Efficacy of cx601 (darvadstrocel) for the treatment of perianal fistulizing Crohn's disease-A prospective nationwide multicenter cohort study

BACKGROUND

The use of mesenchymal stem cells is considered a novel and promising therapeutic option for patients with perianal fistulizing Crohn's disease; however, data on its clinical application remain scarce. This multicenter nationwide study aimed to assess the clinical efficacy of mesenchymal stem cells in closing complex anal fistulas.

METHODS

In this study 14 Crohn's disease patients (3 males, 11 females) with complex anal fistulas treated in 3 tertiary hospitals in Austria were included between October 2018 and April 2021. Injection of 120 million allogeneic expanded adipose-derived mesenchymal stem cells (Cx601-darvadstrocel) was performed in each patient. Closure of the external fistula opening without secretion by external manual compression was defined as treatment success.

RESULTS

The median age of the patient population at the time of surgery was 32 years (range 26-53 years) with a median body mass index of 21.7 kg/m2 (range 16.7-26.6 kg/m2). Of the patients 12 (86%) received monoclonal antibodies (infliximab, adalimumab, ustekinumab, vedolizumab) at the time of surgery. The median number of complex fistulas was 1.4 (range 1-2), The median operative time was 20 min (range 6-50 min) with no perioperative complications. After a median follow-up of 92 weeks, we found successful fistula closure in 57.1% (n = 8) of treated patients. The perianal disease activity index did not improve significantly from initially 7 to a median of 6 after 52 weeks (p = 0.495).

CONCLUSION

Darvadstrocel is a safe, minimally invasive surgical technique without significant perioperative complications. Clinical success can be expected in about half of the treated patients.

Contrast-enhanced ultrasound of the liver: Vascular pathologies and interventions

Over the past two decades, contrast-enhanced ultrasound (CEUS) has been established as a method complementary to B-mode ultrasound and color Doppler sonography for diagnosing vascular liver pathologies and interventions.The objective of this review is to elucidate the application of CEUS in diagnosing vascular pathologies and interventional procedures.Considering the limitations of ultrasound, CEUS presents a similar alternative to other imaging modalities, such as computed tomography and magnetic resonance imaging, for evaluating vascular pathologies, guiding interventions, identifying complications, and assessing outcomes post intervention. Due to its widespread availability and the absence of radiation exposure, CEUS should be employed as a primary modality. · CEUS plays an important role in the detection of vascular liver pathologies.. · CEUS is helpful in characterizing vascular pathologies.. · CEUS is helpful in guiding interventions and identifying complications..

Ultra-low-dose CT vs. chest X-ray in non-traumatic emergency department patients - a prospective randomised crossover cohort trial

Background

Ultra-low-dose CT (ULDCT) examinations of the chest at only twice the radiation dose of a chest X-ray (CXR) now offer a valuable imaging alternative to CXR. This trial prospectively compares ULDCT and CXR for the detection rate of diagnoses and their clinical relevance in a low-prevalence cohort of non-traumatic emergency department patients.

Methods

In this prospective crossover cohort trial, 294 non-traumatic emergency department patients with a clinically indicated CXR were included between May 2nd and November 26th of 2019 (www.clinicaltrials.gov: NCT03922516). All participants received both CXR and ULDCT, and were randomized into two arms with inverse reporting order. The detection rate of CXR was calculated from 'arm CXR' (n = 147; CXR first), and of ULDCT from 'arm ULDCT' (n = 147; ULDCT first). Additional information reported by the second exam in each arm was documented. From all available clinical and imaging data, expert radiologists and emergency physicians built a compound reference standard, including radiologically undetectable diagnoses, and assigned each finding to one of five clinical relevance categories for the respective patient.

Findings

Detection rates for main diagnoses by CXR and ULDCT (mean effective dose: 0.22 mSv) were 9.1% (CI [5.2, 15.5]; 11/121) and 20.1% (CI [14.2, 27.7]; 27/134; P = 0.016), respectively. As an additional imaging modality, ULDCT added 9.1% (CI [5.2, 15.5]; 11/121) of main diagnoses to prior CXRs, whereas CXRs did not add a single main diagnosis (0/134; P < 0.001). Notably, ULDCT also offered higher detection rates than CXR for all other clinical relevance categories, including findings clinically irrelevant for the respective emergency department visit with 78.5% (CI [74.0, 82.5]; 278/354) vs. 16.2% (CI [12.7, 20.3]; 58/359) as a primary modality and 68.2% (CI [63.3, 72.8]; 245/359) vs. 2.5% (CI [1.3, 4.7]; 9/354) as an additional imaging modality.

Interpretation

In non-traumatic emergency department patients, ULDCT of the chest offered more than twice the detection rate for main diagnoses compared to CXR.

Funding

The Department of Biomedical Imaging and Image-guided Therapy of Medical University of Vienna received funding from Siemens Healthineers (Erlangen, Germany) to employ two research assistants for one year.

Transversal psoas muscle thickness measurement is associated with response and survival in patients with HCC undergoing immunotherapy

BACKGROUND

Sarcopenia is a common problem in patients with HCC. We aimed to evaluate the prognostic and predictive value of baseline transversal psoas muscle thickness (TPMT) measurement in patients with HCC undergoing immunotherapy.

METHODS

HCC patients treated with programmed death ligand 1-based therapies between June 2016 and October 2022 at the Vienna General Hospital (n = 80) and the Hôpital Beaujon Clichy (n = 96) were included and followed until April 2023. TPMT at the level of the third lumbar vertebra was measured independently by 2 radiologists to evaluate interreader reliability. TPMT <12 mm/m in men and <8 mm/m in women indicated sarcopenia.

RESULTS

Overall, 176 patients (age: 66.3±11.7 y; male: n=143, 81%, Barcelona-Clinic Liver Cancer C: n=121, 69%) were included, of which 131 (74%) exhibited cirrhosis. Interreader agreement for the diagnosis of sarcopenia based on TPMT was 92.6%, and Cohen κ showed a "strong agreement" [κ = 0.84 (95% CI: 0.75-0.92)]. Sarcopenia, present in 58 patients (33%), was associated with shorter median overall survival [7.2 (95% CI: 5.0-9.5) vs. 22.6 (95% CI: 16.4-28.8 months); p < 0.001] and median progression-free survival [3.4 (95% CI: 0.2-6.8) vs. 7.9 (95% CI: 5.8-9.9 months), p = 0.001], and an independent predictor of overall [adjusted HR: 1.63 (95% CI: 1.07-2.48)] and progression-free mortality [adjusted HR: 1.54 (95% CI: 1.06-2.23)] in multivariable analyses. The objective response rate [evaluable in 162 subjects (92.0%)] per modified Response Evaluation Criteria In Solid Tumors (mRECIST) in patients with and without sarcopenia was 22% and 39%, respectively (p = 0.029). Survival and radiological responses were worse in patients with sarcopenia and systemic inflammation [median overall survival: 6.1 (95% CI: 3.6-8.6) mo; median progression-free survival: 2.8 (95% CI: 2.1-3.4) mo; objective response rate=16%; disease control rate=39%].

CONCLUSIONS

Evaluation of sarcopenia using TPMT measurement is reliable and identifies HCC patients with a dismal prognosis and response to immunotherapy.

Measuring what matters in healthcare: a practical guide to psychometric principles and instrument development

The provision of quality healthcare relies on scales and measures with robust evidence of their psychometric properties. Using measurement instruments with poor reliability, validity, or feasibility, or those that are not appropriate for the target diagnostic group or construct/dimension under consideration, may be unfavorable for patients, unproductive, and hinder empirical advancement. Resources from the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) group can assist in identifying and developing psychometrically sound measures. The COSMIN initiative is the only international, research-based practice taxonomy and methodological guidelines for measurement in healthcare. This manuscript aims to provide an accessible introduction to theories, principles and practices of psychometrics, instrument properties, and scale development, with applied examples from the COSMIN recommendations. It describes why measurement in healthcare is critical to good practice, explains the concepts of the latent variable and hypothetical construct and their importance in healthcare assessments, explores issues of flawed measurement and briefly explains key theories relevant to psychometrics. The paper also outlines a ten-step process to develop and validate a new measurement instrument, with examples drawn from a recently developed visuoperceptual measure for analysis of disordered swallowing to demonstrate key concepts and provides a guide for understanding properties of and terminology related to measurement instruments. This manuscript serves as a resource for healthcare clinicians, educators, and researchers who seek to develop and validate new measurement instruments or improve the properties of existing ones. It highlights the importance of using psychometrically sound measurement instruments to ensure high-quality healthcare assessments.

Necrotizing pancreatitis, microangiopathic hemolytic anemia and thrombocytopenia following the second dose of Pfizer/BioNTech COVID-19 mRNA vaccine

Implementing vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a major asset in slowing down the coronavirus disease 2019 (COVID-19) pandemic. For mRNA vaccines, the main severe adverse events reported in pharmacovigilance systems and post-authorization studies were anaphylaxis and myocarditis. Pancreatitis after Pfizer/BioNTech COVID-19 vaccination has been reported only in 10 patients.We report a 31-year-old female with a history of borderline personality disorder, intravenous drug abuse, allergic asthma, eating disorder, psoriatic arthritis treated with tofacitinib, neurogenic bladder disturbance, cholecystectomy, recurrent thoracic herpes zoster, vaginal candida infections and urinary tract infections, who developed pancreatitis associated with thrombotic microangiopathy and hemolytic-uremic syndrome 10 days after the second vaccination, whereas the first has been well tolerated. She was treated by plasma exchange, and eventually by transgastric drainage with implantation of a plastic stent to remove fluid abdominal retentions. She was discharged after 19 days. Since then her condition has improved continuously. Computed tomography after 12 months did not reveal retentions anymore.As other causes of pancreatitis have been excluded, this case of acute pancreatitis, microangiopathic hemolytic anemia and thrombocytopenia, temporally associated with the Pfizer-BioNTech COVID-19 vaccine, suggests a causal link.

[CT colonography : Technique and indications]

BACKGROUND

Dedicated radiological expertise and a high-quality examination, performed according to current technical standards and for accepted indications, are prerequisite to achieve excellent results with CT colonography (CTC).

OBJECTIVES

The aim of this article is to review current standards of the examination technique as well as indications and contraindications for CTC based on recent recommendations and guidelines.

MATERIALS AND METHODS

Based on extensive literature research, current knowledge about the examination technique and the indications and contraindications is summarized.

RESULTS

CTC is the radiological examination of choice for the detection of colorectal neoplasia. Beside incomplete or refused colonoscopy and contraindications to colonoscopy, CTC is also a noninvasive option for opportunistic colorectal cancer screening. The examination technique is based on a CTC-specific patient preparation scheme that includes fecal tagging, colonic distension, low-dose CT scans in two patient positions and a combined 2D and 3D data evaluation.

CONCLUSIONS

Performing CTC according to current technical standards is prerequisite for high-quality examinations and is, thus, also a key factor to obtain a correct diagnosis. CTC is a noninvasive examination, capable of providing clinically relevant diagnoses for a wide range of indications.

[Computed tomography and magnetic resonance imaging of colonic diseases]

BACKGROUND

Early diagnosis of a luminal colonic disease is of essential clinical importance to start timely optimised therapy and detect complications early.

OBJECTIVES

This paper aims to provide an overview of the use of radiological methods in diagnosing neoplastic and inflammatory luminal diseases of the colon. Characteristic morphological features are discussed and compared.

MATERIALS AND METHODS

Based on an extensive literature review, the current state of knowledge regarding the imaging diagnosis of luminal pathologies of the colon and their importance in patient management is presented.

RESULTS

Technological advances in imaging have made the diagnosis of neoplastic and inflammatory colonic diseases using abdominal computed tomography and magnetic resonance imaging the established standard. Imaging is performed as part of the initial diagnosis in clinically symptomatic patients, to exclude complications, as a follow-up assessment under therapy and as an optional screening method in asymptomatic individuals.

CONCLUSIONS

Accurate knowledge of the radiological manifestations of the numerous luminal disease patterns, the typical distribution pattern and characteristic bowel wall changes are essential to improve diagnostic decision-making.

Evaluation of Intestinal Fibrosis with 68Ga-FAPI PET/MR Enterography in Crohn Disease

Background In Crohn disease, differentiation between active intestinal inflammation and fibrosis has implications for treatment, but current imaging modalities are not reliably accurate. Purpose To evaluate the predictive value of gallium 68 (68Ga)-labeled fibroblast activation protein inhibitor (FAPI) PET/MR enterography for the assessment of bowel wall fibrosis in Crohn disease. Materials and Methods In this prospective single-center study, consecutive participants with Crohn disease and obstructive symptoms underwent preoperative 68Ga-FAPI PET/MR enterography from May 2021 to January 2022. Histopathologic analysis of resected bowel segments was performed to grade active inflammation (A0-A2) and fibrosis (F0-F2), which served as the reference standard. The fibroblast activation protein (FAP) expression in bowel wall layers was analyzed immunohistochemically for each layer. 68Ga-FAPI-derived maximum standardized uptake value (SUVmax) was compared with histopathologic results by using mixed-model analysis of variance and Bonferroni-corrected post hoc tests. Results In 14 participants (mean age, 45 years ± 9 [SD]; 10 men), fibrosis was diagnosed histopathologically in 28 of 51 bowel segments (grade F1, n = 14; grade F2, n = 14). Mean SUVmax was higher in segments with fibrosis than without (7.6 vs 2.0; P < .001). In severe fibrosis, mean SUVmax was higher than in mild to moderate fibrosis (8.9 ± 0.9 vs 6.2 ± 0.9; P = .045). Bowel segments with isolated active inflammation had lower mean 68Ga-FAPI uptake than segments with combined active inflammation and fibrosis (SUVmax, 3.2 ± 0.4 vs 8.1 ± 0.1; P = .005). With an SUVmax cutoff value of 3.5, the area under the receiver operating characteristic curve for the prediction of fibrosis was 0.94 (95% CI: 0.9, 1.0), with sensitivity of 26 of 28 segments (93%) and specificity of five of six segments (83%). 68Ga-FAPI-derived SUVmax correlated with FAP expression across all bowel layers (R2 = 0.50, P < .001). Conclusion Higher gallium 68 fibroblast activation protein inhibitor uptake at PET/MR enterography was associated with histopathologically assessed bowel wall fibrosis in participants with Crohn disease, suggesting diagnostic potential for treatment decisions. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by O'Shea in this issue.

Imaging features facilitate diagnosis of porto-sinusoidal vascular disorder

OBJECTIVES

Porto-sinusoidal vascular disorder (PSVD) is a recently defined vascular liver disease. Since diagnosis remains challenging, we aimed to evaluate radiological features that are distinct between PSVD and cirrhosis.

METHODS

Clinical, laboratory, and radiological parameters (CT/MRI) of patients with histologically-confirmed PSVD vs. cirrhosis vs. non-cirrhotic parenchymal liver disease were retrospectively evaluated.

RESULTS

Sixty-three PSVD, 155 cirrhosis, and 41 non-cirrhotic patients were included. As compared to cirrhosis, PSVD patients were younger and had lower HVPG, liver stiffness, and MELD. Routine clinical and imaging findings indicative of portal hypertension were similarly common. Intrahepatic portal tract abnormalities (49% vs. 15%; p < 0.001), FNH-like lesions (30% vs. 1%; p < 0.001), and abnormal liver morphology defined as peripheral parenchymal atrophy and compensatory hypertrophy of central segments (32% vs. 7%; p < 0.001) were significantly more common in PSVD patients. Hypertrophy of segment I (70% vs. 84%; p = 0.019), atrophy of segment IV (24% vs. 47%; p = 0.001), and nodular liver surface (22% vs. 89%; p < 0.001) were more common in patients with cirrhosis. In patients with gadoxetic acid-enhanced MRI, we identified the distinct imaging feature of "periportal hyperintensity" in the hepatobiliary phase (HBP) in 42% of patients with PSVD (14/33) vs. 1% in cirrhosis (1/95) vs. 0% in non-cirrhotic controls (0/41); p < 0.001).

CONCLUSIONS

Diagnosis of PSVD must be considered in younger patients presenting with clinical features of portal hypertension, portal tract abnormalities, and FNH-like lesions on CT/MRI. 'Periportal hyperintensity' in the HBP of gadoxetic acid-enhanced MRI was identified as a specific radiological feature of PSVD.

KEY POINTS

• Cross-sectional imaging can provide essential information to identify patients with porto-sinusoidal vascular disorder (PSVD). • Intrahepatic portal tract abnormalities, FNH-like lesions, and abnormal liver morphology are common in PSVD patients. • Periportal hyperintensity on the hepatobiliary phase of gadoxetic acid-enhanced MRI seems to be specific for patients with PSVD.

ECCO-ESGAR Topical Review on Optimizing Reporting for Cross-Sectional Imaging in Inflammatory Bowel Disease

BACKGROUND AND AIMS

The diagnosis and follow up of patients with inflammatory bowel disease [IBD] requires cross-sectional imaging modalities, such as intestinal ultrasound [IUS], magnetic resonance imaging [MRI] and computed tomography [CT]. The quality and homogeneity of medical reporting are crucial to ensure effective communication between specialists and to improve patient care. The current topical review addresses optimized reporting requirements for cross-sectional imaging in IBD.

METHODS

An expert consensus panel consisting of gastroenterologists, radiologists and surgeons convened by the ECCO in collaboration with ESGAR performed a systematic literature review covering the reporting aspects of MRI, CT, IUS, endoanal ultrasonography and transperineal ultrasonography in IBD. Practice position statements were developed utilizing a Delphi methodology incorporating two consecutive rounds. Current practice positions were set when ≥80% of the participants agreed on a recommendation.

RESULTS

Twenty-five practice positions were developed, establishing standard terminology for optimal reporting in cross-sectional imaging. Assessment of inflammation, complications and imaging of perianal CD are outlined. The minimum requirements of a standardized report, including a list of essential reporting items, have been defined.

CONCLUSIONS

This topical review offers practice recommendations to optimize and homogenize reporting in cross-sectional imaging in IBD.

A Visuoperceptual Measure for Videofluoroscopic Swallow Studies (VMV): A Pilot Study of Validity and Reliability in Adults with Dysphagia

The visuoperceptual measure for videofluoroscopic swallow studies (VMV) is a new measure for analysing the recordings from videofluoroscopic swallow studies (VFSS). This study evaluated the reliability and validity of the pilot version of the VMV using classical test theory (CTT) analysis, informed by the consensus-based standards for the selection of health measurement instruments (COSMIN) guidelines. Forty participants, diagnosed with oropharyngeal dysphagia by fibreoptic endoscopic evaluation of swallowing, were recruited. The VFSS and administration of bolus textures and volumes were conducted according to a standardised protocol. Recordings of the VFSS were rated by three blinded raters: a speech-language pathologist, a radiologist and a phoniatrician. Inter- and intra-rater reliability was assessed with a weighted kappa and resulted in 0.889 and 0.944 overall, respectively. Structural validity was determined using exploratory factor analyses, which found four and five factor solutions. Internal consistency was evaluated with Cronbach's alpha coefficients, which found all but one factor scoring within an acceptable range (>0.70 and <0.95). Hypothesis testing for construct validity found the expected correlations between the severity of dysphagia and the VMV's performance, and found no impact of gender on measure performance. These results suggest that the VMV has potential as a reliable and valid measure for VFSS. Further validation with a larger sample is required, and validation using an item response theory paradigm approach is recommended.

Prognostic impact of sarcopenia in cirrhotic patients stratified by different severity of portal hypertension

BACKGROUND AND AIMS

Portal hypertension (PH) and sarcopenia are common in patients with advanced chronic liver disease (ACLD). However, the interaction between PH and sarcopenia and their specific and independent impact on prognosis and mortality has yet to be systematically investigated in patients with ACLD.

METHODS

Consecutive patients with ACLD and hepatic venous pressure gradient (HVPG) ≥10 mm Hg with available CT/MRI imaging were included. Sarcopenia was defined by transversal psoas muscle thickness (TPMT) at <12 mm/m in men and <8 mm/m in women at the level of the third lumbar vertebrae. Hepatic decompensation and mortality was recorded during follow-up.

RESULTS

Among 203 patients (68% male, age: 55 ± 11, model for end-stage liver disease [MELD]: 12 [9-15]), sarcopenia was observed in 77 (37.9%) and HVPG was ≥20 mm Hg in 98 (48.3%). There was no correlation between TPMT and HVPG (r = .031, P = .66), median HVPG was not different between patients with vs without sarcopenia (P = .211). Sarcopenia was significantly associated with first/further decompensation both in compensated (SHR: 3.05, P = .041) and in decompensated patients (SHR: 1.86, P = .021). Furthermore, sarcopenia (SARC) was a significant predictor of mortality irrespective of HVPG (HVPG < 20-SARC: SHR: 2.25, P = .021; HVPG ≥ 20-SARC: SHR: 3.33, P = .001). On multivariate analysis adjusted for age, HVPG and MELD, sarcopenia was an independent risk factor for mortality (aHR: 1.99, 95% confidence interval: 1.2-3.3, P = .007).

CONCLUSION

Sarcopenia has a major impact on clinical outcomes both in compensated and in decompensated ACLD patients. The presence of sarcopenia doubled the risk for mortality independently from the severity of PH.

Designing virtual patient based self-study quizzes covering learning goals in clinical diagnostic sciences for undergraduate medical students - the radiology example

Background: Diagnostic tests and examinations inform clinical decision making. Thus, an essential part of medical students' workplace-based training is dedicated to core skills in clinical diagnostic sciences. Due to a reduction of clinical internships for fifth-year students in the wake of COVID-19 learning activities replacing this aspect of training were needed. Project description: Virtual Patient online learning materials addressing clinical diagnostic sciences, specifically, radiology, were developed to prepare students for the transition to workplace-based learning. Three types of activities related to interprofessional patient treatment, showing how radiology knowledge improves the diagnosing and treatment of patients, were used to design the narrative of each virtual patient. The materials also showed students "how to learn" in the clinical workplace while showing "what to learn". Students complete relevant tasks and compare their approach with experts' approach in a self-directed way. Results: Twenty self-study quizzes, accompanied by nine interactive Webinars were developed, providing 13% of the overall available replacement learning materials for the summer term 2020. In June 2020, 486 students completed the program and collected a mean share of 16% (SD=10) of their required credits by choosing to learn with these materials. Conclusion: Developing virtual patients based on three types of clinical activities to prepare students for the transition to workplace based learning proved successful and allowed rapid development of learning materials. The presented online quiz format and webinar format showed high acceptance and interest among students.

Crohn's disease: prevalence, MR features, and clinical significance of enteric and colonic sinus tracts

Objectives

Enteric and colonic sinus tracts are inflammatory complications that precede intestinal fistulas in patients with Crohn’s disease (CD). The aim of this study was to retrospectively determine the prevalence, morphologic features, and outcome of sinus tracts using MR imaging.

Methods

A consecutive cohort of 642 patients with known CD, referred for MR enterography or MR enteroclysis (study period 01/2014–09/2019), was evaluated retrospectively for the presence of sinus tracts, their locations, presence and length of coexisting strictures, bowel wall thickness, CDMI score, upstream dilation, and bowel distension. Clinical outcome was assessed using medical records. For metric data, means and standard deviation, as well as one-way ANOVA and Pearson’s correlation coefficient, were calculated.

Results

In 36/642 patients with CD undergoing MRE, 49 sinus tracts (forty in small intestine, nine in left-sided colon) were detected with a prevalence of 6.9% in patients with MR-visible signs of CD (n = 519, overall prevalence of 5.6%). Mean segmental bowel wall thickness was 8.9 mm, and mean CDMI score was 9.3. All sinus tracts were located within a stenotic segment, showing mesenteric orientation within the small bowel and upstream dilation in 13 patients. Of 36 patients, 19 underwent immediate surgery and seven developed clinical progression within the segment containing the sinus tract.

Conclusions

Sinus tracts occur in 6.9% of patients with visible signs of CD. They are located within stenotic, severely thickened bowel segments with high MR inflammation scores. Their detection is clinically important, because they indicate a more aggressive phenotype and, if left untreated, may show severe progression.

Key Points

• Sinus tracts occur in 6.9% of patients with MR-visible signs of Crohn’s disease.

• Sinus tracts are a radiological indicator of early penetrating Crohn’s disease, with a high risk of progression, and require dedicated treatment.

• Sinus tracts can be recognized by characteristic findings and typically occur in stenotic, severely thickened bowel segments with high MR inflammation scores.

Electronic cleansing of tagged residue in CT colonography: what radiologists need to know

CT colonography (CTC) is the radiological examination of choice for the diagnosis of colorectal neoplasia. Faecal tagging is considered a mandatory part of bowel preparation. However, the colonic mucosa, obscured by tagged residue, is not accessible to endoluminal 3D views and requires time-consuming 2D evaluation. Electronic cleansing (EC) software algorithms can overcome this limitation by digitally subtracting tagged residue from the colonic lumen. Ideally, this enables a seamless 3D endoluminal evaluation. Despite this benefit, EC is a potential source of a wide range of artefacts. Accurate EC requires proper CTC examination technique and faecal tagging. The digital subtraction process has been shown to affect the relevant morphological features of both colonic anatomy and colonic lesions, if submerged under faecal residue. This article summarises the potential effects of EC on CTC imaging, the consequences for reporting and patient management, and strategies to avoid pitfalls. Furthermore, potentially negative effects on clinical reporting and patient management are shown, and problem-solving techniques, as well as recommendations for the appropriate use of EC techniques, are presented. Radiologists using EC should be familiar with EC-related effects on polyp size and also with correct measurement techniques.

[Differential diagnoses of biliary tract diseases : Computed tomography and magnetic resonance imaging]

CLINICAL/METHODICAL ISSUE

Bile duct diseases can be found in all age groups and show an increased prevalence in northern Europe. Pathologies range from benign diseases to malignant tumors with very poor survival.

STANDARD RADIOLOGICAL METHODS

Magnetic resonance imaging (MRI) and computed tomography (CT) are the radiological methods of choice for a detailed evaluation of the bile duct system in addition to sonography. By assessing the lumen and the wall of the bile ducts as well as the surrounding structures, both obstructive and nonobstructive pathologies can be diagnosed and differentiated with high sensitivity and specificity.

METHODICAL INNOVATIONS

Technical developments with postprocessing modalities as well as the use of biliary-excreted liver-specific MR contrast agents improve the diagnosis of bile duct diseases and enable morphological and functional assessment.

PERFORMANCE

Due to high patient tolerance, minimal procedural risk in contrast to invasive endoscopic methods and the possibility of three-dimensional post-processing, beside CT, MRI with magnetic resonance cholangiography (MRC) represents the method of choice in patients with sonographically or clinically suspected bile duct disease and has significantly reduced the indications of diagnostic endoscopic retrograde cholangiopancreatography (ERCP). A complementary multimodality and multiparametric imaging approach is particularly helpful for preoperative assessment.

PRACTICAL RECOMMENDATIONS

Rapidly evolving technology for both MRI and CT represent opportunities and challenges. By understanding the advantages and limitations of modern MR and CT techniques and by knowing the spectrum of bile duct pathologies, improved diagnosis and narrowing of possible differential diagnosis can be achieved.

[Imaging of gastrointestinal inflammation : Characteristic patterns and signs]

CLINICAL PROBLEM

Pathological conditions of the gastrointestinal tract can result from various disorders, including inflammatory, infectious, neoplastic, and ischemic diseases.

RADIOLOGICAL STANDARD PROCEDURES

Cross-sectional imaging techniques have largely replaced many of the conventional fluoroscopic examinations, such as small bowel follow-through and double-contrast barium enema. The former allow for time-efficient, accurate, and minimally invasive diagnostics. Therefore, they have become important diagnostic tools for the evaluation of inflammatory diseases of the gastrointestinal tract. The distension of the intestinal lumen with orally administered neutral contrast media improves not only the evaluation of the intraluminal aspect, but also of the cross-sectional appearance. Furthermore, with cross-sectional imaging techniques, the additional assessment of the extraintestinal structures and organs is also possible.

METHODICAL INNOVATIONS AND ASSESSMENT

With the ongoing development of scanner and software technology, pathologic conditions of the gastrointestinal wall can be characterized in more detail by both computed tomography and magnetic resonance imaging. A structured approach, based on the analysis of typical radiological signs and patterns, combined with the evaluation of extraintestinal findings may help to assign the observed imaging findings to specific disease groups.

RECOMMENDATIONS

This article summarizes common signs and typical patterns frequently seen in inflammatory conditions of the gastrointestinal tract. A systematic approach for structured analysis of specific and nonspecific imaging features and common pitfalls may aid in the interpretation and help to narrow the spectrum of potential differential diagnoses.

Simultaneous Radiological and Fiberendoscopic Evaluation of Swallowing ("SIRFES") in Patients After Surgery of Oropharyngeal/Laryngeal Cancer and Postoperative Dysphagia

To compare the results of a simultaneously performed videofluoroscopic swallowing study and fiberendoscopic evaluation of swallowing in patients with dysphagia after surgery and radiotherapy for oropharyngeal or laryngeal cancer. This prospective study included 31 patients who were examined simultaneously with a standardized protocol. The fiberendoscopic and videofluoroscopic swallowing loops were independently scored by two otorhinolaryngologists/phoniatricians and two radiologists. The presence of penetration/aspiration, the amount of pharyngeal residues and the position of the bolus head when triggering of pharyngeal swallow begins were evaluated. Generalized linear models were used to model the impact of rater, method, bolus and quantities as well as specified moderation effects on scorings. In addition, post hoc Wilcoxon tests were used. Rater agreement was assessed using weighted kappas and their 95% confidence intervals. A total of 202 swallow sequences in 29 patients was evaluated. Interrater agreement was substantial to excellent for both methods (weighted k = 0.979–0.613). Significant differences between both methods were found when assessing the penetration-aspiration scale (p = 0.001, tendency of higher scores by videofluoroscopic (median = 2.59) as opposed to fiberendoscopic (median = 2.14) and the residue severity scores in the valleculae (p = 0.029) and the sinus piriformes (p = 0.002) with larger residues scored by fiberendoscopic evaluation of swallowing. No significant differences were found regarding the time point of triggering (p = 0.273). Simultaneous evaluation of swallowing with FEES and VFSS showed significantly different results in symptomatic patients after tumor operation and radiotherapy.

Visceral fat area measured with computed tomography does not predict postoperative course in Crohn´s disease patients

The role of visceral fat measured by computer tomography is yet not well defined in patients with Crohn's disease. Therefore, the present study was designed to assess the impact of visceral fat area on postoperative short-term outcome and surgical characteristics. We analyzed 95 patients, who underwent intestinal resection for symptomatic Crohn's disease at an academic tertiary referral center between 2003 and 2008. Visceral fat area was measured on preoperative computed tomography scans. Postoperative morbidity was graded according to the Clavien-Dindo classification. Visceral fat area was correlated with baseline characteristics, disease phenotype and 30-day morbidity. Body mass index and age were significantly associated with a higher visceral fat area (p = 0.001). Overall 19 (20.0%) postoperative complications were observed, of whom 7 (7.4%) patients required surgical re-intervention. No significant difference was found with regard to visceral fat area between patients with an uneventful and eventful postoperative course (no complications: median visceral fat area 52.0 cm² SD 59.7, complications: 41.3 cm² SD 42.8; p = 0.465). In contrast to current literature, we cannot support the role of visceral fat area for predicting postoperative course in Crohn's disease. In addition, no correlation of the visceral fat area and disease behavior was detected.

[Incidental findings of the kidneys, adrenal glands, adnexa uteri, gastrointestinal tract, mesentery and lymph nodes : Assessment and management recommendations]

CLINICAL ISSUE

Besides the upper abdominal parenchymal organs, the increasing application of cross-sectional imaging has also led to a rising number of incidental findings in the kidneys, adrenal glands, adnexa uteri, the gastrointestinal tract, mesentery and abdominal lymph nodes.

STANDARD RADIOLOGICAL METHODS

Abdominal computed tomography investigations often show unexpected findings without any correlating symptoms. The growing clinical relevance is due to the large number of incidental findings as well as an increasing awareness of ethical and socioeconomic factors.

ACHIEVEMENTS

When interpreting radiological findings not only morphological criteria but also individual risk factors of the patient and the clinical context are of great importance.

PRACTICAL RECOMMENDATIONS

The aims of this article are the description and evaluation of frequent incidental findings detected by computed tomography and to provide information about management recommendations.

Taking the history in patients with swallowing disorders: an international multidisciplinary survey

Purpose

Clinical assessment of swallowing disorders (dysphagia) requires accurate and comprehensive medical history-taking to further tailor the diagnostic work-up, but functional health care questionnaires show a large variability and various limitations. The aim of this study was to assess the way in which international swallowing experts from various disciplines asses swallowing problems in order to improve the radiologist´s ability to take a thorough medical history in this specific patient group.

Methods

A two-step Delphi method was used to collect swallowing experts’ ways of taking the medical history in patients with swallowing disorders. The questions obtained in a first interview round were pooled and structured by dividing them into general and specific questions, including several subcategories, and these were scored by the experts in a second step based on to their clinical relevance.

Results

Eighteen experts provided 25 different questions categorized as general questions and 34 dimension-specific questions (eight attributed to ‘suspicion of aspiration,’ 13 to ‘dysphagia,’ six to ‘globus sensation,’ four to ‘non-cardiac chest pain,’ and three to ‘effect of life.’) In the second interview round, the experts´ average predictive values attributed to those questions showed the varying importance of the presented items. Seven general and 13 specific questions (six of them attributed to ‘effect on life’ and seven ‘others’) were also added.

Conclusions

This collection of questions reflects the fact that a multidisciplinary approach when obtaining the medical history in patients with swallowing disorders may contribute to an improved technique for performing a symptom-oriented medical history-taking for radiologists of all training levels.

What is the role of radiological testing of lower esophageal sphincter function?

Radiological fluoroscopic evaluation remains the primary imaging modality of choice to evaluate patients with swallowing disorders, despite the increasing availability and technical advantages of nonradiological techniques and the current radiological focus on cross-sectional imaging studies, such as computed tomography and magnetic resonance imaging. The radiological swallowing evaluation should be tailored to assess the entire upper gastrointestinal tract, including the lower esophageal sphincter. Fluoroscopy enables the simultaneous assessment of esophageal motility disorders, as well as structural pathologies, including strictures, webs, rings, diverticula, and tumors. Mono- and double-contrast esophagrams and solid bolus tests together allow assessment of lower esophageal sphincter function and complement other methods, such as endoscopy, manometry, or impedance planimetry. Here we review the role of radiological studies for correct assessment of structural and functional pathologies at the level of the lower esophageal sphincter.

Videofluoroscopy of deglutition in children after repair of esophageal atresia

Purpose: To evaluate the functional disorders of the oral and pharyngeal phases of deglutition after repair of esophageal atresia in children.

Material and Methods: 19 children (10 girls, 9 boys, mean age 22 months) underwent videofluoroscopy of deglutition after repair of esophageal atresia. The videofluoroscopic studies were assessed according to functional and morphological changes in the oral, pharyngeal and esophageal phases. The persistence of radiologic findings on videofluoroscopy was determined.

Results: The oral phase was normal in all patients. The main functional disorder of the pharyngeal phase was aspiration in 7 (37%) children. A completely normal deglutition in the pharyngeal and esophageal phases was not seen in any patient.

Conclusion: Videofluoroscopy after repair of esophageal atresia is helpful in differentiation of functional and morphological disorders that can lead to prandial aspiration and have an influence on the decision about continued therapy.

[Swallowing Disorders]

Swallowing disorders are a common disease in all ages. The spectrum of diseases in patients with swallowing disorders has significantly changed in the last decades. Often complexe clinical pictures require a multidisciplinary approach including various different professionals. Videofluoroscopy is the method of choice for evaluation of the entire swallowing tract within one investigation. Functional as well as morphological changes can be diagnosed and as a therapeutic study, it helps guide decisions regarding further swallow therapy based on those findings.

[Modern MRI of the small bowell]

CLINICAL METHODOLOGICAL ISSUES

The radiological diagnostics of diseases of the small intestine have undergone a great change in the last two decades. Through rapid progress with new treatments and an increasing therapeutic focus on transmural healing, a complete evaluation of the gastrointestinal tract is now crucial.

STANDARD RADIOLOGICAL METHODS

With the introduction of endoscopy, gastrointestinal imaging with a relatively high radiation exposure had only limited applications. The development of cross-sectional imaging allowed a much broader radiological evaluation of abdominal diseases. Due to rapid investigation techniques, excellent soft tissue contrast and the distinct advantage of eliminating exposure to radiation, magnetic resonance imaging (MRI) of the gastrointestinal tract has gained increasing importance. With sufficient filling of the intestinal lumen, simultaneous imaging of all the intestinal wall layers, the perienteric structures and associated abdominal pathologies is now possible.

METHODOLOGICAL INNOVATIONS

New MR sequences, such as diffusion-weighted sequences, dynamic contrast-enhanced sequences and MR fluoroscopy, enable the detection of morphological changes, with additional characterization of affected bowel loops as well as the assessment of functional pathologies with dynamic information about intestinal motility disturbances.

ACHIEVEMENTS

Recent guidelines of European radiological and gastroenterological organizations have confirmed the importance of cross-sectional imaging and particularly of MRI for diagnostics and follow-up in patients with Crohn's disease. Due to the possibility of assessment of all the layers of the intestinal wall and the presence of extramural complications, MRI has a significant impact on further therapeutic treatment in patients with inflammatory bowel disease.

PRACTICAL RECOMMENDATIONS

Especially in patients with inflammatory bowel disease, MR enterography and MR enteroclysis should be the methods of choice for the evaluation of small bowel pathologies because of radiation issues and the great diagnostic value they provide. A variety of MR sequences has enabled not only the detection but also the characterization of pathological changes of the small intestine, which are vital for further treatment of these patients.

Upper esophageal sphincter dysfunction: diverticula-globus pharyngeus

The following discussion of upper esophageal sphincter dysfunction includes commentaries on the role of the cricopharyngeus muscle in reflux disease; the etiology and treatment of Zenker diverticulum; the use of videofluoroscopy in patients with dysphagia, suspicion of aspiration, or globus; the role of pH-impedance monitoring in globus evaluation; and treatment for reflux-associated globus.

Neurogenic [corrected] and oropharyngeal dysphagia

Oropharyngeal dysphagia (OD) is a swallowing disorder caused by congenital abnormalities and structural damage and disease-associated damage of the oral cavity, pharynx, and upper esophageal sphincter. Patients with OD lack the protective mechanisms necessary for effective swallowing, exhibiting difficulty controlling food in the mouth and initiating a swallow, leading to choking, coughing, and nasal regurgitation. OD is a major risk factor for malnutrition, dehydration, and aspiration pneumonia. The following on OD includes commentaries on the application of simulation of oropharyngeal transient receptor potential vanilloid 1 (TRPV1) and maneuvers like the Shaker exercise to improve the safety and efficacy of swallow in OD patients; the prevalence of esophageal pathologies in OD patients and the need to evaluate the esophagus, esophagogastric junction, and stomach; and strategies for clinical screening to detect OD and aspiration among high-risk patients and to improve oral health care, maintain nutrition and hydration, and prevent aspiration pneumonia.

Preoperative evaluation of colorectal liver metastases: comparison between gadoxetic acid-enhanced 3.0-T MRI and contrast-enhanced MDCT with histopathological correlation

OBJECTIVES

The aim of this prospective study was to compare the diagnostic performance of 64-row MDCT and gadoxetic-acid-enhanced MRI at 3.0 T in patients with colorectal liver metastases in correlation with histopathological findings.

METHODS

Lesions detected at MDCT and MRI were interpreted by three blinded readers and compared with histopathological workup as the term of reference. Two subgroups of lesions were additionally evaluated: (1) metastases smaller than 10 mm and (2) lesions in patients with and without steatosis of the liver, assessed histopathologically.

RESULTS

Surgery and histopathological workup revealed 81 colorectal liver metastases in 35 patients and diffuse metastatic involvement in 3 patients. In a lesion-by-lesion analysis, significant sensitivity differences could only be found for reader 1 (P = 0.035) and reader 3 (P = 0.003). For segment-based evaluation, MRI was more sensitive only for reader 3 (P = 0.012). The number of false-positive results ranged from 3 to 12 for MDCT and 8 to 11 for MRI evaluation. In the group of small lesions, the sensitivity differed significantly between both methods (P = 0.003). In patients with hepatic steatosis, MRI showed a trend toward better performance than MDCT, but without statistical performance.

CONCLUSIONS

The 3.0-T MRI with liver-specific contrast agents is the preferred investigation in the preoperative setting, especially for the assessment of small colorectal liver metastases.

KEY POINTS

• Potential surgical treatment requires accurate radiological assessment of colorectal liver metastases • Magnetic resonance imaging with gadoxetic acid is the preferred imaging investigation. • MRI is better than multidetector CT for detecting small liver metastases.

Gadobenate dimeglumine-enhanced 3.0-T MR imaging versus multiphasic 64-detector row CT: prospective evaluation in patients suspected of having pancreatic cancer

PURPOSE

To compare the diagnostic performance (detection, local staging) of multiphasic 64-detector row computed tomography (CT) with that of gadobenate dimeglumine-enhanced 3.0-T magnetic resonance (MR) imaging in patients suspected of having pancreatic cancer.

MATERIALS AND METHODS

The institutional review board approved this prospective study, and all patients provided written informed consent. Multidetector CT and MR imaging were performed in 89 patients (48 women aged 46-89 years [mean, 65.6 years] and 41 men aged 46-86 years [mean, 65.3 years]) suspected of having pancreatic cancer on the basis of findings from clinical examination or previous imaging studies. Two readers independently assessed the images to characterize lesions and determine the presence of focal masses, vascular invasion, distant metastases, and resectability. Findings from surgery, biopsy, endosonography, or follow-up imaging were used as the standard of reference. Logistic regression, the McNemar test, and κ values were used for statistical analysis.

RESULTS

Focal pancreatic masses were present in 63 patients; 43 patients had adenocarcinoma. For reader 1, the sensitivities and specificities in the detection of pancreatic adenocarcinoma were 98% (42 of 43 patients) and 96% (44 of 46 patients), respectively, for CT and 98% (42 of 43 patients) and 96% (44 of 46 patients) for MR imaging. For reader 2, the sensitivities and specificities were 93% (40 of 43 patients) and 96% (44 of 46 patients), respectively, for CT and 95% (41 of 43 patients) and 96% (44 of 46 patients) for MR imaging. Vessel infiltration was determined in 22 patients who underwent surgery, and reader 1 obtained sensitivities and specificities of 90% (nine of 10 vessels) and 98% (119 of 122 vessels), respectively, for CT and 80% (eight of 10 vessels) and 96% (117 of 122 vessels) for MR imaging; for reader 2, those values were 70% (seven of 10 vessels) and 98% (120 of 122 vessels) for CT and 50% (five of 10 vessels) and 98% (120 of 122 vessels) for MR imaging. Both readers correctly assessed resectability in 87% (13 of 15 patients) of cases with CT and 93% (14 of 15 patients) of cases with MR imaging. Nonresectability was assessed correctly with CT in 75% (six of eight patients) of cases by reader 1 and 63% (five of eight patients) of cases by reader 2; nonresectability was correctly assessed with MR imaging in 75% (six of eight patients) of cases by reader 1 and 50% (four of eight patients) of cases by reader 2. None of the differences between modalities and readers were statistically significant (P > .05).

CONCLUSION

Both CT and MR imaging are equally suited for detecting and staging pancreatic cancer.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11101189/-/DC1.

Uveitis and neurologic diseases: an often overlooked relationship

AIM

Eye and brain are linked by development, and immune privileges preserve the integrity of these delicate organs thereby preventing irreversible defects in function. Manifestation of inflammatory or immune-mediated diseases in both systems seems perspicuous, yet during check-up of patients with uveitis they are rarely considered. In this study we aimed to determine the frequency of neurologic diseases in our uveitis patients and to describe the characteristics of ophthalmologic findings.

METHODS

We analyzed the database of 1973 consecutive patients seen between 2000 and 2004 at the uveitis clinic at the hospital of the Medical University of Vienna. All cases of uveitis associated with neurologic co-manifestations of immune-mediated diseases were selected.

RESULTS

Of 1973 patients with uveitis, 52 (2.6%) had neurologic diseases that were considered to be related to the eye inflammation. The most frequent entities were multiple sclerosis, Vogt-Koyanagi-Harada's disease, neurobehcet, central nervous system lymphoma, neurosyphilis and neurosarcoidosis. Uveitis was only rarely seen with infectious meningoencephalitis (neuroborreliosis, mumps, measles), Takayasu arteritis, Guillain-Barre syndrome or orbital pseudotumor.

CONCLUSIONS

Several diseases can cause both ocular and/or central nervous system inflammation. This should prompt ophthalmologists and neurologists in the presence of one to rule out the other. In uveitis patients without evident neurological symptoms, specific ocular pathologies can help the treating ophthalmologist to tailor the work-up, whereas neurologists should always screen their patients, even when they are asymptomatic for ocular disease. Early diagnosis in both cases can help to initiate adequate treatment, thereby modulating the course of the disease and preventing complications.

Unenhanced Multi–Detector Row CT in Patients Suspected of Having Urinary Stone Disease: Effect of Section Width on Diagnosis

PURPOSE

To assess prospectively the effect of section width in multi-detector row computed tomographic (CT) evaluation of patients with acute flank pain who are suspected of having or known to have urinary stone disease.

MATERIALS AND METHODS

This study was approved by the ethics committee of the authors' university, and written informed consent was obtained from all patients. One hundred forty-seven patients (age range, 11-101 years; mean, 51.4 years +/- 18.7 [standard deviation]) suspected of having urinary stone disease underwent unenhanced multi-detector row CT. CT was performed with four detector rows, a section thickness of 1.0 mm, an effective tube current-time product of 100 mAs, and a tube voltage of 120 kVp (CT dose index, 11.4 mGy). From these data, three sets of transverse images were reconstructed with section widths of 1.5, 3.0, and 5.0 mm and approximately 50% of overlap each. Scans were evaluated in varying random orders by two radiologists for the number, size, and location of uroliths and nephroliths and for the presence of phleboliths, renal cysts, and secondary signs of obstruction. The significance of differences between the numbers of detected calcifications and the numbers of associated abnormalities on the scans obtained with varying section widths was tested with the McNemar test at a P level of less than .05. Spearman rho rank correlation coefficients were calculated to assess the correlation between the presence of uroliths and the presence of secondary signs.

RESULTS

Uroliths were found in 72 of 147 (49.0%) patients, and nephroliths were found in 16 patients (10.9%). There was no significant difference between section widths of 1.5 and 3.0 mm with regard to the number of detected stones (264 uroliths and 61 nephroliths for both protocols). Transverse sections 5.0-mm wide revealed significantly fewer uroliths (n = 231; P < .001) and nephroliths (n = 47; P < .016). The final diagnosis was changed in four of 72 patients. All missed renal and ureteral stones measured less than 3 mm in diameter.

CONCLUSION

Overlapping 3-mm sections are sufficient for the detection of urinary stone disease. Small calculi (<3 mm) may be missed on 5.0-mm-thick sections.

Characterization of Hepatocellular Tumors

PURPOSE

To assess the value of mangafodipir trisodium-enhanced MR imaging for characterization of hepatocellular lesions.

MATERIALS AND METHODS

Magnetic resonance images of 41 patients with 48 histopathologically proven hepatocellular lesions (20 cases of focal nodular hyperplasia [FNH], 4 adenomas, 15 hepatocellular carcinomas [HCCs], 7 regenerative nodules, and 2 others) were retrospectively studied. Magnetic resonance imaging was performed on a 1.5-T unit (Vision, Siemens, Erlangen, Germany; ACS-NT, Philips, Best, The Netherlands) using T2-weighted, fat-saturation, turbo spin echo imaging and T1-weighted gradient echo imaging before and 20 minutes after infusion of 5 micromol/kg mangafodipir (Amersham Health, Oslo, Norway). Qualitative analysis by 4 blinded independent readers included assessment of unenhanced images and, in a second step, assessment of unenhanced and contrast-enhanced images together. Lesions were classified as benign or malignant using a 5-point scale, and readers made a specific diagnosis.

RESULTS

For characterization of hepatocellular lesions, mangafodipir-enhanced imaging was significantly superior to unenhanced imaging (P < 0.05). On receiver operating characteristic analysis, the area under the curve was 0.768 (95% confidence interval: 0.633-0.903) for unenhanced images and 0.866 (95% confidence interval: 0.767-0.966) for evaluation of unenhanced and contrast-enhanced images together (P < 0.05). Analysis of enhancement patterns aided in characterization and classification of tumors.

CONCLUSION

Administration of mangafodipir improves the differentiation between adenoma or HCC and "nonsurgical" lesions (FNH or regenerative nodules). The accuracy for arriving at a specific diagnosis is higher when unenhanced and mangafodipir-enhanced images are considered together than for unenhanced MR images alone.

Effects of gastric acid on euro coins: chemical reaction and radiographic appearance after ingestion by infants and children

OBJECTIVES

This study investigated whether coins of the new European currency (euro) corrode when they are exposed to gastric acid, and whether this change can be detected radiographically.

METHODS

The eight different denominations of coins were immersed for seven days in 0.15 N hydrochloride acid (HCl), which corresponds to the level of post-prandial gastric acid. A Swedish crown coin and three different Austrian schilling coins were used as controls. The coins were weighed and radiographed daily to evaluate visible corrosions and HCl was analysed daily for possible dissolved substances.

RESULTS

All coins lost weight within 24 hours after exposure to HCl. The 1, 2, and 5 euro cent coins developed changes that were visible on radiographs. The weights of all coins decreased by 0.43% to 11.30% during one week. The dissolved substances measured in the HCl corresponded to the different metals and alloys of the coins, except for copper, which does not dissolve in HCl. The highest absolute weight loss was observed in the Swedish crown coin (0.67 g), and the highest relative weight loss in the 1 Austrian schilling coin (11.30%). The two coins that showed the highest absolute and relative weight losses were the 2 euro (0.54 g or 6.35%) and the 1 euro (0.48 g or 6.39%) coin.

CONCLUSIONS

A higher rate of toxicity for the new European coins compared with coins of other currencies is not expected, unless a massive coin ingestion occurs.

Detectability of Catheters on Bedside Chest Radiographs: Comparison between Liquid Crystal Display and High-Resolution Cathode-Ray Tube Monitors

PURPOSE

To compare observer performance with a flat-panel liquid crystal display (LCD) monitor and with a high-resolution gray-scale cathode-ray tube (CRT) monitor in the detection of simulated support catheters on bedside chest radiographs.

MATERIALS AND METHODS

The ethics committee did not require approval or patient informed consent when this study began. Because of a change in regulations, before images were acquired the nature of the study and procedures were explained to patients or their relatives, and consent was then obtained. A total of 131 catheter fragments (12-14 per radiograph) were superimposed over 10 anteroposterior bedside chest radiographs obtained with storage phosphor technology. Images were displayed on an LCD monitor (1536 x 2048 matrix) and a CRT monitor (2048 x 2560 matrix). Five radiologists independently located the catheter fragments and rated their confidence in detection with bright and subdued ambient light. A two-way analysis of variance and the Friedman test were used for statistical analysis.

RESULTS

There was no significant difference for either display type with respect to correctly detected catheter fragments (mean sensitivity, 56.6% and 56.0% for the CRT and the LCD monitors, respectively, with bright light and 61.2% for both monitors with subdued light). With both display types, detection rate with bright light decreased significantly (P < .05). False-positive rates and confidence ratings were not significantly affected by monitor type or ambient light.

CONCLUSION

In a study with simulation of clinical conditions, performance of the LCD monitor and high-resolution CRT monitor for detection of support catheters on bedside chest radiographs was equivalent. With both displays, detection performance was equally reduced with bright ambient light.

Quantification of axial alignment of the lower extremity on conventional and digital total leg radiographs

The purpose was to assess axial alignment of the lower limb using mechanical axis measurements on conventional and digital radiographs. Total-leg radiographs of 24 patients, 8 male and 16 female, with a mean age of 68.6+/-10.2 years, were performed in a standardized anterior-posterior projection and standing position using a conventional and digital phosphor storage film screen radiography system. Knee joint angulation was assessed by measuring the angle between a line drawn from the center of the femoral head to the middle of the femoral condyles and a line drawn from the middle of the tibial condyles to the midpoint of the malleolus. On conventional leg radiographs, line drawing and angle measurement were performed manually with a transparent goniometer. Angle measurement on digital leg radiographs was performed on a PACS workstation using computer-assisted measurement software (IMPAX, AGFA-GEVAERT, Belgium). Evaluation time for both measurements was recorded. We diagnosed 14 varus and 10 valgus angulations of the knee joint. The mean individual difference between axis deviation of conventional digital leg radiographs was 0.93+0.6 degrees (min 0 degrees, max 2 degrees), the mean difference in varus angulation was 1.13+/-0.45 degrees (min 0.3 degrees, max 2 degrees), and the mean difference in valgus angulation was 0.65+/-0.71 degrees (min 0 degrees, max 2 degrees). Angle measurements on conventional and digital radiographs did not show any statistically significant difference. Mean time exposure was 4.9 min/patient for manual and 1.08 min/patient for computer-assisted angle measurement (P<0.001). Computer-assisted angle measurement on digital total-leg radiographs represents a reliable method with no significant angle differences compared to conventional radiographic systems and offers a significantly lower evaluation time.

Comparison of liquid crystal versus cathode ray tube display for the detection of simulated chest lesions

The purpose of the study was to compare the detection performance of a cathode ray tube (CRT) monitor versus a liquid crystal display (LCD) monitor for simulated subtle pulmonary lesions. Ten templates containing simulated lung lesions were superimposed on an anthropomorphic chest phantom. Posteroanterior radiographs were obtained using flat panel technology and were displayed on a CRT and an LCD monitor. Image processing and reading conditions were equivalent for both softcopy displays. Five observers assessed lesion detectability using receiver-operating characteristic (ROC) methodology. A multivariate test (Pillai trace) was used to test the significance of differences (P<0.05). The multivariate test revealed significantly different detection rates for the lesion types, but no significant difference between the two display modes. Detection performance for both monitors was higher for nodules and micro-nodules and lower for lines and patchy opacities. Analysis of lesion subgroups according to their location in lucent/obscured lung areas was also not statistically significant. Under ideal reading conditions, CRT and LCD displays perform equivalently for the detection of simulated subtle pulmonary lesions.

Acute colonic pseudo-obstruction (Ogilvie’s-syndrome) and Pneumatosis intestinalis in a kidney recipient patient

Acute colonic pseudo-obstruction (Ogilvie's syndrome) is a clinical entity characterized by massive nontoxic dilatation of the colon in the absence of mechanical obstruction and is associated with increased morbidity and mortality in the immunosuppressed patient. We present a case of a kidney transplant recipient developing a life-threatening condition with acute colonic pseudo-obstruction associated with radiologic findings of a linear pneumatosis intestinalis (PI). Urgent laparotomy and resection of the dilated cecum, colon ascendens and transversum was performed because of bowel necrosis with multiple serosal defects. Stool cultures and special stains for microorganisms were all negative, and there was no evidence for viral or fungal infection. The patient was discharged 31 days after transplantation with normal renal function. In conclusion, this steroid-induced ileus (pseudo-obstruction) is a potentially malignant early form of colonic dysmotility rarely reported in transplant recipients. Awareness and early recognition of the condition are critical for a successful outcome. Colonoscopic decompression can achieve reversal of colonic dilatation in most cases, but in some patients prophylactic laparotomy is indicated for prevention of the catastrophic consequences of perforation.

First experiences with multidetector CT in traumatized children

INTRODUCTION

The aim of this study was to describe and discuss first experiences with multidetector CT (MDCT) in the assessment of traumatized children.

MATERIAL AND METHODS

Since the implementation of a MDCT scanner in April 2002, 85 children (31 girls, 54 boys with a mean age of 9.2 years) consecutively underwent MDCT (Siemens, Erlangen, Germany) with different protocols depending on age, weight, trauma mechanism and clinical presentation. In all patients in whom pathology was suspected, multiplanar reformations (MPR) in coronal and or sagittal orientation was performed. Examinations were evaluated by two radiologists retrospectively and in consensus.

RESULTS

In 55 (65%) children, a MDCT solely of the head was performed, in 46 there was no pathology found. In six (7%), head and facial bones were scanned. Head and abdomen was examined in two (2%), in two (2%) the abdomen only and in one (1%) the pelvis solely. Scans of the spine were obtained in seven (8%) children. A thorax and abdomen examination only was obtained in one (1%) child each. In 11 (13%) children, a polytrauma protocol was performed. In all patients, the time of examination did not exceed 17 min, including setup time. All children survived at the writing of this report.

CONCLUSION

MDCT was promising in the management of traumatized children and seems to shorten the necessary time to reach diagnosis and to initiate life-saving treatment.

Ultrasound of the appendix in children: is the child too obese?

The negative influence of obesity on the detection rate of the appendix for US in adults has been reported. It has been assumed that obesity is a limiting factor in the detection of the appendix with US in children as well, but this has not yet been proven. The aim of our study was to evaluate whether nutritional condition (defined by the body mass index-for-age percentiles: BMI-FAP) influences the detection of the appendix in children on US. One hundred twenty-six children (65 girls and 61 boys) with a mean age of 11.4 years with clinically suspected acute appendicitis underwent ultrasound on a commercially available high-end machine (HDI 5000, ATL, Bothell, Wash.). The BMI was calculated, and children were divided in three weight groups in accordance with the BMI-FAP, and were correlated with US findings. Evaluation of the three weight groups in accordance with the BMI-FAP demonstrated significant differences ( p=0.04) in the detection of the appendix. There was no statistical significance for the BMI, weight, height, and age solely for the detection of the appendix. In children there is a correlation between the nutritional condition as defined by the BMI-FAP and the detection of the appendix.

Videofluoroscopy of swallowing abnormalities in 22 symptomatic patients after cardiovascular surgery

OBJECTIVE

The aim of this study was to evaluate the types of swallowing abnormalities that occur in symptomatic patients who have undergone cardiovascular surgery.

MATERIALS AND METHODS

From 1994 to 2001, 22 patients (17 males and five females; age range, 4-89 years; mean age, 64 years) who had swallowing abnormalities after cardiovascular surgery were referred for a videofluoroscopic swallowing study. Each study was analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, upper esophageal sphincter, and esophagus. Also, the performance of transesophageal echocardiography, long-term intubation, or both was noted.

RESULTS

Swallowing abnormalities were present in 18 patients (81.8%) (range, one to eight functional abnormalities; mean, 3.9 functional abnormalities). The distribution of abnormalities across the functional units statistically significantly deviated (chi(2) = 14.4; df = 6; p = 0.025) from uniform distribution, with abnormalities most commonly involving the hyoid and larynx (13 patients [59.1%]) and the pharynx (10 patients [45.5%]). Aspiration was found in 13 patients (59.1%) (predeglutitive, n = 1; intradeglutitive, n = 4; postdeglutitive, n = 3; and mixed, n = 5). In the 14 patients (63.6%) who underwent transesophageal echocardiography, long-term intubation, or both, we frequently found incomplete tilting of the epiglottis, pharyngeal weakness, and postdeglutitive aspiration.

CONCLUSION

Most patients with swallowing problems after cardiovascular surgery present with multiple abnormalities that most commonly affect the hyoid and larynx and the pharynx and result predominantly in intra- or postdeglutitive aspiration. The performance of transesophageal echocardiography and long-term intubation may influence the types of swallowing abnormalities.

[MR imaging in congenital complicated anterior body wall defects]

INTRODUCTION

Aim of this study was to estimate the value of postmortem MR imaging in evaluation of specimen with congenital anterior body wall defects of the museum of pathologic-anatomy.

MATERIAL AND METHODS

We examined 19 specimen with a 1.5 Tesla unit by using T 1 - and T 2 -weighted sagittal and coronal sequences. In some specimen additional axial T 2 -weighted images were obtained. We evaluated the site of the bowel, the liver, the heart and presence of associated disorders.

RESULTS

The bowels were completely intraabdominal, in two specimen, completely extraabdominal in 12 specimen and in 5 specimen intra- and extraabdominal. The liver was in two specimen completely extraabdominal/ in 12 completely intracorporal, and in 5 specimen intra- and extraabdominal. In 5 cases the heart was located extraanatomically. In 12 specimen we found disorders of the spine and the extremities. Congenital disorders of the kidneys were found in 6 specimen.

CONCLUSION

MR imaging is of great value in the assessment of congenital anterior body wall defects. In the light of ultrafast sequences the role of fetal MR imaging in the evaluation of congenital body wall defects may be mandatory in the future.

Significant symptomatic relief after transoral endoscopic staple-assisted treatment of Zenker's diverticulum

BACKGROUND

Zenker's diverticulum is associated with characteristic symptoms of progressive dysphagia and regurgitation. As most patients are elderly, the perioperative risk is usually high. We report our clinical experience with the transoral endoscopic staple-assisted method, including a thorough assessment of the symptomatic relief achieved by the procedure.

METHODS

46 consecutive patients (29 m, 17 f) with a median age of 61 years (range, 37-96 years) were treated between 1997 and 2002. The symptoms and their frequency were registered. The follow-up consisted of clinical and radiographic investigations.

RESULTS

The median size of the diverticulum was 4 cm (range, 2-12 cm). Transoral treatment was successful in 39 patients; in 7 cases (15.2%) a switch to open surgery was required. The median operating time was 30 min (range, 10-150 min). Mortality rate was nil, while morbidity was 7.7%. The median duration of the postoperative hospital stay was 5 days (range, 1-65 days). After a median follow-up of 11 months (range, 1-40 months), 5 patients had been reoperated on endoscopically due to clinical recurrence. Clinical symptoms were significantly reduced (dysphagia of liquids p <or= 0.0001, dysphagia of solids p <or= 0.001, regurgitation p <or= 0.001).

CONCLUSION

Our results confirm that minimal invasive treatment of Zenker's diverticulum is a safe method and provides significant symptomatic relief.

Videofluoroscopy of deglutition in children after repair of esophageal atresia

PURPOSE

To evaluate the functional disorders of the oral and pharyngeal phases of deglutition after repair of esophageal atresia in children.

MATERIAL AND METHODS

19 children (10 girls, 9 boys, mean age 22 months) underwent videofluoroscopy of deglutition after repair of esophageal atresia. The videofluoroscopic studies were assessed according to functional and morphological changes in the oral, pharyngeal and esophageal phases. The persistence of radiologic findings on videofluoroscopy was determined.

RESULTS

The oral phase was normal in all patients. The main functional disorder of the pharyngeal phase was aspiration in 7 (37%) children. A completely normal deglutition in the pharyngeal and esophageal phases was not seen in any patient.

CONCLUSION

Videofluoroscopy after repair of esophageal atresia is helpful in differentiation of functional and morphological disorders that can lead to prandial aspiration and have an influence on the decision about continued therapy.