 3.8% laryngeal cleft, and 1.2% vocal fold paresis. Multisutural craniosynostosis patients (n = 122) were more likely to have obstructive sleep apnea (P = 0.005), adenotonsillar hypertrophy (P = 0.014), tracheomalacia (P = 0.011), subglottic stenosis (P < 0.001), and epiglottic/base of tongue collapse (P = 0.003) and require tracheostomy (P = 0.001) and mechanical ventilation (P = 0.017) compared with single suture craniosynostosis. Syndromic craniosynostosis patients (n = 33) were more likely to have obstructive sleep apnea (P < 0.001), laryngomalacia (P = 0.047), and subglottic stenosis (P = 0.009) compared with nonsyndromic patients.

Conclusion

Airway anomalies are prevalent in patients with craniosynostosis; patients with multisutural or syndromic types have an increased risk of developing certain abnormalities. There should be a lower threshold for referral for airway evaluation in these populations.

Level of Evidence

4. Laryngoscope, 2018

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The effects of cryotherapy on vocal fold healing in a rabbit model

Objectives/Hypothesis

Cryotherapy has been shown to be a scarless treatment modality for dermal lesions; however, there are limited data addressing the effect of cryotherapy on vocal fold tissue. The aim of this study was to clarify the effectiveness of cryotherapy for prevention of postsurgical vocal fold scarring.

Study Design

Prospective animal study in rabbits.

Methods

The lamina propria of 20 rabbit vocal folds was bilaterally stripped, followed by randomized unilateral cryotherapy. Five larynges were harvested for real‐time polymerase chain reaction (RT‐PCR) analysis at 1 day, 3 days, and 7 days postinjury. The remaining five were harvested for histologic analysis at 3 months. Images of the healing phase were recorded by laryngoscopy. Analyses of RT‐PCR for cyclooxygenase (COX)‐2, interleukin (IL)‐6, collagen I, collagen III, matrix metallopeptidase 1 (MMP1), transforming growth factor β (TGFβ1), α smooth muscle actin (α‐SMA), and hyaluronan synthase 1 (HAS1) were completed. Histological samples were completed for collagen and hyaluronic acid analysis.

Results

RT‐PCR results revealed that higher expressions of HAS1 and MMP1 and lower expressions of COX‐2, IL‐6, collagen I, collagen III, TGFβ1, and α‐SMA were observed, and histological examination showed significantly increased hyaluronic acid, decreased deposition, and more organized configuration of collagen in injury with the cryotherapy cohort compared with the injury cohort.

Conclusions

Cryotherapy can inhibit the inflammatory reaction and simulate a fetal healing environment in extracellular matrix synthesis to regenerate vocal fold tissue with less fibrosis. Histological results showed that cryotherapy achieves a mature healing result with less scar, which tends to return to normal. In summary, the findings of this study suggest that administration of cryotherapy at the time of injury has the potential to minimize vocal fold scarring.

Level of Evidence

NA Laryngoscope, 2018

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Acute inflammatory response to contrast agent aspiration and its mechanisms in the rat lung

Objectives/Hypothesis

Contrast agent (CA) aspiration is an established complication of upper gastrointestinal and videofluoroscopic swallow studies. The underlying molecular biological mechanisms of acute response to CA aspiration in the respiratory organs remain unclear. The aims of this study were to elucidate the histological and biological influences of three kinds of CAs on the lung and to clarify the differences in acute responses.

Study Design

Animal model.

Methods

Eight‐week‐old male Sprague Dawley rats were divided into five groups (n = 6 in each group). Three groups underwent tracheal instillation of one of three different CAs: barium (Ba) sulfate, nonionic contrast agents (NICAs), and ionic contrast agents (ICAs). A control group was instilled with saline and a sham group was instilled with air. All animals were euthanized on day 2 after treatment and histological and gene analysis was performed.

Results

No animal died after CA or control/sham aspiration. Ba caused severe histopathologic changes and more prominent inflammatory cell infiltration in the lungs compared with the two other iodinated contrast agents. Increases in expressions of inflammatory cytokines (tumor necrosis factor [Tnf], interleukin‐1β [Il1b], and interferon‐γ [Ifng]) were observed in Ba aspiration rats, and upregulation of Il1b was seen in ICA aspiration rats. NICA did not cause obvious histologic changes or expressions of inflammatory cytokines and fibrosis‐related genes in the lungs.

Conclusions

Ba caused significantly more acute lung inflammation in a rodent model than did ioinic and nonionic iodinated CAs. Nonionic contrast did not cause any discernible inflammatory response in the lungs, suggesting that it may be the safest contrast for videofluoroscopic swallow studies.

Level of Evidence

NA

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Physician impact on the patient and family experience in a pediatric otolaryngology practice

Objective

On the Press Ganey (PG) survey, the item "likelihood of recommending practice" is a proxy for patient satisfaction because only the most satisfied patients will recommend a practice to friends and family. The objective of this study is to determine which other items on the PG survey best correlate with "likelihood of recommending practice" as a measure of patient satisfaction in pediatric otolaryngology.

Study Design

Retrospective analysis of a survey database.

Methods

The PG survey, consisting of 24 questions scaled from 1 to 5 representing (1) very poor, (2) poor, (3) fair, (4) good, and (5) very good, was sent to 28 different pediatric otolaryngology practices. Using the Pearson correlation coefficient, the statistical relationship of each PG survey question was analyzed in its association to the PG question "likelihood of recommending practice." Factors with a correlation coefficient greater than 0.65 were considered significant.

Results

Ten of 24 questions on the PG survey correlated with a top "likelihood of recommending practice" score. Eight of these 10 items were from the Care Provider category and were related to the physician–patient/family interaction.

Conclusion

Patient satisfaction surveys are utilized as a quality metric of the patient and family experience. These scores serve as one of several measures that affect reimbursement. The results demonstrate that most of the factors correlated with "likelihood of recommending practice" are provider‐based. In conclusion, the physician–patient interaction strongly influences the potential for a practice to earn top box scores on the PG item "likelihood of recommending practice" and thereby achieve the highest patient satisfaction.

Level of Evidence

NA. Laryngoscope, 2018

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Solving periprosthetic leakage with a novel prosthetic device

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Validation of a septoplasty deformity grading system for the evaluation of nasal obstruction

Objectives/Hypothesis

We developed and validated a septal deformity grading (SDG) system that accounts for anatomic location and grading of deformity severity.

Study Design

Retrospective cohort study.

Methods

Subjects were patients with nasal obstruction presenting to University of California, Irvine Medical Center. Subjects were given pre‐ and postoperative Nasal Obstruction Symptom Evaluation (NOSE) questionnaires and were evaluated by a facial plastic surgeon using our septal deformity grading (SDG) system. Validity and reliability analyses were conducted on the SDG results. Statistical analyses were conducted on SDG and NOSE data to assess and compare instruments, and to validate the SDG instrument using the NOSE instrument.

Results

One hundred thirty‐five patients met inclusion criteria. Cronbach's α was ≥ 0.7 for SDG and pre‐ and postoperative NOSE scores. There was a significant difference in pre‐ and postoperative NOSE scores (Z score = −7.21, P < .001). Correlations between postoperative NOSE and SDG scores were significant (P = .014), and convergent construct validity was achieved. There was a significant difference in SDG scores between primary versus revision operations (P < .001), history versus no history of nasal trauma, and nasal/septal surgery (P = .025, P = .003, respectively). The odds of having a revision operation were 2.3 times higher for high SDG scores (P < .001), of having a history of nasal trauma were 1.33 times higher for high SDG scores (P = .014), and of having a history of nasal/septal surgery were 2.9 times higher for low SDG scores.

Conclusions

Our SDG system addresses the challenge of providing objective anatomic information on the severity of nasal septal deformities, and may be valuable when used in conjunction with subjective data gathered from the NOSE questionnaire.

Level of Evidence

4 Laryngoscope, 2018

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Medialization laryngoplasty/arytenoid adduction: U.S. outcomes, discharge status, and utilization trends

Objectives/Hypothesis

To evaluate trends, outcomes, and healthcare utilization following medialization laryngoplasty (ML) with or without arytenoid adduction (AA) over 10 years.

Study Design

Retrospective observational study.

Methods

Using OptumLabs Data Warehouse, trends, outcomes, and healthcare utilization from 2006 to 2015 were examined with a focus on discharge type (same day or not). Predictors of postoperative emergency department (ED) use and hospitalization were determined by multivariable logistic regression.

Results

Overall rate of ML was 1.09 per 100 thousand enrollees per year. Of these, 7.8% ML were combined with an AA. Outpatient same‐day discharge represented 62.0% (1,142 of 1,843) of total patients, steadily increasing over the 10‐year period (P < 0.01). There was a 5.9% revision ML rate and 1.0% rate of tracheotomy within 1 day of ML. A total of 5.6% visited an ED, and 5.4% were admitted to a hospital following initial discharge within 30 days. Same‐day discharge was found to be a predictor of hospitalization within 30 days after ML (odds ratio [OR] 1.74, P = 0.0452), along with Elixhauser comorbidity index of 4 + (OR 5.74, P = 0.0001). Pulmonary embolism, pulmonary hypertension, and weight loss were top predictors of ED visit or hospitalization.

Conclusion

To our knowledge, this is the first search evaluating national claims data for ML with or without AA. Overall rate of ML is low, and same‐day discharge has become more common over a 10‐year period, with an associated higher 30‐day hospital admission risk. Correct patient selection criteria for disposition status cannot be fully determined based on current data, but a high Elixhauser comorbidity index clearly carries increased risk for hospitalization after initial discharge.

Level of Evidence

4. Laryngoscope, 2018

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Analysis of patient factors associated with 30‐day mortality after tracheostomy

Objective

Mortality has been reported to be 22% to 45% in patients with a tracheostomy. To better counsel patients and families, we aimed to determine the effect of body mass index (BMI), socioeconomic status (SES), and the 17 conditions of the Charlson comorbidity index (CCI) on 30‐day survival posttracheostomy.

Methods

This retrospective cohort study identified adult patients enrolled from our institution in the Global Tracheostomy Collaborative database from March 2014 to June 2015. Data collected included age, BMI, residential zip code, and comorbidities. Cox proportionate univariate and multivariate analyses were used to measure the impact of BMI, SES, and CCI variables with 30‐day posttracheostomy survival. We used geocoding as a surrogate for patients' SES. We used Deyo's modification of the CCI, which utilized International Classification of Diseases, 9th Revision, codes to identify comorbidities.

Results

Of 326 tracheostomies identified, the 30‐day mortality rate was 15.6%. No significant differences were noted in BMI or in any of the SES categories between survivors and nonsurvivors. CCI was significantly higher in the 30‐day mortality group. Congestive heart failure (hazard ratio [HR] = 2.39), severe liver disease (HR = 3.15), and peripheral vascular disease (HR = 2.62) were found to significantly impact 30‐day survival.

Conclusion

Higher CCI and specifically severe liver disease, congestive heart failure, and peripheral vascular disease were associated with increased 30‐day mortality posttracheostomy. No association was found between BMI or SES and 30‐day survival. This study identified three comorbidities that independently affect mortality in tracheostomy patients, which should be discussed with patients and families before tracheostomy.

Level of Evidence

3. Laryngoscope, 2018

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Do steroids improve recovery in vestibular neuritis?

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Should the Contralateral Tonsil Be Removed in Cases of HPV‐Positive Squamous Cell Carcinoma of the Tonsil?

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Second primary lung malignancy following head and neck squamous cell carcinoma

Objectives/Hypothesis

Analyze the characteristics of second primary lung malignancies (SPLMs) following an index head and neck squamous cell carcinoma (HNSCC).

Study Design

Retrospective cohort study.

Methods

The Surveillance, Epidemiology and End Results database was queried for all cases of HNSCC between 1973 and 2014 (N = 101,856). This population was compared to a standard population to assess relative risk for lung cancer, calculated as the standardized incidence ratio (SIR). Patients who developed SPLMs were extracted (N = 8,116) and compared to all other cases of lung cancer (N = 1,160,853) to assess histopathological differences. SPLM subpopulations divided by head and neck primary site were compared for lung cancer histology and time interval between cancer diagnoses.

Results

Overall, 8.0% of HNSCC patients developed SPLMs (SIR = 4.22, P < .001), diagnosed an average of 6.7 years later. Patients with HNSCC of the supraglottis and hypopharynx were at the highest risk relative to a standard population, with SIRs of 8.10 and 6.34, respectively. When comparing SPLMs to all other lung cancers, there was no difference in the distribution of lung lobe affected, but SPLMs were significantly more likely to be of squamous cell carcinoma histology (42.0% vs. 21.0%, P < .001). Among head and neck subsites, lung cancers following larynx tumors had a significantly higher proportion of small cell histology, and those following oropharyngeal or hypopharyngeal tumors had significantly higher proportions of squamous cell histology.

Conclusions

Patients who undergo curative treatment of HNSCC are at high risk for developing SPLMs. Subsite‐specific differences may help elucidate the degree of risk attributable to smoking, genetic susceptibility, human papillomavirus infection, or metastasis masquerading as an SPLM.

Level of Evidence

4 Laryngoscope, 2018

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Levator claviculae muscle: Anatomic variation found during neck dissection

The levator claviculae muscle is a variant of the anatomy of the posterior triangle of the neck. It is reported in 2% to 3% of all humans. All previous articles described this muscle as an incidental finding during cadaveric or radiological examinations. We report here, for the first time, a case discovering this muscle variation intraoperatively during a modified radical neck dissection. The muscle was identified on the left side, originating from the transverse processes of the upper cervical vertebrae (C2‐C3), attached to the upper aspect of the middle part of the clavicle. This muscle was innervated by the supraclavicular nerve, coming from the third and fourth rami of the cervical spinal nerves. Blood supply to the muscle could not be identified clearly during the surgical procedure. Surgeons and radiologists should be aware of the presence of this rare variant muscle so as not to misinterpret the anatomy. Laryngoscope, 2018

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Feasibility of shotgun metagenomics to assess microbial ecology of pediatric tracheostomy tubes

Objective

Biofilm formation on medical devices such as tracheostomy tubes (TTs) is a serious problem. The clinical impact of biofilms on the airway is still unclear. Biofilms may play a role in granulation tissue development, recurrent airway infections, and failure of laryngotracheal reconstructions. The microbial ecology on TTs has yet to be elucidated. The purpose of this study was to determine the feasibility of shotgun metagenomics to assess the biodistribution of microorganisms on TTs.

Methods

Four TTs were collected from pediatric patients (1.4–10.2 years) with (n = 2) and without (n = 2) granulation tissue formation. Duration of TT placement prior to retrieval from patients ranged from 5 to 365 days. DNA extraction was performed using the MO BIO UltraClean Microbial Isolation (Mo Bio Laboratories, Carlsbad, CA). Library generation using Nextera XT adapters (Illumina Inc., San Diego, CA) and metagenomic shotgun sequencing was performed using the Illumina NextSeq500 (Illumina Inc, San Diego, CA). Salinibacter ruber, a species not found in mammalian microbiome communities, was used as a DNA standard and represented 0.7% to 5.7% of the microbiome, ensuring good quality and abundance of sample DNA.

Results

Metagenomic shotgun sequencing was successful for all patients. In TTs associated with granuloma, Fusobacterium nucleatum, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae were predominant, most of which are considered pathogens. From TTs without granulomas, Neisseria mucosa, Neisseria sicca, Acinetobacter baumannii, and Haemophilus parainfluenzae were identified, primarily consistent with respiratory microbiome.

Conclusion

This study reveals that metagenomic shotgun sequencing of biofilms formed on pediatric TTs is feasible with an apparent difference in microbiome for patients with granulation tissue. Further studies are necessary to elucidate the pathogenesis of microbial ecology and its role in airway disease in patients with TTs.

Level of Evidence

2c. Laryngoscope, 2018

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The Impact of a Stepwise Approach to Primary Tumor Detection in Squamous Cell Carcinoma of the Neck With Unknown Primary

Objectives/Hypothesis

To examine the cumulative effect of diagnostic steps for primary tumor identification in patients with head and neck squamous cell carcinoma of unknown primary (HNSCCUP), including lingual tonsillectomy, and the impact of primary tumor identification on subsequent treatment.

Study Design

Retrospective analysis.

Methods

We reviewed the records of 110 patients diagnosed with HNSCCUP between 2003 and 2015. Results of diagnostic imaging (fluorodeoxyglucose‐positron emission tomography/computed tomography [FDG‐PET/CT]), tumor detection with direct laryngoscopy with biopsies, palatine tonsillectomy, and transoral robotic surgery (TORS) lingual tonsillectomy were recorded. Associations between demographic and treatment variables with overall survival (OS) and progression‐free survival (PFS) were modeled with Cox proportional hazards models.

Results

FDG‐PET/CT was suspicious for a primary site in 23/77 (30%) patients. Direct laryngoscopy identified a primary tumor in 34/110 patients (31%). Forty‐seven patients underwent palatine tonsillectomy, which identified 17 primaries (36%), yielding a cumulative primary tumor identification of 51/110 (46%). Fourteen patients underwent TORS lingual tonsillectomy, which identified eight primaries (57%), resulting in a cumulative identification of 59/110 (53%). The detection rate increased from 28/63 (44%) to 31/47 (66%) after the addition of TORS lingual tonsillectomy to our institutional approach. Detection rates varied by HPV status. Primary tumor identification altered subsequent radiation planning, as patients with an identified primary tumor received radiation to a smaller volume of tissue than did those without an identified primary tumor. However, there was no significant association between primary tumor identification and OS or PFS.

Conclusions

A stepwise approach to primary tumor identification identifies a primary tumor in a majority of patients.

Level of Evidence

4 Laryngoscope, 2018

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader https://ift.tt/2RcmAVx

Olfactory function in mild cognitive impairment and Alzheimer's disease: A meta‐analysis

Objective

Olfactory function is altered in mild cognitive impairment (MCI) and Alzheimer's disease (AD); therefore, it may serve as a useful tool for the early detection of MCI before its advancement to AD. The aim of this meta‐analysis was to investigate olfactory deficits in patients with MCI and AD.

Study Design

Literature search.

Methods

A search was conducted of the electronic databases PubMed, Embase, and Web of Science from their inception until 2017. We included original articles with adequate data on the identification, threshold, and/or discrimination of olfactory function in MCI or AD. The standard mean difference and 95% confidence interval (CI) were calculated. The studies were weighted according to inverse variance estimates. The effect sizes were categorized as small [Cohen's d = 0.2], medium (d = 0.5), or large (d ≥ 0.8) based on these methods. Subgroup analyses were performed based on mean age and sex differences between the groups.

Results

Twelve articles (reporting 21 effects) examining 563 patients with MCI and 788 patients with AD, were included in the meta‐analysis. Compared to MCI, AD had moderate to large heterogeneous effects on olfactory function (Cohen's d = 0.64, 95% CI: 0.50, 0.78). Olfactory identification tests demonstrated larger effects (d = 0.71, 95% CI: 0.51, 0.91) than did tests of other olfactory domains.

Conclusions

Meta‐analysis results revealed that olfactory identification was more profoundly impaired in patients with AD than in those with MCI. These findings suggest that a simple test of odor identification is valuable in differentiating individuals at a risk of AD.

Level of Evidence

NA Laryngoscope, 2018

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader https://ift.tt/2PRrvOV

Over–under versus medial tympanoplasty: Comparison of benefit, success, and hearing results

Objectives/Hypothesis

A hybrid variation of a tympanoplasty technique, termed over–under tympanoplasty (OUT), was evaluated to demonstrate the long‐term outcomes and complications compared to medial tympanoplasty.

Study Design

Retrospective review.

Methods

Patients who underwent a tympanoplasty between 2010 and 2015 were included. Primary outcome measures included graft healing at 18 months, change in air‐bone gap (ABG), and change in high‐frequency hearing at 8 kHz. The Shapiro‐Wilk test, Student t test, and nonparametric Mann‐Whitney test were used to compare results. Univariate logistic regression analysis was used to identify potential predictors of surgical success.

Results

One hundred eleven patients were included; 84 underwent the over–under technique and 27 underwent medial tympanoplasty. At the 18‐month follow‐up, 100% of patients in the medial tympanoplasty group had closure of the TM perforation compared to 84% (71/84) in the over–under group. In the over–under group, 12% of patients developed small or pinpoint perforations, and 4% developed larger, recurrent perforations. Mean improvement in ABG was similar between the two groups (11.6 dB for the medial group vs. 11.9 dB for the over–under group, P < .001). No hearing loss was noted in either group. No lateralization of the graft or anterior blunting was noted.

Conclusions

In this series, the OUT technique had a high success rate with TM perforations, including anterior, near total, and total perforations. Hearing loss from dissection on the malleus was not found. This approach blends the advantages and minimizes the disadvantages of the classic techniques and is well suited for all types of tympanic membrane perforations.

Level of Evidence

3b Laryngoscope, 2018

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader https://ift.tt/2RbTuFE

Novel approach using transoral robotic surgery for resection of cervical spine chordoma

Chordomas are rare, infiltrative neoplasms of notochordal origin that present along the spinal canal; en bloc surgical resection is paramount to successful treatment. Limited visualization and complex anatomy are major challenges to resection of upper cervical spine chordomas and often require invasive surgery. A 27‐year‐old male presented with an incidentally discovered chordoma of the midline second cervical vertebra of the spine. To obtain en bloc resection of the lesion while both overcoming limitations due to access and without introducing morbidity from traditional anterior approaches, we elected using transoral robotic surgery for resection. Due to complete resection, the patient remains disease‐free and was spared adjuvant radiation. Laryngoscope, 2018

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Airway anomalies in patients with craniosynostosis

Objectives

1) Characterize the spectrum of airway anomalies in patients with craniosynostosis, and 2) identify clinical characteristics of these patients that may be associated with the development of airway anomalies.

Methods

This study is a retrospective case series assessing the type and frequency of airway anomalies in all patients with craniosynostosis seen at a tertiary‐care children's hospital between 2000 and 2016. Cohort analyses were then performed to identify differences in airway anomalies dependent on syndromic associations, multisutural fusion, and location of suture fusion. Clinical characteristics examined included demographics and additional neurologic and craniofacial abnormalities.

Results

Four hundred and ninety‐six patients with craniosynostosis (83.5% white, 64.5% male; 33.9% sagittal, 28.8% metopic, 11.5% coronal, 1.2% lambdoid, and 24.6% multisutural) were included. Notable airway anomalies included the following: 13.3% adenotonsillar hypertrophy, 8.9% laryngomalacia, 7.3% tracheomalacia, 7.1% subglottic stenosis, 4.0% bronchomalacia, 3.8% laryngeal cleft, and 1.2% vocal fold paresis. Multisutural craniosynostosis patients (n = 122) were more likely to have obstructive sleep apnea (P = 0.005), adenotonsillar hypertrophy (P = 0.014), tracheomalacia (P = 0.011), subglottic stenosis (P < 0.001), and epiglottic/base of tongue collapse (P = 0.003) and require tracheostomy (P = 0.001) and mechanical ventilation (P = 0.017) compared with single suture craniosynostosis. Syndromic craniosynostosis patients (n = 33) were more likely to have obstructive sleep apnea (P < 0.001), laryngomalacia (P = 0.047), and subglottic stenosis (P = 0.009) compared with nonsyndromic patients.

Conclusion

Airway anomalies are prevalent in patients with craniosynostosis; patients with multisutural or syndromic types have an increased risk of developing certain abnormalities. There should be a lower threshold for referral for airway evaluation in these populations.

Level of Evidence

4. Laryngoscope, 2018

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader https://ift.tt/2Ri1Aws

Progression of hearing loss in neurofibromatosis type 2 according to genetic severity

Objectives/Hypothesis

This study set out to describe the progression of hearing loss in patients with neurofibromatosis type 2 (NF2), treated in a quaternary multidisciplinary clinic. It also aimed to compare hearing loss across patients grouped according to a known genetic severity score to explore its utility for prognostication.

Study Design

Retrospective cohort study.

Methods

We conducted a study of 147 patients with confirmed NF2 diagnosis for a mean observational period of 10 years. Pure‐tone average (PTA), optimum discriminations scores (ODS), and genotype data were collected. Patients were classified according to hearing class (American Academy of Otolaryngology), their candidacy for auditory implantation (UK National NF2 consensus) and grouped by genetic severity as: 1 = tissue mosaic, 2A = mild classic, 2B = moderate classic, and 3 = severe. Survival analysis investigated the effect of genetic severity on the age of loss of serviceable hearing.

Results

Genetic severity was a significant predictor of hearing outcomes such as ODS, hearing classification, and maximum annual PTA deterioration. Although the overall median age of loss of serviceable hearing was 78 years, there was significant variation according to the genetic severity; the median for severe patients was 32 years compared to a median of 80 for tissue mosaic patients.

Conclusions

This is the first description of long‐term hearing outcomes in a clinical setting across a large heterogeneous cohort of patients with NF2. The results highlight the potential importance and benefit of considering the genetic severity score of patients when undertaking treatment decisions, as well as planning future natural history studies.

Level of Evidence

2c Laryngoscope, 2018

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Using word clouds to Re‐envision letters of recommendation for residency applicants

Objectives/Hypothesis

To develop a "word cloud"–based visual letter of recommendation (VLOR) and to evaluate its efficiency in discerning applicant quality compared to narrative letters of recommendation (NLORs).

Study Design

Cross‐sectional cohort study.

Methods

NLORs for 48 otolaryngology residency applicants interviewed from the 2016 application cycle were identified and mined for descriptive terms to generate a word cloud, referred to as a VLOR. Eight individuals reviewed and rated a total of 187 blinded NLORs and 48 VLORs on a four‐point scale (negative to exceptional). Median VLOR and NLOR scores and the time to review for each candidate were compared using the Wilcoxon signed rank test.

Results

It took significantly more time to review the NLORs in comparison to the VLORs (67 seconds, interquartile range [IQR]: 41–98 seconds vs. 17 seconds, IQR: 11–26 seconds, P < .001). There was no significant difference between median scores for VLORs and NLORs (P = .136). Review time and score correlated positively for VLORs and was statistically significant (ρ = 0.459, P = .001), indicating that more time spent reviewing equates to higher scores. The same relationship appeared with NLORs, but was not statistically significant (ρ = 0.276, P = .058).

Conclusions

VLORs are a novel and efficient additive tool for screening candidates for otolaryngology residency interview slots. Their scores do not significantly vary from NLOR scores and are significantly faster to evaluate.

Level of Evidence

2b Laryngoscope, 2018

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Titanium dental implants with different collar design and surface modifications: a systematic review on survival rates and marginal bone levels

Abstract

Aim

To compare clinical and radiographic outcomes of dental implants with different neck characteristics.

Methods

A protocol‐oriented search aimed at the question: "In patients subjected to tooth replacement with screw‐type dental implants does the modification of the implant neck macro or micro‐geometry contribute to the improvement of survival rates and maintenance of the peri‐implant marginal bone levels?" Primary outcomes were survival and marginal bone level (MBL) changes evaluated on randomized controlled trials with >10 participants and follow‐up >1 year. Risk of bias was evaluated using the Cochrane Collaboration's tool. The review follows the PRISMA statement.

Results

Forty‐three studies compared: 1. One‐ versus two‐piece implants (N=7); 2. Two‐piece implants with different neck characteristics (machined and rough collars, microthreads, LASER microtexturing) (N=21); 3. Two‐piece implants with macrogeometry modifications (tapering, back‐tapering and scalloping) (N=6). One‐ and two‐piece implants showed similar survival (RR= 0.45, 95% CI: [0.12, 1.66], p=0.23) and MBL changes (WMD=0.09mm, 95% CI: [‐0.27, 0.45], p=0.64) at 1‐year post‐loading. Machined collar implants have higher risk of early failure than rough collar implants (RR= 3.96, 95% CI: [1.12, 13.93], p=0.03) and 0.43mm higher bone resorption (95% CI: [0.0, 0.86], p=0.05). Microthreads (WMD= 0.07mm, 95% CI: [‐0.01, 0.15], p=0.10) and LASER microtexturing (WMD=0.15mm, 95% CI: [‐0.35, 0.65], p=0.56) do not reduce bone resorption. Scalloped implants have 1.26mm higher resorption (95% CI: [0.72, 2.00], p<0.001).

Conclusions

One‐ and two‐piece implants have similar survival and MBL changes. Rough collar implants have lower MBL changes than machined collar implants. Additional modifications to rough collars are irrelevant.

This article is protected by copyright. All rights reserved.

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Disseminated Trichosporonosis with Atypical Histology Findings in a Patient with Acute Lymphocytic Leukemia

We report a case of disseminated Trichosporon asahii in a patient on systemic anti‐fungal therapy who presented with multiple cutaneous nodules suggestive of fungal infection. Histologic features resembled neutrophilic eccrine hidradenitis but staining with periodic acid‐Schiff and Gomori methenamine silver confirmed the clinical diagnosis. This case highlights the importance of maintaining suspicion for trichosporonosis and contextualizing histologic findings within the underlying clinical picture.

This article is protected by copyright. All rights reserved.

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Disseminated Trichosporonosis with Atypical Histology Findings in a Patient with Acute Lymphocytic Leukemia

We report a case of disseminated Trichosporon asahii in a patient on systemic anti‐fungal therapy who presented with multiple cutaneous nodules suggestive of fungal infection. Histologic features resembled neutrophilic eccrine hidradenitis but staining with periodic acid‐Schiff and Gomori methenamine silver confirmed the clinical diagnosis. This case highlights the importance of maintaining suspicion for trichosporonosis and contextualizing histologic findings within the underlying clinical picture.

This article is protected by copyright. All rights reserved.

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Student and foundation doctor perspectives on promoting entry to ENT specialist training

Abstract

In recent years, there has been a decline in the number of applications per ST3 post for ENT. The majority of medical students and foundation doctors have a limited exposure to ENT during undergraduate medical training. This is a common issue in smaller surgical specialties, and is acknowledged as one factor deterring students from surgical careers.

This article is protected by copyright. All rights reserved.

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Student and foundation doctor perspectives on promoting entry to ENT specialist training

Abstract

In recent years, there has been a decline in the number of applications per ST3 post for ENT. The majority of medical students and foundation doctors have a limited exposure to ENT during undergraduate medical training. This is a common issue in smaller surgical specialties, and is acknowledged as one factor deterring students from surgical careers.

This article is protected by copyright. All rights reserved.

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T1ρ and T2 mapping for the determination of articular cartilage denaturalization with osteonecrosis of the femoral head: A prospective controlled trial

Background

In the future, biochemical MRI might provide a valuable noninvasive quantitative analysis of the biochemical composition of cartilage in osteonecrosis of the femoral head (ONFH).

Purpose

To investigate the diagnostic performance of T₁ρ and T₂ mapping in cartilage denaturalization with ONFH and to determine the correlation between T₁ρ and T₂ mapping and the Association Research Circulation Osseous (ARCO) stage.

Study Type

Prospective.

Subjects

Forty‐seven patients with ONFH (stage I to III according to the ARCO criteria) and 24 volunteers (control group) were recruited for the prospective study.

Sequence

Conventional MRI, multiple echo recalled gradient echo (MERGE), and T₁ρ and T₂ mapping sequences.

Assessment

Pseudocolor images and MERGE images were combined in the AW4.5 workstation. The region of interest (ROI) of the hip cartilage was 4–6 mm². The sagittal T₁ρ and T₂ mapping values were calculated by the two first authors.

Statistical Tests

One‐way analysis of variance (ANOVA), LSD t‐tests, Pearson correlation analysis, and receiver operator characteristic (ROC) curves. The significance level was set at P < 0.05.

Results

The T₁ρ and T₂ mapping values of the ONFH group were significantly higher than the values of the control group (P = 0.000). Regarding the assessment of the severity of ARCO staging, both T₁ρ (r = 0.66, P = 0.004) and T₂ mapping (r = 0.501, P = 0.002) were positively associated with disease severity. The T₁ρ values were positively correlated with the T₂ mapping values (r = 0.381, P = 0.000). The areas under the curve (AUC) for the T₁ρ and T₂ mapping values were 0.822 and 0.791, respectively. The diagnostic sensitivity and specificity were 72.34% and 70.83% for T₁ρ mapping and 72.34% and 58.33%, respectively, for T₂ mapping.

Data Conclusion

Both T₁ρ and T₂ mapping performed well in diagnosing the cartilage denaturalization in ARCO stage I‐III ONFH patients. T₁ρ mapping had a higher diagnostic sensitivity and specificity than T₂ mapping.

Level of Evidence: 2

Technical Efficacy: Stage 2

J. Magn. Reson. Imaging 2018.

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T1ρ and T2 mapping for the determination of articular cartilage denaturalization with osteonecrosis of the femoral head: A prospective controlled trial

Background

In the future, biochemical MRI might provide a valuable noninvasive quantitative analysis of the biochemical composition of cartilage in osteonecrosis of the femoral head (ONFH).

Purpose

To investigate the diagnostic performance of T₁ρ and T₂ mapping in cartilage denaturalization with ONFH and to determine the correlation between T₁ρ and T₂ mapping and the Association Research Circulation Osseous (ARCO) stage.

Study Type

Prospective.

Subjects

Forty‐seven patients with ONFH (stage I to III according to the ARCO criteria) and 24 volunteers (control group) were recruited for the prospective study.

Sequence

Conventional MRI, multiple echo recalled gradient echo (MERGE), and T₁ρ and T₂ mapping sequences.

Assessment

Pseudocolor images and MERGE images were combined in the AW4.5 workstation. The region of interest (ROI) of the hip cartilage was 4–6 mm². The sagittal T₁ρ and T₂ mapping values were calculated by the two first authors.

Statistical Tests

One‐way analysis of variance (ANOVA), LSD t‐tests, Pearson correlation analysis, and receiver operator characteristic (ROC) curves. The significance level was set at P < 0.05.

Results

The T₁ρ and T₂ mapping values of the ONFH group were significantly higher than the values of the control group (P = 0.000). Regarding the assessment of the severity of ARCO staging, both T₁ρ (r = 0.66, P = 0.004) and T₂ mapping (r = 0.501, P = 0.002) were positively associated with disease severity. The T₁ρ values were positively correlated with the T₂ mapping values (r = 0.381, P = 0.000). The areas under the curve (AUC) for the T₁ρ and T₂ mapping values were 0.822 and 0.791, respectively. The diagnostic sensitivity and specificity were 72.34% and 70.83% for T₁ρ mapping and 72.34% and 58.33%, respectively, for T₂ mapping.

Data Conclusion

Both T₁ρ and T₂ mapping performed well in diagnosing the cartilage denaturalization in ARCO stage I‐III ONFH patients. T₁ρ mapping had a higher diagnostic sensitivity and specificity than T₂ mapping.

Level of Evidence: 2

Technical Efficacy: Stage 2

J. Magn. Reson. Imaging 2018.

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Two cases of occupational allergic contact dermatitis caused by abacavir

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Sensitivity to imidazoles/nitroimidazoles in subjects sensitized to methylchloroisothiazolinone/methylisothiazolinone: A simple coincidence?

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Phytophotodermatitis related to Peucedanumpaniculatum Loisel , a case report

Phytophotodermatitis is a skin reaction due to ultraviolet light exposure after previous contact with a photosensitising plant compound such as furocoumarins. Phytophotodermatitis are often described with lime (1), fig leaves (2) or celery (3). We report the case of a 60‐years‐old man who developed phytophotodermatitis after encountering Peucedanum paniculatum Loisel during a walk in Corsica, France.

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Fixed drug eruption caused by fulvestrant confirmed by skin tests: First case

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Patch testing with alkyl glucosides: concomitant reactions are common but not ubiquitous

Background

Alkyl glucosides are a family of mild surfactants that are increasingly used in a wide range of cosmetics and household products. Contact allergy to alkyl glucosides may be more frequent than previously suspected, especially in atopic patients.

Objectives

To investigate the frequency of contact allergy to alkyl glucosides and to identify concomitant reactivity.

Patients/Methods

We retrospectively reviewed all cases of suspected allergic contact dermatitis (ACD) in which patients were either patch tested with a cosmetic series that includes five alkyl glucosides (decyl glucoside, lauryl glucoside, coco glucoside, cetearyl glucoside, caprylyl/capryl glucoside) or a specific alkyl glucoside series from November 2013 to April 2017 in two UK centres.

Results

A total of 5775 patients were patch tested across the two centres. Twenty‐nine (1.04%) of the 2796 patients tested to the cosmetic/alkyl glucoside series had a positive patch test reaction to at least one of the alkyl glucosides. Twenty three (79.3%) were sensitised to multiple alkyl glucosides; 21 patients (72.4%) were female. The mean age was 43.5 years. Twelve patients (41.4%) had a background of atopic dermatitis.

Conclusions

The prevalence of alkyl glucoside‐induced ACD is relatively high and there are frequent concomitant reactions between different alkyl glucosides. We recommend the inclusion of alkyl glucosides in all cosmetic series.

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Cobalt content of a convenience sample of leather shoes and gloves in Denmark

Chromium is a well‐known allergen in leather products, however, cobalt has not historically been associated with leather exposure. Cobalt allergic contact dermatitis (ACD) from leather in furniture upholstery has been reported in Denmark,^1,2 and leather furniture samples obtained in the United States also were found to contain cobalt.³ However, no clear cases of cobalt ACD from leather gloves or shoes have been reported. In this study we examined cobalt content in a convenience sample of shoes and gloves.

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Two cases of occupational allergic contact dermatitis caused by abacavir

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader https://ift.tt/2P1dwRk

Sensitivity to imidazoles/nitroimidazoles in subjects sensitized to methylchloroisothiazolinone/methylisothiazolinone: A simple coincidence?

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader https://ift.tt/2zqXQCa

Phytophotodermatitis related to Peucedanumpaniculatum Loisel , a case report

Phytophotodermatitis is a skin reaction due to ultraviolet light exposure after previous contact with a photosensitising plant compound such as furocoumarins. Phytophotodermatitis are often described with lime (1), fig leaves (2) or celery (3). We report the case of a 60‐years‐old man who developed phytophotodermatitis after encountering Peucedanum paniculatum Loisel during a walk in Corsica, France.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader https://ift.tt/2P1k1ns

Fixed drug eruption caused by fulvestrant confirmed by skin tests: First case

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader https://ift.tt/2zmIAWU

Patch testing with alkyl glucosides: concomitant reactions are common but not ubiquitous

Background

Alkyl glucosides are a family of mild surfactants that are increasingly used in a wide range of cosmetics and household products. Contact allergy to alkyl glucosides may be more frequent than previously suspected, especially in atopic patients.

Objectives

To investigate the frequency of contact allergy to alkyl glucosides and to identify concomitant reactivity.

Patients/Methods

We retrospectively reviewed all cases of suspected allergic contact dermatitis (ACD) in which patients were either patch tested with a cosmetic series that includes five alkyl glucosides (decyl glucoside, lauryl glucoside, coco glucoside, cetearyl glucoside, caprylyl/capryl glucoside) or a specific alkyl glucoside series from November 2013 to April 2017 in two UK centres.

Results

A total of 5775 patients were patch tested across the two centres. Twenty‐nine (1.04%) of the 2796 patients tested to the cosmetic/alkyl glucoside series had a positive patch test reaction to at least one of the alkyl glucosides. Twenty three (79.3%) were sensitised to multiple alkyl glucosides; 21 patients (72.4%) were female. The mean age was 43.5 years. Twelve patients (41.4%) had a background of atopic dermatitis.

Conclusions

The prevalence of alkyl glucoside‐induced ACD is relatively high and there are frequent concomitant reactions between different alkyl glucosides. We recommend the inclusion of alkyl glucosides in all cosmetic series.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader https://ift.tt/2P1QERK

Cobalt content of a convenience sample of leather shoes and gloves in Denmark

Chromium is a well‐known allergen in leather products, however, cobalt has not historically been associated with leather exposure. Cobalt allergic contact dermatitis (ACD) from leather in furniture upholstery has been reported in Denmark,^1,2 and leather furniture samples obtained in the United States also were found to contain cobalt.³ However, no clear cases of cobalt ACD from leather gloves or shoes have been reported. In this study we examined cobalt content in a convenience sample of shoes and gloves.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader https://ift.tt/2zrbTrv

How wildfire smoke and poor air quality can affect your health

As firefighters in California get closer to fully containing the fires, people in the region have had to deal with massive amounts of smoke in the air. Thick smog forced many residents to wear masks when going outside. Dr. David Agus joins "CBS This Morning: Saturday" to discuss the health implications of breathing the polluted air and a new study about a drug that could allow those with severe peanut allergies to consume the nut safely. (Source: Health News: CBSNews.com)

MedWorm Message: Have you tried our new medical search engine? More powerful than before. Log on with your social media account. 100% free.

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How wildfire smoke and poor air quality can affect your health

As firefighters in California get closer to fully containing the fires, people in the region have had to deal with massive amounts of smoke in the air. Thick smog forced many residents to wear masks when going outside. Dr. David Agus joins "CBS This Morning: Saturday" to discuss the health implications of breathing the polluted air and a new study about a drug that could allow those with severe peanut allergies to consume the nut safely. (Source: Health News: CBSNews.com)

MedWorm Message: Have you tried our new medical search engine? More powerful than before. Log on with your social media account. 100% free.

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How wildfire smoke and poor air quality can affect your health

As firefighters in California get closer to fully containing the fires, people in the region have had to deal with massive amounts of smoke in the air. Thick smog forced many residents to wear masks when going outside. Dr. David Agus joins "CBS This Morning: Saturday" to discuss the health implications of breathing the polluted air and a new study about a drug that could allow those with severe peanut allergies to consume the nut safely. (Source: Health News: CBSNews.com)

MedWorm Message: Have you tried our new medical search engine? More powerful than before. Log on with your social media account. 100% free.

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How wildfire smoke and poor air quality can affect your health

As firefighters in California get closer to fully containing the fires, people in the region have had to deal with massive amounts of smoke in the air. Thick smog forced many residents to wear masks when going outside. Dr. David Agus joins "CBS This Morning: Saturday" to discuss the health implications of breathing the polluted air and a new study about a drug that could allow those with severe peanut allergies to consume the nut safely. (Source: Health News: CBSNews.com)

MedWorm Message: Have you tried our new medical search engine? More powerful than before. Log on with your social media account. 100% free.

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Dining out with food allergies may be safer with at least 15 precautions

(Reuters Health) - A survey of people with food allergies who dine out successfully has found they employ quite a few strategies. (Source: Reuters: Health)

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Allergic bronchopulmonary aspergillosis complicating COPD is associated with a higher exacerbation rate and a distinct pattern on chest CT scan compared to COPD

Conference abstracts (Source: The Aspergillus Website - updates)

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Changes in total IgE levels predict pulmonary outcome in cystic fibrosis related allergic bronchopulmonary aspergillosis

Conference abstracts (Source: The Aspergillus Website - updates)

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IgE immunadsorption in allergic bronchopulmonary aspergillosis: A pilot study

Conference abstracts (Source: The Aspergillus Website - updates)

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Serum level directed itraconazole therapy in allergic bronchopulmonary aspergillosis

Conference abstracts (Source: The Aspergillus Website - updates)

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Dining out with food allergies may be safer with at least 15 precautions

(Reuters Health) - A survey of people with food allergies who dine out successfully has found they employ quite a few strategies. (Source: Reuters: Health)

MedWorm Message: Have you tried our new medical search engine? More powerful than before. Log on with your social media account. 100% free.

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Allergic bronchopulmonary aspergillosis complicating COPD is associated with a higher exacerbation rate and a distinct pattern on chest CT scan compared to COPD

Conference abstracts (Source: The Aspergillus Website - updates)

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Changes in total IgE levels predict pulmonary outcome in cystic fibrosis related allergic bronchopulmonary aspergillosis

Conference abstracts (Source: The Aspergillus Website - updates)

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IgE immunadsorption in allergic bronchopulmonary aspergillosis: A pilot study

Conference abstracts (Source: The Aspergillus Website - updates)

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Serum level directed itraconazole therapy in allergic bronchopulmonary aspergillosis

Conference abstracts (Source: The Aspergillus Website - updates)

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Accuracy of Dual-Energy Virtual Monochromatic CT Numbers: Comparison between the Single-Source Projection-Based and Dual-Source Image-Based Methods

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Takashi Ueguchi, Ryota Ogihara, Sachiko Yamada

Rationale and Objectives

To investigate the accuracy of dual-energy virtual monochromatic computed tomography (CT) numbers obtained by two typical hardware and software implementations: the single-source projection-based method and the dual-source image-based method.

Materials and Methods

A phantom with different tissue equivalent inserts was scanned with both single-source and dual-source scanners. A fast kVp-switching feature was used on the single-source scanner, whereas a tin filter was used on the dual-source scanner. Virtual monochromatic CT images of the phantom at energy levels of 60, 100, and 140 keV were obtained by both projection-based (on the single-source scanner) and image-based (on the dual-source scanner) methods. The accuracy of virtual monochromatic CT numbers for all inserts was assessed by comparing measured values to their corresponding true values. Linear regression analysis was performed to evaluate the dependency of measured CT numbers on tissue attenuation, method, and their interaction.

Results

Root mean square values of systematic error over all inserts at 60, 100, and 140 keV were approximately 53, 21, and 29 Hounsfield unit (HU) with the single-source projection-based method, and 46, 7, and 6 HU with the dual-source image-based method, respectively. Linear regression analysis revealed that the interaction between the attenuation and the method had a statistically significant effect on the measured CT numbers at 100 and 140 keV.

Conclusions

There were attenuation-, method-, and energy level-dependent systematic errors in the measured virtual monochromatic CT numbers. CT number reproducibility was comparable between the two scanners, and CT numbers had better accuracy with the dual-source image-based method at 100 and 140 keV.

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Tailoring CT Dose to Patient Size: Implementation of the Updated 2017 ACR Size-specific Diagnostic Reference Levels

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Yan Klosterkemper, Elisabeth Appel, Christoph Thomas, Oliver T. Bethge, Joel Aissa, Patric Kröpil, Gerald Antoch, Johannes Boos

Rationale and Objectives

To use an automatic computed tomography (CT) dose monitoring system to analyze the institutional chest and abdominopelvic CT dose data as regards the updated 2017 American College of Radiology (ACR) diagnostic reference levels (DRLs) based on water-equivalent diameter (Dw) and size-specific dose estimates (SSDE) to detect patient-size subgroups in which CT dose can be optimized.

Materials and Methods

All chest CT examinations performed between July 2016 and April 2017 with and without contrast material, CT of the pulmonary arteries, and abdominopelvic CT with and without contrast material were included in this retrospective study. Dw and SSDE were automatically calculated for all scans using a previously validated in-house developed Matlab software and stored into our CT dose monitoring system. CT dose data were analyzed as regards the updated ACR DRLs (size groups: 21–25 cm, 25–29 cm, 29–33 cm, 33–37 cm, 37–41 cm). SSDE and volumetric computed tomography dose index (CTDIvol) were used as CT dose parameter.

Results

Overall, 30,002 CT examinations were performed in the study period, 3860 of which were included in the analysis (mean age 62.1 ± 16.4 years, Dw 29.0 ± 3.3 cm; n = 577 chest CT without contrast material, n = 628 chest CT with contrast material, n = 346 CT of chest pulmonary, n = 563 abdominopelvic CT without contrast material, n = 1746 abdominopelvic CT with contrast material). Mean SSDE and CTDIvol relative to the updated DRLs were 43.3 ± 26.4 and 45.1 ± 27.9% for noncontrast chest CT, 52.3 ± 23.1 and 52.0 ± 23.1% for contrast-enhanced chest CT, 68.8 ± 29.5 and 70.0 ± 31.0% for CT of pulmonary arteries, 41.9 ± 29.2 and 43.3 ± 31.3% for noncontrast abdominopelvic CT, and 56.8 ± 22.2 and 58.8 ± 24.4% for contrast-enhanced abdominopelvic CT. Lowest dose compared to the DRLs was found for the Dw group of 21–25 cm in noncontrast abdominopelvic CT (SSDE 30.4 ± 21.8%, CTDIvol 30.8 ± 21.4%). Solely the group of patients with a Dw of 37–41 cm undergoing noncontrast abdominopelvic CT exceeded the ACR DRL (SSDE 100.3 ± 59.0%, CTDIvol 107.1 ± 63.5%).

Conclusions

On average, mean SSDE and CTDIvol of our institutional chest and abdominopelvic CT protocols were lower than the updated 2017 ACR DRLs. Size-specific subgroup analysis revealed a wide variability of SSDE and CTDIvol across CT protocols and patient size groups with a transgression of DRLs in noncontrast abdominopelvic CT of large patients (Dw 37–41 cm).

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Comparison of Local Injection of Fresh Frozen Plasma to Traditional Methods of Hemostasis in Minimally Invasive Procedures

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): John Haaga, Shiraz Rahim, Victor Kondray, Jon Davidson, Indravadan Patel, Dean Nakamoto

Rationale and Objectives

To evaluate different techniques for reducing hemorrhagic complications in coagulopathic patients with elevated international normalized ratio having an image-guided percutaneous invasive procedure; techniques included systemic transfusion of fresh frozen plasma (FFP), local injection of FFP, percutaneous injection of gelatin sponge, and percutaneous placements of angiographic coils.

Materials and Methods

Retrospective review of 232 consecutive patients with known coagulopathy undergoing image-guided minimally invasive procedures were selected. Ninety-one patients had local FFP injected, 40 patients underwent local synthetic gelatin injection, 16 patients had percutaneous coil embolization, and 85 patients received systemic FFP. The number of bleeds, complications related to bleeds, and systemic complications were recorded. A 30 cc threshold was used to delineate significant bleeding.

Results

No patients experienced clinically significant or insignificant bleeding with local FFP injection (P value <.05). Other local hemostatic methods (Gelfoam, systemic FFP, and coil embolization) were associated with higher levels of bleeding (12.5%, 17.1%, 37.5%, respectively) and complications (7.5%, 31.4%, 37.5%, respectively). Systemic FFP infusion was associated with respiratory, infectious, and mortal complications.

Conclusions

Local injection of blood products provides a safe and efficacious hemostatic agent to reduce the incidence of postprocedural bleeding. The technique is associated with lower rates of bleeding and systemic complications when compared to other local and systemic techniques. Further randomized prospective studies with a larger patient cohort need to be performed to corroborate these initial findings.

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Does Enhancement or Perfusion on Preprocedure CT Predict Outcomes After Embolization of Hepatocellular Carcinoma?

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Alessandra Borgheresi, Adrian Gonzalez-Aguirre, Karen T. Brown, George I. Getrajdman, Joseph P. Erinjeri, Anne Covey, Hooman Yarmohammadi, Etay Ziv, Constantinos T. Sofocleous, Franz Edward Boas

Rationale and Objective

The objective of this study was to evaluate whether quantitative enhancement or perfusion measurements on preprocedure triphasic computed tomography (CT) can be used to predict response or overall survival after embolization of hepatocellular carcinoma.

Materials and Methods

The institutional review board approved this retrospective review of 63 patients with hepatocellular carcinoma treated with particle embolization between March 2009 and December 2014. Quantitative enhancement and perfusion measurements were performed on the target tumor and the background liver on the triphasic CT performed before treatment. Microvascular invasion (MVI) and degree of differentiation were determined from a core biopsy specimen. Quantitative enhancement and perfusion values were then correlated with pathology (two-tailed t test), response to embolization on modified Response Evaluation Criteria In Solid Tumors (two-tailed t test), and overall survival after embolization (Cox proportional hazards model).

Results

Arterial enhancement did not predict immediate response or overall survival after embolization. The degree of differentiation or presence of MVI also did not predict immediate response or overall survival after embolization. However, high hepatic artery coefficient or low portal vein coefficient, both in the tumor (P = .011 and P = .004) and in the background liver (P = .015 and P = .009), were associated with worse survival. Hepatic artery coefficient, both in the tumor (P = .025) and in the background liver (P = .013), were independent predictors of survival in a multivariate model including the Child-Pugh score and the BCLC stage.

Conclusions

Tumor and liver perfusion parameters estimated from preprocedure triphasic CT were predictive of survival after embolization. Arterial-phase enhancement and histology (degree of differentiation or MVI) did not predict immediate response or overall survival after particle embolization.

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Breast Lesions Detected via Molecular Breast Imaging: Physiological Parameters Affecting Interpretation

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Jason G. Ching, Rachel F. Brem

Rationale and Objectives

To evaluate correlations between molecular breast imaging (MBI) descriptor characteristics and positive predictive value (PPV) in detecting breast cancer.

Materials and Methods

A retrospective review was performed on 193 suspicious findings from 153 women (31–81 years) with positive MBI examinations. We assessed associations between (i) lesion pattern (mass vs. nonmass) and PPV; (ii) lesion pattern and suspected likelihood of cancer (low vs. moderate vs. high); (iii) background parenchymal uptake (BPU) (homogeneous vs. heterogeneous) and PPV; (iv) breast density (dense vs. non-dense) and PPV; and (v) BPU and density.

Results

One hundred ten of 153 patients were diagnosed with malignancy or high-risk pathology (PPV1 = 71.9%), and 130/193 biopsies resulted in malignant or high-risk lesions (PPV3 = 67.4%). Biopsies of mass vs. nonmass findings had comparable PPV3 (71.7% vs. 61.3%; P = .0717). Mass findings were correlated with higher suspicion for cancer than nonmass findings (P < .001). There was no significant difference in PPV3 when comparing biopsies from homogeneous vs. heterogeneous BPU (72.5% vs. 60.7%; P = .103). No association was found between patients' BPU and diagnosed cancer or high-risk lesions (P = .513). Biopsies from nondense breasts demonstrated higher PPV3 than biopsies from dense breasts (85.4% vs. 60.6%; P = .0025); patients with nondense breasts were more likely to be diagnosed with cancer or high-risk pathology (PPV1 = 87.8% vs. 66.0%; P = .00844). Dense breasts had a greater association with heterogeneous BPU (P = .0844).

Conclusion

Neither variability in mass or nonmass positive MBI findings, nor variability in BPU on MBI were significant determinants for the probability of malignancy. Dense breasts were associated with lower predictability and heterogeneous BPU on MBI.

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Posterior Inferior Cerebellar Artery Aneurysm: Have You Ever Been Misdiagnosed?

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Yuan Zhang, Shiqing Sun, Qi Xu, Weihua Feng, Haisong Chen

Rationale and Objectives

The posterior inferior cerebellar artery aneurysm (PICAA), especially distal PICAA, is easily missed by a doctor, leading to misdiagnosis and treatment delays. The objective of this article is to report the computed tomography angiography (CTA) presentations of 30 cases of PICAA proved by digital subtraction angiography (DSA) or surgical operation, and analyze the causes of misdiagnosis of PICAA by CTA.

Materials and Methods

Thirty cases of patients with PICAA that were proved by DSA or surgical operation were included in this study, all of whom underwent CTA before surgical procedure. The relationship between the locations of PICAA and the rates of missed diagnosis by CTA was analyzed. The detection rates of the PICAA by volume rendering (VR) images and original thin axial images of CTA were compared.

Results

Twelve cases (12 of 30, 40%) of aneurysm lied on the proximal end of posterior inferior cerebellar artery (PICA) (border with vertebral artery) and all of them (12 of 12,100%) were clearly displayed on the VR images of CTA and correctly diagnosed by doctors. Eighteen cases (18 of 30, 60%) of aneurysm lied on the distal part of the PICA, whereas only 2 of them (2/18, 11.1%) were displayed on the VR images and correctly diagnosed before surgical procedure. After surgical operation, the respective review of the CTA images demonstrated that all aneurysms (30 of 30, 100%) can be found on the thin axial images after careful observation and are shown on VR images after adjusting the display threshold when the locations of the PICAA through thin axial images were known, including the distal PICAA.

Conclusions

Thin axial CT images are most important and reliable for the detection of distal PICAA. Overdependence on three-dimensional VR images of CTA is the main cause of misdiagnosis.

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A Radiomics Signature in Preoperative Predicting Degree of Tumor Differentiation in Patients with Non–small Cell Lung Cancer

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Xin Chen, Mengjie Fang, Di Dong, Xinhua Wei, Lingling Liu, Xiangdong Xu, Xinqing Jiang, Jie Tian, Zaiyi Liu

Rationale and Objectives

Poorly differentiated non–small cell lung cancer (NSCLC) indicated a poor prognosis and well-differentiated NSCLC indicates a noninvasive nature and good prognosis. The purpose of this study was to build and validate a radiomics signature to predict the degree of tumor differentiation (DTD) for patients with NSCLC.

Materials and Methods

A total of 487 patients with pathologically diagnosed NSCLC were retrospectively included in our study. Five hundred ninety-one radiomics features were extracted from each tumor from the contrast-enhanced computed tomography images. A minimum redundancy maximum relevance algorithm and a logistic regression model were used for dimension reduction, feature selection, and radiomics signature building. The performance of the radiomics signature was assessed using receiver operating characteristic analysis, and the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy were calculated to quantify the association between a signature and DTD. An independent validation set contained 184 consecutive patients with NSCLC.

Results

A nine-radiomics-feature-based signature was built and it could differentiate low and high DTDs in the training set (AUC = 0.763, sensitivity = 0.750, specificity = 0.665, and accuracy = 0.687), and the radiomics signature had good discrimination performance in the validation set (AUC = 0.782, sensitivity = 0.608, specificity = 0.752, and accuracy = 0.712).

Conclusions

A radiomics signature based on contrast-enhanced computed tomography imaging is a potentially useful imaging biomarker for differentiating low from high DTD in patients with NSCLC.

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Variability of CT Airways Measurements in COPD Patients Between Morning and Afternoon: Comparisons to Variability of Spirometric Measurements

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Maxime Hackx, Elodie Gyssels, Tiago Severo Garcia, Isabelle De Meulder, Marie Bruyneel, Alain Van Muylem, Vincent Ninane, Pierre Alain Gevenois

Rationale and Objectives

Computed tomography (CT) airways measurements can be used as surrogates to spirometric measurements for assessing bronchodilation in a particular patient with chronic obstructive pulmonary disease. Although spirometric measurements show variations within the opening hours of a hospital department, we aimed to compare the variability of CT airways measurements between morning and afternoon in patients with chronic obstructive pulmonary disease to that of spirometric measurements.

Materials and Methods

Twenty patients had pulmonary function tests and CT around 8 am and 4 pm. Luminal area (LA) and wall thickness (WT) of third and fourth generation airways were measured twice by three readers. The percentage of airway area occupied by the wall (WA%) and the square root of wall area at an internal perimeter of 10 mm (√WAPi10) were calculated. The effects of examination time, reader, and measurement session on CT airways measurements were assessed, and the variability of these measurements was compared to that of spirometric measurements.

Results

Variability of LA^3rd and LA^4th was greater than that of spirometric measurements (P values ranging from <.001 to .033). There was no examination time effect on √WAPi10, WT^3rd, LA^4th, or WA%^4th (P values ranging from .102 to .712). There was a reader effect on all CT airways measurements (P values ranging from <.001 to .028), except in WT^3rd (P > .999). There was no effect of measurement session on any CT airway measurement (P values ranging from .535 to >.999).

Conclusion

As the variability of LA^3rd and LA^4th is greater than that of spirometric measurements, clinical studies should include cohorts with larger numbers of patients when considering LA than when considering spirometric measurements as end points.

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It is About "Time": Academic Neuroradiologist Time Distribution for Interpreting Brain MRIs

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Altaib Al Yassin, Mohammad Salehi Sadaghiani, Suyash Mohan, R. Nick Bryan, Ilya Nasrallah

Rationale and Objectives

Efficiency is central to current radiology practice. Knowledge of report generation timing is essential for workload optimization and departmental staffing decisions. Yet little research evaluates the distribution of activities performed by neuroradiologists in daily work.

Materials and Methods

This observational study tracked radiologists interpreting 358 brain magnetic resonance imaging (MRI) in an academic practice over 9 months. We measured the total duration from study opening to report signing and times for five activities performed during this period: image viewing, report transcription, obtaining clinical data, education, and other. Attendings, fellows, and residents reading studies independently and attendings over-reading trainee-previewed studies were observed.

Results

Ten attendings, 12 fellows, and 13 residents spent a mean of 11, 18, and 16 minutes reading brain MRIs independently. Mean duration was significantly different comparing attendings in all assignments to fellows (18.36 ± 1.05 minutes, p = 0.0001) or residents (16.31 ± 1.11 minutes, p = 0.001) but not between fellows/residents. Mean duration among attendings reading independently versus over-reading trainees was not statistically different. Attendings spent the same time on image viewing (4.07–5.33 minutes) with or without trainees. Attending transcription time was shortest when over-reading trainees (2.24 minutes) and longest when reading independently (4.20 minutes), demonstrating benefit of the draft report. Fellows and Residents spent longer on image viewing (7.14 minutes and 8.06 minutes, respectively) and transcription (7.02 minutes and 5.40 minutes, respectively) than attendings reading independently.

Conclusion

Neuroradiologist time/activity distributions for reading brain MRI studies were measured, setting the stage to establish a benchmark for future reference and suggesting opportunities for greater efficiency. Furthermore, report production time can be decreased when a draft report is available.

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The Impact of Interruptions on Chest Radiograph Interpretation: Effects on Reading Time and Accuracy

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Rachel M. Wynn, Jessica L. Howe, Linda C. Kelahan, Allan Fong, Ross W. Filice, Raj M. Ratwani

Rationale and Objectives

The objective of this study was to experimentally test the effect of interruptions on image interpretation by comparing reading time and response accuracy of interrupted case reads to uninterrupted case reads in resident and attending radiologists.

Materials and Methods

Institutional review board approval was obtained before participant recruitment from an urban academic health-care system during January 2016–March 2016. Eleven resident and 12 attending radiologists examined 30 chest radiographs, rating their confidence regarding the presence or the absence of a pneumothorax. Ten cases were normal (ie, no pneumothorax present), 10 cases had an unsubtle pneumothorax (ie, readily perceivable by a nonexpert), and 10 cases had a subtle pneumothorax. During three reads of each case type, the participants were interrupted with 30 seconds of a secondary task. The total reading time and the accuracy of interrupted and uninterrupted cases were compared. A mixed-factors analysis of variance was run on reading time and accuracy with experience (resident vs attending) as a between-subjects factor and case type (normal, unsubtle, or subtle) and interruption (interruption vs no interruption) as within-subjects factors.

Results

Interrupted tasks had significantly longer reading times than uninterrupted cases (P = .032). During subtle cases, interruptions reduced accuracy (P = .034), but during normal cases, interruptions increased accuracy (P = .038).

Conclusions

Interruptions increased reading times and increased the tendency for a radiologist to conclude that a case is normal for both resident and attending radiologists, demonstrating that interruptions reduce efficiency and introduce patient safety concerns during reads of abnormal cases.

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When Residents Hear the Bell Toll

Publication date: Available online 23 November 2018

Source: Academic Radiology

Author(s): Jared R Shields, Richard B Gunderman

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Machine Learning Algorithms Utilizing Functional Respiratory Imaging May Predict COPD Exacerbations

Publication date: Available online 23 November 2018

Source: Academic Radiology

Author(s): Maarten Lanclus, Johan Clukers, Cedric Van Holsbeke, Wim Vos, Glenn Leemans, Birgit Holbrechts, Katherine Barboza, Wilfried De Backer, Jan De Backer

Rationale and Objectives

Acute chronic obstructive pulmonary disease exacerbations (AECOPD) have a significant negative impact on the quality of life and accelerate progression of the disease. Functional respiratory imaging (FRI) has the potential to better characterize this disease. The purpose of this study was to identify FRI parameters specific to AECOPD and assess their ability to predict future AECOPD, by use of machine learning algorithms, enabling a better understanding and quantification of disease manifestation and progression.

Materials and Methods

A multicenter cohort of 62 patients with COPD was analyzed. FRI obtained from baseline high resolution CT data (unenhanced and volume gated), clinical, and pulmonary function test were analyzed and incorporated into machine learning algorithms.

Results

A total of 11 baseline FRI parameters could significantly distinguish ( p < 0.05) the development of AECOPD from a stable period. In contrast, no baseline clinical or pulmonary function test parameters allowed significant classification. Furthermore, using Support Vector Machines, an accuracy of 80.65% and positive predictive value of 82.35% could be obtained by combining baseline FRI features such as total specific image-based airway volume and total specific image-based airway resistance, measured at functional residual capacity. Patients who developed an AECOPD, showed significantly smaller airway volumes and (hence) significantly higher airway resistances at baseline.

Conclusion

This study indicates that FRI is a sensitive tool (PPV 82.35%) for predicting future AECOPD on a patient specific level in contrast to classical clinical parameters.

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Accuracy of Dual-Energy Virtual Monochromatic CT Numbers: Comparison between the Single-Source Projection-Based and Dual-Source Image-Based Methods

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Takashi Ueguchi, Ryota Ogihara, Sachiko Yamada

Rationale and Objectives

To investigate the accuracy of dual-energy virtual monochromatic computed tomography (CT) numbers obtained by two typical hardware and software implementations: the single-source projection-based method and the dual-source image-based method.

Materials and Methods

A phantom with different tissue equivalent inserts was scanned with both single-source and dual-source scanners. A fast kVp-switching feature was used on the single-source scanner, whereas a tin filter was used on the dual-source scanner. Virtual monochromatic CT images of the phantom at energy levels of 60, 100, and 140 keV were obtained by both projection-based (on the single-source scanner) and image-based (on the dual-source scanner) methods. The accuracy of virtual monochromatic CT numbers for all inserts was assessed by comparing measured values to their corresponding true values. Linear regression analysis was performed to evaluate the dependency of measured CT numbers on tissue attenuation, method, and their interaction.

Results

Root mean square values of systematic error over all inserts at 60, 100, and 140 keV were approximately 53, 21, and 29 Hounsfield unit (HU) with the single-source projection-based method, and 46, 7, and 6 HU with the dual-source image-based method, respectively. Linear regression analysis revealed that the interaction between the attenuation and the method had a statistically significant effect on the measured CT numbers at 100 and 140 keV.

Conclusions

There were attenuation-, method-, and energy level-dependent systematic errors in the measured virtual monochromatic CT numbers. CT number reproducibility was comparable between the two scanners, and CT numbers had better accuracy with the dual-source image-based method at 100 and 140 keV.

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Tailoring CT Dose to Patient Size: Implementation of the Updated 2017 ACR Size-specific Diagnostic Reference Levels

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Yan Klosterkemper, Elisabeth Appel, Christoph Thomas, Oliver T. Bethge, Joel Aissa, Patric Kröpil, Gerald Antoch, Johannes Boos

Rationale and Objectives

To use an automatic computed tomography (CT) dose monitoring system to analyze the institutional chest and abdominopelvic CT dose data as regards the updated 2017 American College of Radiology (ACR) diagnostic reference levels (DRLs) based on water-equivalent diameter (Dw) and size-specific dose estimates (SSDE) to detect patient-size subgroups in which CT dose can be optimized.

Materials and Methods

All chest CT examinations performed between July 2016 and April 2017 with and without contrast material, CT of the pulmonary arteries, and abdominopelvic CT with and without contrast material were included in this retrospective study. Dw and SSDE were automatically calculated for all scans using a previously validated in-house developed Matlab software and stored into our CT dose monitoring system. CT dose data were analyzed as regards the updated ACR DRLs (size groups: 21–25 cm, 25–29 cm, 29–33 cm, 33–37 cm, 37–41 cm). SSDE and volumetric computed tomography dose index (CTDIvol) were used as CT dose parameter.

Results

Overall, 30,002 CT examinations were performed in the study period, 3860 of which were included in the analysis (mean age 62.1 ± 16.4 years, Dw 29.0 ± 3.3 cm; n = 577 chest CT without contrast material, n = 628 chest CT with contrast material, n = 346 CT of chest pulmonary, n = 563 abdominopelvic CT without contrast material, n = 1746 abdominopelvic CT with contrast material). Mean SSDE and CTDIvol relative to the updated DRLs were 43.3 ± 26.4 and 45.1 ± 27.9% for noncontrast chest CT, 52.3 ± 23.1 and 52.0 ± 23.1% for contrast-enhanced chest CT, 68.8 ± 29.5 and 70.0 ± 31.0% for CT of pulmonary arteries, 41.9 ± 29.2 and 43.3 ± 31.3% for noncontrast abdominopelvic CT, and 56.8 ± 22.2 and 58.8 ± 24.4% for contrast-enhanced abdominopelvic CT. Lowest dose compared to the DRLs was found for the Dw group of 21–25 cm in noncontrast abdominopelvic CT (SSDE 30.4 ± 21.8%, CTDIvol 30.8 ± 21.4%). Solely the group of patients with a Dw of 37–41 cm undergoing noncontrast abdominopelvic CT exceeded the ACR DRL (SSDE 100.3 ± 59.0%, CTDIvol 107.1 ± 63.5%).

Conclusions

On average, mean SSDE and CTDIvol of our institutional chest and abdominopelvic CT protocols were lower than the updated 2017 ACR DRLs. Size-specific subgroup analysis revealed a wide variability of SSDE and CTDIvol across CT protocols and patient size groups with a transgression of DRLs in noncontrast abdominopelvic CT of large patients (Dw 37–41 cm).

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Comparison of Local Injection of Fresh Frozen Plasma to Traditional Methods of Hemostasis in Minimally Invasive Procedures

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): John Haaga, Shiraz Rahim, Victor Kondray, Jon Davidson, Indravadan Patel, Dean Nakamoto

Rationale and Objectives

To evaluate different techniques for reducing hemorrhagic complications in coagulopathic patients with elevated international normalized ratio having an image-guided percutaneous invasive procedure; techniques included systemic transfusion of fresh frozen plasma (FFP), local injection of FFP, percutaneous injection of gelatin sponge, and percutaneous placements of angiographic coils.

Materials and Methods

Retrospective review of 232 consecutive patients with known coagulopathy undergoing image-guided minimally invasive procedures were selected. Ninety-one patients had local FFP injected, 40 patients underwent local synthetic gelatin injection, 16 patients had percutaneous coil embolization, and 85 patients received systemic FFP. The number of bleeds, complications related to bleeds, and systemic complications were recorded. A 30 cc threshold was used to delineate significant bleeding.

Results

No patients experienced clinically significant or insignificant bleeding with local FFP injection (P value <.05). Other local hemostatic methods (Gelfoam, systemic FFP, and coil embolization) were associated with higher levels of bleeding (12.5%, 17.1%, 37.5%, respectively) and complications (7.5%, 31.4%, 37.5%, respectively). Systemic FFP infusion was associated with respiratory, infectious, and mortal complications.

Conclusions

Local injection of blood products provides a safe and efficacious hemostatic agent to reduce the incidence of postprocedural bleeding. The technique is associated with lower rates of bleeding and systemic complications when compared to other local and systemic techniques. Further randomized prospective studies with a larger patient cohort need to be performed to corroborate these initial findings.

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Does Enhancement or Perfusion on Preprocedure CT Predict Outcomes After Embolization of Hepatocellular Carcinoma?

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Alessandra Borgheresi, Adrian Gonzalez-Aguirre, Karen T. Brown, George I. Getrajdman, Joseph P. Erinjeri, Anne Covey, Hooman Yarmohammadi, Etay Ziv, Constantinos T. Sofocleous, Franz Edward Boas

Rationale and Objective

The objective of this study was to evaluate whether quantitative enhancement or perfusion measurements on preprocedure triphasic computed tomography (CT) can be used to predict response or overall survival after embolization of hepatocellular carcinoma.

Materials and Methods

The institutional review board approved this retrospective review of 63 patients with hepatocellular carcinoma treated with particle embolization between March 2009 and December 2014. Quantitative enhancement and perfusion measurements were performed on the target tumor and the background liver on the triphasic CT performed before treatment. Microvascular invasion (MVI) and degree of differentiation were determined from a core biopsy specimen. Quantitative enhancement and perfusion values were then correlated with pathology (two-tailed t test), response to embolization on modified Response Evaluation Criteria In Solid Tumors (two-tailed t test), and overall survival after embolization (Cox proportional hazards model).

Results

Arterial enhancement did not predict immediate response or overall survival after embolization. The degree of differentiation or presence of MVI also did not predict immediate response or overall survival after embolization. However, high hepatic artery coefficient or low portal vein coefficient, both in the tumor (P = .011 and P = .004) and in the background liver (P = .015 and P = .009), were associated with worse survival. Hepatic artery coefficient, both in the tumor (P = .025) and in the background liver (P = .013), were independent predictors of survival in a multivariate model including the Child-Pugh score and the BCLC stage.

Conclusions

Tumor and liver perfusion parameters estimated from preprocedure triphasic CT were predictive of survival after embolization. Arterial-phase enhancement and histology (degree of differentiation or MVI) did not predict immediate response or overall survival after particle embolization.

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Breast Lesions Detected via Molecular Breast Imaging: Physiological Parameters Affecting Interpretation

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Jason G. Ching, Rachel F. Brem

Rationale and Objectives

To evaluate correlations between molecular breast imaging (MBI) descriptor characteristics and positive predictive value (PPV) in detecting breast cancer.

Materials and Methods

A retrospective review was performed on 193 suspicious findings from 153 women (31–81 years) with positive MBI examinations. We assessed associations between (i) lesion pattern (mass vs. nonmass) and PPV; (ii) lesion pattern and suspected likelihood of cancer (low vs. moderate vs. high); (iii) background parenchymal uptake (BPU) (homogeneous vs. heterogeneous) and PPV; (iv) breast density (dense vs. non-dense) and PPV; and (v) BPU and density.

Results

One hundred ten of 153 patients were diagnosed with malignancy or high-risk pathology (PPV1 = 71.9%), and 130/193 biopsies resulted in malignant or high-risk lesions (PPV3 = 67.4%). Biopsies of mass vs. nonmass findings had comparable PPV3 (71.7% vs. 61.3%; P = .0717). Mass findings were correlated with higher suspicion for cancer than nonmass findings (P < .001). There was no significant difference in PPV3 when comparing biopsies from homogeneous vs. heterogeneous BPU (72.5% vs. 60.7%; P = .103). No association was found between patients' BPU and diagnosed cancer or high-risk lesions (P = .513). Biopsies from nondense breasts demonstrated higher PPV3 than biopsies from dense breasts (85.4% vs. 60.6%; P = .0025); patients with nondense breasts were more likely to be diagnosed with cancer or high-risk pathology (PPV1 = 87.8% vs. 66.0%; P = .00844). Dense breasts had a greater association with heterogeneous BPU (P = .0844).

Conclusion

Neither variability in mass or nonmass positive MBI findings, nor variability in BPU on MBI were significant determinants for the probability of malignancy. Dense breasts were associated with lower predictability and heterogeneous BPU on MBI.

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Posterior Inferior Cerebellar Artery Aneurysm: Have You Ever Been Misdiagnosed?

Publication date: December 2018

Source: Academic Radiology, Volume 25, Issue 12

Author(s): Yuan Zhang, Shiqing Sun, Qi Xu, Weihua Feng, Haisong Chen

Rationale and Objectives

The posterior inferior cerebellar artery aneurysm (PICAA), especially distal PICAA, is easily missed by a doctor, leading to misdiagnosis and treatment delays. The objective of this article is to report the computed tomography angiography (CTA) presentations of 30 cases of PICAA proved by digital subtraction angiography (DSA) or surgical operation, and analyze the causes of misdiagnosis of PICAA by CTA.

Materials and Methods

Thirty cases of patients with PICAA that were proved by DSA or surgical operation were included in this study, all of whom underwent CTA before surgical procedure. The relationship between the locations of PICAA and the rates of missed diagnosis by CTA was analyzed. The detection rates of the PICAA by volume rendering (VR) images and original thin axial images of CTA were compared.

Results

Twelve cases (12 of 30, 40%) of aneurysm lied on the proximal end of posterior inferior cerebellar artery (PICA) (border with vertebral artery) and all of them (12 of 12,100%) were clearly displayed on the VR images of CTA and correctly diagnosed by doctors. Eighteen cases (18 of 30, 60%) of aneurysm lied on the distal part of the PICA, whereas only 2 of them (2/18, 11.1%) were displayed on the VR images and correctly diagnosed before surgical procedure. After surgical operation, the respective review of the CTA images demonstrated that all aneurysms (30 of 30, 100%) can be found on the thin axial images after careful observation and are shown on VR images after adjusting the display threshold when the locations of the PICAA through thin axial images were known, including the distal PICAA.

Conclusions

Thin axial CT images are most important and reliable for the detection of distal PICAA. Overdependence on three-dimensional VR images of CTA is the main cause of misdiagnosis.

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