Sex estimation with the total area of the proximal femur: A densitometric approach.

The estimation of sex is a central step to establish the biological profile of an anonymous skeletal individual. Imaging techniques, including bone densitometry, have been used to evaluate sex in remains incompletely skeletonized. In this paper, we present a technique for sex estimation using the total area (TA) of the proximal femur, a two-dimensional areal measurement determined through densitometry. TA was acquired from a training sample (112 females; 112 males) from the Coimbra Identified Skeletal Collection (University of Coimbra, Portugal). Logistic regression (LR), linear discriminant analysis (LDA), reduce error pruning trees (REPTree), and classification and regression trees (CART) were employed in order to obtain models that could predict sex in unidentified skeletal remains. Under cross-validation, the proposed models correctly estimated sex in 90.2-92.0% of cases (bias ranging from 1.8% to 4.5%). The models were evaluated in an independent test sample (30 females; 30 males) from the 21st Century Identified Skeletal Collection (University of Coimbra, Portugal), with a sex allocation accuracy ranging from 90.0% to 91.7% (bias from 3.3% to 10.0%). Overall, data mining classifiers, especially the REPTree, performed better than the traditional classifiers (LR and LDA), maximizing overall accuracy and minimizing bias. This study emphasizes the significant value of bone densitometry to estimate sex in cadaveric remains in diverse states of preservation and completeness, even human remains with soft tissues.

A glimpse from the past: osteoporosis and osteoporotic fractures in a Portuguese identified skeletal sample.

UNLABELLED: The diachronic variation of etiological factors, like longevity or diet, affected the prevalence of osteoporosis and the so-called osteoporotic fractures in the past. As such, it is important to understand the epidemiology of this disease in historical populations; with behaviors and customs that were unalike the modern westernized lifestyle. OBJECTIVES: The main objective of this study is to characterize the epidemiological patterns of osteoporosis and related fractures in an identified Portuguese skeletal sample from the mid 19th - early 20th centuries. MATERIALS AND METHODS: The sample studied comprised 196 skeletal individuals with known sex and age-at-death, housed at the University of Coimbra. Bone mineral density (BMD) was evaluated in the proximal femur through dual X-ray absorptiometry and osteoporotic fractures were recorded according to clinical and paleopathological protocols. RESULTS: BMD decreased significantly with age-at-death, both at the ROI «Total hip¼ and the ROI «Neck¼. At the «Total hip¼, peak bone mass (PBM) was achieved early (20-29 years age group) in both sexes. In the study-group as a whole, BMD was significantly higher in males when compared to females. As expected, the prevalence of osteoporosis in the proximal femur is higher in women and rises steeply with age. Comparisons with two modern Portuguese samples showed an equivalent pattern of BMD reduction. Nonetheless, BMD is usually lower in the skeletal sample. Women with osteoporosis had a much larger probability of showing a fragility fracture than women diagnosed with «normal¼ BMD or osteopenia. CONCLUSIONS: In spite of enormous lifestyle differences, the epidemiological pattern of bone mass decrease in a Portuguese skeletal sample is strikingly similar to the ones observed in modern populations. This study adds further data to the recent notion that osteoporosis is a disease with deep roots in the past.

Rest myocardial perfusion imaging: a valuable tool in ED.

BACKGROUND: Acute chest pain is a frequent cause of emergency department (ED) visits. Rest myocardial perfusion imaging (RMPI) during or immediately after an episode of chest pain can provide diagnostic and prognostic information concerning acute coronary syndromes. AIM: Our purpose was to evaluate the RMPI score in risk stratification of chest pain suspected to be of cardiac ischemic origin and negative troponin assessment. METHODS: Ninety-six patients without an ongoing myocardial infarction or a history of coronary artery disease and in whom RMPI was performed in the ED because of chest pain suspected to be related with acute myocardial ischemia were included. Follow-up was performed considering the occurrence of death, myocardial infarction, or revascularization in a 12-month period admission. RESULTS: Fourteen (14.6%) patients had events. According to survival analysis, the variables related with events were a history of angina (hazard ratio [HR], 4.5; P ≤ .01), an ischemic electrocardiogram (HR, 4.0; P ≤ .01), the abnormal RMPI (HR, 11.4; P ≤ .05), and the RMPI score (HR, 1.1; P ≤ .0001). When the variables of interest were forced into a multivariate model, the χ(2) associated with the model that includes clinical and electrocardiogram information was 16.3 (P ≤ .005) and in the model that also includes RMPI score, it was 23.0 (P ≤ .0005). CONCLUSION: In a low- to intermediate-risk group of patients with suspected acute myocardial ischemia, RMPI gives not only diagnostic information but adds prognostic value to the traditional ED risk stratification tools.

Prognosis of normal stress-only gated-SPECT myocardial perfusion imaging: a single center study.

It has been advocated that using the stress followed by rest protocol, if the stress images were normal there is no need of rest images, reducing radiation exposure and costs. Our purpose was to assess the prognosis of a group of patients with normal stress-only gated-SPECT myocardial perfusion imaging. This was retrospective study that includes 790 patients with normal myocardial stress only perfusion gated SPECT images. Images were considered as normal if a homogeneous myocardial distribution of the tracer was associated with a normal ejection fraction. The mean follow-up was of 42.8 ± 13.3 months. The considered events were death of all causes, myocardial infarction and myocardial revascularization. During this period there were 85 events (10.8 %), including 57 deaths of all causes (67.1 %), 9 myocardial infarctions (10.6 %), 19 revascularizations (2.4 %). In the first year of follow-up there were 32 events (4.0 %) and excluding non cardiac deaths there were 8 events (1.0 %). Using Cox survival analysis, diabetes (HR = 2.2; CI = 1.4-3.4; p ≤ 0.0005), the history of coronary artery disease (CAD) (HR = 2.1; CI = 1.3-3.2; p ≤ 0.001), age (HR = 1.0; CI = 1.0-1.0; p ≤ 0.05) and type of stress protocol were related with events (exercise test vs. adenosine) (Exercise test: HR = 0.5; CI = 0.3-0.8; p ≤ 0.01). In a multivariate analysis the independent predictors were diabetes, CAD and the type of stress protocol. Based on these results, normal stress-only images are associated with an excellent prognosis even in patients at higher risk, diabetics and patients with known CAD.

Left ventricular mechanical dyssynchrony in patients with impaired left ventricular function undergoing gated SPECT myocardial perfusion imaging.

INTRODUCTION: Gated SPECT myocardial perfusion imaging (MPI) has been used to quantify mechanical dyssynchrony. Mechanical dyssynchrony appears to be related to response to cardiac resynchronization therapy. OBJECTIVE: To evaluate the presence and predictors of mechanical dyssynchrony in patients with impaired left ventricular function (LVEF) ≤50%. METHODS: The study included 143 consecutive patients referred for gated SPECT MPI with LVEF ≤50%. Gated SPECT MPI was performed according to a stress/rest protocol acquiring images with Tc 99m-tetrofosmin. Emory Cardiac Toolbox software was used for phase analysis and a standard deviation (SD) ≥43° was considered to indicate mechanical dyssynchrony. RESULTS: Mechanical dyssynchrony was present in 53.1% of the patients. Its predictors were diabetes (OR 2.0, p≤0.05), summed stress score (OR 1.1, p≤0.0005), summed rest score (OR 1.1, p≤0.0001), end-diastolic volume (OR 1.0, p≤0.0001), LVEF (OR 0.9, p≤0.0001), LVEF ≤35% (OR 3.1, p≤0.005) and LVEF ≤35% and QRS ≥120 ms (OR 3.5, p≤0.05). In this study QRS width and QRS ≥120 ms were not predictors of mechanical dyssynchrony. CONCLUSIONS: Myocardial perfusion imaging can be used to assess mechanical dyssynchrony. In patients with impaired ventricular function mechanical dyssynchrony was highly prevalent and was related to parameters of left ventricular function and perfusion.

Age at death estimation using bone densitometry: testing the Fernández Castillo and López Ruiz method in two documented skeletal samples from Portugal.

This study aims to evaluate the accuracy, precision and bias of a method for age at death estimation based in bone mineral density values assessed by dual X-ray absorptiometry at Ward's area (proximal femur). Estimated age at death was contrasted with documented age at death in two Portuguese reference samples (Coimbra Identified Skeletal Collection - CISC, and Identified Skeletal Collection of the 21st Century - Santarém XXI). Mean absolute error (accuracy) varies between 10.5 years (females) and 11.6 years (males) in the CISC sample; and between 11.9 years (males) and 12.7 years (females) in the Santarém XXI study base. The precision of the method varies between 13.0 years (females) and 14.5 years (males), in the CISC sample, and between 8.4 years (females) and 9.5 years (males), in the Santarém XXI sample. Mean error values (bias) suggest that this method tends to overestimate age in younger individuals, and to underestimate it in older individuals, regardless of sex or sample. Nonetheless, the method seems to perform as well as, or better than, other widely tested age estimation techniques, making it a suitable option when more accurate tests are not feasible in any given situation.

Prediction of sentinel node status and clinical outcome in a melanoma centre.

Background. Sentinel lymph node biopsy (SLNB) is a standard procedure for patients with localized cutaneous melanoma. The National Comprehensive Cancer Network (NCCN) Melanoma Panel has reinforced the status of the sentinel lymph node (SLN) as an important prognostic factor for melanoma survival. We sought to identify predictive factors associated with a positive SLNB and overall survival in our population. Methods. We performed a retrospective chart review of 221 patients who have done a successful SLNB for melanoma between 2004 and 2010 at our department. Univariate and multivariate analyses were done. Results. The SLNB was positive in 48 patients (21.7%). Univariate analysis showed that male gender, increasing Breslow thickness, tumor type, and absence of tumor-infiltrating lymphocytes were significantly associated with a positive SLNB. Multivariate analysis confirmed that Breslow thickness and the absence of tumor-infiltrating lymphocytes are independently predictive of SLN metastasis. The 5-year survival rates were 53.1% for SLN positive patients and 88.2% for SLN negative patients. Breslow thickness and the SLN status independently predict overall survival. Conclusions. The risk factors for a positive SLNB are consistent with those found in the previous literature. In addition, the SLN status is a major determinant of survival, which highlights its importance in melanoma management.

Persistent primary hyperparathyroidism: an uncommon location for an ectopic gland--case report and review.

Primary hyperparathyroidism (PHPT) is a common endocrine disorder that mainly affects middle-aged women. Patients are usually asymptomatic. The disease might be ascribable to hyperplasia, carcinoma, and single or multiple adenomas. PHPT may be sporadic or familial, the latter comprising multiple endocrine neoplasia type 1 or 2A, familial benign hypocalciuria hypercalcemia, and hyperparathyroidism-jaw tumor syndrome. The most common causes for persistent PHPT are multiglandular disease, and missed abnormal ectopic or orthotopic parathyroid glands. Imaging localization studies should precede a new surgical intervention. Ectopic parathyroid glands are rarely located at the aortopulmonary window. For diagnosis confirmation, (99m)Tc-sestamibi SPECT/CT seems to be an advantageous test. Another possibility is to perform (99m)Tc-sestamibi followed by thoracic CT or MRI. Parathyroidectomy may be performed by means of median sternotomy, thoracotomy, or video-assisted thoracoscopy. We describe a case of persistent primary hyperparathyroidism due to the presence of an ectopic parathyroid gland found at the aortopulmonary window. As the investigation necessary to clarify the etiology of recurrent nephrolithiasis proceeded, the diagnosis of PHPT was determined. The patient underwent subtotal parathyroidectomy; nevertheless, PHPT persisted. Genetic syndromes that could account for this condition were excluded. Imaging studies available at that time were not able to locate abnormal glands; moreover, the patient refused to undergo surgical exploration. Later, the patient underwent (99m)Tc-sestamibi SPECT/CT, which revealed a parathyroid gland at the aortopulmonary window.

Persistent primary hyperparathyroidism: an uncommon location for an ectopic gland - Case report and review / Hiperparatiroidismo primário persistente: glândula ectópica em localização rara - Caso clínico e revisão

Primary hyperparathyroidism (PHPT) is a common endocrine disorder that mainly affects middle-aged women. Patients are usually asymptomatic. The disease might be ascribable to hyperplasia, carcinoma, and single or multiple adenomas. PHPT may be sporadic or familial, the latter comprising multiple endocrine neoplasia type 1 or 2A, familial benign hypocalciuria hypercalcemia, and hyperparathyroidism-jaw tumor syndrome. The most common causes for persistent PHPT are multiglandular disease, and missed abnormal ectopic or orthotopic parathyroid glands. Imaging localization studies should precede a new surgical intervention. Ectopic parathyroid glands are rarely located at the aortopulmonary window. For diagnosis confirmation, 99mTc-sestamibi SPECT/CT seems to be an advantageous test. Another possibility is to perform 99mTc-sestamibi followed by thoracic CT or MRI. Parathyroidectomy may be performed by means of median sternotomy, thoracotomy, or video-assisted thoracoscopy. We describe a case of persistent primary hyperparathyroidism due to the presence of an ectopic parathyroid gland found at the aortopulmonary window. As the investigation necessary to clarify the etiology of recurrent nephrolithiasis proceeded, the diagnosis of PHPT was determined. The patient underwent subtotal parathyroidectomy; nevertheless, PHPT persisted. Genetic syndromes that could account for this condition were excluded. Imaging studies available at that time were not able to locate abnormal glands; moreover, the patient refused to undergo surgical exploration. Later, the patient underwent 99mTc-sestamibi SPECT/CT, which revealed a parathyroid gland at the aortopulmonary window.

O hiperparatiroidismo primário (HPP) é uma endocrinopatia frequente que afeta maioritariamente mulheres de meia-idade e é geralmente assintomática. A doença pode ser atribuível a hiperplasia, carcinoma, adenomas únicos ou múltiplos. O HPP inclui formas esporádicas e familiares. As formas familiares englobam neoplasia endócrina múltipla tipo 1 ou 2A, hipercalcemia hipocalciúrica familiar e síndrome hiperparatiroidismo/tumor mandibular-maxilar. As causas mais frequentes de HPP persistente são a presença de doença multiglandular ou de paratiroide anômala ectópica ou ortotópica não identificada previamente. É recomendável que a localização imagiológica preceda a reintervenção cirúrgica. A janela aortopulmonar é uma localização ectópica rara, sendo o 99mTc-sestamibi SPECT/TC um exame de confirmação vantajoso ou, alternativamente o 99mTc-sestamibi seguido de TC ou RM torácica. A paratiroidectomia pode ser efetuada por meio de esternotomia mediana, toracotomia ou toracoscopia videoassistida. Descrevemos um caso de HPP persistente atribuível à presença de uma glândula paratiroide ectópica localizada à janela aortopulmonar. O diagnóstico de HPP foi estabelecido na sequência da investigação requisitada para esclarecimento etiológico da nefrolitíase recidivante constatada nessa doente. Foi submetida à paratiroidectomia subtotal; não obstante, o HPP persistiu. Excluíram-se síndromes genéticas que pudessem justificar esse quadro clínico. Os exames imagiológicos disponíveis (à época) revelaram-se infrutíferos na detecção de paratiroides anômalas; adicionalmente, a doente recusou exploração cirúrgica. Posteriormente, a doente foi submetida a 99mTc-sestamibi SPECT/TC, que revelou a presença de uma paratiroide na janela aortopulmonar.