Multi-detector row CT of the small bowel: peak enhancement temporal window--initial experience

PURPOSE: To prospectively determine quantitatively and qualitatively the timing of maximal enhancement of the normal small-bowel wall by using contrast material-enhanced multi-detector row computed tomography (CT). MATERIALS AND METHODS: This HIPAA-compliant study was approved by the institutional review board. After information on radiation risk was given, written informed consent was obtained from 25 participants with no history of small-bowel disease (mean age, 58 years; 19 men) who had undergone single-level dynamic CT. Thirty seconds after the intravenous administration of contrast material, a serial dynamic acquisition, consisting of 10 images obtained 5 seconds apart, was performed. Enhancement measurements were obtained over time from the small-bowel wall and the aorta. Three independent readers qualitatively assessed small-bowel conspicuity. Quantitative and qualitative data were analyzed during the arterial phase, the enteric phase (which represented peak small-bowel mural enhancement), and the venous phase. Statistical analysis included paired Student t test and Wilcoxon signed rank test with Bonferroni correction. A P value less than .05 was used to indicate a significant difference. RESULTS: The mean time to peak enhancement of the small-bowel wall was 49.3 seconds +/- 7.7 (standard deviation) and 13.5 seconds +/- 7.6 after peak aortic enhancement. Enhancement values were highest during the enteric phase (P < .05). Regarding small-bowel conspicuity, images obtained during the enteric phase were most preferred qualitatively; there was a significant difference between the enteric and arterial phases (P < .001) but not between the enteric and venous phases (P = .18). CONCLUSION: At multi-detector row CT, peak mural enhancement of the normal small bowel occurs on average about 50 seconds after intravenous administration of contrast material or 14 seconds after peak aortic enhancement.

Effect of echo time pair selection on quantitative analysis for adrenal tumor characterization with in-phase and opposed-phase MR imaging: initial experience

PURPOSE: To determine the effect of two pairs of echo times (TEs) for in-phase (IP) and opposed-phase (OP) 3.0-T magnetic resonance (MR) imaging on (a) quantitative analysis prospectively in a phantom study and (b) diagnostic accuracy retrospectively in a clinical study of adrenal tumors, with use of various reference standards in the clinical study. MATERIALS AND METHODS: A fat-saline phantom was used to perform IP and OP 3.0-T MR imaging for various fat fractions. The institutional review board approved this HIPAA-compliant study, with waiver of informed consent. Single-breath-hold IP and OP 3.0-T MR images in 21 patients (14 women, seven men; mean age, 63 years) with 23 adrenal tumors (16 adenomas, six metastases, one adrenocortical carcinoma) were reviewed. The MR protocol involved two acquisition schemes: In scheme A, the first OP echo (approximately 1.5-msec TE) and the second IP echo (approximately 4.9-msec TE) were acquired. In scheme B, the first IP echo (approximately 2.4-msec TE) and the third OP echo (approximately 5.8-msec TE) were acquired. Quantitative analysis was performed, and analysis of variance was used to test for differences between adenomas and nonadenomas. RESULTS: In the phantom study, scheme B did not enable discrimination among voxels that had small amounts of fat. In the clinical study, no overlap in signal intensity (SI) index values between adenomas and nonadenomas was seen (P < .05) with scheme A. However, with scheme B, no overlap in the adrenal gland SI-to-liver SI ratio between adenomas and nonadenomas was seen (P < .05). With scheme B, no overlap in adrenal gland SI index-to-liver SI index ratio between adenomas and nonadenomas was seen (P < .05). CONCLUSION: This initial experience indicates SI index is the most reliable parameter for characterization of adrenal tumors with 3.0-T MR imaging when obtaining OP echo before IP echo. When acquiring IP echo before OP echo, however, nonadenomas can be mistaken as adenomas with use of the SI index value.

Prognostic value of the modified American College of Cardiology/American Heart Association lesion morphology classification for clinical outcome after sirolimus-eluting stent placement (results of the prospective multicenter German Cypher Registry)

The modified American College of Cardiology/American Heart Association (ACC/AHA) lesion morphology classification scheme has prognostic impact for early and late outcomes when bare-metal stents are used. Its value after drug-eluting stent placement is unknown. The predictive value of this lesion morphology classification system in patients treated using sirolimus-eluting stents included in the German Cypher Registry was prospectively examined. The study population included 6,755 patients treated for 7,960 lesions using sirolimus-eluting stents. Lesions were classified as type A, B1, B2, or C. Lesion type A or B1 was considered simple (35.1%), and type B2 or C, complex (64.9%). The combined end point of all deaths, myocardial infarction, or target vessel revascularization was seen in 2.6% versus 2.4% in the complex and simple groups, respectively (p = 0.62) at initial hospital discharge, with a trend for higher rates of myocardial infarction in the complex group. At the 6-month clinical follow-up and after adjusting for other independent factors, the composite of cumulative death, myocardial infarction, and target vessel revascularization was nonsignificantly different between groups (11.4% vs 11.2% in the complex and simple groups, respectively; odds ratio 1.08, 95% confidence interval 0.8 to 1.46). This was also true for target vessel revascularization alone (8.3% of the complex group, 9.0% of the simple group; odds ratio 0.87, 95% confidence interval 0.72 to 1.05). In conclusion, the modified ACC/AHA lesion morphology classification system has some value in determining early complications after sirolimus-eluting stent implantation. Clinical follow-up results at 6 months were generally favorable and cannot be adequately differentiated on the basis of this lesion morphology classification scheme.

Changing ‘Multi-Problem Families’ – Developing a Multi-Contextual Systemic Approach

Over the past 30 years the Marlborough Family Service in London has pioneered multi-family work with marginalized families presenting simultaneously with abuse and neglect, family violence, substance misuse, educational failure and mental illness. The approach is based on a systemic multi-contextual mode and this chapter describes the evolving work, including the establishment of the first permanent multiple family day setting, specifically designed for and solely dedicated to the work with seemingly ‘hopeless’ families. The ingredients of ‘therapeutic assessments’ of parents and families are outlined and the importance of initial network meetings with professionals and family members is emphasized.

Effectiveness of an Online Social Constructivist Mathematical Problem Solving Course for Malaysian Pre-Service Teachers

This study assessed the effectiveness of an online mathematical problem solving course designed using a social constructivist approach for pre-service teachers. Thirty-seven pre-service teachers at the Batu Lintang Teacher Institute, Sarawak, Malaysia were randomly selected to participate in the study. The participants were required to complete the course online without the typical face-to-face classes and they were also required to solve authentic mathematical problems in small groups of 4-5 participants based on the Polya’s Problem Solving Model via asynchronous online discussions. Quantitative and qualitative methods such as questionnaires and interviews were used to evaluate the effects of the online learning course. Findings showed that a majority of the participants were satisfied with their learning experiences in the course. There were no significant changes in the participants’ attitudes toward mathematics, while the participants’ skills in problem solving for “understand the problem” and “devise a plan” steps based on the Polya’s Model were significantly enhanced, though no improvement was apparent for “carry out the plan” and “review”. The results also showed that there were significant improvements in the participants’ critical thinking skills. Furthermore, participants with higher initial computer skills were also found to show higher performance in mathematical problem solving as compared to those with lower computer skills. However, there were no significant differences in the participants’ achievements in the course based on gender. Generally, the online social constructivist mathematical problem solving course is beneficial to the participants and ought to be given the attention it deserves as an alternative to traditional classes. Nonetheless, careful considerations need to be made in the designing and implementing of online courses to minimize problems that participants might encounter while participating in such courses.

Strategies for Optimizing Value of Finished Cattle in Value-Based Marketing Grids

Performance and carcass data from 624 steers in three experiments were used to evaluate potential strategies that might be used with incoming feeders to remove animals that produce low value carcasses when cattle are sold in a valuebased grid. Removing 10% of the carcasses with the lowest net value from each group increased the overall average net value of the remaining carcasses $17.50 to $21.09. Carcass weight was found to be the most significant factor determining net value of the carcass. Gain of the steers during the first 3 to 5 weeks of the feeding period was significantly related to average final gain and carcass value, but accounted for a small portion of the overall variation in gain or carcass value. Use of initial gain was successful in identifying ten of the sixty-four carcasses with least net value in a value-based grid. Adding frame score and measurement of initial thickness of backfat along with initial gain did not significantly improve identification of the low-value carcasses. Sorting the steers as feeders based on frame score and initial thickness of backfat resulted in differences in performance and carcass measurements. The low-value carcasses tended to be concentrated in the smaller-framed steers.

Effects of Sorting Steer Calves on Feedlot Performance and Carcass Value

Three groups of steer calves totaling 480 head were sorted into smaller and larger frame sizes, and those groups were sorted into groups with more and less backfat. There was no difference in age among the four sorted groups. The larger steers and steers with less fat had faster rates of gain and tended to have superior feed efficiencies. Steers with more initial fat were fed fewer days. The larger framed steers and steers with less fat had heavier carcasses, less carcass backfat, more yield grade 1 carcasses and a lower percentage of Choice carcasses, but they also had greater value per carcass when evaluated using a grid paying premiums for quality and yield grades. The greatest profit to the feedyard was realized from the smaller framed steers and those with less initial backfat. For similar profit it was calculated that the larger steers should have been discounted as feeders $3.50 per hundred compared with the smaller steers and the steers with more fat discounted $5.00 per hundred compared with those having less initial fat. The results of this study suggest that sorting based on initial fat thickness may have more potential for enhancing the value of finished cattle than sorting based on frame score.

The Effects of Feeding a Live Microbial Product on Feedlot Performance and Carcass Value of Finishing Steers Fed Wet Corn Gluten Feed

This experiment was conducted to evaluate the efficacy of daily feeding a live microbial preparation containing two live organisms to finishing cattle. One organism was a lactobacillus, and the other was a propionibacterium, thought to work in concert to improve fermentation in the rumen and overall digestion. The study was conducted with Angus steers with an average initial weight of 550 lbs that were fed a finishing ration containing 50% wet corn gluten feed on a dry basis for 184 days. Feeding the microbial product improved daily gain and feed efficiency 1.7% and 2.4%, respectively, but the differences were not statistically significant. The microbial preparation increased carcass weights 1% but had no effects on quality or yield grades. It is concluded that potential benefits of this product are more likely to be greater when cattle are fed high grain rations rather than diets containing high concentrations of corn gluten feed.

Effect of Frame Size and Hormone Implant on Performance and Carcass Characteristics of Finishing Yearling Heifers: Returns to a Value-Based Market

Four groups of yearling heifers representing different frame sizes—small, medium, and large Angus and medium Simmental—were fed high-grain finishing diets to average Low Choice quality grade. Half the heifers were implanted with estrogen and trenbolone acetate. Backfat and ribeye area were measured by ultrasound four times during the study to assess growth of muscle and fat. Increasing frame size resulted in increased feed intake, greater rates of gain, and a trend towards reduced feed conversion. Greater returns would have been realized from each of the four groups had they been sold in a premium market based on yield grade rather than the conventional grade and yield market. Increasing frame size resulted in greater returns to the value-based market. Implants increased rate of gain and improved feed conversion but did not result in significantly greater returns to the value-based market compared with the grade and yield market. Ribeye area and backfat increased with body weight and time on feed. Increase in ribeye area was linear with time, whereas accumulation of backfat was exponential. Rate of increase in area of ribeye tended to increase and backfat tended to decrease as frame size increased. Implants increased rate of increase in ribeye area but had no effect on rate of deposition of subcutaneous fat. Equations describing growth of ribeye area and backfat for each group predicted average growth for the heifers but did not predict growth of individual heifers. Final carcass yield grade was related to initial thickness of backfat but not to initial ribeye area. These results indicate that the type of cattle selected to be fed for a premium market based on yield grade is important to the success of the program. More work is needed to develop growth equations from ultrasound measurements, but ultrasound will likely be a useful tool in selecting feeder cattle for a value-based market.

Serial lactate and admission SOFA scores in trauma: an analysis of predictive value in 724 patients with and without traumatic brain injury

Objective Arterial lactate, base excess (BE), lactate clearance, and Sequential Organ Failure Assessment (SOFA) score have been shown to correlate with outcome in severely injured patients. The goal of the present study was to separately assess their predictive value in patients suffering from traumatic brain injury (TBI) as opposed to patients suffering from injuries not related to the brain. Materials and methods A total of 724 adult trauma patients with an Injury Severity Score (ISS) ≥ 16 were grouped into patients without TBI (non-TBI), patients with isolated TBI (isolated TBI), and patients with a combination of TBI and non-TBI injuries (combined injuries). The predictive value of the above parameters was then analyzed using both uni- and multivariate analyses. Results The mean age of the patients was 39 years (77 % males), with a mean ISS of 32 (range 16–75). Mortality ranged from 14 % (non-TBI) to 24 % (combined injuries). Admission and serial lactate/BE values were higher in non-survivors of all groups (all p < 0.01), but not in patients with isolated TBI. Admission SOFA scores were highest in non-survivors of all groups (p = 0.023); subsequently septic patients also showed elevated SOFA scores (p < 0.01), except those with isolated TBI. In this group, SOFA score was the only parameter which showed significant differences between survivors and non-survivors. Receiver operating characteristic (ROC) analysis revealed lactate to be the best overall predictor for increased mortality and further septic complications, irrespective of the leading injury. Conclusion Lactate showed the best performance in predicting sepsis or death in all trauma patients except those with isolated TBI, and the differences were greatest in patients with substantial bleeding. Following isolated TBI, SOFA score was the only parameter which could differentiate survivors from non-survivors on admission, although the SOFA score, too, was not an independent predictor of death following multivariate analysis.

Prognostic value of the Geneva prediction rule in patients with pulmonary embolism

BACKGROUND Assessment of pre-test probability of pulmonary embolism (PE) and prognostic stratification are two widely recommended steps in the management of patients with suspected PE. Some items of the Geneva prediction rule may have a prognostic value. We analyzed whether the initial probability assessed by the Geneva rule was associated with the outcome of patients with PE. METHODS In a post-hoc analysis of a multicenter trial including 1,693 patients with suspected PE, the all-cause death or readmission rates during the 3-month follow-up of patients with confirmed PE were analyzed. PE probability group was prospectively assessed by the revised Geneva score (RGS). Similar analyses were made with the a posteriori-calculated simplified Geneva score (SGS). RESULTS PE was confirmed in 357 patients and 21 (5.9%) died during the 3-month follow-up. The mortality rate differed significantly with the initial RGS group, as with the SGS group. For the RGS, the mortality increased from 0% (95% Confidence Interval: [0-5.4%]) in the low-probability group to 14.3% (95% CI: [6.3-28.2%]) in the high-probability group, and for the SGS, from 0% (95% CI: [0-5.4%] to 17.9% (95% CI: [7.4-36%]). Readmission occurred in 58 out of the 352 patients with complete information on readmission (16.5%). No significant change of readmission rate was found among the RGS or SGS groups. CONCLUSIONS Returning to the initial PE probability evaluation may help clinicians predict 3-month mortality in patients with confirmed PE. (ClinicalTrials.gov: NCT00117169).

Adaptation to Changes in the Coffee Value Chain and the Price of Coiffee among Coffee Producers in Two Villages in Kilimanjaro, Tanzania

Market liberalization in Tanzania has eroded the monopoly of the cooperative unions by allowing private coffee buyers (PCBs) to compete with them on equal footing. Similarly, farmers groups and primary societies are now allowed to sell coffee at auction. Thus, farmers have various options for selling their coffee. Similarly, the coffee industry has experienced large fluctuations in prices and stagnation in production. How do farmers react to these changes? Can and do farmers profit from different market conditions and sell to different traders at the lower end of the value chain, or do they remain with cooperatives or farmers groups? This study was conducted in Mruwia and Mshiri villages in Moshi Rural district. Whereas Mshiri village remains attached to the Kilimanjaro Native Cooperative Union (KNCU), Mruwia has detached from this organization and sells coffee independently. The sample (103) was randomly selected from the coffee farmers in the two villages. Data were collected through surveys, focus group discussions (FGDs), and socio-anthropological methods (participant-observation, biographies, and thematic interviews). Results indicate that the selection of whom to sell coffee depends largely on farmers’ dependence on coffee and prices, other benefits accrued, and whether the initial costs are covered by buyers. Additionally, most respondents did not sell coffee to PCBs. Thus, prices, the institutional infrastructure, and the structure of local communities were important when making decisions about how and with whom to trade.

Personality dimensions in persons symptomatically at risk of psychosis: pronounced but lacking a characteristic profile

AIM Personality dimensions are frequently abnormal in psychosis. We examined if these abnormalities form a personality profile that is characteristic for patients symptomatically at risk of psychosis. METHODS Four higher order personality dimensions were assessed in 104 at-risk patients, 67 clinical and 97 healthy controls with the 'Dimensional Assessment of Personality Pathology', and analysed by two-step cluster procedure to detect personality profiles. Logistic regression was used to test for predictors of profile assignment. RESULTS Low and high scorers were distinguished by two profiles. Patients were more likely high scorers. The presence of clinically relevant depression, though equally frequent in clinical groups, best predicted high scorers among patients. CONCLUSIONS Though at-risk patients were significantly more often high scorers, this seemed to be a general reflection of the level of psychopathology rather than a group characteristic. Thus, personality dimensions might be of little value for facilitating early detection but might be important to consider in early intervention approaches.

Evaluation of the diagnostic value of the ELISA tests developed by using EgHF, Em2 and EmII/3-10 antigens in the serological diagnosis of alveolar echinococcosis

Alveolar echinococcosis (AE), caused by larva stage of Echinococcus multilocularis, is one of the lethal parasitic diseases of man and a major public health problem in many countries in the northern hemisphere. When the living conditions and habits in Turkey were considered in terms of relation with the life cycle of the parasite, it was suggested that AE has been much more common than reported mainly from the Eastern Anatolia region of Turkey. Since in vitro serologic diagnosis tests with high specificity for AE have not been used in our country, most of the cases with liver lesions were misdiagnosed by radiological investigations as malignancies. The aim of this study was to evaluate the diagnostic value of the in-house ELISA methods developed by using three different antigens (EgHF, Em2, EmII/3-10) in the serological diagnosis of AE. The study samples included a total of 100 sera provided by Bern University Parasitology Institute where samples were obtained from patients with helminthiasis and all were confirmed by clinical, parasitological and/or histopathological means. Ten samples from each of the cases infected by E.multilocularis, E.granulosus, Taenia solium, Wuchereria bancrofti, Strongyloides stercolaris, Ascaris lumbricoides, Toxocara canis, Trichinella spiralis, Fasciola hepatica and Schistosoma haematobium were studied. In the study, EgHF (E.granulosus hydatid fluid) antigens were prepared in our laboratory from the liver cyst fluids of sheeps with cystic echinococcosis, however Em2 (E.multilocularis metacestode-purified laminated layer) and EmII/3-10 (E.multilocularis recombinant protoscolex tegument) antigens were provided by Bern University Parasitology Institute. Flat bottom ELISA plates were covered with EgHF, Em2 and EmII/3-10 antigens in the concentrations of 2.5 µg, 1 µg and 0.18 µg per well, respectively, and all sera were tested by EgHF-ELISA, Em2-ELISA and EmII/3-10-ELISA methods. For each tests, the samples which were reactive above the cut-off value (mean OD of negative controls+2 SD) were accepted as positive. The sensitivity of the ELISA tests performed with EgHF, Em2 and Em2II/3-10 antigens were estimated as 100%, 90% and 90%, respectively, whereas the specificity were 63%, 91% and 91%, respectively. When Em2-ELISA and EmII/3-10-ELISA tests were evaluated together, the specificity increased to 96%. Our data indicated that the highest sensitivity (100% with EgHF-ELISA) and specificity (96% with Em2-ELISA + EmII/3-10-ELISA) for the serodiagnosis of AE can be achieved by the combined use of the ELISA tests with three different antigens. It was concluded that the early and accurate diagnosis of AE in our country which is endemic for that disease, could be supported by the use of highly specific serological tests such as Em2-ELISA ve EmII/3-10-ELISA contributing radiological data.

Combination of MRI and dynamic FET PET for initial glioma grading

AIM MRI and PET with 18F-fluoro-ethyl-tyrosine (FET) have been increasingly used to evaluate patients with gliomas. Our purpose was to assess the additive value of MR spectroscopy (MRS), diffusion imaging and dynamic FET-PET for glioma grading. PATIENTS, METHODS 38 patients (42 ± 15 aged, F/M: 0.46) with untreated histologically proven brain gliomas were included. All underwent conventional MRI, MRS, diffusion sequences, and FET-PET within 3±4 weeks. Performances of tumour FET time-activity-curve, early-to-middle SUVmax ratio, choline / creatine ratio and ADC histogram distribution pattern for gliomas grading were assessed, as compared to histology. Combination of these parameters and respective odds were also evaluated. RESULTS Tumour time-activity-curve reached the best accuracy (67%) when taken alone to distinguish between low and high-grade gliomas, followed by ADC histogram analysis (65%). Combination of time-activity-curve and ADC histogram analysis improved the sensitivity from 67% to 86% and the specificity from 63-67% to 100% (p < 0.008). On multivariate logistic regression analysis, negative slope of the tumour FET time-activity-curve however remains the best predictor of high-grade glioma (odds 7.6, SE 6.8, p = 0.022). CONCLUSION Combination of dynamic FET-PET and diffusion MRI reached good performance for gliomas grading. The use of FET-PET/MR may be highly relevant in the initial assessment of primary brain tumours.