Multiparametric Ultrasound for Diagnosing Testicular Lesions: Everything You Need to Know in Daily Clinical Practice

BACKGROUND

Ultrasonography (US) represents the gold standard imaging method for the assessment of testicular lesions (TL). The gray-scale (GSUS) and color-Doppler (CDUS) ultrasound examination allow sonographers to investigate the size, margins, echotexture, and vascular features of TLs with the aim to differentiate benign from malignant lesions. Recently, the use of contrast-enhanced US (CEUS) and sonoelastography (SE) has led to further improvements in the differential diagnosis of TL. Although GSUS and CDUS are often sufficient to suggest the benign or malignant nature of the TL, CEUS can be decisive in the differential diagnosis of unclear findings, while SE can help to strengthen the diagnosis. The contemporary combination of GSUS, CDUS, CEUS, and SE has led to a new diagnostic paradigm named multiparametric US (mp-US), which is able to provide a more detailed characterization of TLs than single techniques alone. This narrative and pictorial review aimed to describe the mp-US appearance of several TLs.

METHODS

An extensive Medline search was performed to identify studies in the English language focusing on the mp-US evaluation of TLs.

RESULTS

A practical mp-US "identity card" and iconographic characterization of several benign and malignant TLs is provided herein.

CONCLUSIONS

The mp-US characterization of TL reported herein can be useful in daily clinical practice.

Utility of contrast enhanced ultrasound (CEUS) in penile trauma

Penile traumatic injuries are rare with potentially severe consequences, with clinical assessment challenging due to pain and swelling. Ultrasound is the primary imaging modality for assessing the penis. It has a high spatial resolution and rapid availability and is portable. Contrast enhanced ultrasound is an advanced ultrasound technique that adds real-time dynamic vascular imaging safely, increasing diagnostic precision and confidence, allowing for better therapeutic management of traumatic penile injuries. Contrast enhanced ultrasound helps to delineate the extent of a haematoma, distinguishing this from the herniated corpus cavernosum, detecting the point of rupture of the tunica albuginea, showing vascular abnormalities, localising a dislocated penis and determining penile viability. The integrity of the urethra may be assessed with intracavitary contrast enhanced ultrasound. Additionally, contrast enhanced ultrasound allows monitoring of the response to endovascular and surgical treatment. This review aims to detail the anatomy and pathogenesis of penile trauma, to give guidance on optimising the contrast enhanced ultrasound technique and to obtain diagnostic examinations. Illustration of the spectrum of aspects of penile trauma will be complemented with a literature review.Critical relevance statement Contrast enhanced ultrasound is a safe and efficient imaging modality that allows for highly accurate diagnoses, helping achieve more successful and conservative treatments of penile trauma complications.Key points• Ultrasound is an accurate and safe imaging test for penile trauma.• CEUS adds dynamic vascular imaging in real-time increasing diagnostic confidence.• CEUS can delineate penile haematomas, locate fractures and demonstrate vessel integrity.• CEUS potentially allows for more conservative treatment of penile trauma complications.

[Comparison of pingyangmycin fibrin glue composite and pingyangmycin dexamethasone composite in the treatment of pharyngolaryngeal venous malformation]

Objective: To analyze and compare the efficacy and safety of pingyangmycin fibrin glue composite (PFG) and pingyangmycin dexamethasone composite (PD) in the treatment of pharyngolaryngeal venous malformation (VM). Methods: The clinical data of 98 patients with pharyngolaryngeal VM who underwent sclerotherapy with pingyangmycin composite in the First Affiliated Hospital of Sun Yat-sen University from June 2013 to November 2022 were retrospectively analyzed. According to their treatment, patients were divided into PFG group (n=34) and PD group (n=64), among those patients there were 54 males and 44 females, aged 1-77(37.06±18.86)years. The lesion size, total treatment times and adverse events were recorded before and after treatment. And the efficacy was divided into three grades: recovery, effective and invalid. According to the length of VM, all patients were divided into three subgroups, to compare the differences in efficacy and treatment times between each two groups.And finally the adverse events and their treatments were analyzed. SPSS 25.0 software was used for statistical analysis. Results: The efficacy of PFG group was 94.11%(32/34), the recovery rate was 85.29%(29/34).And the efficacy of PD group was 93.75%(60/64), the recovery rate was 64.06%(41/64). No serious adverse eventst occurred in subgroup comparison, there was no statistical difference between the two groups in efficacy and the times of treatments when the length was≤3 cm (Z_efficacy=1.04, t_{treatment times}=2.18, P>0.05); when the length was 3-5 cm, there was no significant efficacy difference between the two groups(Z_efficacy=1.17, P>0.05), but the treatment times of PFG were less (t_{treatment times}=4.87, P<0.01); when the length≥5 cm, efficacy of PFG was significantly better than PD (Z_efficacy=2.94, P<0.01), and had fewer treatments times (t_{treatment times}=2.16, P<0.01). There were no serious adverse events in either group during treatment and follow-up. Conclusion: Both PFG and PD are safe and effective composite sclerotherapy agent for the treatment of laryngeal VM, but PFG has a higher cure rate and fewer treatment times for massive lesions.

[Cadmium induces apoptosis of mouse spermatocytes (GC-2 spd) by promoting mitochondrial fission]

Objective: To study the underlying mechanism of cadmium-induced apoptosis of mouse spermatocytes (GC-2 spd) . Methods: In March 2021, GC-2 spd cells were exposed to different concentrations of CdCl(2) for 24 hours, namely 5 μmol/L CdCl(2) (low-dose) group and 10 μmol/L CdCl(2) (high-dose) group, and unexposed GC-2 spd cells were used as control group. Mitochondrial morphology was observed in the cells stained with Mito-Track Red CMXRos fluorescent probes by confocal microscopy and the mitochrondrial membrane potential was measured by flow cytometry with JC-1 fluorescent probes. Mitochrondrial proteins, cytosolic proteins and total cellular proteins of GC-2 spd cells were extracted using cell mitochondria isolation kit and RIPA buffer, respectively. The expression of mitochondrial homeostasis regulatory proteins (FIS1 and OPA1), and apoptosis-related proteins (Cytochrome c and cleaved Caspase-3) were examined by Western blot. Results: Compared with the cells in the control group, the relative ratio of JC-1 red/green fluorescence signal in the cells of the low-dose and high-dose CdCl(2) groups decreased significantly (0.740±0.071, 0.570±0.028), with a statistically significant difference (P=0.017, 0.004) ; The morphology of mitochondria changed from long tube to point, and the proportion of cells containing point mitochondria increased significantly (45.1%±3.7% and 25.7%±4.9%), the difference was statistically significant (P=0.005, 0.001) ; The relative expression level of mitochondrial FIS1 in cells of low and high dose CdCl(2) groups was significantly higher (1.271±0.120, 1.693±0.155), the difference was statistically significant (P=0.046, 0.000) ; The relative expression level of OPA1 decreased significantly (0.838±0.050, 0.682±0.040), and the difference was statistically significant (P=0.049, 0.001). Compared with the control group, the relative expression level of cytochrome c protein in the cytoplasm of cells in the low dose group of CdCl(2) was not significantly increased (1.249±0.151), and the difference was not statistically significant (P=0.075). However, the relative expression level in the cytoplasm of cells in the high dose group of CdCl(2) was significantly increased (2.355±0.110), and the difference was statistically significant (P=0.000) ; The relative expression level of Cytochrome c in mitochondria of low and high dose CdCl(2) groups decreased significantly (0.681±0.043, 0.619±0.114), with a statistically significant difference (P=0.004, 0.001) ; Moreover, the level of cleaved Caspase-3 protein in cells gradually increased (5.486±0.544, 11.493±1.739), the difference was statistically significant (P=0.004, 0.000) . Conclusion: Cadmium induced cleaved Caspase-3 mediated apoptosis of GC-2 spd cells via promoting mitochrondrial fission and the release of Cytochrome c from the mitochrondria to the cytosol.

Multiparametric ultrasound imaging characteristics of multiple testicular adrenal rest tumours in congenital adrenal hyperplasia

INTRODUCTION

Testicular adrenal rest cell tumours (TART) are rare benign adrenocorticotropic hormone-dependent testicular tumours, which can develop in patients with congenital adrenal hyperplasia. If left untreated, they can cause testicular tissue damage and infertility. Ultrasound is the imaging modality of choice allowing for non-invasive diagnosis provided that characteristic features are seen. In recent times, magnetic resonance imaging characteristics have also been described to aid diagnosis.

CASE REPORT

This case describes the imaging features of multiple bilateral TART in a young patient with congenital adrenal hyperplasia. Traditional greyscale and colour Doppler ultrasound demonstrated intratesticular, predominantly hypoechoic areas, with increased surrounding colour Doppler flow. In addition, contrast-enhanced ultrasound and strain elastography were performed, showing increased TART vascularisation and increased stiffness in the hypoechoic areas. Subsequent magnetic resonance imaging confirmed bilateral lobulated, well demarcated, intratesticular lesions, which appeared predominantly isointense on T1-weighted imaging, hypointense on T2-weighted imaging, with heterogeneous enhancement following gadolinium administration.

DISCUSSION

This case illustrates the sonographic features including greyscale, colour Doppler, contrast and elastography ultrasound of TART in a patient with congenital adrenal hyperplasia. Both contrast-enhanced ultrasound and elastography can provide information about tissue properties not normally derived from conventional ultrasound and aid accurate diagnosis. Additional magnetic resonance imaging is not normally required with typical ultrasound appearances. The unusual findings seen on the ultrasound examination were likely secondary to poor compliance with treatment.

CONCLUSION

Familiarity and recognition of characteristic and uncommon imaging features of these tumours are important to avoid misdiagnosis and surgical intervention.

[A cohort study on the incidence of HIV infection in drug abusers among men who have sex with men in Shanghai and Tianjin]

Objective: To analyze the incidence of HIV infection and identify associated risk factors in drug abusers among men who have sex with men (MSM) in Tianjin and Shanghai through a cohort study and provide a basis for HIV prevention in this population. Methods: A prospective cohort study was conducted among MSM who had a history of drug abuse in the past six months from June 2016 to June 2018 in the two cities. MSM were investigated to obtain information on sociodemographic characteristics, HIV-related sexual behaviors, and drug abuse. Follow-up investigation and HIV testing were carried out based on the baseline survey and testing. Cox regression analysis was conducted to identify the risk factors for HIV infection. Results: There were 455 eligible subjects, and 16 new HIV infection cases were identified in the 2-year follow-up survey. The cumulative follow-up time was 586.08 person-years, and the incidence of HIV infection was 2.73/100 person-years. The multivariate Cox regression analysis results showed that compared with those aged ≥25 years, consistent condom use during anal sex with men in the past six months, without mixed-use of drugs, these aged <25 years (HR=5.01, 95%CI: 1.09-23.11), inconsistent condom use during anal sex with men in the past six months (HR=1.58, 95%CI: 1.04-2.41) and mixed-use of drugs (HR=1.92, 95%CI: 1.08-3.40) were significantly associated with HIV infection in this cohort. Conclusions: The younger age, inconsistent condom use during anal sex with men, and mixed drug use appeared as risk factors of new HIV infection in drug abusers among MSM. HIV prevention and intervention in this population should be further strengthened.

[The role of RUNX1 in the apoptosis of epithelial cells in nasal polyps]

Objective: To explore the expression of Runt-related transcription factor 1 (RUNX1) in nasal polyps (NPs) tissues and the potential role on apoptosis of primary human nasal epithelial cells (pHNECs) in NPs. Methods: The expression level of RUNX1 in NPs tissues was determined by Western blot (WB) and immunohistochemical staining (IHC). In vitro, TNF-α (20 ng/ml) was used to stimulate pHNECs to establish the apoptosis injury model. Hoechst staining was performed to observe pHNECs apoptosis by kit. Subsequently, quantitative real-time PCR (qRT-PCR) and WB were utilized to detect the expression of apoptosis-related proteins B-cell lymphoma-2 (BCL-2), BCL2-associated X (BAX) and cysteinyl aspartate specific proteinase-3 (Caspase-3) to assess the level of apoptosis. The plasmid of sh-RUNX1-6 was transfected into the pHNECs apoptosis model, then the effect of RUNX1 silence on apoptosis was evaluated by WB and flow cytometry. Statistical analysis was performed by the SPSS 19.0 and GraphPad Prism5 software. Results: The expression of RUNX1 in NPs tissue was significantly higher than that in inferior turbinates, and the difference was statistically significant (0.274±0.042 vs 0.110±0.027, t=9.675, P<0.05). Compared with the inferior turbinates, BAX and Caspase-3 expressions were increased whereas BCL-2 was decreased in NPs, and the differences were statistically significant (BAX 0.346±0.032 vs 0.302±0.037, Caspase-3 0.228±0.061 vs 0.158±0.065, BCL-2 0.090±0.047 vs 0.276±0.057, t value was 2.680, 2.361 and 7.575, respectively, all P<0.05). The expression levels of RUNX1 and apoptosis in pHNECs increased in a time-dependent manner after TNF-α exposure (P<0.05). Plasmid of sh-RUNX1-6 transfected silenced the expression of RUNX1 in pHNECs treated by TNF-α. After silencing RUNX1 in pHNECs apoptosis model, the protein levels of BAX and Caspase-3 were decreased, while the expression of BCL-2 was increased, the rate of apoptosis was decreased (P<0.05). Conclusions: RUNX1 is increased in NPs. Silencing RUNX1 can inhibit the apoptosis and reduce cell inflammatory damage of pHNECs induced by TNF-α.

An unusual cause of free air in the abdomen: emphysematous cystitis with bladder diverticulum perforation

A 64-year-old male, with a history of chronic urinary outflow obstruction secondary to benign prostatic hyperplasia, presented with haematuria and urinary retention following spontaneous removal of his long-term catheter. The patient was septic on admission and a CT examination of the abdomen and pelvis showed an acutely inflamed urinary bladder diverticulum and extensive intra-abdominal free air. The patient was treated medically for emphysematous cystitis centred on a perforated bladder diverticulum, which was thought to be caused by the underlying infectious/inflammatory process. Alternative aetiologies for free air in the abdomen such a traumatic bladder perforation and gastrointestinal perforation were considered and excluded. The patient responded well to medical management and was discharged after an 11 day in-patient stay.

Contrast-Enhanced Ultrasound Quantification Assessment of Focal Fatty Variations in Liver Parenchyma: Challenging the Traditional Qualitative Paradigm of Uniform Enhancement With Adjacent Parenchyma

OBJECTIVES

The purpose of this study was to quantify contrast-enhanced ultrasound enhancement of focal fatty sparing (FFS) and focal fatty infiltration (FFI) and compare it with adjacent liver parenchyma.

METHODS

This was a retrospective observational study yielding 42 cases in the last 4 years. Inclusion criteria were a focal liver lesion, adequate video availability, and an established diagnosis of FFS or FFI based on clinical or imaging follow-up or a second modality. Contrast-enhanced ultrasound examinations were performed with a standard low-mechanical index technique. Commercially available software calculated quantitative parameters for a focal liver lesion and a reference area of liver parenchyma, producing relative indices.

RESULTS

In total, 42 patients were analyzed (19 male) with a median age of 18 (interquartile range, 42) years and a median lesion diameter of 30 (interquartile range, 16) mm. The cohort included 26 with FFS and 16 with FFI. Subjectively assessed, 27% of FFS and 25% of FFI were hypoenhancing in the arterial phase, and 73% of FFS and 75% of FFI were isoenhancing. In the venous and delayed phases, all lesions were isoenhancing. The peak enhancement (P = .001), wash-in area under the curve (P < .01), wash-in rate (P = .023), and wash-in perfusion index (P = .001) were significantly lower in FFS compared with adjacent parenchyma but not the mean transit time. In the FFI subgroup, no significant difference was detected. Comparing relative parameters, only the wash-in rate was significantly (P = .049) lower in FFS than FFI. The mean follow-up was 2.8 years.

CONCLUSIONS

Focal fatty sparing shows significantly lower and slower enhancement than the liver parenchyma, whereas FFI enhances identically. Focal fatty sparing had a significantly slower enhancement than FFI.

Paratesticular lesions: Aetiology and appearances on ultrasound

BACKGROUND

Ultrasound (US) is the primary modality for the investigation of scrotal pathology, including both intra- and paratesticular abnormalities.

OBJECTIVE

To describe the abnormalities of the paratesticular space.

MATERIALS/METHODS

The paratesticular space contains the epididymis, spermatic cord and the tunica vaginalis cavity and is affected by a variety of inflammatory or tumoral entities. Differential diagnosis based on US criteria is frequently problematic, as the findings are non-specific.

RESULTS

Some general rules apply: (i) unlike testicular lesions, extra-testicular entities are usually benign in the adult, (ii) the first steps to accurate diagnosis include careful localization of the lesion and assessment of its consistency (solid or cystic) and (iii) magnetic resonance imaging can be useful for further tissue characterization of lesions suspected to contain fat, but surgical biopsy will often provide the definite diagnosis. Contrast-enhanced ultrasound (CEUS) has been applied with limited experience indicating a narrow role, primarily for the differential diagnosis of echogenic cystic entities and the delineation of a necrotic abscess from a solid neoplasm.

DISCUSSION

The various abnormalities are discussed and illustrated.

CONCLUSION

This manuscript summarizes the literature on paratesticular lesions and the value of US in diagnosis.

Critically Ill COVID-19 Patients With Acute Kidney Injury Have Reduced Renal Blood Flow and Perfusion Despite Preserved Cardiac Function: A Case-Control Study Using Contrast-Enhanced Ultrasound

BACKGROUND

Acute kidney injury (AKI) is a common complication of COVID-19 critical illness but the pathophysiology is uncertain. Some evidence has indicated that a vascular aetiology may be implicated. We used contrast-enhanced ultrasound (CEUS) and echocardiography to study renal perfusion and global blood flow and compared our findings with measurements taken in a group of septic shock patients and healthy volunteers.

METHODS

Prospective case-control study. Renal perfusion variables were assessed with CEUS; macrovascular blood flow was assessed using Doppler analysis of large renal vessels; echocardiography was used to assess right and left heart function and cardiac output.

RESULTS

CEUS-derived parameters were reduced in COVID-19 associated AKI compared with healthy controls (perfusion index 3,415 vs. 548 a.u., P = 0·001; renal blood volume 7,794 vs. 3,338 a.u., P = 0·04). Renal arterial flow quantified using time averaged peak velocity was also reduced compared with healthy controls (36·6 cm/s vs. 20·9 cm/s, P = 0.004) despite cardiac index being similar between groups (2.8 L/min/m2 vs. 3.7 L/min/m2, P = 0.07). There were no differences in CEUS-derived or cardiac parameters between COVID-19 and septic shock patients but patients with septic shock had more heterogeneous perfusion variables.

CONCLUSION

Both large and small vessel blood flow is reduced in patients with COVID-19 associated AKI compared with healthy controls, which does not appear to be a consequence of right or left heart dysfunction. A reno-vascular pathogenesis of COVID-19 AKI seems likely.

A pictorial review of the utility of CEUS in thoracic biopsies

Lung cancer is one of the commonest malignancies worldwide and necessitates both early and personalised treatment. A key requirement is histological sampling with immunohistochemistry obtained usually from percutaneous biopsy. Conventionally thoracic biopsies are performed using CT guidance, but more recently, there has been development of physician led ultrasound biopsy for pleural lesions. Contrast-enhanced ultrasound (CEUS) has been increasingly used in interventional procedures and is able to offer benefits for thoracic biopsies including improving lesional visualisation and characterisation, targeting viable tissue and avoiding critical vascular structures as well as evaluating for the presence of post-procedural complications. This educational review aims to benefits of the role of CEUS in thoracic biopsies.

Contrast-enhanced ultrasound of the small organs in children

In pediatric and adult populations, intravenous contrast-enhanced ultrasound (CEUS) remains off-label for imaging of organs other than the liver and heart. This limited scope inhibits potential benefits of the new modality from a more widespread utilization. Yet, CEUS is potentially useful for imaging small organs such as the thyroid gland, lymph nodes, testes, ovaries and uterus, with all having locations and vasculature favorable for this type of examination. In the adult population, the utility of CEUS has been demonstrated in a growing number of studies for the evaluation of these small organs. The aim of this article is to present a review of pediatric CEUS of the thyroid gland, lymph nodes, testes, ovaries and uterus as well as to draw from the adult literature indications for possible applications in children.

Outcomes after Emergency Admission with a Diabetic Foot Attack Indicate a High Rate of Healing and Limb Salvage But Increased Mortality: 18-Month Follow-up Study

AIM

The diabetic foot attack (DFA) is perhaps the most devastating form of diabetic foot infection, presenting with rapidly progressive skin and tissue necrosis, threatening both limb and life. However, clinical outcome data in this specific group of patients are not available.

METHODS

Analysis of 106 consecutive patients who underwent emergency hospitalisation for DFA (TEXAS Grade 3B or 3D and Infectious Diseases Society of America (IDSA) Class 4 criteria). Outcomes evaluated were: 1) Healing 2) major amputation 3) death 4) not healed. The first outcome reached in one of these four categories over the follow-up period (18.4±3.6 months) was considered. We also estimated amputation free survival.

RESULTS

Overall, 57.5% (n=61) healed, 5.6% (n=6) underwent major amputation, 23.5% (n=25) died without healing and 13.2% (n=14) were alive without healing. Predictive factors associated with outcomes were: Healing (age<60, p=0.0017; no Peripheral arterial disease (PAD) p= 0.002; not on dialysis p=0.006); major amputation (CRP>100 mg/L, p=0.001; gram+ve organisms, p=0.0013; dialysis, p= 0.001), and for death (age>60, p= 0.0001; gram+ve organisms p=0.004; presence of PAD, p=0.0032; CRP, p=0.034). The major amputation free survival was 71% during the first 12 months from admission, however it had reduced to 55.4% by the end of the follow-up period.

CONCLUSIONS

In a unique population of hospitalised individuals with DFA, we report excellent healing and limb salvage rates using a dedicated protocol in a multidisciplinary setting. An additional novel finding was the concerning observation that such an admission was associated with high 18-month mortality, almost all of which was after discharge from hospital.

Vascularity of Intra-testicular Lesions: Inter-observer Variation in the Assessment of Non-neoplastic Versus Neoplastic Abnormalities After Vascular Enhancement With Contrast-Enhanced Ultrasound

The aim of this study is to assess the additional benefit of contrast-enhanced ultrasound (CEUS) over conventional ultrasonography (US) in identifying intra-testicular abnormalities among observers of different experiences. In this study, 91 focal testicular lesions (46 neoplastic, 45 non-neoplastic) imaged with gray-scale US/Doppler US and CEUS were classified using a 5-point scale. Three experienced and four inexperienced observers rated each lesion using gray-scale/color Doppler US alone and then with the addition of CEUS. Improved diagnostic specificity and accuracy with the addition of CEUS was observed for both experienced (specificity: 71.1% vs. 59.3%, p = 0.005; accuracy: 83.5% vs. 76.9%, p = 0.003) and inexperienced observers (specificity: 75.6% vs. 51.7%, p = 0.005; accuracy: 80.2% vs. 72.0%, p < 0.001). Significant inter-observer variability between the experienced and inexperienced observers when assessing conventional US alone was eliminated with the addition of CEUS. CEUS improves diagnostic accuracy of focal intra-testicular lesions for both experienced and inexperienced observers and reduces inter-observer variability in inexperienced operators.

The role of multiparametric ultrasound in the diagnosis of paediatric scrotal pathology

Multiparametric ultrasound (MPUS), combining conventional techniques (greyscale and colour Doppler ultrasound), ultrasound strain elastography, and contrast-enhanced ultrasound (CEUS), has been successfully used in the assessment of adult scrotal pathology. Contrast-enhanced ultrasound can confidently establish testicular tissue vascularity even in the small-volume paediatric testis. Elastography provides further assessment of tissue stiffness, potentially adding useful diagnostic information. In children, ultrasonography is particularly advantageous, being safe, radiation-free and negating the need for sedation or general anaesthesia during the imaging evaluation. In this review article, we aim to familiarise readers with the MPUS scanning protocol used for paediatric scrotal examination and provide an overview of scrotal MPUS features, with particular focus to clinical indications where MPUS may be advantageous over conventional ultrasonography.

The role of contrast-enhanced ultrasound (CEUS) in the evaluation of scrotal trauma: a review

Testicular trauma is common, usually trivial and rarely requires hospital attendance, but if it does, then imaging becomes essential as scrotal assessment may be difficult due to pain and/or scrotal disruption. Ultrasound (US) assumes a crucial role as other cross-sectional modalities have a limited use in the acute presentation. Despite the acceptable accuracy of conventional US techniques, there are limitations which hinder a thorough evaluation, critically the assessment of tissue viability, crucial for clinical management and prognosis. Contrast-enhanced ultrasound (CEUS) has been shown to offer improved flow visualisation and tissue perfusion compared with conventional Doppler techniques. CEUS can accurately and confidently demonstrate the viability of testicular parenchyma, delineate fracture lines and haematomas and guide treatment for testis-sparing surgery or orchidectomy. The purpose of this review is to present the literature, familiarise physicians with the principles of CEUS and findings of scrotal trauma and illustrate the main abnormalities through characteristic and educative cases.

General principles and overview of vascular contrast-enhanced ultrasonography

Ultrasonography (US) is the first-line modality for the evaluation of vascular pathology. Although well-established for many diseases, US has inherent limitations that can occasionally hinder an accurate diagnosis. The value of US was improved by the introduction of microbubbles as ultrasonographic contrast agents (UCAs) and the emergence of contrast-enhanced ultrasonography (CEUS), following the introduction of second-generation UCAs and the emergence of modern contrast-specific techniques. CEUS offers valuable information about vascular disease, both on a macrovascular and a microvascular level, with well-established applications for carotid disease, post-interventional follow-up of abdominal aortic aneurysms, and the assessment of portal vein thrombosis. The purpose of this review is to discuss the principles of CEUS and to present an overview of its vascular applications.

Elastography of focal testicular lesions: current concepts and utility

As a relatively new sonographic technique, tissue elastography has emerged as a qualitative and potentially quantitative adjunctive tool to provide additional information on tissue stiffness, aiming to further improve diagnostic confidence in discriminating benign from malignant focal testicular lesions. The purpose of this review is to provide an overview of the elastography techniques used to assess focal testicular lesions and their typical appearance on tissue elastography.

Endocavitary contrast enhanced ultrasound (CEUS): a novel problem solving technique

Abstract

Contrast-enhanced ultrasound (CEUS) is a technique that has developed as an adjunct to conventional ultrasound. CEUS offers a number of benefits over conventional axial imaging with computerised tomography and magnetic resonance imaging, primarily as a “beside” test, without ionising radiation or the safety concerns associated with iodinated/gadolinium-based contrast agents. Intravascular use of ultrasound contrast agents (UCAs) is widespread with extensive evidence for effective use. Despite this, the potential utility of UCAs in physiological and non-physiological cavities has not been fully explored. The possibilities for endocavitary uses of CEUS are described in this review based on a single-centre experience including CEUS technique and utility in confirming drain placement, as well as within the biliary system, urinary system, gastrointestinal tract and intravascular catheters.

Teaching Points

• CEUS offers an excellent safety profile, spatial resolution and is radiation free.

• Endocavitary CEUS provides real-time imaging similar to fluoroscopy in a portable setting.

• Endocavitary CEUS can define internal architecture of physiological cavities.

• Endocavitary CEUS can confirm drain position in physiological and non-physiological cavities.

Internal jugular vein aneurysm in an adult: diagnosis on non-invasive imaging

We report the case of a 48-year-old man with a right fusiform internal jugular venous aneurysm, presenting as a unilateral painless neck swelling on coughing or laughing. This is a rare condition, more commonly seen in the paediatric population and can be diagnosed using non-invasive modalities such as Doppler ultrasound and contrast-enhanced CT. This anomaly is frequently misdiagnosed or overlooked, and our case highlights the importance of considering venous aneurysm as a differential to prevent invasive imaging and inappropriate management.

Common and uncommon features of focal splenic lesions on contrast-enhanced ultrasound: a pictorial review

The characterization of focal splenic lesions by ultrasound can be quite challenging. The recent introduction of contrast-enhanced ultrasound (CEUS) has come to play a valuable role in the field of imaging splenic pathologies, offering the possibility of an ionizing radiation-free investigation. Because CEUS has been incorporated into everyday clinical practice, malignant diseases such as focal lymphomatous infiltration, metastatic deposits, benign cysts, traumatic fractures, and hemangiomas can now be accurately depicted and characterized without the need for further imaging. More specifically, splenic traumatic fractures do not require additional imaging by computed tomography (with ionizing radiation exposure) for follow-up, because splenic fractures and their complications are safely imaged with CEUS. In the new era of CEUS, more patients benefit from radiation-free investigation of splenic pathologies with high diagnostic accuracy.

[The clinical characteristics of adult hemophagocytic lymphohistiocytosis treated with haploidentical donor hematopoietic stem cell transplantation]

Objective: To analyze the clinical characteristics of adult patients with hemophagocytic lymphohistiocytosis (HLH) receiving haploidentical donor hematopoietic stem cell transplantation (HID HSCT). Method: We retrospectively reviewed 20 adult patients with HLH from August 2009 to August 2014.The clinical features and outcome were analyzed. Results: Conditioning regimens consisted of total body irradiation/etoposide/cyclophosphamide (TBI/VP-16/CTX) and busulfan (Bu)/VP-16/CTX in HLH with anti-thymocyte globulin (ATG) 8 mg/kg.The stem cells were mobilized from donors' peripheral blood.Median time to white blood cell engraftment was 13 (9-27) days.Median time to platelet engraftment was 14 (10-28) days.Mixed chimerism after transplantation developed in 4 patients and no patient presented graft failure.Eight patients developed grade Ⅱ to Ⅲ acute graft-versus-host disease (GVHD), while as chronic GVHD occurred in 9 patients.Among 12 patients with EB virus(EBV) reactivation, 2 patients developed post-transplant lymphoproliferative disorder (PTLD), 7 were suspected as PTLD and 3 were considered as relapse of primary disease.With a median follow-up of 20 months (range: 0.5-108 months) after transplantation, the estimated 2-year overall survival (OS) rate was (60.0±11.0)% in all patients.During the follow-up, 12 patients survived, 8 died including 5 within 100 days after HSCT.Among 5 non-remission patients before HSCT, 4 patients died within 100 days after HCT. Conclusions: HID HSCT is an effective treatment for adult patients with HLH to achieve remission and long-term survival. High proportion of mixed chimerism has been seen at early stage after transplantation.EBV reactivation and early transplant-related mortality are common.

Contrast-enhanced US-guided Interventions: Improving Success Rate and Avoiding Complications Using US Contrast Agents

Ultrasonography (US) is an established modality for intervention. The introduction of microbubble US contrast agents (UCAs) has the potential to further improve US imaging for intervention. According to licensing, UCAs are currently approved for clinical use in restricted situations, but many additional indications have become accepted as having clinical value. The use of UCAs has been shown to be safe, and there is no risk of renal toxic effects, unlike with iodinated or gadolinium contrast medium. Broadly speaking, UCAs can be injected into the bloodstream (intravascular use) or instilled into almost any accessible body cavity (endocavitary use), either in isolation or synchronously. In microvascular applications, contrast-enhanced US (CEUS) enhances delineation of necrotic areas and the vascularized target to improve real-time targeting. The ability of CEUS to allow true assessment of vascularity has also been used in follow-up of devascularizing intervention. In macrovascular applications, real-time angiographic images can be obtained with CEUS without nephrotoxic effects or radiation. In endocavitary applications, CEUS can achieve imaging similar to that of iodinated contrast medium-based fluoroscopy; follow-up to intervention (eg, tubography and nephrostography) can be performed at the bedside, which may be advantageous. The use of UCAs is a natural progression in US-guided intervention. The aim of this article is to describe the indications, contraindications, and techniques of using UCAs as an adjunctive tool for US-guided interventional procedures to facilitate effective treatment, improve complication management, and increase the overall success of interventional procedures. Online supplemental material is available for this article. ^©RSNA, 2016.

Multiparametric Sonography of Hematologic Malignancies of the Testis: Grayscale, Color Doppler, and Contrast-Enhanced Ultrasound and Strain Elastographic Appearances With Histologic Correlation

Primary testicular lymphoma is rare and appears with nonspecific findings on grayscale and color Doppler sonography. We present 8 patients further examined with contrast-enhanced sonography, strain elastography, and histologic analysis after orchiectomy. Seven of 8 patients had a diagnosis of large B-cell lymphoma, and 1 of 8 had a diagnosis of granulocytic sarcoma, with solitary lesions (2 of 8), multiple lesions (3 of 8), or entire testicular involvement (3 of 8). Lesions appeared hypoechoic (7 of 8) or isoechoic (1 of 8), all with increased vascularity on color Doppler sonography and a nonbranching linear pattern of intratumoral vessels (7 of 8). Contrast-enhanced ultrasound (CEUS) confirmed this pattern and showed increased enhancement in all lesions. On strain elastography, all lesions were hard, with an elasticity score of greater than 4. Multiparametric sonography of testicular lymphoma identifies increased vascularity on color Doppler and contrast-enhanced ultrasound and increased lesion stiffness on strain elastography.

Sonographic imaging of extra-testicular focal lesions: comparison of grey-scale, colour Doppler and contrast-enhanced ultrasound

Extra-testicular lesions are usually benign but present with nonspecific grey-scale sonography findings. This study assesses conventional sonographic characteristics in the differentiation of extra-testicular tumoural from inflammatory lesions and whether contrast-enhanced ultrasound has a role. A retrospective database analysis was performed. All patients were examined by experienced sonographers employing standard techniques combining grey-scale, colour Doppler sonography and contrast-enhanced ultrasound. Features recorded were: clinical symptoms, size, location, echogenicity, colour Doppler sonography and contrast-enhanced ultrasound enhancement. Vascularity on colour Doppler sonography and contrast-enhanced ultrasound was graded and compared. The lesions were classified as tumoural or inflammatory. The Chi-square test was used to analyse the sonographic patterns and kappa coefficient to measure the agreement between colour Doppler sonography and contrast-enhanced ultrasound. A total of 30 lesions were reviewed (median diameter 12 mm, range 5-80 mm, median age 52 years, range 18-86 years), including 13/30 tumoural and 17/30 inflammatory lesions. Lesions were hypoechoic (n = 12), isoechoic (n = 6), hyperechoic (n = 2) or mixed (n = 10). Grey-scale characteristics of tumoural vs. inflammatory lesions differed significantly (P = 0.026). On colour Doppler sonography, lesions had no vessels (n = 16), 2-3 vessels (n = 10) and ≥4 vessels (n = 4). On contrast-enhanced ultrasound, lesions showed no vascularity (n = 17), perfusion similar to testis (n = 7) and higher (n = 6). All abscesses identified (n = 9) showed no vascularity on both colour Doppler sonography and contrast-enhanced ultrasound. There was good agreement between these techniques in evaluating vascularity (κ = 0.719) and no significant difference between colour Doppler sonography and contrast-enhanced ultrasound of tumoural vs. inflammatory lesions (P > 0.05). The grey-scale appearances of extra-testicular lesions are essential for characterisation. Colour Doppler sonography and contrast-enhanced ultrasound findings are not useful in that respect. Contrast-enhanced ultrasound is excellent in establishing absence of vascularity.

Multiparametric sonographic imaging of a capillary hemangioma of the testis: appearances on gray-scale, color Doppler, contrast-enhanced ultrasound and strain elastography

We report a case of a lobular capillary hemangioma in a 66-year-old man, who presented with left testicular pain, with an asymptomatic incidental right testicular lesion found on ultrasonography. The sonographic examination demonstrated a heterogeneous mainly iso-echoic intratesticular lesion with marked vascularity on the color Doppler examination. Further evaluation with contrast-enhanced ultrasound and strain elastography was performed; the multiparametric imaging suggested a benign tumor. The multidisciplinary team decision with patient consent was to perform a radical orchiectomy with subsequent histopathology confirming a benign lobular capillary hemangioma.

Multiparametric Sonography of Testicular Hematomas: Features on Grayscale, Color Doppler, and Contrast-Enhanced Sonography and Strain Elastography

We investigated the appearances of intratesticular hematomas on multiparametric sonography combining grayscale, color Doppler, and contrast-enhanced sonography and strain elastography. Over a 3-year period, 17 hematomas in 8 patients were analyzed. Blunt trauma (n = 7) and surgery (n = 1) were preceding events. Grayscale sonography showed well-defined oval or round predominantly hypoechoic and heterogeneous, peripherally (n = 13) or centrally (n = 4) located lesions. Three showed contrast enhancement of septations, and 4 showed peripheral lesion rim enhancement. On strain elastography, the mean strain ratio was 1.19 (range, 0.41-2.36), and elasticity score were 3 or lower (n = 13) and 5 (n = 4). Multiparametric sonography shows nonenhancement with contrast and predominantly "soft" elastographic properties and aids in the interpretation of the benign nature of intratesticular hematomas.

Effect of the Schneiderian membrane on the formation of bone after lifting the floor of the maxillary sinus: an experimental study in dogs

A titanium membrane was used to isolate the Schneiderian membrane of the bony walls of the sinus so that we could investigate their role on the formation of bone after sinus lifts compared with a control group (conventional raising of the sinus floor) in which we did not use a membrane to isolate any area. Three canine models of lifting the sinus floor using the lateral window technique were established: conventional lifting of the floor (control group), raising of the floor with the mucosa shielded (mucosal shielding group), and raising of the floor with the bony wall shielded (bony wall shielding group). The formation of bone one and three months after the sinus floor had been lifted was compared in each group both grossly and by histopathological examination. An appreciable amount of new bone had formed in the control group, with abundant areas near the inferior bony wall, and some near the raised Schneiderian membrane. Similarly, new bone had also formed in the mucosal shielding group, with abundant new bone near the inferior bony wall, but none near the raised Schneiderian membrane. However, there was considerably less new bone in the bony wall shielding group, with none in tissues adjacent to the inferior bony wall and little in tissues near the raised Schneiderian membrane. The Schneiderian membrane has osteogenic capability and participates in the formation of bone after the sinus floor has been lifted. However, its osteogenic role is weaker than that of the surrounding bony wall of the maxillary sinus.

The diabetic foot: the importance of coordinated care

Because of the severe morbidity and mortality associated with diabetes, diabetic foot care is an essential component of a peripheral vascular service. The goal of this article is to describe the vascular diabetic foot care pathway and how the coordinated foot care service for diabetic patients is delivered at King's College Hospital, London.

Transformation of the Multidisciplinary Diabetic Foot Clinic Into a Multidisciplinary Diabetic Foot Day Unit

The natural history of the diabetic foot is aggressive and complex. To counteract this, we describe the transformation of a Multidisciplinary Diabetic Foot Clinic into a Multidisciplinary Diabetic Foot Day Unit, which delivers an emergency open access system for patients, with a “one-stop,” same day service in which investigations are performed, results reviewed and treatment implemented. It also provides joint clinics with vascular, orthopaedic, and plastic surgeons and specialized clinics for casting of complex neuropathic feet and for the administration of intravenous or intramuscular antibiotics on the same day. The aim was to document these increasingly wide-ranging facilities by undertaking a retrospective evaluation over a 6-week period, with analysis of notes, investigations, and an anonymous patient satisfaction survey. The clinic was visited by 597 patients who attended in 1076 appointments, of which 112 (10.4%) were emergency visits; these patients attended the clinic without a booked appointment but via an open access policy, 93 of whom were known to the clinic, but 19 were new self-referred patients to the service. Furthermore, 197 (18%) were seen in a Joint Vascular Diabetic Foot Clinic and 98 (9%) were seen in a Joint Orthopaedic Plastic Diabetic Foot Clinic, 570 (53%) were seen in an Active Ulcer Clinic and 97 (9%) in a Total Contact Casting Clinic. Forty-five percent of patients were prescribed antibiotics, including 188 (76%) as oral and 45(18%) as intravenous antibiotics and 15(6%) as intramuscular injections. Of the 1076 appointments, 150 (14%) patients were in the foot clinic for more than 4 hours. Sixty (10%) patients were reviewed 4 or more times over the 6-week period. Only 22 (2%) were admitted to hospital. Of the 125 survey responders, 98% were satisfied with this service, which has evolved from a Diabetic Foot Clinic into a Multidisciplinary Diabetic Foot Day Unit.

Cortical necrosis secondary to trauma in a child: contrast-enhanced ultrasound comparable to magnetic resonance imaging

Cortical necrosis is an uncommon cause of renal impairment and is rarely a consequence of blunt abdominal trauma. We present a case of unilateral traumatic acute cortical necrosis in a child demonstrated on contrast-enhanced US with confirmation on MRI. Contrast-enhanced US provides a rapid, accurate evaluation of renal parenchyma abnormalities in blunt abdominal trauma in children without exposure to ionising radiation or the risk of sedation.

Effects of partial tonsillectomy on the immune functions of children with obstructive sleep apnea-hypopnea syndrome at early stage

The purpose of this study was to investigate the changes in the humoral and cellular immunity of children with obstructive sleep apnea-hypopnea syndrome and hypertrophy of tonsils before and after plasma-mediated temperature-controlled radiofrequency ablation treatment. Fifty-seven children suffering from obstructive sleep apnea-hypopnea syndrome and with hypertrophy of tonsils were enrolled in this study. Thirty-seven children were grouped in the partial tonsillectomy group and 20, in the tonsillectomy group. The levels of CD3(+), CD4(+), CD8(+), and CD4(+)/CD8(+) were measured for cellular immunity, and the levels of IgG, IgA, and IgM were measured for humoral immunity. Blood samples were collected before and 1 and 3 months after the operation. The IgG, IgA, and IgM levels in the tonsillectomy group were significantly decreased 1 month after the operation, and recovered to the normal levels within 3 months of the operation (P < 0.05). However, the levels of IgG, IgA, and IgM in the partial tonsillectomy group decreased slightly, without a significant difference (P > 0.05). The cellular immunity of the 2 groups was not statistically different pre- and post-operation (P > 0.05). The results from the present study indicate that partial tonsillectomy by plasma-mediated temperature-controlled radiofrequency ablation did not impact on the humoral and cellular immunity of children.

Reduced mortality and severe disability rates in the SENTIS trial

BACKGROUND AND PURPOSE

The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial showed a trend for reduced all-cause mortality and positive secondary safety end point outcomes. We present further analyses of the mortality and severe disability data from the Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial.

MATERIALS AND METHODS

The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial was a multicenter, randomized, controlled trial that evaluated the safety and effectiveness of the NeuroFlo catheter in patients with stroke. The current analysis was performed on the as-treated population. All-cause and stroke-related mortality rates at 90 days were compared between groups, and logistic regression models were fit to obtain ORs and 95% CIs for the treated versus not-treated groups. We categorized death-associated serious adverse events as neurologic versus non-neurologic events and performed multiple logistic regression analyses. We analyzed severe disability and mortality by outcomes of the mRS. Patient allocation was gathered by use of a poststudy survey.

RESULTS

All-cause mortality trended in favor of treated patients (11.5% versus 16.1%; P = .079) and stroke-related mortality was significantly reduced in treated patients (7.5% versus 14.2%; P = .009). Logistic regression analysis for freedom from stroke-related mortality favored treatment (OR, 2.41; 95% CI, 1.22, 4.77; P = .012). Treated patients had numerically fewer neurologic causes of stroke-related deaths (52.9% versus 73.0%; P = .214). Among the 90-day survivors, nominally fewer treated patients were severely disabled (mRS 5) (5.6% versus 7.5%; OR, 1.72; 95% CI, 0.72, 4.14; P = .223). Differences in allocation of care did not account for the reduced mortality rates.

CONCLUSIONS

There were consistent reductions in all-cause and stroke-related mortality in the NeuroFlo-treated patients. This reduction in mortality did not result in an increase in severe disability.

Complete mitochondrial genomes of the Bright Sunbeam Curetis bulis and the Small Copper Lycaena phlaeas (Lepidoptera: Lycaenidae) and their phylogenetic implications

In this study, the complete mitochondrial genomes of Curetis bulis and Lycaena phlaeas were determined and analyzed. The circular genomes are 15,162 bp long for C. bulis and 15,280 bp long for L. phlaeas, with a total A+T content of 82.6 and 83.1%, respectively. Both mitogenomes contain 37 genes, and their gene orders are similar to those of other lepidopterans. All protein-coding genes (PCGs) are initiated by ATN codons, except for cox1, which is started with the CGA codon; all PCGs terminate in the typical stop codon TAA, except for cox1, cox2, and nad4, which end with a single T. The codons TTA (Leu), ATT (Ile), TTT (Phe), ATA (Met), and AAT (Asn) appear the most frequently. Both of the mitogenome A+T-rich regions harbor the motif ATAGA, followed by a 19-bp poly(T) stretch, with C. bulis containing a microsatellite-like (AT)5 element next to the ATTTA motif, and L. phlaeas containing a microsatellite-like (TA)6 (AT) element next to the ATTTA motif. The phylogenetic trees of the 17 representative butterfly species, including the two species of this study, were reconstructed with the maximum likelihood and Bayesian inference methods, based on the 13 PCG nucleotide sequence data. The results of the phylogenetic analyses strongly supported the relationships of ((((Lycaenidae + Pieridae) + Nymphalidae) + Hesperiidae) + Papilionidae), which was markedly different from the traditional morphological view of the Lycaenidae and Nymphalidae considered to be sisters of each other.

Focal testicular lesions: colour Doppler ultrasound, contrast-enhanced ultrasound and tissue elastography as adjuvants to the diagnosis

The aim of this review is to illustrate the potential of different and newer ultrasound techniques beyond conventional B-mode imaging, including colour Doppler ultrasound, contrast-enhanced ultrasound (CEUS) and tissue elastography, in the characterisation of both benign and malignant intratesticular lesions. Normally, testicular malignancies, either primary or secondary, demonstrate an increase in colour Doppler signal. However, there is a diversity of benign testicular lesions that may mimic testicular malignancies. The use of CEUS improves characterisation of testicular lesions, and confirms lack of vascularity in benign abnormalities such as epidermoid cysts, infarctions, abscesses and changes following trauma. Tissue elastography allows further evaluation of the cellular consistency of the abnormality. Familiarity with the appearances seen with these ultrasound techniques in both benign and malignant abnormalities should aid in improving confidence in arriving at the correct diagnosis.

Effect of Aeromonas hydrophila on reductive dechlorination of DDTs by zero-valent iron

This study presents a reductive transformation method that combines zerovalent iron (ZVI) and Aeromonas hydrophila HS01 with iron oxide reduction property to degrade DDT (1,1-trichloro-2,2-bis(4-chlorophenyl)ethane) under anoxic conditions. The results suggest that HS01 has weak capability in terms of reducing DDT to DDD (1,1-dichloro-2,2-bis(p-chlorophenyl)ethane) and nearly failed to reduce DDD or its transformed intermediates. The coexistence of ZVI and HS01 results in a slight enhancement of DDT degradation compared with the ZVI system alone. The reduction of intermediates by ZVI, however, can be obviously accelerated in the presence of HS01, and the addition of anthraquinone-2,6-disulfonic disodium salt (AQDS) can accelerate the transformation rates further, especially for intermediate reduction. The analysis of the amount and electrochemical properties of Fe(III)/Fe(II) indicates that the presence of HS01 with or without AQDS is beneficial to the reduction of Fe(III) to Fe(II), resulting in the removal of passivating ferric precipitates on the ZVI surface. A mechanism and pathway that clarify the roles of ZVI, HS01, and AQDS in the ZVI + HS01 + AQDS system for DDT transformation are proposed. The quick removal of surface ferric precipitates is thought to be the reason for the enhancement of the transformation of DDT and its intermediates.

Malignant Atrophic Papulosis with Severe Gastrointestinal Perforation and Omental Necrosis: A Case Report

Malignant atrophic papulosis (MAP) is a rare disease with an extremely grim prognosis, death being due to gastrointestinal perforation and neurological disorders. We report a severe case of MAP in a 37-year old woman. The patient had three emergent laparotomies in 3 months for recurrent acute peritonitis due to omental thrombosis resulting in necrosis, multiple intestinal and mesenteric lesions, and severe gastrointestinal perforations. Multiple papular skin lesions were present for 1 year prior to surgery. Pathological findings revealed MAP. Surgical intervention was successful and the patient recovered smoothly but later died of malnutrition and septicaemia.

Enhanced reductive dechlorination of DDT in an anaerobic system of dissimilatory iron-reducing bacteria and iron oxide

The transformation of DDT was studied in an anaerobic system of dissimilatory iron-reducing bacteria (Shewanella decolorationis S12) and iron oxide (alpha-FeOOH). The results showed that S. decolorationis could reduce DDT into DDD, and DDT transformation rate was accelerated by the presence of alpha-FeOOH. DDD was observed as the primary transformation product, which was demonstrated to be transformed in the abiotic system of Fe(2+)+alpha-FeOOH and the system of DIRB+alpha-FeOOH. The intermediates of DDMS and DBP were detected after 9 months, likely suggesting that reductive dechlorination was the main dechlorination pathway of DDT in the iron-reducing system. The enhanced reductive dechlorination of DDT was mainly due to biogenic Fe(II) sorbed on the surface of alpha-FeOOH, which can serve as a mediator for the transformation of DDT. This study demonstrated the important role of DIRB and iron oxide on DDT and DDD transformation under anaerobic iron-reducing environments.