Diagnostic performance of a streamlined 18F-choline PET-CT protocol for the detection of prostate carcinoma recurrence in combination with appropriate-use criteria.

AIM: To evaluate the efficacy of single time-point half-body (skull base to thighs) fluorine-18 choline positron emission tomography-computed tomography (PET-CT) compared to a triple-phase acquisition protocol in the detection of prostate carcinoma recurrence. MATERIALS AND METHODS: Consecutive choline PET-CT studies performed at a single tertiary referral centre in patients with biochemical recurrence of prostate carcinoma between September 2012 and March 2017 were reviewed retrospectively. The indication for the study, imaging protocol used, imaging findings, whether management was influenced by the PET-CT, and subsequent patient outcome were recorded. RESULTS: Ninety-one examinations were performed during the study period; 42 were carried out using a triple-phase protocol (dynamic pelvic imaging for 20 minutes after tracer injection, half-body acquisition at 60 minutes and delayed pelvic scan at 90 minutes) between 2012 and August 2015. Subsequently following interim review of diagnostic performance, a streamlined protocol and appropriate-use criteria were introduced. Forty-nine examinations were carried out using the single-phase protocol between 2015 and 2017. Twenty-nine (69%) of the triple-phase studies were positive for recurrence compared to 38 (78%) of the single-phase studies. Only one patient who had a single-phase study would have benefited from a dynamic acquisition, they have required no further treatment or imaging and are currently under prostate-specific antigen (PSA) surveillance. CONCLUSION: Choline PET-CT remains a useful tool for the detection of prostate recurrence when used in combination with appropriate-use criteria. Removal of dynamic and delayed acquisition phases reduces study time without adversely affecting accuracy. Benefits include shorter imaging time which improves patient comfort, reduced cost, and improved scanner efficiency.

Exchange nailing for nonunion of diaphyseal fractures of the tibia: our results and an analysis of the risk factors for failure.

AIMS: The aim of this study was to identify risk factors for the failure of exchange nailing in nonunion of tibial diaphyseal fractures. PATIENTS AND METHODS: A cohort of 102 tibial diaphyseal nonunions in 101 patients with a mean age of 36.9 years (15 to 74) were treated between January 1992 and December 2012 by exchange nailing. Of which 33 (32%) were initially open injuries. The median time from primary fixation to exchange nailing was 6.5 months (interquartile range (IQR) 4.3 to 9.8 months). The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union. RESULTS: Multiple causes for the primary nonunion were found for 28 (27%) tibiae, with infection present in 32 (31%). Six patients were lost to follow-up. Further surgical procedures were required in 35 (36%) nonunions. Other fixation modalities were required in five fractures. A single nail exchange procedure achieved union in 60/96 (63%) of all nonunions. Only 11 out of 31 infected nonunions (35.4%) healed after one exchange nail procedure. Up to five repeated exchange nailings, with or without bone grafting, ultimately achieved union in 89 (93%) fractures. The median time to union after exchange nailing was 8.7 months (IQR 5.7 to 14.0 months). Univariate analysis confirmed that an oligotrophic/atrophic pattern of nonunion (p = 0.002), a bone gap of 5 mm or more (p = 0.04) and infection (p < 0.001), were predictive for failure of exchange nailing Multiple regression analysis found that infection was the strongest predictor of failure (p < 0.001). CONCLUSION: Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion. However, in the presence of severe infection with a highly resistant organism, or extensive sclerosis of the bone, other fixation modalities, such as Ilizarov treatment, should be considered. TAKE HOME MESSAGE: Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion.

Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure.

The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing, of which six were open injuries. The median time to exchange nailing from primary fixation was 8.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Multiple causes for non-union were found in 16 (40%) cases, with infection present in 12 (30.0%) patients. Further surgical procedures were required in nine (22.5%) cases, one of whom (2.5%) required the use of another fixation modality to achieve union. Union was ultimately achieved with exchange nailing in 34/37 (91.9%) patients. The median time to union after the exchange nailing was 9.4 months. Cigarette smoking and infection were risk factors for failure of exchange nailing. Multivariate analysis found infection to be the strongest predictor of exchange failure (p<0.05). Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. However, 50% of patients undergoing exchange nailing in the presence of infection required at least one further procedure. It is important to counsel patients of this so that they can plan for it and do not consider that the first exchange operation has failed.

mRNA profiling of the cancer degradome in oesophago-gastric adenocarcinoma.

BACKGROUND: Degradation of the extracellular matrix is fundamental to tumour development, invasion and metastasis. Several protease families have been implicated in the development of a broad range of tumour types, including oesophago-gastric (OG) adenocarcinoma. The aim of this study was to analyse the expression levels of all core members of the cancer degradome in OG adenocarcinoma and to investigate the relationship between expression levels and tumour/patient variables associated with poor prognosis. METHODS: Comprehensive expression profiling of the protease families (matrix metalloproteinases (MMPs), members of the ADAM metalloproteinase-disintegrin family (ADAMs)), their inhibitors (tissue inhibitors of metalloproteinase), and molecules involved in the c-Met signalling pathway, was performed using quantitative real-time reverse transcription polymerase chain reaction in a cohort of matched malignant and benign peri-tumoural OG tissue (n=25 patients). Data were analysed with respect to clinico-pathological variables (tumour stage and grade, age, sex and pre-operative plasma C-reactive protein level). RESULTS: Gene expression of MMP1, 3, 7, 9, 10, 11, 12, 16 and 24 was upregulated by factors >4-fold in OG adenocarcinoma samples compared with matched benign tissue (P<0.01). Expression of ADAM8 and ADAM15 correlated significantly with tumour stage (P=0.048 and P=0.044), and ADAM12 expression correlated with tumour grade (P=0.011). CONCLUSION: This study represents the first comprehensive quantitative analysis of the expression of proteases and their inhibitors in human OG adenocarcinoma. These findings implicate elevated ADAM8, 12 and 15 mRNA expression as potential prognostic molecular markers.

Who will participate in acute stroke trials?

BACKGROUND: Despite the high incidence of acute stroke, only a minority of patients are enrolled in acute stroke treatment trials. We aimed to identify factors associated with participation in clinical trials of novel therapeutic agents for acute stroke. METHODS: Prospective survey of patients with acute stroke <72 hours from onset. A structured interview was administered to the patient or primary decision-maker. If offered participation in an actual acute treatment trial, questions focused on decisions about that trial; otherwise a similar mock trial was proposed. The primary outcome was whether the subject agreed to participate in the proposed trial. RESULTS: A total of 200 subjects (47% patients, 53% proxies) completed the survey: mean age 63 +/- 14 years, 47% women, 44% white, 50% black. A real acute trial was offered to 22%; others were offered a mock trial. Overall, 57% (95% confidence interval: 50%-64%) of respondents stated they would participate in the proposed acute treatment trial. There were no differences with respect to age, sex, race, educational level, self-assessed stroke severity or stroke type, vascular risk factors, or comorbidities. Misconceptions about key research concepts were found in 50% but did not impact participation. Participation was associated with the perceived risk of the proposed trial intervention (p < 0.001), prior general attitudes about research (p < 0.001), and influences attributed to family, religion, and other personal beliefs (p < 0.001). Patients were more likely to participate than proxy decision-makers (p = 0.04). CONCLUSIONS: Demographic factors, clinical factors, and prior knowledge about research have little impact on the decision to participate in acute stroke clinical trials. Preexisting negative attitudes and external influences about research strongly inhibit participation. Patients are more inclined to participate than their proxy decision-makers.

The effect of written informed consent on detection of violence in the home.

UNLABELLED: Studies of programmatic interventions for victims of violence in the home may require the use of informed consent. The use of informed consent may result in ascertainment bias, with victims of violence being less likely to participate. OBJECTIVE: To investigate the effect of written informed consent on the detection of violence in the home during emergency department (ED) screening. METHODS: The authors performed a nonrandomized, controlled trial of 3,466 patients at an urban university ED. On odd days, patients (n = 1,857) were read a brief scripted statement and screened using standardized questions. On even days, patients (n = 1,609) received standard written informed consent prior to the same screening questions (writ-IC). The main outcome was the number of cases of violence in the home detected using each screening protocol. RESULTS: Fewer writ-IC patients participated in screening (82% vs 92%; p < 0.001). Despite a higher refusal rate in the writ-IC group, there was no difference in the number of victims detected by each screening method: choked/kicked/bit/punched? (writ-IC, 7.3 vs routine screen, 6.5%; p = 0.3); slapped/grabbed/shoved? (7.3 vs 6.7%; p = 0.4); threatened/actually used knife/gun to scare/hurt you? (8.3 vs 9.4%; p = 0.3); thrown object to harm you? (5.2 vs 4.6%; p = 0.4); forced sex? (5.8 vs 4.7%; p = 0.15); or afraid current/former intimate partner would hurt you physically? (13.9 vs 11.9%; p = 0.9). CONCLUSIONS: A written informed consent process in screening for violence in the home is associated with a higher refusal rate than routine screening, but use of written informed consent does not result in a lower rate of detection for multiple forms of violence. The authors did not find any support for the hypothesis that the use of written informed consent would decrease detection of violence in the home.

A randomized, controlled trial of a simple emergency department intervention to improve the rate of primary care follow-up for patients with acute asthma exacerbations.

STUDY OBJECTIVE: We determined whether a simple emergency department intervention improves the likelihood of primary care provider (PCP) follow-up after ED discharge for an acute asthma exacerbation. METHODS: This randomized, controlled clinical trial was conducted in an urban university-based ED. Participants were patients with asthma between the ages of 16 and 45 years who were treated and discharged from the ED. The study intervention was usual care or an intervention that consisted of a free 5-day course of prednisone, vouchers for transportation to and from their PCP, and a 48-hour telephone reminder to make an appointment with their PCP. The main outcome was whether the patient received follow-up care as determined by PCP contact at 4 weeks. RESULTS: One hundred ninety-two patients with asthma were enrolled over 8 months; 178 (93%) had complete follow-up. The intervention and control groups were similar with regard to age, sex, ethnicity, or years of education. The 2 groups were also comparable with respect to multiple measures of baseline access/barriers to care and severity of ED exacerbation. Patients receiving the intervention were significantly more likely to follow up with their PCP than control patients (relative risk 1.6; 95% confidence interval [CI] 1.1, 2.4). When adjusted for other factors influencing PCP follow-up care (ethnicity, prior PCP relationship, insurance status, regular car access), intervention patients were more likely to follow up with their PCP (odds ratio 3.1; 95% CI 1.5, 6.3). CONCLUSION: Providing medication, transportation vouchers, and a telephone reminder to make an appointment increased the likelihood that discharged patients with asthma obtained PCP follow-up.

Pediatric emergency medicine education in emergency medicine training programs. SAEM Pediatric Education Training Task Force. Society for Academic Emergency Medicine.

BACKGROUND: The educational goal of emergency medicine (EM) programs has been to prepare its graduates to provide care for a diverse range of patients and presentations, including pediatric patients. OBJECTIVE: To evaluate the methods used to teach pediatric emergency medicine (PEM) to EM residents. METHODS: A written questionnaire was distributed to 118 EM programs. Demographic data were requested concerning the type of residency program, number of residents, required pediatric rotations, elective pediatric rotations, type of hospital and settings in which pediatric patients are seen, and procedures performed. Information was also requested on the educational methods used, proctoring EM received, and any formal curriculum used. RESULTS: Ninety-four percent (111/118) of the programs responded, with 80% of surveys completed by the residency director. Proctoring was primarily performed by PEM attendings and general EM attendings. Formal means of PEM education most often included the EM core curriculum (94%), journal club (95%), EM grand rounds (94%), and EM morbidity and mortality (M&M) conference (91%). Rotations and electives most often included the pediatric intensive care unit (PICU) and the emergency department (ED) (general and pediatric). CONCLUSIONS: Emergency medicine residents are exposed to PEM primarily by rotating through a general ED, the PED, and the PICU, being proctored by PEM and EM attendings and attending EM lectures and EM M&M conferences. Areas that may merit further attention for pediatric emergency training include experience in areas of neonatal resuscitation, pediatric M&M, and specific pediatric electives. This survey highlights the need to describe current educational strategies as a first step to assess perceived effectiveness.

An approach to community consultation prior to initiating an emergency research study incorporating a waiver of informed consent.

OBJECTIVES: In November 1996, the Food and Drug Administration (FDA) and the Department of Health and Human Services (DHHS) enacted rules allowing a narrow exception to the requirement for prospective informed consent when enrolling critically ill patients in clinical research studies of emergency treatments. These rules require that, prior to initiation of the study, the applicable institutional review board (IRB) assess the acceptability of the proposed research study to members of the community in which the research will be conducted. Specifically, the IRB must perform community consultation-a process during which community members learn about the proposed research and communicate their opinions regarding its acceptability to investigators or IRB representatives. The FDA and DHHS rules do not define specific acceptable methods for performing this community consultation. The objective of this study is to demonstrate the feasibility and utility of one proposed method for performing such community consultation. METHODS: Parents of children being seen for minor traumatic injuries in three pediatric EDs were asked to participate in a study regarding informed consent. After consent, an instructor described to the parent a prospective, randomized, placebo-controlled trial of phenytoin for the prophylaxis of posttraumatic seizures in children with severe closed head trauma. All parents were then asked whether they would have consented for their own child's participation, if their child had suffered such head injury. The parents were further asked to explain the reason(s) for their responses. RESULTS: Parents of 227 children (children's mean +/- SD age 8.0 +/- 4.8 years, 57% male) were interviewed. Sixty-six percent of parents (149/227) stated they would give consent for their child's participation. Of the 149 consenting parents, 85% (126/149) cited potential benefit to their child, 72% (107/149) cited potential benefit to other children, and 60% (90/149) cited furthering medical knowledge. Of the 78 nonconsenting parents (34% of total), 54% (42/78) cited fear of adverse effects, 39% (30/78) did not want their child to be a research subject in general, 27% (21/78) believed they needed to discuss participation with family members who were unavailable, and 26% (20/78) stated they were unable to decide unless they were in the actual situation. Parental ethnicity and household income were found to influence the consent decision, while the parent's gender, religion, language, and educational level were not associated with the consent decision. CONCLUSIONS: Community consultation regarding the acceptability of an emergency research protocol can be obtained via interview techniques in the ED. This methodology may allow investigators to obtain data on opinion from a targeted community for IRB consideration during the review of emergency research studies proposing a waiver of informed consent.

Emergency department treatment of minors.

This article discusses the practical application of ethical issues in the ED treatment of minors, beginning with a brief discussion of basic principles (including differences between adults and minors), and issues of consent and confidentiality. The remainder of the article focuses on case studies that explore the topics of drug and alcohol screening, sexually transmitted diseases, pregnancy, and sexual assault.

Association of missense and 5'-splice-site mutations in tau with the inherited dementia FTDP-17.

Thirteen families have been described with an autosomal dominantly inherited dementia named frontotemporal dementia and parkinsonism linked to chromosome 17 (FTDP-17), historically termed Pick's disease. Most FTDP-17 cases show neuronal and/or glial inclusions that stain positively with antibodies raised against the microtubule-associated protein Tau, although the Tau pathology varies considerably in both its quantity (or severity) and characteristics. Previous studies have mapped the FTDP-17 locus to a 2-centimorgan region on chromosome 17q21.11; the tau gene also lies within this region. We have now sequenced tau in FTDP-17 families and identified three missense mutations (G272V, P301L and R406W) and three mutations in the 5' splice site of exon 10. The splice-site mutations all destabilize a potential stem-loop structure which is probably involved in regulating the alternative splicing of exon10. This causes more frequent usage of the 5' splice site and an increased proportion of tau transcripts that include exon 10. The increase in exon 10+ messenger RNA will increase the proportion of Tau containing four microtubule-binding repeats, which is consistent with the neuropathology described in several families with FTDP-17.

Primary varicella in adults: pneumonia, pregnancy, and hospital admission.

STUDY OBJECTIVE: To define the rate of complications of adult varicella, including pneumonia, and to determine the association of such complications with pregnancy. METHODS: Retrospective, descriptive case series of consecutive adult emergency department patients with primary varicella seen over a 31-month period in an urban county hospital. RESULTS: A total of 130 patients were identified, with a mean age of 23.9 +/- 6.1 years; 69 (53%) were female. Thirteen patients (10.0%) had pneumonia; 6 of these were hospitalized. Two patients admitted with pneumonia had significant underlying comorbid disease and expired from respiratory failure. The remaining 4 admitted patients recovered uneventfully. Four of the 7 patients discharged with pneumonia were known to have recovered uneventfully. Twenty-eight (41%) of the 69 female study patients were pregnant; 7 of these (25%) were admitted, with admission diagnoses of pneumonia (1), active labor (2), and pregnancy with varicella (4). Incidence of pneumonia in pregnant patients was 3.6% (1 of 28; 95% confidence interval, 1% to 18.3%). All 7 admitted pregnant patients and the 19 (of 21) discharged pregnant patients who were contacted recovered uneventfully. No congenital anomalies or perinatal complications were noted in the infants of the 26 mothers with documented follow-up. CONCLUSION: Hospital admission should be considered for adults with varicella pneumonia, especially if they have significant comorbid disease. It does not appear that pregnant women are at increased risk of developing varicella pneumonia.

Emergency medical service system development: results of the statewide emergency medical service Technical Assessment Program.

STUDY OBJECTIVE: The National Highway Traffic Safety Administration developed the EMS (emergency medical services) Technical Assessment Program to assist states in developing and improving their EMS systems. The main goals of this evaluation were to document the level of improvement in EMS system development following completion of the Technical Assessment Program and to identify necessary program improvements at the National Highway Traffic Safety Administration. DESIGN: Independent investigators retrospectively reviewed the information in Technical Assessment Program reports from 35 states that participated in the program during a 5-year period. RESULTS: Training and certification programs for prehospital personnel were the most well-developed elements of EMS systems. Conversely, comprehensive quality management and EMS system evaluation programs were almost uniformly absent (89% of states). Areas of need targeted for improvement included enabling legislation for EMS (60%) or trauma system development (69%), an improved mechanism to assess system resources (71%), an established or updated state EMS plan (80%), aging and unreliable communications equipment (89%), fully operational prehospital data collection systems (89%), and consistent medical oversight for all prehospital providers (92%). CONCLUSION: Program evaluation revealed that significant recommendation-based changes occurred in all components of EMS systems. The Technical Assessment Program is one tool that states can use to promote EMS system improvements.

Fecal impaction: a rare cause of respiratory arrest in childhood.

Cardiopulmonary arrest in childhood is usually due to respiratory failure leading to hypoxemia, acidosis, cardiac dysfunction, and terminal asystole. Respiratory failure is the end result of either impaired oxygenation, impaired ventilation, or both. We report a case of severe fecal impaction in an eight year old that resulted in a significant depression of ventilation by severely restricting respiratory mechanics and that ultimately progressed to respiratory failure and circulatory compromise. Physicians should be aware of this rare but possible etiology for life-threatening events in children.

Incentive effects of choosing a therapist.

Investigated the effects of offering clients (N = 55) a choice of therapeutic style on show rate and reactions to the initial interview. Individuals who called for an appointment were assigned randomly to Choice and Attention-Control conditions. Choice Ss were informed that they would be assigned to a therapist who identified with one of two descriptions of therapy styles from which they could choose. Based on this choice, these persons were scheduled with the next therapist in line who had identified him/herself with the selected style. Attention-Control clients were informed about the range of services available at the clinic and paired with a therapist regardless of style on the usual rotating basis. A significantly higher proportion of Choice than Attention-Control Ss kept their schedules appointments. However, no significant differences were found on client and therapist evaluations of the initial interview.