This paper presents an update on cranial nerve imaging with new imaging techniques applied on a nerve by nerve based literature research. Imaging small structures in the human body such as the cranial nerves often poses a challenge in MRI imaging. It requires investment in spatial resolution with acceptable MRI scantimes. The radiologist should also be aware of the anatomical course of all 12 cranial nerves, and know which type of sequence is best used to visualize each part of the cranial nerve from the brainstem to the end-organ. This paper does not cover the complex radiological anatomy of the cranial nerves, this is already available in many other manuscripts. Nor will this paper cover all the possible pathologies that can affect the cranial nerves, this is also described in many other manuscripts. Newer imaging techniques, such as contrast-enhanced black-blood T1-weighted imaging, are increasingly used to improve detection of cranial nerve inflammation. While diffusion tensor imaging is currently used primarily to evaluate the integrity of the cisternal nerve segments, contrast-enhanced black-blood T1-weighted imaging can provide additional information about the cisternal, foraminal, cavernous, and extracranial portions of the cranial nerves. MR neurography techniques have recently been developed with better demonstration of the extracranial course of the cranial nerves. Detection of inflammatory or demyelinating nerve disease will mostly benefit from using these new imaging techniques. Some practical tips to optimize cranial nerve MRI scanning are provided.
Anticoagulation during extracorporeal membrane oxygenation (ECMO) requires balancing thrombotic and bleeding risks, yet early coagulation dynamics may differ between venovenous (VV) and venoarterial (VA) support. This study prospectively characterized standard coagulation tests and viscoelastic profiles during the first 48 h of ECMO and related these to early bleeding and transfusion need. Multicenter, prospective cohort in four Belgian ICUs (03/2021–01/2023; NCT04912336). Adults initiated on VV- or VA-ECMO were enrolled immediately before cannulation and sampled at inclusion, + 2 h, + 24 h, and + 48 h. Laboratory tests (aPTT, PT/INR, fibrinogen, platelets, anti-Xa, D-dimer, AT), ROTEM, bleeding (BARC, GUSTO), and transfusions were recorded. Forty-three patients were included (23 VV, 20 VA). At inclusion, platelet counts were higher in VV than in VA (median 292 vs. 145·109/L). Thrombocytopenia was present at enrollment in 30
BACKGROUND:PORTEC-4a investigated molecular risk profile-based individualised adjuvant treatment for women with high-intermediate risk endometrial cancer, aiming to reduce both overtreatment and undertreatment while optimising locoregional control. METHODS:PORTEC-4a was a randomised, open-label, phase 3, multicentre, non-inferiority trial, conducted across eight European countries. Women (aged ≥18 years and with a WHO performance score of 0-2) with early stage high-intermediate risk endometrial cancer were eligible. Patients were randomly assigned post-surgery in a 2:1 ratio to either adjuvant treatment according to their molecular integrated risk profile or to standard vaginal brachytherapy. Allocation used a biased-coin minimisation with stratification for participating centre, grade, and lymphadenectomy. Adjuvant treatment in the molecular-profile group in case of favourable profile (POLE-mutated or no specific molecular profile [NSMP]-CTNNB1 wildtype) was observation, for intermediate profile (mismatch repair deficient or NSMP-CTNNB1 mutated) was brachytherapy (21 Gy in three fractions of 7 Gy given at 5 to 7 day intervals), and for unfavourable profile (p53 abnormal or substantial lymphovascular space invasion or L1 cell adhesion molecule overexpression) was pelvic radiotherapy (45·0-48·6 Gy in 1·8-2·0 Gy fractions, 5 days per week). The primary endpoint was overall 5-year cumulative incidence of vaginal recurrence as first event. Kaplan-Meier, Cox model, and cumulative incidence with competing risks were used for final analysis in the intention-to-treat population. Patient advocates were involved during grant application and trial conduct. The trial is registered with the Netherlands Trial Registry (NTR5841), the ISRCTN registry (ISRCTN11659025), and ClinicalTrials.gov (NCT03469674), and follow-up is ongoing. FINDINGS:Between June 1, 2016, and Dec 24, 2021, 569 patients were enrolled in PORTEC-4a. After the addition of 23 favourable patients out of PORTEC-4, the final combined PORTEC-4a cohort consisted of 564 eligible and evaluable patients (367 in the molecular profile group and 197 in the standard group). All patients were female, the median age was 69·0 years (IQR 63·0-73·5), and data on race and ethnicity were not collected. Median follow-up was 58·1 months (IQR 40·7-63·6). In the molecular profile group 168 (46%) patients had a favourable profile, 148 (40%) had an intermediate profile, and 51 (14%) had an unfavourable profile. The 5-year cumulative incidence of vaginal recurrence was 4·5% (95% CI 2·23-6·76) in the molecular profile group and 1·6% (0·00-3·32) in the standard group (HR 2·71 [95% CI 0·79-9·34]). The upper-bound of the one-sided confidence interval of the difference (5·3%) was below the predefined-equivalence margin of 7·0% (pnon-inferiority=0·005). The second primary analysis in patients with a favourable molecular profile showed 5-year vaginal recurrence of 4·1% (95% CI 0·81-7·37) in the molecular profile group versus 0·9% (0·00-2·78) in the standard group (HR 3·97 [95% CI 0·48-32·95]). Adverse events were mainly grades 1-2, with grade 3 or above related genitourinary toxicities in four (1%) of 367 versus four (2%) of 197, without substantial differences between groups. Five serious adverse events occurred, of which one was possibly related to treatment (vaginal scar dehiscence). No treatment-related deaths occurred. INTERPRETATION:Individualised adjuvant treatment by molecular integrated risk profile is safe and effective for patients with high-intermediate risk endometrial cancer; it spared 46% of patients with a favourable profile from adjuvant treatment, and reduces both overtreatment and undertreatment. FUNDING:KWF Dutch Cancer Society.
The Norton scale (NS) is a widely used instrument to estimate the risk for pressure ulcers in adult, hospitalized patients. Lower NS scores, with the cut-off less than 15, indicate higher risk for pressure ulcer development. The NS assesses 5 domains: mental condition, physical condition, mobility, activity in daily living and incontinence. However, its discriminatory power to predict pressure ulcers is rather low. Since the NS reflects the patients' daily functioning it might be an independent risk factor of outcome of patients in the Intensive Care Unit (ICU), apart from the severity of acute critical illness scores. We therefore performed a single center retrospective study in critically ill patients who were admitted to a tertiary intensive care unit in 2021. NS scores and patients' characteristics and outcomes were collected from computerized databases. The primary outcome was 90-day mortality. Of the 2271 patients who were admitted to the ICU in 2021, 1889 patients were included, of which the NS was measured upon admission (83%). In this cohort, the mean age was 64 years, the Apache III score 59 and the Charlson Comorbidity index 4.4. Increased risk for pressure ulcers (NS <= 14) was detected in 9.7% of patients. Patients with a NS <= 14 were older, more severely ill upon admission and had more comorbidities. The 90-day mortality was 32% in the NS <= 14 group and 11.6% in the NS of more than 14 group (p<0.0001). A reduction in one point in the NS score was inversely associated with a relative increase in mortality by 13%. Furthermore, when corrected for disease severity and comorbidity, NS <= 14 was still independently associated with lower survival (OR 0.47 (0,32-0,70). NS may be an independent prognostic marker for mortality in critically ill patients and could be used in prognostication for critically ill patients. These findings need to be confirmed in prospective, multicentric observational studies.
