T2-weighted short-tau inversion recovery (T2w-STIR) imaging is the best approach for oedema-weighted cardiac magnetic resonance imaging (MRI), as it suppresses the signal from flowing blood and from ...fat and enhances sensitivity to tissue fluid. The purpose of this pictorial review is to illustrate the clinical use and application of this technique in various ischaemic and non-ischaemic conditions. In ischaemic heart disease, T2w-STIR represents the technique of choice for detecting oedema in patients with acute myocardial infarction (MI), allowing discrimination of acute and chronic injuries. Myocardial haemorrhage may also be depicted as a region of signal abnormality characterised by a central hypointense core with a peripheral hyperintense rim, presumably reflecting the presence of intracellular methaemoglobin within the necrotic area. In the acute setting, elevated T2 relaxation times in association with regional contractile dysfunction but no signs of delayed enhancement may also signify a reversible ischaemic injury without necrosis. In acute myocarditis, the distribution pattern of T2w hyperintensity may be focal in approximately 30% of patients or diffuse in the remaining 70%, and myocardial oedema may be the only marker of disease. Tissue oedema may also be observed in various other conditions, such as primary cardiomyopathies (CMP), storage disease, pulmonary hypertension and cardiac transplant rejection. T2w-STIR represents an appealing and versatile technique that can be applied in a wide variety of ischaemic and non-ischaemic conditions, allowing detection of segmental or global increase of myocardial free water content, reflecting an acute myocardial injury.
Metformin and glyburide are antihyperglycemic agents that are widely used in the United States. There have been several cases of overdose of these medications reported in the world literature. ...Glyburide overdose is associated with hypoglycemia that can be severe, while metformin overdoses have been associated with lactic acidosis. In many cases of metformin overdose, lactic acidosis has led to profound hypotension and respiratory failure. In this article we will present the case of a 49-year-old man who ingested 52 grams of metformin and 350 mg of glyburide in a suicide attempt. The patient developed hypoglycemia, lactic acidosis, hypotension, respiratory failure and a profound sudden sensorineural hearing loss. We discuss prior cases of overdose with these agents, and the connection between overdose and the development of sudden sensorineural hearing loss.
Antidepressant augmentation strategies for treatment-resistant depression (TRD) are discussed here with an analysis of patient out-of-pocket costs for various medications. The choice of agent ranges ...from newer atypical antipsychotics (aripiprazole, brexpiprazole, quetiapine) to older agents including buspirone, liothyronine (T3), and lithium. We sought to better understand the differences among these agents to aid in clinical decision making.
We conducted a focused review of the support for each of the aforementioned agents in antidepressant augmentation. We then compared the approximate out-of-pocket cost for each medication during a typical augmentation trial using the typical prescription costs on ClinCalc.com derived from the Medical Expenditure Panel Survey. We calculated the cost to achieve response for one patient with TRD based on the number needed to treat (NNT).
We observed significant variance in cost to achieve response based on the NNT derived from our review of each of the medications. For example, the overall out-of-pocket cost for one patient to achieve response with aripiprazole (the costliest generic agent) could cover lithium prescriptions for 4 to 5 patients with TRD to achieve response. Although brexpiprazole was estimated separately because of its brand name cost, we estimated that 324 patients receiving lithium could achieve response for same cost of single patient receiving brexpiprazole.
These findings suggest that among augmentation agents, there are differences in cost that may be highly important in clinical decision making. Other issues of medication monitoring may incur additional costs, and brand name medications offer significantly greater complexity and potential out-of-pocket costs to patients. The use of lithium as a first-line agent for TRD should be considered based on low cost, lowest NNT, and data in support of its efficacy.
L’hypothèse selon laquelle l’administration prophylactique d’un verrou fibrinolytique (composé de 25,000 unités d’urokinase, de taurolidine et de citrate) une fois par semaine permet de réduire les ...dysfonctions thrombotiques de 50 % chez des patients avec antécédents de dysfonctions thrombotiques de leurs hémocathéters a été testée dans cette étude multicentrique randomisée contrôlée en double aveugle.
Les patients de 8 centres de dialyse en Belgique ayant présenté au minimum 2 dysfonctions thrombotiques de leurs hémocathéters dans les 6 mois précédant l’inclusion et consentants à participer furent randomisés en double aveugle en 2 groupes : le groupe recevant le verrou fibrinolytique une fois par semaine (et un verrou standard de taurolidine, citrate et héparine lors des deux autres sessions d’hémodialyse) et le groupe contrôle recevant une poudre placebo une fois par semaine diluée dans le verrou standard de taurolidine (administré après chaque hémodialyse). Les ampoules contenant la poudre d’urokinase et le placebo étaient indistinguables l’une de l’autre. Chaque patient était suivi pendant 6 mois après la randomisation.
Le premier objectif était de comparer l’incidence de dysfonctions thrombotiques définies par le recours à de l’urokinase (instillée dans la lumière de l’hémocathéter) dans les 2 groupes. Le second objectif était de comparer le nombre d’échecs de fibrinolyse locale par urokinase menant au retrait du cathéter ou à la fibrinolyse systémique.
Soixante-huit patients ont été randomisés (32 dans le groupe contrôle et 36 dans le groupe recevant le verrou fibrinolytique prophylactique) et suivis pendant 9821 cathéter jours. Quinze sur trente-six patients (42 %) du groupe recevant le verrou fibrinolytique a nécessité au minimum d’une administration thérapeutique d’urokinase contre 23/32 (72 %) dans le groupe contrôle (p=0,012). Au total, 24 administrations d’urokinase (incidence de thromboses 4,8/1000 cathéter jours) ont été relevées dans le groupe bénéficiant du verrou fibrinolytique prophylactique comparé à 59 (incidence de thromboses 12,3/10 000 cathéter jours) dans le groupe contrôle (Rate ratio 0,39 ; IC 95 % 0,23 à 0,63 ; p<0,0001). Il n’y avait pas de différence statistiquement significative dans le nombre de dysfonctions thrombotiques réfractaires dans les 2 groupes. Aucune complication hémorragique ne fut observée durant l’étude.
L’utilisation prophylactique d’un verrou à base d’urokinase une fois par semaine permet de réduire de manière significative et sûre le recours thérapeutique à de l’urokinase dans une population à risque de patients hémodialysés mais ne permet pas de réduire la survenue de complications thrombotiques plus sévères responsables de la perte du cathéter.
To compare ultrasound (US), low-mechanical index contrast enhanced US (CEUS) and multidetector-CT (MDCT) for the detection of hepatic metastases from colorectal cancer.
From January to June 2006, 110 ...patients (65 males, 45 females; mean age 62 years; range 39-78) with suspected hepatic lesions from colorectal cancer were prospectively evaluated with US, CEUS and MDCT by two independent readers. Intraoperative ultrasonography (IOUS, n = 45) or a follow-up up for at least 6 months by using MDCT or Gd-BOPTA-enhanced MRI was considered the gold standard. McNemar test was employed.
Reference standards revealed 430 metastases in 110 patients. On a patient-by-patients analysis, CEUS improved US sensitivity from 67.4-71.6% to 93.4-95.8% (p < 0.05). On a lesion-by-lesion analysis, CEUS improved the sensitivity of US from 60.9-64.9% to 85.3-92.8% (p < 0.001). The specificity increased from 50-60% to 76.7-83.3%. No significant differences in sensitivity or specificity between CEUS and MDCT were found. Contrast-enhanced US was significantly more sensitive than baseline US in the detection of metastases smaller than 1 cm (p < 0.001) with an increase in sensitivity from 29.1-35% to 63.3-76.6% no significant statistical difference was identified when compared with MDCT (sensitivity of 73.3-75.8%).
CEUS is significantly more accurate than US and highly comparable with MDCT in the detection of liver metastases from colorectal cancer. Therefore, in the evaluation of patients with suspected hepatic metastases from colorectal tumour, US examination must be performed after contrast administration.
Malware detection is one of the most important tasks in cybersecurity. Recently, increasing interest in Convolutional Neural Networks (CNN) and Machine Learning algorithms, which are widely used in ...image analysis and predictive modelling, led to their use in static malware classification and to the application of these powerful tools in computer industry and industrial internet of things. Many studies claim that the static malware detection approach, under well-defined conditions, can deliver fast and accurate malware classification results with relatively little human effort once the framework is implemented, relying solely on the binary content of the file. This becomes evident if we compare static malware detection to other techniques of dynamic nature. The focus of our research is to highlight strengths and weaknesses of CNNs used for static malware detection, starting from images obtained from byte-wise conversion of binary executable files to pixel images to critically analyze the assumptions underlying the performance of this type of technique.
•Malware may have dramatic effects on both personal and public digital assets.•Potential vulnerabilities on image-based malware detection through CNNs are discussed.•A novel polymorphic engine is designed to highlight weaknesses in CNN-based malware detection.•The proposed approach is implemented and validated on real malware datasets.•Mitigation countermeasures relying on Adversarial Training are proposed, tested, and analyzed.
Purpose
This study was done to evaluate the diagnostic accuracy of dual-energy X-ray absorptiometry (DXA) compared with conventional radiography for identifying vertebral fractures.
Materials and ...methods
A total of 930 postmenopausal women underwent conventional radiography and DXA imaging of the spine. The images were evaluated by two expert skeletal radiologists using the semiquantitative (SQ) method for conventional radiography and the morphometric vertebral fracture assessment (VFA) for DXA.
Results
The SQ method for radiography (SQ-Rx) analysed 99.1% of vertebrae, identifying 442 vertebral fractures; VFA analysed 97.5% vertebrae, detecting 420 vertebral fractures. Agreement between SQ-Rx and VFA reached 98.76%, and the κ-score was 0.96 95% confidence interval (CI), 0.95–0.98. Assessing the grading of vertebral fractures, agreement reached 97.5% and the κ-score was 0.841 (95% CI, 0.821–0.891). Considering SQ-Rx method as “gold standard”, VFA had a sensitivity of 97.85 % and a specificity of 99.81%. The negative (NPV) and positive (PPV) predictive value for VFA were 99.83 % and 98.15%, respectively. Fractures were identified in 251 (27 %) and 242 (26 %) of patients on SQ-Rx and VFA, respectively. On a per-patient basis, the agreement between the two methods was 97% and the κ-score was 0.95 (95% CI, 0.920–0.968). The diagnostic parameters for VFA were 97.23% sensitivity, 98.86% specificity, 97.60% PPV and 98.84% NPV.
Conclusions
This study demonstrated that VFA with DXA may reach a high level of accuracy for diagnosing vertebral fractures, suggesting that VFA should be introduced in the screening of individuals with a risk of osteoporosis and in the follow-up of osteoporotic patients receiving treatment.
Abstract
Congenital heart disease is one of the most frequent prenatal malformation representing an incidence of 5/1000 live births; moreover, it represents the first cause of death in the first year ...of life. There is a wide range of severity in congenital heart malformations from lesions which require no treatment such as small ventricular septal defects, to lesions which can only be treated with palliative surgery such as hypoplastic left heart syndrome. A good prenatal examination acquires great importance in order to formulate an early diagnosis and improve pregnancy management. Nowadays, echocardiography still represents the gold standard examination for fetal heart disease. However, especially when preliminary ultrasound is inconclusive, fetal MRI is considered as a third-level imaging modality. Preliminary experiences have demonstrated the validity of this reporting a diagnostic accuracy of 79%. Our article aims to outline feasibility of fetal MRI in the anatomic evaluation, the common indication to fetal MRI, its role in the characterization of congenital heart defects, and at last its main limitations.
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