Findings in 1,123 Men with Preoperative 68Ga-Prostate-Specific Membrane Antigen Positron Emission Tomography/Computerized Tomography and Multiparametric Magnetic Resonance Imaging Compared to Totally Embedded Radical Prostatectomy Histopathology: Implications for the Diagnosis and Management of Prostate Cancer.

PURPOSE: Multiparametric magnetic resonance imaging (mpMRI) fails to identify some men with significant prostate cancer. Prostate-specific membrane antigen positron emission tomography/computerized tomography (PSMA PET/CT) is recommended for staging of prostate cancer, but its additional benefit above mpMRI alone in local evaluation for prostate cancer is unclear. The study aim was to evaluate the ability of mpMRI and PSMA PET/CT individually and in combination, to predict tumor location and Gleason score ≥3+4 on robot-assisted laparoscopic radical prostatectomy (RALP) histology. MATERIALS AND METHODS: We retrospectively reviewed 1,123 men with a preoperative mpMRI and 68Ga-PSMA PET/CT prior to a RALP. Tumor locations were collected from both imaging modalities and compared to totally embedded prostate histology. Lowest apparent diffusion coefficient value on mpMRI and the highest maximum standardized uptake value (SUVmax) on 68Ga-PSMA PET/CT were collected on the index lesions to perform analysis on detection rates. RESULTS: Median prostate specific antigen was 6. Median Gleason score on biopsy and RALP histology was 4+3. The index lesion and multifocal tumor detection were similar between mpMRI and 68Ga-PSMA PET/CT (p=0.10; p=0.11). When combining mpMRI and 68Ga-PSMA PET/CT, index Gleason score ≥3+4 cancer at RALP was identified in 92%. Only 10% of patients with Gleason score ≤3+4 on biopsy with an SUVmax <5 were upgraded to ≥4+3 on RALP histology, compared to 90% if the SUVmax was >11. CONCLUSIONS: The addition of a diagnostic 68Ga-PSMA PET/CT to mpMRI can improve the detection of significant prostate cancer and improve the ability to identify men suitable for active surveillance.

Knowledge of and attitudes expressed toward epilepsy by carers of people with epilepsy: a UK perspective.

OBJECTIVE: The aim of this study was to investigate the knowledge and attitudes possessed by carers of people with epilepsy. METHODS: A postal survey of 2000 carers recruited from the membership list of a UK epilepsy charity was conducted using a standard set of questions. The questions covered their knowledge of epilepsy (e.g., estimating prevalence and identifying causes of epilepsy) and their attitudes (e.g., about the characteristics of people with epilepsy). RESULTS: Overall, 651 carers responded. Only 29% of carers were male, with the majority between 40 and 60 years of age. The majority of respondents (76%) overestimated the prevalence of epilepsy. Twenty-five percent believed that epilepsy was caused by stress. The majority of respondents believed that people with epilepsy were treated differently by others. Only a small percentage believed that people with epilepsy should be barred from such professions as teaching and nursing. CONCLUSIONS: Carers of people with epilepsy generally possessed high levels of knowledge about most aspects of epilepsy, and their attitudes toward those with epilepsy were benign. There were, however, particular groups who were more likely to hold more positive attitudes, and these included younger and better-educated individuals. Limitations of this study include that the sample was self-selected and that only a third of the people to whom the questionnaire was mailed responded.

Determination of right ventricular ejection fraction from reprojected gated blood pool SPET: comparison with first-pass ventriculography.

Gated blood pool (GBP) studies are widely available and relatively inexpensive. We have previously published a simple and convenient method for measuring left ventricle ejection fraction (EF) with increased accuracy from single-photon emission tomography (SPET) GBP scans. This paper describes an extension of this method by which right ventricular EF may also be measured. Gated SPET images of the blood pool are acquired and re-oriented in short-axis slices. Counts from the left ventricle are excluded from the short-axis slices, which are then reprojected to give horizontal long-axis images. Time-activity curves are generated from each pixel around the right ventricle, and an image is created with non-ventricular pixels "greyed out". This image is used as a guide in drawing regions of interest around the right ventricle on the end-diastolic and end-systolic long-axis images. In 28 patients, first-pass ventriculography studies were acquired followed by SPET GBP scans. The first-pass images were analysed a total of four times by two observers and the SPET images were analysed three times each by two observers. The agreement between the two techniques was good, with a correlation coefficient of 0.72 and a mean absolute difference between first-pass and reprojected SPET EFs of 4.8 EF units. Only four of the 28 patients had a difference of greater than 8 EF units. Variability was also excellent for SPET right ventricular EF values. Intra-observer variability was significantly lower for SPET than for first-pass EFs: standard error of the estimate (SEE)=5.1 and 7.3 EF units, respectively (P<0.05). Inter-observer variability was comparable in the two techniques (SEE=5.2 and 6.9 EF units for SPET and first-pass ventriculography, respectively).

Unusual extrathyroidal iodine accumulation in a post-ablative I-131 scan.

A case of iodine-131 accumulation in the gall bladder following an ablative dose for thyroid carcinoma is presented.

Evaluation of portable bladder ultrasound: accuracy and effect on nursing practice in an acute care neuroscience unit.

The purpose of this evaluation was to determine the accuracy of a portable ultrasound instrument in assessing bladder volume in an acute care neuroscience population and the effect of ultrasound assessment on nursing practice in an acute care neuroscience unit. In a 6-week prospective evaluation, 105 paired ultrasound measurements were performed by 45 nurses on 30 patients suspected to be retaining urine. Sixty-seven catheterizations were performed, and volumes were compared with corresponding ultrasound readings. The first ultrasound volume readings slightly underestimated the catheterized volumes, but the volumes from the first ultrasound readings and the catheterized volumes were highly correlated. Volume readings from a second ultrasound, the average of the first and second ultrasound readings, and the higher of the two ultrasound readings did not add to the ability of the ultrasound instrument to predict catheterized volumes. Patient age and gender did not change the relationship between ultrasound and catheterized volumes. The ultrasound assessment changed nursing practice in 51% of the instances; the most common change (32%) was that nurses did not catheterize the patient. The ultrasound assessment did not change nursing practice in 49% of the instances; the most common reason (41%) was that the ultrasound confirmed the need to catheterize the patient. The instrument was therefore judged to be an accurate and reliable tool that changed nursing practice in an acute care neuroscience unit.

Nuclear medicine imaging in early vertebral osteomyelitis: still of clinical utility.

A case is presented of vertebral osteomyelitis in an elderly confused patient with poorly localizing signs. The lesion was not diagnosed on the initial MRI study of the spine due to poor targeting. The abnormality was detected on a bone scan the following day. This was confirmed with a gallium scan 3 days later, and also a repeat MRI study 11 days after the first MRI, using an optimized protocol over the region of interest established by the bone scan.

Can CT pulmonary angiography replace ventilation-perfusion scans as a first line investigation for pulmonary emboli?

A prospective study was performed to determine efficacy of diagnosis of pulmonary emboli by computed tomographic pulmonary angiography (CTPA) in patients who underwent both CTPA and ventilation-perfusion (V/Q) scanning. The results were compared with the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study in which conventional pulmonary angiography had been performed instead of CTPA. Forty-two of 161 (26%) patients had a positive CTPA compared with a 27% prevalence in the PIOPED population. Fourteen of 16 patients (87.5%) with high-probability V/Q scans also had a positive CTPA compared with 87% in PIOPED. Twelve of 40 patients (30%) with intermediate probability V/Q scans also had a positive CTPA compared with 34.7% in PIOPED, while 12 of 80 patients (15%) who had low-probability V/Q scans had positive CTPA compared with 14.5% in PIOPED. Four of 25 patients (16%) with normal V/Q scans had positive CTPA compared with 0% in PIOPED. While the present study size was relatively small, the results compared favourably with PIOPED, suggesting that equivalent prevalence of clot was being detected using CTPA. This result, together with the cost considerations, has led us to replace V/Q scanning with CTPA for investigation of the majority of cases of suspected, acute pulmonary emboli.

Lap belt abdominal aortic trauma.

A case of vehicle accident trauma to the abdominal aorta in a patient wearing a lap-type seat belt is presented, together with its diagnosis and management. The role of the radiologist is emphasized.

Achievement motivation, anxiety and academic success in first year Master of Nursing students.

Forty-one first semester master level nursing students from three Canadian universities participated in this descriptive correlational study to identify the influence of achievement motivation and anxiety on their academic success. Academic success was determined by their first semester grade point average (GPA). Participants had high achieving tendencies (M = 73.5) and academic ability (M = 81.9), supporting Atkinson's (1957, 1964) achievement motivation theory which was used as the framework. While state anxiety was negatively correlated, trait anxiety was the only valid predictor of academic success. Academic ability and inherent anxiety had a greater potential for predicting students who would succeed, which has implications for nurse educators, administrators and researchers. However, the need to assess both cognitive and non-cognitive variables to determine master level nursing students' ability to succeed is recommended.

Topical diclofenac/hyaluronic acid gel in the treatment of solar keratoses.

A randomized double-blind controlled trial of 130 patients was performed to study the efficacy and tolerability of topical 3% diclofenac in 2.5% hyaluronic acid (HA) gel (active) versus gel containing 2.5% HA alone (control) in the treatment of solar keratoses. Patients were asked to apply trial gel to the target lesion twice a day and also sunscreen once a day for 24 weeks. The complete response rates were 29% for the active gel and 17% for the control gel. The difference was not statistically significant (P = 0.14). A high percentage of patients in both groups experienced a partial response to treatment (38% active, 45% control) but there was no significant difference in the spectrum of response between the two treatments (P = 0.18). Local adverse reactions occurred significantly more frequently in patients using the active gel (29% compared to 5% using control gel, P = 0.0002).

Laryngeal Uhthoff's phenomenon: a case report.

An Uhthoff-like phenomenon was recently observed in a patient with clinically definite MS who experienced transient dysphonia brought on by exertion and relieved by cooling. The patient's dysphonia was felt to be related to intermittent temperature-dependent conduction block associated with a demyelinating plaque in the region of the left nucleus ambiguus. We have termed the patient's intermittent dysphonia 'laryngeal Uhthoff's phenomenon'.

Oral premedication for local anesthesia in plastic surgery: prospective, randomized, blind comparison of lorazepam and temazepam.

Patients undergoing plastic surgical procedures under local anesthesia as inpatients were entered into a phase III randomized, blind trial designed to compare two commonly used oral premedications, lorazepam and temazepam. The effects of the drugs on each patient's memory, pain, sedation, and anxiety were assessed by questions asked of the patient, the nurse, and the surgeon. Analysis was based on 100 randomized patients. Lorazepam had a significantly greater amnesic effect (p < 0.0001), resulted in less pain with the local anesthetic injection (p = 0.006), and had a greater sedative effect than temazepam (p < 0.0001, patient's assessment; p = 0.005, observers' assessments). There was no significant difference in anxiolysis between the two premedications (p = 0.20). If premedication is indicated, we advocate the use of lorazepam rather than temazepam as premedication for plastic surgical procedures to be performed under local anesthesia, provided there is adequate postoperative supervision.

Late recurrence of localized cutaneous melanoma: its influence on follow-up policy.

This paper reports 11 cases of recurrence 10 years or more after primary treatment of clinically local cutaneous melanoma at the Peter MacCallum Cancer Institute. Using the product-limit method for estimating recurrence-free survival, two late recurrence rates have been calculated. The estimated late recurrence rate among all treated patients is 5 percent (95 percent confidence interval: 2 to 8 percent), and the estimated late recurrence rate for the group who survived the first 10 years without recurrence is 7 percent (95 confidence interval: 3 to 11 percent). No prognostic factors were found that could identify a patient subgroup significantly at risk of late recurrence. Recurrence-free survival curves show that most recurrences have presented by the end of 6 years, but later recurrences are seen, the latest in this series being 18.2 years following treatment. While patients probably do not require long-term follow-up in specialist clinics provided they are adequately educated in the nature of their disease, this paper shows the value of long-term statistical surveillance.

Treatment of non-melanoma skin cancer: a review of recent trends with special reference to the Australian scene.

Non-melanoma skin cancer (NMSC) is rarely recorded in cancer registries and it is only relatively recently that the serious public health implications, especially in terms of morbidity and expense, have been appreciated. Increased recreational sun exposure (particularly among the young) and ozone layer depletion have generated concern in many countries. Histological confirmation of the diagnosis, either by excision biopsy or punch biopsy is essential if management of the condition is to be rational and the results assessed. Surgery or radiotherapy or other dermatological techniques will cure over 90% of all NMSC. Comparison of the results of various modalities is difficult and poorly documented. Local recurrence rates of 2.0% for surgery and 3.7% for superficial X-ray treatment (SXRT), with 96% and 90% 5-year failure-free-survival respectively are reported from the Peter MacCallum Cancer Institute. More comparative trials are required with good cosmetic and late normal tissue damage evaluation. Factors affecting modality choice trends in Australia are discussed, where the role of plastic surgery has considerably expanded. The indications for radiotherapy and its fractionation require clarification, as does the use of moulds and implants. The belief that solar keratoses transform to invasive cancer has been seriously brought into question by recent Australian epidemiological studies. There can, however, be little doubt of the fact that keratoses are markers of cumulative solar damage, which is a well recognised risk factor for development of NMSC. There is a move away from aggressive ablative treatment of keratoses. The management of keratoacanthoma (KA) by observation is the usual practice, although radiotherapy is occasionally used when the lesion is conspicuous and unsightly.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of nonmelanoma skin cancer at a large Australian center.

One thousand one hundred fifty-four cases of nonmelanoma skin cancer (NMSC) referred to the Consultative Skin Clinic at Peter MacCallum Cancer Institute (PMCI) (Melbourne, Australia) in 1980 were reviewed. The median age was 68 years, and the male to female ratio was 1.5:1. Final diagnosis was basal cell carcinoma (BCC) in 901 patients (78%), squamous cell carcinoma (SCC) in 242 patients (21%), and basosquamous carcinoma in 11 patients (1%). Seven hundred twelve (62%) were biopsy proven. Comparison of clinical and histologic diagnoses showed that BCC were correctly diagnosed clinically in 85% of cases but only 53% of SCC were correctly diagnosed. The distribution of sites was as follows: head and neck 871 (75%), limbs 131 (11%), trunk 50 (4%), and multiple sites 102 (9%). One thousand eighty-nine (94%) had primary lesions and 65 (6%) had recurrent lesions. The lesions were treated with surgery in 55% of cases, superficial radiotherapy in 39%, other types of radiotherapy in 3%, cryotherapy in 1%, and 5-fluorouracil in 0.2%. Recurrent lesions, lesions on the eyelids, ears or nose, and T4 lesions were significantly associated with increased failure rates. Superficial radiotherapy was associated with a 2.3-fold increase in failure rate compared to surgery when other prognostic factors were taken into account (P = 0.01, 95% confidence interval = 1.2-4.3). Nonsuperficial radiotherapy was associated with an 11.5-fold increase in failure rate compared to surgery (P less than 0.0001, 95% confidence interval = 4.9-27.1), but several of these cases were treated for palliative purposes only. The results of, and indications for treatment with surgery or radiotherapy at PMCI are discussed.

Invasive melanoma in the donor and recipient sites of a Hutchinson's freckle transplanted in a split skin graft.

An extraordinary case of synchronous development of invasive melanoma in the donor and recipient sites of a split skin graft is reported. The histological features suggest transplantation of a Hutchinson's melanotic freckle (lentigo maligna) at operation 10 years previously as the probable cause. The case is particularly interesting in that the invasive melanoma at both sites was at a similar stage despite a considerable difference in exposure to sunlight in the long postoperative period, perhaps discounting this factor as a precipitating cause of melanoma in Hutchinson's melanotic freckle (lentigo maligna melanoma).