Fluorine-18 labelled prostate-specific membrane antigen (PSMA)-1007 positron-emission tomography-computed tomography: normal patterns, pearls, and pitfalls.

Prostate-specific membrane antigen (PSMA)-based positron-emission tomography (PET)-computed tomography (CT) has shown great promise in prostate cancer imaging. This technique has demonstrated particular utility in the staging of high-risk primary cancer and in the localisation of recurrent disease. The use of fluorine-18 PSMA-1007 is advantageous, as it is excreted via the hepatobiliary system rather than urinary and the longer half-life of fluorine-18 compared to gallium tracers, allows for PSMA imaging in centres without a gallium generator. However, imaging with this tracer is not without flaws and areas of ambiguity remain. In this article, the biodistribution, clinical indications, and pearls of 18F-PSMA-1007 PET-CT in patients with prostate cancer will be discussed, as well as the potential pitfalls in the reporting of these studies.

Is the endoscopic third ventriculostomy success score an appropriate tool to inform clinical decision-making?

INTRODUCTION: The endoscopic third ventriculostomy success score (ETVSS) is a model, which provides each patient with a prediction of the outcome of endoscopic third ventriculostomy. The objective of this study was to determine if there is clinical value to the use of the ETVSS in the decision for ETV. METHODS: Prospectively collected data on all ETV procedures with the Republic of Ireland in children ≤16 years of age, totalling 112, from 2008 to 2014 was analysed. The percentage chance of success at six months was retrospectively calculated according to the ETVSS. A multivariable model, comprising the risk factors from the ETVSS - age, aetiology and previous shunt - was created and its performance compared to that of the ETVSS. RESULTS: The ETVSS achieved an AUC of 0.61 (95% CI: 0.49-0.71) with a sensitivity and specificity of 50% and 76%, respectively, at its optimal cutoff. The ETVSS was not significantly well calibrated in this cohort and there was a limited net benefit on decision curve analysis in comparison with the strategy of performing ETV in all patients. The multivariable model achieved an AUC of 0.67 (95% CI: 0.56-0.78), was well calibrated and was associated with a superior net benefit over that of the ETVSS. CONCLUSION: The ETVSS represents the future of patient risk stratification with an easy to use, individualised approach for each patient. The ETVSS has performed adequately in this study. However, through the addition of novel risk factors, the continuous updating of the model and recalibration where needed, the ETVSS can become a tool that the paediatric neurosurgeon cannot do without.

Surgical learning activities for house officers: do they improve the surgical experience?

OBJECTIVE: To ascertain whether house officers (HOs) attain a more satisfactory surgical rotation experience when they perform basic surgical learning activities. We also sought to establish how many and which learning activities HOs achieve and the effect on their surgical experience. METHODOLOGY: A questionnaire listing 20 learning activities and questions regarding satisfaction with an overall experience was disseminated to HOs in the UK and Ireland who had completed ≥3 months of surgical rotations. Satisfaction with surgical experience was dichotomised in order to perform logistic regression using R Studio software v0.98. RESULTS: The survey was completed by 150 respondents, with 26 % completing at least 10 basic surgical learning activities during their surgical rotation. On multivariate analysis, the completion of these learning activities was significantly associated with a satisfactory rotation experience (p < 0.001). Furthermore, the use of a checklist of surgical activities provided to HOs was associated with a significant increase in the performance of learning activities (p = 0.003). CONCLUSION: Surgical HOs who were informed about potential basic surgical learning activities that can be performed during their rotations performed significantly more of these activities. And these activities were associated with a significantly greater satisfaction with surgical rotations. Therefore, we recommend facilitating HOs completion of these activities as this will ensure that basic surgical competencies are achieved and that HOs will be more satisfied with their surgical experience.

Predicting prostate cancer: analysing the clinical efficacy of prostate cancer risk calculators in a referral population.

BACKGROUND: The decision to proceed to biopsy for the diagnosis of prostate cancer in clinical practice is a difficult one. Prostate cancer risk calculators allow for a systematic approach to the use of patient information to predict a patient's likelihood of prostate cancer. AIMS: In this paper, we validate the two leading prostate cancer risk calculators, the prostate cancer prevention trial (PCPT) and the European Randomized Study of Screening for Prostate Cancer (ERSPC) in an Irish population. METHODS: Data were collected for 337 men referred to one tertiary referral center in Ireland. Calibration analysis, ROC analysis and decision curve analysis were undertaken to ascertain the performance of the PCPT and the ERSPC risk calculators in this cohort. RESULTS: Of 337 consecutive biopsies, cancer was subsequently diagnosed in 146 men (43 %), 98 (67 %) of which were high grade. The AUC for the PCPT and ERSPC risk calculators were 0.68 and 0.66, respectively for the prediction of prostate cancer. Each calculator was sufficiently calibrated in this cohort. Decision curve analysis demonstrated a net benefit via the use of the PCPT and ERSPC risk calculators in the diagnosis of prostate cancer. CONCLUSIONS: The PCPT and ERSPC risk calculators achieve a statistically significant prediction of prostate cancer in this Irish population. This study provides external validation for these calculators, and therefore these tools can be used to aid in clinical decision making.

Preoperative irradiation of selected mediastinal masses.

During a 17-year period from 1982 to 1999, 117 patients underwent surgical treatment of mediastinal masses. Resection was accomplished in the majority (81 or 69%) of these masses; with the remaining patients (36 or 31%) having biopsy procedures only. Malignant tumors were found in 43 patients (37%). A small subset of the biopsy group (4 patients or 11%) with symptomatic anterior masses were assessed to be of high risk for significant complications of anesthesia during the biopsy procedure and were treated with a short course of preoperative radiation to the mass prior to operation. All patients were operated upon without complication and definitive pathologic diagnosis was made in all cases despite preoperative low dose irradiation to the area of biopsy. Our experience demonstrates a practical and effective way of dealing with a potentially disastrous situation without compromising the accuracy of diagnosis.

Pericardio peritoneal window: laparoscopic approach.

Transdiaphragmatic approach to the pericarium through the use of the laparoscope is a safe and rapid way to obtain biopsy of the pericardium and create a window. No drainage tubes are needed: pericardial fluid is absorbed by the peritoneum; there is no need for double lumen tubes for one lung ventilation; and the laparoscopy incisions are small and almost painless.

Spontaneous cervical and mediastinal emphysema.

Subcutaneous cervical emphysema often appears as a result of surgery or trauma. However, when it occurs spontaneously, the patient may present with clinically impressive and dramatic features. The etiology is related to the rupture of terminal alveoli and dissection of air along the pulmonary vasculature. Exercise may contribute to the process by increases in intrathoracic pressure. Six cases of spontaneous cervical emphysema, all related to SCUBA diving training at a Naval facility, were recently seen at our institution. Proper management entails having a high index of suspicion for diagnosis, and then being able to identify potentially life-threatening complications.

Intraoperative coronary artery spasm successfully treated with nitroglycerin and nifedipine.

Coronary artery spasm is recognized as a major cause of angina and may coexist with fixed coronary artery disease. This report presents the case of a patient who developed recurrent coronary artery spasm in the operating room following effective coronary artery bypass grafting. The coronary artery spasm was manifested by sudden ST segment elevation, hypotension, and decreased cardiac output. Direct injection of nitroglycerin into each coronary artery graft was necessary to reverse the coronary artery spasm. Peripheral intravenous nitroglycerin plus nifedipine administered through a nasogastric tube prevented further recurrence of coronary artery spasm.

Abdominal injuries in automobile accidents: review of care of fatally injured patients.

Hypovolemia continues to be an important cause of death in patients who die as a result of vehicular trauma. Diagnosis and treatment of a series of 127 patients who died with blunt abdominal trauma from automobile accidents during 1969-1974 in Vermont are reported. The most frequent errors in the cases reviewed were failure to recognize and adequately treat hypovolemia, and to appreciate the urgent need for surgery. Death on the X-ray table while allowing persistence of hypovolemia was the common denominator in four of the five victims who died of ruptured spleens in the emergency departments, after having arrived alive following vehicular trauma. Forty-seven per cent of all reported deaths in automobile accidents had blunt abdominal trauma. Of those with blunt abdominal trauma who arrived alive, 26% might have survived with appropriate treatment which should have been available.