Imaging patterns of liver uptakes on PET scan: pearls and pitfalls

Objective: PET imaging is becoming increasingly universal, and therefore increased liver uptake is frequently encountered. The purpose of this article is to describe and illustrate the various morphological patterns of increased metabolic activity within the liver with an emphasis on the diagnostic pitfalls and potential limitations.Conclusion: Knowing the pitfalls of PET imaging, correlation with clinical background and findings from other imaging modalities are all important in the correct interpretation of increased hepatic activity on PET imaging

APSS-ASJ Best Clinical Research Award: Predictability of Curve Progression in Adolescent Idiopathic Scoliosis Using the Distal Radius and Ulna Classification

Study DesignProspective study.PurposeTo determine the risk of clinically significant curve progression in adolescent idiopathic scoliosis (AIS) based on the initial Cobb angle and to test the utility of the distal radius and ulna (DRU) classification in predicting these outcomes.Overview of LiteratureDetermining the remaining growth potential in AIS patients is necessary for predicting prognosis and initiating treatment. Limiting the maturity Cobb angle to <40° and <50° reduces the risk of adulthood progression and need for surgery, respectively. The risk of curve progression is the greatest with skeletally immature patients and thus warrants close monitoring or early intervention. Many parameters exist for measuring the skeletal maturity status in AIS patients, but the DRU classification has been shown to be superior in predicting peak growth and growth cessation. However, its predictive capabilities for curve progression are unknown.MethodsTotally, 513 AIS patients who presented with Risser 0–3 were followed until either skeletal maturity or the need for surgery, with a minimum 2-year follow-up period. Outcomes of 40° and 50° were used for probability analysis based on the cut-offs of adulthood progression risk and surgical threshold, respectively.ResultsAt the R6/U5 grade, most curves (probability of ≥48.1%–55.5%) beyond a Cobb angle of 25° progressed to the 40° threshold. For curves of ≥35°, there was a high risk of unfavorable outcomes, regardless of skeletal maturity. Most patients with the R9 grade did not progress, regardless of the initial curve magnitude (probability of 0% to reach the 50° threshold for an initial Cobb angle of ≥35°).ConclusionsThis large-scale study illustrates the utility of the DRU classification for predicting curve progression and how it may effectively guide the timing of surgery. Bracing may be indicated for skeletally immature patients at an initial Cobb angle of 25°, and those with a scoliosis ≥35° are at an increased risk of an unfavorable outcome, despite being near skeletal maturity

Speak-up culture in an intensive care unit in Hong Kong: a cross-sectional survey exploring the communication openness perceptions of Chinese doctors and nurses

Objectives Despite growing recognition of the importance of speaking up to protect patient safety in critical care, little research has been performed in this area in an intensive care unit (ICU) context. This study explored the communication openness perceptions of Chinese doctors and nurses and identified their perceptions of issues in ICU communication, their reasons for speaking up and the possible factors and strategies involved in promoting the practice of speaking up. Design A mixed-methods design with quantitative and sequential qualitative components was used. Setting and participants Eighty ICU staff members from a large public hospital in Hong Kong completed a questionnaire regarding their perceptions of communication openness. Ten clinicians whose survey responses indicated support for open communication were then interviewed about their speak-up practices. Results The participating ICU staff members had similar perceptions of their openness to communication. However, the doctors responded more positively than the nurses to many aspects of communication openness. The two groups also had different perceptions of speaking up. The interviewed ICU staff members who indicated a high level of communication openness reported that their primary reasons for speaking up were to seek and clarify information, which was achieved by asking questions. Other factors perceived to influence the motivation to speak up included seniority, relationships and familiarity with patient cases. Conclusions Creating an atmosphere of safety and equality in which team members feel confident in expressing their personal views without fear of reprisal or embarrassment is necessary to encourage ICU staff members, regardless of their position, to speak up. Because harmony and saving face is valued in Chinese culture, training nurses and doctors to speak up by focusing on human factors and values rather than simply addressing conflict management is desirable in this context.This work was supported by funding from the Hospital Authority’s Kowloon Central Cluster Research Grant (grant number: KCC/RC/G/1516-B03)

Salivary Gland Scintigraphy in Patients with Sjogren’s Syndrome: A local Experience with Dual-tracer

Objective(s): To review the findings of the patients with Sjögren’s syndrome (SS) having technetium-99m-pertechnetate (99mTc-pertechnetate) and gallium-67 citrate (Ga-67) salivary gland scintigraphy in the past eight years.Methods: The patients with SS, who were referred to our department for salivary gland scintigraphy during January 2008-December 2015 were studied using both 99mTc-pertechnetate and Ga-67 citrate scintigraphy.Results: Eighteen patients were included in the study, 17 of whom had positive findings on 99mTc- pertechnetate salivary gland scintigraphy. One patient had negative parotid glands findings on 99mTc-pertechnetate, but positive findings in Ga-67 study. Four patients had asymmetric involvement of the parotid glands, and one patient had asymmetric involvement of the submandibular glands in 99mTc-pertechnetate salivary gland scintigraphy. On the other hand, one patient had only submandibular gland involvement in the 99mTc-pertechnetate scan.Nine patients (9/18) had positive parotid gland findings on Ga-67 study. The involvements of the parotid glands were all symmetrical, except for one patient. No abnormal gallium uptake in the submandibular glands in our patients was noted.Conclusion: 99mTc-pertechnetate salivary gland scintigraphy is sufficient for the assessment in the majority of patients with SS. Ga-67 scintigraphy may be a useful supplementary test, especially if the result of 99mTc-pertechnetate scintigraphy is not conclusive

Recording Natural Head Position Using Cone Beam Computerized Tomography

The purpose of this study was to develop a technique to record the natural head position (NHP) of a subject using the scout images of cone beam computerized tomography (CBCT) scans. The first step was to align a hanging mirror with the vertical (XY) plane of the CBCT field-of-view (FOV) volume. Then, two scout CBCT images, at frontal and at sagittal planes, were taken when the subject exhibited a NHP. A normal CBCT scan on the subject was then taken separately. These scout images were used to correct the orientation of the normal CBCT scan. A phantom head was used for validation and performance analysis of the proposed method. It was found that the orientation detection error was within 0.88&deg;. This enables easy and economic NHP recording for CBCT without additional hardware

Improvement of bone mineral density after enzyme replacement therapy in Chinese late-onset Pompe disease patients

Abstract Objective Late-onset Pompe disease (LOPD) is a lysosomal storage disease resulted from deficiency of the enzyme acid α-glucosidase. Patients usually develop a limb-girdle pattern of myopathy and respiratory impairment, and enzyme replacement therapy (ERT) is the only specific treatment available. Recently, LOPD has been associated with low bone mineral density (BMD), but the effect of ERT on BMD is inconclusive. In this report we described our early observations on the change of BMD after ERT in Chinese LOPD patients. Results We studied four Chinese LOPD patients with different severities of myopathy. All were underweight, and three had osteoporosis at baseline. We found significant weight gain in three patients after ERT and all four patients showed improvement in BMD. The biggest improvement, 84.4% increase in BMD, was seen in a lady with the most prominent weight recovery. Our results suggest that ERT improves BMD in Chinese LOPD and weight gain could be a major contributor to this effect

Effect on Germline Mutation Rate in a High-Risk Chinese Breast Cancer Cohort after Compliance with The National Comprehensive Cancer Network (NCCN) 2023 v.1 Testing Criteria

Background: The National Comprehensive Cancer Network (NCCN) testing criteria for the high-penetrance breast cancer susceptibility genes, specifically BRCA1, BRCA2, CDH1, PALB2, PTEN, and TP53, have been recently modified in 2023 to 2023 v.1. The following criteria have been changed: (1) from a person diagnosed with breast cancer at ≤45 to ≤50; (2) from aged 45–50 of personal breast diagnosis to any age of diagnosis with multiple breast cancers; and (3) from aged ≥51 of personal breast diagnosis to any age of diagnosis with family history listed in NCCN 2022 v.2. Methods: High-risk breast cancer patients (n = 3797) were recruited from the Hong Kong Hereditary Breast Cancer Family Registry between 2007 and 2022. Patients were grouped according to NCCN testing criteria 2023 v.1 and 2022 v.2. A 30-gene panel for hereditary breast cancer was performed. The mutation rates on high-penetrance breast cancer susceptibility genes were compared. Results: About 91.2% of the patients met the 2022 v.2 criteria, while 97.5% of the patients met the 2023 v.1 criteria. An extra 6.4% of the patients were included after the revision of the criteria, and 2.5% of the patients did not meet both testing criteria. The germline BRCA1/2 mutation rates for patients meeting the 2022 v.2 and 2023 v.1 criteria were 10.1% and 9.6%, respectively. The germline mutation rates of all 6 high-penetrance genes in these two groups were 12.2% and 11.6%, respectively. Among the additional 242 patients who were included using the new selection criteria, the mutation rates were 2.1% and 2.5% for BRCA1/2 and all 6 high-penetrance genes, respectively. Patients who did not meet both testing criteria were those with multiple personal cancers, a strong family history of cancers not listed in the NCCN, unclear pathology information, or the patient’s voluntary intention to be tested. The mutation rates of BRCA1/2 and the 6 high-penetrance genes in these patients were 5.3% and 6.4%, respectively. Conclusion: This study provided a real-world application of the revision of NCCN guidelines and its effect on the germline mutation rate in the Chinese population. Applying the updated criteria for further genetic investigation would increase the positive detection rate, and potentially more patients would benefit. The balance between the resource and outcome requires careful consideration

Use of Miniplates and Local Bone Grafts to Prevent Spring Back in Laminoplasty for Cervical Spondylotic Myelopathy

Background/Purpose: Cervical spondylotic myelopathy/ossification of posterior longitudinal ligament can be treated by anterior or posterior decompression. For multiple levels, it is common to perform posterior decompression by laminoplasty. Hirabayashi described his open-door expansive laminoplasty in 1977, which soon became popular. Spring back of the lamina has always been a problem. Many methods including suturing to soft tissue, suture anchors, bone grafts, hydroxyapatite blocks, and ceramic spacers were used to prevent this problem, but with considerable failure. Recently, miniplates were used to prevent spring back. Methods: Twenty-nine consecutive patients who had underwent Hirabayashi open-door expansive laminoplasty in a single centre were recruited in this retrospective study. Miniplates were used to keep the laminae open. In addition, the spinous processes of lower cervical vertebrae were excised and used as local bone grafts to fill the gap between the cut laminae. Computerized tomography scans were performed postoperatively for all patients to assess bone union and spring back. Results: A total of 126 levels of laminoplasty and 51 local bone grafts were studied. The minimal follow-up period was 12 months. Signs of bone union were demonstrated in 123 hinges (97.6%) and 51 bone grafts (100%). No spring back was detected. The clinical outcome in terms of Hirabayashi recovery rate was 47.2%. Conclusion: Miniplates and local bone grafts are promising and effective tools for preventing spring back in cervical laminoplasty

Mapping the SRS-22r questionnaire onto the EQ-5D-5L utility score in patients with adolescent idiopathic scoliosis

<div><p>This is a prospective study to establish prediction models that map the refined Scoliosis Research Society 22-item (SRS-22r) onto EuroQoL-5 dimension 5-level (EQ-5D-5L) utility scores in adolescent idiopathic scoliosis (AIS) patients. Comparison of treatment outcomes in AIS can be determined by cost-utility analysis. However, the mainstay spine-specific health-related quality of life outcome measure, the SRS-22r questionnaire does not provide utility assessment. In this study, AIS patients were prospectively recruited to complete both the EQ-5D-5L and SRS-22r questionnaires by trained interviewers. Ordinary least squares regression was undertaken to develop mapping models, which the validity and robustness were assessed by using the 10-fold cross-validation procedure. EQ-5D-5L utility scores were regressed on demographics, Cobb angle, curve types, treatment modalities, and five domains of the SRS-22r questionnaire. Three models were developed using stepwise selection method. EQ-5D-5L scores were regressed on 1) main effects of SRS-22r subscale scores, 2) as per 1 plus squared and interaction terms, and 3) as per 2 plus demographic and clinical characteristics. Model goodness-of-fit was assessed using R-square, adjusted R-square, and information criteria; whereas the predictive performance was evaluated using root mean square error (RMSE), mean absolute error (MAE), and the proportion of absolute error within the threshold of 0.05 and 0.10. A total of 227 AIS patients with mean age of 15.6 years were recruited. The EQ-5D-5L scores were predicted by four domains of SRS-22r (main effects of ‘Function’, ‘Pain’, ‘Appearance’ and ‘Mental Health’, and squared term of ‘Function’ and ‘Pain’), and Cobb angle in Model 3 with the best goodness-of-fit (R-square/adjusted R-square: 62.1%/60.9%). Three models demonstrated an acceptance predictive performance in error analysis applying 10-fold cross-validation to three models where RMSE and MAE were between 0.063–0.065 and between 0.039–0.044, respectively. Model 3 was therefore recommended out of three mapping models established in this paper. To our knowledge, this is the first study to map a spine-specific health-related quality of life measure onto EQ-5D-5L for AIS patients. With the consideration and incorporation of demographic and clinical characteristics, over 60% variance explained by mapping model 3 enabled the satisfactory prediction of EQ-5D-5L utility scores from existing SRS-22r data for health economic appraisal of different treatment options.</p></div

The scatterplot of observed and predicted EQ-5D-5L utility scores by mapping function.

<p>There was overestimation for more severe health states when the observed EQ-5D-5L utility scores was smaller than 0.8. Underestimation was demonstrated for observed EQ-5D-5L utility scores beyond 0.8.</p