Performance of apparent diffusion coefficient values and ratios for the prediction of prostate cancer aggressiveness across different MRI acquisition settings

PURPOSE:In this study, we assessed the performance of apparent diffusion coefficient (ADC) and diffusion-weighted imaging (DWI) metrics and their ratios across different magnetic resonance imaging (MRI) acquisition settings, with or without an endorectal coil (ERC), for the evaluation of prostate cancer (PCa) aggressiveness using whole-mount specimens as a reference.METHODS:We retrospectively reviewed the data of prostate carcinoma patients with a Gleason score (GS) of 3+4 or higher who underwent prostate MRI using a 3T unit at our institution. They were divided into two groups based on the use of ERC for MRI acquisition, and patients who underwent prostate MRI with an ERC constituted the ERC (n = 55) data set, while the remaining patients accounted for the non-ERC data set (n = 41). DWI was performed with b-values of 50, 500, 1000, and 1,400 s/mm2, and ADC maps were automatically calculated. Additionally, computed DWI (cDWI) was performed with a b-value of 2000 s/mm2. Six ADC and two cDWI parameters were evaluated. In the ERC data set, receiver operating characteristic (ROC) curves were plotted for each metric to determine the best cutoff threshold values for differentiating GS 3+4 PCa from that with a higher GS. The performance of these cutoff values was assessed in non-ERC dataset. The diagnostic accuracies and area under the curves (AUCs) of the metrics were compared using Fisher’s exact test and De Long’s method, respectively.RESULTS:Among all metrics, the ADCmean-ratio yielded the highest AUC, 0.84, for differing GS 3+4 PCa from that with a higher GS. The best threshold cutoff values of ADCmean-ratio (£0.51) for discriminating GS 3+4 PCa from that with a higher GS classified 48 patients out of 55 with an accuracy of 87.27%. However, there was no significant difference between each metric in terms of accuracy and AUC (p = 0.163 and 0.214). Similarly, in the non-ERC data set, the ADCmean-ratio provided the highest diagnostic accuracy (82.92%) by classifying 34 patients out of 41. However, Fisher’s exact test yielded no significant difference between DWI and ADC metrics in terms of diagnostic accuracy in non-ERC data (p = 0.561).CONCLUSION:The mean ADC ratio of the tumor to the normal prostate showed the highest accuracy and AUC in differentiating GS 3+4 PCa and PCa with a higher GS across different MRI acquisition settings; however, the performance of different ADC and DWI metrics did not differ significantly

A Comparative Study of Multiparametric MRI Sequences in Measuring Prostate Cancer Index Lesion Volume

Objectives: To compare the effectiveness of individual multiparametric prostate MRI (mpMRI) sequences—T2W, diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC), and dynamic contrast-enhanced (DCE)—in assessing prostate cancer (PCa) index lesion volume using whole-mount pathology as the ground-truth; to assess the impact of an endorectal coil (ERC) on the measurements. Materials and Methods: We retrospectively enrolled 72 PCa patients who underwent 3T mpMRI with (n = 39) or without (n = 33) an ERC. A pathologist drew the index lesion borders on whole-mount pathology using planimetry (whole-mountvol). A radiologist drew the borders of the index lesion on each mpMRI sequence—T2Wvol, DWIvol, ADCvol, and DCEvol. Additionally, we calculated the maximum index lesion volume for each patient (maxMRIvol). The correlation and differences between mpMRI and whole-mount pathology in measuring the index lesion volume and the impact of an ERC were investigated. Results: The median T2Wvol, DWIvol, ADCvol, DCEvol, and maxMRIvol were 0.68 cm3, 0.97 cm3, 0.98 cm3, 0.82 cm3, and 1.13 cm3. There were good positive correlations between whole-mountvol and mpMRI sequences. However, all mpMRI-derived volumes underestimated the median whole-mountvol volume of 1.97 cm3 (P ≤ 0.001), with T2Wvol having the largest volumetric underestimation while DWIvol and ADCvol having the smallest. The mean relative index lesion volume underestimations of maxMRIvol were 39.16% ± 32.58% and 7.65% ± 51.91% with and without an ERC (P = 0.002). Conclusion: T2Wvol, DWIvol, ADCvol, DCEvol, and maxMRIvol substantially underestimate PCa index lesion volume compared with whole-mount pathology, with T2Wvol having the largest volume underestimation. Additionally, using an ERC exacerbates the volume underestimation

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Apparent diffusion coefficient characteristics of parenchymal neuro-Behcet's disease

Aim To evaluate apparent diffusion coefficient (ADC) characteristic of parenchymal neuro-Behcet's disease (NBD). Methods We retrospectively reviewed cranial magnetic resonance imaging (MRI) examinations of NBD patients with acute or chronic parenchymal lesions. ADC measurements of the lesions and contralateral normal brain parenchyma were performed by a consensus of two radiologists. To compare the ADC value of the chronic and acute lesions, relative ADC values (rADC) were calculated. The ratio of the lesions' ADC to contralateral normal brain parenchyma ADC yielded a rADC value of the lesions. Contrast enhancement patterns and the locations of the lesions were also noted. Results A total of 24 NBD patients with 45 parenchymal lesions, 25 acute, and 20 chronic, were enrolled in the study. A significant difference was observed between the mean ADC value of the acute lesions (1074.48 +/- 138.31 m/s) and the mean ADC value of the contralateral normal brain parenchyma (841.20 +/- 142.96 m/s; P < 0.0001). A significant difference was observed between the mean ADC value of the chronic lesions (1069.95 +/- 143.95 m/s) and the mean ADC value of the contralateral normal brain parenchyma (793.90 +/- 96.71 m/s; P < 0.0001). No significant difference was observed between the mean rADC (1.35 +/- 0.20) and the mean rADC value of the chronic lesions (1.29 +/- 0.15; P = 0.22). Conclusions ADC measurements might provide substantial information about the histopathological aspect of parenchymal NBD lesions

Surgical results of the slipped medial rectus muscle after hang back recession surgery

<b>AIM:</b>To analyze the surgical results of a slipped medial rectus muscle (MRM) after hang back recession surgery for esotropia.<b>METHODS:</b>Twenty-one patients who underwent re-exploration for diagnosed slipped muscle after hang back recession surgery were included in this retrospective study. Dynamic magnetic resonance imaging was performed to identify the location of the slipped muscle. Ocular motility was evaluated with assessment with prism and cover test in gaze at cardinal positions. The operations were performed by the same consultant. Intraoperative forced duction test was performed under general anesthesia. The empty sheath of the slipped MRM was resected and the muscle was advanced to the original insertion site in all patients.<b>RESULTS:</b>The average age of 21 patients who hadconsecutive exotropia with a slipped MRM at the time of presentation was 17.4±5.4y (5-50y). The average duration between the first operation and the diagnosis of the slipped muscle was 25mo (12 to 36mo). The mean follow up after the corrective surgery was 28mo. The mean preoperative adduction limitation in the field of action of the slipped muscle was -2.26 (ranging from -1 to -4). All patients had full adduction postoperatively.<b>CONCLUSION:</b>The diagnosis of the slipped muscle should be confirmed during the strabismus surgery. The slipped muscle may be caused due to insufficient suture and excessive rubbing of the eye. When divergent strabismus is observed after the recession of the MRM, a slipped muscle should be considered in the differential diagnosis