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Objectives: Intravenous tenecteplase (TNK) is increasingly used to treat adult patients with acute arterial ischemic stroke, but the risk profile of TNK in childhood stroke is unknown. This study aims to prospectively gather safety data regarding TNK administration in children., Methods: Since December 2023, a monthly email survey was sent to participants recruited from the International Pediatric Stroke Study and Pediatric Neurocritical Care Research Group querying recent experience with TNK in childhood stroke. Limited demographic, safety, and outcome data were collected in a secure REDCap database. Detailed clinical data were not collected., Results: Eleven children were reported to have received TNK between February 2023 and January 2024. Ten were adolescents (13-17 years old), and 1 was between 5 and 12 years old. TNK was given at an outside facility before transfer to the reporting facility in 7 cases. Final diagnosis was stroke in 8 cases and stroke mimic in 3 cases. No major safety concerns or TNK-related intracranial hemorrhages on follow-up imaging were reported., Discussion: Our initial data suggest that TNK may be safe in childhood arterial ischemic stroke. Strategically designed prospective studies are needed to further define safety, optimal dosage, and efficacy of TNK in acute pediatric stroke.

Objective: To investigate the association of personal accomplishment (PA) with the other subscales, assess its association with well-being outcomes, and evaluate drivers of PA by resident level., Background: Most studies investigating physician burnout focus on the emotional exhaustion (EE) and depersonalization (DP) subscales, neglecting PA. Therefore, the role of PA is not well understood., Methods: General surgery residents were surveyed following the 2019 American Board of Surgery In-Training Examination regarding their learning environment. Pearson correlations of PA with EE and DP were assessed. Multivariable logistic regression models assessed the association of PA with attrition, job satisfaction, and suicidality and identified factors associated with PA by PGY., Results: Residents from 301 programs were surveyed (85.6% response rate, N = 6956). Overall, 89.4% reported high PA, which varied by PGY-level (PGY1: 91.0%, PGY2/3: 87.7%, PGY4/5: 90.2%; P = 0.02). PA was not significantly correlated with EE (r = -0.01) or DP (r = -0.08). After adjusting for EE and DP, PA was associated with attrition (OR 0.60, 95%CI 0.46-0.78) and job satisfaction (OR 3.04, 95%CI 2.45-3.76) but not suicidality (OR 0.72, 95%CI 0.48-1.09). Although the only factor significantly associated with PA for interns was resident cooperation, time in operating room and clinical autonomy were significantly associated with PA for PGY2/3. For PGY4/5s, PA was associated with time for patient care, resident cooperation, and mentorship., Conclusion: PA is a distinct metric of resident well-being, associated with job satisfaction and attrition. Drivers of PA differ by PGY level and may be targets for intervention to promote resident wellness and engagement., Competing Interests: The authors declare no conflict of interests., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Purpose- Data regarding the safety and efficacy of intravenous tPA (tissue-type plasminogen activator) in childhood acute arterial ischemic stroke are inadequate. The TIPS trial (Thrombolysis in Pediatric Stroke; National Institutes of Health grant R01NS065848)-a prospective safety and dose-finding trial of intravenous tPA in acute childhood stroke-was closed for lack of accrual. TIPS sites have subsequently treated children with acute stroke in accordance with established institutional protocols supporting data collection on outcomes. Methods- Data on children treated with intravenous tPA for neuroimaging-confirmed arterial ischemic stroke were collected retrospectively from 16 former TIPS sites to establish preliminary safety data. Participating sites were required to report all children who were treated with intravenous tPA to minimize reporting bias. Symptomatic intracranial hemorrhage (SICH) was defined as ECASS (European Cooperative Acute Stroke Study) II parenchymal hematoma type 2 or any intracranial hemorrhage associated with neurological deterioration within 36 following tPA administration. A Bayesian beta-binomial model for risk of SICH following intravenous tPA was fit using a prior distribution based on the risk level in young adults (1.7%); to test for robustness, the model was also fit with uninformative and conservative priors. Results- Twenty-six children (age range, 1.1-17 years; median, 14 years; 12 boys) with stroke and a median pediatric National Institutes of Health Stroke Scale score of 14 were treated with intravenous tPA within 2 to 4.5 hours (median, 3.0 hours) after stroke onset. No patient had SICH. Two children developed epistaxis. Conclusions- The estimated risk of SICH after tPA in children is 2.1% (95% highest posterior density interval, 0.0%-6.7%; mode, 0.9%). Regardless of prior assumption, there is at least a 98% chance that the risk is <15% and at least a 93% chance that the risk is <10%. These results suggest that the overall risk of SICH after intravenous tPA in children with acute arterial ischemic stroke, when given within 4.5 hours after symptom onset, is low.

Purpose of Review: Asthma outcomes are influenced by factors at multiple ecological levels: the individual and his/her family, home, medical care, and community. This systematic review describes recently published single-level and multilevel behavioral interventions to improve asthma outcomes., Recent Findings: Of the 23 total title/abstracts reviewed in the original systematic search of PubMed, Ovid, Scopus, PsychINFO, and CIHAHL reference review databases, six met inclusion criteria. Five of the studies focused on low-income and/or minority populations. Promising interventions include culturally tailored online asthma self-management programs and family-centered asthma education delivered at the bedside during hospitalization for an acute asthma exacerbation., Summary: Culturally, tailored online self-management programs offer difficult-to-reach populations asthma support that can be completed at the time and pace most convenient for the individual user. Family-focused asthma education, delivered at the bedside during an acute asthma hospitalization by highly motivated lay volunteers, is an efficacious and low-cost approach to improving pediatric asthma self-management.

Objective: The aim of this study was to evaluate response of the targeted tumor burden by functional magnetic resonance imaging (MRI) including volumetric diffusion-weighted imaging and volumetric contrast-enhanced MRI (CE-MRI) and its impact on survival in patients with hepatocellular carcinoma treated with intra-arterial therapy (IAT)., Materials and Methods: This institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study included 157 hepatocellular carcinoma lesions in 97 patients (78 men and 19 women; mean age, 64 years) treated with IAT. All patients had pretreatment and 3- to 4-week follow-up MRI with diffusion-weighted imaging and CE-MRI. All lesions 2 cm or larger that were targeted during the first session of IAT were segmented using research software (MR-Oncotreat) to determine targeted tumor burden relative to liver volume (%). Targeted tumor burden was stratified into low (≤10%) or high (>10%). Response using volumetric functional apparent diffusion coefficient (ADC; increase by ≥25%) and CE-MRI (decrease by ≥50% and ≥65% in arterial and venous enhancement [VE], respectively) was assessed in all targeted tumors (range, 1-11) using paired t tests. Kaplan-Meier survival analysis was performed and log-rank test was used to compare pairs of survival curves. Multivariate Cox regression analysis was performed to determine the simultaneous effect of treatment response and tumor burden on survival after adjusting for age, sex, and Child Pugh status., Results: There was a significant increase in volumetric ADC (median, 15%; P < 0.001) and a decrease in volumetric arterial enhancement (AE) and VE (median AE, -43% and portal venous phase (PVP), -29%, respectively; P < 0.001) 3 to 4 weeks after treatment in the targeted tumor burden. Multivariable Cox regression demonstrated that both ADC response and low tumor burden were independently associated with greater survival (hazard ratios, 0.53 and 0.55; P values, 0.025 and 0.016, respectively) after adjustment for age, sex, and Child Pugh status. Multivariable Cox regression models demonstrated no statistically significant relationship between AE response and survival after adjusting for tumor burden. However, multivariable Cox regression demonstrated that VE response was associated with greater survival only in those with low tumor burden (hazard ratio, 0.10; P = 0.001), indicating a strong interaction between VE response and tumor burden., Conclusion: Quantifying targeted tumor burden is important in predicting patient survival when using functional MRI metrics in assessing treatment response.

The potential for immune cells to control cancers has been recognized for many decades, but only recently has real excitement begun to spread through the oncology community following clear evidence that therapeutic blockade of specific immune-suppressive mechanisms is enough to make a real difference in survival for patients with several different advanced cancers. However, impressive and encouraging as these new clinical data are, it is clear that more effort should be devoted toward understanding the full spectrum of factors within cancer patients, which have the potential to block or weaken antitumor activity by immune cells. The goal of this brief review is to highlight recent literature revealing interactive stress and metabolic pathways, particularly those mediated by the sympathetic nervous system, which may conspire to block immune cells from unleashing their full killing potential. There is exciting new information regarding the role of neurogenesis by tumors and adrenergic signaling in cancer progression (including metabolic changes associated with cachexia and lipolysis) and in regulation of immune cell function and differentiation. However, much more work is needed to fully understand how the systemic metabolic effects mediated by the brain and nervous system can be targeted for therapeutic efficacy in the setting of immunotherapy and other cancer therapies.

Purpose: This study evaluated the effect of intravenous (IV) catheter gauge size on catheter placement, contrast infusion, and image quality for patients undergoing IV contrast-enhanced multidetector computed tomography (MDCT)., Materials and Methods: One thousand consecutive adult outpatients undergoing IV contrast-enhanced MDCT and 10 IV insertion CT nurses were observed from IV catheter selection through IV removal. Patients' demographics, number of sticks required, catheter gauge during each attempt, time for catheter placement, IV nurses' assessment of vein quality and contrast infusion parameters were recorded. Scan quality was assessed subjectively., Results: Subjects included 547 men and 453 women, with a mean age 59.2 years (range, 19-92 years). Median number of catheter attempts was 1 per patient (range, 1-9). Catheters were successfully placed in 98%. First and final catheters were most commonly 20 gauge (59% and 56%, respectively), followed by 22 gauge (34% for both), 18 gauge (6% for both), and 24 gauge (2% and 3%, respectively). Mean infusion rate correlated with catheter gauge: 5.3 mL/s for 18 gauge; 3.5 mL/s for 20 gauge; 2.3 mL/s for 22 gauge; and 1.7 mL/s for 24 gauge (P < 0.0001). Target infusion rate of ≥ 3 mL/s was related to catheter gauge (100% of 18 gauge, 71% of 20 gauge, 11% of 22 gauge, and 0% of 24 gauge; P < 0.0001). Nine hundred sixty-eight subjects underwent imaging. Most of the CT examinations (935/968 [97%]) were of acceptable quality., Conclusion: Experienced IV starters usually achieve IV access in one attempt by tailoring IV catheter gauge to vein quality; however, target infusion rates are not likely to be achieved with 22- and 24-gauge catheters, used in nearly 1/3 of the patients in this study.

Objective: To compare the coefficient of variation (CV) and long-term reproducibility of apparent diffusion coefficient (ADC) in a simple fluid-filled phantom and abdominal organs simultaneously., Materials and Methods: Retrospective institutional review board-approved and Health Insurance Portability and Accountability Act-compliant study sequentially selected 100 patients who underwent clinically indicated abdominal magnetic resonance imaging. A subset of 58 patients had repeat scans within 2 to 5 months after the initial magnetic resonance imaging. Two diffusion-weighted imaging techniques (b-values 0-750 mm/s) were performed to compare the ADC values. Mean ADC values were calculated for 10 locations and the reference phantom. The CV and Bland-Altman plots were calculated for the phantom and soft tissues at each session and location., Results: There were no significant differences in the mean ADC values between repeated acquisitions. However, ADC values were statistically higher using dual-b-value than multi-b-value diffusion-weighted imaging. The CV for the phantom was 8.6 versus 10.8 for dual-b-value and multi-b-value, respectively. The CVs for the soft tissues had a wider range compared with that of the phantom (liver, 12.6 vs 9.0; spleen, 11.7 vs 11.2; gallbladder, 11.0 vs 13.6; head of pancreas, 14.6 vs 14.7; body of pancreas, 13.4 vs 13.0; tail of pancreas, 14.8 vs 16.3; right kidney, 9.1 vs 9.6; left kidney, 9.3 vs 9.3; right paraspinal muscle, 7.9 vs 7.5; left paraspinal muscle, 7.3 vs 7.3, respectively)., Conclusions: A change in ADC less than 11% falls into the range of measurement variability. Paraspinal muscle could potentially be used as an internal reference parameter.

Background: Increased left ventricular myocardial thickness (LVMT) is a feature of several cardiac diseases. The purpose of this study was to establish standard reference values of normal LVMT with cardiac magnetic resonance and to assess variation with image acquisition plane, demographics, and left ventricular function., Methods and Results: End-diastolic LVMT was measured on cardiac magnetic resonance steady-state free precession cine long and short axis images in 300 consecutive participants free of cardiac disease (169 women; 65.6 ± 8.5 years) of the Multi-Ethnic Study of Atherosclerosis cohort. Mean LVMT on short axis images at the mid-cavity level was 5.3 ± 0.9 mm and 6.3 ± 1.1 mm for women and men, respectively. The average of the maximum LVMT at the mid-cavity for women/men was 7/9 mm (long axis) and 7/8 mm (short axis). Mean LVMT was positively associated with weight (0.02 mm/kg; P=0.01) and body surface area (1.1 mm/m(2); P<0.001). No relationship was found between mean LVMT and age or height. Greater mean LVMT was associated with lower left ventricular end-diastolic volume (0.01 mm/mL; P<0.01), a lower left ventricular end-systolic volume (-0.01 mm/mL; P=0.01), and lower left ventricular stroke volume (-0.01 mm/mL; P<0.05). LVMT measured on long axis images at the basal and mid-cavity level were slightly greater (by 6% and 10%, respectively) than measurements obtained on short axis images; apical LVMT values on long axis images were 20% less than those on short axis images., Conclusions: Normal values for wall thickness are provided for middle-aged and older subjects. Normal LVMT is lower for women than men. Observed values vary depending on the imaging plane for measurement.

Objective: To examine diagnostic accuracy of semiquantitative and qualitative magnetic resonance neurography criteria in common peroneal nerve (CPN) neuropathy., Materials and Methods: Institutional review board approval was obtained with a waiver of informed consent for this Health Insurance Portability and Accountability Act-compliant retrospective study. A review of 28 knees in 28 subjects (12 males and 16 females; age range, 13-84 years; mean [SD] age, 42 [20] years) who had undergone magnetic resonance neurography of the knee was performed. Thirteen patients who had a final diagnosis of CPN were classified as cases, and 15 patients who lacked a final diagnosis of CPN neuropathy were classified as controls. Morphological characteristics of the CPN, including nerve T2 signal intensity, nerve size, nerve course, fascicles morphology, regional muscle edema, and fatty infiltration, and an overall assessment of the CPN as being normal or abnormal were evaluated by 2 independent radiologists blinded to the clinical history. Overall sensitivity, specificity, and accuracy compared against our reference standards were expressed as percentages. Interobserver agreements were assessed using linear weighted κ statistics., Results: Common peroneal nerve T2 signal abnormality had the highest sensitivity (77%) in identifying CPN neuropathy. Except for T2 signal abnormality, overall specificity for the nerve morphological parameters and muscle denervation change assessed was fairly high, ranging from 94% to 100%. The consensus accuracy ranged from 68% to 79% for the morphological characteristics assessed. The interobserver reproducibility was very good (k = 0.90 to 0.91) for assessment of regional muscle denervation changes and moderate (k = 0.46 to 0.59) for morphological CPN characteristics., Conclusion: Magnetic resonance neurography is a useful modality in supplementing the diagnosis of CPN. Using predefined classification criteria helps standardize the morphological criteria of CPN neuropathy diagnosis.

Background and Purpose: There is controversy about the optimal patient position for the detection of right-to-left shunt (RLS). The study was performed to investigate which patient position best detects RLS during contrast-enhanced transcranial Doppler., Methods: We prospectively evaluated consecutive patients with ischemic stroke or TIA referred to our Noninvasive Cerebrovascular Laboratory for suspected paradoxical embolism. The standard protocol for RLS detection recommended by the International Consensus Criteria was followed. Each patient was examined at rest and after Valsalva maneuver in 4 positions: supine, right lateral decubitus, right lateral leaning, and upright sitting, in random order. RLS was graded 0 (no microbubbles [mB] detected), 1 (1-10 mB), 2 (>10 mB but no curtain), and 3 (curtain, shower of mB). Blood pressure, heart rate, and neurological symptoms were monitored. Data were analyzed using SPSS version 17., Results: RLS was detected in at least 1 position in 89 of 240 patients (37.1%; 95% CI, 33.1%-43.3%). The detection of at least 1 mB with normal breathing was lowest in supine position and highest in right lateral decubitus. With Valsalva maneuver, this was highest in upright sitting (20.4% versus 8.3%; P<0.0002). If mB were undetected on upright sitting position, then they may still be detected in other positions. Changes in the position of the body and the injection of agitated saline were well-tolerated., Conclusions: RLS is best detected in the upright sitting position with Valsalva maneuver. If negative, then other positions may be used. Validation of our findings by other centers may be helpful.

Objectives: Recent studies suggest that tumor cells overexpressing aldoketoreductases (AKRs) exhibit increased resistance to DNA damaging agents such as anthracyclines. AKRs may induce resistance to the anthracycline doxorubicin by catalyzing its conversion to the less toxic 13-hydroxy metabolite doxorubicinol. However, it has not been established whether during selection for anthracycline resistance, AKR overexpression in tumor cells can be correlated with the onset or magnitude of drug resistance and with appreciable conversion of anthracyclines to 13-hydroxy metabolites., Methods and Findings: Through microarray and quantitative polymerase chain reaction studies involving rigid selection criteria and both correlative discriminate statistics and time-course models, we have identified several genes whose expression can be correlated with the onset and/or magnitude of anthracycline resistance, including AKR1C2 and AKR1C3. Also associated with the onset or magnitude of anthracycline resistance were genes involved in drug transport (ABCB1, ABCC1), cell signaling and transcription (RDC1, CXCR4), cell proliferation or apoptosis (BMP7, CAV1), protection from reactive oxygen species (AKR1C2, AKR1C3, FTL, FTH, TXNRD1, MT2A), and structural or immune system proteins (IFI30, STMN1). As expected, doxorubicin-resistant and epirubicin-resistant cells exhibited higher levels of doxorubicinol than wild-type cells, although at insufficient levels to account for significant drug resistance. Nevertheless, an inhibitor of Akr1c2 (5beta-cholanic acid) almost completely restored sensitivity to doxorubicin in ABCB1-deficient doxorubicin-resistant cells, while having no effect on ABCB1-expressing epirubicin-resistant cells., Conclusion: Taken together, we show for the first time that a variety of genes (particularly redox genes such as AKR1C2 and AKR1C3) can be temporally and causally correlated with the acquisition of anthracycline resistance in breast tumor cells.

Purpose: To compare supine magnetic resonance imaging (MRI), with and without rectal contrast, with fluoroscopic cystocolpoproctography (CCP) for the diagnosis of pelvic organ prolapse., Materials and Methods: Supine MRI and CCP studies were reviewed in 82 patients. All patients were women with an average age of 58.8 years, and the studies were done a mean of 25 days apart. Magnetic resonance imaging was performed with rectal contrast (n = 35) and without rectal contrast (n = 47). Fluoroscopic cystocolpoproctography was performed with rectal (n = 82), vaginal (n = 82), small bowel (n = 81), and bladder (n = 78) contrast, and images were corrected for magnification. Each study was independently reviewed by 2 readers, and outcome variables were presence/absence of cystocele, vaginal prolapse, enterocele, sigmoidocele, and anterior rectocele. Sigmoidoceles were included with enteroceles for data analysis., Results: For the entire patient group, the prevalence of cystoceles was 89% on CCP and 80% on MRI; vaginal prolapse was 81% on CCP and 56% on MRI; enteroceles, 38% on CCP and 24% on MRI; and anterior rectoceles, 45% on CCP and 37% on MRI. There were significantly more cystoceles (odds ratio [OR] 4.7, P = 0.003), vaginal prolapses (OR 5.2, P < 0.0005), and enteroceles (OR 3.8, P< 0.0005) on CCP than on MRI. For MRI with rectal contrast versus CCP, the prevalence of cystoceles was 94% on CCP and 91% on MRI; vaginal prolapse, 74% on CCP and 70% on MRI; enteroceles, 36% on CCP and 19% on MRI; and anterior rectoceles, 51% on CCP and 59% on MRI. There was statistical significance only for enteroceles, more of which were found on CCP (OR 7.4, P = 0.003). For MRI without rectal contrast versus CCP, the prevalence of cystoceles was 85% on CCP and 72% on MRI; vaginal prolapse, 86% on CCP and 46% on MRI; enteroceles, 40% on CCP and 28% on MRI; and anterior rectoceles, 39% on CCP and 21% on MRI. There were significantly more cystoceles (OR 6.6, P = 0.003), vaginal prolapses (OR 20.8, P < 0.0005), enteroceles (OR 2.9, P = 0.015), and rectoceles (OR 4.9, P = 0.001) on CCP than on noncontrast MRI., Conclusions: Magnetic resonance imaging without rectal contrast showed statistically fewer pelvic floor abnormalities than CCP. Except for enteroceles, MRI with rectal contrast showed statistically similar frequency of pelvic organ prolapse as CCP.

Purpose: To evaluate the role of diffusion-weighted imaging in differentiating between hepatic hemangiomas, both typical and atypical, and other hypervascular liver lesions., Methods: Retrospective review of 182 hypervascular liver lesions in 117 patients was performed. Diffusion and contrast-enhanced magnetic resonance imaging were performed using a 1.5-T unit. Imaging protocol consisted of T2-weighted fast spin-echo images, breath-hold diffusion-weighted echo-planar images, and breath-hold unenhanced and contrast-enhanced T1-weighted 3-dimensional fat-suppressed spoiled gradient-echo images in the arterial phase (20 seconds) and portal venous phase (60 seconds). Signal intensity changes and apparent diffusion coefficient (ADC) values were evaluated for all lesions. Unpaired t test was used to compare the mean ADC values for different lesions, and statistical significance was set at P < 0.01. Receiver operating characteristic analysis was used to determine the accuracy of diffusion-weighted imaging in differentiating hemangiomas from other hypervascular liver lesions., Results: Lesions included typical and atypical hemangioma (n = 38), hepatocellular carcinoma (HCC; n = 58), focal nodular hyperplasia (FNH; n = 22), and neuroendocrine tumor metastasis (NET; n = 64) with a mean tumor size of 5.3 cm. Mean ADC value for hemangioma, HCC, FNH, and NET was 2.29 x 10(-3), 1.55 x 10(-3), 1.65 x 10(-3), and 1.43 x 10(-3) mm2/s, respectively. There was a statistically significant difference in the ADC value of hemangioma compared with that of FNH (P < 0.001), HCC (P < 0.001), and NET (P < 0.001), respectively. The area under the receiver operating characteristic curve was 0.91., Conclusions: Diffusion-weighted magnetic resonance imaging and ADC maps can provide rapid quantifiable information to differentiate typical and atypical hemangiomas from other hypervascular liver lesions.

Genome profiling approaches such as cDNA microarray analysis and quantitative reverse transcription polymerase chain reaction are playing ever-increasing roles in the classification of human cancers and in the discovery of biomarkers for the prediction of prognosis in cancer patients. Increasing research efforts are also being directed at identifying set of genes whose expression can be correlated with response to specific drugs or drug combinations. Such genes hold the prospect of tailoring chemotherapy regimens to the individual patient, based on tumour or host gene expression profiles. This review outlines recent advances and challenges in using genome profiling for the identification of tumour or host genes whose expression correlates with response to chemotherapy drugs both in vitro and in clinical studies. Genetic predictors of response to a variety of anticancer agents are discussed, including the anthracyclines, taxanes, topoisomerase I and II inhibitors, nucleoside analogs, alkylating agents, and vinca alkaloids.

Background: Accumulating evidence suggests that white matter lesions are associated with vascular cognitive impairment. The authors investigated the relationships between white matter lesions, cognitive impairment, and risk of recurrent hemorrhage in a prospectively identified cohort of patients with lobar intracerebral hemorrhage (ICH)., Methods: The authors collected clinical and genetic information on 182 consecutive patients age > or = 55 who had CT scan at admission for lobar ICH. White matter disease was graded on CT in all subjects and on MRI in a subset of 82 patients. All scans were interpreted blinded to clinical information. Survivors were followed for recurrent ICH by telephone interview., Results: White matter damage was common (present on CT in 77%) and severe (advanced CT grade in 32%). White matter damage was correlated with the total number of hemorrhages on gradient-echo MRI and with risk of recurrent ICH. Subjects with cognitive impairment prior to their index ICH were more likely to have severe white matter damage on CT (OR 3.6, 95% CI 1.6 to 8.1, p = 0.003) and more likely to have advanced periventricular hyperintensities on MRI. The relationships between white matter damage and cognitive impairment were similar in the subset of 88 subjects meeting criteria for probable or definite cerebral amyloid angiopathy and remained independent after adjustment for age, cortical atrophy, and APOE genotype., Conclusions: White matter damage in lobar ICH is common and is associated with cognitive impairment. These data support the possibility that an underlying vasculopathy in lobar ICH patients, possibly cerebral amyloid angiopathy, can cause clinically important vascular dysfunction.

Purpose: To determine the accuracy of breath-hold magnetic resonance (MR) imaging for preoperative staging of patients with organ-confined (stage I) renal cell carcinoma., Materials and Methods: Preoperative MR examinations of 43 patients (50 lesions) who underwent nephrectomy were reviewed. The MR examination consisted entirely of breath-hold sequences, and images were retrospectively evaluated by 2 blinded radiologists. Reviewers independently evaluated each case for findings that could affect the radiologic staging, particularly those that distinguish between organ-confined (stage I) and non-organ-confined (>stage II) disease. Each reviewer assigned a stage, and results were correlated with findings at surgery and pathologic examination., Results: The difference between both reviewers and pathologic findings in evaluating an intact renal capsule (stage I) was statistically significant (P < 0.05) and resulted in a statistically significant difference between radiologic and pathologic staging (Wilcoxon test, P < 0.05). The kappa test demonstrated moderate agreement between radiologic and pathologic staging (82% and 80% for reviewers 1 and 2, kappa = 0.54 and 0.80, respectively) and substantial agreement (90%, kappa = 0.80) between the 2 reviewers in assigning a radiologic stage., Conclusion: Breath-hold MR imaging has an accuracy ranging between 80% and 82% in staging patients with organ-confined renal cell carcinoma, with substantial (90%) agreement between readers.

Complications (severe bleeding/thromboembolism) may occur during ventricular assist device (VAD) circulation, caused mainly by platelet dysfunction from platelet activation. We hypothesized that S-nitrosoglutathione (GSNO), having platelet activity preservation properties like nitric oxide (NO), may be a titratable agent to diminish platelet activation and thus preserve platelet function. Dose-response measurement of platelet aggregation by GSNO was performed using an aggregometer. GSNO (1,000 microM) caused inhibition of collagen and ristocetin induced aggregation by approximately 50%. Next, in vitro ventricular assist device (VAD) circulation was performed (over 48 hours using human whole blood), both without (control) and with GSNO (1,000 microM), and the aggregability of perfusate was measured at 0, 0.5, 1, 3, 6, 12, 24, and 48 hours. In control VAD circuits, collagen induced platelet aggregability gradually decreased and became significantly lower after 3 hours of circulation. With GSNO, platelet function did not significantly decrease until after 12 hours. Similar results were seen for ristocetin induced aggregation; control aggregation dropped significantly after 6 hours, but not until after 24 hours with GSNO. Liquid phase measurement of total nitrogen oxides (NO(T)) confirmed added GSNO maintained high perfusate NO(T) compared with control. GSNO is effective in preserving platelet aggregation during the first 12 to 24 hours in vitro and may be effective in preserving platelet function by inhibiting platelet activation during in vivo VAD circulation.

Ventricular Assist Devices (VADs) have been used as bridges to heart transplantation. However, VAD circulation is complicated by the incidence of thromboembolism, prolonged bleeding, and activation of the inflammatory cascade. We hypothesize that platelet and neutrophil activation are interrelated and linked to the activation of the glycoprotein (GP) IIb/IIIa platelet receptor. The purpose of this study is to evaluate the effects of Tirofiban, a platelet GP IIb/IIIa receptor inhibitor, on platelet and neutrophil activation during simulated VAD circulation. Two groups of five in vitro VAD circuits were simulated with and without Tirofiban using 450 cc of human blood. Blood samples were drawn at specific time intervals up to 72 hours, measuring leukotriene C4 (LTC4), platelet factor four (PF4), and neutrophil elastase. Tirofiban decreased serum levels of PF4 and LTC4 during VAD circulation. Neutrophil elastase secretion was not affected by Tirofiban administration. Preconditioning of VAD circulation with Tirofiban attenuated platelet activation as demonstrated by a decrease in serum PF4 levels. Tirofiban administration ameliorates the inflammatory response by altering platelet-neutrophil interaction as demonstrated by a decrease in LTC4 production. Continued elastase secretion indicates that the inflammatory response is not completely inhibited by Tirofiban administration. These results suggest that neutrophils may be activated by alternative mechanisms. Early complement activation has been demonstrated during in vivo and in vitro VAD circulation and may play a role in mediating inflammatory and thromboembolic reactions during VAD use.

Purpose: The purpose of this work was to determine normal contrast enhancement of the small bowel with biphasic spiral CT, using water as oral contrast agent., Method: Biphasic spiral CT was performed in 50 healthy patients undergoing evaluation as potential renal donors. All patients received 500 ml of water as oral contrast agent and 150 ml of Omnipaque 350 administered by mechanical injector at a rate of 3 ml/s. Dual phase CT of the abdomen was performed in each patient. Acquisition of early phase images began 30 s after the start of the intravenous injection, and portal phase images were obtained 60 s after initiation of the contrast agent injection. Attenuation measurements (in Hounsfield units) were obtained from the wall of the small bowel (duodenum, jejunum, ileum) in both the arterial and the portal phases., Results: During the arterial phase, the mean (95% confidence interval) attenuation of the duodenum, jejunum, and ileum was 120 (+/- 5), 119 (+/- 5), and 118 (+/- 5) HU, respectively. During the portal phase, the average attenuation of the duodenum, jejunum, and ileum was 111 (+/- 4), 111 (+/- 3), and 107 (+/- 3) HU, respectively. There was no statistically significant difference between the attenuation of the duodenum, jejunum, or ileum within either the arterial or the portal venous phases. There was a statistically significant difference in small bowel enhancement between the arterial and portal venous phases., Conclusion: There is no important variation in small bowel attenuation during the 30 and 60 s scanning phases. This study serves as a normal reference that may be helpful when spiral CT is used to evaluate ischemic bowel or inflammatory small bowel diseases.

The distribution of 222Rn concentrations in 33 buildings near Canonsburg, PA, Lewiston, NY and Middlesex, NJ was investigated over a 2-yr period. One or 2 week-long time-integrated measurements of radon concentration, repeated several times during the study period, were obtained in the living and working areas of the buildings. Average air concentrations of radon, measured over the study period, varied from 0.32 to 4.5 pCi/l. among the buildings, but in only one building did the annual radon concentration exceed the U.S. Nuclear Regulatory Commission's limit of 3pCi/l. for continuous exposure in uncontrolled areas.

This article presents the significance of cyanide in medicolegal investigation of fires. It discusses the various aspects of fire investigation and the pathophysiology of cyanide toxicity and evidence interpretation in fire investigations.