Determining and updating PET/CT and SPECT/CT diagnostic reference levels : a systematic review

The aim of this systematic review is to investigate the national diagnostic reference level (NDRL) methods for positron emission tomography/computed tomography (PET/CT) and single photon emission tomography/computed tomography (SPECT/CT) procedures. A search strategy was based on the preferred, reporting items for systematic review and meta-analysis (PRISMA). Relevant articles retrieved from Medline, Scopus, Web of Science, Embase, Cinahl, and Google Scholar published up to October 2017. The search yielded 1,057 articles. Fourteen articles were included in the review after a screening process. Relevant information from the selected articles were summarised and analysed. Discrepancies were found between the methodologies utilised to establish and report both PET/CT and SPECT/CT NDRLs, e.g. patient sampling and administered activity. Further research should focus on reporting more NDRLs for hybrid PET/CT and SPECT/CT examinations, and establish a robust NDRL standard for the CT portion associated with PET/CT and SPECT/CT examinations. This review provides updated NDRL reommndations to deliver more comparable international radation doses for administered activity and CT dose across PET/CT and SPECT/CT clinics

Effective dose and effective risk from post-SPECT imaging of the lumbar spine

Purpose Planar bone scans play an important role in the staging and monitoring of malignancy and metastases. Metastases in the lumbar spine are associated with significant morbidity, therefore accurate diagnosis is essential. Supplementary imaging after planar bone scans is often, required to characterise lesions, however, this is associated with additional radiation dose. This paper provides information on the comparative effective dose and effective risk from supplementary lumbar spine radiographs, low-dose CT (LDCT) and diagnostic CT (DCT). Method Organ dose was measured in a phantom using thermo-luminescent dosimeters. Effective dose and effective risk were calculated for radiographs, LDCT, and DCT imaging of the lumbar spine. Results Radiation dose was 0.56mSv for the antero-posterior and lateral lumbar spine radiographs, 0.80mSv for LDCT, and 3.78mSv for DCT. Additional imaging resulted in an increase in effective dose of 12.28%, 17.54% and 82.89%for radiographs, LDCT and DCT respectively. Risk of cancer induction decreased as age increased. The difference in risk between the modalities also decreased. Males had a statistically significant higher risk than female patients (p=0.023) attributed to the sensitive organs being closer to the exposed area. Conclusion Effective Dose for LDCT is comparable to radiographs of the lumbar spine. Due to the known benefits image fusion brings it is recommended that LDCT replace radiographs imaging for characterisation of lumbar spine lesions identified on planar bone scan. DCT is associated with significantly higher effective dose than LDCT. Effective risk is also higher and the difference is more marked in younger female patients

Characteristics of Jupiter’s X‐ray auroral hot spot emissions using Chandra

To help understand and determine the driver of jovian auroral X-rays, we present the first statistical study to focus on the morphology and dynamics of the jovian northern hot spot (NHS) using Chandra data. The catalogue we explore dates from 18 December 2000 up to and including 8 September 2019. Using a numerical criterion, we characterize the typical and extreme behaviour of the concentrated NHS emissions across the catalogue. The mean power of the NHS is found to be 1.91 GW with a maximum brightness of 2.02 Rayleighs (R), representing by far the brightest parts of the jovian X-ray spectrum. We report a statistically significant region of emissions at the NHS center which is always present, the averaged hot spot nucleus (AHSNuc), with mean power of 0.57 GW and inferred average brightness of ∼ 1.2 R. We use a flux equivalence mapping model to link this distinct region of X-ray output to a likely source location and find that the majority of mappable NHS photons emanate from the pre-dusk to pre-midnight sector, coincident with the dusk flank boundary. A smaller cluster maps to the noon magnetopause boundary, dominated by the AHSNuc, suggesting that there may be multiple drivers of X-ray emissions. On application of timing analysis techniques (Rayleigh, Monte Carlo, Jackknife), we identify several instances of statistically significant quasi-periodic oscillations (QPOs) in the NHS photons ranging from ∼ 2.3-min to 36.4-min, suggesting possible links with ultra-low frequency activity on the magnetopause boundary (e.g. dayside reconnection, Kelvin-Helmholtz instabilities)

Identifying the Variety of Jovian X-Ray Auroral Structures: Tying the Morphology of X-Ray Emissions to Associated Magnetospheric Dynamics

We define the spatial clustering of X-rays within Jupiter's northern auroral regions by classifying their distributions into “X-ray auroral structures.” Using data from Chandra during Juno's main mission observations (24 May 2016 to 8 September 2019), we define five X-ray structures based on their ionospheric location and calculate the distribution of auroral photons. The morphology and ionospheric location of these structures allow us to explore the possibility of numerous X-ray auroral magnetospheric drivers. We compare these distributions to Hubble Space Telescope (HST) and Juno (Waves and MAG) data, and a 1D solar wind propagation model to infer the state of Jupiter's magnetosphere. Our results suggest that the five sub-classes of “X-ray structures” fall under two broad morphologies: fully polar and low latitude emissions. Visibility modeling of each structure suggests the non-uniformity of the photon distributions across the Chandra intervals are likely associated with the switching on/off of magnetospheric drivers as opposed to geometrical effects. The combination of ultraviolet (UV) and X-ray morphological structures is a powerful tool to elucidate the behavior of both electrons and ions and their link to solar wind/magnetospheric conditions in the absence of an upstream solar monitor. Although much work is still needed to progress the use of X-ray morphology as a diagnostic tool, we set the foundations for future studies to continue this vital research

Sulindac targets nuclear β-catenin accumulation and Wnt signalling in adenomas of patients with familial adenomatous polyposis and in human colorectal cancer cell lines

Nonsteroidal anti-inflammatory drugs (NSAIDs) have chemopreventive potential against colorectal carcinomas (CRCs). Inhibition of cyclooxygenase (COX)-2 underlies part of this effect, although COX-2-independent mechanisms may also exist. Nonsteroidal anti-inflammatory drugs appear to inhibit the initial stages of the adenoma-carcinoma sequence, suggesting a link to the APC/beta-catenin/TCF pathway (Wnt-signalling pathway). Therefore, the effect of the NSAID sulindac on nuclear (nonphosphorylated) beta-catenin and beta-catenin/TCF-mediated transcription was investigated. Nuclear #946;-catenin expression was assessed in pretreatment colorectal adenomas and in adenomas after treatment with sulindac from five patients with familial adenomatous polyposis (FAP). Also, the effect of sulindac sulphide on beta-catenin/TCF-mediated transcription was studied. Adenomas of FAP patients collected after treatment with sulindac for up to 6 months showed less nuclear beta-catenin expression compared to pretreatment adenomas of the same patients. Sulindac sulphide abrogated beta-catenin/TCF-mediated transcription in the CRC cell lines DLD1 and SW480, and decreased the levels of nonphosphorylated beta-catenin. As a result, the protein levels of the positively regulated TCF targets Met and cyclin D1 were downregulated after sulindac treatment. This study provides in vivo and in vitro evidence that nuclear beta-catenin localisation and beta-catenin/TCF-regulated transcription of target genes can be inhibited by sulindac. The inhibition of Wnt-signalling provides an explanation for the COX-2-independent mechanism of chemoprevention by NSAID

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

Breast composition : measurement and clinical use

Breast density is a measure of the extent of radiodense fibroglandular tissue in the breast. The risk of developing breast cancer and the risk of missing cancer at screening rise with higher breast density. In this paper, the historical background to breast density measurement is outlined and current evidence based practice is explained. The relevance of breast density knowledge to mammographic practice and image interpretation is considered in the light of clinical assessment and notification of mammographic breast density (MBD). The current work also discusses risk stratification for decision-making regarding screening frequency and better modalities for earlier detection of breast cancer in the dense breast. Automated volumetric approaches are explained while ultrasound, digital breast tomosynthesis, molecular breast imaging, and magnetic resonance imaging are introduced as valuable adjuncts to digital mammography for imaging the dense breast. The work concludes on the important note that screened women should be notified of their breast density, and such notification should be accompanied with clear and adequate information about breast density and cancer risk, strategies associated with lower MBD, as well as best screening intervals and pathways for women with dense breasts. Adoption of these strategies may be crucial to early detection and treatment of cancer and improving survival from the disease