A clinician-centred programme for behaviour change in the optimal use of staging investigations for newly diagnosed prostate cancer.

OBJECTIVES: To improve imaging utilisation and reduce the widespread overuse of staging investigations, in the form of computed tomography (CT) and whole-body bone scans for men with newly diagnosed prostate cancer in the Hunter region of NSW, Australia, by implementation of a multifaceted clinician-centred behaviour change programme. PATIENTS AND METHODS: Records of all patients with a new diagnosis of prostate cancer were reviewed prior to the intervention (July 2014 to July 2015), and the results of this audit were presented to participating urologists by a clinical champion. Urologists then underwent focused education based on current guidelines. Patterns of imaging use for staging were then re-evaluated (November 2015 to July 2016). Patients were stratified into low-, intermediate- and high-risk groups as described by the D'Amico classification system. RESULTS: A total of 144 patients were retrospectively enrolled into the study cohort. The use of diagnostic imaging for staging purposes significantly decreased in men with low- and intermediate-risk disease post intervention. In low-risk patients, the use of CT decreased from 43% to 0% (P = 0.01). A total of 21% of patients underwent bone scans in the pre-intervention group compared with18% in the post-intervention group (P = 0.84). In intermediate-risk patients, the use of CT decreased from 89% to 34% (P < 0.001), whilst the use of bone scan decreased from 63% to 37% (P = 0.02). In high-risk patients, the appropriate use of imaging was maintained, with CT performed in 87% compared with 85% and bone scan in 87% compared with 65% (P = 0.07). CONCLUSION: Our results show that a focused, clinician-centred education programme can lead to improved guideline adherence at a regional level. The assessment of trends and application of such a programme at a state-based or national level could be further assessed in the future with the help of registry data. This will be particularly important in future with the advent of advanced imaging, such as prostate-specific membrane antigen positron-emission tomography.

Prostate-Specific Membrane Antigen Positron Emission Tomography-Computed Tomography for Prostate Cancer: Distribution of Disease and Implications for Radiation Therapy Planning.

PURPOSE: To explore the prostate-specific membrane antigen (PSMA)-avid distribution of prostate cancer (PC) on positron emission tomography (PET), both at the time of initial diagnosis and at the time of relapse after definitive local treatment. METHODS AND MATERIALS: A total of 179 PSMA PET scans in patients with nil or ≤3 lesions on conventional imaging were retrospectively categorized into 3 subgroups: group A, high-risk PC with no prior definitive therapy (n=34); group B, prior prostatectomy (n=75); and group C, prior radiation therapy (n=70). The numbers and locations of the PSMA-avid lesions were mapped. The PSMA-positive lesions were identified subjectively by a nuclear medicine physician on the basis of clinical experience and taking into account the recent literature and artefacts. RESULTS: A total of 893 PSMA-avid lesions were identified; at least 1 lesion was detected in 80% of all scans. A high detection rate was present even at very low serum PSA levels (eg, at PSA ≤0.20 ng/mL in group B, the detection rate was 46%). Thirty-eight percent of studies revealed extrapelvic disease (41%, 31%, and 46% in groups A, B, and C, respectively). Almost one-third of all studies showed only oligometastases (24%, 36%, and 31% in groups A, B, and C, respectively). A large proportion of these (40%) were a solitary lesion. CONCLUSIONS: Prostate-specific membrane antigen PET demonstrated a large number of otherwise unknown metastatic lesions. Therefore we recommend PSMA PET for more accurate assessment of disease burden in initial staging of high-risk PC, as well as for restaging in patients with prostate-specific antigen relapse after primary therapies. Furthermore, a high proportion of oligometastases on PSMA PET provides a prime opportunity to investigate the role of targeted local therapies for oligometastatic PCs.

Spinal multiparametric MRI and DEXA changes over time in men with prostate cancer treated with androgen deprivation therapy: a potential imaging biomarker of treatment toxicity.

OBJECTIVES: To explore changes in bone mineral density (BMD) measured by DEXA and MRS fat fraction (FF), Dixon FF, and ADC in lower spinal vertebral bodies in men with prostate cancer treated with androgen deprivation therapy (ADT). METHODS: Twenty-eight men were enrolled onto a clinical trial. All received ADT. DEXA imaging was performed at baseline and 12 months. L-spine MRI was done at baseline and 6 months. RESULTS: The number of patients who underwent DEXA, Dixon, ADC, and MRS at baseline/follow-up were 28/27, 28/26, 28/26, and 22/20. An increase in FF was observed from T11 to S2 (average 1 %/vertebra). There was a positive correlation between baseline MRS FF and Dixon FF (r = 0.85, p < 0.0001) and a negative correlation between MRS FF and ADC (r = -0.56, p = 0.036). Over 6 months, MRS FF increased by a median of 25 % in relative values (p = 0.0003), Dixon FF increased (p < 0.0001) and ADC values decreased (p = 0.0014). Men with >5 % BMD loss after 1 year had triple the percentage increase in MRS FF at 6 months (61.1 % vs. 20.9 %, p = 0.19). CONCLUSIONS: Changes are observed on L-spine MRI after 6 months of ADT. Further investigation is warranted of MRS change as a potential predictive biomarker for later BMD loss. KEY POINTS: • Spinal marrow fat fraction increases after 6 months of androgen deprivation therapy. • More inferior vertebral bodies tend to have higher fat fractions. • MRS fat fraction changes were associated with later changes in DEXA BMD.

Abdominal wall infected ischemic necrosis mimicking necrotizing fasciitis.

Emergency surgery to revascularize an ischemic leg in the presence of an aortic aneurysm presents a series of difficult management decisions in both the operative and postoperative phases. We present a case of infected ischemic necrosis that developed in a discrete tissue plane from a transverse incision mimicking necrotizing fasciitis. A 57-year-old man presented with an ischemic leg associated with a 5-cm abdominal aortic aneurysm. The sudden appearance of gangrenous tissue in the inferior flap of the transverse abdominal incision prompted urgent surgical debridement. This case report describes the management of a potentially misleading clinical condition. The key points to remember are to maintain a high index of suspicion for potentially life-threatening soft tissue infections, to be vigilant about regular wound inspection, and to act decisively when urgent wound debridement is indicated.

Determination of added fat in meat paste using microwave and millimetre wave techniques.

By evaluating the sensitivity of measurement parameters such as dielectric constant and microwave loss to fat content, several microwave and millimetre methods were compared to identify optimal frequency measurement bands. The results showed that the optimum frequency range lay between 8 and 20GHz where these parameters vary linearly, by up to a factor of 8, as fat is increased to 50% volume. A narrowband waveguide sensor cell was designed and constructed for this optimum range. The imaginary part (ε'') of the complex permittivity demonstrated a better measurements resolution for determining fat content than the real part (ε'). The waveguide method has excellent repeatability as indicated by low relative standard deviation (RSD<4.88%). Temperature and sample density had minimal impact on the accuracy, repeatability and robustness of the final measurement system. A method of mixtures model for complex permittivity was shown to be a useful predictor of fat content.

The effect of different enzymes on the quality of high-fibre enriched brewer's spent grain breads.

The brewing industry produces large quantities of waste co-products. There is increasing pressure to ensure total utilisation of such products to address economic and environmental concerns. Brewer's spent grain (BSG) the main by-product of the brewing industry is rich in dietary fibre and has a strong potential to be recycled. The overall objective of this study was to incorporate BSG into wheat flour breads together with a range of different enzymes (Maxlife 85, Lipopan Extra, Pentopan Mono BG and Celluclast) and evaluate the bread quality. A number of nutritional and textural properties of the finished product were studied. The incorporation of BSG significantly (P<0.0001) improved the dietary fibre but the major difficulty encounted was to achieve a good structure and high loaf volume. Increasing the level of dietary fibre significantly (P<0.001) increased dough development time, dough stability and crumb firmness but decreased the degree of softening and loaf volume. It was found that addition of Lipopan Extra (LE), Pentopan Mono (PE) and a mixture of Pentopan Mono and Celluclast (PCE) enzymes improved the texture, loaf volume and shelf life while Maxlife 85 enzyme (ME) was not significantly different from control samples (wheat flour breads containing 0%, 10%, 20% and 30% BSG). Image analysis of the bread structure obtained from the C-cell analyzer showed that the most significantly (P<0.001) open network was obtained using LE, followed by PE and PCE.

Physical evaluation of a maize-based extruded snack with curry powder.

Response surface methodology was used to analyze the effect of screw speed (200-280 rpm), feed moisture (13.0-17.0%, wet basis), and curry powder (6.0-9.0%) on the bulk density, lateral expansion, and firmness of maize-based extruded snack with curry powder. Regression equations describing the effect of each variable on the responses were obtained. Responses were most affected by changes in feed moisture followed by screw speed and curry powder (p < 0.05). Lateral expansion increased linearly as the amount of curry powder added was increased whereas a quadratic increase was obtained in lateral expansion with decreasing feed moisture. The firmness of samples was increased with an increase in feed moisture. The bulk density of samples was increased with increasing feed moisture and screw speeds. Radial expansion was found to be a better index to measure the physical properties of the extruded product indicated by a higher correlation coefficient.

Lost bits: particle shedding with polyvinyl chloride intravenous administration sets.

Silicone particles have been demonstrated in the effluent from silicone intravenous (IV) tubing. It has been widely suspected that polyvinyl chloride (PVC) particles are also lost. We sought to clarify the situation in a carefully controlled laboratory setting using the apparatus and flow rates common in a paediatric setting, using scanning electron microscope techniques (SEM), we found that particles were indeed shed from IV tubing during use, but they were not PVC.