Use Of Imaging Studies Research Articles

Safer Radiologic Imaging of Otolaryngologic Disease in Children

Program Description: Radiation exposure from medical imaging has increased six-fold over the past 30 years, and such imaging has been estimated to provide half of an individual’s radiation exposure. The risk of cancer development from such radiation exposure has been discussed recently in the medical literature and the lay press. These issues are most notable in children, with long life expectancy and the potential for multiple exposures to medical imaging in their future. This symposium will be a multi-speaker symposium, and at the end of the various presentations, specific case scenarios will be presented with the opportunity to use the Audience Response System for audience participation for better understanding of current otolaryngology practice patterns related to imaging study selection in pediatric patients. The speakers will include a pediatric radiologist as well as 3 pediatric otolaryngologists, and presentations will include strategies on how to use reduced radiation doses for select imaging studies, review the current American College of Radiology Appropriateness Criteria for Otolaryngology related image study selection, appropriateness of using the MiniCAT image system in the office setting, as well as risks and benefits for each image modality for specific pediatric head and neck diseases. Educational Objectives: 1) Discuss current issues related to safety of radiologic imaging studies used most often in children. 2) Review specific case scenarios and discuss imaging options, relative risks, and benefits of each modality. 3) Enhance judicious use of imaging studies for given pathology, and counseling of parents about risks.

Decafluorobutane as a Phase-Change Contrast Agent for Low-Energy Extravascular Ultrasonic Imaging

Currently available microbubbles used for ultrasound imaging and therapeutics are limited to intravascular space due to their size distribution in the micron range. Phase-change contrast agents (PCCAs) have been proposed as a means to overcome this limitation, since droplets formed in the hundred nanometer size range might be able to extravasate through leaky microvasculature, after which they could be activated to form larger highly echogenic microbubbles. Existing PCCAs in the sub-micron size range require substantial acoustic energy to be vaporized, increasing the likelihood of unwanted bioeffects. Thus, there exists a need for PCCAs with reduced acoustic activation energies for use in imaging studies. In this article, it is shown that decafluorobutane, which is normally a gas at room temperature, can be incorporated into metastable liquid sub-micron droplets with appropriate encapsulation methods. The resulting droplets are activatable with substantially less energy than other favored PCCA compounds. Decafluorobutane nanodroplets may present a new means to safely extend ultrasound imaging beyond the vascular space.

Fine Needle Aspiration of the Thyroid: A Contemporary Experience of 3981 Cases

Fine needle aspiration (FNA) is an essential tool for the management of thyroid nodules. Recently, several national organizations have recommended FNA of all thyroid nodules >1 cm. With the increase use of imaging in the practice of medicine over the last decade, the number of incidentally discovered thyroid nodules is rising. Therefore, we analyzed our experience to determine if these changes in practice led to alterations in the population of patients undergoing FNA at our institution. Data were collected from 981 consecutive patients who underwent thyroid FNA at our institution between 2002 and 2009. Patients were divided in two groups: the early time period 2002-2005 (group 1) and later time period 2006-2009 (group 2). Data from the two groups were analyzed with t-test and χ(2) tests (SPSS, Inc., Chicago, IL). Comparing the groups, the number of FNAs performed in the later time period increased significantly by 250%. Patients in the later time period (group 2) were more likely to be female and were significantly older. With regard to FNA diagnoses, the number of benign FNAs increased, while the percentage of FNAs diagnosed as malignant and as follicular neoplasm decreased. There also appears to be an increase in the incidence of thyroiditis. The use of thyroid FNA has markedly increased during this contemporary series. This rise in thyroid FNA appears to be due to biopsy of benign thyroid nodules. With time, more females and older patients have undergone FNA, possibly reflecting the increased use of imaging studies in this patient population.

Overuse of Imaging for Staging Low Risk Prostate Cancer

Routine imaging for staging low risk prostate cancer is not recommended according to current guidelines. We characterized patterns of care and factors associated with imaging overuse. We used SEER-Medicare linked data to identify men diagnosed with low risk prostate cancer from 2004 to 2005, and determined if imaging (computerized tomography, magnetic resonance imaging, bone scan, abdominal ultrasound) was obtained following prostate cancer diagnosis before treatment. Of the 6,444 men identified with low risk disease 2,330 (36.2%) underwent imaging studies. Of these men 1,512 (23.5%), 1,710 (26.5%) and 118 (1.8%) underwent cross-sectional imaging (computerized tomography or magnetic resonance imaging), bone scan and abdominal ultrasound, respectively. Radiation therapy vs surgery was associated with greater odds of imaging (OR 1.99, 95% CI 1.68-2.35, p <0.01), while active surveillance vs surgery was associated with lower odds of imaging (OR 0.44, 95% CI 0.34-0.56, p <0.01). Associated with increased odds of imaging was median household income greater than $60,000 (OR 1.41, 95% CI 1.11-1.79, p <0.01), and men from New Jersey vs San Francisco (OR 3.11, 95% CI 2.24-4.33, p <0.01) experienced greater odds of imaging. Men living in areas with greater than 90% vs less than 75% high school education experienced lower odds of imaging (OR 0.76, 95% CI 0.6-0.95, p = 0.02). There is widespread overuse and significant geographic variation in the use of imaging to stage low risk prostate cancer. Moreover treatment associated variation in imaging was noted with the greatest vs lowest imaging use observed for radiation therapy vs active surveillance.

Management of maternofetal emergency in shock with fracture of femur

Trauma is the leading nonobstetric cause of maternal death. The worst complication can be fetal compromise that threatens premature labor or even fetal death. We are reporting a case of a 30-year-old primi, short stature woman who had fracture femur with hypovolaemic shock. Managing such trauma complicated by shock in a pregnant patient needs multidisciplinary approach. Clinician team evaluating and coordinating the care of pregnant trauma patient should understand the pathophysiological changes in pregnancy with trauma to manage hypovolaemic shock, related complications, treatment of fracture, and radiation exposure to the fetus. The use of imaging studies, invasive hemodynamics and surgery, if necessary, should be individualized. A clear understanding of fetal viability, physiological changes of pregnancy, and pathophysiology of shock, is mandatory for optimal, maternal functional, and obstetrical outcome.

An Unexpected Cause of Coffee Ground Emesis and Dysphagia

Purpose: Introduction: Esophageal perforation as a complication of anterior cervical discectomy and fusion (ACDF) is a rare but potentially fatal occurrence. We report a case of a patient presenting with chronic dysphagia and coffee ground emesis who had undergone ACDF three years prior and is found to have erosion of cervical hardware into his esophagus on endoscopy. Case Report: A 47-year-old man with a history of quadriplegia after sustaining a traumatic C2 fracture in 2007 requiring ACDF presented with coffee ground emesis and melena. He had also undergone gastrostomy tube placement, a diverting colostomy and tracheostomy. The patient has chronic dysphagia with aspiration. He underwent colostomy revision two weeks prior to presentation with abscess formation requiring an open abdomen. Physical exam revealed an open abdomen with diminished bowel sounds and diffuse abdominal tenderness. He was anemic with a cat scan of the abdomen negative for any acute abnormalities. He underwent upper endoscopy which revealed metal eroding into the posterior wall of the esophagus. A cat scan of the cervical spine was obtained and showed that the upper esophagus appeared to communicate freely with the anterior aspect of the cervical hardware at the C5 level. Surgical intervention was then planned. Discussion: In 2009, a review article by Ardon et al. reported a 0% to 3.4% incidence of injuries to the esophagus related to cervical spine surgery. Esophageal perforation occurred more commonly after surgery for traumatic fractures of the cervical spine with most taking place at the C5 to C6 and C6 to C7 levels. Esophageal perforations can present acutely or they can be delayed. Anterior migration or dislocation of the fixation devices are more likely associated with delayed presentations. While patients can be asymptomatic, most patients present with dysphagia, evidence of infection, subcutaneous emphysema, or gastrointestinal bleeding. The diagnosis of this entity involves the use of imaging studies and endoscopy, but clinical suspicion is key. Management consists of surgical removal of the existing hardware with closure of the perforation if possible. Drainage of abscesses combined with antibiotic therapy and parenteral nutrition maybe necessary.Figure

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We would like to thank the editor for his positive comment. On the basis of this analysis, the color Doppler ultrasound (CDS) results were incorporated in clinical decision making at our department and the number of surgical interventions was reduced without missing a testicular torsion. Moreover, we could prove that with proper training, CDS can be performed by the urologist, with excellent results. It also improves patient counseling and the relationship between the doctor, the patient, and the patient's parents, as the children were examined by only 1 person, which helps to reduce anxiety and improve compliance. Proper documentation of the CDS results may also constitute an indispensable support in medicolegal terms, when the necessity of surgical exploration is disputed. Editorial CommentUrologyVol. 75Issue 5PreviewThis article on acute scrotum reaffirms several previously documented features of this diagnosis and provides several new ones. In the end, the diagnosis of testicular torsion should be based on the clinical presentation and supported by the adjunct use of imaging studies, whether Doppler ultrasound or nuclear scintigraphy when time permits. As shown here, and confirmed by investigators who evaluate and treat these boys, the physical examination may not always secure the diagnosis depending on the level of cooperation by the child, and the examination skills of the examiner. Full-Text PDF

Introduction to the American College of Radiology Appropriateness Criteria® Review Series

As Chair and Vice-Chair of the American College of Radiology (ACR) Appropriateness Criteria® Thoracic Imaging panel, we are honored to provide this introduction to a new Journal of Thoracic Imaging (JTI) series devoted to a concise review of selected Appropriateness Criteria topics in Thoracic Imaging. The Appropriateness Criteria have been in existence for more than a decade. Since their inception, the Appropriateness Criteria have served as a unique resource to radiologists and clinicians. The purpose of the Appropriateness Criteria is to provide evidence-based criteria regarding the appropriateness of specific imaging tests for precise clinical indications. The Appropriateness Criteria have been produced using a well-delineated and reproducible two-step process. The first step consists of a focused review of current literature on the specific topic, with the development of an evidence table, referenced narrative, and ratings table (with relevant imaging modalities and suggested ratings/treatments). The second step is consensus building, using a modified Delphi technique (an anonymous voting process). Both of these steps require extensive participation by the expert panel. Each topic is reviewed annually or biannually.1 Thanks to the constantly updated reviews, it has become clear over the years that some topics should be retired and that new clinically relevant topics should be generated. This is a formidable strength of the process: it ensures routine review of the criteria and revision when important new data emerge. Criteria are developed to as great an extent as possible on sound clinical data rather than on individual or collective opinions. Overall, the intent is to provide information that is both scientifically accurate and practical. As stated by the ACR, the intended main users of the individual Appropriateness Criteria are clinicians who request imaging examinations of their patients. In this way, the Appropriateness Criteria provide guidance as to the appropriateness of specific imaging modalities for particular clinical situations. As radiologists play an important consultative role to clinicians in the appropriate use of imaging studies, it is also important for radiologists to be familiar with these criteria. Toward this end, and to promote greater visibility of these published criteria, the ACR and JTI have joined together to provide a series of concise reviews of the recently updated or new Appropriateness Criteria topics that are highly relevant to the JTI readership. This is an immensely valuable opportunity, for which the ACR Appropriateness Criteria® Thoracic Imaging expert panel is extremely grateful. Each Appropriateness Criteria topic has been drafted by a chest radiologist with expertise in the clinical area and has subsequently been extensively vetted by a panel of specialists, with added representation as necessary from the American College of Chest Physicians and the Society of Thoracic Surgeons. The inaugural publication for this Web-exclusive series, “Chronic Dyspnea, Suspected Pulmonary Origin,” drafted by Debra S. Dyer, MD, can be found in the Web version of this issue of the Journal at www.thoracicimaging.com.2 We enthusiastically invite the readers of JTI to learn more about the ACR through this and future summary articles in upcoming issues. For those readers who are interested in more detailed information, the complete ACR Appropriateness Criteria® are also available at www.acr.org/ac.

513 THE RATES OF METASTATIC RENAL CELL CARCINOMA ARE DECREASING OVER TIME: A POPULATION-BASED ANALYSIS

You have accessJournal of UrologyKidney Cancer: Evaluation and Staging I1 Apr 2010513 THE RATES OF METASTATIC RENAL CELL CARCINOMA ARE DECREASING OVER TIME: A POPULATION-BASED ANALYSIS Giovanni Lughezzani, Claudio Jeldres, Lars Budaus, Shahrokh F. Shariat, Rodolphe Thuret, Daniel Liberman, Philippe Arjane, Hugues Widmer, Paul Perrotte, Jean-Jacques Patard, Francesco Montorsi, and Pierre I. Karakiewicz Giovanni LughezzaniGiovanni Lughezzani Milano, Italy More articles by this author , Claudio JeldresClaudio Jeldres Montreal, Canada More articles by this author , Lars BudausLars Budaus Hamburg, Germany More articles by this author , Shahrokh F. ShariatShahrokh F. Shariat Montreal, Canada More articles by this author , Rodolphe ThuretRodolphe Thuret Montpellier, France More articles by this author , Daniel LibermanDaniel Liberman Montreal, Canada More articles by this author , Philippe ArjanePhilippe Arjane Montreal, Canada More articles by this author , Hugues WidmerHugues Widmer Montreal, Canada More articles by this author , Paul PerrottePaul Perrotte Montreal, Canada More articles by this author , Jean-Jacques PatardJean-Jacques Patard Rennes, France More articles by this author , Francesco MontorsiFrancesco Montorsi Milano, Italy More articles by this author , and Pierre I. KarakiewiczPierre I. Karakiewicz Montreal, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.589AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We assessed the rate of metastatic renal cell carcinoma (mRCC) at diagnosis in a large population-based tumor registry. METHODS Between 1988 and 2006 87842 patients were identified within 17 Surveillance, Epidemiology and End Results (SEER) registries with tissue-proven diagnosis of RCC of all stages. We examined the rates of mRCC at diagnosis throughout the study period. Multivariable logistic regression models examined the impact of year of diagnosis quartiles (1988-1992 vs. 1993-1997 vs. 1998-2002 vs. 2003-2006) on mRCC rates after adjusting for patient age, gender, race and socioeconomic status. RESULTS The overall rate of mRCC was 19.1% and it decreased from 23.8% in the first year quartile to 16.5% over the study period (chi-square trend: p<0.001). The decrease in mRCC rates was more pronounced in females (-8.6%) than in males (-6.9%), in older individuals (-12.3% in ≥80 years) than in younger patients (-7.0% in <50 years), in African-American (-9.7%) than in Caucasian patients (-7.3%), and in patients within the highest socioeconomic status quartile (-8.9%) relative to individuals within the lowest socioeconomic status quartile (-7.3%). In multivariable logistic regression models more advanced age (p<0.001), male gender (p<0.001), race other than Caucasian and African-American (p=0.02) and lower socioeconomic status (p<0.001) represented independent predictors of mRCC diagnosis. Finally, more contemporary year of diagnosis remained the foremost predictor of lower rate of mRCC at initial diagnosis (p<0.001). CONCLUSIONS Our findings are highly encouraging and suggest that a larger proportion of patients will harbor curable or highly treatable stages of RCC. Conversely, an increasingly smaller proportion of mRCC will hopefully contribute to the overall RCC patient population. The increased use of imaging studies may represent an explanation for the observed results. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e203 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Giovanni Lughezzani Milano, Italy More articles by this author Claudio Jeldres Montreal, Canada More articles by this author Lars Budaus Hamburg, Germany More articles by this author Shahrokh F. Shariat Montreal, Canada More articles by this author Rodolphe Thuret Montpellier, France More articles by this author Daniel Liberman Montreal, Canada More articles by this author Philippe Arjane Montreal, Canada More articles by this author Hugues Widmer Montreal, Canada More articles by this author Paul Perrotte Montreal, Canada More articles by this author Jean-Jacques Patard Rennes, France More articles by this author Francesco Montorsi Milano, Italy More articles by this author Pierre I. Karakiewicz Montreal, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Trauma in Pregnancy

In the United States, trauma is the leading nonobstetric cause of maternal death. The principal causes of trauma in pregnancy include motor vehicle accidents, falls, assaults, homicides, domestic violence, and penetrating wounds. The managing team evaluating and coordinating the care of the pregnant trauma patient should be multidisciplinary so that it is able to understand the physiologic changes in pregnancy. Blunt trauma to the abdomen increases the risk of placental abruption. Evaluation of the pregnant trauma patient requires a primary and secondary survey with emphasis on airway, breathing, circulation, and disability. The use of imaging studies, invasive hemodynamics, critical care medications, and surgery, if necessary, should be individualized and guided by a coordinating team effort to improve maternal and fetal conditions. A clear understanding of gestational age and fetal viability should be documented in the record.

Functional Magnetic Resonance Imaging (fMRI) and Expert Testimony

Medical experts frequently use imaging studies to illustrate points in their court testimony. This article reviews how these studies impact the credibility of expert testimony with judges and juries. The apparent "objective" evidence provided by such imaging studies can lend strong credence to a judge's or jury's appraisal of medical expert's testimony. However, as the court usually has no specialized scientific expertise, the use of complex images as part of courtroom testimony also has the potential to mislead or at least inappropriately bias the weight given to expert evidence. Recent advances in brain imaging may profoundly impact forensic expert testimony. Functional magnetic resonance imaging and other physiologic imaging techniques currently allow visualization of the activation pattern of brain regions associated with a wide variety of cognitive and behavioral tasks, and more recently, pain. While functional imaging technology has a valuable role in brain research and clinical investigation, it is important to emphasize that the use of imaging studies in forensic matters requires a careful scientific foundation and a rigorous legal assessment.

Controversies in Appendicitis

Appendectomy for appendicitis is a common operation that is performed by most general surgeons. Despite the large number of appendectomies, numerous management controversies continue. Review of the pertinent English language literature. Controversy persists regarding the use of imaging studies for diagnosis, laparoscopic vs. open surgical methods, nonoperative management of uncomplicated appendicitis, delayed management of the patient with phlegmon from severe appendicitis, the necessity for interval appendectomy, and the merits of deferral of off-hour appendectomy until the following morning. This review identifies the published reports that support the pros and cons of each controversy. Class I data generally are lacking to support the resolution of these controversies. Additional well-controlled clinical trials are necessary to obtain definitive answers.

Postoperative Surveillance of Differentiated Thyroid Carcinoma: Rationale, Techniques, and Controversies

Although differentiated thyroid cancer (DTC) is typically an indolent disease with a high rate of cure, recurrence is common (15%-30% of patients), even in early-stage disease. These high rates of recurrence have resulted in the widespread adoption of intensive posttherapy surveillance algorithms. Currently used strategies rely primarily on serial serum thyroglobulin measurements combined with cervical ultrasonography (US): US is utilized to search for recurrences within the thyroid bed or anterior cervical lymph nodes and as a guidance system for directed fine-needle aspiration biopsy of suspicious lesions. Positron emission tomography (PET) and coregistered computed tomography/fluorine 18 fluorodeoxyglucose PET are used primarily in the setting of non-iodine-avid tumors. Intensive surveillance has improved the ability to detect small-volume tumor recurrence with a sensitivity that surpasses current understanding of the clinical implications of detecting clinically occult residual or recurrent disease. Knowledge of currently used treatment and surveillance strategies is crucial for understanding the appropriate use of imaging studies, the clinical implications of imaging findings, and the appropriate use of US-guided tissue sampling in patients with DTC. Recent advances in the understanding of DTC tumor biology hold promise for improving the ability to predict tumor behavior and aggressiveness, thereby allowing more appropriate risk stratification, imaging surveillance, and treatment.

Geographic Differences in Clinical Presentation, Treatment, and Outcomes in Type A Acute Aortic Dissection (from the International Registry of Acute Aortic Dissection)

Although several studies have provided robust evidence about global differences for several cardiovascular emergencies, such as myocardial infarction and stroke, data were limited for aortic disease. The aim was to explore geographic variation in type A acute aortic dissection (TA-AAD) in a large group of consecutive patients. Patients (n = 615) from the IRAD with TA-AAD were studied with respect to presenting symptoms and signs, diagnosis, management, and outcomes in Europe versus North America. Compared with Europeans, North Americans were more likely to be older and present with atypical features and without many of the classic chest X-ray findings of AAD. In the North American cohort, electrocardiographic findings showed higher rates of nonspecific ST changes and a trend toward ST-elevation or new myocardial infarction (North Americans vs Europeans 7.9% vs 4.4%; p = 0.09). Use of imaging studies to confirm the diagnosis of AAD varied between North American and European centers. North American centers performed an average of 1.6 imaging studies compared with 1.8 in the European group (p = 0.002). Furthermore, they were significantly less likely to use computed tomography and significantly more likely to use transesophageal examination as part of the overall diagnostic algorithm. Compared with Europeans, TA-AAD occurred at smaller aortic diameters and there was a substantial delay to presentation and diagnosis in North Americans. No significant differences for early mortality rates were observed between the 2 groups. In conclusion, geographic differences in presentation and initial management were highlighted, but this did not translate into a difference in early mortality.

S247 – Mediastinitis in Infants: Role of the Otolaryngologist

Objectives To describe mediastinitis from retropharyngeal abscess in 3 infants. Methods Case reports of 3 patients. Results 3 patients presented in a span of 2 winter months to a tertiary care, pediatric, inner-city hospital. The patients were 8 months, 9 months, and 18 months old. All presented with retropharyngeal phlegmon on CT scan, were started on clindamycin and cefotaxime, and monitored as in-patients for 2–4 days prior to surgery. Interval CT scans revealed progression to retropharyngeal abscess with mediastinal extension. One patient's retropharyngeal abscess was drained trans-orally, one externally, and one required a combined approach. 2 of the 3 patients required video-assisted thoracoscopic debridement of the mediastinitis. 2 cultures grew out methicillin-resistant staphylococcus aureus, while one grew out methicillin-sensitive staphylococcus aureus (all were clindamycin sensitive). The patients' peak white blood cell counts were 18.4, 30.2, and 44.9 thousand. All 3 patients survived and were discharged on long-term antibiotics. Conclusions Despite appropriate initial empiric antibiotic therapy, all 3 patients developed retropharyngeal abscess with mediastinal extension. The otolaryngologist should maintain vigilance when treating infants with intravenous antibiotics for a deep neck space infection, liberal use of imaging studies should be performed to monitor progression of the infection, a significantly elevated white blood cell count should be interpreted with caution, and initial empiric therapy should include clindamycin. Despite the adult literature that quotes a 50% mortality rate from mediastinitis, infant mediastinitis may be a different disease process, as all 3 of our patients survived.

Recommendations for optimal use of imaging studies to clinically stage mediastinal lymph nodes in non-small-cell lung cancer patients

Appropriate clinical staging of mediastinal lymph nodes in non-small-cell lung cancer (NSCLC) patients has important therapeutic and prognostic implications. Because of the wide variations in practice patterns among community and academic physicians, we reviewed the literature so that we could provide evidence-based recommendations on the use of imaging studies in the pretreatment clinical staging of NSCLC patients. We concluded that the most sensitive and accurate method of noninvasive mediastinal nodal staging is a positron emission tomography/computed tomography fusion scan; we believe this tool should be a component of clinical staging of all NSCLC patients. Given insufficient sensitivity with currently available imaging studies, mediastinal nodal staging should also include histologic evaluation.

Endovascular Treatment of Visceral Artery Aneurysms

Visceral artery aneurysms, although uncommon, can present with life-threatening hemorrhage. The increasing use of imaging studies has allowed for earlier identification and intervention of these aneurysms, thus avoiding the high morbidity and mortality associated with rupture. The treatment options for visceral artery aneurysms range from conventional open surgical repair to minimally invasive techniques using covered stents or embolization materials. Anatomic features and patient selection determine which treatment option would result in the most durable treatment and outcome. This article reviews our experience with the endovascular treatment of visceral artery aneurysms.

Whole isolated neocortical and hippocampal preparations and their use in imaging studies

This study shows that two whole isolated preparations from the young mouse, the neocortical ‘slab’ and the hippocampal formation, are useful for imaging studies requiring both global monitoring using light transmittance (LT) imaging and high resolution cellular monitoring using 2-photon laser scanning microscopy (2PLSM). These preparations share advantages with brain slices such as maintaining intrinsic neuronal properties and avoiding cardiac or respiratory movement. Important additional advantages include the maintenance of all local input and output pathways, the absence of surfaces injured by slicing and the preservation of three-dimensional tissue structure. Using evoked extracellular field recording, we demonstrate long-term (hours) viability of both whole preparations. We then show that propagating cortical events such as anoxic depolarization (AD) and spreading depression (SD) can be imaged in both preparations, yielding results comparable to those in brain slices but retaining the tissue's three-dimensional structure. Using transgenic mice expressing green fluorescent protein (GFP) in pyramidal and granule cell neurons, 2PLSM confirms that these preparations are free of the surface damage observed in sliced brain tissue. Moreover the neurons undergo swelling with accompanying dendritic beading following AD induced by simulated ischemia, similar to cortical damage described in vivo.

Imaging for the diagnosis and follow-up of ankylosing spondylitis: Development of recommendations for clinical practice based on published evidence and expert opinion

Objective To develop recommendations regarding imaging studies for the diagnosis and follow-up of patients with axial forms of ankylosing spondylitis (AS) seen in everyday practice. Methods Evidence from the literature and expert opinion were used to develop the recommendations. Using the Delphi consensus procedure, a scientific committee selected five areas of interest, about which scientific evidence was sought by searching Medline and the databases maintained by the French Society for Rheumatology, European League against Rheumatism, and American College of Rheumatology. Based on this evidence, a panel of experienced rheumatologists drafted recommendations, using expert opinion if needed to supplement gaps in evidence. For each recommendation, the level of evidence and the extent of agreement among the experts were specified. Results The five areas of interest dealt with the usefulness of imaging studies for the diagnosis, follow-up, prognostic evaluation, and assessment of treatment responses in patients with AS. The literature search retrieved 144 articles based on titles and abstracts. After elimination of articles that did not include an analysis of the radiological evaluation of AS, 73 articles were left for review. Eight recommendations were drafted then validated by having all panel participants vote during a final meeting. Conclusion Eight recommendations about the use of imaging studies in patients with AS were developed. They can be expected to improve clinical practice uniformity and, in the longer term, to optimize the management of patients with AS.

LITIGATION OF MISSED CERVICAL SPINE INJURIES IN PATIENTS PRESENTING WITH BLUNT TRAUMATIC INJURY

Approximately 800,000 cervical spines are cleared in emergency departments each year. Errors in diagnosis of cervical spine injury are a potentially huge medicolegal liability, but no established protocol for clearance of the cervical spine is known to reduce errors or delays in diagnosis. The Lexis-Nexis, Westlaw, and Medline databases were queried for cases of missed cervical injury. Errors were categorized according to a novel system of classification. Type I errors occurred when inadequate or improper tests were ordered. Type II errors occurred when adequate tests were ordered, but were either misread or not read. Type III errors occurred when adequate tests were ordered and read accurately, but the ordered test was not sensitive enough to detect the injury. Twenty cases of missed or delayed diagnosis of cervical spine injury were found in 10 jurisdictions. Awards averaged 2.9 million dollars (inflation adjusted to 2002 dollars). Eight cases resulted in verdicts in favor of the defendant, but none of these cases involved an alleged Type II error. Fear of lawsuits encourages defensive medicine and complicates the process of clearing a patient's cervical spine. This analysis adds medicolegal support for the judicious use of imaging studies in current cervical spine clearance protocols. However, exposure to significant liability suggests that a low threshold for computed tomography is a reasonable alternative.