Additional Diagnostic Investigations Research Articles

Clinical impact of whole-body MRI in staging and surveillance of patients with myxoid liposarcoma: a 14-year single-centre retrospective study.

To assess the clinical impact of regular whole-body magnetic resonance imaging (WBMRI) surveillance in myxoid liposarcoma patients. This was a retrospective cohort study of myxoid liposarcoma patients who underwent at least one WBMRI at our institution between October 2006 and December 2020. The effect of WBMRI on clinical management, namely treatment modification or additional diagnostic investigations was studied. A standardised WBMRI surveillance protocol was instituted in 2015. We compared patient outcomes for the metastatic patients who had and had not received regular WBMRI surveillance and performed survival analysis for both subgroups. Of the 56 patients (60.7% male, median age: 48.1 years) who underwent 345 WBMRI, 17 (30.3%) had metastases, and 168 WBMRI were performed in this group. The median imaging follow-up for the entire cohort was 35 months; the metastatic group had a median follow-up of 42 months. WBMRI changed the clinical management in 13 (76.5%) metastatic patients, with 33 instances of treatment modification. Thirty-five lesions were labelled 'indeterminate,' 16 (45.7%) had additional investigations/interventions, and 4 (11.4%) were confirmed to be metastatic. Twenty-one metastatic lesions were missed initially on WBMRI and confirmed on subsequent WBMRI, of which 5 (23.8%) were clinically significant. The 5-year survival since the detection of metastasis was better in the regular surveillance subgroup (85.7% vs. 45%), but this was not statistically significant (p = 0.068). Five patients (8.9%) developed their first metastasis more than 5 years after diagnosing the primary lesion. Regular WBMRI surveillance of myxoid liposarcoma patients considerably impacts clinical management by frequently influencing treatment decisions. WBMRI has been recently recommended as an imaging option for the staging and surveillance of myxoid liposarcoma patients. Our study highlights the impact of regular WBMRI surveillance on the clinical management of these patients and how it affects their survival.

Intralenticular Metallic Foreign Body: A Case Report

Background: Intraocular foreign body (IOFB) injuries exhibit variations based on multiple factors, including size, composition, location, type, contamination, the extent of tissue damage, and potential complications that may arise. Case Presentation: This case study describes a 48-year-old male patient who presented to the outpatient clinic with a progressive decline in vision in the right eye lasting three weeks. The patient reported a history of redness in the affected eye, occurring for several days after performing maintenance work. Intraocular pressure measurements were normal for both eyes. The slit lamp examination revealed a corneal opacity near the limbus at the 2 o'clock position in the right eye, along with a small peripheral iris hole aligned with the corneal opacity. Additional diagnostic investigations, including a B-scan ultrasound and a CT scan of the orbit without contrast, were conducted. The B-scan ultrasound showed a clear vitreous and a flat retina, while the CT scan detected a metallic foreign body measuring 3x3 mm. The foreign body was found to be partially embedded in the lens and partially in the vitreous, as confirmed by the imaging. As a result, the patient was admitted to the hospital, and a comprehensive treatment plan was implemented. Topical antibiotics, steroids, cycloplegic, and nonsteroidal anti-inflammatory eye drops were prescribed. The patient underwent cataract surgery with sulcus intraocular lens implantation, combined with a pars plana vitrectomy to remove the foreign body. Additional procedures, such as 360 laser treatment, air-fluid exchange, and injection of SF6 gas, were performed. Conclusion: This case highlights the successful management of an intraocular foreign body injury, emphasizing the significance of prompt diagnosis and appropriate surgical intervention in achieving positive visual outcomes.

Clinical findings using echocardiography and plasma cardiac troponin I and pathological findings in dogs with hypertrophic cardiomyopathy: A retrospective study.

Hypertrophic cardiomyopathy (HCM) is considered rare in dogs, and there is a lack of clinical data. Cardiac troponin I (cTnI) is a biomarker of cardiomyocyte damage and necrosis and can be used to diagnose cat and human HCM. We investigated whether the presence of cTnI in clinical data can be used in conjunction with echocardiography to diagnose canine HCM. This study comprised client-owned dogs with clinical evidence of concentric hypertrophy on echocardiographic images, serum total thyroxine levels of ≤5 µg/dl, systolic blood pressure of ≤180 mmHg, and absence of aortic stenosis. All cases were necropsied. Cardiomyocyte hypertrophy (mean diameter, 18.3 ± 1.8 µm), myocardial fiber disarray (70%), interstitial fibrosis (80%), and small vessel disease (100%) were assessed. In dogs with HCM, the left ventricles were concentric, almost symmetrical, and hypertrophied above the aortic diameter. The end-diastolic interventricular septum normalized to body weight [intraventricular septal thickness in diastole (IVSDN)] was 0.788 [interquartile range (IQR), 0.7-0.92], which exceeded the normal range (5%-95%, IQR: 0.33-0.52). In total, 70% of the dogs with HCM had syncope and dyspnea, and all dogs had high cTnI levels (median, 3.94 ng/ml), exceeding the upper limit of normal (0.11 ng/ml) and indicating cardiomyocyte damage. IVSDN and serum cTnI levels were correlated (ρ = 0.839, p = 0.01). Ventricular wall thickening and high serum cTnI levels can provide a presumptive diagnosis of HCM and prompt the initiation of treatment or additional diagnostic investigations.

Лінійний IgA-бульозний дерматоз у дитини під час воєнного стану. Клінічний випадок

Linear IgA-bullous dermatosis (chronic childhood disease) - a rare autoimmune subepithelial vesiculobulular disease caused by the formation of IgA autoantibodies, directed against various hemidesmosomal antigens, which is more common in children of early preschool age. Purpose - is to describe our own clinical observation of a case of linear IgA-bullous dermatosis in a girl aged 2 years 9 months to increase the level of alertness of doctors regarding this pathology in children, especially at an early age. Clinical case. At the time of admission her condition was of moderate severity due to the presence of a confluent papular-vesicular rash located on the face, neck, limbs. The rash was accompanied by the development of erosions surrounded by a ring of vesicles and caused a feeling of discomfort, severe itching. During local treatment and systemic antifungal tablets, the child’s condition improved, however, complete remission was not achieved after 7 week of the therapy, new bullas appeared. Additional diagnostic investigation allowed to suppose the diagnosis linear IgA - bullous dermatosis. Adjustment of therapy was made (steroids per os administration) and the child's condition improved gradually in a month. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Investigating Specialized Chronic Pain Care Among Emerging Adults

AIMS: To investigate characteristics of emerging adults accessing a specialized chronic non-cancer pain clinic and describe interventions offered and utilized by this group. A retrospective chart review was conducted of emerging adults and middle-aged adults with chronic pain receiving care over a six-month period. A chronic pain clinic in Southeastern Ontario. 82 participants comprised of 41 emerging adults (aged 18-29) and 41 middle-aged adults (aged 30-64) METHODS: Groups were matched on sex and number of pain sites. Demographic and pain characteristics, interventions, referrals, and clinic utilization were examined using bivariate and multivariate analysis. Emerging adults reported lower pain severity scores (t(80)=-2.15, p=.035), were more likely to receive referrals for additional consultation and/or diagnostic investigations (X2(1, n=82)=4.97, p=.026) and to have at least one psychology visit (X2=7.29, p=.007). Moreover, emerging adults with higher depression scores were more likely to see a psychologist (OR 1.23, 95% CI 1.014-1.492). Pain presentation and care patterns differed between emerging adults and middle-aged adults. Increased use of non-pharmacologic interventions in emerging adults may reflect differences in pain presentations as well as clinician's sensitivity to emerging adult's particular developmental needs but further research is needed. Further research is needed to contribute to nurses' understanding of the quality and efficacy of pain management approaches.

Spasm of the near reflex: a common diagnostic dilemma?

To report the clinical characteristics and diagnostic procedures used in patients with spasm of the near reflex (SNR), in order to present common investigation strategies and diagnostic pitfalls. Retrospective case series of twenty-two patients, mainly children, with SNR or accommodation spasm (AS). AS was diagnosed on the basis of blurred vision and a difference of ≥2 dioptres between manifest and cycloplegic retinoscopy. If esotropia and miosis were present, the patients were diagnosed with SNR. All patients underwent visual acuity testing, orthoptic evaluation, assessment of refraction before and after cycloplegia, and dilated fundoscopy. Additional diagnostic investigations, such as neuroimaging, lumbar puncture (LP), electrophysiology and blood tests, were also recorded. Screen use among children was assessed in hours per day. There were 19 female and 3 male patients (age range 7-33y, median=10y). Seventeen patients had AS and 5 patients had SNR, with episodic blurry vision and headaches being the most common symptoms. Brain neuroimaging was performed in six patients (27%), although only one had a history of brain trauma. Two of those patients underwent visual evoked potentials and three also underwent LP and received intravenous steroid therapy. The majority of patients (90%) reported prolonged daily screen time (>2h/d), and in 55% of cases there were concurrent social problems or psychological triggers. Treatment consisted of careful explanation of the condition, atropine 1% eye drops and full cycloplegic correction by means of bifocal glasses. The diagnosis of SNR and AS may be challenging, because symptoms are usually intermittent and nonspecific, and a large number of patients are often subjected to redundant and potentially time-consuming examinations and treatment, that may exaggerate the underlying psychological disorder. Hence, detailed clinical testing and assessment of psychosocial profile is necessary, in order to avoid unnecessary investigations. Neuroimaging should be performed only in selected cases. Finally, due to prolonged screen use SNR and AS may become more frequent in the future.

Baseline Screening MRI Uptake and Findings in Women with ≥ 20% Lifetime Risk of Breast Cancer.

The American Cancer Society recommends screening magnetic resonance imaging (MRI) for patients with a ≥ 20% lifetime breast cancer risk. This study assesses the outcomes of baseline MRI screens in women from a high-risk breast clinic (HRBC). We retrospectively reviewed patients from our institution's HRBC, excluding those with prior breast cancer and predisposing genetic mutations. Screening MRI was recommended for a lifetime risk of ≥ 20% using the Tyrer-Cuzick model. We determined baseline MRI results, biopsy rates, and frequency of MRI-detected high-risk lesions (HRLs) and breast cancers. Overall, 319 women attended our HRBC; median age was 48years and 4.7% had prior atypia/lobular carcinoma in situ. Screening MRI was recommended for 282 patients, of whom 196 (69.5%) completed a baseline screen. A Breast Imaging-Reporting and Data System (BIRADS) 3 or 4 finding occurred in 19.6% of patients; 23 (12.3%) required 6-month follow-up MRI, 16 (8.6%) underwent core biopsy, and 4 (2.1%) underwent excisional biopsy after initial core. An additional 7 (3.7%) patients had a non-breast incidental finding. An HRL was identified in 2 (1.1%) patients (atypical ductal and lobular hyperplasia, respectively), and 2 (1.1%) were diagnosed with T1N0 breast cancers. In the setting of an HRBC, 70% of women with a ≥ 20% lifetime risk of breast cancer pursued screening MRI when recommended. On baseline screen, the rate of MRI-detected breast cancer was low (1%); however, malignancies were mammographically occult and identified at an early stage. Despite a low cancer rate, nearly one in four women required additional diagnostic investigation. Prescreening counselling should include a discussion of this possibility, and longer-term follow-up of screening MRI is needed in this high-risk population.

Design of an Auscultation System for Phonoangiography and Monitoring of Carotid Artery Diseases.

Cerebrovascular diseases such as stenosis of the carotid artery are accountable for about 1 million death per year across Europe. Diagnostic tools like US, angiography or MRI require specific hardware and highly depend on the experience of the examining clinician. In contrast auscultation with a stethoscope can be used to screen for bruits - audible vascular sounds associated with turbulent blood flow. Dynamical changes in the flow due to pathological narrowing of the vessel can indicate the need for additional diagnostic investigations. A reliable auscultation setup is prerequisite to ensure high signal quality, adequate processing and the objective evaluation of a still subjectively assessed audible signal. We propose a computer assisted auscultation device for the characterisation of carotid bruits to facilitate the assessment of long-term changes in the vessel condition. Main goal of this work are design considerations regarding the mechanical interface of the proposed system to the skin. An experimental setup was used to compare the signal quality and morphology of different setups to a digital stethoscope. A combined system with two different interface configurations is proposed, current limitations of the system and potential improvements are discussed.

Prospective evaluation of rapid point-of-care tests for the diagnosis of acute leptospirosis in dogs

The early diagnosis of acute leptospirosis is still a major challenge in dogs. The aim of this prospective study was to evaluate the suitability of two in-clinic tests detecting anti-leptospiral IgM and IgG antibodies in diagnosing canine leptospirosis. The performances of the two rapid tests were compared to the microscopic agglutination test (MAT) carried out on acute sera and to diagnostic criteria adopted in this study to confirm leptospirosis infection (MAT upon admission, convalescent MAT and quantitative real-time PCR on blood and/or urine). The dogs were enrolled on the basis of reported exposure to known risk factors and clinical presentation (acute kidney injury and/or systemic inflammatory response syndrome with multi-organ damage). Eighty-nine dogs included in the study were sub-grouped on the basis of the results of the diagnostic criteria adopted: (1) confirmed leptospirosis cases (42/89 dogs); (2) negative leptospirosis cases (36/89 dogs); and (3) unconfirmed leptospirosis cases (11/89 dogs). The results supported the usefulness of the two rapid diagnostic tests as a first in-clinic screening tool for suspected leptospirosis; positive results in the in-clinic tests in dogs with suggestive clinical and laboratory signs strongly indicated acute leptospirosis, while negative results required additional diagnostic investigation to exclude the infection. Confirmatory tests recommended for canine leptospirosis are still necessary in addition to the use of rapid in-clinic tests.

Successful Repatriation of Breast Cancer Surveillance for High-Risk Women to the UK National Health Service Breast Screening Programme

BackgroundSince April 2013, the UK’s National Health Service Breast Screening Programme (NHSBSP) centers have been obliged to provide services for women at the highest risk of breast cancer, including those carrying highly penetrant single gene mutations (BRCA1, BRCA2, TP53). Since then, such individuals previously undergoing surveillance in the Royal Marsden Hospital were referred to their local NHSBSP centers. We aimed to assess patient experience of surveillance provided by local NHSBSP services at 1 and 3 years after repatriation. Patients and MethodsHigh-risk gene mutation carriers referred to the NHSBSP for breast cancer surveillance were identified from a departmental database in the Cancer Genetics Unit and invited to complete questionnaires about their experience of surveillance under this new pathway, first in 2014 and again in 2016. ResultsThree hundred forty-six individuals were invited to participate in 2014, of whom 182 responded (53%). A total of 464 patients were invited in 2016, of whom 246 (53%) completed the second questionnaire. Ninety-four percent of patients with residual breast tissue received some screening at the first (n = 161) and second (n = 185) time points. Ninety-one percent of patients (n = 146) received at least recommended surveillance in the year preceding the initial survey, a proportion decreasing slightly by the second time point (n = 164, 87%). Seventeen percent of individuals required additional diagnostic investigations, with cancers detected in 2%. These proportions remained stable between surveys. ConclusionRepatriation of high-risk individuals from Royal Marsden Hospital to NHSBSP centers has been successfully accomplished. Most individuals received appropriate recommended annual surveillance. Further improvements are required to ensure equal and timely provision of recommended surveillance.

Acute medical impairment among elderly patients involved in motor vehicle collisions

BackgroundThe association between acute medical illness and motor vehicle collisions (MVCs) among elderly emergency department patients is unclear. We sought to determine the prevalence of acute medical conditions that might impair driving ability among the elderly involved in MVCs and determine if there was an increased risk of the driver having an acute medical condition compared to similarly aged passengers. MethodsWe reviewed charts of patients aged 65 years or older whose emergency department visit was prompted by a motor vehicle collision between 1 July 2000 and 30 June 2010 at two Level 1 trauma centres. The exposure of interest was occupancy status (driver vs. passenger), and the outcome measure was the presence of any predefined acute medical illness that might impair driving ability. ResultsFinal analysis included 871 drivers (cases) and 307 passengers (controls). An acute medical illness was recorded in 107 patients (9%): 97 drivers (11%) and 10 passengers (3%). Compared to passengers, drivers had significantly higher odds of presenting with acute medical illness (OR 3.7, 95% CI 1.9–7.2). After controlling for potential confounders, the adjusted odds ratio was 5.5 (95% CI 2.3–13.0). ConclusionAcute medical conditions are a moderately common diagnosis among elderly drivers, presenting in about one in ten patients. A difference in the risk of finding an acute medical illness when comparing elderly drivers and passengers evaluated in the emergency department after a collision suggests the need for considering additional diagnostic investigation and post-discharge surveillance in this population.

Correlation of fine-needle aspiration with fluorodeoxyglucose positron emission tomography and ultrasonography imaging in head and neck lymph nodes

Fluorodeoxyglucose positron emission tomography (FDG-PET) is a well-established tracer technique, particularly useful for oncologic conditions. However, in the head and neck region, this modality may have limitations due to the complex anatomy and high frequency of normal variants in FDG-PET uptake resulting in diagnostic errors. Hence, FDG-PET results often require additional diagnostic investigations including ultrasonography (US), and guided fine-needle aspirations (FNAs) in order to improve diagnosis and patient care. A total of 87 cases of head and neck lymph node FNA were accessioned in the cytopathology laboratory between 2010 and 2013, 75 cases with corresponding standard uptake values (SUVs) were selected to form the current study cohort. Patient demographics, primary tumor site, size of the biopsied lymph node, PET SUV, and US findings, as well as FNA diagnoses and surgical follow-ups were reviewed. SUVs were grouped into 5 ranges: A (2.2-2.9), B (3.0-4.9), C (5.0-6.9), D (7.0-9.9), and E (10.0 +). The SUV cutoff of 5.0 was seen in the groups C, D, and E, which increased the probability of malignancy in the FNA specimens from 67% to 100%. The average size of the lymph nodes was 18.57 mm (range 6-41 mm); it was 13.4, 14.2, 19.7, 18.4, and 20.2 for groups A, B, C, D, and E, respectively. The lymph node measurements represented similarities in groups A and B (13.4, 14.2), and groups C, D, and E (19.7, 18.4, 20.2). Albeit a few exceptions, an increase in the lymph node size 14.2 to 19.7 (ie, from groups A and B to groups C, D, and E) correlated with SUV and US abnormalities. Abnormal US findings were pronounced (100%) in group E, and ranged between 67% and 73% of the cases in other groups. This study documents the usefulness of SUV range in FDG-PET results and not an absolute "cutoff" number for diagnosing suspicious head and neck lymph nodes due to an overlap in the SUVs between malignant and benign lesions. False positive and negative results may occur in hyperplastic and necrotic lymph nodes. An increase in the lymph node size generally compares well with SUVs and US abnormalities; use of US-guided FNAs in these cases can be helpful to achieve definite diagnosis.

Undifferentiated febrile illness in Kathmandu, Nepal.

Undifferentiated febrile illnesses (UFIs) are common in low- and middle-income countries. We prospectively investigated the causes of UFIs in 627 patients presenting to a tertiary referral hospital in Kathmandu, Nepal. Patients with microbiologically confirmed enteric fever (218 of 627; 34.8%) randomized to gatifloxacin or ofloxacin treatment were previously reported. We randomly selected 125 of 627 (20%) of these UFI patients, consisting of 96 of 409 (23%) cases with sterile blood cultures and 29 of 218 (13%) cases with enteric fever, for additional diagnostic investigations. We found serological evidence of acute murine typhus in 21 of 125 (17%) patients, with 12 of 21 (57%) patients polymerase chain reaction (PCR)-positive for Rickettsia typhi. Three UFI cases were quantitative PCR-positive for Rickettsia spp., two UFI cases were seropositive for Hantavirus, and one UFI case was seropositive for Q fever. Fever clearance time (FCT) for rickettsial infection was 44.5 hours (interquartile range = 26–66 hours), and there was no difference in FCT between ofloxacin or gatifloxacin. Murine typhus represents an important cause of predominantly urban UFIs in Nepal, and fluoroquinolones seem to be an effective empirical treatment.

Decisions to Withhold Diagnostic Investigations in Nursing Home Patients with a Clinical Suspicion of Venous Thromboembolism

BackgroundThis study aimed to gather insights in physicians' considerations for decisions to either refer for- or to withhold additional diagnostic investigations in nursing home patients with a suspicion of venous thromboembolism.MethodsOur study was nested in an observational study on diagnostic strategies for suspected venous thromboembolism in nursing home patients. Patient characteristics, bleeding-complications and mortality were related to the decision to withhold investigations. For a better understanding of the physicians' decisions, 21 individual face-to-face in-depth interviews were performed and analysed using the grounded theory approach.ResultsReferal for additional diagnostic investigations was forgone in 126/322 (39.1%) patients with an indication for diagnostic work-up. ‘Blind’ anticoagulant treatment was initiated in 95 (75.4%) of these patients. The 3month mortality rates were higher for patients in whom investigations were withheld than in the referred patients, irrespective of anticoagulant treatment (odds ratio 2.45; 95% confidence interval 1.40 to 4.29) but when adjusted for the probability of being referred (i.e. the propensity score), there was no relation of non-diagnosis decisions to mortality (odds ratio 1.75; 0.98 to 3.11). In their decisions to forgo diagnostic investigations, physicians incorporated the estimated relative impact of the potential disease; the potential net-benefits of diagnostic investigations and whether performing investigations agreed with established management goals in advance care planning.ConclusionReferral for additional diagnostic investigations is withheld in almost 40% of Dutch nursing home patients with suspected venous thromboembolism and an indication for diagnostic work-up. We propose that, given the complexity of these decisions and the uncertainty regarding their indirect effects on patient outcome, more attention should be focused on the decision to either use or withhold additional diagnostic tests.

Management of penetrating injuries of the upper extremities

Routine surgical exploration after penetrating upper extremity trauma (PUET) to exclude arterial injury leads to a large number of negative explorations and iatrogenic injuries. Selective non-operative management (SNOM) is gaining in favor for patients with PUET. The present study was undertaken to assess the validity of SNOM in PUET and to present a practical management algorithm. All consecutive patients presenting to a tertiary referral center following PUET were included in this prospective observational cohort study. Patients were managed along Advanced Trauma Life Support (ATLS©) guidelines, and based on clinical manifestations, either underwent emergency surgery or were treated conservatively with or without additional diagnostic investigations. Computed tomography angiography (CTA) was indicated by a preset protocol based on the physical examination. During the four-month study period, 161 patients with PUET were admitted. Sixteen (9.9%) patients underwent emergency surgery, revealing 14 vascular injuries. Another 8 (5.0%) patients underwent vascular exploration following CTA. The remaining patients (n=137) were managed non-operatively for vascular matters. Eighteen (11.2%) patients required semi-elective surgical intervention for fractures or nerve injuries. During the follow- up, no missed vascular injuries were detected. Neither routine exploration nor routine CTA is indicated after PUET. Stable patients should undergo additional investigation based on clinical findings only. SNOM is a feasible and safe strategy after PUET.

Computational Algorithm Based On Serum Immunoassays for the Identification of Haematological Disease May Identify Patients with Other Acute Disorders

AbstractAbstract 4001 IntroductionSerum free light chain (FLC) measurements are used routinely to identify monoclonal immunoglobulin (M-Ig) production in patients. In addition, summated kappa + lambda concentrations have recently been shown to have prognostic value in chronic lymphocytic leukaemia (CLL), Hodgkins lymphoma and HIV patients; presumably reflecting immune stimulation. A recently developed companion assay to FLC testing measures intact immunoglobulin heavy chain/light chain (HLC) pairs in serum calculating Ig’κ/Ig’λ ratios as a reflection of clonality. Here we report on a computational approach combining FLC and HLC measurements to identify clonal disease, hyper- and hypo-gammaglobulinemia, and as markers of immune dysfunction. Furthermore, we comment on the potential of such an algorithm to risk stratify haematological and non-haematological malignancies. Patients, Materials and Methods1468 patients referred to the Royal Wolverhampton Hospital for haematological evaluation were enrolled on to the study. Median patient age was 64 years, with a slight female preponderance (60%). Patient sera were analysed at presentation using routine electrophoresis tests (serum protein electrophoresis, SPEP and immunofixation, IFE). FLC and HLC (IgG, IgA and IgM) were measured by nephelometric immunoassay. Each immunoassay result was assessed with respect to individual normal ranges (FLCκ = 3.3–19.4mg/L, FLCλ = 5.71–26.30mg/L, IgGκ = 4.03–9.78g/L, IgGλ = 1.97–5.71g/L, IgAκ = 0.48–2.82g/L, IgAλ = 0.36–1.98, IgMκ = 0.29–1.82g/L, IgMλ = 0.17–0.94g/L) and ratios (FLCκ/FLCλ = 0.26–1.65, Gκ/Gλ = 0.98–2.75, Aκ/Aλ = 0.8–2.04, Mκ/Mλ = 0.96–2.3). The results were used to create an algorithm which assessed the degree of abnormality individually and with respect to the other results generated. Diagnosis was recorded ∼3 months after the analysis and patients were followed for up to 3 years. Results293/1468 (19%) samples had an abnormal SPEP of which 95/293 were confirmed by IFE including: 10 intact immunoglobulin Multiple Myeloma (MM, 6 IgGκ, 1 IgGλ, 2 IgAκ, 1 IgAλ), 6 light chain MM (LCMM, 4 FLCκ, 2 FLCλ), 2 Waldenstrom macroglobulinemia (2 IgMκ), 1 IgMκ cryoglobulinemia, 3 CLL, 1 mantle cell lymphoma, 3 other lymphoma, 1 IgGκ plasmacytoma, and 68 MGUS patients, 26/68 were confirmed MGUS (1 FLCκ, 13 IgGκ, 4 IgGλ, 4 IgAκ, 2 IgMκ, 2 IgMλ), 42 were laboratory findings requiring follow up (1FLCκ, 3 FLCλ, 19 IgGκ, 5 IgGλ, 4 IgAκ, 1 IgAλ, 8 IgMκ, 1 IgMλ).FLC/HLC algorithm identified 85/95 IFE positive patients; of the 10 patients reported not identified by the algorithm, 3 had oligoclonal banding indicative of infection and 7 had monoclonal bands secondary to other diagnoses (including 2 colon cancer patients and 2 rheumatoid arthritis patients). In addition the algorithm identified 15 IFE negative patients with M-Ig production including: 2 AL amyloid patients, 1 asymptomatic LCMM, 1 patient with ∼1g/L FLCκ (lost to follow up), 1 follicular lymphoma patient and 1 CLL; diagnosis was not available for 9/15 patients. Furthermore, the algorithm identified 205/1468 patients as having elevated polyclonal FLC (cFLC) >50mg/L without evidence of clonal production. In a subset analysis comparing matched numbers of patients with elevated or normal cFLC concentrations, cFLC >50mg/L predicted all cause mortality (logistic regression odds ratio 9.96, 95% CI 4.72–21.0, p<0.001), and was associated with poorer overall survival (Kaplan Meier p<0.001, Cox regression hazard ratio 8.73, 95% CI 4.47–17.02). DiscussionMM presents with disparate and vague symptoms pervasive in an elderly population. Current guidelines recommend SPEP and FLC analysis reflexing to IFE for confirmation in the event of abnormality. However, SPEP and IFE require interpretation making the assessment variable. Standardised immunoassays (FLC+HLC) may obviate the need for interpretation and in this study identified additional haematological malignancies. Furthermore, standard assessments can be used to identify M-Ig, but in the absence of this finding may offer little information pertaining to the symptoms that prompted referral. By contrast this algorithm identified patients with elevated cFLC which in agreement with other reports was associated with increased risk of mortality. Further work is required to assess the algorithm, and determine if cFLC measurements should be used as a prompt for additional diagnostic investigations. Disclosures:Faint:The Binding Site Group, Ltd.: Employment. Harding:The Binding Site Group Ltd.: Membership on an entity's Board of Directors or advisory committees. Mirbahai:The Binding Site Group, Ltd: Employment.

Cost Effectiveness Analysis of Clinically Driven versus Routine Laboratory Monitoring of Antiretroviral Therapy in Uganda and Zimbabwe

BackgroundDespite funding constraints for treatment programmes in Africa, the costs and economic consequences of routine laboratory monitoring for efficacy and toxicity of antiretroviral therapy (ART) have rarely been evaluated.MethodsCost-effectiveness analysis was conducted in the DART trial (ISRCTN13968779). Adults in Uganda/Zimbabwe starting ART were randomised to clinically-driven monitoring (CDM) or laboratory and clinical monitoring (LCM); individual patient data on healthcare resource utilisation and outcomes were valued with primary economic costs and utilities. Total costs of first/second-line ART, routine 12-weekly CD4 and biochemistry/haematology tests, additional diagnostic investigations, clinic visits, concomitant medications and hospitalisations were considered from the public healthcare sector perspective. A Markov model was used to extrapolate costs and benefits 20 years beyond the trial.Results3316 (1660LCM;1656CDM) symptomatic, immunosuppressed ART-naive adults (median (IQR) age 37 (32,42); CD4 86 (31,139) cells/mm3) were followed for median 4.9 years. LCM had a mean 0.112 year (41 days) survival benefit at an additional mean cost of $765 [95%CI:685,845], translating into an adjusted incremental cost of $7386 [3277,dominated] per life-year gained and $7793 [4442,39179] per quality-adjusted life year gained. Routine toxicity tests were prominent cost-drivers and had no benefit. With 12-weekly CD4 monitoring from year 2 on ART, low-cost second-line ART, but without toxicity monitoring, CD4 test costs need to fall below $3.78 to become cost-effective (<3xper-capita GDP, following WHO benchmarks). CD4 monitoring at current costs as undertaken in DART was not cost-effective in the long-term.ConclusionsThere is no rationale for routine toxicity monitoring, which did not affect outcomes and was costly. Even though beneficial, there is little justification for routine 12-weekly CD4 monitoring of ART at current test costs in low-income African countries. CD4 monitoring, restricted to the second year on ART onwards, could be cost-effective with lower cost second-line therapy and development of a cheaper, ideally point-of-care, CD4 test.

The potential use of 2-[18F]fluoro-2-deoxy-D-galactose as a PET/CT tracer for detection of hepatocellular carcinoma

The aim of the study was to evaluate the feasibility of using the hepatocyte-specific positron emission tomography (PET) tracer 2-[(18)F]fluoro-2-deoxy-D-galactose (FDGal) as a tracer for hepatocellular carcinoma (HCC). In addition to standard clinical investigations, 39 patients with known HCC or suspected of having HCC underwent a partial-body FDGal PET/CT (from base of skull to mid-thigh). Diagnosis of HCC was based on internationally approved criteria. FDGal PET/CT images were analysed for areas with high (hot spots) or low (cold spots) tracer accumulation when compared to surrounding tissue. Seven patients did not have HCC and FDGal PET/CT was negative in each of them. Twenty-three patients had HCC and were included before treatment. FDGal PET/CT correctly identified 22 of these patients, which was comparable to contrast-enhanced CT. Interestingly, FDGal PET/CT was conclusive in 12 patients in whom conventional imaging techniques were inconclusive and required additional diagnostic investigations or close follow-up. Nine patients were included after treatment of HCC and in these patients FDGal PET/CT was able to distinguish between viable tumour tissue as hot spots and areas with low metabolic activity as cold spots. FDGal PET/CT detected extrahepatic disease in nine patients which was a novel finding in eight patients. FDGal PET/CT has great clinical potential as a PET tracer for detection of extra- but also intrahepatic HCC. In the present study, the specificity of FDGal PET/CT was 100%, which is very promising but needs to be confirmed in a larger, prospective study.

Short report of an unusual ballistic trauma

INTRODUCTIONPortable firearms have a relevant medico-legal interest, being a major cause of injury. Bullet entry wounds generally have a particular appearance, including contusion, skin introflection, and simple or excoriated ecchymosis. The skin wound is typically a hole with frayed margins, whose diameter is smaller than that of the bullet. PRESENTATION OF CASEWe report the case of a 19-year-old man with ballistic trauma. Examination of the patient's lesions indicated that the bullet had entered from the left mandibular parasymphysis, creating a small hole without the typical bullet wipe and blackening. Subsequently, the bullet seemed to have fractured the left chin region immediately below the lower alveolar process, and it finally stopped in the submandibular area in the suprahyoid region of the neck. DISCUSSIONThis case is peculiar because the distinctive features of a firearm injury were absent; the lack of bleeding and edema made the case difficult to interpret without additional diagnostic investigations. CONCLUSIONBallistic trauma can manifest in different ways; therefore, internal trauma should be suspected even in the absence of clear external signs. This case report shows how an unusual bullet entry hole can mask quite serious injuries.

Angiography for Diagnosing Peripheral Arterial Occlusive Disease – A Technical, Clinical and Cost Comparison of Contrast-enhanced Magnetic Resonance Angiography and Unenhanced Magnetic Resonance Imaging Techniques with a Focus on Fresh Blood Imaging

This study compares the clinical and technical utility of non-contrast-enhanced magnetic resonance angiography (nce-MRA) and contrastenhanced MRA (ce-MRA) in a mini-review of patients with suspected peripheral arterial occlusive disease (PAOD) in whom both MRA approaches were indicated. It also looks at the costs of angiography for diagnosing peripheral arterial occlusive disease using either ce-MRA or nce-MRA in comparison with the example of fresh blood imaging (FBI). The costs for MRA were taken from a previous cost study and those for nce-MRA/FBI from published data and appropriate calculations. The average total investigation costs for ce-MRA were found to be €205, including €59 for consumables, mainly originating from the contrast agent costs (according to German list prices for 2009). On the other hand, for nce-MRA, average total costs ranged from €190 to €239, depending on the acquisition time (12–32 minutes), and a larger number of additional diagnostic investigations were found. Irrespective of costs, several clinical and technical benefits such as image quality, higher robustness and the absence of limitations with complex vessel courses favoured ce-MRA. The consequences of using ce-MRA were fewer technical failures and, therefore, a higher throughput of patients indicated for contrast agent use in the radiology department; this led to more procedures per day and, therefore, more efficient use of diagnostic imaging resources.