Diagnostic performance of CT with Valsalva maneuver for the diagnosis and characterization of inguinal hernias

PURPOSE

Inguinal hernias are mainly diagnosed clinically, but imaging can aid in equivocal cases or for treatment planning. The purpose of this study was to evaluate the diagnostic performance of CT with Valsalva maneuver for the diagnosis and characterization of inguinal hernias.

METHODS

This single-center retrospective study reviewed all consecutive Valsalva-CT studies between 2018 and 2019. A composite clinical reference standard including surgery was used. Three blinded, independent readers (readers 1-3) reviewed the CT images and scored the presence and type of inguinal hernia. A fourth reader measured hernia size. Interreader agreement was quantified with Krippendorff's α coefficients. Sensitivity, specificity, and accuracy of Valsalva-CT for the detection of inguinal hernias was computed for each reader.

RESULTS

The final study population included 351 patients (99 women) with median age 52.2 years (interquartile range (IQR), 47.2, 68.9). A total of 381 inguinal hernias were present in 221 patients. Sensitivity, specificity, and accuracy were 85.8%, 98.1%, and 91.5% for reader 1, 72.7%, 92.5%, and 81.8% for reader 2, and 68.2%, 96.3%, and 81.1% for reader 3. Hernia neck size was significantly larger in cases correctly detected by all three readers (19.0 mm, IQR 13, 25), compared to those missed by all readers (7.0 mm, IQR, 5, 9; p < 0.001). Interreader agreement was substantial (α = 0.723) for the diagnosis of hernia and moderate (α = 0.522) for the type of hernia.

CONCLUSION

Valsalva-CT shows very high specificity and high accuracy for the diagnosis of inguinal hernia. Sensitivity is only moderate which is associated with missed smaller hernias.

Phase Ib dose-escalation study of the hypoxia-modifier myo-inositol trispyrophosphate in patients with hepatopancreatobiliary tumors

Objective

Hypoxia is present in most solid tumors and acts as a driver of malignancy. Myo-inositol trispyrophosphate (ITPP) is a novel re-oxygenating compound without apparent toxicity. In preclinical models, it potentiates the efficacy of subsequent chemotherapy through vascular normalization. We sought to assess the safety, tolerability, and preliminary efficacy of ITPP.

Methods

In this monocentric, open-label, dose-escalation study following a 3+3 design, eligible patients with advanced primary and secondary hepatopancreatobiliary tumors received nine 8-h infusions of ITPP during 3 weeks across eight dose levels (1866–14,500 mg/m2/dose), followed by standard chemotherapy. Primary endpoints were safety and tolerability. Secondary endpoints were pharmacokinetics and estimation of efficacy based on radiological responses and angiogenic serum markers. Registration number: NCT02528526.

Results

From April 2015 to July 2018, a total of 28 enrolled patients were assessed for the primary endpoints. ITPP was safe up to single doses of 12,390 mg/m2, and 32 ITPP-related adverse events occurred: 19 (67.8%) hypercalcemia, 5 (17.8%) hyponatremia, and 4 (14.2%) hypomagnesemia. Following ITPP monotherapy, 52% of patients displayed morphological disease stabilization. Following subsequent chemotherapy, 10% showed a partial response, and 60% had stable disease. Angiogenic markers were decreased in 60% after ITPP and tended to correlate with responses and survival after chemotherapy.

Conclusion

Administration of ITPP is safe up to 12,390 mg/m2 with favorable pharmacokinetics. Preliminary translational efficacy data show decreased angiogenic markers, which might indicate an anti-hypoxic effect and enhancement of chemotherapy through ITPP.

Reduced and standard field-of-view diffusion weighted imaging in patients with rectal cancer at 3 T-Comparison of image quality and apparent diffusion coefficient measurements

PURPOSE

To compare a zoomed EPI-DWI (z-EPI) with a standard EPI-DWI (s-EPI) in the primary diagnostics of rectal cancer and assess its potential of reduced image artifacts.

METHOD

22 therapy-naïve patients with rectal cancer underwent rectal MRI at a 3 T-system. The protocols consisted of a z-EPI DWI and s-EPI DWI sequence. Images were assessed by two independent and experienced readers regarding overall image quality and artifacts on a 5-point Likert scale, as well as overall sequence preference. In a lesion-based analysis, tumor and lymph node detection were rated on a 4-point Likert scale. Apparent diffusion coefficient (ADC) measurements were performed.

RESULTS

Overall Image quality score for z-EPI and s-EPI showed no statistically significant differences (p = 0.80/0.54, reader 1/2) with a median score of 4 ("good" image quality) for both sequences. The image quality preference rank for z-EPI and s-EPI was given the category 'no preference' in 64 % (reader 1) and 50 % (reader 2). Most artifact-related scores (susceptibility, motion and distortion) did not show reproducible significant differences between z-EPI and s-EPI. The two sequences exhibited comparable, mostly good and excellent quality scores for tumor and lymph node detection (p = 0.19-0.99). ADC values were significantly lower for z-EPI than for s-EPI (p = 0.001/0.002, reader 1/2) with good agreement of ADC measurements between both readers.

CONCLUSION

Our data showed comparable image quality and lesion detection for the z-EPI and the s-EPI sequence in MRI of rectal cancer, whereas the mean ADC of the tumor was significantly lower in z-EPI compared to s-EPI.

Novel monoclonal antibodies for measuring 5-fluorouracil concentrations in biological fluids

2055

Background: Therapeutic drug monitoring of anticancer drugs has potential for improving treatment of individual patients. 5-Fluorouracil (5-FU) has been reported to exhibit high pharmacokinetic variability and in some cases severe toxicity. Pharmacokinetic guided dosing of 5-FU using physical methodologies has demonstrated clinical usefulness in decreasing toxicity while resulting in equivalent or improved outcomes. The current physical methods for measuring 5-FU require specially trained personnel, are expensive, time consuming and therefore not amenable for widespread use. However, an automated immunoassay would provide a rapid, simple and inexpensive method to routinely measure levels of 5-FU in patients. Methods: In order to develop monoclonal antibodies that were selective for 5-FU, immunogens were prepared by attaching the drug to keyhole limpet hemocyanin (KLH) or bovine thyroglobulin (BTG) via a hydrocarbon tether bound through the N-3 nitrogen. Mice were immunized and the resulting antibodies were screened by ELISA. The selection of antibodies was based on sensitivity and cross-reactivity characteristics. Results: These immunogens were successful in eliciting 20 highly selective monoclonal antibodies for 5-FU with immunoassay dose response curves in the clinical range of 10 ng/mL to 5000 ng/mL. The immunoassay was tested with a mixture of the various pyrimidine compounds at their respective endogenous levels and shown to have no impact on the measurement of 5-FU. The Table below lists typical cross-reactivity performance characteristics that are elicited by this type of immunogen. Conclusion: This library of monoclonal antibodies represents the first report of antibodies selective for 5-fluorouracil. These antibodies will be useful for the rapid and cost effective analysis of 5-FU in human samples, providing a tool for optimization of 5-FU levels by pharmacokinetic guided dosing.

[Table: see text]

[Table: see text]

Cardiovascular responses to light isometric and aerobic exercise in 21- and 59-year-old males

The effects of aging on the cardiovascular response to continuous light isometric and aerobic exercise remains to be determined. Thus, the purpose of this study was to compare the cardiovascular response of young and older males during light handgrip and cycle ergometry exercise. Blood pressure, heart rate, rate pressure product, as well as pre-ejection period (derived from impedance cardiography) were obtained for 15 young [mean (SE) age: 21 (0.7) years] and 15 older males [59 (0.8) years] during and after light handgrip exercise and cycle ergometry. The parasympathetic influence on the heart was also assessed through a time-series analysis of heart period variability (HPVts). Both during and when recovering from the handgrip exercise and cycle ergometry, the older subjects exhibited a significantly higher absolute systolic and diastolic blood pressure, and rate pressure product, and a lower HRVts than the young subjects. Relative to baseline, the change in pre-ejection period was lower for the young subjects during the handgrip and cycle ergometry, tasks. These results indicate that although the sympathetic influence on both the myocardium and the vasculature was less pronounced in the older males, the aging cardiovasculature was under greater hemodynamic stress both during rest and during exposure to light isometric and aerobic challenge.

Cardiovascular response of young and older males to mental challenge

Blood pressure, heart rate, rate pressure product, heart rate variability, stroke volume, cardiac output, peripheral resistance, and cardiac contractility derived from impedance cardiography were obtained from 15 young and 15 old males during and after the Stroop task. The old group demonstrated significantly higher absolute heart rate, systolic and mean arterial pressure, peripheral resistance, and rate pressure product, and lower cardiac output, stroke volume, and heart rate variability both during and recovering from Stroop. The young group showed significantly greater relative heart rate increase at the start of Stroop, higher relative levels of contractility during and recovering, and greater relative levels of peripheral resistance during and recovering from Stroop. Overall, old compared to young subjects possessed greater absolute but smaller relative cardiovascular responses during and recovering from Stroop. These results suggest that although the aging cardiovasculature may be less reactive, it may be under greater hemodynamic stress both during rest and mental challenge.

Urinary symptoms, sexual intercourse and significant bacteriuria in male patients attending STD clinics

OBJECTIVE

To assess the relationship between sexual behaviour, urinary symptoms, urinalysis and bacteriuria in men attending STD clinics.

DESIGN

A prospective study recording sexual behaviour, urinary symptoms and collecting mid-stream urine specimens.

SETTING

Two West Midlands STD clinics, UK.

SUBJECTS

1086 new male patients.

RESULTS

704 patients had had sexual intercourse (SI) within 14 days of testing, 424 had urinary symptoms and 122 had pyuria. All 13 patients with positive culture had SI < 14 days before testing, urinary symptoms and pyuria. No association was found between sexual orientation, type of SI, number of sexual partners, condom usage and bacteriuria.

CONCLUSION

Bacteriuria does not behave as an STD but SI may be a factor in acquiring bacteriuria. Dysuria with or without urethral discharge is the most predictive symptom of bacteriuria. Pyuria has a high sensitivity for predicting bacteriuria among males.

Comparison of shoulder injury in collegiate- and master's-level swimmers

The need to investigate shoulder injury in swimmers other than the young and elite is evident, as all ages and levels are represented in the 100 million Americans who classify themselves as swimmers. To investigate the differences between young, highly competitive collegiate swimmers and older, less elite swimmers, a survey questionnaire was distributed to 100 collegiate and 100 master's swim teams. Questions regarding swimming routines, performance standards, and several possible predisposing factors associated with "swimmer's shoulder," as implicated in the literature, were investigated. As expected, the results revealed that the collegiate group swam the higher yardage, with considerably faster times in both the 50- and the 1,000-yd freestyle, and more than double the number of workouts per week. However, the collegiate and master's group reported similar percentages, 47 and 48%, respectively, experiencing shoulder pain lasting 3 weeks or more, despite the lesser distances and intensities associated with the latter group. Chi-square analysis revealed no association between shoulder pain and perceived level of flexibility, hand paddle usage, or breathing side for either group. However, over 50% of the swimmers with shoulder pain in both groups perceived that increased intensities and/or distance provoked shoulder pain, indicating that fatigue may be the issue to avoid and on which to focus. Strengthening the muscles of the shoulder, specifically those shown to have a propensity to fatigue, provides a strong defense against injury, as fatigue of the shoulder muscles may be the initial antecedent to swimmer's shoulder. These results give the swimmer, coach, and medical practitioner feedback to consider for a swimmer of any age or level.

Control of herpes simplex virus infections of the genital tract by vaccination

The apparent increasing incidence of herpes simplex virus infections of the genital tract has focused attention on the efficacy of vaccination in preventing infection or modifying established disease. Results of an 'open trial' using a DNA-free inactivated virus subunit vaccine have shown that vaccination of subjects at risk of contracting infection from their sexual partner reduced the transmission rate from 34% in unvaccinated controls to 0.5%. In a separate study, vaccination of patients who had experienced their first overt attack of herpes genitalis (the initial clinical episode) had significantly fewer recurrences over the follow-up period of 12 months than the unvaccinated control group. The results, we feel, justify a placebo controlled trial.

Efficacy of vaccine Ac NFU1 (S-) MRC 5 given after an initial clinical episode in the prevention of herpes genitalis

A subunit antigenoid vaccine, Ac NFU1 (S-) MRC 5, was used in patients who had had a clinical episode of herpes genitalis. The rate of recurrence was compared with that in unvaccinated patients to determine the efficacy of vaccination in preventing recurrence and spread of the virus in the community. Seven of 22 (31%) vaccinated patients had eight recurrences after the initial clinical episode; in contrast there were 51 recurrences in 17 of 20 (85%) unvaccinated patients. Although further studies are needed, the results indicate that the vaccine may prevent recurrent episodes of herpes genitalis and thereby reduce the dissemination of this virus in the population.

The relative infrequency and low levels of neutralising and immunoprecipitating antibody to herpes simplex viruses types 1 and 2 in patients with a history of recurrent herpes genitalis

Twenty-seven per cent of 70 patients with a history of recurrent herpes genitalis but no concomitant history of recurrent oral or peri-genital disease, had no detectable neutralising antibody against type 1 or type 2 herpes simplex virus; the prevalence and levels of neutralising antibody were similar to 53 patients with no history of herpetic disease and significantly lower than 67 patients with a history of recurrent herpes genitalis in association with oral or peri-genital disease all of whom had neutralising antibody against both virus types. There were similar differences between groups for immunoprecipitating antibody where 80% of patients were herpes genitalis alone had no detectable immunoprecipitating antibody. The results indicate that the failure to detect immunising and immunoprecipitating antibody in an individual's serum is compatible with a long and even severe history of recurrent herpes genitalis and consequently that the development of neutralising antibody does not necessarily indicate an episode of primary herpetic disease.