Coronary artery spasm and non-Q-wave myocardial infarction following intravenous ephedrine in two healthy women under spinal anaesthesia

Vasovagal episodes occur frequently in young healthy patients undergoing venous cannulation and loco-regional anaesthesia. We report two cases of severe coronary vasospasm and non-Qwave infarction in healthy young women after administration of ephedrine for vasovagal symptoms at the onset of spinal anaesthesia. In the light of unopposed vagal predominance predisposing patients to coronary vasospasm, even in young healthy patients, atrophine and not ephedrine should be the first line treatment for bradycardia with or without hypotension under spinal anaesthesi

Prospective multicentre study using high intensity focused ultrasound (HIFU) for the focal treatment of prostate cancer: Safety outcomes and complications

Purpose To investigate focal therapy using High Intensity Focused Ultrasound (HIFU) for the treatment of localized prostate cancer (CaP), we analyzed the safety and complications of this procedure. Methods Patients (pts) eligible for this multicenter prospective cohort study suffered from low to intermediate risk localized CaP with no prior treatment. After tumor identification on multiparametric MRI and in prostate biopsy, the lesions were treated with HIFU observing a safety margin of 8 to 10 mm. Adverse events (AE) after 30 and 90 days, as well as the required interventions were assessed and stratified for treatment localizations. Results Of the 98 men included in the study in two European centers, 35 (35.7%) experienced AEs in the first 30 days after HIFU intervention with Clavien-Dindo grade ≤ II: 15 pts (15.3%) had a postoperative urinary tract infection and 26 pts (26.5%) a urinary retention. Four pts (4.1%) underwent subsequent intervention (Clavien-Dindo grade IIIa/b). The number of late postoperative complications occurring between 30 and 90 days after intervention was low (2.0%). The highest complication rate was associated with tumors located at the anterior base (50.0%). The inclusion of the urethra in the ablation zone led to AEs in 20 out of 41 cases (48.8%) and represented a significant risk factor for complications within 30 days (odds ratio = 2.53; 95% confidence interval: 1.08–5.96; P = 0.033). Conclusions Focal therapy of CaP lesions with a robotic HIFU-probe is safe and renders an acceptable rate of minor early AEs. The inclusion of the urethra in the ablation zone leads to an increase in early complications and should be avoided whenever possible

Coronary reserve in patients with aortic valve disease before and after successful aortic valve replacement

In patients with aortic valve disease and normal coronary angiograms coronary reserve was determined by the coronary sinus thermodilution technique. Three groups of patients were studied: 37 preoperative patients; 18 different patients 12.52 months after aortic valve replacement and seven control subjects with no cardiac disease. Coronary flow ratio (dipyridamole/rest) was diminished in preoperative compared with postoperative patients (1.66±0.44 vs 2.22±0.85; P<0.05) as well as with controls (2.80±0.84; P<0.01), and corresponding coronary resistance ratio (dipyridamolej rest) was higher in preoperative patients than in both other groups (0.61±0.17 vs 0.48±0.14; P<0.05 vs 0.37±0.10; P<0.01). Differences in the flow ratio, but not in the resistance ratio, were significant (P<0.05) in patients after aortic valve replacement compared with controls. Total coronary sinus blood flow at rest was elevated in preoperative compared with both postoperative patients and controls (252±99 vs 169±63; P<0.01; vs 170±35 ml.min−1, P<0.05), whereas flows after maximal vasodilation did not differ among the three groups (416± 184 vs 361 ± 150 vs 488± 235 ml.min−1). Postoperative patients showed a distinct, though not total regression of left ventricular angiographic muscle mass index and wall thickness. Nine of the 18 postoperative patients showed a normal coronary flow reserve and nine showed subnormal response. These two subgroups did not differ with respect to preoperative macroscopic and microscopic measures of hypertrophy. Thus in aortic valve disease, the reduced coronary vasodilator capacity is mainly due to an elevated coronary flow at rest, while the maximal coronary blood flow achieved is identical to that of postoperative patients and controls. With regression of left ventricular hypertrophy, flow at rest decreases and this leads to a distinct improvement of coronary flow reserv

68Ga-PSMA-11 PET/MR Can Be False Positive in Normal Prostatic Tissue

Prostate-specific membrane antigen (PSMA) is a transmembrane glycoprotein expressed in the cytosol of normal prostate tissue and highly overexpressed on the membrane of prostate cancer, therefore increasingly used to image prostate cancer. We report a case of a 65-year-old man with two focal PSMA-positive areas on a Ga-PSMA-11 PET/MR, one corresponding to a prostate carcinoma (Gleason score 4 + 3) and another region without any evidence of malignancy, but with corresponding high PSMA-expression on immunohistochemistry

Index lesion contouring on prostate MRI for targeted MRI/US fusion biopsy - Evaluation of mismatch between radiologists and urologists

PURPOSE: Mistargeting of focal lesions due to inaccurate segmentations can lead to false-negative findings on MRI-guided targeted biopsies. The purpose of this retrospective study was to examine inter-reader agreement of prostate index lesion segmentations from actual biopsy data between urologists and radiologists. METHOD: Consecutive patients undergoing transperineal MRI-targeted prostate biopsy for PI-RADS 3-5 lesions between January 2020 and December 2021 were included. Agreement between segmentations on T2w-images between urologists and radiologists was assessed with Dice similarity coefficient (DSC) and 95 % Hausdorff distance (95 % HD). Differences in similarity scores were compared using Wilcoxon test. Differences depending on lesion features (size, zonal location, PI-RADS scores, lesion distinctness) were tested with Mann-Whitney U test. Correlation with prostate signal-intensity homogeneity score (PSHS) and lesion size was tested with Spearman's rank correlation. RESULTS: Ninety-three patients (mean age 64.9 ± 7.1y, median serum PSA 6.5 [4.33-10.00]) were included. Mean similarity scores were statistically significantly lower between urologists and radiologists compared to radiologists only (DSC 0.41 ± 0.24 vs. 0.59 ± 0.23, p < 0.01; 95 %HD 6.38 ± 5.45 mm vs. 4.47 ± 4.12 mm, p < 0.01). There was a moderate and strong positive correlation between DSC scores and lesion size for segmentations from urologists and radiologists (ρ = 0.331, p = 0.002) and radiologists only (ρ = 0.501, p < 0.001). Similarity scores were worse in lesions ≤ 10 mm while other lesion features did not significantly influence similarity scores. CONCLUSION: There is significant mismatch of prostate index lesion segmentations between urologists and radiologists. Segmentation agreement positively correlates with lesion size. PI-RADS scores, zonal location, lesion distinctness, and PSHS show no significant impact on segmentation agreement. These findings could underpin benefits of perilesional biopsies

Prediction of pelvic lymph node metastases and PSMA PET positive pelvic lymph nodes with multiparametric MRI and clinical information in primary staging of prostate cancer

PURPOSE To compare the accuracy of multiparametric MRI (mpMRI), $^{68}$Ga-PSMA PET and the Briganti 2019 nomogram in the prediction of metastatic pelvic lymph nodes (PLN) in prostate cancer, to assess the accuracy of mpMRI and the Briganti nomogram in prediction of PET positive PLN and to investigate the added value of quantitative mpMRI parameters to the Briganti nomogram. METHOD This retrospective IRB-approved study included 41 patients with prostate cancer undergoing mpMRI and $^{68}$Ga-PSMA PET/CT or MR prior to prostatectomy and pelvic lymph node dissection. A board-certified radiologist assessed the index lesion on diffusion-weighted (Apparent Diffusion Coefficient, ADC; mean/volume), T2-weighted (capsular contact length, lesion volume/maximal diameters) and contrast-enhanced (iAUC, k$_{ep}$, K$^{trans}$, v$_{e}$) sequences. The probability for metastatic pelvic lymph nodes was calculated using the Briganti 2019 nomogram. PET examinations were evaluated by two board-certified nuclear medicine physicians. RESULTS The Briganti 2019 nomogram performed superiorly (AUC: 0.89) compared to quantitative mpMRI parameters (AUCs: 0.47-0.73) and $^{68}$Ga-PSMA-11 PET (AUC: 0.82) in the prediction of PLN metastases and superiorly (AUC: 0.77) in the prediction of PSMA PET positive PLN compared to MRI parameters (AUCs: 0.49-0.73). The addition of mean ADC and ADC volume from mpMRI improved the Briganti model by a fraction of new information of 0.21. CONCLUSIONS The Briganti 2019 nomogram performed superiorly in the prediction of metastatic and PSMA PET positive PLN, but the addition of parameters from mpMRI can further improve its accuracy. The combined model could be used to stratify patients requiring ePLND or PSMA PET

Diagnostic Accuracy of a MR Protocol Acquired with and without Endorectal Coil for Detection of Prostate Cancer: A Multicenter Study

Introduction The purpose of this study was to compare diagnostic accuracy of a prostate multiparametric magnetic resonance imaging (mpMRI) protocol for detection of prostate cancer between images acquired with and without en-dorectal coil (ERC). Materials This study was approved by the regional ethics committee. Between 2014 and 2015, 33 patients (median age 51.3 years; range 42.1-77.3 years) who underwent prostate-MRI at 3T scanners at 2 different institutions, acquired with (mpMRI) and without (mpMRI) ERC and who received radical prostatectomy, were included in this retrospective study. Two expert readers (R1, R2) attributed a PI-RADS version 2 score for the most suspect (i. e. index) lesion for mpMRI and mpMRI. Sensitivity and positive predictive value for detection of index lesions were assessed using 2 × 2 contingency tables. Differences between groups were tested using the McNemar test. Whole-mount histopathology served as reference standard. Results On a quadrant-basis cumulative sensitivity ranged between 0.61-0.67 and 0.76-0.88 for mpMRI and mpMRI protocols, respectively (p > 0.05). Cumulative positive predictive value ranged between 0.80-0.81 and 0.89-0.91 for mpMRI and mpMRI protocols, respectively. The differences were not statistically significant for R1 (p = 0.267) or R2 (p = 0.508). Conclusion Our results suggest that there may be no significant differences for detection of prostate cancer between images acquired with and without an ERC

External Validation and Comparison of Prostate Cancer Risk Calculators Incorporating Multiparametric Magnetic Resonance Imaging for Prediction of Clinically Significant Prostate Cancer

PURPOSE: To externally validate recently published prostate cancer risk calculators (PCa-RCs) incorporating multiparametric magnetic resonance imaging (mpMRI) for the prediction of clinically significant prostate cancer (csPCa) and compare their performance to mpMRI-naïve PCa-RCs. MATERIAL AND METHODS: Men without previous PCa diagnosis undergoing transperineal template saturation prostate biopsy with fusion-guided targeted biopsy between 11/2014 and 03/2018 in our academic tertiary referral center were identified. Any Gleason pattern ≥4 was defined to be csPCa. Predictors (age, PSA, DRE, prostate volume, family history, previous prostate biopsy and highest region of interest according to PIRADS) were retrospectively collected. Four mpMRI-PCa-RCs and two mpMRI-naïve PCa-RCs were evaluated for their discrimination, calibration and clinical net benefit using a ROC analysis, calibration plots and a decision curve analysis, respectively. RESULTS: Out of 468 men, 193 (41%) were diagnosed with csPCa. Three mpMRI-PCa-RCs showed similar discrimination with area-underneath-the-receiver-operating-characteristic-curves (AUC) from 0.83 to 0.85, which was significantly higher than the other PCa-RCs (AUCs: 0.69-0.74). Calibration-in-the-large showed minimal deviation from the true amount of csPCa by 2% for two mpMRI-PCa-RCs, while the other PCa-RCs showed worse calibration (11-27%). A clinical net benefit could only be observed for three mpMRI-PCa-RCs at biopsy thresholds ≥15%, while none of the six investigated PCa-RCs demonstrated clinical utility against a biopsy all strategy at thresholds <15%. CONCLUSIONS: Performance of the mpMRI-PCa-RCs varies, but they generally outperform mpMRI-naïve PCa-RCs in regard to discrimination, calibration and clinical usefulness. External validation in other biopsy settings is highly encouraged

Two-year clinical outcome after implantation of sirolimus-eluting and paclitaxel-eluting stents in diabetic patients

Aims Percutaneous coronary intervention (PCI) in diabetic patients is associated with an increased risk of restenosis and major adverse cardiac events (MACE). We assessed the impact of diabetes on long-term outcome after PCI with sirolimus-eluting (SES) and paclitaxel-eluting (PES) stents. Methods and results In the SIRTAX trial, 1012 patients were randomized to treatment with SES (n = 503) or PES (n = 509). A stratified analysis of outcomes was performed according to the presence or absence of diabetes. Baseline characteristics were well balanced between SES and PES in patients with (N = 201) and without diabetes (N = 811). Clinical outcome was worse in diabetic compared with non-diabetic patients regarding death (9.0% vs. 4.1%, P = 0.004) and MACE (defined as cardiac death, myocardial infarction, or TLR; 19.9% vs. 12.7%, P = 0.007) at 2 years. Among diabetic patients, SES reduced MACE by 47% (14.8% vs. 25.8%, HR = 0.52, P = 0.05) and TLR by 61% (7.4% vs. 17.2%, HR = 0.39, P = 0.03) compared with PES at 2 years. Conclusion Diabetic patients have worse prognosis than non-diabetic patients undergoing PCI with DES. Among the diabetic patient population of this trial, SES reduce repeat revascularization procedures and MACE more effectively than PES and to a similar degree as in non-diabetic patient