CT identification of abdominal injuries in abused pre-school-age children

BACKGROUND

Although the abdominopelvic CT findings of abdominal trauma in children have been described, little has been written about the subset of children who are victims of abuse.

OBJECTIVE

Our purpose is to describe abdominopelvic injuries in abused pre-school-age children as identified on CT.

MATERIALS AND METHODS

An IRB-approved retrospective review of our institutional child abuse registry was performed. Searching a 14-year period, we identified 84 children ≤ 5 years of age with medically diagnosed abuse who underwent CT. We reviewed imaging studies, operative reports, autopsy findings and patient outcomes. Consensus review of the CT examinations was performed by CAQ-certified pediatric radiologists, and findings were categorized as normal or by injury types (solid organ versus bowel). The injuries were analyzed in light of existing literature on pediatric accidental and non-accidental injuries.

RESULTS

Of the 84 children, 35 (41.7%) had abdominal injuries. Abdominal injuries included liver (15), bowel (13), mesentery (4), spleen (6), kidneys (7), pancreas (4) and adrenal glands (3). Of these children, 26% (9/35) required surgical intervention for bowel, mesenteric and pancreatic injuries. Another 9/35 children died, not as a result of abdominal injuries but as a direct result of inflicted intracranial injuries.

CONCLUSION

Our data indicate that abdominal injuries in abused children present in a pattern similar to that of children with accidental abdominal trauma, underscoring the need for vigilance and correlative historical and clinical data to identify victims of abuse. Mortality in abused children with intra-abdominal injury was frequently related to concomitant head injury.

The estimation of absorbed dose rates for non-human biota: an extended intercomparison

An exercise to compare 10 approaches for the calculation of unweighted whole-body absorbed dose rates was conducted for 74 radionuclides and five of the ICRP's Reference Animals and Plants, or RAPs (duck, frog, flatfish egg, rat and elongated earthworm), selected for this exercise to cover a range of body sizes, dimensions and exposure scenarios. Results were analysed using a non-parametric method requiring no specific hypotheses about the statistical distribution of data. The obtained unweighted absorbed dose rates for internal exposure compare well between the different approaches, with 70% of the results falling within a range of variation of ±20%. The variation is greater for external exposure, although 90% of the estimates are within an order of magnitude of one another. There are some discernible patterns where specific models over- or under-predicted. These are explained based on the methodological differences including number of daughter products included in the calculation of dose rate for a parent nuclide; source-target geometry; databases for discrete energy and yield of radionuclides; rounding errors in integration algorithms; and intrinsic differences in calculation methods. For certain radionuclides, these factors combine to generate systematic variations between approaches. Overall, the technique chosen to interpret the data enabled methodological differences in dosimetry calculations to be quantified and compared, allowing the identification of common issues between different approaches and providing greater assurance on the fundamental dose conversion coefficient approaches used in available models for assessing radiological effects to biota.

Early postoperative statin therapy is associated with a lower incidence of acute kidney injury after cardiac surgery

OBJECTIVE

To test the hypothesis that perioperative statin use reduces acute kidney injury (AKI) after cardiac surgery.

DESIGN

A retrospective analysis of prospectively collected data from an ongoing clinical trial.

SETTING

A quaternary-care university hospital.

PARTICIPANTS

Three hundred twenty-four adult elective cardiac surgery patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The authors assessed the association of preoperative statin use, early postoperative statin use, and acute statin withdrawal with the incidence of AKI. Early postoperative statin use was defined as statin treatment within the first postoperative day. Statin withdrawal was defined as the discontinuation of preoperative statin treatment before surgery until at least postoperative day 2. Logistic regression and propensity score modeling were used to control for AKI risk factors. Sixty-eight of 324 patients (21.0%) developed AKI. AKI patients stayed in the hospital longer (p = 0.03) and were more likely to develop pneumonia (p = 0.002) or die (p = 0.001). A higher body mass index (p = 0.003), higher central venous pressure (p = 0.03), and statin withdrawal (27.4 v 14.7%, p = 0.046) were associated with a higher incidence of AKI, whereas early postoperative statin use was protective (12.5% v 23.8%, p = 0.03). Preoperative statin use did not affect the risk of AKI. In multivariate logistic regression, age (p = 0.03), male sex (p = 0.02), body mass index (p < 0.001), and early postoperative statin use (odds ratio = 0.32; 95% confidence interval, 0.14-0.72; p = 0.006) independently predicted AKI. Propensity score-adjusted risk assessment confirmed the association between early postoperative statin use and reduced AKI (odds ratio = 0.30; 95% confidence interval, 0.13-0.70; p = 0.005).

CONCLUSIONS

Early postoperative statin use is associated with a lower incidence of AKI among both chronic statin users and statin-naive cardiac surgery patients.

Significance of epiphyseal cartilage enhancement defects in pediatric osteomyelitis identified by MRI with surgical correlation

BACKGROUND

Epiphyseal cartilage enhancement defects (ED) may occur in the setting of epiphyseal osteomyelitis (OM), and its significance is uncertain.

OBJECTIVE

The aim of this study is to evaluate the incidence and clinical impact of epiphyseal cartilage ED in pediatric epiphyseal OM.

MATERIALS AND METHODS

The 13 children involved in this retrospective review were younger than 6 years of age and diagnosed with OM. They underwent contrast-enhanced MRI and surgical exploration yielding 14 study epiphyses. Seventeen age-matched children without evidence of infection who underwent contrast-enhanced MRI in the same period yielded 28 control epiphyses. Images were reviewed for focal/global ED, correlated with cartilage abscesses and compared with surgical reports.

RESULTS

Study and control ED were respectively present in 10/14 (71.4%-6 global, 4 focal) and 6/28 (21.4%-0 global, 6 focal), P=0.0017. An analysis of ED patterns between study and control patients showed significant difference for global (P=0.0006), but no difference for focal ED (P=0.71). For the six study epiphyses with global ED, epiphyseal abscesses were present in two (33.3%). For the four study epiphyses with focal ED, epiphyseal abscesses were present in two (50%). For the controls, no abnormalities were found on follow-up of epiphyses with focal ED.

CONCLUSION

ED are seen normally but more commonly in children with OM. ED should not be confused with epiphyseal abscesses.

Prevalence and characteristics of psoriatic arthritis in Chinese patients with psoriasis

BACKGROUND

The prevalence and clinical characteristics of psoriatic arthritis (PsA) in patients with psoriasis vary widely in different countries and studies on Chinese population are rarely reported.

OBJECTIVE

The aim of this study was to evaluate the prevalence and clinical characteristics of PsA in a Chinese population of patients with psoriasis.

METHODS

A large cross-sectional observational study was conducted in our outpatient dermatology department and consecutive psoriatic patients were evaluated for PsA according to Classification of Psoriatic arthritis (CASPAR) criteria. Demographic and medical parameters were recorded.

RESULTS

Among 1928 patients with psoriasis, 112 patients (5.8%) had PsA, of which 92% was newly diagnosed. Oligoarthritis (48.2%) was the most common manifestation pattern, followed by spondylitis (26.8%), polyarthritis (19.6%) and classic distal interphalangeal (DIP) arthritis (5.4%). Enthesitis was present in 26.8% and dactylitis in 13.4% of the patients. Compared with patients without PsA, patients with PsA had more severe skin disease (mean PASI 9.7 vs. 6.0), higher frequency of nail changes (46.4% vs. 21.0%) and scalp involvement (90.2% vs. 76.4%).

CONCLUSION

The findings are consistent with a low prevalence of PsA among patients with psoriasis in Asia and confirm a high percentage of undiagnosed cases with active arthritis among PsA patients in dermatologist's office. Dermatologists should screen for PsA in their patients, especially those with risk characteristics and early signs.

MicroRNA in Osteoarthritis

Osteoarthritis (OA) is the most prevalent degenerative joint disease and is accompanied by pain and joint dysfunction. Its clinical treatment tends to be unsatisfactory. Novel targets in OA include genes that are involved in OA pathophysiology and have been discovered using gene network, epigenetic and microRNA (miRNA) approaches. miRNA has been implicated in important cellular processes such as lipid metabolism, apoptosis, differentiation and organ development. The importance of miRNA regulation in cellular function is becoming increasingly clear as new miRNA targets are revealed. The present review summarizes the current evidence of the important role played by miRNA in determining the complex gene expression patterns of OA chondrocytes and their role in the regulation of transcription, and possible demethylation mechanisms that might be applicable in OA. In summary, miRNA may have important diagnostic and therapeutic potential, and might provide a novel means of treating OA.

Accounting for data errors discovered from an audit in multiple linear regression

A data coordinating team performed onsite audits and discovered discrepancies between the data sent to the coordinating center and that recorded at sites. We present statistical methods for incorporating audit results into analyses. This can be thought of as a measurement error problem, where the distribution of errors is a mixture with a point mass at 0. If the error rate is nonzero, then even if the mean of the discrepancy between the reported and correct values of a predictor is 0, naive estimates of the association between two continuous variables will be biased. We consider scenarios where there are (1) errors in the predictor, (2) errors in the outcome, and (3) possibly correlated errors in the predictor and outcome. We show how to incorporate the error rate and magnitude, estimated from a random subset (the audited records), to compute unbiased estimates of association and proper confidence intervals. We then extend these results to multiple linear regression where multiple covariates may be incorrect in the database and the rate and magnitude of the errors may depend on study site. We study the finite sample properties of our estimators using simulations, discuss some practical considerations, and illustrate our methods with data from 2815 HIV-infected patients in Latin America, of whom 234 had their data audited using a sequential auditing plan.

Abstract P4-02-06: Beyond CYP2D6 Genotyping: Personalized Dosing of Tamoxifen (Tam) Based on Low Serum Endoxifen Levels

Background: The efficacy of Tam varies widely. Tam is biotransformed to endoxifen and 4-OH-Tam by the cytochrome P450 2D6 enzymes. Studies on 2D6 variants as a predictor of Tam's efficacy show conflicting results. Compared to Tam, endoxifen and 4-OH-Tam have a 100-fold greater affinity for the estrogen receptor (ER) and in suppressing estrogen-dependent cell proliferation. However, endoxifen is present at concentrations up to 20-fold higher and is pharmacologically distinct from 4-OH-Tam. Endoxifen's effect on ERα-degredation and transcription is concentration dependent; serum endoxifen levels ≥40nM block ERα-mediated transcriptional activation and inhibit estrogen-induced breast cancer cell proliferation.

Methods: Pts taking Tam 20 mg/day, for any reason, were potentially eligible. Serum Tam, Tam metabolites and nineteen 2D6 alleles were analyzed. 2D6 genotyping was performed by PCR-based procedures and metabolites were assessed on Liquid Chromatography/Tandem Mass Spectrometry. Pts were stratified by 2D6 function into 3 groups: extensive metabolizers (EM) who had normal enzyme activity; intermediate metabolizers (IM) who had reduced enzyme activity; and poor metabolizers (PM) who had no enzyme activity. Tam was increased to 30 mg/day if serum endoxifen &lt; 40nMol. Serum Tam and Tam metabolites were measured every 2 weeks for 90 days.

Results: 121 patients have enrolled to date. Age, ethnicity, BMI, concomitant medications, and adherence were recorded. 25/117 (21%) pts had low serum endoxifen; all of these pts were increased to Tam 30 mg/day. Of this cohort, 36% were PMs (PM/PM and PM/IM), 32% were IMs (EM/PM and IM/IM) and 32% were EMs (EM/EM and EM/IM). All patients’ serum endoxifen increased to &gt;40nMol by day 30 (Diagram below).

Conclusions: 1) Sub-therapeutic serum endoxifen can be found in any 2D6 phenotype. 2) It is possible to achieve therapeutic serum endoxifen/Tam metabolite levels by optimizing the dose of Tam. 3) Subsequently, it is likely that other gene variants are involved in Tam metabolism hence why 2D6 testing may lead to conflicting results. 4). Further investigation is warranted as personalizing the dose of Tam is feasible and may potentially improve the outcome of pts taking Tam regardless of 2D6 genotype. Figure available in online version.

The DNA methylome of human peripheral blood mononuclear cells

Analysis across the genome of patterns of DNA methylation reveals a rich landscape of allele-specific epigenetic modification and consequent effects on allele-specific gene expression.

DNA methylation plays an important role in biological processes in human health and disease. Recent technological advances allow unbiased whole-genome DNA methylation (methylome) analysis to be carried out on human cells. Using whole-genome bisulfite sequencing at 24.7-fold coverage (12.3-fold per strand), we report a comprehensive (92.62%) methylome and analysis of the unique sequences in human peripheral blood mononuclear cells (PBMC) from the same Asian individual whose genome was deciphered in the YH project. PBMC constitute an important source for clinical blood tests world-wide. We found that 68.4% of CpG sites and <0.2% of non-CpG sites were methylated, demonstrating that non-CpG cytosine methylation is minor in human PBMC. Analysis of the PBMC methylome revealed a rich epigenomic landscape for 20 distinct genomic features, including regulatory, protein-coding, non-coding, RNA-coding, and repeat sequences. Integration of our methylome data with the YH genome sequence enabled a first comprehensive assessment of allele-specific methylation (ASM) between the two haploid methylomes of any individual and allowed the identification of 599 haploid differentially methylated regions (hDMRs) covering 287 genes. Of these, 76 genes had hDMRs within 2 kb of their transcriptional start sites of which >80% displayed allele-specific expression (ASE). These data demonstrate that ASM is a recurrent phenomenon and is highly correlated with ASE in human PBMCs. Together with recently reported similar studies, our study provides a comprehensive resource for future epigenomic research and confirms new sequencing technology as a paradigm for large-scale epigenomics studies.

Epigenetic modifications such as addition of methyl groups to cytosine in DNA play a role in regulating gene expression. To better understand these processes, knowledge of the methylation status of all cytosine bases in the genome (the methylome) is required. DNA methylation can differ between the two gene copies (alleles) in each cell. Such allele-specific methylation (ASM) can be due to parental origin of the alleles (imprinting), X chromosome inactivation in females, and other as yet unknown mechanisms. This may significantly alter the expression profile arising from different allele combinations in different individuals. Using advanced sequencing technology, we have determined the methylome of human peripheral blood mononuclear cells (PBMC). Importantly, the PBMC were obtained from the same male Han Chinese individual whose complete genome had previously been determined. This allowed us, for the first time, to study genome-wide differences in ASM. Our analysis shows that ASM in PBMC is higher than can be accounted for by regions known to undergo parent-of-origin imprinting and frequently (>80%) correlates with allele-specific expression (ASE) of the corresponding gene. In addition, our data reveal a rich landscape of epigenomic variation for 20 genomic features, including regulatory, coding, and non-coding sequences, and provide a valuable resource for future studies. Our work further establishes whole-genome sequencing as an efficient method for methylome analysis.

Utilizing spiral computerized tomography during the removal of a fractured endodontic instrument lying beyond the apical foramen

AIM

To present a case that used spiral computerized tomography (CT) to locate and successfully remove a fractured endodontic instrument lying beyond the apical foramen using a surgical approach.

SUMMARY

The fracture of an endodontic instrument beyond the apical foramen is rare. In this case report, after an attempt to remove a fractured instrument failed, a multi-slice spiral computerized tomography (MSCT) was used for diagnosis and treatment planning. The fractured segment was precisely located and found in the soft tissue and successfully removed by surgery. For the successful removal of a fractured endodontic instrument beyond the apical foramen, the following are necessary: (i) knowledge of the cause of fracture and how to plan treatment; (ii) determining the precise location of the fractured segment using CT; and 3) skilful operation.

KEY LEARNING POINTS

•  Fractured endodontic instruments might lie within the soft tissue. •  Computerized tomography is an effective diagnostic aid for localizing the precise position of fractured instruments.