Routine Radiological Imaging Research Articles

Opportunistically identifiable vertebral fractures on routine radiological imaging predict mortality: observational cohort study

SummaryIn men and women with opportunistically identifiable vertebral fractures (VFs) on routine CT scans including the chest and/or abdomen, the risk of death is 51% higher than in those with no VF on the CT scan, and 325% higher than an age- and sex-matched general population cohort.PurposeThere is little knowledge about the risk of death in patients with VFs present on routine radiological imaging. We evaluated the risk of death in men and women aged 50 years or older with opportunistically identifiable VFs on routine CT scans and not treated with osteoporosis medications.MethodsThoracic and lumbar VFs were identified through a blinded, two-step approach on CT scans performed as part of normal clinical care in a Danish hospital in 2010 or later. Subjects with VF were matched on age and sex against those with no VF (1:2-ratio) and a general population cohort (1:3-ratio), respectively, and followed for up to 7 years through the national Danish registers. Subjects treated with an osteoporosis medication in the year prior to baseline were excluded.ResultsSubjects with VF had a significantly higher risk of death during follow-up as compared to subjects with no VF on the CT scan (adjusted hazard ratio [HR] 1.51 [95% confidence interval 1.27–1.79; p < 0.001]) and even more so when compared to the general population cohort (HR 4.25 [3.53–5.12; p < 0.001]). In subjects with versus without VF on the CT scan, the risk was higher in those with moderate or severe VF, in those with no malignancy prior to baseline, and in those with a lower Charlson comorbidity index score.ConclusionSubjects with VF available for identification on routine CT scans face a substantially increased risk of death. Opportunistic identification and reporting of VF is important to identify these patients to allow intervention if indicated.

Fracture Risk in Men and Women With Vertebral Fractures Identified Opportunistically on Routine Computed Tomography Scans and Not Treated for Osteoporosis: An Observational Cohort Study.

Vertebral fractures (VFs) have been associated with future fractures, yet few studies have evaluated whether this pertains to VFs available for identification on routine radiological imaging. We sought to evaluate the risk of subsequent fractures in subjects with VF identified opportunistically on computed tomography (CT) scans performed as part of routine clinical practice. From the radiology database of Holbæk Hospital we identified the first CT scan including the thorax and/or abdomen of 2000 consecutive men and women aged 50 years or older, performed from January 1, 2010 onward. The scans were assessed in a blinded approach to identify chest and lumbar VF, and these data linked to national Danish registers. Subjects were excluded if treated with an osteoporosis medication (OM) in the year prior to baseline (date of CT), and the remaining subjects with VF matched on age and sex in 1:2 ratio against subjects with no VF. We found that the risk of major osteoporotic fractures (hip, non-cervical vertebral, humerus, and distal forearm fractures) was higher for subjects with VF than without VF: incidence rates (IRs) were 32.88 and 19.59 fractures per 1000 subject-years, respectively, and the adjusted hazard ratio (HRadj) was 1.72 (95% confidence interval [CI], 1.03-2.86). Subsequent hip fracture IRs were 16.75 and 6.60; HRadj 3.02 (95% CI, 1.39-6.55). There were no significant differences in other fracture outcomes (including a pooled estimate of any subsequent fracture, except face, skull, and fingers: IRs 41.52 and 31.38; HRadj 1.31 [95% CI, 0.85-2.03]). Our findings suggest that subjects undergoing routine CT scans including the chest and/or abdomen are a high risk population in terms of fracture risk. Even within this group, subjects with VF are at higher risk of future major osteoporotic fracture (MOF), in particular hip fracture. Hence, systematic opportunistic screening for VF and subsequent fracture risk management is important to reduce the risk of new fractures. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

PREVALANCE OF RADIOLOGICAL INVESTIGATION IN LOW BACK PAIN – AN OBSERVATIONAL STUDY

Introduction: Lumbar spine pathology is major healthcare burden encountered in district and urban hospitals. Diagnostic imaging in these patients is not always indicated.Imaging is considered in those patients who show little or no improvement in their LBP after approximately six weeks of medical management with or without physical therapy,the current study was undertaken to assess the appropriateness of LBP imaging in primary care following the ACP guidelines. Method: The inclusion criteria for the study were adult patients with persistent low back pain with or without radiculopathy post six weeks of medical management affecting their activity of daily living. And the exclusion criteria were spinal trauma ,neurological impairment,bladder and bowel involvement, spinal malformations,history of malignancy presenting at the time of index visit. Result: The study included total 115 patients. Out of 115 patients 87 [70%] patients showed abnormal finding on the radiographs.The most common abnormal finding was disco vertebral degeneration such as spondylosis (osteophyte formation) in 49.6%. Conclusion: Routine x-ray imaging in low back pain patients is not always warranted. Moreover routine radiological imaging methods are not associated with meaningful clinical outcomes for the patients. Unnecessary imaging can lead to harmful radiation exposure of the patients and can further lead to additional medical expenditure and needless surgical intervention. Diagnostic radiological imaging should be used judicially.

Outcomes of Port A Catheter Implantations in Cancer Patients: Experience in 102 Cases

Abstract Aim This study evaluates cancer patients undergoing port catheter implantation. Patients and methods The study was conducted among patients admitted to the cardiovascular department of Düzce State Hospital from June 2018 to July 2020. The inclusion criterion was the implantation of a vascular port for at during 2 years. One hundred and two patients were enrolled in the study. The most common acute outcomes such as pneumothorax, haemothorax, thoracic duct damage and cardiac tamponade and the demographic characteristics of all patients were recorded. Patients were evaluated for the late complications of port catheter, such as thrombosis, infection and kinking, catheter fracture and occlusion. Results Complications of port catheter occurred early (≤30 days) and delayed (&gt;30 days) at rates of up to 8% and 15%, respectively. The most common early and late complications were pneumothorax and non-functional port (occlusion, thrombosis, kinking), respectively. Conclusions Thrombosis is the most common cause of dysfunction in central port catheters used in the treatment of cancer patients. Routine radiological imaging can help in early detection of catheter-related complications.

Perioperative circulating tumor DNA as a potential prognostic marker for operable stage I to IIIA non-small cell lung cancer.

Circulating tumor DNA (ctDNA) has emerged as a noninvasive biomarker for dynamically monitoring tumors. However, published data on perioperative ctDNA in patients with operable non-small cell lung cancer (NSCLC) are currently limited. This prospective study recruited 123 patients with resectable stage I to IIIA NSCLC. Preoperative and postoperative plasma samples and tumor tissue samples were subjected to next-generation sequencing with a panel of 425 cancer-related genes. Peripheral blood samples were collected before surgery, postoperatively within 1 month, and every 3 to 6 months for up to 3 years. After 4 exclusions, 119 eligible patients were enrolled from June 2016 to February 2019. Presurgical ctDNA was detectable in 29 of 117 patients (24.8%) and was associated with inferior recurrence-free survival (RFS; hazard ratio [HR], 2.42; 95% CI, 1.11-5.27; P = .022) and inferior overall survival (OS; HR, 5.54; 95% CI, 1.01-30.35; P = .026). Similarly, ctDNA was detected in 12 of 116 first postsurgical samples (10.3%) and was associated with shorter RFS (HR, 3.04; 95% CI, 1.22-7.58; P = .012). During surveillance after surgery, longitudinal ctDNA-positive patients (37 of 119; 31.1%) had significantly shorter RFS (HR, 3.46; 95% CI, 1.59-7.55; P < .001) and significantly shorter OS (HR, 9.99; 95% CI, 1.17-85.78; P = .010) in comparison with longitudinal ctDNA-negative patients. Serial ctDNA detection preceded radiologic disease recurrence by a median lead time of 8.71 months. These results suggest that perioperative ctDNA analyses can predict recurrence and survival, and serial ctDNA analyses can identify disease recurrence/metastasis earlier than routine radiologic imaging in patients with resectable NSCLC. The utility of serial circulating tumor DNA (ctDNA) monitoring for predicting disease recurrence and survival for early-stage non-small cell lung cancer (NSCLC) has not been well characterized. The detection of ctDNA before and after surgery is associated with the identification of a high risk of disease recurrence and long-term patient outcomes for resectable NSCLC. Perioperative ctDNA analyses identify disease recurrence earlier than routine radiologic imaging. ctDNA analyses can detect minimal residual disease for resectable NSCLC and thus can facilitate early intervention.

Giant renal oncocytoma presenting with right flank pain and hematoma

Renal oncocytomas are benign tumors representing 3% to 7% of primary renal neoplasms. Oncocytomas are often asymptomatic, discovered incidentally on routine radiological imaging. We report a giant renal oncocytoma in a 68-year-old male with chronic kidney disease. Patient had right upper quadrant pain and hematoma. The mass was palpable on physical exam. CT scan showed a 16 cm × 14 cm right renal mass, consistent with renal cell carcinoma, no major adenopathy, no renal vein invasion. Right radical nephrectomy was performed and histological examination was consisted with oncocytoma.

Urolithiasis secondary to primary obstructive megaureter in an adult: a case report

BackgroundPrimary obstructive megaureter is relatively uncommon in adults. This condition usually regresses spontaneously or is treated during infancy. It can remain asymptomatic for decades until adulthood when symptoms may manifest in the event of complications or during a routine radiologic imaging. Primary obstructive megaureter has been reported to favor stone formation in the upper urinary tract.Case presentationWe present the case of a 35-year-old Moroccan man who had a 10-year history of intermittent left flank pain and hematuria. A computed tomography urogram revealed a left megaureter with giant ureteral and renal calculi.ConclusionsPrimary obstructive megaureter should be a differential diagnosis in an adult with hydroureteronephrosis associated with urolithiasis especially when there is kidney impairment. Through this case report we will discuss the diagnosis and management of primary obstructive megaureter associated with urolithiasis in adults.

Routine Imaging for Surveillance in Patients with Aggressive Non-Hodgkin Lymphoma in Complete Remission after Frontline Chemotherapy

PurposeRoutine imaging is commonly performed as a surveillance practice to detect the relapse of aggressive non-Hodgkin's lymphoma (aNHL) after achieving complete remission (CR), based on the expectation to discover progression before the appearance of symptoms associated with disease. However, there are limited data on the benefits for routine imaging for surveillance. In addition, there are concerns about the radiation hazards such as secondary malignancies. The purpose of this study is to determine whether routine radiologic imaging is beneficial to detect the asymptomatic relapse of aNHL and to improve the post-relapse survival by salvage chemotherapy. For this purpose, we retrospectively analyzed patients with aNHL who achieved CR after frontline chemotherapy.MethodsWe conducted a retrospective chart review of patients with aNHL (diffuse large B-cell lymphoma, peripheral T-cell lymphoma, Burkitt's lymphoma, and lymphoblastic lymphoma) who achieved CR after frontline chemotherapy between June 1995 and March 2016. All patients were followed with clinical visits (history taking, physical examination, and laboratory tests) every 1 to 6 months, and routine imaging (CT: involved fields or whole body) was performed every 3 or 6 months, according to the physician's preference. Cases with identified relapse were categorized into a clinical symptom-based group or routine imaging-based group. The primary endpoint was post-relapse survival (PRS) in each group. In addition, PRS according to surveillance interval was evaluated in each group, and subgroup analysis to determine the benefit of routine imaging was performed. PRS was defined as the time interval from the date of identified relapse to the date of death. PRS was evaluated using the Kaplan-Meier method and compared using the log-rank test. Subgroup analysis was performed using the Cox proportional hazard method.ResultsOf 1,349 patients diagnosed with aNHL, 629 achieved CR after frontline chemotherapy, and 170 relapsed. Median follow-up duration was 51.6 months. Relapse was detected by clinical symptoms in 103 patients (60.6%) and by routine imaging in 67 (39.4%). Median time to relapse was similar between the 2 groups (10.0 months vs. 9.9 months, p= 0.412). The routine imaging-based group had less extranodal involvement at relapse, but other characteristics including stage were similar (Table 1). PRS did not differ whether relapse was detected by clinical symptoms or by routine imaging (36.8 months, range: 7.2-66.4, vs. 36.0 months, range: 11.1-60.8; p = 0.754). Among patients with relapse detected by routine imaging, there was no statistical difference in PRS between 3- and 6-month intervals (p = 0.705). Routine imaging showed marginal significance in the subgroup of patients lesser than 60 (Table 2).ConclusionThese results might suggest that thorough history and physical examination is the more important surveillance tool than routine imaging to detect the relapse of treated aNHL. However, the usefulness of routine imaging for the detection of asymptomatic aNHL relapse was also observed in patients lesser than 60. So, further studies will be warranted to establish the guideline for surveillance of treated aNHL patients to detect disease relapse early and efficiently. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Endovascular Treatment for Near Occlusion of the Internal Carotid Artery : 30-Day Outcome and Long-Term Follow-Up.

The treatment strategy and the correct incidence of near occlusion (NO) of the internal carotid artery (ICA) is still controversial. In routine radiological imaging NO can easily be misdiagnosed as complete occlusion and there is no consensus on the standard treatment strategy. To present our perioperative and long-term follow-up results of ICA NO patients treated with carotid artery stenting (CAS). Between 2004-2014 a total of 182patients with ICA NO were evaluated for CAS. The study included 132male (72.5 %) and 50female (27.5 %) patients with amean age of 70.2years. Patients underwent a clinical neurological evaluation and radiological imaging of the carotid arteries before the CAS procedure. Of the patients 80 (44 %) were asymptomatic. The median clinical and carotid Doppler ultrasound (DUS) follow-up period was 64months (range 18-124months). In 182patients CAS were performed, 4 patients (2.2 %) developed minor stroke, 2 patients (1.1 %) developed myocardial infarction but no major stroke or death occurred in the following 30-day period. Asymptomatic restenosis was detected in seven patients (3.8 %) in the follow-up period. With sufficient neurological evaluation during pretreatment and posttreatment periods and when the procedure is performed with technologically developed products by an experienced interventional team, CAS is beneficial in patients with ICA NO.

Reproducibility of radiomics for deciphering tumor phenotype with imaging.

Radiomics (radiogenomics) characterizes tumor phenotypes based on quantitative image features derived from routine radiologic imaging to improve cancer diagnosis, prognosis, prediction and response to therapy. Although radiomic features must be reproducible to qualify as biomarkers for clinical care, little is known about how routine imaging acquisition techniques/parameters affect reproducibility. To begin to fill this knowledge gap, we assessed the reproducibility of a comprehensive, commonly-used set of radiomic features using a unique, same-day repeat computed tomography data set from lung cancer patients. Each scan was reconstructed at 6 imaging settings, varying slice thicknesses (1.25 mm, 2.5 mm and 5 mm) and reconstruction algorithms (sharp, smooth). Reproducibility was assessed using the repeat scans reconstructed at identical imaging setting (6 settings in total). In separate analyses, we explored differences in radiomic features due to different imaging parameters by assessing the agreement of these radiomic features extracted from the repeat scans reconstructed at the same slice thickness but different algorithms (3 settings in total). Our data suggest that radiomic features are reproducible over a wide range of imaging settings. However, smooth and sharp reconstruction algorithms should not be used interchangeably. These findings will raise awareness of the importance of properly setting imaging acquisition parameters in radiomics/radiogenomics research.

Clinic research on the treatment for humeral shaft fracture with minimal invasive plate osteosynthesis: a retrospective study of 128 cases.

Minimal invasive plate osteosynthesis (MIPO) is one of the most important techniques in the treatment for humeral shaft fractures. This study was performed to evaluate the efficacy of MIPO technique for the treatment for humeral shaft fractures. We retrospectively evaluated 128 cases with humeral shaft fractures that were treated with MIPO technique from March 2005 to August 2008. All the patients were followed up by routine radiological imaging and clinical examinations. Constant-Murley score and HSS elbow joint score were used to evaluate the treatment outcome. The average duration of the surgery was 60min (range 40-95min) without blood transfusion. All fractures healed without infection. All cases recovered carrying angle except four cases with 10°-15° cubitus varus. After the average follow-up of 23 (13-38) months, satisfactory function was achieved according to Constant-Murley score and HSS elbow joint score. Constant-Murley score was 80 on average (range 68-91). According to HSS elbow joint score, there were 123 cases of excellent clinical outcome and five cases of effective outcome. It seems to be a safe and effective method for managing humeral shaft fractures with MIPO technique.

How well surgeons are aware of risks associated with routine diagnostic imaging?

s / International Journal of Surgery 23 (2015) S15eS134 S104 concise review of current assessment, diagnosis and management of each disease. Conclusion: The Gordon Museum and similar collections present unique opportunities to learn about fundamental surgical disease. We hope that the study presented here offers a novel insight into the wealth of educational material available. 0747: HOW WELL SURGEONS ARE AWARE OF RISKS ASSOCIATED WITH ROUTINE DIAGNOSTIC IMAGING? R. Hafeez , A. Ahad , N. Obeid , F. Smedley . King’s college Hospital, UK; Darent valley Hospital, UK; 3 Lewisham and Greenwich NHS Trust, UK Aim: To assess the level of awareness among surgeons of the nature and risks associated with routine diagnostic imaging. Methods: 114 clinicians from different surgical specialties were asked to fill a questionnaire which include total 32 questions about nature of radiations used in routine imaging, effective radiation dose, natural background radiation exposure, dose of single chest X-ray, estimated dose of other radiological investigation in comparisons to CXR, common side effects and organs aff5cted by the exposure. Participants were also asked to select the level of cancer risk association among different age groups and whether they consider alternative investigations. Results: 54(47.37%) participants have misunderstanding that routine radiological imaging involve non ionizing radiations. 47 (41.2%) knew correct effective radiation dose unit (mSv) while just 30% were aware of natural background radiation exposure. 73% overestimated the dose of CXR but 42% underestimated the cancer risk associated with CT abdomen. Although only 27% identified common side effects and organs aff5cted by exposure however majority (80%) do consider patient’s age and alternative investigations before requesting one. Conclusion: Surgeons need to be educated about the linear relation between radiation exposure and cancer development in order to minimize unnecessary exposure of patients. 0752: DEVELOPING THE LEADERSHIP SKILLS OF JUNIOR SURGICAL TRAINEES THROUGH A HANDS ON APPROACH A.A. Abdullah, J.M. Norris, N. Noor, L. Thorley. Bedford Hospital, UK Aim: The expanding role of doctors continues to evolve within the healthcare setting, in particular the need for leadership and managerial (L&M) skills. This case series provides a platform for junior doctors to develop their L&M skills through running structured courses Methods: A surgical course is designed based on a tested infrastructure to meet the needs of junior doctors, following an audit. The course is carried out with the support of previous course directors (CD). Effectiveness of the course and it's delivery are ascertained through a reaudit process. Participants are then encouraged to repeat the course using the same infrastructure with the help of their CD, ensuring the cycle continues. The CD are evaluated using a questionnaire and subsequent projects they run. Results: 3 CD in 3 different trusts ran 3 courses with 50 participants. A reaudit showed 100% of participants had benefitted from the course with 60% implementing their new skills in a clinical context. 67% of the CD have since lead other projects. 100% of the CD had learnt new skills, gained confidence from the process and would recommend it to others. Conclusion: This process offers junior doctors hands-on experience in developing L&M skills under supervision and support 0754: SIMULATION OF TENDON REPAIR USING MICROFOAM TAPE A. Elfaki, N. Abreo, M. Wilmot, S. Murphy, P. Gillespie. Addenbrookes

Preoperative vascular access evaluation for haemodialysis patients.

Haemodialysis treatment requires reliable vascular access. Optimal access is provided via functional arteriovenous fistula (fistula), which compared with other forms of vascular access, provides superior long-term patency, requires few interventions, has low thrombosis and infection rates and cost. However, it has been estimated that between 20% and 60% of fistulas never mature sufficiently to enable haemodialysis treatment. Mapping blood vessels using imaging technologies before surgery may identify vessels that are most suitable for fistula creation. We compared the effect of conducting routine radiological imaging evaluation for vascular access creation preoperatively with standard care without routine preoperative vessel imaging on fistula creation and use. We searched Cochrane Kidney and Transplant's Specialised Register to 14 April 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. We included randomised controlled trials (RCTs) that enrolled adult participants (aged ≥ 18 years) with chronic or end-stage kidney disease (ESKD) who needed fistulas (both before dialysis and after dialysis initiation) that compared fistula maturation rates relating to use of imaging technologies to map blood vessels before fistula surgery with standard care (no imaging). Two authors assessed study quality and extracted data. Dichotomous outcomes, including fistula creation, maturation and need for catheters at dialysis initiation, were expressed as risk ratios (RR) with 95% confidence intervals (CI). Continuous outcomes, such as numbers of interventions required to maintain patency, were expressed as mean differences (MD). We used the random-effects model to measure mean effects. Four studies enrolling 450 participants met our inclusion criteria. Overall risk of bias was judged to be low in one study, unclear in two, and high in one.There was no significant differences in the number of fistulas that were successfully created (4 studies, 433 patients: RR 1.06, 95% CI 0.95 to 1.28; I² = 76%); the number of fistulas that matured at six months (3 studies, 356 participants: RR 1.11, 95% CI 0.98 to 1.25; I² = 0%); number of fistulas that were used successfully for dialysis (2 studies, 286 participants: RR 1.12, 95% CI 0.99 to 1.28; I² = 0%); the number of patients initiating dialysis with a catheter (1 study, 214 patients: RR 0.66, 95% CI 0.42 to 1.04); and in the rate of interventions required to maintain patency (1 study, 70 patients: MD 14.70 interventions/1000 patient-days, 95% CI -7.51 to 36.91) between the use of preoperative imaging technologies compared with standard care (no imaging). Based on four small studies, preoperative vessel imaging did not improve fistula outcomes compared with standard care. Adequately powered prospective studies are required to fully answer this question.

Minimal Invasive Percutaneous Osteosynthesis for Elderly Valgus Impacted Proximal Humeral Fractures with the PHILOS.

There is a growing concern about elderly valgus impacted proximal humeral fractures. The aim of this study was to evaluate the treatment and clinical outcomes following minimal invasive percutaneous plate osteosynthesis (MIPPO) with the proximal humeral internal locking system (PHILOS) for the treatment of elderly valgus impacted proximal humeral fracture. Between May 2008 and May 2012, 27 patients (average age 67.3, range 61–74) with valgus impacted proximal humeral fractures were enrolled in the study. The patients were treated with MIPPO using PHILOS-plate through the anterolateral delta-splitting approach. Rehabilitation exercises were done gradually. The NEER score and Constant-Murley score were used to evaluate shoulder function. All the patients were followed up by routine radiological imaging and clinical examination. There were 15 cases of II-part greater tuberosity fractures, 10 cases of III-part greater tuberosity fractures, and 2 cases of IV-part fractures according to the NEER classification. The surgery was successful in all patients with an average follow-up of 20.8 (range: 11–34) months. The fractures united in an average of 7.2 (6–14) weeks without implant loosening. According to NEER score, there were 17 excellent, 7 satisfactory, 2 unsatisfactory, and 1 poor. The mean Constant-Murley score was 89.4 ± 4.35. No complication including axillary nerve damage, postoperative nerve or vessel damage, infections, DVT, or death was observed. In conclusion, the MIPPO technique with the PHILOS through the anterolateral delta-splitting approach seems to be a safe and easy treatment for elderly valgus impacted proximal humeral fractures. A case-control study and longer follow-up time are needed.

Editorial: Traumatic brain injury and postoperative CT

The classic teaching of neurosurgery residents has always emphasized the importance of the neurological examination in medical decision making. This is particularly true when deciding whether the postoperative patient requires an unplanned return to the operating room. The threshold for a return to the operating room to evacuate a hematoma or correct an unforeseen surgical issue is necessarily high, because such a return significantly increases the risk of untoward outcomes. It is therefore not terribly surprising that the analysis of the institutional experience in a large cohort of patients presented in the accompanying paper by Fontes et al.1 should find that no patient whose neurological examination demonstrated either no deficit or an expected deficit required additional, unplanned neurosurgical procedures. In other words, a routine postoperative head CT scan appeared to have no additional value in the absence of an unexpected neurological deficit (that would have ordinarily prompted an imaging study anyway). Fontes et al.’s findings add to a growing body of evidence that supports a reduction in the reliance on routine postoperative imaging. The authors argue that the added cost of such studies, as well as the incremental radiation risk, is simply not justified by the data. Although this study should provide a level of comfort for neurosurgeons trying to reduce their reliance on routine radiological imaging in the postoperative patient, it is important that the limitations of this study be kept in mind. First and foremost, the patient cohort reported here was treated in a large, busy, and well-staffed academic medical center. This may not reflect the resources available in other health care environments. A smaller hospital with fewer dedicated neurosurgical staff available to care for these patients may need to rely more on rotating staff, who may have less experience in detecting and managing changes in the neurological examination. In these smaller hospitals, CT scans may have greater utility in alerting staff to patients with a higher risk of deterioration. In addition, it is important to keep in mind the retrospective nature of this study. Interpretation of neurological findings, done retrospectively, may well influence how patients were grouped. This type of bias may easily affect the findings of the analysis and cannot be avoided, despite the best intentions of the authors. Finally, the definition of relevant neurosurgical intervention used by the authors excluded such procedures as repositioning of ventricular catheter tips based on imaging findings. It may be argued that patients who had such minor interventions were spared more significant sequelae as a result. Obtaining a CT scan that in retrospect does not appear to influence the management of the patient is very different from not doing the study in the first place. The authors of this study are to be commended for performing a detailed analysis of their large experience, and for documenting it thoroughly and thoughtfully. They do provide the reader with food for thought. However, despite the findings of this study, I suspect that routine postoperative CT scans will continue to be performed. In an era of high patient acuity and increasing prevalence of work-hour restrictions and handoffs, there is a greater potential that the significance of a neurological finding would be lost in the postoperative course. A patient who is initially only slightly drowsy after emerging from an anesthetic could be cared for by a series of physicians and midlevel providers who were previously unfamiliar with the patient, and who may miss a slow deterioration in the patient’s sensorium. Although this study argues that this has not been the case in a large institutional cohort, the retrospective nature of the data may have influenced how patients were grouped. Only a large, prospective study could answer the question of the utility of routine head CT scans definitively. One could argue that the performance of routine CT scans is partly a reflection of the advent of faster and more portable CT equipment, and partly a response to the pressures posed by the increasing “rotation” of the medical team caring for the postoperative patient. It provides the medical team with objective data on the patient’s status easily transportable from one practitioner to the next. Whether or not this is borne out in reality, routine scanning appears to protect the patient from the increasingly fragmented nature of the medical team in the immediate postoperative period. Although data from the Rush University study argue that this protection is more virtual than real, I suspect that this practice will continue for some time to come. (http://thejns.org/doi/abs/10.3171/2014.2.JNS14380)

Is there a role for ???routine radiological imaging??? in stage IIb and IIc melanoma follow-up?

1Castle Hill Hospital 2Oncology Department, Princess Royal Hospital, Hull Abstracts of the Perspectives in Melanoma X and The Third Annual International Melanoma Research Congress, 14–16 September 2006, Noordwijk, The Netherlands

Effect of treatment with pegvisomant on meningioma growth in vivo

Pegvisomant is a pegylated analogue of human growth hormone (GH) that functions as a GH receptor antagonist. Although its use is currently limited to patients with acromegaly (1), there exists considerable interest in the potential use of pegvisomant for the treatment of a variety of tumours whose growth may be promoted by insulin-like growth factor-I (IGF-I). We report the case of a 74-year-old woman with acromegaly, treated with pegvisomant, in whom we have documented the growth rate of a meningioma noted incidentally during the course of routine radiological imaging. The patient’s acromegaly was diagnosed in 1992 on the basis of failure of suppression of serum GH during a 75 g oral glucose load (nadir serum GH 10 mU/l) and an elevated serum IGF-I concentration (489 ng/ml, age-adjusted normal range 109 –269). Magnetic resonance imaging (MRI) of the pituitary demonstrated a 9 mm intrasellar pituitary mass lesion. She declined surgical adenomectomy or pituitary irradiation and was successfully treated with thrice-daily s.c. octreotide (serum IGF-I within ageadjusted normal range). In 1998, she enrolled in a 12 week placebo-controlled study of pegvisomant in the treatment of acromegaly (2) and was randomised to receive pegvisomant 10 mg daily. At its conclusion, she continued pegvisomant in an open-label study, but therapy was suspended after 9 months because of a shortage of drug. Eight weeks after cessation of pegvisomant, depot octreotide 10 mg four-weekly was commenced and continued for 26 months. In December 2001, she enrolled in an open-label study of patients with acromegaly converting from stable treatment with depot octreotide to therapy with pegvisomant and continued this drug at a dose of 10 mg daily until May 2004. Regular surveillance pituitary imaging was performed during both clinical trials. Incidental note was made, at the start of the first trial, of a dural-based homogeneously enhancing mass related to the greater wing of the sphenoid, typical of a meningioma (Fig. 1A). She reported no symptoms referable to the mass and declined any surgical intervention. Axial, sagittal and coronal dimensions of the mass were recorded at each scan and the volume calculated, for a prolate ellipsoid, using the formula 4/3p(height/2) (width/2)(depth/2) (3). The volume of the meningioma increased from 470 to 4810 mm 5 years later (Fig. 1B), with no discernible inhibitory effect of pegvisomant therapy (Fig. 2). Pegvisomant inhibits the functional dimerisation of cell surface GH receptors, thereby reducing IGF-I

Cerebral atrophy in Cushing’s disease

BACKGROUND Cushing’s disease causes significant pathological changes throughout the body as a result of elevated cortisol levels. Very few systematic investigations have focused on the morphologic effects of hypercortisolism on the central nervous system. The validity of using premature cerebral atrophy as a diagnostic tool for Cushing’s disease remains unknown. METHODS This study includes 63 patients with Cushing’s disease who were evaluated and treated at the University of Virginia Medical Center. Radiologists randomly compared these individuals with age- and sex-matched controls in a blinded protocol, assessing the degree of cerebral atrophy on computed tomography and magnetic resonance scans. RESULTS Patients with Cushing’s disease showed significant premature atrophy when compared with controls. This trend continued after subdividing the groups based on age and duration of symptoms except in the following groups: age greater than 60, duration of symptoms less than 1 year, and symptoms lasting between 4–5 years. CONCLUSIONS Excluding the three aforementioned groups, the hypercortisolemic state manifested in patients with Cushing’s disease promotes the premature development of cerebral atrophy, which can be identified on routine radiologic imaging and may assist in the clinical diagnosis of the condition.

The incidence of nephrolithiasis in patients with spinal neural tube defects.

Bladder stones are common in patients with spinal neural tube defects but there are little data on the incidence of renal calculi in this population. We examined the incidence, nature and risk factors of nephrolithiasis in our clinic population of patients with neural tube defects. We retrospectively reviewed the charts and radiological studies of 327 patients followed at our neural tube defects clinic with routine radiological imaging of the urinary tract. Additional confirmatory studies were performed when stones were noted. Renal calculi were identified in 20 patients with neural tube defects (6.1%). The incidence of nephrolithiasis increased with age. Renal stones were noted in 19 patients (10.7%) 12 years old or older. Management of the stones in these patients resulted in overall 53% stone-free and 87% recurrence rates after intervention. Major risk factors for new and/or recurrent renal stone formation were bacteriuria in 95% of the cases, lower urinary tract reconstruction in 80%, pelvicalicectasis in 70%, vesicoureteral reflux in 65%, a thoracic level spinal defect in 60% and renal scarring in 55%. These data suggest that there is a higher incidence of nephrolithiasis in patients with neural tube defects than in the general population and the risk of stone recurrence is also elevated. Most patients with stones had undergone lower urinary tract reconstruction. Other risk factors were bacteriuria, pelvicalicectasis, vesicoureteral reflux and a thoracic level neural tube defect.

THE INCIDENCE OF NEPHROLITHIASIS IN PATIENTS WITH SPINAL NEURAL TUBE DEFECTS

Purpose Bladder stones are common in patients with spinal neural tube defects but there are little data on the incidence of renal calculi in this population. We examined the incidence, nature and risk factors of nephrolithiasis in our clinic population of patients with neural tube defects. Materials and Methods We retrospectively reviewed the charts and radiological studies of 327 patients followed at our neural tube defects clinic with routine radiological imaging of the urinary tract. Additional confirmatory studies were performed when stones were noted. Results Renal calculi were identified in 20 patients with neural tube defects (6.1%). The incidence of nephrolithiasis increased with age. Renal stones were noted in 19 patients (10.7%) 12 years old or older. Management of the stones in these patients resulted in overall 53% stone-free and 87% recurrence rates after intervention. Major risk factors for new and/or recurrent renal stone formation were bacteriuria in 95% of the cases, lower urinary tract reconstruction in 80%, pelvicalicectasis in 70%, vesicoureteral reflux in 65%, a thoracic level spinal defect in 60% and renal scarring in 55%. Conclusions These data suggest that there is a higher incidence of nephrolithiasis in patients with neural tube defects than in the general population and the risk of stone recurrence is also elevated. Most patients with stones had undergone lower urinary tract reconstruction. Other risk factors were bacteriuria, pelvicalicectasis, vesicoureteral reflux and a thoracic level neural tube defect.