Adding MR Diffusion Imaging and T2 Signal Intensity to Neck Imaging Reporting and Data System Categories 2 and 3 in Primary Sites of Postsurgical Oral Cavity Carcinoma Provides Incremental Diagnostic Value

BACKGROUND AND PURPOSE

The NI-RADS lexicon doesn't use ADC parameters and T2 weighted signal for ascribing categories. We explored ADC, DWI, and T2WI to examine the diagnostic accuracy in primary sites of postsurgical oral cavity carcinoma in the Neck Imaging Reporting and Data System (NI-RADS) categories 2 and 3.

MATERIALS AND METHODS

We performed a retrospective analysis in clinically asymptomatic post-surgically treated patients with oral cavity squamous cell carcinoma who underwent contrast-enhanced MRI between January 2013 and January 2016. Histopathology and follow-up imaging were used to ascertain the presence or absence of malignancy in subjects with "new enhancing lesions," which were interpreted according to the NI-RADS lexicon by experienced readers, including NI-RADS 2 and 3 lesions in the primary site. NI-RADS that included T2WI and DWI (referred to as NI-RADS A) and ADC (using the best cutoff from receiver operating characteristic curve analysis, NI-RADS B) was documented in an Excel sheet to up- or downgrade existing classic American College of Radiology NI-RADS and calculate diagnostic accuracy.

RESULTS

Sixty-one malignant and 23 benign lesions included in the study were assigned American College of Radiology NI-RADS 2 (n = 33) and NI-RADS 3 (n = 51) categories. The recurrence rate was 90% (46/51) for NI-RADS three, 45% (15/33) for NI-RADS 2, and 73% (61/84) overall. T2WI signal morphology was intermediate in 45 subjects (53.5%) and restricted DWI in 54 (64.2%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the American College of Radiology NI-RADS were the following: NI-RADS (75.4%, 78.3%, 90.1%, 54.5%, and 76.1%); NI-RADS A (79.1%, 81.2%, 91.9%, 59.1%, and 79.6%); and NI-RADS B (88.9%, 72.7%, 91.4%, 66.7%, and 85.1%), respectively.

CONCLUSIONS

Adding MR imaging diagnostic characteristics like T2WI, DWI, and ADC to the American College of Radiology NI-RADS improved diagnostic accuracy and sensitivity.

Electroconvulsive therapy with a memory reactivation intervention for post-traumatic stress disorder: A randomized controlled trial

BACKGROUND

Post-traumatic Stress Disorder (PTSD) often does not respond to available treatments. Memories are vulnerable to disruption during reconsolidation, and electroconvulsive therapy (ECT) has amnestic effects OBJECTIVE/HYPOTHESIS: To test the use of ECT to disrupt the reconsolidation of traumatic memories as a potential treatment for PTSD METHODS: Participants were adults from the civilian population and were referred for ECT treatment for severe depression with comorbid PTSD symptoms. Twenty-eight participants were randomly assigned to reactivation of a traumatic or non-traumatic memory using audio script driven imagery prior to each ECT treatment. Primary outcomes were change in scores on the Modified PTSD Symptom Scale - Self Report (MPSS-SR) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Secondary outcomes included a comparison of the change in heart rate while listening to the script RESULTS: Twenty-five female patients who completed a post-ECT assessment were included in the analysis. No significant group differences were found in the MPSS-SR or CAPS-5 scores from pre-ECT to post-ECT or 3-month follow-ups. However, both groups improved at post-ECT and 3-month follow up. Partial eta squared estimates of effect size showed large effect sizes for all outcomes (η² > 0.13). Changes in heart rate were not significantly different between groups or over time CONCLUSIONS: ECT paired with pre-treatment traumatic memory reactivation was not more effective for treating PTSD symptoms than ECT with non-traumatic memory reactivation. While our primary hypothesis was not supported, our data provides further support for the efficacy of ECT for improving symptoms of PTSD with comorbid depression. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT04027452.

IDENTIFIER

NCT04027452.

The glucocorticoid receptor-FKBP51 complex contributes to fear conditioning and posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) can develop after exposure to severe psychological trauma, leaving patients with disabling anxiety, nightmares, and flashbacks. Current treatments are only partially effective, and development of better treatments is hampered by limited knowledge of molecular mechanisms underlying PTSD. We have discovered that the glucocorticoid receptor (GR) and FK506 binding protein 51 (FKBP51) form a protein complex that is elevated in PTSD patients compared with unaffected control subjects, subjects exposed to trauma without PTSD, and patients with major depressive disorder (MDD). The GR-FKBP51 complex is also elevated in fear-conditioned mice, an aversive learning paradigm that models some aspects of PTSD. Both PTSD patients and fear-conditioned mice had decreased GR phosphorylation, decreased nuclear GR, and lower expression of 14-3-3ε, a gene regulated by GR. We created a peptide that disrupts GR-FKBP51 binding and reverses behavioral and molecular changes induced by fear conditioning. This peptide reduces freezing time and increases GR phosphorylation, GR-FKBP52 binding, GR nuclear translocation, and 14-3-3ε expression in fear-conditioned mice. These experiments demonstrate a molecular mechanism contributing to PTSD and suggest that the GR-FKBP51 complex may be a diagnostic biomarker and a potential therapeutic target for preventing or treating PTSD.

Effects of preceding endoscopic mucosal resection on the efficacy and safety of radiofrequency ablation for treatment of Barrett's esophagus: results from the United States Radiofrequency Ablation Registry

The effects of preceding endoscopic mucosal resection (EMR) on the efficacy and safety of radiofrequency ablation (RFA) for treatment of nodular Barrett's esophagus (BE) is poorly understood. Prior studies have been limited to case series from individual tertiary care centers. We report the results of a large, multicenter registry. We assessed the effects of preceding EMR on the efficacy and safety of RFA for nodular BE with advanced neoplasia (high-grade dysplasia or intramucosal carcinoma) using the US RFA Registry, a nationwide study of BE patients treated with RFA at 148 institutions. Safety outcomes included stricture, gastrointestinal bleeding, and hospitalization. Efficacy outcomes included complete eradication of intestinal metaplasia (CEIM), complete eradication of dysplasia (CED), and number of RFA treatments needed to achieve CEIM. Analyses comparing patients with EMR before RFA to patients undergoing RFA alone were performed with Student's t-test, Chi-square test, logistic regression, and Kaplan-Meier analysis. Four hundred six patients were treated with EMR before RFA for nodular BE, and 857 patients were treated with RFA only for non-nodular BE. The total complication rates were 8.4% in the EMR-before-RFA group and 7.2% in the RFA-only group (P = 0.48). Rates of stricture, bleeding, and hospitalization were not significantly different between patients treated with EMR before RFA and patients treated with RFA alone. CEIM was achieved in 84% of patients treated with EMR before RFA, and 84% of patients treated with RFA only (P = 0.96). CED was achieved in 94% and 92% of patients in EMR-before-RFA and RFA-only group, respectively (P = 0.17). Durability of eradication did not differ between the groups. EMR-before-RFA for nodular BE with advanced neoplasia is effective and safe. The preceding EMR neither diminished the efficacy nor increased complication rate of RFA treatment compared to patients with advanced neoplasia who had RFA with no preceding EMR. Preceding EMR is not associated with poorer outcomes in RFA.

The impact of endoscopic ultrasound findings on clinical decision making in Barrett's esophagus with high-grade dysplasia or early esophageal adenocarcinoma

The clinical utility of endoscopic ultrasound (EUS) for staging patients with Barrett's esophagus and high-grade dysplasia (HGD) or intramucosal carcinoma (IMC) prior to endoscopic therapy is unclear. We performed a retrospective analysis of patients with HGD or IMC referred to an American medical center for endoscopic treatment between 2004 and 2010. All patients had pretreatment staging by EUS. We examined the frequency that EUS findings consistent with advanced disease (tumor invasion into the submucosa, lymph node involvement, or regional metastasis) led to a change in management. The analysis was stratified by nodularity and pre-EUS histology. We identified one hundred thirty-five patients with HGD (n = 106, 79%) or IMC (n = 29, 21%) had staging by EUS (79 non-nodular, 56 nodular). Pathologic lymph nodes or metastases were not found by EUS. There were no endosonographic abnormalities noted in any patient with non-nodular mucosa (0/79). Abnormal EUS findings were present in 8/56 patients (14%) with nodular neoplasia (five IMC, three HGD). Endoscopic mucosal resection was performed in 44 patients with a nodule, with 13% (6/44) having invasive cancer. In nodular neoplasia, the EUS and endoscopic mucosal resection were abnormal in 24% (5/21) and 40% (6/15) of those with IMC and 9% (3/35) and 0% (0/29) of those with HGD, respectively. In this study we found that EUS did not alter management in patients with non-nodular HGD or IMC. Because the diagnostic utility of EUS in subjects with non-nodular Barrett's esophagus is low, the value of performing endoscopic mucosal resection in this setting is questionable. For patients with nodular neoplasia, resection of the nodule with histological examination had greater utility than staging by EUS.

Primary central nervous system lymphoma: a study of clinicopathological features and trend in western India

INTRODUCTION

Primary central nervous system lymphoma (PCNSL) is rare and accounts for 1-2% of all primary intracranial tumors (ICT). There are conflicting reports regarding the increased incidence of PCNSL over the last two decades in both immunocompromised and immunocompetent patients.

AIM

This study was designed to study the clinicopathological characteristics of PCNSL and to access the trend of PCNSL at our institute.

MATERIALS AND METHODS

All the histopathologically proven cases of PCNSL were reviewed from January 1997 to December 2009 (13 years). Immunophenotyping was performed on available paraffin-embedded tissue blocks. Immune status was evaluated and human immunodeficiency virus (HIV) serology was performed in all cases. Cerebrospinal fluid (CSF) findings were recorded whenever available. Possibility of secondary involvement by a systemic lymphoma was excluded in every case. Statistical analysis was done using χ2 -test.

RESULTS

During the study period (13 years), a total of 4715 cases of ICT were diagnosed, out of which 66 cases were PCNSL, which accounted for 1.4%. The age ranged from 10 to 75 years with a median age of 46 years. All the patients were immunocompetent. Frontal lobe was the most common site of involvement. Diffuse large B-cell lymphoma was the histological pattern in all the cases. CSF involvement was seen in only one case.

CONCLUSIONS

In this study, no significant increase in the incidence of PCNSL was found at our institute. Association of PCNSL cases with HIV or acquired immunodeficiency syndrome was not found in our study.

Risks of routine iron and folic acid supplementation for young children

CONTEXT

Almost 70% of young children in India are anemic. Current policy recommends routine iron-folic acid (IFA) supplementation to all under 5 children. A potential risk of this approach is an increase in infectious diseases in general, and malaria in particular.

EVIDENCE ACQUISITION

An extensive literature search including PubMed, the World Health Organization (WHO) document library, and the Indian Government database, for documents regarding IFA supplementation in under-5 children.

RESULTS

Previously, systematic reviews had suggested adverse effects of IFA supplementation in malaria endemic settings. However, a recent large trial in Tanzania has found clear evidence of increased mortality, chiefly due to malaria, among children receiving routine IFA, whilst a simultaneous study in Nepal (a non-malarious region) found no adverse effects on morbidity or mortality from infectious disease attributable to IFA. These findings have prompted the World Health Organization to revise recommendations regarding IFA supplementation in malaria endemic areas.

CONCLUSIONS

India has a non-homogenous distribution of malaria endemicity. We propose that although no change to IFA supplementation be made in non-malarious regions, routine IFA should be provided in malarious regions once malaria control and primary health care infrastructure are functioning well.

Should beta-blockers be withdrawn in post-myocardial infarction patients before treadmill test?

In most patients of myocardial infarction, beta-blockers are used for secondary prophylaxis and a treadmill test is required for risk stratification. To study the effect of oral beta-blockers on interpretation of treadmill test, 54 consecutive patients were subjected to treadmill test four to six weeks after myocardial infarction. Fourteen patients with strongly positive treadmill test were referred for coronary angiography. Treadmill test was repeated in 37 patients 72 hours after withdrawal of beta-blockers. The peak exercise heart rate was significantly different while off and on beta-blockers (148 +/- 13 bpm vs 124 +/- 14 bpm, respectively; p < 0.01). The test was negative on both the occasions in 17 patients. On stopping beta-blockers, the negative test became mildly positive in five and strongly positive in six patients. The mildly positive test became strongly positive in four patients and remained almost unchanged in five. In 10 patients there was conversion of negative or mildly positive treadmill test into strongly positive result after withdrawal of beta-blockers. Thus the risk stratification changed significantly in 27 percent patients. It is suggested that beta-blockers can and should be withdrawn in post-MI patients before doing treadmill test.

Diet and oral cancer - a case control study

Apart from strong genotoxic carcinogens, other environmental factors are implicated in both causes and prevention of cancers. A hospital based case control study was conducted to examine the role of diet in the aetiology of oral and oropharyngeal cancers. In this article, past dietary intake and nutrient estimates, obtained through diet history method and biochemical nutritional status at the onset of the disease are presented. The results of the study suggest that poor dietary intake of vegetables and fruits coupled with low estimated intake of betacarotene, thiamine, riboflavin, folate, vitamin C, iron and copper, modify the risk potential. The biological indicators of the nutritional status such as plasma vitamin A, E, red cell folate and plasma zinc were significantly reduced in cases and yielded moderate risk estimates. The risk estimates though of moderate magnitude are of importance in relatively homogeneous subjects with respect to diet and nutrition. The findings are in line with several other epidemiological observations. The combined effects of micro nutrients appears to be protective in countering the adverse effects of exogenous exposures to tobacco. The protective role of vegetables and fruits is of potential interest in terms of etiologic causes and prevention.

A case control study of selenium in cancer

As selenium has been shown to be a risk modifier of cancer at several sites in a case-control approach, selenium nutriture was studied in oral and oesophageal cancer patients. The mean selenium level in oral cancer patients was 102.6 ng/ml and in oesophageal cancer 103.3 ng/ml, while in the matched controls it was 117.5 and 116.2 ng/ml respectively. Relative risk estimates were 3.16 (P < 0.02) and 16.0 (P < 0.01) in oral and oesophageal cancer patients respectively. The risk appears to increase with selenium levels lower than 115 ng/ml.

Esophageal cancer and diet--a case-control study

It has been estimated that approximately 40% of human cancers may be associated with dietary factors. The relationship is more significant in esophageal cancers. Case-control studies involving 35 subjects of early-diagnosed esophageal cancers showed low mean blood levels of retinol, zinc (p less than 0.001), folic acid (p less than 0.01), and albumin (p less than 0.05). Relative risk was significantly higher for low levels of retinol and zinc. Diet, in general, in both groups reflected poor intake of several nutrients.

Near-death experiences in India. A preliminary report

The authors report some features of 16 cases of near-death experiences that they investigated in India. After presenting brief accounts of four such experiences, the authors describe and discuss features in which the Indian cases differ from a larger sample of American cases. They note that some of these features seem to be culture-bound, but they caution against accepting this observation as adequate evidence that the case derive only from culture-bound beliefs. Some differences may derive from the effects of a person's beliefs on what actually does happen after death, and some different features may, on closer examination, be found to be basically similar in nature if not in detail.

Growth profile of preschool children from an urban low socio-economic community in India

A five years longitudinal study on the growth and development was carried out on 68 infants from a low-socio-economic urban community in India. Ninety four percent of them suffered from Protein Calorie Malnutrition of varying degree at some time or the other during their first six years and of them 30% suffered severe PCM. The effect on heights and head circumference followed the same pattern as body weight. Their developmental quotients correlated with the degree of PCM till age of four years. This observation brings into focus a growth profile of underprivileged toddlers which is far worse than what is brought out by cross sectionals surveys. The family at greatest risk is one with a young mother who is ill equipped with the techniques of successful breast feeding and supplemental feeding of her infant. Additional factor is early onset of diarrhoeal illnesses in these children. It is suggested that such a vulnerable family requires special support from the health delivery system planned for urban communities.