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Background Computed tomography perfusion (CTp), a useful technique in oncology, is not widely utilized due to the high radiation dose delivered from it. It involves scanning the region of interest every second for 50 seconds following intravenous contrast administration. Doubling sampling interval (SI) to 2 seconds will half the radiation dose, but may impact its effectiveness, which needs to be evaluated. Objectives To evaluate a dose reduction strategy in CTp by determining agreement between standard dose (SD) CTp (acquisition with SI 1 second) and low-dose CTp techniques with SI of 2 seconds (achieved either by reconstruction only or true low-dose acquisition). Materials and methods This cross-sectional study was conducted on histopathology-proven head and neck squamous cell carcinoma (HNSCC) patients who underwent CTp on 64 slice multidetector CT. A total of 56 patients had SD and 24 patients underwent true low dose (LD) acquisition. SD data were also reconstructed at SI 2 seconds to obtain a dataset simulating low dose (low-dose reconstruction [LDr]). Paired t -test was applied to compare CTp in SD and LDr groups and the Bland-Altman plot drawn to calculate 95% confidence limit of agreement. The Kolmogorov-Smirnov test compared CTp parameters for LDr and LD groups. Results There was no statistical difference in CTp parameters (except blood flow in malignant) in SD and LDr groups for both malignant and normal tissues. CTp of malignant tissue was not statistically different in LDr and LD groups but the radiation dose was half in the LD group. Conclusion Reduction of radiation dose to half achieved by doubling the SI does not affect the CTp parameters significantly. So LD acquisitions will increase the use of CTp in HNSCC.

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BACKGROUND: Cervical pedicle screw insertion is a technically demanding procedure that carries the risk of catastrophic damage to surrounding neurovascular structures. Here, we analyzed computed tomography (CT)-based three-dimensional cervical spine pedicle geometry to determine the level and sex-specific morphologic differences in the adult Indian population. METHODS: The CT scans of 200 patients (2400 pedicles) without significant cervical spine pathology were collected. The mean pedicle width (PW), pedicle height (PH), pedicle axial length (PAL), and pedicle transverse angle (PTA) from C2 to C7 were measured. RESULTS: The smallest mean PW was at C3 in both males (4.85 ± 0.73 mm) and females (4.31 ± 0.43 mm); 7.08% of all pedicles were found to have mean PW of <4 mm. The smallest mean PH was at C5 in both males (6.25 ± 0.67mm) and females (5.54 ± 0.52 mm). The smallest mean PAL was at C2 in both males (27.46 ± 1.69mm) and females (25.90 ± 1.88 mm). The mean PW, PH, and PAL were significantly greater in males than females at all levels (P < 0.05). The smallest mean PTA was at C3 in males (41.79 ± 2.53°) and at C7 in females (42.40 ± 2.27°). CONCLUSION: In the adult Indian population, the PW, PH and PAL were smaller than in the typical western population. Females had even smaller PW, PH and PAL as compared to males. We recommend that a small inventory of 3.5mm screws between 20mm to 30mm length be used in most cases where cervical pedicle screws are being used in the Indian population. However, individual vertebrae should be screened preoperatively with CT scans to exclude gross anatomical variations, especially in females and at the C3 and C4 levels.

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BACKGROUND: Only a few studies have reported on postprandial lipid responses and endothelial function in prediabetic subjects. None of the study has compared role of familial predisposition in determining postprandial endothelial dysfunction and postprandial hypertriglyceridemia in subjects with prediabetes. OBJECTIVE: The objective was to study the postprandial triglyceride (PPTG) responses and endothelial function in prediabetic first-degree relatives of patients with diabetes. METHODS: Thirty-nine subjects were recruited on the basis of oral glucose tolerance test into 3 groups: group 1, prediabetic subjects who had a first-degree relative with diabetes; group 2, prediabetic subjects without family history of diabetes; and group 3, normal glucose tolerance subjects without family history of diabetes. Oral fat challenge test was performed in all study subjects and PPTG responses were measured up to 8 hours. Postprandial endothelial function after 4 hours of fat challenge was estimated by flow-mediated dilation. RESULTS: Postprandial endothelial dysfunction was greatest in group 1 and significantly higher in group 1 compared with group 2 (P < .001) and group 2 compared with group 3 (P < .001). PPTG responses (TG-AUC, TG-peak, TG-6 hour, and TG-8 hour) were significantly higher in group 1 compared with groups 2 and 3. However, they were similar between groups 2 and 3. Endothelial function showed significant negative correlation with TG-6 hour and TG-8 hour. CONCLUSION: Prediabetic subjects respond to fat challenge with a greater degree of TG response and endothelial dysfunction compared with normal glucose tolerance subjects especially if they have a first-degree relative with diabetes. This may contribute to enhanced cardiovascular risk reported in prediabetic individuals.

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Well differentiated papillary carcinoma of thyroid frequently metastasizes to regional lymph nodes and the patients usually present with cervical or mediastinal lymphadenopathy. In this article, we report a case of papillary thyroid carcinoma with hepatic metastasis presenting as liver mass in absence of lymph nodal metastasis, a presentation not previously reported to the best of our knowledge.

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OBJECTIVE: To evaluate the non-inferiority of a lower therapeutic dose (300,000 IU) in comparison to standard dose (600,000) IU of Vitamin D for increasing serum 25(OH) D levels and achieving radiological recovery in nutritional rickets. DESIGN: Randomized, open-labeled, controlled trial. SETTING: Tertiary care hospital. PARTICIPANTS: 76 children (median age 12 mo) with clinical and radiologically confirmed rickets. INTERVENTION: Oral vitamin D3 as 300,000 IU (Group 1; n=38) or 600,000 IU (Group 2; n=38) in a single day. OUTCOME VARIABLES: Primary: Serum 25(OH)D, 12 weeks after administration of vitamin D3; Secondary: Radiological healing and serum parathormone at 12 weeks; and clinical and biochemical adverse effects. RESULTS: Serum 25(OH)D levels [geometric mean (95% CI)] increased significantly from baseline to 12 weeks after therapy in both the groups [Group 1: 7.58 (5.50­10.44) to 16.06 (12.71­ 20.29) ng/mL, P<0.001]; Group 2: 6.57 (4.66­9.25) to 17.60 (13.71­22.60, P<0.001]. The adjusted ratio of geometric mean serum 25(OH)D levels at 12 weeks between the groups (taking baseline value as co-variate) was 0.91 (95% CI: 0.65­1.29). Radiological healing occurred in all children by 12 weeks. Both groups demonstrated significant (P<0.05) and comparable fall in the serum parathormone and alkaline phosphatase levels at 12 weeks. Relative change [ratio of geometric mean (95% CI)] in serum PTH and alkaline phosphatase, 12 weeks after therapy, were 0.98 (0.7­1.47) and 0.92 (0.72­1.19), respectively. The serum 25(OH)D levels were deficient (<20 ng/mL) in 63% (38/60) children after 12 weeks of intervention [Group 1: 20/32 (62.5%); Group 2: 18/28 (64.3%)]. No major clinical adverse effects were noticed in any of the children. Hypercalcemia was documented in 2 children at 4 weeks (1 in each Group) and 3 children at 12 weeks (1 in Group 1 and 2 in Group 2). None of the participants had hypercalciuria or hypervitaminosis D. CONCLUSION: A dose of 300,000 IU of vitamin D3 is comparable to 600,000 IU, administered orally, over a single day, for treating rickets in under-five children although there is an unacceptably high risk of hypercalcemia in both groups. None of the regime is effective in normalization of vitamin D status in majority of patients, 3 months after administering the therapeutic dose.

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AIM: To evaluate the role of virtual cystoscopy (VC) comparing it with cystopanendoscopy (CPE) for detecting bladder tumor(s). MATERIAL AND METHODS: Ethical clearance was obtained from the Institutional ethics committee. After an informed consent 30 patients fulfilling the inclusion criteria were enrolled in the prospective non-randomized clinical study and were evaluated as per protocol with VC performed by a qualified radiologist who was blinded to the findings of CPE performed by a qualified urologist. The results so obtained were analyzed using appropriate statistical tools. RESULTS: The mean age of the patients was 56 years. Sensitivity of VC in detecting bladder lesions was 92%. However, when axial images were also interpreted along with VC, the sensitivity increased to 96% for detecting bladder lesions. The specificity of VC with axial CT was 40% in respect of detecting bladder lesions. VC with axial CT was 85.7% sensitive in identifying multiple bladder tumors. There were no complications on account of performing VC. Minor problems were encountered with VC and CPE in 16.7% and 13.3% patients respectively. CONCLUSIONS: VC with axial CT is 96% sensitive in detecting bladder lesions and 85.7% sensitive in detecting the multiplicity of the tumors. VC may be a useful complementary diagnostic tool for the workup of select patients with suspected bladder lesions. However, larger randomized controlled studies are needed to better define the precise clinical and diagnostic role of VC in routine practice. SETTINGS AND DESIGN: Prospective Clinical Comparative Non Randomized Clinical Study.

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AIMS: To report and describe the clinical presentation and outcome of a woman presenting with gross perinephric urinary extravasation (due to spontaneous renal forniceal rupture), secondary to malignant obstructive uropathy caused by advanced cervical carcinoma. To review the etiopathogenesis, approach to diagnosis and management of 'spontaneous renal forniceal rupture. METHODS: The published English literature (PubMed) was searched for similar cases of 'spontaneous renal forniceal rupture' using the keywords: carcinoma cervix, metastatic carcinoma cervix, renal pelvis rupture, renal fornix rupture, spontaneous renal fornix rupture and urinoma. RESULTS: The diagnosis of renal forniceal rupture with gross urinoma formation secondary to advanced cervical carcinoma was suspected on ultrasound and was subsequently confirmed by a computed tomographic scan of the abdomen. Percutaneous nephrostomy with a pigtail catheter resolved the urinoma. Search results for similar cases yielded several causes of spontaneous renal forniceal rupture, however, only one such case report due to advanced cervical carcinoma was found. CONCLUSION: To the best of our knowledge, this is the second case of spontaneous renal forniceal rupture secondary to ureteral obstruction caused by advanced cervical carcinoma to be reported in the published English literature. A high clinical index of suspicion is warranted in any patient of advanced cervical carcinoma that presents with sudden uremia or oliguria with flank pain and swelling in order to arrive at an early diagnosis. A decompressive nephrostomy may provide the much needed comfort and succor towards prolonging the life of such unfortunate patients.

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The time course of changes in apparent diffusion coefficient (ADC) and signal intensity on diffusion-weighted magnetic resonance imaging (DW MR) imaging in acute ischemic stroke is a very dynamic event. There is an initial reduction in ADCs with no change on T2-W imaging but signal intensity increase on T2-weighted takes place about 6-12 hours after onset of stroke. As necrosis begins to set in, there is a gradual reversal of ADC change, and around 3-10 days post-onset, ADC pseudonormalizes. Twenty-four patients of acute stroke underwent diffusion MR imaging in addition to conventional T1W, T2W, and Fluid Attenuated Inversion Recovery (FLAIR) sequence performed within 12 hours, at 30 days, and at 90 days. The mean signal intensity at b = 0 s/mm2 and at b = 1000 s/mm2 were significantly higher than control values for all time periods. The ratio of signal intensity at b = 0 (rSI b=0) significantly increased from 1.63 +/- 0.20 in the acute stage to 2.19 +/- 0.24 in the chronic stage (P < 0.001). The ratio of signal intensity on DWI (r SIDWI) decreased from 2.54 +/- 0.46 to 1.54 +/- 0.22. The mean ADC in the lesion was found to be 41% lower than the mean ADC in the contralateral hemisphere .Linear regression analysis between rADC and log hours showed that pseudonormalization occurred at 6.61 days (P < 0.001). We conclude that the above information could be useful in the management of very early stroke.

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Hyperlipidemia and increased serum lipoprotein (Lp)(a) are independent risk factors for atherosclerosis and its complications. Serum Lp(a) concentration is not influenced by most lipid-lowering therapies other than niacin. Recently aspirin also has been reported to decrease its levels. In the current study, we evaluated the serum levels of Lp(a) and lipids in 25 patients with first-ever diagnosed ischemic stroke, aged 21 to 60 years, and compared their levels with an equal number of age- and sex-matched healthy control subjects. In addition, the effect of aspirin on Lp(a) levels was studied by estimating its levels after 4 weeks of daily treatment with 150 mg of aspirin. Both groups were comparable regarding their anthropometric measurements and routine laboratory parameters except that erythrocyte sedimentation rate was higher in the patients. Serum lipids were not significantly different between the two groups, although Lp(a) levels were significantly higher in the patients (27.40 +/- 22.30 mg/dL) as compared with the control subjects (14.68 +/- 11.75 mg/dL) (P = .005). Twenty of 25 patients (80%) had serum Lp(a) levels of more than 10 mg/dL, whereas only 11 of 25 control subjects (44%) had serum Lp(a) levels of more than 10 mg/dL (P = .009). After 4 weeks of treatment with aspirin, Lp(a) levels declined significantly (46.24%) from baseline 27.40 +/- 22.30 mg/dL to 14.73 +/- 10.47 mg/dL (P < .001). Patients with baseline levels greater than 25 mg/dL showed greater decline (55.63%) compared with those with levels less than 25 mg/dL (26.63%) (P = .008). Results of our study confirm that aspirin lowers the increased Lp(a) levels in patients with ischemic stroke.

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OBJECTIVES: To evaluate the clinical efficacy and outcome of 99% ethanol as a sclerosing agent for managing chronic flank pain due to dominant cysts in selected patients with adult polycystic kidney disease. Traditionally, such patients have been treated with analgesics and surgical/laparoscopic deroofing. Cyst aspiration sclerotherapy is a minimally invasive therapeutic option for such patients, and limited published data exist on this subject. This formed the basis for the present study. METHODS: A pilot study was undertaken during a 1-year period to evaluate the clinical efficacy of ultrasound-guided cyst aspiration-ethanol injection sclerotherapy in 15 preselected patients with diagnosed adult polycystic kidney disease. All punctures were performed with strict aseptic precautions and local anesthesia on an outpatient basis. The patients were evaluated with serial scans, pain scores, and serum creatinine values. RESULTS: A total of 48 dominant cysts were successfully treated in all 15 patients with regard to cyst aspiration and shrinkage. At the end of 1 year, the pain and dominant cysts had completely disappeared in 13 patients and had recurred in 2; repeat cyst aspiration and sclerotherapy was done in 3 patients. Nephrocutaneous fistula and urinary tract infection occurred in 1 patient each. The decrease in the pain score and the rise in the serum creatinine level were statistically significant at P <0.05 and P <0.001, respectively. CONCLUSIONS: Alcohol cyst sclerotherapy is a minimally invasive, safe, and effective alternative to conventional surgical/laparoscopic deroofing for managing chronic flank pain due to adult polycystic kidney disease in selected patients. It should be considered as a safe and viable therapeutic option in patients in whom the primary symptom is chronic flank pain due to one or more dominant cysts.

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