ALCAPA and CAF as Congenital Coronary Artery Anomalies in Two Children: Two case reports

INTRODUCTION

Congenital coronary artery anomalies (CCAAs) represent the second most common cause of sudden cardiac death among young athletes. Their clinical import relates mainly to the resultant probable myocardial ischemia. Many CCAAs have minimal impact on myocardial perfusion, and thus, patients may remain asymptomatic as is the case in congenital coronary artery fistula. However, other anomalies such as anomalous origin of the left coronary artery from the pulmonary artery may be symptomatic as they significantly affect blood flow to the heart muscle.

CASE PRESENTATION

We present two cases of surgical repair of ALCAPA in a 5-year-old girl, and right coronary artery fistula to the right ventricle in a 9-year-old boy.

DISCUSSION

CCAA are anomalies that can be asymptomatic or symptomatic. Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA) often requires prompt surgical intervention, even if asymptomatic, with the preferred method of reimplantation of the anomalous left coronary artery (LCA) into the aorta. This significantly improves heart function. Coronary artery fistula (CAF) is a rare congenital defect that often originates from the right coronary artery (RCA) and predominantly drains into the right heart structures. Most CAFs in asymptomatic children can be left untreated, but some recommend early closure to avoid severe complications.

CONCLUSION

CCAAs are rare congenital heart defects, but early diagnosis and surgical intervention are critical in cases like ALCAPA to prevent serious outcomes. Surgical repair of isolated CAF can also lead to excellent outcomes.

Phosphotungstic Acid Staining to Visualize the Vagus Nerve Perineurium Using Micro-CT

BACKGROUND AND PURPOSE

Peripheral nerve stimulation is approved by the US Food and Drug Administration for treating various disorders, but it is often limited by side effects, highlighting the need for a clear understanding of fascicular and fiber organization to design selective therapies. Micro-CT imaging of contrast-stained nerves enables the visualization of tissue microstructures, such as the fascicular perineurium and vasculature. In this work, we evaluated phosphotungstic acid (PTA) as a contrast agent and assessed its compatibility with downstream histology.

METHODS

Human vagus nerve samples were collected from three embalmed cadavers and subjected to three different staining methods, followed by micro-CT imaging: Lugol's iodine, osmium tetroxide, and PTA. Contrast ratios of adjacent tissue microstructures (perineurium, interfascicular epineurium, and fascicle) were quantified for each stain and compared. We further developed a pipeline to optimize micro-CT scan acquisition parameters based on objective metrics for sharpness, noise, and pixel saturation. The PTA-stained samples underwent subsequent histological processing and staining with hematoxylin and eosin, Masson's trichrome, and immunohistochemistry and were assessed for tissue degradation.

RESULTS

PTA enhanced the visualization of perineurium, providing high contrast ratios compared to iodine and osmium tetroxide. Optimized scanning parameters for PTA-stained nerves (55 kV and 109 µA) effectively balanced noise and sharpness. While we found that PTA is generally nondestructive for downstream histology, higher concentrations and longer exposure could alter the optical density of nuclei and affect stain differentiation in special stains.

CONCLUSION

PTA serves as a valuable micro-CT contrast agent for nerve imaging, effective in visualizing the perineurium with minimal impact on histological integrity.

Terahertz scanning near-field optical microscopy for biomedical detection: Recent advances, challenges, and future perspectives

Terahertz (THz) radiation is widely recognized as a non-destructive, label-free, and highly- sensitive tool for biomedical detections. Nevertheless, its application in precision biomedical fields faces challenges due to poor spatial resolution caused by intrinsically long wavelength characteristics. THz scanning near-field optical microscopy (THz-SNOM), which surpasses the Rayleigh criterion, offers micrometer and nanometer-scale spatial resolution, making it possible to perform precise bioinspection with THz imaging. THz-SNOM is attracting considerable attention for its potential in advanced biomedical research and diagnosis. Currently, its family typically includes four members based on distinct principles, which are suitable for different biological applications. This review provides an overview of the principles of these THz-SNOM modalities, outlines their various applications, identifies the obstacles hindering their performance, and envisions their future development.

Prevalence of anomalies and variants of coronary arteries: A single center study by coronary CT angiography

PURPOSE

It has been demonstrated that the coronary artery anomalies (CAAs) are generally asymptomatic. However, some cases can cause severe life threatening events. As coronary computed tomography angiography (CCTA) has emerged as a non-invasive alternative to invasive coronary angiography for the evaluation of coronary anatomy, the prevalence of CAAs in CCTA may more closely reflect the true prevalence in the general population. So we aimed to review and determine the prevalence of CAAs and variants retrospectively in patients who underwent CCTA at our center.

METHODS

Reports of 1802 patients who underwent CCTA at the radiology department of our university hospital were traced for CAAs. At least two independent investigators reviewed the images, which were selected for further assessment prior to final classification.

RESULTS

One hundred and fifty two anomalies in 152 patients (8.44 %) were encountered. Origin of any coronary artery from the pulmonary trunk in 1 (0.06 %), origin of LMCA from right sinus in 1 (0.06 %), origin of right coronary artery (RCA) from left sinus in 5 (0.28 %), origin of left anterior descending artery (LAD) from right sinus in 2 (0.11 %), origin of circumflex branch (RCx) of LMCA from right sinus in 6 (0.33 %), origin of RCx from RCA in 4 (0.22 %), origin of any coronary artery from the ascending aorta in 2 (0.11 %), split RCA in 5 (0.28 %), RCx and left marginal artery from the first diagonal artery in 1 (0.06 %), myocardial bridging in 123 (6.83 %) and fistula in 2 (0.11 %) were detected as CAAs.

CONCLUSION

The prevalence of CAAs observed in this study was similar to the literature. CCTA can clearly visualize the anomalous origin, course and termination of the coronary artery.

Neurovascular crossing patterns between leash of Henry and deep branch of radial nerve: implications for neurointervention and diagnostic imaging

OBJECTIVE

To detail the neurovascular crossing patterns between the leash of Henry (LoH) and the deep branch of the radial nerve (DBRN) in supination and pronation of the forearm, using imaging methods with anatomic correlation.

MATERIALS AND METHODS

This cross-sectional study was performed ex vivo with HRUS and MRI with anatomic correlation on 6 samples and in vivo with HRUS with Doppler on 55 participants scanned bilaterally. The in vivo participants were enrolled over a 6-month period. The crossing patterns between the LoH and DBRN were assessed ex vivo and in vivo. Additional morphological features of the DBRN, LoH, and fat plane were assessed in vivo only. Biometric features of the participants were recorded. Statistical analyses were performed using Shapiro-Wilk, parametric and non-parametric tests.

RESULTS

The most common neurovascular crossing pattern was the ascending branch of the radial recurrent artery (RRAab) crossing below (ex vivo: 83.3%, in vivo: 85.3%) and the muscular branch crossing above (ex vivo: 100%, in vivo: 63.2% %) the DBRN. Both the deep and superficial surfaces of the DBRN exhibited an intimate relationship with the vessels of the LoH. A positive correlation between vessel diameter and anthropometric factors was observed. In addition, the muscular branch exhibited a significantly smaller diameter than the RRAab.

CONCLUSION

Our study detailed the relationship between the LoH and the DBRN and highlighted the high incidence of vessel crossing above the DBRN at the level of the muscular branch. Knowledge of neurovascular crossings is crucial for understanding neurovascular entrapment syndromes and planning interventional procedures to reduce vascular complications.

Trends and comparative outcomes between operative approaches for segmentectomy in lung cancer

BACKGROUND

Segmentectomy is increasingly performed for non-small cell lung cancer. However, comparative outcomes data among open, robotic-assisted, and video-assisted thoracoscopic approaches are limited.

METHODS

A retrospective cohort study of non-small cell lung cancer segmentectomy cases (2013-2021) from the Society of Thoracic Surgeons General Thoracic Surgery Database was performed. Baseline characteristics were balanced using inverse probability of treatment weighting and compared by operative approach. Volume trends, outcomes, and nodal upstaging were assessed.

RESULTS

Of 9927 patients who underwent segmentectomy, 84.8% underwent minimally invasive surgery, with robotic-assisted thoracoscopic surgery becoming the most common approach in 2019. Open segmentectomy is more likely to be performed at low-volume centers (P < .0001), whereas robotic-assisted thoracoscopic surgery is more likely to be performed at high-volume centers (P < .0001). Video-assisted thoracoscopic surgery had a higher open conversion rate than robotic-assisted thoracoscopic surgery (odds ratio, 11.8; CI, 7.01-21.6; P < .001). Minimally invasive surgery had less 30-day morbidity compared with open segmentectomy (video-assisted thoracoscopic surgery odds ratio, 0.71; 95% CI, 0.55-0.94; P = .013; robotic-assisted thoracoscopic surgery odds ratio, 0.59; CI, 0.43-0.81; P = .001). The number of nodes and stations harvested were highest for robotic-assisted thoracoscopic surgery; however, N1 upstaging was more likely in open compared with robotic-assisted thoracoscopic surgery (odds ratio, 0.63; CI, 0.45-0.89; P < .007) and video-assisted thoracoscopic surgery (odds ratio, 0.61; CI, 0.46-0.83; P = .001).

CONCLUSIONS

Segmentectomy volume has increased considerably, with robotic-assisted thoracoscopic surgery becoming the most common approach. Minimally invasive surgery has less major morbidity compared with open segmentectomy, with no difference between video-assisted thoracoscopic surgery and robotic-assisted thoracoscopic surgery. However, risk of open conversion is higher with video-assisted thoracoscopic surgery. Robotic-assisted thoracoscopic surgery had increased nodal harvest, whereas hilar nodal upstaging was highest with thoracotomy. This study reveals significant differences in outcomes exist between segmentectomy operative approach; the impact of approach on survival merits further investigation.

Laparoscopic Cecostomy Placement for Antegrade Enema Access in the Pediatric Population

AIM

Use of the appendix for an antegrade continence enema (ACE) is not always possible. Various methods exist for creating cecostomy tubes, including percutaneous, endoscopic, or surgical placement. We describe our laparoscopic cecostomy technique and review short- and long-term outcomes.

METHODS

Single institution retrospective review of children who underwent laparoscopic cecostomy placement from June 2016-June 2023. The cecum is secured to the abdominal wall with trans-fascial sutures and placement of an enterostomy button under direct vision. Half-volume flushes begin after 48 h; after two weeks, patients transition to full flushes. Demographic, intraoperative, and postoperative variables were analyzed.

RESULTS

Forty patients were included [24 (60 %) female; 31 (77.5 %) Caucasian]. Twenty-one (52.5 %) had myelomeningocele, 15 (37.5 %) had an anorectal malformation and 4 (10 %) had functional constipation. Twenty-five (62.5 %) underwent laparoscopic cecostomy placement alone, while 15 (37.5 %) had it performed with another procedure. Median operative time was 1.12 (IQR 0:93-1.45) hours for isolated cecostomy placement, with median post-operative stay of 2.0 days (2.2-3.1) days. Post-operatively, one patient had severe withholding, ultimately requiring a diverting ileostomy. No other 30-day complications (surgical site infection, tube removal) were identified. One patient required revision four months post-op due to inadvertent placement in the sigmoid. At one-year follow-up, 11/36 (30.6 %) children noted granulation tissue, and 11 (30.6 %) noted superficial leakage. Two (6 %) patients had transitioned to oral laxatives.

CONCLUSION

Laparoscopic cecostomy tube placement is a safe and alternative method of developing ACE access that can be done concurrently with other procedures.

Differentiation of bacterial orbital cellulitis and diffuse non-specific orbital inflammation on magnetic resonance imaging

PURPOSE

To examine the radiological differences between bacterial orbital cellulitis (OC) and diffuse non-specific orbital inflammation (DNSOI) on magnetic resonance imaging (MRI).

METHODS

Retrospective study of patients with OC and DNSOI with an MRI orbital scan. Localised orbital inflammation (e.g., idiopathic dacryoadenitis and myositis), quiescent orbital inflammation and pre-septal cellulitis were excluded.

RESULTS

Thirty-two patients presenting between 2008 and 2023, including twenty-one OC patients (mean age: 42.5 ± 24.9 years old, male: 6), and eleven DNSOI patients (mean age: 52.3 ± 17.8 years old, male: 16). Both OC and DNSOI demonstrate orbital fat contrast-enhancement. However, whilst OC demonstrated a hyperintense T2 signal (P < 0.001), variable signal was observed in DNSOI, with a hypointense T2 signal more suggestive of DNSOI (P = 0.012). When the lacrimal glands were involved, indistinct margins were more likely in OC (P < 0.001), whilst gross enlargement and contrast-enhancement was observed in DNSOI (P = 0.032 and 0.017, respectively). Peripheral contrast-enhancement of the extraocular muscle (EOM) (P = 0.002) was more common in OC, whilst DNSOI demonstrated variable contrast-enhancement throughout the affected EOM (P < 0.001). The presence of contralateral abnormalities, such as lacrimal gland enlargement and EOM involvement, are more suggestive of DNSOI.

CONCLUSION

Several MRI features, beyond overt sinogenic disease, may help to differentiate OC from DNSOI, including the orbital fat signal intensity, EOM and/or lacrimal gland involvement, and contralateral orbital abnormalities. However, these features may not be specific, and thus highlights the ongoing radiological dilemma clinicians are faced when tasked with differentiating between infectious and non-infectious orbital inflammatory disease.

Efficacy of ultrasound in the evaluation of iliac vein stenting

Objectives: The current study evaluated the efficacy of iliac and IVC ultrasound alone for follow-up evaluation of iliac vein stents in patients with pelvic venous disorders or iliac occlusion from chronic deep vein thrombosis. Methods: A retrospective single site cohort study was conducted by evaluating the most recent 100 iliac vein and inferior vena cava ultrasounds in patients who had undergone iliac vein stenting. Inclusion criteria included a history of iliac vein stent placement. Exclusion criteria included patients under 18-years-old, duplicates of the same patient, and pregnancy at the time of ultrasound. The degree of visualization for color flow, gray scale, and phasicity were determined and classified into the following categories: complete, partial, or none. In addition, each chart was assessed for external compression, in-stent narrowing, and requirements for further imaging. Results: Of the 100 iliac vein and IVC ultrasounds assessed in this review, 99 of the ultrasounds were sufficient for evaluation during follow-up visits without requiring further investigation. Within this study cohort, the average follow-up time was 22 months. The average participant body mass index was 27.6. One iliac vein and IVC ultrasound was considered inadequate for follow-up evaluation and required further imaging. Conclusion: The use of iliac and IVC venous doppler ultrasound alone in the follow-up evaluation of iliac stent patency is effective and noninvasive and avoids unnecessary radiation exposure and cost.

Deep learning-based intratumoral and peritumoral features for differentiating ocular adnexal lymphoma and idiopathic orbital inflammation

OBJECTIVES

To evaluate the value of deep-learning-based intratumoral and peritumoral features for differentiating ocular adnexal lymphoma (OAL) and idiopathic orbital inflammation (IOI).

METHODS

Nighty-seven patients with histopathologically confirmed OAL (n = 43) and IOI (n = 54) were randomly divided into training (n = 79) and test (n = 18) groups. DL-based intratumoral and peritumoral features were extracted to characterize the differences in heterogeneity and tissue invasion between different lesions, respectively. Subsequently, an attention-based fusion model was employed to fuse the features extracted from intra- and peritumoral regions and multiple MR sequences. A comprehensive comparison was conducted among different methods for extracting intratumoral, peritumoral, and fused features. Area under the curve (AUC) was used to evaluate the performance under a 10-fold cross-validation and independent test. Chi-square and student's t-test were used to compare discrete and continuous variables, respectively.

RESULTS

Fused intra-peritumoral features achieved AUC values of 0.870-0.930 and 0.849-0.924 on individual MR sequences in the validation and test sets, respectively. This was significantly higher than those using intratumoral features (p < 0.05), but not significantly different than those using peritumoral features (p > 0.05). By combining multiple MR sequences, AUC values of the intra-peritumoral features were boosted to 0.943 and 0.940, higher than those obtained from each sequence alone. Moreover, intra-peritumoral features yielded higher AUC values compared to entire orbital cone features extracted by either the intra- or the peritumoral DL model, although no significant difference was found from the latter (p > 0.05).

CONCLUSION

DL-based intratumoral, peritumoral, and especially fused intra-peritumoral features may help differentiate between OAL and IOI.

KEY POINTS

Question What is the diagnostic value of the peritumoral region and its combination with the intratumoral region for radiomic analysis of orbital lymphoproliferative disorders? Findings Fused intra- and peritumoral features achieved significantly higher performance than intratumoral features, but had no significant difference to the peritumoral features. Clinical relevance Peritumoral contextual features, which characterize the invasion patterns of orbital lesions within the surrounding areas of the entire orbital cone, might serve as an independent imaging marker for differentiating between OAL and IOI.

Role of Cardiovascular MR Imaging and MR Angiography in Patients with Pulmonary Vascular Disease

Cardiac MR imaging and pulmonary MR angiography (MRA) are important clinical tools for the assessment of pulmonary vascular diseases. There are evolving noncontrast and contrast-enhanced techniques to evaluate pulmonary vasculature. Pulmonary MRA is a feasible imaging alternative to CTA in pulmonary embolism detection. Perfusion MR imaging and cardiac MR imaging help diagnose and monitor the treatment response of chronic thromboembolic pulmonary hypertension. Cardiac MR imaging is pivotal in assessing the potential underlying etiology and impact of pulmonary hypertension on the heart. Multiphasic acquisitions and dynamic phase imaging are unique to pulmonary MRA, which aid in diagnosing many pulmonary vascular diseases, including shunts and masses.

Comparison of five preservation methods for fascia allograft

IMPORTANCE

Research on tissue preservation, including cortical bone, skin, nerves, and vessels in glycerol and cortical bone in honey, has shown positive results. On the other hand, relatively few studies have been performed on fascia preservation, and comparisons between different fascia preservation methods remain scarce.

OBJECTIVE

This in vitro study compared the biomechanical properties of five different methods of preserving fascia lata.

METHODS

The control group underwent biomechanical testing immediately after decellularization, while the other five groups were stored in glycerol, honey, deep freezer, lyophilizer, and liquid nitrogen for 30 days. The ultimate load, elongation at failure, and stiffness for each group were determined from a load-elongation curve.

RESULTS

A comparison of the ultimate load showed that the control group had the highest value, followed by the glycerol group. The glycerol group was the only group that did not show a significant difference from the control group, while all the other groups showed a significantly lower ultimate load. A comparison of elongation at failure revealed the glycerol group to have the highest value at failure among all groups and was significantly higher than the deep freeze, honey, and cryopreservation groups.

CONCLUSIONS AND RELEVANCE

Glycerol can be used as an effective method for preserving fascia allografts because the resulting allografts show a similar ultimate load to the control group and the highest mean elongation at failure.

Shear wave elastosonography applied to synovitis: A preliminary study

AIM

This study aims to evaluate the utility of shear wave elastography (SWE) in identifying synovitis in patients with a history of arthritis within the diagnosis of a defined rheumatological disease.

MATERIALS AND METHODS

We performed B-mode and SWE (ultrasound) on 58 participants divided into two groups: group 1 included 29 patients with confirmed active wrist and/or hand synovitis; group 2 included 29 healthy volunteers without suspicion of synovitis. In a subset of patients (n=8), joint counts and disease evaluations were performed during the elastography to study the correlation between clinical and radiological findings.

RESULTS

The mean maximum kPa value and the average joint kPa value were significantly different between cases and controls: maximum kPa value for cases was 38.14±35.08kPa, while for controls it was 4.72±5.93kPa; average joint value for cases was 29.77±26.07kPa, while for controls it was 4.17±5.22. The most frequent location for joint effusion in both, cases and controls, was the dorsal radiocarpal joint: 41.4% of controls had a mean kPa value of 7.66±5.39kPa, while 58.6% of cases had a mean kPa value of 40.61±40.76kPa (p-value 0.004). kPa values correlated with disease activity measurements in the 8 patients clinically evaluated at the moment of the SWE.

CONCLUSIONS

SWE is a promising technique that may have a role in the diagnosis and assessment of synovial inflammatory activity in arthritis.

Radiographers' knowledge, clinical expertise and application of pain management strategies in the radiology department: Results from a qualitative focus group

BACKGROUND

Radiographers are frequently involved in imaging patients in pain thus requiring a heightened awareness and focus on this crucial issue.

PURPOSE

To explore the challenges radiographers encounter when imaging patients in pain and to identify strategies that could be implemented to improve overall patient-centered care.

METHODS

A qualitative research study with a single focus group (FG) was conducted using six radiographers working within Irish hospitals. The research questions focused on pain management challenges in the radiology department, particularly identifying radiographers' current practices and strategies to address these challenges. The FG was moderated and video-recorded to facilitate comprehensive analysis. The audio obtained from the FG was transcribed and then analyzed thematically.

RESULTS

Data from the FG identified four main themes: 1) consequences of pain management, 2) communication, 3) professional experience, and 4) barriers. In addition, the study highlighted the absence of current protocols, policies, and guidelines in practice for the effective management of challenges associated with imaging patients in pain within the radiology department.

CONCLUSION

The primary challenges identified include the stress experienced by both staff and patients, the potential for obtaining suboptimal images, concerns regarding patient safety, and adverse effects on image quality. This study elucidates the manner in which patient discomfort adversely impacts the imaging process and delineates the potential implications for radiographers aiming to achieve optimal image quality. At present, there are no established policies or procedures within the radiology department to direct the imaging of patients in pain.

The role of ultrasound imaging of temporomandibular joint condyle-disc complex disorders

OBJECTIVE

This study aimed to determine the diagnostic value of ultrasonography (US) in internal derangements of temporomandibular joint (TMJ) and to compare its efficacy with magnetic resonance imaging (MRI).

METHODS

Fifty patients with MRI indications due to a TMJ disorder were enrolled. Findings of the clinical examination, US examination and MRI examination were noted by seperate clinicians and the sensitivity, specificity and diagnostic accuracies of all examinations were compared.

RESULTS

When compared with MRI, the sensitivity, specificity and diagnostic accuracy of the clinical examination for the internal derangements were 73%, 37%, and 70%, respectively and 75.7%, 33.3% and 73.0% for US examination, respectively.

CONCLUSION

US can be considered as an alternative to MRI as it can be used to detect the disc position, internal derangements, intraarticular fluid accumulations and superficial condyle changes with minimally better results than clinical examination.

Size-specific dose estimates calculated using patient size measurements from scanned projection radiograph in high-resolution chest computed tomography

INTRODUCTION

Size-specific dose estimates (SSDE) are used to assess patient-specific radiation exposure in Computed Tomography (CT), complementing the volume CT dose index (CTDIvol). This study compared SSDE calculated using patient's lateral size from scan projection radiograph (SPR) with SSDE calculated using water equivalent diameter (Dw) from tomographic images in adult chest high-resolution CT (HRCT).

METHODS

In a single-centre study, the CTDIvol and dose-length product (DLP) were recorded from HRCT dose reports of adult patients. Lateral width (SLat), at the centre of the scan range, from the SPR was measured and the SSDE (SSDER) was calculated using conversion factors related to SLat. Average CT number, area of the slice, and lateral size of the patient (AxLat) were measured on the middle slice. The Dw and SSDE from Dw (SSDEW) were calculated. SSDER and SSDEW were compared using Wilcoxon signed rank test. Correlation between patient size and dosimetry parameters were investigated using Spearman Correlation test with statistical significance at P < 0.05. Bland-Altman plot was also used to test agreement between the two SSDE values.

RESULTS

Median CTDIvol, DLP, SSDER and SSDEW were 11.0 mGy, 372 mGy.cm, 11.6 mGy and 12.9 mGy, respectively. Small but statistically significant differences (P < 0.03) were found between SLat and AxLat as well as between SSDER and SSDEW. Bland-Altman analysis resulted in borderline agreement between SSDE values. Moderate correlations were observed between dosimetry quantities and patient size measurements (ρ > 0.640; P < 0.001). SSDEw showed statistically significant correlation (ρ = 0.587 and P < 0.001) with SSDER.

CONCLUSION

SSDER may be used to assess patients' absorbed radiation dose, before the scan, in adult chest HRCT. The median value of SSDER was about 10% lower than the median value SSDEW. However, the SSDEW should be used after the scan to establish effective dose and radiation risk to the patient.

The autonomic response following taVNS predicts changes in level of consciousness in DoC patients

Advancements in emergency medicine and critical care have significantly improved survival rates for patients with severe acquired brain injuries(sABI), subsequently increasing the prevalence of disorders of consciousness (DoC) such as Unresponsive Wakefulness Syndrome (UWS) and Minimally Conscious State (MCS). However, the assessment of conscious states relies on the observation of behavioral responses, the interpretation of which may vary from evaluator to evaluator, as well as the high rate of misdiagnosis, which together pose significant challenges for clinical diagnosis. The study investigates the utility of transcutaneous auricular vagus nerve stimulation (taVNS) in modulating autonomic responses, as evidenced through heart rate variability (HRV), for distinguishing between healthy individuals and DoC patients and for prognosticating patient outcomes. A prospective randomized clinical trial was conducted from Februry 9, 2022, to February 4, 2024, at Hangzhou Armed Police Hospital in China. Healthy controls (HC) and DoC patients were enrolled in this study. The taVNS was administered to each subject for ten minutes. There electrocardiogram (ECG) signals were recorded for the analysis of HRV both during the stimulation and the ten minutes of rest that preceded and followed the stimulation. Subsequent investigations utilized Support Vector Machine (SVM) modeling, enhanced by a Radial Basis Function (RBF) kernel, to explore potential predictors of patient outcomes. This approach aimed to differentiate HC from DoC and MCS from UWS patients. 26 HC and 36 patients diagnosed with DoC were included in the analysis,. The DoC group consisted of 17 patients with a diagnosis of MCS and 19 with diagnosis of UWS/VS. Significant modulations in HRV parameters (HF, VLF, SampEn) were observed, indicating variations in autonomic response between the control group and DoC patients. Using the VLF, LF, and SampEn features in SVM model, DoC and HC were correctly classified with an accuracy of 86%. Similarly, MCS and UWS were classified with an accuracy of 78%. The SVM modeling achieved an 86% accuracy rate in predicting outcomes three months post-intervention, with a 71% confirmation rate at six months.The results highlight taVNS's potential as a therapeutic modality in managing DoC by demonstrating its impact on autonomic regulation and suggesting pathways for enhancing recovery, which accentuates the significance of exploring brain-heart dynamics in DoC, presenting a novel approach to therapeutic strategies. Trial Registration Information: URL: chictr.org.cn; Unique identifier: ChiCTR2100045161. Date of the first registration: 9th/ April/ 2021.

Diffusion weighted MRI and neutrophil lymphocyte ratio non-invasively predict infection in pancreatic necrosis: a pilot study

BACKGROUND

Infected pancreatic necrosis (IPN) is a major determinant of mortality in acute pancreatitis (AP). Non-invasive diagnosis of IPN could guide the intervention in AP. We aimed to investigate the role of non-invasive methods like diffusion weighted magnetic resonance imaging (DW-MRI) and clinico-laboratory parameters as predictors of IPN.

METHODS

Prospective evaluation for predictors of IPN by diffusion restriction (DR) on DW-MRI and clinico-laboratory parameters was performed.

RESULTS

Out of 39 patients included, 31 were analysed after exclusion. Twenty-six (83.8%) patients had moderately severe AP, and the rest had severe disease. They were categorized into Group A: patients with documented infection after intervention (n = 17) and Group B: successfully managed without intervention or negative culture after intervention (n = 14). On univariate analysis, Group A had significantly more incidence of fever (P = 0.020), persistent unwellness (P = 0.003), elevated neutrophil count (P = 0.007), lymphocyte count (P = 0.007), neutrophil lymphocyte ratio (NLR) (P = 0.028), DR on DW-MRI (P = 0.001) and low apparent diffusion coefficient (ADC) (P = 0.086). Multivariate analysis revealed DR on DW-MRI (P = 0.004) and NLR (P = 0.035) as significant predictors of IPN, among other factors. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DW-MRI were 94.1%, 78.6%, 91.66%, and 84.21%, respectively. The area under curve of NLR on the ROC plot was 0.85 and the best cutoff was >3.5, with sensitivity, specificity, PPV, and NPV of 70.6%, 78.6%, 80%, and 68.7% respectively.

CONCLUSION

DW-MRI and NLR are promising non-invasive tools for accurate prediction of IPN and hence can guide the need for intervention in acute pancreatitis.

Which Endpoints Should be Applied in Interventional Trials? -: From Single Uni-dimensional Assessment Tailored to a Drug's Mechanism of Action to Multi-Component Measures and Multi-Domain Composites

Objective

A vast array of structural/imaging and clinical endpoints/outcomes are available today to osteoarthritis epidemiologists or trialists. Which assessments are best suited for which studies remains unsettled. When several assessments are available, these may be analyzed together (simultaneously or hierarchically), using statistical modeling and adjustment. Or, alternatively, they may be combined to form more complex multi-component or composite (potentially multi-domain) endpoints/outcomes. This review describes such concepts and their challenges, using examples from current osteoarthritis imaging research.

Design

A narrative, non-systematic literature search (PubMed and others) was conducted, and informal consultations were held with experts in the field. The identified concepts and experimental findings were then organized to present an integrated framework.

Results

Single imaging assessments can encompass one (uni-dimensional) or more (multi-dimensional) structures. Integration of image assessments of one structure/tissue across anatomical locations provides aggregate measures. This can also be created across heterogeneous (multi-dimensional) types of assessments (multi-component/composite), either within an area (such as imaging - single domain) or across broader areas of health and well-being (multi-domain). Weighting, standardization, and (clinical) usefulness are crucial characteristics of multi-component/composite endpoints. Examples of these concepts are here provided in the context of osteoarthritis imaging.

Conclusions

Options for multi-component/composite endpoints in osteoarthritis research are virtually infinite. Smart research strategies are required to explore and validate these vast possibilities, with appropriate statistical treatment being paramount. A one-size/endpoint-fits-all approach will likely fail in observational and interventional studies. Imaging assessment needs to be tailored to both the drug's unique mechanism of action, and to the participants' morpho-type.

Preparation of nano(micro)particles from Cotinus coggygria scop. Extracts and investigation of their antimicrobial effects in vivo Caenorhabditis elegans model

Cotinus coggygria Scop. (Anacardiaceae) is traditionally used in Türkiye for wound and burn treatment. A series of nano/micro-sized polymeric particles were prepared from aqueous and ethanol extracts of Cotinus coggygria leaves by reverse micellar microemulsion polymerization. Optimization studies were conducted with the effect of the solvent/surfactant, crosslinker, and extract components and their amount. Thermal Gravimetric Analysis, Fourier Transform Infrared Spectroscopy, Scanning Electron Microscopy, and Zeta Potential measurement were conducted. In vitro antimicrobial microdilution method was utilized with minor modifications against Staphylococcus aureus ATCC 6538. Polymeric particles' toxicity and in vivo antimicrobial effect were evaluated on the life span Caenorhabditis elegans assay and C. elegans-S. aureus infection model, respectively. Synthesized microparticles (GS04) in vitro antimicrobial activity was investigated against S. aureus ATCC 6538. GS04 (Minimum Inhibitory Concentration = 62.5 μg/mL) microparticle was more effective against S. aureus, demonstrating no nematode survival changes at 500, 250, 125, 62.5, 31.25, and 15.625 μg/mL concentrations, achieving anti-infective effect at 250-15.625 μg/mL for GS04. Nanoparticles did not affect the colonization of S. aureus in the nematode model system. Therefore, concentrations of the selectively nontoxic anti-infective effect of synthesized nanoparticles from C. coggygria were identified for the first time against S. aureus ATCC 6538.

Exploring communication gaps and parental needs during paediatric CT scan risk-benefit dialogue in resource-constrained facilities

BACKGROUND

Clear communication during informed consent is crucial in paediatric computed tomography (CT) procedures, particularly in resource-constrained settings. CT offers valuable diagnostic information but carries potential radiation risks, especially for paediatric patients. Parents play a critical role in decision-making, necessitating thorough risk-benefit discussions. This study aimed to explore parental experiences regarding risk-benefit communication during their children's CT scans in under-resourced healthcare facilities.

METHODS

A qualitative approach with a descriptive design was employed. Semi-structured interviews were conducted with 13 purposefully selected and consenting parents accompanying paediatric patients for CT scans at two public hospitals. Data were analysed using Tesch's eight-step method and ATLAS.ti software.

RESULTS

Participants were parents of children aged 0-10 years (8 males, 5 females), with 11 making their first visit to the CT department. Three main themes emerged: (1) Compromised consenting process, characterised by inadequate explanation of consent and limited risk-benefit communication; (2) Procedural information deficiency, including minimal communication about the procedure and lack of information on examination results; and (3) Preference for improved communication, with parents expressing a desire for comprehensive information and varied opinions on who should disseminate this information. Parents reported feeling uninformed, anxious, and unable to make well-informed decisions due to communication gaps.

CONCLUSIONS

Significant improvements are needed in risk-benefit communication during paediatric CT scans. Healthcare providers should use simplified language, visual aids, and patient-centred discussions to enhance understanding and reduce parental anxiety. Radiographers should allocate sufficient time for discussions, involve referring physicians when necessary, and document the informed consent process thoroughly. Addressing these issues can improve patient experiences and contribute to positive health outcomes in resource-constrained settings.

Intra- and inter-session reliability and repeatability of 1H magnetic resonance spectroscopy for determining total creatine concentrations in multiple brain regions

Using proton magnetic resonance spectroscopy (1H MRS) to determine total creatine (tCr) concentrations will become increasingly prevalent, as the role of creatine (Cr) in supporting brain health gains interest. Methodological limitations and margins of error in repeated 1H MRS, which often surpass reported effects of supplementation, permeate existing literature. We examined the intra- and inter-session reliability and repeatability of 1H MRS for determining tCr concentrations across multiple brain regions (midbrain, visual cortex and frontal cortex). Eighteen healthy adults aged 20-32 years were recruited (50% female; n = 14 intra-session; n = 15 inter-session). 1H Magnetic resonance imaging and spectroscopy were completed at 3 T. Intra-session analyses involved repeated 1H MRS of the midbrain, visual cortex and frontal cortex without participant or voxel repositioning, whereas inter-session analyses involved measurements of the same regions, but with participant and voxel repositioning between repeated measurements. The 1H MRS data (174 spectra) were analysed using TARQUIN and OSPREY, and voxel fractions (grey/white matter and CSF) were determined using segmentation. Our findings show that tCr concentrations can be determined reliably and repeatably using 1H MRS, within an error of <2%, and that large inter-regional differences in tCr concentration are present in the human brain. We provide new minimum detectable change data for tCr concentrations, a detailed discussion of the inherent error sources in repeated 1H MRS, including the substantial effect of the analysis package on tCr quantification, and suggestions for how these should be managed to improve the interpretability and clinical value of future research. More studies are needed to determine whether our findings can be replicated in other centres and different populations.

Unusual Presentation of Obstructive Atherosclerotic Coronary Artery Disease With Chronic, Persistent Neck and Shoulder Pain: A Case Report

Ischaemic chest pain or its equivalents are acute-onset in acute coronary syndrome (ACS) and chronic, episodic, and transient in chronic coronary syndrome (CCS). A 56-year-old Caucasian male with a history of premature atherosclerotic coronary artery disease (CAD) presented to secondary care with recurrent presyncope and syncope. He reported a year-long history of persistent left-sided neck and shoulder dull ache/tightness, unrelated to exertion and fluctuating unpredictably. His primary care had diagnosed the pain as musculoskeletal, attributing it to prior physical trauma. However, the pain did not respond to treatment. During his admission for suspected cardiac syncope, he experienced transient chest discomfort, transient inferior ST-segment elevation on electrocardiogram (ECG), and elevated troponin levels, indicating a non-ST-elevation myocardial infarction (NSTEMI). Coronary angiography revealed obstructive atherosclerotic two-vessel disease, with severe proximal stenosis in the right coronary artery (RCA) and moderate-to-severe stenosis in the left anterior descending artery (LAD). His chronic neck and shoulder pain resolved after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) placement in the RCA, confirming it was an anginal equivalent. Although the chronicity of this anginal equivalent may align it more with CCS than ACS, its unremitting nature is inconsistent with CCS. Our patient's history also showed that his ischaemic symptoms changed over time, from remote exertional dyspnoea to persistent neck and shoulder pain, and then to the chest discomfort that preceded his NSTEMI. Our case highlights the importance of heightened clinician awareness of atypical CAD presentations and symptom variability over time. Symptoms initially considered non-anginal should be reassessed for CAD, particularly when alternative treatments prove ineffective. Similar cases like ours, in the future, could prompt updates to CCS diagnostic guidelines to address atypical presentations with persistent pain.

Peripheral dose assessment in radiation therapy using photon beams: experimental results with optically stimulated luminescence dosimeter

The estimation of peripheral dose (PD) is vital in cancer patients with long life expectancy. Assessment of PD to radiosensitive organs is important to determine the possible risk of late effects. An attempt has been made to assess the peripheral dose using optically stimulated luminescence dosimeter (OSLD) with megavoltage photon beams as a function of field size, depth, energy, and distance from the field edge. The PD measurements were carried out at 13 locations starting from 1.5 cm to 20.8 cm from radiation field edge for three different field sizes at three different depths with 6 and 18 MV photon beams. In addition, the measurements were carried out to analyze the response in PD due to the presence of wedge. The %PD decreases gradually with an increase in distance from the radiation field edge. The %PD at surface for 10 × 10cm2 with 6MV photon beams was 6.77 ± 0.32% and 1.0 ± 0.04% at 1.5 cm and 20.8 cm away from field edge. For 20 × 20 cm2 field, %PD was found to be much higher at surface than at 5 cm depth for all distances from field edge. This study demonstrates the suitability of OSLD for PD assessment in megavoltage photon beams. The PD increases as field size increases, primarily due to greater amount of out-of-field scatter generated by larger surface area of the collimator defining the larger field size. An enhancement in PD was observed with wedge when the thick end was oriented towards the OSLDs. This study assessed PD that would be a risk factor of the normal tissue complication and secondary cancer induction.

Unusual Pulmonary Manifestation in a Child With Congenital Mitral Stenosis: A Case Report

Congenital mitral valve stenosis (MVS) in children is usually isolated. However, it is, in rare cases, associated with secondary pulmonary hemosiderosis. It is hypothesized that secondary pulmonary hemosiderosis results from chronic pulmonary venous congestion and repeated microvascular hemorrhage due to elevated left atrial pressure. We describe the case of a six-year-old child with congenital severe MVS who developed coexisting pulmonary hypertension and hemosiderosis. The child was successfully managed with surgical repair of MVS through papillary muscle splitting and commissurotomy. This case illustrates the rare association between MVS and pulmonary hemosiderosis in a child with easy fatiguability and heart failure symptoms.

Is 18 F-fluoride PET/CT an Accurate Tool to Diagnose Loosening After Total Joint Arthroplasty?

BACKGROUND

Several studies using positron emission tomography (PET) show highly elevated periprosthetic bone uptake of fluorine-18 sodium fluoride ( 18 F-fluoride), suggestive of implant loosening after arthroplasty. Focus so far has been on qualitative but not on quantitative assessment. There is also a lack of intraoperative confirmation of preoperative 18 F-fluoride PET findings. Although the method seems to have acceptable accuracy and high sensitivity, an attempt to improve the specificity and an overall validation of the method appear warranted.

QUESTIONS/PURPOSES

(1) Is there a difference in 18 F-fluoride uptake around loose versus well-fixed THA and TKA components? (2) Can 18 F-fluoride uptake measures provide a threshold that differentiates loose from well-fixed implants undergoing revision for a variety of septic and aseptic indications? (3) In a population restricted to THA and TKA undergoing revision for aseptic indications, can measurement of 18 F-fluoride uptake still distinguish loose from well-fixed components? (4) What is the interrater reliability of measuring 18 F-fluoride uptake?

METHODS

This was a retrospective assessment of a diagnostic test, 18 F-fluoride PET/CT, which was performed prior to revision surgery. We included 63 patients with 31 THAs and 32 TKAs. Sixty-five percent of patients were female, and the mean age at 18 F-fluoride PET/CT was 66 years. The THA had different modes of fixation (cemented, cementless, and hybrid; 45%, 32%, and 23%, respectively), whereas all TKAs were cemented. Imaging was conducted using routine protocols 1 hour after tracer injection. The interobserver reproducibility was analyzed using Spearman rank correlations and Bland-Altman analyses. Two independent observers were trained separately by a nuclear physician to measure maximal periprosthetic standardized uptake values (SUV max ) for each arthroplasty component (n = 126). Findings at surgery (whether the components were well fixed or loose, as well as the presence or absence of infection) were used as a reference. Presence of periprosthetic joint infection was retrospectively determined based on the criteria suggested by the European Bone and Joint Infection Society (EBJIS): clinical features in combination with blood analysis, synovial fluid cytologic analysis, and microbiology test results. Receiver operating characteristic (ROC) curves were plotted to assess the area under the curve (AUC) for each investigated component separately, indicating suitable SUV max thresholds that differentiate loose from well-fixed components. After excluding patients with confirmed or suspected PJI per the EBJIS criteria (n = 12), the above analysis was repeated for the remaining patients with aseptic loosening (n = 51).

RESULTS

We found higher 18 F-fluoride uptake around loose versus well-fixed components in all but femoral TKA components (median [range] SUV max for well-fixed versus loose THA cups 10 [7 to 30] versus 22 [6 to 64], difference of medians 12; p = 0.003; well-fixed versus loose TKA femoral components 14 [4 to 41] versus 19 [9 to 42], difference of medians 5; p = 0.38). We identified favorable ROC curves for all investigated components except femoral TKA components (THA cups AUC 0.81 [best threshold 13.9]; THA femoral stems AUC 0.9 [best threshold 17.3]; femoral TKA components AUC 0.6 [best threshold 14.3]; tibial TKA components AUC 0.83 [best threshold 15.8]). 18 F-fluoride was even more accurate at diagnosing loosening when we limited the population to those patients believed not to have prosthetic joint infection (THA cups AUC 0.87 [best threshold 14.2]; THA femoral stems AUC 0.93 [best threshold 15.0]; femoral TKA components AUC 0.65 [best threshold 15.8]; tibial TKA components AUC 0.86 [best threshold 14.7]). We found strong interrater correlation when assessing SUV max values, with Spearman ρ values ranging from 0.96 to 0.99 and Bland-Altman plots indicating excellent agreement between the two independent observers.

CONCLUSION

Measuring SUV max after 18 F-fluoride PET/CT is a useful adjunct in the diagnostic evaluation for suspected implant loosening after THA and TKA. The method appears to be both accurate and reliable in diagnosing implant loosening for all components except femoral TKA components. In a real-world mixed population with both low-grade infection and aseptic loosening, the method seems to be fairly easy to learn and helpful to subspecialized arthroplasty clinicians. When infection can be ruled out, the method probably performs even better. Further prospective studies are warranted to explore the reason why femoral TKA component loosening was more difficult to ascertain using this novel technique.

LEVEL OF EVIDENCE

Level III, diagnostic study.

A Comparative Evaluation of Radiographic and Computed Tomography Results in Patients With Lower Respiratory Tract Infections With Positive and Negative Sputum Cultures: A Retrospective Observational Study

BACKGROUND AND AIM

There is limited data on the correlation between findings of lower respiratory tract infections detected by chest computed tomography but not by chest radiography and sputum culture results. The aim of this study is to evaluate the relationship among sputum culture results, chest radiographic findings and computed tomography outcomes in patients diagnosed with lower respiratory tract infections.

MATERIALS AND METHODS

Between January 2021 and September 2023, the clinical and radiological findings of patients diagnosed with lower respiratory tract infections, both those with and without positive sputum cultures, were retrospectively evaluated.

RESULTS

In the studied cohort, 65.4% (n = 172) of the patients were male and 34.6% (n = 91) were female, with an overall mean age of 67.18 ± 13.77 years. On chest computed tomography, consolidation was observed in 39.53% (n = 34) of patients with positive sputum cultures, compared to 23.72% (n = 42) of patients with negative cultures (p = 0,005). Furthermore, necrotising pneumonia findings were noted in 5.81% (n = 5) of culture-positive patients and 1.13% (n = 2) of culture-negative patients (p = 0.034). Infiltrative changes were detected in 81.4% (n = 70) of patients with positive cultures and 66.6% (n = 118) of patients with negative cultures on chest radiography (χ2 = 20,492; p < 0.001).

CONCLUSION

The identification of findings on chest radiography is notably challenging in patients diagnosed with lower respiratory tract infections due to the presence of non-consolidative infiltrates and their respective anatomical locations. Moreover, the probability of detecting radiological findings on chest radiographs is enhanced in patients exhibiting positive sputum cultures.

High-Resolution US vs MR Neurography for Diagnosis of Upper Extremity Peripheral Nerve Disorders

"Just Accepted" papers have undergone full peer review and have been accepted for publication in Radiology. This article will undergo copyediting, layout, and proof review before it is published in its final version. Please note that during production of the final copyedited article, errors may be discovered which could affect the content. Background High-resolution imaging methods contribute important pathomorphological information in diagnosing peripheral nerve disorders, but their diagnostic roles remain unclear due to limited clinical evidence. Purpose To investigate the diagnostic performance of high-resolution nerve US (HRUS) and MR neurography (MRN). Materials and Methods This prospective observational, single-center cohort study included 800 patients referred for clinically suspected peripheral neuropathy of the upper extremity from November 2015 to February 2022. All patients underwent both HRUS and MRN, performed and interpreted independently by experienced neuroradiologists. Accuracy, sensitivity, and specificity of HRUS and MRN in diagnosing peripheral neuropathy correctly were calculated in reference to the final diagnosis, based on compound results of clinical, electrophysiological, imaging, and surgical/histopathological findings and compared by means of the McNemar's test and X2-Testing. Results In total 800 patients (431 male, 369 female; mean age 47.8 ± 16.5 years) were included. Overall, MRN provided higher accuracy (85.4% [95%CI: 82.7%, 87.8%] vs. 70.6% [95%CI: 67.3%, 73.8%], P<.001) and sensitivity (91.6% [95%CI: 89.1%,93.7%] vs. 68.7% [95%CI: 64.8%,72.3%], P<.001), while HRUS achieved higher specificity (76.0% [95%CI: 69.4%,81.9%] vs. 66.2% [95%CI: 59.1%,72.8%], P<.001) for diagnosing peripheral neuropathy correctly. Conclusion For diagnosing peripheral neuropathies of the upper extremity, MRN achieved higher accuracy and sensitivity while HRUS achieved higher specificity. See also the editorial by Deshmukh in this issue.

Evaluation of an updated pencil beam algorithm for enhanced dosimetric accuracy in stereotactic radiotherapy

INTRODUCTION

This study evaluates enhancements introduced in version 4.0 of Brainlab's Pencil Beam algorithm within the Elements treatment planning system (TPS) for radiotherapy dose calculations. These updates include a new scatter model to improve dose calculation accuracy and updated commissioning recommendations involving asynchronous sweeping gap (a-SG) measurements to refine multileaf collimator (MLC) parameters such as dynamic leaf shift (DLS) and tongue-and-groove (TG) size.

MATERIALS AND METHODS

The original (version 3.0) and updated (version 4.0) implementations of the Pencil Beam algorithm were compared using a Varian TrueBeam STx accelerator with 6-MV flattening filter-free energy and high-definition MLC. Dosimetric accuracy was assessed through phantom-based point dose and volumetric measurements for clinical cases, including treatments for single and multiple brain metastases with volumetric modulated arc therapy (VMAT) and dynamic conformal arcs (DCA).

RESULTS

The updated algorithm demonstrated superior performance compared to the original version. Point dose measurements showed a reduction in discrepancies between calculated and measured doses, with improvements of up to 2.1 % for smaller targets. Volumetric measurements revealed increased gamma pass rates, with improvements of up to 15.9 % at a 95 % dose threshold in VMAT and DCA treatments.

CONCLUSION

These findings highlight advancements in dose calculation accuracy, particularly for small fields and multiple targets. These improvements of the Pencil Beam algorithm, driven by the scatter model and enhanced MLC parameter commissioning, contribute to more reliable dose predictions. As findings are specific to the 6-MV FFF beam and TrueBeam STx system, further investigations are needed for other energies and linear accelerators.

A Rare Case of Spontaneous Elbow Osteomyelitis Presenting With Aseptic Effusion

Spontaneous osteomyelitis of the capitellum is an exceptionally rare condition, particularly in the absence of identifiable risk factors or inciting events. This case report describes a previously healthy 20-year-old male who presented with progressive elbow pain and swelling, initially raising suspicion for septic arthritis. Point-of-care ultrasound (POCUS) identified a significant joint effusion, and subsequent arthrocentesis revealed purulent fluid with a high white blood cell count, strongly suggestive of a septic joint. The patient was treated empirically with antibiotics and underwent surgical debridement, but cultures from both the arthrocentesis and the surgical washout were negative. Further imaging with MRI ultimately revealed findings consistent with osteomyelitis of the capitellum. This case highlights the diagnostic challenges associated with musculoskeletal infections, particularly in atypical sites like the capitellum, and underscores the importance of advanced imaging modalities such as MRI when initial diagnostics are inconclusive. The report also emphasizes the utility of POCUS in identifying joint effusions and guiding arthrocentesis in the emergency setting. Early recognition and appropriate management of osteomyelitis are crucial to avoid serious complications such as chronic infection, joint dysfunction, or limb deformity. This case contributes to the limited literature on capitellum osteomyelitis, particularly in the setting of an aseptic effusion, and advocates for the integration of multidisciplinary approaches and advanced diagnostic tools in the evaluation of pediatric and young adult musculoskeletal infections. Further research is needed to better understand the pathophysiology and management of rare presentations like this one.

Juvenile sudden cardiac death due to congenital coronary ostial valve-like ridges: A case report and literature review

Coronary artery anomalies are a heterogeneous group of congenital disorders affecting the coronary pattern with a characteristic (origin, number, number of hosts, course, etc.). They are rarely found in the population. We report the case of a 21-year-old male who died from sudden cardiac death caused by an isolated coronary ostial obstruction, secondary to a rare anomaly, the presence of a valve-like ridge consisting of a small fold in the Valsalva aortic sinus. The study provides a brief literature review on the pathophysiology, diagnosis, and clinical and medico-legal issues in coronary artery anomaly cases that may be helpful in forensic practice when dealing with sudden cardiac death in young people and highlights key points for further research and public health measures.

Diagnostic Test Accuracy of Contrast-Enhanced Ultrasound With Sonazoid for Assessment of Focal Liver Lesions: A Systematic Review and Meta-Analysis

This meta-analysis examined the diagnostic accuracy of Sonazoid-enhanced ultrasonography (SZ-CEUS) in discriminating malignant from benign focal liver lesions (FLLs) and HCC from non-HCC FLLs. Finding relevant studies required a rigorous PubMed, EMBASE, and other database search. To distinguish malignant from benign FLLs, SZ-CEUS had a pooled sensitivity of 94% (95% CI: 0.91-0.95) and specificity of 84% (95%: 0.78-0.89). HCC distinction had 83% sensitivity and 96% specificity (95% CI: 0.80-0.85 and 0.95-0.97). SZ-CEUS accurately distinguishes malignant from benign FLLs and HCC from non-HCC lesions, especially smaller HCC lesions.

Development of an MRI based artificial intelligence model for the identification of underlying atrial fibrillation after ischemic stroke: a multicenter proof-of-concept analysis

Background

Atrial fibrillation (AF) represents a major risk factor of ischemic stroke recurrence with serious management implications. However, it often remains undiagnosed due to lack of standard or prolonged cardiac rhythm monitoring. We aim to create a novel end-to-end artificial intelligence (AI) model that uses MRI data to rapidly identify high AF risk in patients who suffer from an acute ischemic stroke.

Methods

This study comprises an internal retrospective cohort and a prospective cohort from Shanghai sixth people's hospital to train and validate an MRI-based AI model. Between January 1, 2018 and December 31, 2021, 510 patients were retrospectively enrolled for algorithm development and performance was measured using fivefold cross-validation. Patients from this trial were registered with http://www.chictr.org.cn, ChiCTR2200056385. Between September 1, 2022 and July 31, 2023, 73 patients were prospectively enrolled for algorithm test. An external cohort of 175 patients from Huashan Hospital, Minhang Hospital, and Shanghai Tenth People's Hospital was also enrolled retrospectively for further model validation. A combined classifier leveraging pre-defined radiomics features and de novo features extracted by convolutional neural network (CNN) was proposed to identify underlying AF in acute ischemic stroke patients. Area under the curve (AUC), sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for model evaluation.

Findings

The top-performing combined classifier achieved an AUC of 0.94 (95% CI, 0.90-0.98) in the internal retrospective validation group, 0.85 (95% CI, 0.79-0.91) in the external validation group, and 0.87 (95% CI, 0.90-0.98) in the prospective test group. Based on subgroup analysis, the AI model performed well in female patients, patients with NIHSS > 4 or CHA2DS2-VASc ≤ 3, with the AUC of 0.91, 0.94, and 0.90, respectively. More importantly, our proposed model identified all the AF patients that were diagnosed with Holter monitoring during index stroke admission.

Interpretation

Our work suggested a potential association between brain ischemic lesion pattern on MR images and underlying AF. Furthermore, with additional validation, the AI model we developed may serve as a rapid screening tool for AF in clinical practice of stroke units.

Funding

This work was supported by grants from the National Natural Science Foundation of China (NSFC, Grant Number: 81871102 and 82172068); Shanghai Jiao Tong University School of Medicine, Two-Hundred Talent Program as Research Doctor (Grant Number: SBR202204); Municipal Science and Technology Commission Medical Innovation Project of Shanghai, (Grant/Award Number: 20Y11910200); Research Physician Program of Shanghai Shen Kang Hospital Development Center (Grant Number: SHD2022CRD039) to Dr. Dong Huang and the SJTU Trans-med Awards Research (No. 20220101) to Dahong Qian.

Impact of soft pancreas on pancreaticoduodenectomy outcomes and the development of the preoperative soft pancreas risk score

Backgrounds/Aims

Pancreatic texture is difficult to predict without palpation. Soft pancreatic texture is associated with increased post-operative complications, including postoperative pancreatic fistula (POPF), cardiac, and respiratory complications. We aimed to develop a calculator predicting pancreatic texture using patient factors and to illustrate complications from soft pancreatic texture following pancreaticoduodenectomy.

Methods

Data was collected from the 2016 to 2021 American College of Surgeons National Surgical Quality Improvement database including 17,706 pancreaticoduodenectomy cases. Patients were categorized into two cohorts based on pancreatic texture (9,686 hard, 8,020 soft). Multivariable modeling assessed the impact of patient factors on complications, mortality, and pancreatic texture. These preoperative factors were integrated into a risk calculator (preoperative soft pancreas risk score [PSPRS]) that predicts pancreatic texture.

Results

Patients with a soft pancreas had higher rates of postoperative complications compared to those with a hard pancreas (56.5% vs 42.2%; p < 0.001), particularly a threefold increase in POPF rate, and at least a twofold increase in rates of acute kidney injury, deep organ space infection, septic shock, and prolonged length of stay. Female sex (odds ratio [OR]: 1.14, confidence interval [CI]: 1.06-1.22, p < 0.001) and higher body mass index (OR: 1.12, CI: 1.09-1.16, p < 0.001) were independently associated with a soft pancreas. PSPRS ≥6 correctly identified >40% of patients preoperatively as having a hard pancreas (68.9% specificity).

Conclusions

A soft pancreas was independently associated with serious postoperative complications. Our results were integrated into a risk calculator predicting pancreatic texture from preoperative patient factors, potentially enhancing preoperative counseling and surgical decision-making.

Patterns and Correlates of Bone Mineral Density Parameters Measured Using Calcaneus Quantitative Ultrasound in Chinese Adults

Background: Monitoring bone mineral density (BMD) in adults is critical for early detection of osteoporosis and prevention of fracture, for which quantitative ultrasound (QUS) is a good non-invasive tool. We examined the associations of QUS measures, including stiffness index (SI) and T-score, with socio-demographic, lifestyle, and anthropometric correlates and risk of subsequent fracture. Methods: Calcaneal QUS was performed using GE's Lunar Achilles EXPII among 24,651 adults (mean age 59.5 years, 61.7% women) from the China Kadoorie Biobank study. Socio-demographic and lifestyle information was collected using an interviewer-administered electronic questionnaire, and anthropometrics were measured following standard protocols. Incidence of fracture and osteoporosis was recorded via linkage with nationwide health insurance database. Linear and Cox regression analyses were conducted, adjusting for potential confounders. Results: On average, men had higher SI (92.8 vs. 86.0) but lower T-score (-0.85 vs. -0.64) than women. In both men and women, advanced age and smoking were inversely associated with SI and T-score, while physical activity and tea drinking were positively so (p < 0.0001 for all). Except for height, all other anthropometric measures were significantly and positively associated with both BMD measures. With each SD lower SI, the risk of subsequent fracture was 26% (95% confidence interval: 10-44%) and 40% (25-57%) higher in men and women, and the corresponding associations of T-score were identical. Conclusions: Among Chinese adults, the SI and T-score provided by Achilles EXPII had similar patterns and predictive values for subsequent fracture, despite the T-score for men and women not being directly comparable because of gender-specific references used. Future studies are needed to confirm or refute the causality of relationship between lifestyle and anthropometric factors and BMD.

Cone Beam Computed Tomography Evaluation and Proposal of a Functional Radiographic Classification of the Coronoid Process-A Cross-Sectional Study

Background: The objective of this study is to investigate the cone beam computed tomography (CBCT) features of the coronoid process in patients without limitations in mouth opening and to develop a functional classification of the coronoid process, considering its relationship with the zygomatic bone. Methods: This cross-sectional retrospective study analyzed the CBCT features of 408 coronoid processes. Volume rendered and axial images were evaluated to assess the shape, surface configuration, length of the coronoid process, the coronoid/condyle ratio, the distance of the coronoid process from the posteromedial surface of the zygoma, and its vertical level. The coronoid process was considered hyperplastic when the coronoid/condyle ratio was >1. Results: The maximum coronoid processes had a triangular shape (221). The mean length of the coronoid process was 13.85 mm. The mean coronoid/condyle ratio was 0.84. A total of 85 coronoid processes were hyperplastic. The mean distance from the coronoid process to the posteromedial surface of the zygoma was 15.99 mm, ranging from 5.8-27.9 mm. The mean vertical level of the coronoid process in the study sample was 9.6 mm. A novel functional radiographic classification was developed. The coronoid processes were classified as Type I, II, III (a,b,c), and IV (a,b,c). Type IIIa was the most common (45.83%), followed by Type II (29.68%), Type I (16.17%), Type IIIc (4.41%), Type IIIb (3.18%), Type IVa (0.49%), and Type IV b (0.24%). Conclusions: The vertical extension of the coronoid process beyond the lower border of the zygomatic bone/arch and its distance from the posterior surface of the body of the zygoma could play a significant role in impacting the mandibular movements.

Roles of olive oil and physical exercise in non-alcoholic fatty liver disease after ultrasound-based evaluation

Non-alcoholic fatty liver disease (NAFLD) without special drugs shows symptoms of liver fat accumulation and steatosis in patients without alcohol intake. Ultrasound evaluation is a critical method in the early diagnosis of NAFLD stages as well as image processing and should be encouraged. Olive oil is an important component of the Mediterranean diet and has a beneficial role in the prevention of NAFLD progression. Physical activity and exercise can have anti-oxidant and anti-inflammatory effects to reduce liver fat and body weight via regulation of mitochondrial capacity in the development of NAFLD. Both the Mediterranean diet and physical exercise should be combined to achieve the ideal fat content reduction and weight loss in patients with NAFLD.

Comparison of MR Spectroscopy, 2-Point Dixon, and Multi-Echo T2* Sequences in Assessing Hepatic Fat Fraction Across a Diverse Range of Body Mass Index (BMI) and Waist Circumference Ratio (WCR) Values

Objective

The study aimed to compare and evaluate the accuracy of three magnetic resonance imaging (MRI) sequences-MR liver spectroscopy, 2-point Dixon, and multi-echo T2*-in assessing hepatic fat fraction in patients with various body mass indexes (BMIs).

Methods

167 participants were recruited, including 110 healthy subjects with diverse BMIs and 57 bariatric surgery candidates. The MRI protocol involved three sequences: multi-echo single voxel STEAM 1H spectroscopy, 2-point mDixon, and multi-echo T2* sequence. Hepatic fat fraction was measured using these sequences and analyzed statistically to determine correlations and agreement between the methods.

Results

A strong positive correlation was observed between BMI and waist circumference ratio (WCR) (rs(165) = 0.910, p<0.001). MRS obtained hepatic fat fraction numerical values in 13.33% of the normal BMI group, 48.48% of the overweight group, and 72.97% of the obese group. Strong correlations were found between all methods, with significant agreement, particularly between MRS and multi-echo T2*.

Conclusion

Robust correlations were observed between MR spectroscopy, 2-point Dixon, and multi-echo T2* methods for liver fat fraction measurement, especially in patients with higher BMI and WCR. These findings highlight the importance of BMI and WCR in interpreting fat fraction measurements, as method performance can vary across body composition profiles.

Comparative Study of AI Modes in Ultrasound Diagnosis of Breast Lesions

Objectives: This study evaluated the diagnostic performance of the S-Detect ultrasound system's three selectable AI modes-high-sensitivity (HSe), high-accuracy (HAc), and high-specificity (HSp)-for breast lesion diagnosis, comparing their performance in a clinical setting. Methods: This retrospective analysis evaluated 260 breast lesions from ultrasound images of 232 women (mean age: 50.2 years) using the S-Detect system. Each lesion was analyzed under the HSe, HAc, and HSp modes. The study employed ROC curve analysis to comprehensively compare the diagnostic performance of the AI modes against radiologist diagnoses. Subgroup analyses focused on the age (<45, 45-55, >55 years) and lesion size (<1 cm, 1-2 cm, >2 cm). Results: Among the 260 lesions, 73% were identified as benign and 27% as malignant. Radiologists achieved a sensitivity of 98.6%, specificity of 64.2%, and accuracy of 73.5%. The HSe mode exhibited the highest sensitivity at 95.7%. The HAc mode excelled with the highest accuracy (86.2%) and positive predictive value (71.3%), while the HSp mode had the highest specificity at 95.8%. In the age-based subgroup analyses, the HAc mode consistently showed the highest area under the curve (AUC) across all categories. The HSe mode achieved the highest AUC (0.726) for lesions smaller than 1 cm. In the case of lesions sized 1-2 cm and larger than 2 cm, the HAc mode showed the highest AUCs of 0.906 and 0.776, respectively. Conclusions: The S-Detect HSe mode matches radiologists' performance. Alternative modes provide sensitivity and specificity adjustments. The patient age and lesion size influence the diagnostic performance across all S-Detect modes.

Advances and challenges in echocardiographic diagnosis and management of cardiac amyloidosis

Cardiac amyloidosis is an infiltrative cardiomyopathy characterized by the abnormal accumulation of amyloid proteins within the heart muscle. It is recognized as a rare yet significant cardiac disease that is often overlooked as a potential cause of heart failure and cardiac arrhythmias, particularly in older individuals with rates escalating from 8 to 17 cases per 100,000 individuals. Cardiac amyloidosis primarily manifests as two predominant subtypes: light-chain and transthyretin amyloidosis, collectively accounting for over 95% of clinical cases. Early diagnosis of these conditions is often hindered by overlapping symptoms with other cardiac pathologies, resulting in diagnostic delays and suboptimal patient outcomes. Echocardiography, a non-invasive imaging technique, has become indispensable for diagnosing cardiac amyloidosis, uncovering crucial echocardiographic signs such as thickening of the left ventricular wall, diastolic dysfunction, and a granular appearance of the myocardium. Recent advancements in echocardiography have significantly enhanced the diagnostic accuracy of cardiac amyloidosis and improved patient management. Advanced echocardiographic techniques, including strain imaging, 3D echocardiography, and contrast echocardiography, have significantly enhanced diagnostic accuracy and prognostication. Future directions in echocardiography encompass the integration of artificial intelligence, the development of novel contrast agents, and the refinement of 4D echocardiography to further optimize patient care. This study explores the pivotal role of echocardiography in both diagnosing and managing cardiac amyloidosis, delving into the disease's underlying mechanisms, distinctive imaging characteristics, the significance of regular echocardiographic assessments, and discusses the challenges associated with differentiating between various types of amyloidosis without supplemental imaging or biopsy methods.

Unraveling the Dynamics of Human Filarial Infections: Immunological Responses, Host Manifestations, and Pathogen Biology

Lymphatic filariasis (LF), or elephantiasis, is a neglected tropical disease caused by filarial worms, primarily Wuchereria bancrofti, transmitted through mosquito bites. It often begins in childhood but may not show symptoms until later, leaving many individuals asymptomatic for long periods. LF disrupts the lymphatic system, causing severe swelling in the limbs and genitals, leading to deformities and disabilities. The World Health Organization estimates that around 51 million people are affected globally, with 36 million suffering from chronic conditions like lymphedema and hydrocele. In 2021, approximately 882.5 million people in 44 countries required preventive chemotherapy, making LF the second leading parasitic cause of disability, significantly impacting socioeconomic status. The immune response to filarial parasites is complex, involving both innate and adaptive immune cells. A key feature of LF immunology is the antigen-specific Th2 response, expansion of IL-10-producing CD4+ T cells, and a muted Th1 response. This T cell hypo-responsiveness is crucial for sustaining long-term infections with high parasite densities. While the correlates of protective immunity are not fully understood-due in part to a lack of suitable animal models-T cells, particularly CD4+ Th2 cells, and B cells, play essential roles in immune protection. Moreover, host immune responses contribute to the disease's pathological manifestations. A failure to induce T cell hypo-responsiveness can lead to exaggerated inflammatory conditions such as lymphedema, hydrocele, and elephantiasis. Filarial infections also induce bystander effects on various immune responses, impacting responses to other infectious agents. This intricate immune interplay offers valuable insights into the regulation of immune responses to chronic infections. This review explores recent immunological research on lymphatic filarial worms, highlighting their effects on both innate and adaptive immune responses in humans and the mechanisms underlying this neglected tropical disease.

A pictorial essay on cross-sectional imaging findings of pathologies in the second (D2) segment of the duodenum in adults

The duodenum, the initial segment of the small intestine, is divided into four parts: the superior (D1), descending (second) (D2), horizontal (D3), and ascending (D4) segments. Despite its short length, the descending part (D2 segment) holds clinical significance due to its anatomical proximity to structures such as the gallbladder, right kidney, colon, and pancreas. This anatomical localization and contiguity give rise to various pathologies, including congenital, inflammatory, infectious, neoplastic, vascular, and traumatic conditions. Cross-sectional imaging modalities play a pivotal role in evaluating pathologies of the second (D2) segment of the duodenum. This article aims to provide a comprehensive overview of these pathologies and delineate their imaging characteristics.

MRI findings for the pretreatment diagnosis of small Meckel's cave tumors: comparison of meningiomas and schwannomas

BACKGROUND

Both meningiomas and schwannomas are the most common Meckel's cave (MC) tumors in terms of distinct imaging features. When they are small, they may present with similar imaging characteristics that make their diagnosis difficult. The aim of this study was to diagnose small meningiomas and schwannomas of the MC on the basis of their clinical and MRI findings.

METHODS

The clinical data of 33 patients who were diagnosed with small MC tumors (SMCTs) (17 schwannomas, 16 meningiomas) between August 2002 and August 2023 were retrospectively evaluated. SMCTs were defined as MC tumors that were less than 3 cm in size. We analyzed their clinical and MRI findings, including demographic features, lesion morphologies and changes in adjacent structures.

RESULTS

The rate of subtotal resection of meningiomas less than 3 cm in size was significantly lower than that of schwannomas less than 3 cm in size (43.8% vs. 100%, p = 0.032). The MRI features of meningiomas and schwannomas were as follows: 1) a prominent dura tail sign (8/16 [50%] vs. 0/17 [0%], p < 0.001); 2) few cystic components (0/16 [0%] vs. 9/17 [52.94%], p < 0.001); 3) lower minimum ADC (ADCmin) values (820.575 ± 302.545 [86.1-1144.4] vs. 1372.424 ± 561.337 [355.7-2616.6], p < 0.001); and 4) minimal ipsilateral masticatory muscle atrophy (-6.71% ± 22.43% [-85.71% ~ 13.79%] vs. 11.24% ± 11.98% [-14% ~ 38%], p < 0.001). Very small MC tumors (VSMCTs) were ≤ 2 cm in size, and the subgroup analysis of very small meningiomas and schwannomas revealed no differences in terms of ipsilateral masticatory muscle atrophy (p = 0.078), prominence of the dural tail (p = 0.236), or the presence of cystic components (p = 0. 364). However, the ADCmin values were significantly lower for very small meningiomas than for very small schwannomas (p = 0.009).

CONCLUSION

MRI features such as a prominent dural tail appearance, the presence of fewer cystic components, and less masticatory muscle atrophy may aid in differentiating meningiomas from schwannomas less than 3 cm in size. The ADC and DWI parameters provided additional critical insights, particularly for VSMCTs, thus facilitating preoperative diagnoses.

Ultrasonography reference values for the calcaneus in children and adolescents living at high altitude in Peru

Objective

The evaluation of bone health during the growth stage is extremely important, as it is a key factor to prevent bone diseases in adulthood. The objectives of the study were: a) to verify if there are differences in bone health with other geographic regions, b) to develop bone health curves using quantitative ultrasonography (QUS) through the Broadband Ultrasonic Attenuation (BUA) parameter in children and adolescents residing in a high altitude region of Peru and c) to determine specific cut-off points for bone health assessment in this particular population.

Methods

A cross-sectional study was carried out in schoolchildren in a high altitude region of Peru. The sample consisted of 1468 children and adolescents (724 males and 744 females). The age range was 6.0 to 17.9 years old. Weight and height were evaluated. Body Mass Index (BMI) was calculated. Bone quality was evaluated by quantitative ultrasonography (QUS) of the calcaneus. The parameters measured were Speed of Sound (SOS, m/s); Broadband Ultrasonic Attenuation (BUA, dB/MHz); and Bone Quality Index (BQI= αSOS+αBUA, αβ: temperature corrections).

Results

There were small discrepancies in bone health (BUA) between studies from various geographic regions. Values differed across all age ranges from ~0.36 to ~10.86 in males and from ~0.26 to ~6.68 in females. At later ages during adolescence the values are relatively similar, reaching a plateau around 16 and 17 years of age. Percentiles were calculated for BUA by age and sex. Sensitivity and specificity values in females are slightly higher relative to males. However, the Youden Index reflects 0.84 for both sexes and the appropriate cut-off point for men is ≤67.8 and for women is ≤63.7.

Conclusion

The study demonstrated that there are small discrepancies in bone health (BUA) among children between children and adolescents from different geographic regions. These findings support the creation of specific references and cut-off points for bone health in the pediatric population of a high altitude region of Peru. The results suggest the application of percentiles for the assessment of bone health in school and epidemiological contexts.

Radiation safety: knowledge, attitudes, practices and perceived socioeconomic impact in a limited-resource radiotherapy setting

Healthcare workers in teaching-hospital settings face numerous occupational hazards, necessitating comprehensive safety protocols to protect both staff and patients. Radiation safety is particularly critical in regions like sub-Saharan Africa, where the sharp rise in radiological procedures and radiation treatments demands stringent protocols to mitigate health risks. The study aimed to assess the knowledge, attitudes and practices related to radiation safety among healthcare workers in a limited-resource setting, as well as evaluate the perceived socioeconomic impact of implementing radiation safety protocols. The research was a quantitative case study of one of the largest radiotherapy centres in Africa. Participants were selected using a stratified random sampling technique. Data were collected using a modified structured questionnaire based on the validated International Atomic Energy Agency radiation safety knowledge, attitudes and practice questionnaire. Data were analysed with the Statistical Package for Social Sciences software. Both descriptive and inferential statistical analyses were performed. Data were summarized using frequencies, percentages, means and standard deviations. The study involved 78 participants, comprising 13 physicians, 40 nurses and 25 other health workers. In all, 53.8% were males, whereas 46.2% were females. The mean age was 24.9 years (SD 4.7) ranging from 23 to 47 years. A significant majority (82%) were knowledgeable about effective ways of reducing radiation exposure. All participants considered radiation safety extremely important, with 55% feeling extremely confident in their ability to practice radiation safety measures. The majority (92%) believed that radiation safety was a shared responsibility within the organization. Only 51% frequently checked radiation safety equipment. There was a strong consensus that these protocols positively affect healthcare worker well-being (a mean score of 4.49) and benefit patient care (a mean score of 4.45). Implementation of workplace safety protocols was perceived to improve worker well-being (B = 0.337 and p = 0.001) and benefit patient care (B = 0.391 and p = 0.014). The study highlights a high level of knowledge and positive attitudes towards radiation safety among healthcare workers in a limited-resource radiotherapy setting. While most participants recognized the importance of radiation safety and its shared responsibility, less than half regularly checked safety equipment. There were significant perceptions of the socioeconomic benefits of implementing safety protocols.

Surgical intervention of coronary-pulmonary artery fistula with multiple coronary aneurysms and Vieussens' arterial ring formation

BACKGROUND

To our knowledge, there have been extremely few clinical reports on coronary-pulmonary artery fistula (CPAF) accompanied by coronary artery aneurysm (CAA) and Vieussens' arterial ring (VAR), and few reports on related surgical treatments.

CASE PRESENTATION

A 61-year-old female patient was admitted with dyspnea and fatigue after exertion. Coronary CTA, echocardiography and coronary angiography revealed multiple CPAF, along with formation of multiple CAAs and VAR. The patient underwent successful surgical intervention under general anesthesia and cardiopulmonary bypass and experienced an uneventful recovery.

CONCLUSION

Hereby we reported this clinically unusual case of CPAFs with multiple CAAs and VAR and also the details of a successful surgical procedure.