Complementary Diagnostic Procedures Research Articles

Myasthenia Gravis: A Systematic Review.

Myasthenia gravis (MG), a rare disease, is the most common neuromuscular junction problem. It's the quintessential autoimmune disease with ocular, bulbar, respiratory, axial, and limb muscles exhibiting a typical fatigable weakening due to the development of antibodies against the acetylcholine receptor (AChR). Infections, stress, surgeries, thymus gland anomalies, and pharmaceutical side effects can also cause it. Ocular symptoms are initially experienced by most of the sufferers. The majority of the sufferers will go through at least one episode of symptom exacerbation during their illness. The immune system in MG interferes with nerve-muscle communication, causing muscles to become weak and tired quickly. The actual cause is not yet known, but a problem in the thymus gland may be the cause. In a person suffering from this disease, the size of the thymus becomes larger than normal, which is also called thymic hyperplasia. It is more common for women to have early-onset MG (EOMG) than for males to have late-onset MG (LOMG). Merely clinical evidence, encompassing the patients' medical history and physical indications of fluctuating muscle weakness in a specific region, is utilized to diagnose MG. Complementary diagnostic procedures and lab techniques aid in confirming the synaptic dysfunction and characterizing its kind and degree. Early diagnosis and the availability of effective treatments have reduced the burden of severe impairment and high mortality previously associated with MG. Current immunomodulation-based therapies come with side effects brought on by persistent immune suppression. Improved knowledge of this relatively uncommon but curable condition is required among primary carers. The objective of this review is to provide information about MG and to help people recognize its symptoms and start treatment without panic so that the progression of this disease can be stopped and complications can be avoided.

Dilated Cardiomyopathy: A Comprehensive Approach to Diagnosis and Risk Stratification

Dilated cardiomyopathy (DCM) represents one of the most common causes of non-ischemic heart failure, characterised by ventricular dilation alongside systolic dysfunction. Despite advances in therapy, DCM mortality rates remain high, and it is one of the leading causes of heart transplantation. It was recently recognised that many patients present minor structural cardiac abnormalities and express different arrhythmogenic phenotypes before overt heart-failure symptoms. This has raised several diagnostic and management challenges, including the differential diagnosis with other phenotypically similar conditions, the identification of patients at increased risk of malignant arrhythmias, and of those who will have a worse response to medical therapy. Recent developments in complementary diagnostic procedures, namely cardiac magnetic resonance and genetic testing, have shed new light on DCM understanding and management. The present review proposes a comprehensive and systematic approach to evaluating DCM, focusing on an improved diagnostic pathway and a structured stratification of arrhythmic risk that incorporates novel imaging modalities and genetic test results, which are critical for guiding clinical decision-making and improving outcomes.

Evidence of expert clinical practice among nuclear medicine non-medical staff: a scoping review.

This scoping review concerns expertclinical practice (ECP) by nuclear medicine practitioners (NMP), encompassing radiographers, technologists and nurses. ECP is typically demonstrated by clinical skills with higher levels of autonomy and responsibility traditionally fulfilled by physicians. The Advanced Clinical Practice (ACP) framework by Health Education England (2017) specifies ECP as one aspect of advanced role progression. This scoping review aims to identify and categorise the extent and type of the existing NMP ECP evidence to support the establishment of Nuclear Medicine ACP. PubMed, Cumulative Index to Nursing and Allied Health Literature, and Ovid Medline were searched for peer-reviewed literature published between 2001 and 2021 using extended and advanced practice as key terms alongside nuclear medicine and each NMP profession. Due to the sparsity of results, conference abstracts from prominent international societies were also searched. Studies were independently reviewed and graded for inclusion by four NMP. Of the 36 studies that met the inclusion criteria, 80.6% were conference abstracts and 66.7% were single-centres studies. Commonly reported NM ECP activities included image interpretation, cardiac stressing and therapies. Less reported activities include ordering complementary diagnostic procedures, invasive procedures and physical examinations. The United Kingdom presented itself at the forefront of NMP ECP publications. This study demonstrates evidence of NMP ECP across a variety of clinical roles. The dominance of conference abstracts highlights NMP ECP as an emerging area of role extension and a potential preference for information dissemination by NMP. Greater research into specific NMP ECP activities is required particularly studies of greater sample size and robusticity.

Diagnosis of Schistosomiasis without a Microscope: Evaluating Circulating Antigen (CCA, CAA) and DNA Detection Methods on Banked Samples of a Community-Based Survey from DR Congo.

Detection of Schistosoma eggs in stool or urine is known for its low sensitivity in diagnosing light infections. Alternative diagnostics with better sensitivity while remaining highly specific, such as real-time PCR and circulating antigen detection, are progressively used as complementary diagnostic procedures but have not yet replaced microscopy. This study evaluates these alternative methods for the detection of Schistosoma infections in the absence of microscopy. Schistosomiasis presence was determined retrospectively in 314 banked stool and urine samples, available from a previous survey on the prevalence of taeniasis in a community in the Democratic Republic of the Congo, using real-time PCR, the point-of-care circulating cathodic antigen (POC-CCA) test, as well as the up-converting particle lateral flow circulating anodic antigen (UCP-LF CAA) test. Schistosoma DNA was present in urine (3%) and stool (28%) samples, while CCA (28%) and CAA (69%) were detected in urine. Further analysis of the generated data indicated stool-based PCR and the POC-CCA test to be suitable diagnostics for screening of S. mansoni infections, even in the absence of microscopy. A substantial proportion (60%) of the 215 CAA-positive cases showed low antigen concentrations, suggesting that even PCR and POC-CCA underestimated the “true” number of schistosome positives.

Store-and-forward teleneurology results in a large Brazilian city.

Neurology is a high-demand specialty with long waiting lines. Some pathologies require rapid decision-making. Through technology, telemedicine can allow neurological patients to have faster access to specialized assessment. In store-and-forward telemedicine, the specialist physician evaluates data collected by a general practitioner and optimizes screening. The aim of the present study is to evaluate the effectiveness of asynchronous telemedicine, used to refer patients from primary care to neurology, in the city of Curitiba, in southern Brazil. A retrospective analysis of all patients referred from primary care to neurology between September 2019 and February 2020. After a request is made by a general medical doctor for a specialist's opinion, 5 neurologists with complete access to patients' records are tasked with the decision-making. The main variables analyzed were clinical reasons for telemedicine request, neurologist decision, final diagnosis, indication for diagnostic procedures, and subsequent follow-up. Between September 2019 and February 2020, 1,035 asynchronous telemedicine consultations were performed. Headache (30.43%), epilepsy (19.03%), and dementia (15.85%) accounted for almost two-thirds of the primary care requests; one-third of the cases (33.62%) required a complementary diagnostic procedure. More than 70% of the cases did not require face-to-face assessment by a neurologist. In this study, store-and-forward teleneurology successfully reduced the need for in-visit consultation in 70% of cases. Further studies should identify the best opportunities for teleneurology in the city of Curitiba to facilitate better integrated care between primary care providers and neurologists.

Periorbital emphysema and pneumomediastinum following blunt orbital fracture: A case report and review of the literature

Objective: Orbital emphysema, defined as the presence of air in orbital and periorbital tissues, is a relatively uncommon clinical condition which occurs mostly following facial trauma. It can not only resolve spontaneously without any treatment, but it can also cause life threatening complications such as pneumomediastinum (PM). PM is an uncommon complication of facial fractures and is defined as the presence of air in the mediastinal space. Developing PM following blunt trauma is commonly considered as a red flag for underlying injuries, such as trachea and esophagus rupture. Therefore, other complementary diagnostic procedures, including bronchoscopy and esophagostomy, are often necessary for patients developing this condition. Case Presentation: A 31-year-old man with a history of facial and neck trauma was presented to the emergency room of our tertiary referral hospital with a complaint of right orbital swelling. On physical examination, vital signs were stable. There was a mild swelling of right upper eyelid, but no proptosis. An hour after admission, following sneezing and blowing his nose, the patient had further swelling of his right face with extension of swelling through the right side of his neck to the nipple. He also complained of dyspnea and acute severe progressive epigastric pain. Conclusion: Orbital emphysema following orbital wall fracture is typically benign and selflimited, but physicians should be aware of serious complications such as PM. Therefore, monitoring the patient is crucial and should be considered in such conditions.

Obstruction level associated with outcome in hypoglossal nerve stimulation

PurposeSelective hypoglossal nerve stimulation (sHNS) constitutes an effective surgical alternative for patients with obstructive sleep apnea (OSA). sHNS results in tongue protrusion and consecutive alleviation of obstructions at the tongue base level (lower obstructions). Furthermore, obstructions at the soft palate level (upper obstructions) may be prevented through palatoglossal coupling as seen on sleep endoscopy. However, it has not been studied if the distribution of obstruction level during a whole night measurement is a relevant factor for the treatment outcome.MethodsObstruction levels were measured with a manometry system during a whole night of sleep in 26 patients with OSA (f = 1, m = 25; age 59.4 ± 11.3; BMI = 29.6 ± 3.6) either before (n = 9) or after sHNS implantation (n = 12). Five patients received a measurement before and after implantation. Obstructions were categorized into velar (soft palate and above), infravelar (below soft palate), and multilevel obstructions. An association between obstruction level and treatment outcome was calculated.ResultsThe mean distribution of preoperative obstruction level could be divided into the following: 38% velar, 46% multilevel, and 16% infravelar obstructions. Patients with a good treatment response (defined as AHI < 15/h and AHI reduction of 50%) had fewer preoperative velar obstructions compared to non-responder (17% vs. 54%, p-value = 0.006). In patients measured after sHNS implantation, a significantly higher rate of multilevel obstructions per hour was measured in non-responders (p-value = 0.012).ConclusionsSelective hypoglossal nerve stimulation was more effective in patients with fewer obstructions at the soft palate level. Manometry may be a complementary diagnostic procedure for the selection of patients for HNS.

A CROSS-SECTIONAL STUDY TO EVALUATE THE ETIOLOGICAL PROFILE OF HEMOPTYSIS AND IT’S CORRELATION WITH SEVERITY

Introduction:- Hemoptysis is the spitting of blood that originated in the lungs or bronchial tubes.The patient's history should help determine the amount of blood and a focused physical examination can lead to the diagnosis in most cases. Chest radiographs often aid in diagnosis and assist in using two complementary diagnostic procedures, fiberoptic bronchoscopy and high-resolution computed tomography, which are useful in difficult cases and when malignancy is suspected. Materials and Methods: -We prospectively evaluated 100 patients with hemoptysis,aged ≥18 years,presented in our hospital during 1-year study period. After applying inclusion and exclusion criteria, study population was selected. Patient underwent thorough clinical,general and respiratory examination.Initial routine blood,sputum and radiological evaluation was done in form of chest radiographs. Further chest computed tomography (CT) and bronchoscopic evaluation was done to find the etiology in cases diagnosis was not confirmed in chest radiograph. Final diagnosis was made, and association is seen between various demographic characteristics, comorbidities, severity of hemoptysis, radiological findings and diagnostic yield of different modalities was made. Results:- Tuberculosis was found to be the most common etiology (39%), followed by bronchogenic carcinoma(14%) and bronchiectasis (13%). The majority of the cases had mild (48%) and moderate (39%) hemoptysis with a small proportion of patients (13%) with severe hemoptysis.The diagnostic yield of CT Chest was 73%,that of FOB was 69.5% and the combined yield using both the modalities was calculated to be 82.6%. Conclusion:- Pulmonary tuberculosis remains a leading cause of hemoptysis because of high prevalence but still it is an alarming symptom and require thorough workup to find out the exact etiology.The combined use of bronchoscopy and chest CT probably gives the best diagnostic yield.

Diagnostic Tools for Autism Spectrum Disorders by Gender: Analysis of Current Status and Future Lines.

Studies on the prevalence of autism spectrum disorders have shown gender disproportion. In recent years, there has been an increasing interest in this investigation area. There are two main research lines; the first is focused mostly on gender-related biological reasons that could account for low ASD prevalence in women (i.e., related to some protective factors related to hormones or the immune system, among others), and the second research line studies possible diagnostic biases. In the present study, a review of the latter line of research is made based on two main objectives: (a) analysis of possible biases in diagnostic tools and (b) other nonbiological ASD prevalence explained by gender differences. As a result of our theoretical review, we found that the articles reviewed showed contradictory results and possible diagnostic biases, not only in their design but also in their assessment standards. We concluded that specific or complementary diagnostic tools and procedures differentiated by gender should be developed in order to reduce these biases.

A review of Wagner classification and current concepts in management of diabetic foot

Diabetic foot is a common complication of diabetes mellitus which affects 15% of diabetic patients in their lifetime. Effective management of diabetic foot can reduce severity of complications such as preventable amputations and possible mortality, and can also improve overall quality of life. The Wagner classification is most commonly used for grading diabetic foot ulcers. Wagner developed a classification system and a treatment algorithm for each grade of ulcer. He asserted that ischemic index derived from Doppler flow pressures is an essential baseline test to predict ulcer healing. The aim of this study was to evaluate and manage different lesions of diabetic foot according to Wagner classification. We propose a treatment-oriented assessment of diabetic foot ulcers based on a cross-examination of the medical, foot, and wound history; a systemized and detailed physical examination; and the results of complementary diagnostic procedures. The pathophysiology and treatment of diabetic foot ulcers are reviewed. While these guidelines cannot dictate the care of all affected patients, they provide evidence based guidance for general patters of practice.

Approach to cystic lesions of the pancreas

Cystic lesions of the pancreas are detected more frequently due to the improvement of imaging technologies. Their prevalence increases with age. In 95 % of cases, the spectrum of cystic neoplasia includes intraductal papillary mucinous neoplasia (IPMN), mucinous cystic neoplasia (MCN), serous cystic neoplasia, and solid pseudopapillary neoplasia (SPN). Diagnostic procedures aim to distinguish between neoplastic cystic and non-neoplastic cystic lesions as well as serous and mucinous lesions because of their different malignant potential. In most cases,cystic lesions are detected incidentally by computed tomography and magnetic resonance imaging (MRI) performed for other reasons. In our opinion, MRI/magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) are complementary diagnostic procedures. In doubtful cases, cyst fluid analysis might be performed. The most frequent lesions are IPMNs. MRI/MRCP allows the detection of the number of cystic lesions, the relation to the main pancreatic duct, and the size of the lesion. EUS is superior to evaluate mural nodules. The relation to the main pancreatic duct can more easily appreciated with secretin MRI, MCN, SPN as well as main-duct type IPMN and BD-IPMN with "high-risk stigmata" for malignancy should be resected. Asymptomatic BD-IPMN without mural nodules, no main duct involvement, and a size less than 30mm can be followed with a watchful waiting strategy.

PD-0007 18F-Fdg Positron Emission Tomography (FDG-PET) and Response to Neoadjuvant Chemoradiotherapy in Rectal Cancer

ABSTRACT Introduction Prediction of rectal cancer response to preoperative, neo-adjuvant chemo-radiation therapy (CRT) provides the opportunity to identify patients in whom a major response is expected and who may therefore benefit from alternative surgical approaches. Traditional morphological imaging techniques are effective in defining tumour extension in the initial diagnostic and staging work-up, but perform poorly in distinguishing residual neoplastic tissue from scarring post CRT, when restaging the patient before surgery. Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is a promising tool for monitoring the effect of anti-tumour therapy. The aim of this study was to prospectively assess the value of sequential FDG-PET scans in predicting the response of locally advanced rectal cancer to neo-adjuvant CRT. Methods 42 patients with locally advance rectal cancer who undergo a neo-adjuvant therapy are included in this study. All patients received chemoradiotherapy treatment. PET-TAC was performed before and six weeks after completion of preoperative neo- adjuvant protocol. Surgical resection included of total mesorectal excision. PET- TAC parameters included maximum standard uptake value (SUV max) and the mean percentage decrease in SUV max. Results were correlated with pathological response, assessed both by histopathological staging of the surgical specimens (pTNM). In all patients the primary lesions showed high SUV max (SUV max 13.14 +/-5). Following neo-adjuvant CRT, of the 42 patients submitted to surgery, 37 patients (88.1%)were classified as responders with relevant decreasing in FDG uptake (75% +/- 25%) while the remaining 5 patients (11.9%) were non-responders. After neo-adjuvant therapy 5 patients (11.9%) showed negative PET-TAC, with complete pathological remission and tumor absence in primary local in 3 patients and 2 patients had partial pathological remission. After neo-adjuvant therapy 32 patients (76.1%) showed decrease in Suv max and16 patients presented partial pathological remission, with a correlation of 84.2% between decrease in Suv max and partial pathological remission of total patients. Conclusion The results suggest the potential utility of FDG-PET as a complementary diagnostic and prognostic procedure in the assessment of neo-adjuvant CRT response of locally advanced rectal cancer. SUV(max) seem the best predictor of CRT response.

Isolated leptomeningeal infiltration of a primary CNS B-cell lymphoma diagnosed by flow cytometry and confirmed by necropsy

The diagnosis of the isolated leptomeningeal involvement of a primary central nervous system B-cell lymphoma without parenchyma lesions may be difficult. Patients with leptomeningeal meningeosis lymphomatosa can present with various neurologic deficits. To demonstrate the impact of cerebrospinal fluid (CSF) flow cytometry in the diagnosis of an isolated leptomeningeal manifestation of B-cell lymphoma by presenting an interesting case report. Flow cytometric analysis of B-cell monoclonality of the CSF was performed as complementary diagnostic procedure in addition to CSF cytology. Final diagnosis was confirmed by necropsy. We suspected isolated leptomeningeal manifestation of B-cell lymphoma with palsy of the VI and VII cranial nerves in a 79-year-old male, because of mononuclear pleocytosis in CSF. Interestingly, the decisive diagnostic hint was given by implementation of flow cytometry of the CSF. Diagnosis was confirmed by postmortem autopsy. Our case shows that flow cytometry of the CSF in addition to conventional CSF cytology has the potential to accelerate diagnosis of lymphomeningeal infiltration of B-cell lymphoma.

RELIABILITY AND VALIDITY OF CLINICAL AND ULTRASOUND EXAMINATIONs OF DEVELOPMENTAL DYSPLASIA OF THE HIP

Developmental dysplasia of the hip (DDH) is the most common congenital deformation of the musculoskeletal system and its successful treatment is closely related to early diagnosis. The study is aimed at examining the incidence of developmental dysplasia of the hip (DDH) and at analysing the validity of clinical examination, which is used for the early detection of DDH in the neonatal period, compared to ultrasound examination. The study involved 400 neonates born in the Banja Luka Region. A new questionnaire was open during the first regular ultrasound and clinical examination of the neonates’ hips and anamnestic and clinical data were recorded in it: the asymmetry of the gluteal, inguinal and femoral folds (Bade sign), the result of abduction test separately for each hip, the Ortolani sign of luxation and the Palmen sign of reposition, then hip sonography. A Toshiba ultrasound machine with a 7.5 MHz linear probe was used. The method employed was Professor Reinhard Graf’s. Out of the total number of the children with a positive sonographic finding for DDH, 63.16% of them have one of the clinical signs of DDH. The ability of a clinical finding to identify those patients who do not have DDH and have a negative sonographic finding is 79.8%. Out of the total number of the examined children with a positive clinical finding, only 15.58% of them also have a positive sonographic finding for DDH. This research has showed that clinical examination of the hips is of low sensitivity, specificity and reliability, and that not all types of DDH can be detected. Clinical examination must remain an integral part of every infant’s examination, but it constitutes a complementary diagnostic procedure to ultrasound examination. The ultrasound examination of DDH has created new possibilities and has filled the void that existed due to the deficiency of clinical tests, and at the same time it has reduced the number of X-ray examinations of the hips. This research has confirmed that clinical examination of the hips does not meet the screening criteria. It must remain an integral part of an infant’s examination because it, among other things, provides the information which enables the orthopaedic surgeon to choose the most beneficial therapeutic procedures in DDH treatment. Acta Medica Medianae 2011;50(1):26-31.

Is Nail Fold Capillaroscopy Useful in Normotensive and Primary Open Angle Glaucoma? A Pilot Study

Purpose: Vascular dysregulation is deemed a significant risk factor in glaucoma occurrence and progression. Capillaroscopy of the blood vessels on the finger nail-fold is a method that can provide information regarding the state of the vascular system at the capillary level. The aim of this pilot study was to determine whether there are significant differences in the morphological characteristics of the peripheral blood vessels in normotensive glaucoma and primary open angle glaucoma.Matherials and Methods: An ophthalmological and capillaroscopic examination was conducted on 30 normotensive glaucoma patients and 30 primary open angle glaucoma patients. The capillaroscopic characteristics described were as follows: capillary row density, capillary diameter, number of spirally formed capillaries, permeability of the loop, and loop resistance.Results: Statistically, significantly more intensively spiraled capillaries were found in normotensive glaucoma patients (χ2 test, p < 0.05).Conclusions: Results confirm the thesis that vascular factors play a significant role in the pathogenesis of the glaucoma, especially in cases where the level of intraocular pressure cannot be deemed responsible for the present damage of the optical nerve. Despite the newer, technologically more developed methods for diagnostics and monitoring glaucoma, it is often not easy to establish the right diagnosis and determine further the course of the illness, since the role the intraocular pressure (IOP) plays compared to the role of vascular factors is unknown; hence, capillaroscopy as a complementary diagnostic procedure can be of help.

Hemoptysis in children

Pulmonary hemorrhage and hemoptysis are uncommon in childhood, and the frequency with which they are encountered by the pediatrician depends largely on the special interests of the center to which the child is referred. Diagnosis and management of hemoptysis in this age group requires knowledge and skill in the causes and management of this infrequently occurring potentially life-threatening condition. We reviewed the causes and treatment options for hemoptysis in the pediatric patient using Medline and Pubmed. A focused physical examination can lead to the diagnosis of hemoptysis in most of the cases. In children, lower respiratory tract infection and foreign body aspiration are common causes. Chest radiographs often aid in diagnosis and assist in using two complementary diagnostic procedures, fiberoptic bronchoscopy and high-resolution computed tomography. The goals of management are threefold: bleeding cessation, aspiration prevention, and treatment of the underlying cause. Mild hemoptysis often is caused by an infection that can be managed on an outpatient basis with close monitoring. Massive hemoptysis may require additional therapeutic options such as therapeutic bronchoscopy, angiography with embolization, and surgical intervention such as resection or revascularization. Hemoptysis in the pediatric patient requires prompt and thorough evaluation and treatment. An efficient systematic evaluation is imperative in identifying the underlying etiology and aggressive management is important because of the potential severity of the problem. This clinical review highlights the various etiological factors, the diagnostic and treatment strategies of hemoptysis in children.

Endometriose de cicatriz cirúrgica: estudo retrospectivo de 72 casos

PURPOSE: to identify the incidence and associated factors of surgical scar endometriosis. METHODS: a retrospective cohort observational study performed from the medical records of female patients attended at the Clinical Hospital of Univesidade Federal de Minas Gerais (UFMG) with histopathological diagnosis of scar endometriosis from May 1978 to December 2003. RESULTS: a total of 72 patients were included in the study. The incidence of scar endometriosis after cesarean section was significantly higher than after episiotomy (0.2% and 0.06%, respectively; p<0.00001) with relative risk of 3.3. The women’s age, when diagnosed, ranged from 16 to 48 years old, (mean=30.8 years old). The scar location varied according to the previous surgery: 46 scars after cesarean sections, one after hysterectomy and one after abdominal surgery (48 lesions in the abdominal wall); 19 scars after episiotomy, one because of relapse and two after pelvic floor surgeries (22 pelvic wounds); two women had not been submitted to previous gynecological surgery (one umbilical endometrioma and one lesion in the posterior vaginal wall). Pain was the most frequent symptom (80%), followed by a node (79%) and, in more than 40%, the pain and the node suffered modification with menstruation. Other less frequent complaints were: dyspareunia, secondary infertility, pelvic pain, dysmenorrhoea, scar secretion, menorrhagia pain when evacuating. The mean time observed between the surgery and the beginning of the symptoms was of 3.7 years. The average size of the endometriomas was 3.07 cm. The diagnosis based on clinic evaluation was correct in 71% of the cases. The choice of treatment in all the cases was the surgical excision. In only one incident there was relapse and new intervention. CONCLUSIONS: scar endometriosis is a rare situation originated, in most cases, after obstetrical surgical procedure, with higher risk after cesarean section. It is a highly suggestive clinical condition, with a rare necessity of complementary diagnostic procedures, and the best treatment choice is the surgical excision.

Sequential FDG-PET/CT reliably predicts response of locally advanced rectal cancer to neo-adjuvant chemo-radiation therapy

Prediction of rectal cancer response to preoperative, neo-adjuvant chemo-radiation therapy (CRT) provides the opportunity to identify patients in whom a major response is expected and who may therefore benefit from alternative surgical approaches. Traditional morphological imaging techniques are effective in defining tumour extension in the initial diagnostic and staging work-up, but perform poorly in distinguishing residual neoplastic tissue from scarring post CRT, when restaging the patient before surgery. Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is a promising tool for monitoring the effect of anti-tumour therapy. The aim of this study was to prospectively assess the value of sequential FDG-PET scans in predicting the response of locally advanced rectal cancer to neo-adjuvant CRT. Forty-four consecutive patients with locally advanced (cT3-4) primary rectal cancer and four patients with pelvic recurrence of rectal cancer were enrolled in this prospective study. Treatment consisted of external beam intensified radiotherapy (50 Gy to the posterior pelvis, 56 Gy to the tumour), chemotherapy (in most cases PVI 5-FU at 300 mg/m(2) per day) and, 8-10 weeks later, surgery with curative intent. All patients underwent FDG-PET/CT both before CRT and 5-6 weeks after completing CRT. One patient died before surgery because of acute myocardial infarction, and was therefore excluded from further analysis. Semi-quantitative measurements of FDG uptake (SUV(max)), absolute difference (DeltaSUV(max)) and percent SUV(max) difference (Response Index, RI) between pre- and post-CRT PET scans were considered. Results were correlated with pathological response, assessed both by histopathological staging of the surgical specimens (pTNM) and by the tumour regression grade (TRG) according to Mandard's criteria (patients with TRG1-2 being defined as responders and patients with TRG3-5 as non-responders). Following neo-adjuvant CRT, of the 45 patients submitted to surgery, 23 (51.1%) were classified as responders according to Mandard's criteria (8 TRG1 and 15 TRG2), while the remaining 22 (48.9%) were non-responders (9 TRG3 and 13 TRG4-5). Considering all patients, the mean pre-CRT SUV(max) was 15.6, significantly higher than the mean value of 5.4 post CRT (p < 0.001). Nevertheless, when stratifying patients according to response to CRT (using Mandard's criteria), the mean RI was significantly higher in responders than in non-responders (75.9% versus 46.9%,p = 0.0015). Using a 66.2% SUV(max) decrease as the cut-off value (identified by ROC analysis) for defining response to therapy, the following parameters were obtained: 79.2% specificity, 81.2% sensitivity, 77% positive predictive value, 89% negative predictive value and 80% overall accuracy. The results suggest the potential utility of FDG-PET as a complementary diagnostic and prognostic procedure in the assessment of neo-adjuvant CRT response of locally advanced rectal cancer. DeltaSUV(max) and RI seem the best predictors of CRT response.

Rhodococcus spp. as ubiquitous contaminants of paraffin‐embedded tissues in PCR analysis for Mycobacterium spp. skin infections

Molecular techniques have greatly enhanced the sensitivity of the laboratory diagnosis of infectious diseases. Highly sensitive polymerase chain reaction (PCR) analysis of tissue DNA is being used to characterize and speciate infectious agents. The use of PCR is increasing in the diagnosis of Mycobacterium spp. infections. Frequently, the primers used are not specific for the genus and they may amplify other closely related organisms such as Rhodococcus spp. Some of these organisms are ubiquitous and, as for organisms of the genus Mycobacterium, they are usually isolated from soil. For this reason, they may be potential contaminants of instruments, reagents or even skin. As part of a study to characterize the causative organisms of feline leprosy, nodular pyogranulomatous lesions from cats with no recognizable organisms in tissue sections, using acid‐fast stains or the BCG technique, were analysed by nested‐PCR. Briefly, samples from 12 cats were obtained retrospectively from paraffin‐embedded tissues, deparaffinized and DNA extracted by standard techniques. Extracted DNA was amplified with previously characterized sets of primers for a fragment of the 16S rRNA gene. Amplified fragments were sequenced in an automated sequencer, analysed and compared by computer analysis with known sequences of related organisms. In addition, 14 feline and canine control tissue samples were analysed. These included mildly inflamed (psychogenic alopecia and allergic skin disease, n = 5) and noninflammatory (neoplastic skin masses, n = 3) skin lesions, and internal organs (liver, spleen and lung, n = 6). The results revealed DNA sequences consistent with Rhodococcus spp. (99–100% homology) in nine of 12 (75%) of the acid‐fast bacteria‐negative nodules. The remaining two samples were negative. None of the samples yielded amplicons with homology to Mycobacterium spp. Additionally, nine of 14 (64%) unrelated control tissues showed similar amplification of a bacterium with high homology (98–99%) to Rhodococcus erythropolis and other Rhodococci; two of 14 amplified a fragment of DNA with homology to Gordonia spp. (soil organism), and one sample amplified a fragment of DNA with homology to Mycobacterium sphagni (soil organism). The remaining two samples were negative. Parallel controls (PCR master mix inoculated with sterile water and PCR master mix alone) were consistently negative. Based on these results, two main scenarios may be in play: (1) in lesions with histologically undetectable acid‐fast organisms, the amount of mycobacterial DNA may be very low, and other dominant contaminant organisms such as Rhodococcus spp. may be amplified preferentially; (2) a negative acid‐fast result obtained histologically may be accurately predictive for an absence of infection with Mycobacterium spp., and only contaminants are amplified. In summary, the significance of Rhodococcus spp. as a causative agent of nodular dermal lesions with no recognizable acid‐fast organisms, when results are obtained exclusively by PCR analysis, should be questioned. In this event, the aetiology of the lesions should be further investigated using other complementary diagnostic procedures (e.g. DNA capture, in situ hybridization, in situ PCR). Funding: Self‐funded.

Unproven diagnostic procedures in IgE-mediated allergic diseases.

A considerable body of literature on therapeutic aspects of complementary and alternative medicine has been published in recent years, but little is known on diagnostic procedures. This short review lists complementary and alternative diagnostic procedures for the diagnosis of allergic diseases and presents an assessment of their usefulness for the daily practice. The review of the literature revealed that neither the determination of specific immunoglobulin G-antibodies in serum, the hair-analysis, the cytotoxic test, kinesiology, iridology, or electrodermal testing represent useful tests for the daily practice. To date, no complementary or alternative diagnostic procedure can be recommended as a meaningful element in the diagnostic work-up of allergic diseases. This is especially true for food allergy: properly performed oral food challenges still represent the gold standard for implementing specific diets in food allergic individuals. Ineffective diagnostic approaches may be costly for the consumer and delay appropriate therapy.