Can Whole-Body Magnetic Resonance Imaging Predict Relapse in Juvenile Idiopathic Arthritis? A Longitudinal Pilot Study

OBJECTIVE

To determine the utility of whole-body magnetic resonance imaging (WB MRI) to predict relapse in children with juvenile idiopathic arthritis (JIA) in clinical remission.

METHODS

Consecutive patients with JIA who fulfilled the Wallace criteria for remission were recruited into this longitudinal pilot study and underwent WB MRI. A radiological score was devised, incorporating synovitis, bone marrow edema, sacroiliitis, enthesitis, and bone erosions. Two readers independently scored the MR data sets. The same score was calculated for both knee joints individually and correlated with outcome for that joint. Score-based models incorporating clinical and laboratory variables were generated. Logistic regression analysis was done to determine predictors for relapse. Receiver operating characteristic curve was drawn for significant variables.

RESULTS

Twenty-two children (median age, 12 years; interquartile range, 9.5-14.25 years) were included in the final analysis. At 24 months' follow-up, 15 joints in 5 children relapsed; knee was the most common site. Seven knee joints had disease relapse. On univariate analysis, synovitis and total score on WB MRI were significant predictors of relapse at follow-up, with odds ratios of 9.46 (bias-corrected 95% confidence interval, 3.07-29.13) and 2.8 (bias-corrected 95% confidence interval, 1.23-6.39) respectively. Two models, which included a higher number of joints involved at presentation and abrupt drug withdrawal strategy as predictor variables, were also statistically significant (odds ratio, approximately 1.9). On multivariate analysis of the predictors variables in models where p < 0.6, it was found that only synovitis score and total score were near statistical significance ( p = 0.06); no clinical or laboratory variables were significant. The areas under the receiver operating characteristic curve for relapse prediction were approximately 0.82, 0.87, 0.79, and 0.81 for synovitis score, total MRI score, and both models, respectively.

CONCLUSION

Synovitis on WB MRI is the strongest independent predictor for disease relapse in children with JIA in remission.

Diagnostic accuracy of whole-body magnetic resonance imaging versus positron emission tomography-computed tomography for the staging of pediatric lymphoma: a systematic review and meta-analysis

BACKGROUND

Whole-body magnetic resonance imaging (MRI) has been investigated by multiple authors as a radiation-free alternative to positron emission tomography computed tomography (PET-CT) in children with lymphoma.

OBJECTIVE

To evaluate the sensitivity, specificity, and diagnostic odds ratio of whole-body MRI compared to PET-CT for the staging of pediatric lymphoma.

METHODS

The databases PubMed, Embase, and Scopus were searched for studies that reported the accuracy of whole-body MRI compared to PET-CT for lymphoma staging in children. Data was collected from included studies to formulate 2 × 2 contingency tables, including the number of true positive, true negative, false positive, and false negative. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated. Summary receiver operating characteristic curves were drawn and the area under the curve (AUC) calculated. In addition, the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS 2) tool was used to assess the risk of bias and applicability concerns.

RESULTS

A total of seven studies were included in the final analysis. Of these, six studies used unenhanced whole-body MRI. The pooled sensitivity of whole-body MRI-based staging was 95.8%, while the pooled specificity was 21.8%. The DOR for whole-body MRI was 1.19. For extranodal staging, the pooled sensitivity was 88.9%, specificity was 97.4%, and DOR was 25.29. The partial AUC for overall staging was 0.63, whereas that for extranodal staging stood at 0.88. Based on the QUADAS 2 tool, all seven studies were at risk of bias (six at high risk, one at unclear risk).

CONCLUSION

Whole-body MRI has high sensitivity for staging of pediatric lymphoma and may be a useful alternative to PET-CT.

Transperineal Ultrasound as an Adjunctive Modality in the Evaluation of 'H or N' Type of Recto-urethral Fistula: Technical Note

Anorectal malformations (ARMs) encompass a complex spectrum of congenital anomalies and H/N type anorectal malformations are extremely rare. In the presence of colostomy, an augmented pressure colostogram with or without retrograde or micturating cystourethrogram is the investigation of choice. Transperineal ultrasound is an imaging technique that allows a fairly accurate morphological assessment of ARMs along with dynamic evaluation of the anorectal structures and pelvic floor anatomy. Here we describe the role of transperineal ultrasound as an adjunctive modality in diagnosis of one such complex anomaly.

Building and evaluating an artificial intelligence algorithm: A practical guide for practicing oncologists

The use of machine learning and deep learning has enabled many applications, previously thought of as being impossible. Among all medical fields, cancer care is arguably the most significantly impacted, with precision medicine now truly being a possibility. The effect of these technologies, loosely known as artificial intelligence, is particularly striking in fields involving images (such as radiology and pathology) and fields involving large amounts of data (such as genomics). Practicing oncologists are often confronted with new technologies claiming to predict response to therapy or predict the genomic make-up of patients. Underst-anding these new claims and technologies requires a deep understanding of the field. In this review, we provide an overview of the basis of deep learning. We describe various common tasks and their data requirements so that oncologists could be equipped to start such projects, as well as evaluate algorithms presented to them.

Imaging in extremity vascular trauma: can MDCT angiography predict the nature of injury?

OBJECTIVE

This study aims to evaluate the utility of computed tomography angiography (CTA) signs of vascular injury in the differentiation of vessel transection from pure thrombosis with intact vessel wall.

METHODS

Retrospective analysis was done on 146 consecutive patients who had undergone CTA and surgical exploration from January 2015 to September 2019. Twelve imaging parameters were assessed. Chi-square was used to test the difference between groups. In addition, a scoring system was devised where one point each was added for the presence of 5 signs and absence of 3 signs. ROC analysis was done for the variables which had shown significant difference between groups and for the composite score.

RESULTS

On surgical exploration, 87 patients had transection of vessel, while 59 had thrombosis. Significant difference was found among the two groups in non-opacification, pseudoaneurysm, extravasation (p = 0.04 each), thrombosed cord (p < 0.001), collaterals (p = 0.001) and hematoma (p = 0.002), while other signs did not show significant difference. The AUC value for each of these variables was < 0.650, while for the score, AUC was .843(.773-.913). A cut-off value of ≥ 1.5 gave 83.1% sensitivity and 70% specificity for diagnosing transection.

CONCLUSION

CTA is a useful tool to classify the nature of vascular injury. It is advisable to use a composite score for maximum diagnostic value.

Walking the Risk-Benefit Tight Rope: A Case of Post Fine Needle Aspiration Haemorrhage in Extramedullary Plasmacytoma

BACKGROUND

Primary extramedullary plasmacytomas (EMP) are rare, however secondary forms may be seen in ~10-15% patients with systemic multiple myeloma (MM). The diagnosis of EMP is based on demonstration of monoclonal plasma cells in the lesion, which requires tissue sampling.

CASE PRESENTATION

We present a case of a 38 year old female with MM, who underwent diagnostic US at our institute. Multiple focal liver lesions were detected, which were suspicious for EMP. She underwent fine needle aspiration cytology (FNAC) for diagnosis, following which she developed hemoperitoneum secondary to deranged clotting parameters (prothrombin time and platelet count). CT Angiography revealed active hepatic capsular bleed. She was taken up for percutaneous embolisation, and the supplying vessel successfully embolised using gelfoam particles. Complications may rarely occur in interventional procedures, particularly in patients with comorbidities. However, prompt diagnosis and management help prevent adverse outcomes.

Transcutaneous Mediastinal Ultrasonography for Lymphadenopathy in Children: A Pictorial Essay of Technique and Imaging Findings

Ultrasonography (US) forms the mainstay of imaging in children; however, in the chest, its use has traditionally been limited to evaluation of pleural pathology. US techniques such as endobronchial and endoscopic ultrasound, which are commonly used for detection of mediastinal lymphadenopathy are invasive, aerosol generating, and often require sedation. Transcutaneous mediastinal sonography (TMUS) offers a useful alternative, which is easier to perform and overcomes these limitations. In this review, we summarize the technique, as well as imaging appearances of lymph nodes on TMUS. We also list common problems faced by operators and suggest troubleshooting methods for these.

Ultrasound-guided percutaneous embolization of post renal biopsy gonadal artery pseudoaneurysm

Hemorrhage is the most frequently encountered post renal biopsy complication; reported in 12% to 14% of patients. Although the vast majority of these are due to renal artery injury, involvement of gonadal arteries is also rarely seen. These may be managed by the endovascular route, which has several limitations in this subset of patients. We report a case of a 69-year-old male with rapidly progressive glomerulonephritis, who underwent renal biopsy and developed a testicular artery pseudoaneurysm (PA). Successful embolization of this PA was performed under ultrasound guidance using a direct percutaneous approach. This is the first such case reported in the literature.

Determinants of Subjective Loneliness and Quality of Life among Community-Dwelling Older Adults in Gorgan, Iran

The purpose of this study was to identify the determinants of, and relationship between, subjective loneliness, general health and quality of life (QoL) among lonely community-dwelling older adults. A cross-sectional study was carried out among a sample of lonely (i.e. live alone without any assistance) older adults living in Gorgan city, Iran. The older adults were invited through a census sampling technique to complete six questionnaires, namely a 20-item UCLA loneliness scale, a six-item Lubben Social Network Scale, a 12-item Multidimensional Scale of Perceived Social Support, a 17-item Self-care Ability Scale for the Elderly (SASE), a General Health Questionnaire-12, and a Control, Autonomy, Self-Realization and Pleasure (CASP-19) questionnaire. Hierarchical multiple linear regressions were done with subjective loneliness and QoL as outcome variables. In total, 213 (91% females) lonely older adults (mean age: 68.2 ± 6.2) participated. Hierarchical multiple linear regressions yield socio-demographic characteristics (p < 0.001), predictor group 1 (p < 0.001), predictor group 2 (p < 0.001) explained 12.5, 13.5 and 46.6% of the observed variance in loneliness, respectively. Moreover, socio-demographic characteristics (p < 0.001), predictor group 1 (p < 0.001), predictor group 2 (p < 0.001) and feeling of loneliness (p < 0.001) accounted for 16.9, 21.1, 48.6 and 55.3% of the observed variance in quality of life, respectively. Both subjective loneliness and QoL were moderate in our sample. We suggest the presence of a probable causal inference between subjective loneliness, general health, and QoL; implying the need of population strategies for correcting subjective loneliness for its own sake as well as to help have an improved general health and QoL among older adults. Beside several non-modifiable factors (such as age, ethnic groups), we suggest that corrective measures should be based on social support and networking, self-care behavior, leisure activities, adapted for age, literacy and racial specifications. Given its population health relevance, there should be increased research and intervention on loneliness among older adults.

Predicting Histology of Tracheobronchial Neoplasms: A CT Based Differentiation Model

BACKGROUND

Tracheobronchial (TB) tumors follow same pathological classification as lung neoplasms; however, some entities are known to favor airways. Distinction of pathological types is necessary for suggesting appropriate management strategy.

PURPOSE

To evaluate utility of multidetector CT (MDCT) in differentiation of primary TB tumors; and assess validity of a scoring system based on imaging biomarkers to differentiate tumor types.

METHODS

MDCT features of 45 patients were analyzed for location, shape, calcification, attenuation, parenchymal changes, bronchoceles, extraluminal extension, lymphadenopathy, metastases. The two largest groups were compared with each other and remaining entities using Chi square tests. Six-point scoring system combining the differentiating features was devised and receiver operating characteristic curve analysis performed.

RESULTS

The most frequent type was neuroendocrine tumors (NET) (51.1%), followed by salivary gland tumors (SGT) (20%); including adenoid cystic carcinoma (ACC) (13.3%) and mucoepidermoid carcinoma (MEC) (6.7%). Comparing NETs with other entities as a whole, and independently with SGTs, significant difference was found among location (p = 0.05 and 0.001 respectively), shape (p < 0.001), calcification (p = 0.038 and 0.041 respectively), attenuation (p = 0.001 and 0.019 respectively), bronchoceles (p = 0.013 and 0.010 respectively). Significant difference was found among ACC and MEC in location (p = 0.01) and morphology (p < 0.001). On receiver operating characteristic (ROC) curve analysis of the score, areas under curve for NET, SGT and ACC were 0.913, 0.872 and 0.962 respectively. Suggested cut-off values were >3.5 for carcinoid (sensitivity 70%, specificity 91%), <2.5 for SGT (sensitivity 78%, specificity 75%), <1.5 for ACC (sensitivity 83%, specificity 92%).

CONCLUSION

Use of a scoring system enables maximum diagnostic accuracy in MDCT differentiation of TB tumors.

Algorithmic Approach to Sonography of Adnexal Masses: An Evolving Paradigm

BACKGROUND

Pelvic US remains the workhorse for detection and characterization of adnexal masses in most centers worldwide. While the differentiation of benign from malignant masses remains the foremost concern, it is imperative to narrow the differential diagnosis for management of benign masses as well as prognostication of malignant masses. The IOTA group as well as ACR have described a five category classification system for adnexal lesions based on morphological patterns. In addition, a six category risk stratification has been proposed, incorporating the probability of malignancy as well as management recommendations.

LEARNING OBJECTIVES

1) Understand pattern based approach to adnexal lesion classification and the possible entities fitting into each pattern with the help of illustrations. 2) Classify lesions into appropriate risk categories based on diagnostic algorithms provided at the end of each section.

[Methodology of neuroepidemiological studies in tropical countries: a challenge?]

The purpose of this paper is to highlight the difficulties of applying neuroepidemiological methods in low income countries or developing countries, which are mostly tropical countries, taking advantage of the experience of the Institute of Neuroepidemiology and Tropical Neurology, which was created in Limoges in 1982. These difficulties could be related to several aspects: methodological, logistical, political or economical, linked to ethical issues, even difficulties to publish the studies. However, concept and neuroepidemiological methods should stay the same worldwide, even if their translation into practice could sometimes raise some problems in developing countries. Study protocol should be more detailed. Some specific epidemiological methods could be useful. Collection of data should be standardized. True cooperation at every level is needed for these researches to be valid.

Multiple sclerosis and solar exposure before the age of 15 years: case-control study in Cuba, Martinique and Sicily

Few studies report a protective role of childhood solar exposure to multiple sclerosis. Our objective was to confirm the protective role of childhood solar exposure in multiple sclerosis in Cuba, Martinique and Sicily. This was a matched case- control study, and cases met Poser criteria for clinically, laboratory (definite, probable) multiple sclerosis. Controls were resident population, without neurological disorder, living close to cases (within 100 km), matched for sex, age (+/-5 years), residence before age 15. We recruited 551 subjects during a 1-year period (193 cases, Cuba n = 95, Sicily n = 50, Martinique n = 48; 358 controls). Some (89%) met definite clinical multiple sclerosis criteria (relapsing remitting form (with and without sequel) (74%), secondary progressive (21%), primary progressive (5%)). Odds ratios in a uni-variate analysis were: family history of multiple sclerosis (5.1) and autoimmune disorder (4.0); wearing shirt (3.5), hat (2.7), pants (2.4); sun exposure causing sunburn (1.8); sun exposure duration (1 h more/day; weekends 0.91, weekdays 0.86); bare-chested (0.6); water sports (0.2). Independent factors in the multivariate analysis were family history of multiple sclerosis (4.8 (1.50-15.10)), wearing pants under sunlight (1.9 (1.10-3.20)), sun exposure duration (1 h more/ day, weekdays 0.90 (0.85-0.98), weekends 0.93 (0.87-0.99)), water sports (0.23 (0.13-0.40)). We conclude that outdoor leisure activities in addition to sun exposure reports are associated with a reduced multiple sclerosis risk, with evidence of dose response.

Acute peritoneal dialysis in neonates: comparison of two types of peritoneal access

A total of 23 sessions of peritoneal dialysis (PD) were given to 20 neonates with acute renal failure. Intravenous cannula (Biovalve 14G Vygon) was used for PD access in 13 procedures and guide wire-inserted femoral vein catheter (Medcomp-pediatric) in 10 procedures. Intraperitoneal bleed was seen in 1 procedure each in both groups. Dialysate leak and catheter blockade were more common with intravenous cannula [3 (23.1%), 8 (61.5%)] than guide wire-inserted femoral vein catheter [1 (10%), 4 (40%), P-NS]. Due to repeated catheter blockade, 5 (38.4%) PD sessions could not be completed with intravenous cannula and had to be prematurely closed; this complication was not seen with guide wire-inserted femoral vein catheter (P<0.05). Percentage reduction of serum creatinine per PD session was significantly higher in neonates being dialyzed with guide wire-inserted femoral vein catheter (51.7%+/-8.5%) than those dialyzed with intravenous cannula (38.3%+/-5.2%). Incidence of peritonitis was not significantly different [2 (15.4%) vs. 1 (10%)]. To conclude, for an effective PD in neonates, guide wire-inserted femoral vein catheter is safe and is associated with fewer access-related problems.

Cytoskeletal regulation of Caco-2 intestinal monolayer paracellular permeability

An abnormal increase in intestinal paracellular permeability may be an important pathogenic factor in various intestinal diseases. The intracellular factors and processes that regulate and cause alteration of intestinal paracellular permeability are not well understood. The purpose of this study was to examine some of the intracellular processes involved in cytoskeletal regulation of intestinal epithelial paracellular permeability using the filter-grown Caco-2 intestinal epithelial monolayers. Cytochalasin-b and colchicine were used to disrupt the cytoskeletal elements, actin microfilaments, and microtubules. Cytochalasin-b (5 micrograms/ml) and colchicine (2 x 10(-5) M) at the doses used caused marked depolymerization and disruption of actin microfilaments and microtubules, respectively. Cytochalasin-b-induced disruption of actin microfilaments resulted in perturbation of tight junctions and desmosomes and an increase in Caco-2 monolayer paracellular permeability. The cytochalasin-b-induced disruption of actin microfilaments and subsequent changes in intercellular junctional complexes and paracellular permeability were not affected by inhibitors of protein synthesis (actinomycin-D or cycloheximide) or microtubule function (colchicine), but were inhibited by metabolic energy inhibitors (2,4-dinitrophenol or sodium azide). The cytochalasin-b-induced disturbance in Caco-2 actin microfilaments and intercellular junctional complexes and increase in paracellular permeability were rapidly reversed. The paracellular pathway "re-tightening" following cytochalasin-b removal was not affected by actinomycin-D, cycloheximide, or colchicine, but was inhibited by 2,4-dinitrophenol and sodium azide. The colchicine-induced disruption of microtubules did not have significant effect on actin microfilaments, intercellular junctions, or paracellular permeability. These findings suggest that cytochalasin-b-induced increase in Caco-2 monolayer paracellular permeability was due to actin microfilament mediated perturbation of intercellular junctional complexes. The re-tightening of paracellular pathways (following removal of cytochalasin-b) resulted from energy-mediated re-assembly of pre-existing actin microfilaments and intercellular junctional complexes. This re-closure process did not require protein synthesis or microtubule-mediated shuttling process.

Autoradiographic determination of permeation pathway of permeability probes across intestinal and tracheal epithelia

Mucosal permeability studies are used to assess intestinal and respiratory barrier functions. Our ability to interpret results of permeability studies are hampered by our lack of understanding of absorptive pathways of permeability markers. The aim of this study was to visually trace the pathway of permeability probes across the small intestinal and tracheal epithelia by using electron microscopic autoradiography and cytochemistry. We saw a constant rate of mucosal to serosal permeation of intestinal permeability probes polyethylene glycol 400 (PEG-400) and mannitol across the everted small intestinal sac and of the pulmonary permeability probe bovine serum albumin (BSA) across the tracheal epithelia. Electron microscopic tracing of the permeation pathways of tritiated PEG-400 and tritiated mannitol revealed that the majority of the probes traversed the intestinal epithelium paracellularly within 1 half distance (1650 A) of the intercellular space. It is interesting that we also found a small but significant transcellular transport of permeability probes. Goblet cells also absorbed permeability probes transcellularly, but in an "all or none" fashion. Similar pathways were identified in studies utilizing the commonly used pulmonary permeability probes iodine 125-labeled BSA and horseradish peroxidase to determine the routes of transfer in the airway epithelia. In the normal unperturbed trachea, these large permeability probes traversed the pulmonary epithelia transcellularly via endocytosis. On barrier disruption by cytochalasin D, the probes permeated predominantly via the paracellular pathway. This study also demonstrates some of the similarities and differences in transmucosal pathways shared by intestinal and pulmonary epithelia.

IEC-18, a nontransformed small intestinal cell line for studying epithelial permeability

Small intestinal epithelium is leaky and allows permeation of hydrophilic molecules of various sizes. Passively absorbed hydrophilic permeability probes have been shown to permeate across intestinal epithelium mainly through the paracellular pathways. In this study we introduce microporous filter-grown IEC-18 epithelial cells, a nontransformed small intestinal cell line, as a in vitro model of intestinal epithelium for the study of epithelial permeability. IEC-18 cells, originally derived from native rat ileal crypts, form confluent epithelium when grown on hydrated collagen-coated Millicell-CM permeable inserts (Millipore Corp., Bedford, Mass.). With scanning and transmission electron microscopy, the presence of tight junctions and desmosomes between cells and the development of microvilli at the apical surface were confirmed. Immunofluorescent labeling of ZO-1 proteins and desmoplakins verified the presence of tight-junctional proteins (ZO-1) and desmosomes in the intercellular junctions of confluent IEC-18 epithelium. The net electrical resistance of IEC-18 epithelium (28 omega-cm2) was similar to resistance values obtained from small intestinal tissue with (50 to 100 omega-cm2) or without (20 to 45 omega-cm2) muscularis and serosal layers. Assessment of mannitol and dextran permeation revealed early "maturation" of paracellular pathway, with increasing restriction of permeation to both probes through day 4. Resistance across IEC-18 epithelium also reached plateau levels between 4 and 7 days. Permeability studies with various probes indicate that cross-sectional diameter rather than molecular weight of the probe is the important determinant of permeation rate. IEC-18 epithelium selectively restricted the permeation of probes proportional to probe size; permeation of larger probes such as albumin was negligible. We conclude that cultured IEC-18 epithelial cells, because of their native crypt origin, similarity in resistance to small intestinal epithelia, retention of ability to differentiate into villus-like enterocytes, and permeability characteristics, are a useful model of intestinal epithelium for the study of permeability and paracellular transport.

Mechanisms of carrageenan injury of IEC18 small intestinal epithelial cell monolayers

Hydrolyzed carrageenan is used to induce ileocecal inflammation in laboratory animals. We used ileal epithelial cell monolayer cultures (IEC18) to study the cellular and paracellular injurious effects of hydrolyzed carrageenan via an examination of its effects on deoxyribonucleic acid synthesis, chromium release, and cell morphology. Phase-contrast microscopy showed that carrageenan-treated cells initially contracted and pulled away from neighboring cells. Cell and viability counts illustrated that hydrolyzed carrageenan retarded cell growth and eventually caused cell death. [3H]Thymidine incorporation revealed that hydrolyzed carrageenan at a concentration of 0.25 g/L inhibited deoxyribonucleic acid synthesis by 20% during a 5-h labeling period in 1-wk-old confluent monolayers. Chromium 51 release assay demonstrated that a 22-h exposure to 0.75 g/L of hydrolyzed carrageenan induced the release of 30% of the 51Cr trapped in 1-wk-old confluent monolayers. Scanning electron microscopy showed that the disruption of cellular junctions occurred before cell membrane injury. When we treated the monolayers with drugs commonly used for the treatment of inflammatory bowel disease, including prednisolone, 5-aminosalicylic acid, metronidazole, and 6-mercaptopurine, we were not able to demonstrate a reduction in carrageenan-induced cell injury; however, catalase at 1 mg/ml decreased carrageenan cytotoxicity. These studies demonstrate that hydrolyzed carrageenan produces intestinal epithelial injury in a time- and dose-dependent fashion. Morphologic injury starts at the site of cell junctions and eventually affects cell membrane integrity. Drugs commonly used to treat inflammatory bowel disease do not inhibit carrageenan injury in this cell model system, although catalase does decrease injury.