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Positron emission tomography (PET) is a functional imaging technique introduced in 1970s. Over the years, PET was used alone but is in 2000 when the first hybrid PET/CT device was clinically introduced. Since then, PET has continuously been marked by technological developments, being the most recent one the introduction of silicon photomultipliers (SiPMs) as an alternative to standard photomultiplier tubes used in analog PET/CT systems. SiPMs, the basis for the so called digital PET/CT systems, are smaller than standard photomultiplier tubes (enabling higher spatial resolution) and provide up to 100% coverage of the crystal area, as well as high sensitivity, low noise, and fast timing resolution. SiPMs in combination with optimized acquisition and reconstruction parameters improve the localization of the annihilation events, provide high definition PET images, and offer higher sensitivity and higher diagnostic performance. This article summarizes the evidence about the superior performance of the state of the art digital PET and highlights its potential clinical implications. Digital PET opens new perspectives in the quantification and characterization of small lesions, which are mostly undetectable using analog PET systems, potentially changing patient management and improving outcomes in oncological and non-oncological diseases. Moreover, digital PET offers the possibility to reduce radiation dose and scan times which may facilitate the implementation of PET to address unmet clinical needs.

Background Multidisciplinary Tumor Boards (MDT) are used to obtain input regarding cancer management. This study assessed the impact of our institutional Endocrine MDT. Methods MDT notes on patients with thyroid cancer treated during 2012–2018 were abstracted retrospectively from the electronic medical record. Management change (MC) was prospectively collected by the MDT coordinator. Biannual evaluations reviewed the impact of the MDT as observed by attendees. Results MC was recommended in 47 (15%) of 286 presentations, with additional imaging being the most frequent (43%). Presentation of recurrences were more likely to result in MC (24% vs. 13% initial, p = 0.03). Overall, 98% of attendees found the conference exceeded educational expectations. About 24% reported intending to use a more evidence/guideline-based approach after attending and this trend increased over time (p = 0.002). Conclusion MDT presentations led to a higher rate of MC particularly in recurrent TC patients and increased evidenced-based practice for attendees.

Objective The use of basic transesophageal echocardiography (TEE) in critically ill and older surgical patients can change patient management and improve outcomes after noncardiac surgery. The authors hypothesized that educating the future generation on basic TEE skills by an intense two-month rotation will help them achieve basic TEE certification by the National Board of Echocardiography (NBE) and facilitate good use of their skills for patient care during their practice. Design This is a descriptive report of graduating anesthesiology residents who completed two months basic TEE rotation at the authors’ residency program between 2013 and 2019. The authors report the clinical training goals, NBE testamur and certification status, and a survey report on the use of basic TEE skills in their practice Settings University medical center. Participants Residents who completed two months basic TEE rotation during their Clinical Anesthesia (CA)-3 year. Interventions None. Measurements and Main Results Of a total of 115 residents, 67 (58%) elected basic TEE rotation. The NBE basic TEE certification and testamur status were achieved by 12 (21%) and 14 (24%) eligible residents, respectively. Residents (n = 43) personally performed 73 ± 21 (mean ± standard deviation) and reviewed 72 ± 28 (mean ± standard deviation basic TEE studies before graduation. The survey indicated that 63.4% of residents trained in basic TEE did not use their skills in their practice. Conclusions Two months’ basic TEE rotation was able to fulfill its educational goals (testamur status and clinical training) but fell short on achieving NBE certification rate and its ultimate impact on practice and patient care.

Pediatric musculoskeletal infections often pose a diagnostic challenge due to their frequently vague and nonspecific clinical presentation. Imaging evaluation is a crucial component to diagnostic workup of these entities. Changed epidemiology of these infections over the past 2 decades has resulted in increases in both disease incidence and severity in the pediatric population. Prompt and accurate diagnosis is essential in order to reduce the risk of morbid sequelae, and to optimize patient management. In this article, the unique pathophysiology of musculoskeletal infections and characteristic imaging findings in children compared with adults are reviewed.

In the last decades, microbiology laboratories have undergone unprecedented technological changes which have revolutionized the diagnosis of infectious diseases. They have last generation technology which allows precise, rapid and effective diagnosis of a wide range of infectious diseases, while also providing valuable information on the antibiotic sensitivity/resistance of the causal microorganism, thereby notably reducing the morbidity and mortality of the patients and at the same time improving in-hospital patient management. Several studies have shown that with the increase in the use of rapid diagnostic techniques this technological advancement has a greater impact when accessibility to the microbiology laboratory is possible beyond the usual 7 h workday. This document discusses the need for clinical microbiology services to work 24 h a day, 7 days a week (24/7).

Prolactin measurement is very common in standard clinical practice. It is indicated not only in the study of pituitary adenomas, but also when there are problems with fertility, decreased libido, or menstrual disorders, among other problems. Inadequate interpretation of prolactin levels without contextualizing the laboratory results with the clinical, pharmacological, and gynecological/urological history of patients leads to erroneous diagnoses and, thus, to poorly based studies and treatments. Macroprolactinemia, defined as hyperprolactinemia due to excess macroprolactin (an isoform of a greater molecular weight than prolactin but with less biological activity), is one of the main causes of such erroneous diagnoses, resulting in poor patient management when not recognized. There is no unanimous agreement as to when macroprolactin screening is required in patients with hyperprolactinemia. At some institutions, macroprolactin testing by polyethylene glycol (PEG) precipitation is routinely performed in all patients with hyperprolactinemia, while others use a clinically based approach. There is also no consensus on how to express the results of prolactin/macroprolactin levels after PEG, which in some cases may lead to an erroneous interpretation of the results. The objectives of this study were: 1. To establish the strategy for macroprolactin screening by serum precipitation with PEG in patients with hyperprolactinemia: universal screening versus a strategy guided by the alert generated by the clinician based on the absence or presence of clinical symptoms or by the laboratory when hyperprolactinemia is detected. 2. To create a consensus document that standardizes the reporting of prolactin results after precipitation with PEG to minimize errors in the interpretation of the results, in line with international standards.

Background Acne is a chronic disease with a varying presentation that requires long-term management. Despite this, the clinical guidelines for acne offer limited guidance to facilitate personalized or longitudinal management of patients. Objectives To generate recommendations to support comprehensive, personalized, long-term patient management that address all presentations of acne and its current and potential future burden. Methods The Personalising Acne: Consensus of Experts panel consisted of 13 dermatologists who used a modified Delphi approach to reach consensus on statements related to longitudinal acne management. The consensus was defined as ≥75% voting "agree" or "strongly agree." All voting was electronic and blinded. Results Key management domains, consisting of distinct considerations, points to discuss with patients, and "pivot points" were identified and incorporated into the Personalised Acne Care Pathway. Long-term treatment goals and expectations and risk of (or fears about) sequelae are highlighted as particularly important to discuss frequently with patients. Limitations Recommendations are based on expert opinion, which could potentially differ from patients' perspectives. Regional variations in health care systems may not have been captured. Conclusions The Personalised Acne Care Pathway provides practical recommendations to facilitate the longitudinal management of acne, which can be used by health care professionals to optimize and personalize care throughout the patient journey.

Background Point-of-care testing (POCT) has applications across medical specialties and holds promise to improve patient care. While cardiovascular medicine has been attractive for POCT applications in recent years, little is known about how cardiovascular health professionals perceive them. Objective The objective of our study was to examine differences in perceptions and attitudes towards POCTs between cardiovascular health professionals compared to other healthcare professionals. Methods We surveyed healthcare professionals to assess perceptions of POCT usage and their benefits and concerns between October 2019 and March 2020. Questions regarding POCT perceptions were assessed on a 5-point Likert scale. Results We received a total of 148 survey responses; of the responders, 52% were male, 59% were physicians, and 50% worked in a hospital setting. We found that cardiology professionals were less likely, compared to other specialties, to view POCTs as improving patient management or reducing errors. These cardiology professionals were not constrained by resources or a lack of investment opportunities to implement these technologies. Conclusion This study provides a better understanding of perceptions about POCTs among healthcare specialists. To improve patient outcomes through the adoption and usage of POCTs, greater collaboration is advised among key industry and healthcare stakeholders.

Purpose Over 1 billion doses of COVID-19 vaccines have been already administered across the United States, the United Kingdom and the European Union at the time of writing. Furthermore, 1.82 million booster doses have been administered in the US since 13th August, and similar booster programmes are currently planned or under consideration in the UK and the EU beginning in the autumn of 2021. Early reports showed an association between vaccine administration and the development of ipsilateral axillary and supraclavicular lymphadenopathy, which could interfere with the diagnosis, treatment and follow-up of breast cancer patients. In this paper, we review the available evidence on vaccine-related lymphadenopathy, and we discuss the clinical implications of the same on breast cancer diagnosis and management. Methods A literature search was performed - PubMed, Ovid Medline, Scopus, CINHAL, Springer Nature, ScienceDirect, Academic Search Premier and the Directory of Open Access Journals were searched for articles reporting on regional palpable or image-detected lymphadenopathy following COVID-19 vaccination. Separately, we compiled a series of case studies from the University Hospitals of Derby and Burton, United Kingdom and the Mayo Clinic in Minnesota, United States of America, to illustrate the impact that regional lymphadenopathy post-COVID-19 vaccination can have on the diagnosis and management of patients being seen in diagnostic and therapeutic breast clinics. Results From the literature search, 15 studies met the inclusion criteria (n = 2057 patients, 737 with lymphadenopathy). The incidence of lymphadenopathy ranged between 14.5% and 53% and persisted for >6 weeks in 29% of patients. Conclusions Clinicians managing breast cancer patients should be aware that the COVID-19 vaccination may result in regional lymphadenopathy in a significant number of patients, which can result in unnecessary investigations, treatment and increased patient anxiety. An accurate COVID-19 vaccination history should be collected from all patients where regional lymphadenopathy is a clinical and/or an imaging finding and then combined with clinical judgement when managing individual cases.

Atrioventricular blocks may be caused by a variety of potentially reversible conditions, such as ischemic heart disease, electrolyte imbalances, medications, and infectious diseases. Such causes must be always ruled out to avoid unnecessary pacemaker implantation. Patient management and reversibility rates depend on the underlying cause. Careful patient history taking, monitoring of vital signs, electrocardiogram, and arterial blood gas analysis are crucial elements of the diagnostic workflow during the acute phase. Atrioventricular block recurrence after the reversal of the underlying cause may pose an indication for pacemaker implantation, because reversible conditions may actually unmask a preexistent conduction disorder.

Background Burn fluid resuscitation guidelines have not specifically addressed mass casualty with resource limited situations, except for oral rehydration for burns below 40% total body surface area (TBSA). The World Health Organization Technical Working Group on Burns (TWGB) recommends an initial fluid rate of 100 mL/kg/24 h, either orally or intravenously, beyond 20% TBSA burned. We aimed to compare this formula with current guidelines. Methods The TWGB formula was numerically compared with 2–4 mL/kg/%TBSA for adults and the Galveston formula for children. Results In adults, the TWGB formula estimated fluid volumes within the range of current guidelines for burns between 25 and 50% TBSA, and a maximal 20 mL/kg/24 h difference in the 20–25% and the 50–60% TBSA ranges. In children, estimated resuscitation volumes between 20 and 60% TBSA approximated estimations by the Galveston formula, but only partially compensated for maintenance fluids. Beyond 60% TBSA, the TWGB formula underestimated fluid to be given in all age groups. Conclusion The TWGB formula for mass burn casualties may enable appropriate fluid resuscitation for most salvageable burned patients in disasters. This simple formula is easy to implement. It should simplify patient management including transfers, reduce the risk of early complications, and thereby optimize disaster response, provided that tailored resuscitation is given whenever specialized care becomes available.

Stereotactic radiotherapy is an ever more common technique, regardless of the location treated. However, spinal stereotactic radiotherapy requires a particular technicality in order to ensure its proper realization. There is now a large literature defining the type of imaging to be used, the dose to be delivered and the delineation of target volumes. This technique can achieve a significant local control and an interesting analgesic efficiency. However, its place in relation to conventional radiotherapy remains limited because it requires MRI imaging and a significantly longer patient management during the treatment fraction. In this context, it is currently mainly restricted to oligometastatic patients or for re-irradiations.

The American Heart Association and American College of Cardiology published practice guidelines for the management of adult congenital heart disease in 2018 and the European Society of Cardiology published analogous guidelines in 2020. Although there are broad areas of consensus between the 2 documents, there are important differences that impact patient management. This review discusses key areas of agreement and disagreement between the 2 guidelines, with discussion of possible reasons for disagreement and potential implications.

Circulating tumor DNA (ctDNA) enables real-time genomic profiling of cancer without the need for tissue biopsy. ctDNA-based technology is seeing rapid uptake in clinical practice due to the potential to inform patient management from diagnosis to advanced disease. In metastatic disease, ctDNA can identify somatic mutations, copy-number variants (CNVs), and structural rearrangements that are predictive of therapy response. However, the ctDNA fraction (ctDNA%) is unpredictable and confounds variant detection strategies, undermining confidence in liquid biopsy results. Assay design also influences which types of genomic alterations are identifiable. Here, we describe the relationships between ctDNA%, methodology, and sensitivity-specificity for major classes of genomic alterations in prostate cancer. We provide recommendations to navigate the technical complexities that constrain the detection of clinically relevant genomic alterations in ctDNA.

Pituitary incidentalomas are discovered in approximately 10% to 40% of brain images. A complete patient history, physical examination, and dedicated pituitary function testing are needed, and subsequent results should lead to appropriate patient management. However, most lesions are asymptomatic pituitary adenomas or Rathke cleft cysts with a benign course. Many lesions can be clinically significant, including prolactinomas or other pituitary adenomas that warrant specific pituitary disease treatment. In other cases, mass effect causing visual compromise or refractory headache indicates a need for surgery. Here, various facets of a complex evaluation and treatment algorithm for pituitary incidentalomas are reviewed.

Mechanical ventilation is a common invasive intervention in intensive care units. While respiratory failure remains the most common indication for mechanical ventilation, the application and indications of this intervention are far more variable. Ventilation causes marked alteration to human physiology and is associated with complications and iatrogenic injuries. This article highlights practical aspects of patient management during invasive ventilation.

WHO recommends a minimum of 80% sensitivity and 97% specificity for antigen-detection rapid diagnostic tests (Ag-RDTs), which can be used for patients with symptoms consistent with COVID-19. However, after the acute phase when viral load decreases, use of Ag-RDTs might lead to high rates of false negatives, suggesting that the tests should be replaced by a combination of molecular and serological tests. When the likelihood of having COVID-19 is low, such as for asymptomatic individuals in low prevalence settings, for travel, return to schools, workplaces, and mass gatherings, Ag-RDTs with high negative predictive values can be used with confidence to rule out infection. For those who test positive in low prevalence settings, the high false positive rate means that mitigation strategies, such as molecular testing to confirm positive results, are needed. Ag-RDTs, when used appropriately, are promising tools for scaling up testing and ensuring that patient management and public health measures can be implemented without delay.

New trends in sleep medicine make use of the increased computational power of digital transformation. A current trend toward fewer sensors on the body of the sleeper and to more data processing from derived signals is observed. Telemedicine technologies are used for data transmission and for better patient management in terms of diagnosis and in terms of treatment of chronic conditions.

Background The transition toward value-based payment models increases focus on the radiologist's direct impact on hospital-provided patient care. Radiology trainees understand inpatient hospital workflows and decision-making paradigms and are well positioned to interface directly with hospital physicians regarding clinical decision making related to diagnostic imaging and/or image guided interventions. A radiology resident-led project with internal medicine residents focused on Clinical Decision Support was designed, implemented, and reviewed, with the objectives of educating clinical teams and positively impacting patient care. Materials and Methods During the 2017-2018 academic year, senior radiology residents (PGY-5) led weekly rounds with medicine residents rotating through inpatient floor units. During these rounds, they discussed indications for and types of hospital inpatient imaging studies, exchanged clinical information, directed further imaging workup, and taught the essentials of image interpretation. Participating medical residents’ degree of radiology-awareness and opinions were systematically surveyed at the conclusion of the academic year. Thirty-four out of a total of 161 (21%) Internal Medicine residents responded to the survey. Thirty one percent of these residents could identify an instance where radiology-led rounds altered patient management and 94% acknowledged an increase in medical knowledge. Sixty-one percent believed evidence-based choice for imaging orders was enhanced by attending radiology-led rounds and 64% developed a better understanding of resources available to guide image ordering. Forty-nine percent of residents made suggestions to their Internal Medicine attending physician or more senior trainee or otherwise applied something learned during radiology-led rounds and 42% cancelled or ordered a study based on what they learned or discussed in radiology rounds. Thirty-nine percent of medicine residents stated that these rounds changed their perception of the role of the radiologist and 75% expressed the desire to see increased participation by radiologists in their daily workflow. Radiology resident-led educational medicine rounds promote cross-specialty collaboration, further educate trainees, and directly affect patient management. It is therefore valuable for radiology trainees to directly engage in the teaching of other medical providers, to enhance their own consultative skill set, promote face-to-face interactions with other physicians, and to directly impact patient care.

Pulmonary immune-related adverse events represent rare but potentially severe side effects of immunotherapies. Diagnosis is often challenging, as symptoms and imaging features are not specific and may mimic other lung diseases, thus potentially delaying appropriate patient management. In this setting, an accurate imaging evaluation is essential for a prompt detection and correct management of these drug-induced lung diseases. The purpose of this article is to review the different types of pulmonary immune-related adverse events, describe their imaging characteristics on both high-resolution computed tomography and positron emission tomography/computed tomography and stress their underlying diagnostic challenge by presenting the mimickers.

Antimicrobial susceptibility tests (AST) are based on the minimal inhibitory concentration (MIC), the method used worldwide to guide antimicrobial therapy. Despite its relevance in correctly predicting clinical outcome for most acute infections, this approach is misleading for multiple clinical cases in which pathogens do not grow rapidly, uniformly or with physical protection. This behaviour, named ‘metabolic evasion’ (ME), enables bacteria to survive antimicrobials. ME can result from different, and sometimes combined, bacterial mechanisms such as biofilms, intracellular growth, persisters or dormancy. We discuss how ME can influence the MIC-based probability of target attainment. We identify clinical cases in which this approach is undermined by ME and propose a new approach that takes ME into account in order to improve patient management and the evaluation of innovative drugs.

Prolonged intensive care unit stay after cardiac surgery is associated with high mortality. The aim of this study was to evaluate the impact of the introduction of a quality improvement program under the supervision of an intensivist on the long-term mortality of high-risk patients with prolonged intensive care unit (ICU) stay after cardiac surgery.Retrospective study of prospectively collected data.Cardiac surgery ICU.A total of 7,549 patients after cardiac surgery.Patients were divided into two periods: 2004 to 2007, before introducing the quality improvement program (3,315 patients), and 2009 to 2014, after introduction of the program (4,234 patients). In the period from 2004 to 2007, patients were divided into group I (ICU stay ≥ seven days), which included 242 patients, and group III (ICU stayseven days), which included 3,073 patients. Also, in the period from 2009 to 2014 patients, were divided into group II (ICU stay ≥seven days), which included 326 patients, and group IV (ICU stayseven days), which included 3,908 patients. Patient outcomes were compared. Follow-up was five years for each group.The European System for Cardiac Operative Risk Evaluation did not differ significantly among the groups. When comparing between group I and group II, 30-day mortality decreased significantly from 24.8% to 16.6%, six-month mortality from 27.3% to 19.3%, one-year mortality from 42.1% to 32.2%, 3-year mortality from 54.5% to 43.3%, and 5-year mortality from 61.2% to 51.8%. In comparing between group III and group IV, the authors did not observe a statistically significant decrease of mortality.Intensivist-led patient management protocol is associated with decreased long-term mortality in high-risk patients with a prolonged ICU stay.

A 76 year old patient presented with two synchronous primary lung tumours. One was identified as an adenocarcinoma and the second as an atypical carcinoid tumour. When reviewing the lymph node slides it was seen that one lymph node contained metastatic deposits from both primary tumours. Synchronous lung tumours are fairly rare occurrences, but even rarer is the finding of synchronous metastases to the same lymph node. The atypical carcinoid deposit was very subtle in appearance and could easily have been overlooked. This case demonstrates a useful learning point to not miss these rare and subtle findings as the resulting tumour staging was affected and may have implications for further patient management.

The World Federation for Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings (IFs) with a series of publications entitled "Incidental Imaging Findings-The Role of Medical Ultrasound." IFs are less commonly encountered in the spleen than in many other abdominal organs but remain a frequent dilemma in clinical practice. A histological diagnosis is rarely necessary for patient management. Many IFs, such as secondary spleens and splenic cysts, are harmless and do not require any further investigation. The diagnosis of many other focal splenic lesions is, however, often problematic. The following overview is intended to illustrate a variety of incidentally detected spleen pathologies such as size variants, shape variants, secondary spleens, focal splenic lesions and splenic calcifications. It should aid the examiner in establishing the diagnosis. Moreover, it should help the ultrasound practitioner decide which pathologies need no further investigation, those requiring interval imaging and cases in which immediate further diagnostic procedures are required.

The 2019 ACR/EULAR Classification Criteria for IgG4-related disease (IgG4-RD) represent a fundamental tool for patient enrollment in research studies and in clinical trials but their usefulness in daily clinical practice remains unknown.To validate the 2019 ACR/EULAR Classification Criteria for IgG4-RD in a real-life setting and to anticipate their utility for orienting disease diagnosis and patient management.Four experts were asked to classify 200 patients diagnosed with IgG4-RD according to the 2019 ACR/EULAR Classification Criteria for IgG4-RD. Agreement between experts was calculated and the Classification score of each patient was correlated with the following variables and outcomes: serum IgG4 and IgE; inflammatory markers; eosinophils; plasmablasts; IgG4-RD responder index; diabetes, osteoporosis, relapses; and use of rituximab.Among the 157/200 cases equally rated by at least three experts, 94 (59.9%) achieved IgG4-RD classification and 63 (40.1%) did not. Strong agreement among IgG4-RD experts was observed in classifying patients (k = 0.711, p0.0001). Clinical presentations not included in the classification algorithm and lack of informative histology were the most common reasons for not achieving classification. In patients achieving classification, the Classification score did not correlate with variables of disease activity and was not associated with specific outcomes.The ACR/EULAR Classification Criteria represent a replicable instrument for classifying patients and a useful framework for orienting diagnosis but are of limited utility for assessing IgG4-RD activity, for predicting disease outcomes, and for defining personalized therapeutic approaches.

Management of fractures in the field starts with successful assessment and stabilization of the patient by the practitioner on the front lines. A careful examination is vital to succesful patient management. This includes identifying the fracture location and severity, evaluating skin integrity and potential contamination of the fracture, and treating any ongoing hemorrhage, hypovolemia or stress. Appropriate application of splints in the field will minimize ongoing tissue damage and improve patient comfort. This ultimately aids further assessment, facilitates referral, and improves opportunities for successful fracture repair.

The spectrum of pathologies affecting the biliary tree in the pediatric population varies depending on the age of presentation. While in utero insults can result in an array of anatomic variants and congenital anomalies in newborns, diverse acquired biliary pathologies are observed in older children. These acquired pathologies display different presentations and consequences than adults. Multimodality imaging assessment of the pediatric biliary system is requisite to establishing an appropriate management plan. Awareness of the imaging features of the various biliary pathologies and conveying clinically actionable information is essential to facilitate appropriate patient management. In this paper, we will illustrate the anatomy and embryology of the pediatric biliary system. Then, we will provide an overview of the imaging modalities used to assess the biliary system. Finally, we will review the unique features of the pediatric biliary pathologies, complemented by histopathologic correlation and discussions of clinical management.

Hydatidiform mole (HM) occurs in 1:500-1000 pregnancies and are generally characterised as a benign proliferative disorder of chorionic villous trophoblast. HM belongs to the group of disorders, collectively known as gestational trophoblastic disease (GTD), which include invasive mole, choriocarcinoma, placental site trophoblastic tumour and epitheloid trophoblastic tumour. Patients with HM are at increased risk of developing these malignant forms and hence accurate diagnosis is very important for monitoring persistent diseases and informing correct patient management. In this review, we describe the current model for HM follow-up in the UK, with special emphasis on the in-house human chorionic gonadotrophin (hCG) radioimmunoassay (RIA) currently employed for monitoring women in our programme. We briefly discuss the structure, function and significance of hCG monitoring in GTD and the limitations and benefits of the current assays used for measuring oncology hCG. In particular, we describe the preliminary work evaluating a replacement antibody for the current gold-standard UK-RIA method.

espanolObjetivo Valorar la utilidad de la 18F-DOPA PET/TC cerebral en el diagnostico diferencial de lesiones cerebrales con RM no concluyente. Material y metodos Se estudiaron 12 pacientes, con un total de 16 lesiones, sin diagnostico definitivo tras RM cerebral. Se adquirio estudio 18F-DOPA PET/TC cerebral con doble adquisicion a los 20 y 90 minutos. Se realizo valoracion visual y semicuantitativa con calculo del SUVmax de las lesiones y calculo del ratio T/S (tumor/estriado contralateral) y ratio T/N (tumor/parenquima sano contralateral) para cada uno de los tiempos. Resultados Con base en la escala de valoracion visual y utilizando los ratios T/S ≥ 1 y T/N ≥ 1,3 para determinar la positividad de un estudio, los valores de sensibilidad (S), especificidad (E) y valor predictivo positivo (VPP) han sido los siguientes: valoracion visual (S 100%, E 33,3%, VPP 71,4%), ratio T/S (S 90%, E 100%, VPP 100%) y ratio T/N (S 100%, E 16,6%, VPP 66,6%). Ninguna lesion mostro un aumento del SUVmax en la adquisicion tardia. La 18F- DOPA PET/TC modifico el comportamiento terapeutico en el 75% de los pacientes. Conclusion La 18F-DOPA PET/TC es una herramienta util para diferenciar la etiologia de lesiones cerebrales con RM no concluyente. La imagen tardia (dual point) no aporta un valor anadido al diagnostico final. Los estudios con F-DOPA tienen impacto en el manejo del paciente modificando la conducta terapeutica. EnglishAim To evaluate the utility of brain 18F-DOPA PET/CT in the differential diagnosis of brain lesions with inconclusive MRI. Material and methods Twelve patients were studied, with a total of 16 lesions, without definitive diagnosis after brain MRI. A double acquisition PET/CT brain scan was acquired at 20 and 90 minutes. Visual and semiquantitative assessment was performed with SUVmax calculation of the lesions and calculation of the T/S ratio (tumor/contralateral striatum) and T/N ratio (tumor/contralateral healthy parenchyma) for each time. Results Based on the visual assessment scale and using T/S ratio ≥ 1 and T/N ratio ≥ 1.3 to determine malignancy, the values of sensitivity (S), specificity (E) and positive predictive value (PPV) were: visual assessment (S 100%, E 33.3%, VPP 71.4%), T/S ratio (S 90%, E 100%, VPP 100%) and T/N ratio (S 100%, E 16.6%, VPP 66.6%). No lesion showed an increase in SUVmax in late acquisition. 18F-DOPA PET/CT modified treatment in 75% of the patients. Conclusion 18F-DOPA PET/CT is a useful tool in the study of brain lesions with inconclusive MRI. Late imaging (dual-point) has no added value in the final diagnosis. F-DOPA has an impact on patient management modifying therapeutic behavior.

Dermatology and medicine are producing data at an increasing rate that are progressively difficult to sort and manage. Artificial intelligence (AI) and machine learning are examples of tools that may have the capability to produce significant and meaningful results from these data. Currently, AI and machine learning have a variety of applications in medicine including, but not limited to, diagnostics, patient management, preventive medicine, and genomic analysis. Although the role of AI in dermatology is greater than ever, its use is still extremely limited. As AI is continually developed and implemented, it is essential that stakeholders understand AI terminology, applications, limitations, and projected uses in dermatology. With the continued development of AI technology, however, its implementation may afford greater dermatologist efficiency, greater increased patient access to dermatologic care, and improved patient outcomes.

Guidelines focus on the accurate, reproducible and complete recording of histopathology data items, that they generally categorize as either core (mandatory) or non-core (recommended but not mandatory). We highlight some issues with this traditional approach and describe an approach focusing on the clinical utility of histopathology data and the importance of effectively communicating this data to the clinical team. A data item that is critical in one clinical scenario may be clinically irrelevant in another setting. Awareness of how histopathology data is used to guide patient management could help pathologists focus limited resources for maximum clinical benefit. Clinicians do not generally view histological material and are often entirely dependent on the histopathology report. It is therefore critical that the histopathological information is appropriately communicated. Effective communication is more important than precision when reporting morphological/biological continuums such as tumour grade. Histopathology reports should be brief without redundant, unnecessary, or duplicated information.

Histopathology data form the basis of most oncological patient management. Pathology guidelines therefore recommend sets of core data items that should be reported in each specimen. The clinical utility of a particular data item depends on the clinical scenario. Awareness of how these data are used to guide patient management could enable pathologists to focus their resources on clinically important issues. For example, it is generally critical to identify even a minor nonseminomatous component in a predominantly seminomatous testicular germ cell tumour as such patients would be managed as a nonseminoma. However, this finding would be less important in a patient with a raised serum alpha fetoprotein level as such a patient would generally be managed as a nonseminoma even if the histological diagnosis is pure seminoma. In this review, we discuss the clinical utility of various histopathology parameters in the management of bladder and testicular cancer.

Prostate biopsy data are critical for patient management. Guidelines focus of detailed criteria to ensure that these are precisely and reproducibly reported. However, conflicting recommendations by different expert groups have led to significant reporting variation that could negatively impact patient care. We describe a different approach focusing on optimising communication of histopathological parameters such as tumour extent and grade to the clinical team. Communication is crucial because clinicians usually do not view histological material and are dependent on the information included in the histopathology report. Precision could become less critical if the biopsy findings are effectively conveyed by the pathologist and correctly interpreted by the clinician. Strategies to effectively communicate the message in contentious scenarios such when a prostate needle biopsy set contains prostate cancer that is discontinuous, of borderline grade, of disparate grades or associated with intraductal carcinoma of the prostate are outlined.

Surveillance of allograft health after transplantation has traditionally relied on biopsy procedures that enable pathologic assessment for acute rejection. Noninvasive methods to assess for graft injury have been developed and tested over the past decade, and now offer a convenient way to reduce reliance on invasive testing and improve patient satisfaction. Emerging evidence suggests that detection of allograft injury via donor-derived cell-free DNA (dd-cfDNA) may, in fact, have better sensitivity compared to traditional biopsy-based strategies. This state-of-the-art review describes the development, testing, and current use of dd-cfDNA assays for acute rejection monitoring after heart transplantation, and discusses innovative ways that such assays can be used for personalized patient management.

This study assessed agreement between MRI reporting radiographers and a consultant radiologist compared with an index neuroradiologist when reporting MRI head (brain/internal auditory meati [IAMs]) examinations. The effect on patient management of any discordant reports was also examined.Two trained MRI reporting radiographers (RRs), a consultant radiologist (CR) and an index neuroradiologist (INR) reported on a random sample of 210 MRI examinations. The radiographers reported during clinical practice and the radiologists in clinical practice conditions. Two independent consultant physicians (neuro-rehabilitation and neuropsychiatry) compared these reports with the index neuroradiologist report for agreement and the clinical importance of discrepant reports.Overall observer agreement between the RRs and CR was comparable in relation to agreement with the INR: RR; 93/210 (44.3%); and the CR; 83/210 (39.4%) for all head MRI examinations (p = 0.32). For brain examinations the difference was similar: RR; 64/180 (35.6%); and CR; 54/190 (30.0%), p = 0.26. Agreement rates for the IAMs examinations were identical, 29/30 (97.7%). For all head MRI examinations (n = 210) there was a very small observed difference of0.5% in mean agreement between the reporting radiographers and the consultant radiologist (p = 0.92) for examinations where a major disagreement would have been likely to have led to a change in patient management.MRI reporting radiographers reported during clinical practice on MRI head examinations to a level of agreement comparable with a consultant radiologist.This is an area in which radiographers could provide additional reporting roles to the reporting service to increase capacity. Wider potential benefits include cost-effectiveness and role development/retention of radiographers.

A modern vascular service cannot function without high quality, timely and relevant diagnostic imaging. In this age of evidence-based medicine, radiological findings and their expert interpretation are fundamental in aiding decisions with regard to patient management and surgical intervention. In this chapter we present the basic principles, clinical indications, advantages and limitations of the different imaging modalities used to assess vascular patients including duplex ultrasound (DUS), computed tomography (CT), magnetic resonance imaging (MR) and digital subtraction angiography (DSA).

Objective In recent years, there has been a growing interest regarding the implementation of multimodal analgesia as an important component of the ideal perioperative patient management. The aim of the current umbrella review was to establish the role of multimodal analgesia in patients undergoing spine surgery during the immediate postoperative period. Methods A systematic review of the pertinent literature was performed. The evaluation was based on a multitude of primary endpoints including the postoperative requirements for patient-controlled analgesia, pain intensity, back-related disability, overall functionality, patient satisfaction, complications, length of hospitalization, and costs. Results The results were summarized using a meta-analysis in the presence of quantitative data or in a narrative review, otherwise. There was a large body of high-quality evidence supporting that the implementation of multimodal analgesia improves patient outcome in terms of the intensity of postoperative pain, the requirements for postoperative opioid analgesia, and the opioid-associated side effects. Similarly, limited high-quality evidence supported that multimodal analgesia improved patients' functionality and satisfaction while decreasing the length of hospitalization and overall costs of surgery. However, the results were inconclusive as far as the disability was concerned. Conclusions Multimodal analgesia seems to have an essential role for the optimal management of patients undergoing spine surgery. Future research is required to optimize the multimodal analgesia protocols in this group of patients.

Purpose Optical coherence tomography (OCT) is a non-invasive method for diagnosis and monitoring of retinal (typically, macular) conditions. The unfamiliar nature of OCT images can present considerable challenges for some community optometrists. The purpose of this research is to develop and assess the efficacy of a novel internet resource designed to assist optometrists in using OCT for diagnosis of macular disease and patient management. Methods An online tool (OCTAID) has been designed to assist practitioners in the diagnosis of macular lesions detected by OCT. The effectiveness of OCTAID was evaluated in a randomised controlled trial comparing two groups of practitioners who underwent an online assessment (using clinical vignettes) based on OCT images, before (exam 1) and after (exam 2) an educational intervention. Participants’ answers were validated against experts’ classifications (the reference standard). OCTAID was randomly allocated as the educational intervention for one group with the control group receiving an intervention of standard OCT educational material. The participants were community optometrists. Results Random allocation resulted in 53 optometrists receiving OCTAID and 65 receiving the control intervention. Both groups performed similarly at baseline with no significant difference in mean exam 1 scores (p = 0.21). The primary outcome measure was mean improvement in exam score between the two exam modules. Participants who received OCTAID improved their exam score significantly more than those who received conventional educational materials (p = 0.005). Conclusion Use of OCTAID is associated with an improvement in the combined skill of OCT scan recognition and patient management decisions.

Patient care involving genetics is challenging for nongenetics health-care providers. Clinical decision support (CDS) tools are a potential solution because they provide patient-specific risk assessments and/or management recommendations. This systematic review synthesized evidence on whether using CDS tools resulted in appropriate changes in genetics-related patient management made by nongenetics health-care providers. A comprehensive search in MEDLINE, Embase, and CINAHL yielded 2,239 unique articles. Two independent reviewers screened abstracts and full texts for quantitative, qualitative, and mixed-methods articles on management changes by nongenetics clinicians using a CDS tool as part of patient care. Effect sizes were calculated for quantitative studies and all articles were analyzed together using narrative synthesis. Twenty articles were included. In 12/16 quantitative studies, CDS tools slightly increased appropriate changes in management, but study design appeared to affect the statistical significance of the effect. The qualitative data in the four remaining studies reaffirmed that CDS tools facilitated management decisions but raised questions about their effect on patient outcomes. Our review assessed clinical utility of CDS tools, finding that they slightly increase appropriate management changes by nongenetics providers. Future studies on CDS tools should explicitly evaluate decision making and patient outcomes.

Aortic dissection remains a highly morbid diagnosis. The treatment of aortic dissection has undergone several paradigm shifts since it was first understood. However, despite the robust research in treatment, the epidemiology of aortic dissection is limited. In this review, we discuss the historical perspectives of aortic dissection with a review of risk factors and presentation. We review the trends in incidence during the past 40 years, with consideration for sex, race, and ethnicity in admission. We further focus our discussion of the classically described Type B aortic dissection treatment. Lastly, we review the impact of long-term events, readmissions, cost assessments, and quality of life studies of patients with aortic dissection. Care for those with aortic dissection remains a long-term challenge for providers and a multispecialty approach is needed for complete patient management.

Frailty and multimorbidity are interrelated complex syndromes. Individuals living with frailty are likely to be multimorbid, but not all multimorbid individuals are frail. Frailty and multimorbidity are principal causes of polypharmacy. In combination, they are associated with significant healthcare use, unscheduled hospital admissions and mortality. However, multiple medication use is not always inappropriate. Early detection of frailty, patient-centred decision-making and review of multimorbid conditions underpinned by principles of comprehensive geriatric assessment are the cornerstones of patient management.

Benign uterine diseases are very common gynecologic conditions that affect women mostly in reproductive age. Ultrasound examination is the first-line imaging technique, but MRI is more accurate for diagnosis, characterization, and patient management. In this review, we especially highlight the added value of MRI in the diagnosis of benign uterine disease, discuss their imaging characteristics, and describe the therapeutic options and the added value of MRI in the treatment planning.

Variability in the results of randomized trials presents challenges to the interpretation and application of the evidence to patient care. Understanding how systematic reviews deal with this problem of "heterogeneity" will help clinicians in applying results in their patient management. This manuscript offers a review of heterogeneity from the clinical urological perspective. PATIENT SUMMARY: Systematic reviews of the literature are necessary to accurately summarize the available evidence to inform clinical decisions. In this mini-review, we explain how to understand and deal with the differences between studies-which we call heterogeneity-included in these types of reviews.

Although the adverse events of pathologic Vieussens' arterial ring (VAR) have been reported, it is difficult to determine optimal clinical management. Thus, we hypothesized that the luminal diameter ratio of VAR obtained from coronary computed tomography angiography (CCTA) could be used as a clinical tool to inform appropriate patient management.A total of 29 patients with pathologic VAR were retrospectively recruited for this study. The VAR luminal diameter ratio was defined as a quotient of VAR fistula divided by the orifice of RCA or LAD, based on which, patients were divided into small fistula group and large fistula group. The AUC, sensitivity, specificity, positive and negative predictive values were obtained from ROC curve. The cutoff value of the VAR luminal diameter ratio was calculated and assessed during the follow-up.The VAR luminal diameter ratio of fistula/RCA orifice was 0.505 ± 0.098 in small fistula group and 1.020 ± 0.150 in large fistula group. The VAR luminal diameter ratio of fistula/LAD orifice was 0.507 ± 0.123 in small fistula group and 1.039 ± 0.151 in large group. The value was correlated with the choice of the treatment (r = 0.643 p 0.01, r = 0.627 p 0.01). The AUC, sensitivity, specificity, positive and negative predictive values were 0.803, 54.5%, 100%, 100% and 78.3% of the fistula/RCA orifice ratio and 0.833, 63.64%, 94.44%, 87.5% and 81.0% of the fistula/LAD orifice ratio, respectively. The cutoff values of both fistula/RCA orifice and fistula/LAD orifice ratios were 0.676.The VAR luminal diameter ratio may be a valuable index to determine appropriate treatment for patients with pathologic VAR.

Background and Aims Kupffer-phase imaging visualized by perfluorobutane (Sonazoid) distribution into normal liver tissues upon phagocytosis by Kupffer cells potentially aids in improving detection of liver metastasis compared with fundamental B-mode EUS (FB-EUS). However, the diagnostic performance of Kupffer-phase imaging in contrast-enhanced harmonic EUS (CH-EUS) remains unclear. Hence, this study aimed to evaluate the usefulness of CH-EUS-based Kupffer-phase imaging for diagnosing liver metastasis from pancreatic cancer. Methods We retrospectively analyzed consecutive patients with pancreatic cancer who underwent contrast-enhanced CT (CE-CT) and FB-EUS, followed by CH-EUS, from 2011 to 2017. The diagnostic ability of CH-EUS against that of CE-CT and FB-EUS for metastasis in the left liver lobe was compared. Subsequently, the influences of CH-EUS on the determination of clinical stage and patient management for pancreatic cancer were assessed. Results We enrolled 426 patients with pancreatic cancer. Metastasis in the left liver lobe was present in 27.2% of patients. The diagnostic accuracy of CE-CT, FB-EUS, and CH-EUS was 90.6%, 93.4%, and 98.4%, respectively. The sensitivity and diagnostic accuracy of CH-EUS for metastasis in the left liver lobe were significantly higher than those of FB-EUS or CE-CT. The sensitivity of CH-EUS for detecting small liver metastasis ( Conclusions CH-EUS-based Kupffer-phase imaging increased the detectability of metastasis in the left liver lobe. This technique could be a reliable pretreatment imaging modality for clinical decision-making in patients with pancreatic cancer.

Diagnosis of patients suspected of multiple myeloma requires a combination of serological and biochemical tests, bone marrow aspirate (BMA) and/or bone marrow trephine (BMT) biopsies as well as complementary information provided by whole-body cross-sectional imaging studies. However, given the heterogeneous nature of multiple myeloma, discrepancies can arise between disease burden on trephine and extent of disease within the marrow on whole-body magnetic resonance imaging (WB-MRI). Here, for the first time, we report on a series of symptomatic multiple myeloma patients for whom there was substantial discordance between disease burden on trephine and WB-MRI.

The number of Fontan patients with circulatory failure and systolic dysfunction is growing rapidly. The last decade has demonstrated that ventricular assist device (VAD) is an effective therapy in properly selected patients. Herein, we discuss the current approach to patient selection, implantation, and patient management.

A diverse range of clinical phenotypes are observed in clear-cell renal cell carcinoma (ccRCC) with resultant therapeutic implications. Molecular characterisation underpinning the diversity observed has been qualified, where the near ubiquitous loss of the short arm of chromosome 3 precedes distinct evolutionary trajectories involving different sequences and combinations of genetic events. Primary tumours are characterised by varying degrees of intratumoural heterogeneity and chromosomal complexity associated with distinct metastatic phenotypes. An evolutionary understanding reconciles the diverse clinical phenotypes observed in metastatic ccRCC and has the potential to impact patient management. PATIENT SUMMARY: Re-tracing the evolutionary paths taken by clear-cell kidney cancer through analyses at the gene level gives an insight into genetic changes that are correlated to metastatic potential. This may provide a framework to guide therapeutic interventions, especially in identifying candidates for surgical intervention.

Neuroimaging plays a vital role in the diagnosis and post-treatment assessment of brain tumors, aiding in treatment optimization, prognostication, and patient management. New clinical treatments have resulted in increased complexity of imaging interpretation, thus integrating complementary information from multiple imaging modalities (computed tomography, magnetic resonance imaging, and nuclear medicine) contributes to a thorough and more accurate evaluation. In review, we discuss current strategies of brain tumor imaging, specifically detailing the role of nuclear medicine single-photon emission computed tomography and positron emission tomography with utilization of both common and uncommon radiotracers in tumor grading, diagnosis, and treatment response.

Introduction To have an overview of pediatric medical simulation within a country would be helpful to improve the offer and quality of teaching. The main objective of this study was to identify the scope for simulation-based teaching in pediatrics in France. Methods An assessment of professional practices was conducted by means of a national survey conducted among all university hospitals between 20 May and 6 August 2018. A standardized GoogleForm® was created and sent to heads of simulation centers or persons responsible for pediatric simulation. Descriptive analyses and comparisons of centers with and without university trainers as well as with and without research activity were performed. Results All 34 teaching hospitals or faculties of medicine responded to our survey. Of these, 31 had a simulation center. There was a median of nine trainers per center (interquartile range: 5–13). Most used simulation for communication and teamwork, as well as for technical and relational skills. These sessions were mainly dedicated to residents and health professionals. All centers reported working on high-fidelity newborn mannequins and 84% used low-fidelity newborn mannequins. Research activity was declared by 14 centers (45%), but only six of these had at least one publication. No difference was identified between centers with and without university trainers or with and without research activity. Conclusion Compared with the 2012 report, 19 new centers have emerged within 6 years in France (+158%). Pursuing research to evaluate the impact of simulation programs on physician skills and patient management would appear to be important.