Percutaneous aspiration and absolute ethanol sclerotherapy in the treatment of symptomatic bronchogenic cyst

Surgical treatment is indicated for both symptomatic and asymptomatic bronchogenic cysts. The goal of treatment is total removal of the cyst. Percutaneous aspiration and absolute ethanol sclerotherapy is an effective, minimally invasive, and safe alternative method. We present the case of a 74-year-old woman with a symptom of persistent dry cough for 5 months. Plain and contrast-enhanced chest computed tomography revealed a large superior mediastinal cyst that could be easily accessed percutaneously. The cyst was treated by aspiration and ethanol sclerotherapy under ultrasound guidance and fluoroscopy. The patient was discharged a day later without complications. Chest CT at 6 months follow-up showed complete regression of the cyst.

Multidrug-resistant tuberculosis in middle ear: A case report

Background

Tuberculosis (TB) continues to be a common disease in developing countries, among which middle ear TB is rare. Furthermore, it is relatively difficult to make an early diagnosis and provide follow-up treatment for middle ear TB. So, it is necessary to report this case for reference and further discussion.

Case presentation

We reported 1 case of multidrug-resistant tuberculosis otitis media. TB otitis media is rare in tuberculosis; multidrug-resistant TB otitis media is even more rare. Our paper analyzes the possible causes, imaging, molecular biology, pathology, and clinical manifestations of multidrug-resistant TB otitis media.

Conclusion

PCR and DNA molecular biology techniques are highly recommended for the early diagnosis of multidrug-resistant TB otitis media. Early, effective anti-tuberculosis treatment is the guarantee for further recovery for patients with multidrug-resistant TB otitis media.

Artificial intelligence-based computer-aided diagnosis system supports diagnosis of lymph node metastasis in esophageal squamous cell carcinoma: A multicenter study

Background

This study aimed to develop an artificial intelligence-based computer-aided diagnosis system (AI-CAD) emulating the diagnostic logic of radiologists for lymph node metastasis (LNM) in esophageal squamous cell carcinoma (ESCC) patients, which contributed to clinical treatment decision-making.

Methods

A total of 689 ESCC patients with PET/CT images were enrolled from three hospitals and divided into a training cohort and two external validation cohorts. 452 CT images from three publicly available datasets were also included for pretraining the model. Anatomic information from CT images was first obtained automatically using a U-Net-based multi-organ segmentation model, and metabolic information from PET images was subsequently extracted using a gradient-based approach. AI-CAD was developed in the training cohort and externally validated in two validation cohorts.

Results

The AI-CAD achieved an accuracy of 0.744 for predicting pathological LNM in the external cohort and a good agreement with a human expert in two external validation cohorts (kappa = 0.674 and 0.587, p < 0.001). With the aid of AI-CAD, the human expert's diagnostic performance for LNM was significantly improved (accuracy [95% confidence interval]: 0.712 [0.669-0.758] vs. 0.833 [0.797-0.865], specificity [95% confidence interval]: 0.697 [0.636-0.753] vs. 0.891 [0.851-0.928]; p < 0.001) among patients underwent lymphadenectomy in the external validation cohorts.

Conclusions

The AI-CAD could aid in preoperative diagnosis of LNM in ESCC patients and thereby support clinical treatment decision-making.

Effect of freezing and embalming of human cadaveric whole head specimens on bone conduction

BACKGROUND AND AIMS

Conserved specimens do not decay and therefore permit long-term experiments thereby overcoming limited access to fresh (frozen) temporal bones for studies on middle ear mechanics. We used a Thiel conservation method which is mainly based on a watery solution of salts. In contrast to pure Formalin, Thiel conservation aims to preserve the mechanical proprieties of human tissue. The aim of this study is to examine the effect of Thiel conservation on bone conduction in the same specimen before and after conservation.

METHODS

Nine ears of five defrosted whole heads were stimulated with a direct, electrically driven, bone anchored hearing system (Baha, Baha SuperPower). The motion produced by bone conduction stimulation was measured with a single point laser Doppler vibrometer (LDV) at the promontory, the ossicular chain, and the round window through a posterior tympanotomy. After the initial experiments, the entire whole heads were placed in Thiel solution. In order to enable direct comparison between fresh frozen and Thiel specimens, our Thiel conservation did not include intravascular and intrathecal perfusion. The measurements were repeated 3 and 12 months later. To determine the effect of freezing, defrosting, and embalming on the whole heads, CT scans were performed at different stages of the experimental procedure. Additionally, three extracted temporal bones were stimulated a Baha, motion of the promontory measured by LDV and embalmed in Thiel solution to investigate the direct impact of Thiel solution on the bone.

RESULTS

The averaged magnitude of motion on the promontory increased in whole head specimens by a mean of 10.3 dB after 3 months of Thiel embalming and stayed stable after 12 months. A similar effect was observed for motion at the tympanic membrane (+7.2 dB), the stapes (+9.5 dB), and the round window (+4.0 dB). In contrast to the whole head specimens, the motion of the extracted temporal bones did not change after 3 months of Thiel embalming (-0.04 dB in average). CT scans of the whole heads after conservation showed a notable brain volume loss mostly >50% as well as a remarkable change in the consistency and structure of the brain. Partial changes could already be observed before the Thiel embalming but after 1-2 days of defrosting. In an additional experiment, a substitution of brain mass and weight by Thiel fluid did not lead to new deterioration in sound transmission. In contrast, a frozen (non-defrosted) whole head showed a distinctively reduced magnitude of promontory motion before defrosting.

DISCUSSION

For our setup, the vibration of the ear due to bone conduction in the same whole head specimens significantly increased after Thiel conservation. Such an increase was not observed in extracted temporal bone specimens. Due to brain changes in the CT scans, we investigated the consequences of the brain volume changes and structure loss on the frozen brain before defrosting. The loss of brain volume alone could not explain the increase of ear vibrations, as we did not observe a difference when the volume was replaced with Thiel fluid. However, freezing and defrosting of the entire brain seems to have a major influence. Beside the destructive effect of freezing on the brain, the modified conservation method without perfusion changed the brain structure. In conclusion, bone conduction in whole heads depends on the physical condition of the brain, rather than on the conservation.

Recurrent upper extremity arterial thrombosis preceding a diagnosis of COVID-19

Arterial thrombosis occurs when there is endothelial damage in the setting of hypercoagulability and arterial blood stasis. COVID-19 has been theorized to cause both endothelial damage and promote hypercoagulability by causing an imbalance of clotting factors. In many studies, there have been a large proportion of COVID-19 patients that suffered a thromboembolic event, in both the venous and arterial systems. Our patient, who did not have a significant past medical history, presented with a recurrent brachial artery occlusion despite medical and surgical management, and subsequently tested positive for COVID-19 late in his admission. In conclusion, there is high suspicion that there is a relationship between COVID-19 infection and recurrent arterial thrombosis.

A missed diagnosis of retrocaval ureter; case report and review of the literature

The retrocaval ureter is an uncommon congenital anomaly due to an abnormal development of the inferior vena cava. Our case describes an 8 year-old boy who was referred to our center as a case of ureteropelvic junction obstruction with persistent hydronephrosis after pyeloplasty. Retrograde pyelogram showed features of retrocaval ureter which was managed surgically with constructive repair of the ureter. The low clinical incidence may be due to a number of asymptomatic cases that are not diagnosed in the patient's lifetime.

A case report of temporomandibular joint tuberculosis in a neonate with eleven years follow-up

Background

Tuberculosis of the Temporomandibular joint (TMJ) in a neonate is a rare entity. Undiagnosed/mismanaged tuberculosis can disseminate and be life-threatening to the patient. The purpose is to present a case of tubercular osteomyelitis of TMJ in a neonate with eleven years of follow-up.

Case presentation

A one-and-a-half-month-old male neonate presented with a firm swelling in front of the left ear for the past 20 days. Ultrasound presented an avascular, hypoechoic lesion of 34*25*25mm. Irregular margins of underlying bone could suggest erosion. Aspiration revealed pus. ZN staining of pus revealed Mycobacterium tuberculosis. After draining the pus, the patient underwent antitubercular therapy. He revisited at ten years of age with a complaint of asymmetry. Although the patient got cured of his tuberculosis, investigations rose to a diagnosis of condylar hypoplasia with ipsilateral coronoid enlargement. A distraction of the mandible improved facial symmetry.

Conclusion

Although pus revealed the presence of Acid-fast bacilli, it is not evident until there is a significant bacterial load. Escalation of tests with higher sensitivity is needed to diagnose tubercular osteomyelitis of TMJ. Patients must be made aware of possible sequelae of tubercular osteomyelitis of TMJ and need appropriate management. Oblique osteotomy at the angle and distraction improves both horizontal and vertical components of the mandible and thus improves symmetry. To the best of the author's knowledge, the following is the first case of primary tuberculosis of TMJ in a neonate and with such an extended follow-up.

A case of Avelumab response to multiple bone and lymph node metastases of plasmacytoid variant bladder cancer

A 74-year-old man was diagnosed with bladder cancer and referred to our department. For definitive diagnosis, transurethral resection of the bladder tumor(TURBT) was performed. The pathological result showed plasmacytoid variant of urothelial carcinoma. Subsequently, robot-assisted radical cystectomy, lymph node dissection and ileal conduit was performed, but multiple bone metastases and periaortic lymph node metastases newly appeared 30 days later. Gemcitabine and cisplatin (GC) was started, and after 4 courses, the patient became Partial Response (PR), and was switched to Avelumab as maintenance therapy. After about 1 year of maintenance therapy, the patient is still in PR.

CT-based radiomics signature of visceral adipose tissue for prediction of disease progression in patients with Crohn's disease: A multicentre cohort study

BACKGROUND

Visceral adipose tissue (VAT) is involved in the pathogenesis of Crohn's disease (CD). However, data describing its effects on CD progression remain scarce. We developed and validated a VAT-radiomics model (RM) using computed tomography (CT) images to predict disease progression in patients with CD and compared it with a subcutaneous adipose tissue (SAT)-RM.

METHODS

This retrospective study included 256 patients with CD (training, n = 156; test, n = 100) who underwent baseline CT examinations from June 19, 2015 to June 14, 2020 at three tertiary referral centres (The First Affiliated Hospital of Sun Yat-Sen University, The First Affiliated Hospital of Shantou University Medical College, and The First People's Hospital of Foshan City) in China. Disease progression referred to the development of penetrating or stricturing diseases or the requirement for CD-related surgeries during follow-up. A total of 1130 radiomics features were extracted from VAT on CT in the training cohort, and a machine-learning-based VAT-RM was developed to predict disease progression using selected reproducible features and validated in an external test cohort. Using the same modeling methodology, a SAT-RM was developed and compared with the VAT-RM.

FINDINGS

The VAT-RM exhibited satisfactory performance for predicting disease progression in total test cohort (the area under the ROC curve [AUC] = 0.850, 95% confidence Interval [CI] 0.764-0.913, P < 0.001) and in test cohorts 1 (AUC = 0.820, 95% CI 0.687-0.914, P < 0.001) and 2 (AUC = 0.871, 95% CI 0.744-0.949, P < 0.001). No significant differences in AUC were observed between test cohorts 1 and 2 (P = 0.673), suggesting considerable efficacy and robustness of the VAT-RM. In the total test cohort, the AUC of the VAT-RM for predicting disease progression was higher than that of SAT-RM (AUC = 0.786, 95% CI 0.692-0.861, P < 0.001). On multivariate Cox regression analysis, the VAT-RM (hazard ratio [HR] = 9.285, P = 0.005) was the most important independent predictor, followed by the SAT-RM (HR = 3.280, P = 0.060). Decision curve analysis further confirmed the better net benefit of the VAT-RM than the SAT-RM. Moreover, the SAT-RM failed to significantly improve predictive efficacy after it was added to the VAT-RM (integrated discrimination improvement = 0.031, P = 0.102).

INTERPRETATION

Our results suggest that VAT is an important determinant of disease progression in patients with CD. Our VAT-RM allows the accurate identification of high-risk patients prone to disease progression and offers notable advantages over SAT-RM.

FUNDING

This study was supported by the National Natural Science Foundation of China, Guangdong Basic and Applied Basic Research Foundation, Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, Nature Science Foundation of Shenzhen, and Young S&T Talent Training Program of Guangdong Provincial Association for S&T.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

Imaging biomarkers to stratify lymph node metastases in abdominal CT - Is radiomics superior to dual-energy material decomposition?

Purpose

To assess the potential of radiomic features in comparison to dual-energy CT (DECT) material decomposition to objectively stratify abdominal lymph node metastases.

Materials and methods

In this retrospective study, we included 81 patients (m, 57; median age, 65 (interquartile range, 58.7-73.3) years) with either lymph node metastases (n = 36) or benign lymph nodes (n = 45) who underwent contrast-enhanced abdominal DECT between 06/2015-07/2019. All malignant lymph nodes were classified as unequivocal according to RECIST criteria and confirmed by histopathology, PET-CT or follow-up imaging. Three investigators segmented lymph nodes to extract DECT and radiomics features. Intra-class correlation analysis was applied to stratify a robust feature subset with further feature reduction by Pearson correlation analysis and LASSO. Independent training and testing datasets were applied on four different machine learning models. We calculated the performance metrics and permutation-based feature importance values to increase interpretability of the models. DeLong test was used to compare the top performing models.

Results

Distance matrices and t-SNE plots revealed clearer clusters using a combination of DECT and radiomic features compared to DECT features only. Feature reduction by LASSO excluded all DECT features of the combined feature cohort. The top performing radiomic features model (AUC = 1.000; F1 = 1.000; precision = 1.000; Random Forest) was significantly superior to the top performing DECT features model (AUC = 0.942; F1 = 0.762; precision = 0.800; Stochastic Gradient Boosting) (DeLong < 0.001).

Conclusion

Imaging biomarkers have the potential to stratify unequivocal lymph node metastases. Radiomics models were superior to DECT material decomposition and may serve as a support tool to facilitate stratification of abdominal lymph node metastases.

Clinical Profile, Patterns of Care & adherence to Guidelines in Patients with Hepatocellular Carcinoma: Prospective multi-center Study

Background and aims

Increasing incidence of hepatocellular carcinoma (HCC) in India is a matter of concern and need for adequate profiling and streamlining management strategies cannot be over-emphasized.

Methods

This is a prospective multi-centric observational cohort study comprising of an oncology center, one university tertiary hospital with specialized hepatology service, one public hospital with gastroenterology service, and a private liver transplant center located within a 3-km radius. The demographic and clinical parameters were recorded on a prospectively maintained database. The clinical profile, demographics, characteristics of HCC and the allocated treatment were noted and compared among the four centers.

Results

In total, 672 patients were enrolled from June 2016 till January 2020. Abdominal pain (64.3%) and weight loss (47.3%) were the most common symptoms. Most common identified etiology was hepatitis B (39%). The cancer center received lesser patients with hepatitis C and those with advanced stage of HCC. The private transplant center reported the highest proportion of NASH, which was also significantly higher in those belonging to higher socioeconomic strata, and lowest proportion of alcoholic cirrhosis. Metastasis was seen in almost one-fifth (19%) cases at diagnosis. Portal vein thrombosis was evident in 40%. Adherence to treatment guidelines was seen in three-fourth cases (76%).

Conclusions

Hepatitis B is the most common underlying cause for HCC, whereas other causes like NASH are on the rise. Etiologic profile may vary with selective specialization of centers catering to patients with HCC. Adherence to guideline while allocating treatment was high among all centers with highest non-adherence in BCLC A.

Dural lymphoma misdiagnosed as subdural hematoma following head trauma after an episode of syncope

Primary dural lymphoma is a rare subtype of primary central nervous system lymphoma. Primary dural lymphoma may be radiologically misdiagnosed as it shares similar imaging characteristics with several pathologies, including meningiomas and subdural or epidural hematomas. We present a patient who was originally diagnosed with a subdural hematoma following a syncopal episode on computed tomography. Follow-up magnetic resonance imaging of the brain demonstrated heterogeneously enhancing dural-based mass overlying the left frontoparietal convexity associated with bidirectional dural tails, suggestive of a malignant meningioma. Neurosurgical histopathology revealed marginal zone B-cell lymphoma. This case represents the potential difficulty in diagnosing primary dural lymphoma, especially in the setting of uncertain clinical history and obscured imaging features.

Utilization of a cloud-based radiology analytics platform to monitor imaging volumes at a large tertiary center

Rationale and objective

In this study, we evaluate the ability of a novel cloud-based radiology analytics platform to continuously monitor imaging volumes at a large tertiary center following institutional protocol and policy changes.

Materials and methods

We evaluated response to environmental factors through the lens of the COVID-19 pandemic. Analysis involved 11 CT/18 MR imaging systems at a large tertiary center. A vendor neutral, cloud-based analytics tool (CBRAP) was used to retrospectively collect information via DICOM headers on imaging exams between Oct. 2019 to Aug. 2021. Exams were stratified by modality (CT or MRI) and organized by body region. Pre-pandemic scan volumes (Oct 2019-Feb. 2010) were compared with volumes during/after two waves of COVID-19 in Illinois (Mar. to May 2020 & Oct. to Dec. 2020) using a t-test or Mann-Whitney U test.

Results

The CBRAP was able to analyze 169,530 CT and 110,837 MR images, providing a detailed snapshot of baseline and post-pandemic CT and MR imaging across the radiology enterprise at our tertiary center. The CBRAP allowed for further subdivision in its reporting, showing monthly trends in average scan volumes specifically in the head, abdomen, spine, MSK, thorax, neck, GU system, or breast.

Conclusion

The CBRAP retrieved data for 300,000 + imaging exams across multiple modalities at a large tertiary center in a highly populated, urban environment. The ability to analyze large imaging volumes across multiple waves of COVID-19 and evaluate quality-improvement endeavors/imaging protocol changes displays the usefulness of the CBRAP as an advanced imaging analytics tool.

Thoracic endometriosis masquerading as Meigs' syndrome in a young woman: A case report and literature review

Thoracic endometriosis is an exceedingly rare condition characterized by the presence of endometriotic deposits on the diaphragm, lungs or pleural space. Patients may present with massive hemothorax, pneumothorax, hemoptysis or pulmonary nodules. It is a complex condition that often proves to be a diagnostic challenge, resulting in under-diagnosis, delays in treatment and significant morbidity in women of reproductive age. We report a case of endometriosis causing massive pleural effusion and ascites, with a left adnexal fibroid mass mimicking Meigs' syndrome in a nulliparous woman in her late 30s. The patient was successfully managed with hormonal therapy following fertility-sparing surgical treatment. This case highlights the diagnostic and therapeutic challenges associated with thoracic endometriosis because of its close resemblance to more sinister gynecological conditions. Hormonal therapy is the long-term treatment of choice in patients with thoracic endometriosis to reduce the risk of symptom recurrence and preserve fertility.

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The most common presentation of thoracic endometriosis is catamenial pneumothorax followed by catamenial hemothorax.

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Thoracic endometriosis should be considered in a woman presenting with a haemothorax and other stigmata of endometriosis

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Although video-assisted thoracoscopy provides a definitive diagnosis, thoracic endometriosis can be diagnosed clinically.

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Hormonal therapy is the mainstay of treatment to control symptoms, reduce recurrence and preserve fertility.

Spermatic cord abscess: Case report and imaging findings

Spermatic cord abscess is a rare condition usually associated with other genitourinary infections. We present a case of a 49-year-old male with past medical history of uncontrolled diabetes mellitus. He presented with right groin swelling and pain for a week. Ultrasound showed a tubular hyperemic structure extending into the scrotal sac. Computed tomography showed concurrent perinephric abscess and right spermatic cord abscess. The spermatic cord abscess was managed surgically by incision and drainage. To our knowledge, this is the first case report of a patient with spermatic cord abscess and concurrent perinephric abscess. We highlight the clinical importance of familiarity with such a rare condition and the role of imaging in establishing the correct diagnosis while excluding close differentials.

Local recurrence of uveal melanoma and concomitant brain metastases associated with an activating telomerase promoter mutation seven years after secondary enucleation

Purpose

To describe a case of local recurrence of uveal melanoma with concomitant brain metastases after secondary enucleation.

Observations

A 73 year-old patient presented with dizziness and gait instability. MRI of the orbits and brain showed an anophthalmic socket with an orbital implant and an associated optic nerve mass as well as multiple mass lesions in the brain. The patient's history was significant for secondary enucleation for uveal melanoma recurrence seven years prior to presentation. Histopathology of the enucleated eye revealed no signs of extrascleral extension or optic nerve invasion. Biopsy of the optic nerve mass confirmed recurrent uveal melanoma with somatic mutations in GNAQ (Q209L) and the telomerase (TERT) promoter (c.1-124C > T) found on targeted next-generation sequencing (NGS). The same mutations were found in the primary tumor in the patient's archived enucleation samples.

Conclusions

Local recurrence of uveal melanoma can occur after enucleation and is associated with an increased risk of systemic metastases. It is important for clinicians to monitor patients for local recurrence and systemic metastases even after enucleation. Genetic biomarkers may play an important role in identifying tumors at highest risk of local recurrence and metastasis. To our knowledge, this is the first case study to describe the TERT promoter mutation c.1-124C > T in the setting of recurrent uveal melanoma.

Immunohistochemical analyses of paraffin-embedded sections after primary surgery or trimodality treatment in esophageal carcinoma

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Changes in the tumor microenvironment of esophageal cancers, both in squamous cell carcinoma and adenocarcinoma, were found when comparing tumor resection specimen having undergone neoadjuvant radiochemotherapy followed by resection or resection only.

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Selected markers of the tumor microenvironment, i.e., Ki67, p53, CXCR4 and PD1 were found to be downregulated in hypoxic regions compared to normoxic regions.

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These findings will be correlated with microscopic tumor extension measurements in a subsequent, prospectively included cohort of esophageal cancer patients.

Background

The microscopic tumor extension before, during or after radiochemotherapy (RCHT) and its correlation with the tumor microenvironment (TME) are presently unknown. This information is, however, crucial in the era of image-guided, adaptive high-precision photon or particle therapy.

Materials and methods

In this pilot study, we analyzed formalin-fixed paraffin-embedded (FFPE) tumor resection specimen from patients with histologically confirmed squamous cell carcinoma (SCC; n = 10) or adenocarcinoma (A; n = 10) of the esophagus, having undergone neoadjuvant radiochemotherapy followed by resection (NRCHT + R) or resection (R)]. FFPE tissue sections were analyzed by immunohistochemistry regarding tumor hypoxia (HIF-1α), proliferation (Ki67), immune status (PD1), cancer cell stemness (CXCR4), and p53 mutation status. Marker expression in HIF-1α subvolumes was part of a sub-analysis. Statistical analyses were performed using one-sided Mann-Whitney tests and Bland-Altman analysis.

Results

In both SCC and AC patients, the overall percentages of positive tumor cells among the five TME markers, namely HIF-1α, Ki67, p53, CXCR4 and PD1 after NRCHT were lower than in the R cohort. However, only PD1 in SCC and Ki67 in AC showed significant association (Ki67: p = 0.03, PD1: p = 0.02). In the sub-analysis of hypoxic subvolumes among the AC patients, the percentage of positive tumor cells within hypoxic regions were statistically significantly lower in the NRCHT than in the R cohort across all the markers except for PD1.

Conclusion

In this pilot study, we showed changes in the TME induced by NRCHT in both SCC and AC. These findings will be correlated with microscopic tumor extension measurements in a subsequent cohort of patients.

Artificial intelligence model on chest imaging to diagnose COVID-19 and other pneumonias: A systematic review and meta-analysis

Objectives

When diagnosing Coronavirus disease 2019(COVID‐19), radiologists cannot make an accurate judgments because the image characteristics of COVID‐19 and other pneumonia are similar. As machine learning advances, artificial intelligence(AI) models show promise in diagnosing COVID-19 and other pneumonias. We performed a systematic review and meta-analysis to assess the diagnostic accuracy and methodological quality of the models.

Methods

We searched PubMed, Cochrane Library, Web of Science, and Embase, preprints from medRxiv and bioRxiv to locate studies published before December 2021, with no language restrictions. And a quality assessment (QUADAS-2), Radiomics Quality Score (RQS) tools and CLAIM checklist were used to assess the quality of each study. We used random-effects models to calculate pooled sensitivity and specificity, I² values to assess heterogeneity, and Deeks' test to assess publication bias.

Results

We screened 32 studies from the 2001 retrieved articles for inclusion in the meta-analysis. We included 6737 participants in the test or validation group. The meta-analysis revealed that AI models based on chest imaging distinguishes COVID-19 from other pneumonias: pooled area under the curve (AUC) 0.96 (95 % CI, 0.94–0.98), sensitivity 0.92 (95 % CI, 0.88–0.94), pooled specificity 0.91 (95 % CI, 0.87–0.93). The average RQS score of 13 studies using radiomics was 7.8, accounting for 22 % of the total score. The 19 studies using deep learning methods had an average CLAIM score of 20, slightly less than half (48.24 %) the ideal score of 42.00.

Conclusions

The AI model for chest imaging could well diagnose COVID-19 and other pneumonias. However, it has not been implemented as a clinical decision-making tool. Future researchers should pay more attention to the quality of research methodology and further improve the generalizability of the developed predictive models.

The Application of Guideline-Based Care for Traumatic Brain and Spinal Cord Injury in Low- and Middle-Income Countries: A Provider-Based Survey

Objective

Neurosurgical guidelines have resulted in improved clinical outcomes and more optimized care for many complex neurosurgical pathologies. As momentum in global neurosurgical efforts has grown, there is little understanding about the application of these guidelines in low- and middle-income countries.

Methods

A 29-question survey was developed to assess the application of specific recommendations from neurosurgical brain and spinal cord injury guidelines. Surveys were distributed to an international cohort of neurosurgeons and neurotrauma stakeholders.

Results

A total of 82 of 222 (36.9%) neurotrauma providers responded to the survey. The majority of respondents practiced in low- and middle-income countries settings (49/82, 59.8%). There was a significantly greater mean traumatic brain injury volume in low-income countries (56% ± 13.5) and middle-income countries (46.5% ± 21.3) compared with high-income countries (27.9% ± 13.2), P < 0.001. Decompressive hemicraniectomy was estimated to occur in 61.5% (±30.8) of cases of medically refractory intracranial pressure with the lowest occurrence in the African region (44% ± 37.5). The use of prehospital cervical immobilization varied significantly by income status, with 36% (±35.6) of cases in low-income countries, 52.4% (±35.5) of cases in middle-income countries, and 95.2% (±10) in high-income countries, P < 0.001. Mean arterial pressure elevation greater than 85 mm Hg to improve spinal cord perfusion was estimated to occur in 71.7% of cases overall with lowest occurrence in Eastern Mediterranean region (55.6% ± 24).

Conclusions

While some disparities in guideline implementation are inevitably related to the availability of clinical resources, other differences could be more quickly improved with accessibility of current evidence-based guidelines and development of local data.

Comparison of temporal evolution of computed tomography imaging features in COVID-19 and influenza infections in a multicenter cohort study

Purpose

To compare temporal evolution of imaging features of coronavirus disease 2019 (COVID-19) and influenza in computed tomography and evaluate their predictive value for distinction.

Methods

In this retrospective, multicenter study 179 CT examinations of 52 COVID-19 and 44 influenza critically ill patients were included. Lung involvement, main pattern (ground glass opacity, crazy paving, consolidation) and additional lung and chest findings were evaluated by two independent observers. Additional findings and clinical data were compared patient-wise. A decision tree analysis was performed to identify imaging features with predictive value in distinguishing both entities.

Results

In contrast to influenza patients, lung involvement remains high in COVID-19 patients > 14 days after the diagnosis. The predominant pattern in COVID-19 evolves from ground glass at the beginning to consolidation in later disease. In influenza there is more consolidation at the beginning and overall less ground glass opacity (p = 0.002). Decision tree analysis yielded the following: Earlier in disease course, pleural effusion is a typical feature of influenza (p = 0.007) whereas ground glass opacities indicate COVID-19 (p = 0.04). In later disease, particularly more lung involvement (p < 0.001), but also less pleural (p = 0.005) and pericardial (p = 0.003) effusion favor COVID-19 over influenza. Regardless of time point, less lung involvement (p < 0.001), tree-in-bud (p = 0.002) and pericardial effusion (p = 0.01) make influenza more likely than COVID-19.

Conclusions

This study identified differences in temporal evolution of imaging features between COVID-19 and influenza. These findings may help to distinguish both diseases in critically ill patients when laboratory findings are delayed or inconclusive.

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Decision tree analysis helps to distinguish COVID-19 and Influenza.

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Pleural effusion is a typical feature of influenza in early disease.

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Ground glass opacities indicate COVID-19 in early disease.

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Lung involvement remains high in COVID-19 patients > 14 days after the diagnosis.

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Pleural and pericardial effusion favor influenza over COVID-19 in later disease.

Simulation-based assessment of trainee's performance in post-cardiac arrest resuscitation

Objectives

To assess trainees’ performance in managing a patient with post-cardiac arrest complicated by status epilepticus.

Methods

In this prospective, observational, single-center simulation-based study, trainees ranging from sub interns to critical care fellows evaluated and managed a post cardiac arrest patient, complicated by status epilepticus. Critical action items were developed by a modified Delphi approach based on American Heart Association guidelines and the Neurocritical Care Society’s Emergency Neurological Life Support protocols. The primary outcome measure was the critical action item sum score. We sought validity evidence to support our findings by including attending neurocritical care physicians and comparing performance across four levels of training.

Results

Forty-nine participants completed the simulation. The mean sum of critical actions completed by trainees was 10/21 (49%). Eleven (22%) trainees verbalized a differential diagnosis for the arrest. Thirty-two (65%) reviewed the electrocardiogram, recognized it as abnormal, and consulted cardiology. Forty trainees (81%) independently decided to start temperature management, but only 20 (41%) insisted on it when asked to reconsider. There was an effect of level of training on critical action checklist sum scores (novice mean score [standard deviation (SD)] = 4.8(1.8) vs. intermediate mean score (SD) = 10.4(2.1) vs. advanced mean score (D) = 11.6(3.0) vs. expert mean score (SD) = 14.7(2.2))

Conclusions

High-fidelity manikin-based simulation holds promise as an assessment tool in the performance of post-cardiac arrest care.

IgG4-Related Sclerosing Cholangitis with Cholecystitis Mimicking Cholangiocarcinoma: A Case Report

IgG4-related diseases are rare multisystem disorders involving salivary glands, retroperitoneum, pancreas, biliary tract, and liver. Isolated biliary strictures and gall bladder involvement are rare in such patients, and presentation with cholangitis and weight loss can misguide the diagnosis toward malignancy. Here, we report an interesting case of IgG4-related biliary stricture with gall bladder involvement, presented with cholangitis and weight loss. The initial symptoms and imaging were guided toward the malignant possibilities of cholangiocarcinoma and pancreatic carcinoma. However, endosonography, serology, and histopathology clinched the diagnosis of IgG4-related disease. The patient was managed without any biliary intervention and with antibiotics, steroids, and steroid-sparing agents. There was a relapse of disease during the steroids taper that improved after hiking its doses. The disease responded with medical management on follow-up. We demonstrated the effectiveness of steroid-sparing agents to treat IgG4-related diseases, especially to avert the steroid-related adverse effects. This case highlights the possible mislead for the diagnosis and delayed management of IgG4 disease due to shared clinical features with hepatobiliary malignancies and the effectiveness of noninvasive measures of management.

Pulmonary nodular lymphoid hyperplasia presenting as multifocal subsolid nodules: A case report and literature review

Pulmonary nodular lymphoid hyperplasia (PNLH) is a rare, benign lymphoproliferative disease, which is characterized by nonclonal lymphoproliferation. PNLH is usually asymptomatic and usually detected incidentally on imaging studies. Common imaging findings include a solitary nodule, multiple nodules, or focal consolidation. Atypically, PNLH may present with persistent subsolid nodules, mimicking adenocarcinoma. Here, we report a rare case of PNLH presenting as multifocal subsolid nodules in both lower lobes. During follow-up, persistency and growth of the subsolid nodules suggested the possibility of malignancy. Wedge resection was performed bilaterally, and PNLH was confirmed on pathological examination.

Diffuse malignant peritoneal mesothelioma mimicking ovarian cancer

Diffuse malignant peritoneal mesothelioma (DMPM) and peritoneal carcinomatosis have similar computed tomography imaging features. Peritoneal carcinomatosis is a known metastatic site for many malignancies and particularly gastrointestinal tract and ovarian cancers. Also, DMPM can masquerade as an ovarian epithelial neoplasm, with very similar clinical presentation and an overlap in imaging findings. When no evident primary tumor is detected other than the peritoneal disease, primary malignant mesothelioma should be considered. Since accurate diagnosis is essential for treatment management, the gold standard in differentiating between these two entities lies in histological analysis. We report a case of DMPM that was initially misdiagnosed as an ovarian cancer, where the biopsy of a peritoneal nodule was able to correct and confirm the diagnosis of DMPM.

SQSTM1 Expression in Hepatocellular Carcinoma and Relation to Tumor Recurrence After Radiofrequency Ablation

BACKGROUND/AIMS

Autophagy is a process that allows the degradation of detrimental components through the lysosome to maintain cellular homeostasis under variable stimuli. SQSTM1 is a key molecule involved in functional autophagy and is linked to different signaling pathways, oxidative responses, and inflammation. Dysregulation of autophagy is reported in a broad spectrum of diseases. Accumulation of SQSTM1 reflects impaired autophagy, which is related to carcinogenesis and progression of various tumors, including hepatocellular carcinoma (HCC). This study investigated SQSTM1 protein expression in HCC and its relation to the clinicopathological features and the likelihood of tumor recurrence after radiofrequency ablation (RFA).

METHODS

This study included 50 patients with cirrhotic HCC of Barcelona Clinic Liver Cancer stages 0/A-B eligible for RFA. Tumor and peritumor biopsies were obtained just prior to local ablation and assessed for tumor pathological grade and SQSTM1 expression by immunohistochemistry. Patients were followed for one year after achieving complete ablation to detect any tumor recurrence.

RESULTS

Serum alpha-fetoprotein level (U = 149.50, P = 0.027∗) and pathological grade of the tumor (χ² = 12.702, P = 0.002∗) associated significantly with the tumor response to RFA. SQSTM1 expression level was significantly increased in HCC compared to the adjacent peritumor cirrhotic liver tissues (Z = 5.927, P < 0.001∗). Significant direct relation was found between SQSTM1 expression level in HCC and the pathological grade of the tumor (H = 33.789, P < 0.001∗). On follow-up, tumor and peritumor SQSTM1 expression levels performed significantly as a potential predictor of the overall survival, but not the disease recurrence.

CONCLUSIONS

SQSTM1 expression could determine aggressive HCC, even with reasonable tumor size and number, and identify the subset of HCC patients with short overall survival and unfavorable prognosis. SQSTM1 expression could not predict post-RFA intrahepatic HCC recurrence. SQSTM1 may be a potential biomarker and target for the selection of HCC patients for future therapies.

Transarterial Chemoembolization (TACE) Combined With Sorafenib versus TACE in Patients With BCLC Stage C Hepatocellular Carcinoma - A Retrospective Study

OBJECTIVE

Advanced-stage hepatocellular carcinoma is a heterogeneous group with limited treatment options. TACE has been advocated recently by various study groups. The purpose of this study was to evaluate if TACE in combination with sorafenib, as well as TACE alone, was safe and efficacious in treating BCLC stage C HCC.

METHODS

A retrospective evaluation of the clinical data of 78 patients with BCLC stage C HCC who received either TACE-sorafenib (TS) combination therapy or TACE monotherapy as their first treatment was done. The two groups were compared in terms of radiological tumor response 1 month after the intervention. The two groups were also compared in terms of time to progression (TTP), overall survival (OS), and adverse events.

RESULTS

The disease control rate (44.9% and 25.8%, respectively, P = 0.09) was higher in the TS combination group than in the TACE monotherapy group after 1 month of treatment. The TS combination group had significantly superior TTP and OS than the TACE group (TTP was 4.6 and 3.1 months, respectively, P = 0.001), and OS was 10.1 and 7.8 months, respectively, P < 0.001). The TACE-S group had a greater cumulative survival time at 6 months, 9 months, and 1 year than the TACE group (97.9%, 51.1%, 25.7% vs. 90.4%, 51.6%, and 0%, respectively).

CONCLUSION

TS combination therapy in advanced-stage (BCLC-C) HCC significantly improved disease control rate, TTP, and OS compared with TACE alone, without any significant increase in adverse reactions.

The Utility of Superselective Rotational Angiography for Frameless Stereotactic Navigation During Craniotomy for Micro-Arteriovenous Malformation

BACKGROUND

Micro-arteriovenous malformations (AVMs) can present challenges to neurosurgeons with respect to localization during resection. We sought to describe a novel method that merges super-selective 3-dimensional angiographic images with magnetic resonance imaging (MRI) sequences to facilitate frameless stereotaxic navigation during AVM surgery.

METHODS

A retrospective analysis was performed comprising cases that employed merging of angiographic and MRI images for navigation purposes. Baseline clinical and imaging features were recorded. The technique and operative experiences were analyzed descriptively and presented alongside detailed illustrative cases.

RESULTS

During the review period, 11 cases were identified where this technique was employed. Successful image acquisition and merging was possible in all cases. Complete obliteration of the target pathology was achieved in all cases. Precise localization of the micro-AVMs minimized dissection in eloquent cortex.

CONCLUSIONS

Superselective 3-dimensional angiographic images merged to baseline MRI sequences facilitates planning and navigation during surgery for micro-AVMs.

Tuberculosis in Cirrhosis - A Diagnostic and Management Conundrum

Background

Diagnosis and management of tuberculosis (TB) in patients with cirrhosis remains challenging. We studied the clinical spectrum, diagnosis, and management of TB along with the assessment of the diagnostic utility of various laboratory investigations in this cohort.

Methods

A retrospective review of records of patients with cirrhosis (July 2017 and December 2019) was done. Out of 30 patients with cirrhosis and TB, 20 patients with pleural/peritoneal TB (cases) were compared with 20 consecutively selected spontaneous bacterial peritonitis (SBP) controls. Composite of clinical, laboratory, radiologic features and response to antituberculosis therapy (ATT) was taken as the gold standard to diagnose TB.

Results

Extrapulmonary TB (EPTB) (n = 23, 76.7%) was more common. Overall, 9 (30%) patients presented with ATT-induced hepatitis. Patients with pleural/peritoneal TB had less severe hepatic dysfunction as compared to SBP group with significantly lower CTP [8 ± 1.5 vs. 9 ± 1.7 (P = 0.01)], MELD [16.3 ± 5.8 vs. 20.2 ± 6.6 (P = 0.02)] and MELD-Na [18.8 ± 5.9 vs. 22.5 ± 7.1 (P = 0.03)] scores. Median ascitic/pleural fluid total protein [2.7 (2.4-3.1) vs. 1.1 (0.9-1.2); P < 0.0001] and adenosine deaminase (ADA) levels [34.5 (30.3-42.7) vs. 15 (13-16); P < 0.0001] were significantly higher in the TB group. Total protein levels had a sensitivity and specificity 81% and 93.3%, respectively, at cut off value of >2 g/dl with an AUROC of 0.89 [(0.79-0.96); P < 0.001] whereas ADA levels at cutoff >26 IU/L showed 80% sensitivity and 90% specificity to diagnose pleural/peritoneal TB with an AUROC of 0.93 [(0.82-0.97); P < 0.001]. Only 11 (36.7%), and 8 (26.6%) patients showed positivity on GeneXpert and mTB-PCR, respectively. Patients with Child-Turcotte-Pugh scores of ≤7 and 8-10 tolerated well two and one hepatotoxic drugs, respectively.

Conclusions

EPTB is more frequent in patients with cirrhosis. Relatively lower cutoffs of ascitic/pleural fluid total protein and ADA may be useful to diagnose EPTB in patients with high pretest probability. Individualized ATT with close monitoring and dynamic modifications is effective and well-tolerated.

Comparison Between Liver Stiffness Measurement by Fibroscan and Splenic Volume Index as NonInvasive Tools for the Early Detection of Oxaliplatin-induced Hepatotoxicity

Background

Oxaliplatin remains an essential component of many chemotherapy protocols for gastrointestinal cancers; however, neurotoxicity and hepatotoxicity may be dose-limiting. The gold standard for the diagnosis of oxaliplatin-induced hepatotoxicity is liver biopsy, which is invasive and costly. Splenomegaly has also been used as a surrogate for liver biopsy in detecting oxaliplatin-induced sinusoidal obstruction syndrome (SOS), but splenic measurement is not routine and can be inaccurate and complex. We investigated the correlation between increased liver elasticity assessed by Fibroscan and the increase in spleen volume on cross-sectional imaging after oxaliplatin as a noninvasive technique to assess liver stiffness associated with oxaliplatin-induced SOS.

Methods

Forty-six patients diagnosed with gastrointestinal cancers and planned to take oxaliplatin containing regimens were included in this prospective study at the American University of Beirut Medical Center (AUBMC). Measurement of spleen volume using cross-sectional imaging and of liver elasticity using Fibroscan was performed at baseline, 3 and 6 months after starting oxaliplatin. Mean liver elasticity measurements were compared between patients stratified by the development of splenomegaly using the Student t-test. Splenomegaly was defined as 50% increase in spleen size compared with baseline.

Results

Patients who developed splenomegaly after oxaliplatin use had significantly higher mean elasticity measurements as reported by Fibroscan at 3 (16.2 vs. 7.8 kPa, P = 0.036) and 6 (9.3 vs. 6.7 kPa, P = 0.03) months.

Conclusion

Measurement of elasticity using Fibroscan could be potentially used in the future as a noninvasive test for predicting oxaliplatin-induced hepatotoxicity.

Intrahepatic inferior vena cava interruption with transhepatic venous continuation initially misdiagnosed as a congenital portosystemic shunt

We report a case of intrahepatic inferior vena cava interruption with azygos and transhepatic venous continuation discovered incidentally on CT angiography for acute aortic syndrome. The lesion was initially misdiagnosed as a congenital portosystemic shunt on multiphase CT of the liver but subsequent fluoroscopic venogram revealed no evidence of portosystemic shunting. While intrahepatic IVC interruption with azygos continuation is an uncommon but well-known anatomical variant, transhepatic venous continuation is extremely rare and only a few cases have been published. Excluding portosystemic shunting is important for determining management as persistent congenital portosystemic shunts can be associated with significant morbidity.

Gallbladder wall thickening in a woman with postpartum preeclampsia: A case report

Background

Preeclampsia (PE) is hallmarked by dysfunction of various organs; therefore, its diagnosis can be challenging, especially when patients present with right upper abdominal pain. Herein, we present a case of postpartum gallbladder wall thickening (GBWT) that led to a diagnosis of PE, rather than hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome or gallbladder and biliary disease.

Case Presentation

A 31-year-old postpartum woman presented with a fever, hypertension, headache, and right upper abdominal pain. HELLP syndrome and intracranial hemorrhage were initially suspected, due to the combination of symptoms and elevated levels of aspartate transaminase, alanine transaminase, and lactate dehydrogenase. However, hemolysis and thrombocytopenia were absent, and a computed tomography (CT) scan of the head did not indicate the presence of intracranial hemorrhage. Further, transabdominal ultrasound and CT revealed GBWT (edematous gallbladder); CT also revealed an enlarged heart, lung edema, pleural effusion, and ascites. Thus, PE, rather than HELLP syndrome or gallbladder or biliary disease, was diagnosed based on gestational hypertension and proteinuria, new-onset headache, liver dysfunction, and edema in several organs, including the lung. Nicardipine treatment quickly improved hypertension and headache, and, over time, the patient's urination increased, and edema subsided throughout the body. Furthermore, laboratory results improved, and the patient was discharged on postpartum day 11.

Conclusion

Postpartum gallbladder wall thickening can be a diagnostic sign of PE.

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Preeclampsia can cause edema in several organs.

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We present a case of postpartum gallbladder wall thickening.

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Gallbladder wall thickening can aid in the diagnosis of preeclampsia in cases with right upper abdominal pain.

Gangliocytic paraganglioma leading to duodeno-jejunal intussusception: A case report

The intussusception of the small bowel is rarely encountered in adult patients and is frequently associated with a lead point that is often malignant. In a 69-year-old female patient with an episode of gastrointestinal (GI) bleeding, computed tomography (CT) showed a duodenal-jejunal intussusception caused by an intraluminal mass. Open polypectomy and reduction of intussusception were performed and the diagnosis of gangliocytic paraganglioma was made at pathological evaluation. It would be important to consider neoplasms like gangliocytic paraganglioma in the setting of adult small bowel intussusception.

Ileal mucosa-associated lymphoid tissue lymphoma diagnosed after emergency surgery: A case report and literature review

Introduction and importance

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue, also called MALT lymphoma, is one of the entities of marginal zone lymphomas. These lymphomas are originated from indolent B-cell lymphomas and involve many organs such as the gastrointestinal tract, salivary gland, skin, lung, thyroid or breast. Ileal MALT lymphoma is relatively rare and clinical symptoms are usually atypical.

Case presentation

We report a case of a 99-year-old man who admitted to the emergency department with increasing and colicky periumbilical pain, vomiting and constipation. Non-contrast-enhanced computed tomography suggested small bowel obstruction due to phytobezoar. Intraoperatively, surgeon discovered the tumor at the site of phytobezoar. Histologically, there was a diffuse infiltration comprised of small to medium sized lymphocytes with monocytoid features. Immunohistochemical result confirmed CD20 positive B-lymphocytes and the Ki-67 proliferation index was 10%. Ileal mucosa-associated lymphoid tissue lymphoma was diagnosed based on histological findings and immunohistochemistry.

Discussion

MALToma of the gastrointestinal tract is related to chronic antigenic, inflammatory bowel disease and malabsorption syndromes. However, the etiology of ileal MALToma is unclear. Moreover, symptom of ileal MALToma is really not typical and overleaped in the context of small intestinal obstruction. It should be differentiated small intestinal MALToma from immunoproliferative small intestinal disease and an alpha heavy chain disease.

Conclusion

Ileal MALT lymphoma remains little known in many previous studies. It is really difficult to preoperatively diagnose. The combination of clinical presentation, postoperative histology and immunohistochemistry contribute to diagnosis and carry out appropriate management.

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Ileal MALT lymphoma is relatively rare compared to others gastrointestinal MALT lymphomas and symptoms are usually atypical.

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A 99-year-old man was hospitalized with the symptoms of bowel obstruction.

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Emergency surgery, postoperative histology and immunohistochemistry confirmed ileal MALT lymphoma.

Noninvasive prediction of pulmonary hemodynamics in chronic thromboembolic pulmonary hypertension by electrocardiogram-gated computed tomography

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Easily measurable parameters from chest CT examinations enable prediction of pulmonary hemodynamics.

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ECG-gated CTPA is superior to non-gated CT.

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Non-invasive pH therapy monitoring or follow-up might be implemented in the future.

Purpose

The aim of the study was to investigate the potential of electrocardiogram (ECG)-gated computed tomography pulmonary angiography (CTPA) as a predictor of disease severity in patients with chronic thromboembolic pulmonary hypertension (CTEPH).

Method

Forty-five CTEPH patients with a mean age of 63.8 years±12.7 y (±standard deviation) who had undergone ECG-gated CTPA and right heart catheterization (RHC) were included in the study. Right ventricular to left ventricular volume ratio (RVV/LVV), diameter ratio on 4-chamber view (RVD4CH/LVD4CH), pulmonary trunk (PT) diameter, PT to aortic diameter ratio (PT/A), and septal angle were correlated to mean pulmonary artery pressure (mPAP). Moreover, RVV/LVV and RVD4CH/LVD4CH were adjusted to pulmonary diameter index (PADi) and PT/A index. Areas under the curve (AUC) for predicting mPAP above 40 mmHg, 35 mmHg, and 30 mmHg were calculated.

Results

RVD4CH/LVD4CH revealed the strongest correlation to mPAP before (r = 0.6507) and after (r = 0.7650; p < 0.0001) PT/A adjustment. The AUCs for predicting pH with mPAP over 40 mmHg and 30 mmHg were 0.9229 and 0.864, respectively. A cutoff value of 1.298 enabled prediction of pH with mPAP over 40 mmHg with a sensitivity, specificity, positive predictive, and negative predictive value of 80.00 %, 95.83 %, 88.46 %, and 94.12 %, respectively. Intra- and interobserver variability were excellent for all parameters.

Conclusion

Combining different and easily evaluable ECG-gated CTPA parameters enables excellent prediction of pulmonary hemodynamics in CTEPH patients. Ventricular diameter ratio on 4-chamber view adjusted by the PT/A ratio yielded the best correlation to mPAP.

Current status of surviving patients with arginase 1 deficiency in Japan

Arginase 1 (ARG1) deficiency is a rare urea cycle disorder (UCD), with an estimated frequency of 1 per 2,200,000 births in Japan. Patients with ARG1 deficiency develop symptoms in late infancy or pre-school age with progressive neurological manifestations and sometimes present with severe hepatic disease. We previously investigated the status of UCDs in Japan; however, only one patient was identified as having ARG1 deficiency. Therefore, we aimed to investigate the current status of patients with ARG1 deficiency in 2018–2021 because almost 10 years have passed since the previous study. We present the disease history, clinical outcome, and treatment of five surviving patients with ARG1 deficiency and discuss the features of ARG1 deficiency in Japan. We found that clinicians often face difficulty in diagnosing ARG1 deficiency at the early stage of onset because of interpatient variability in onset time and clinical manifestations. Blood L-arginine and guanidino compounds were considered to be the major factors causing adverse neurodevelopmental outcomes. Therefore, early detection and intervention of ARG1 deficiency is essential for improved neurodevelopmental outcomes. Liver transplantation has been considered an effective treatment option that can dramatically improve the quality of life of patients, prior to the neurological manifestation of symptoms caused by ARG1 deficiency.

Prediction of treatment response to transarterial radioembolization of liver metastases: Radiomics analysis of pre-treatment cone-beam CT: A proof of concept study

Purpose

To investigate the potential of texture analysis and machine learning to predict treatment response to transarterial radioembolization (TARE) on pre-interventional cone-beam computed tomography (CBCT) images in patients with liver metastases.

Materials and Methods

In this IRB-approved retrospective single-center study 36 patients with a total of 104 liver metastases (56 % male, mean age 61.1 ± 13 years) underwent CBCT prior to TARE and follow-up imaging 6 months after therapy. Treatment response was evaluated according to RECIST version 1.1 and dichotomized into disease control (partial response/stable disease) versus disease progression (progressive disease). After target lesion segmentation, 104 radiomics features corresponding to seven different feature classes were extracted with the pyRadiomics package. After dimension reduction machine learning classifications were performed on a custom artificial neural network (ANN). Ten-fold cross validation on a previously unseen test data set was performed.

Results

The average administered cumulative activity from TARE was 1.6 Gbq (± 0.5 Gbq). At a mean follow-up of 5.9 ± 0.8 months disease control was achieved in 82 % of metastases. After dimension reduction, 15 of 104 (15 %) texture analysis features remained for further analysis. On a previously unseen set of liver metastases the Multilayer Perceptron ANN yielded a sensitivity of 94.2 %, specificity of 67.7 % and an area-under-the receiver operating characteristics curve of 0.85.

Conclusion

Our study indicates that texture analysis-based machine learning may has potential to predict treatment response to TARE using pre-treatment CBCT images of patients with liver metastases with high accuracy.

COVID-19 and pulmonary tuberculosis - A diagnostic dilemma

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Meanwhile, pulmonary tuberculosis(TB) is one of the most common infective lung diseases in developing nations. The concurrence of pulmonary TB and COVID-19 can lead to poor prognosis, owing to the pre-existing lung damage caused by TB. Case presentation: We describe the imaging findings in 3 cases of COVID-19 pneumonia with co-existing pulmonary TB on HRCT thorax. The concurrence of COVID-19 and pulmonary TB can be a diagnostic dilemma. Correct diagnosis and prompt management is imperative to reduce mortality and morbidity. Hence it is pertinent for imaging departments to identify and report these distinct entities when presenting in conjunction.

Common trunk of the right accessory renal artery and right inferior phrenic artery originating from the thoracic artery: An unreported variation

Accessory renal arteries (ARAs) are common and usually originate from the abdominal aorta and the renal artery. Inferior phrenic arteries (IPAs) can also arise from the abdominal aorta or its branches. In this paper, we present the first case of a common trunk of the right ARA and right IPA arising from the thoracic artery at the level of T10, which was discovered by multidetector-row computed tomography in pretherapeutic evaluation and clearly confirmed by selective angiography. It is important to recognize this anatomical variation when performing cardiovascular and interventional radiological procedures.

A study on the clinical application of greater omental pedicle flap transplantation to correct anterior resection syndrome in patients with low rectal cancer

Introduction

Low anterior resection syndrome (LARS) is the most common complication after total mesorectal excision (TME) in patients with low rectal cancer and has been a challenge in colorectal surgery that severely impacts the quality of life of patients. This study aimed to introduce a revised surgical procedure which could effectively maintain rectal compliance and significantly improve LARS after the operation.

Methods

We performed mesorectal reconstruction after routine Dixon TME using greater omental pedicle flap transplantation in 11 patients with low rectal cancer (5 cases of preoperative neoadjuvant chemoradiotherapy, 5 cases of preoperative neoadjuvant chemotherapy, and 1 case of postoperative adjuvant chemotherapy), thereby simulating the initial anatomical structure of the mesorectum and significantly reducing the postoperative anterior resection syndrome. The lars precision syndrome assessment scale (LARSS) was used to access the LARS.

Results

At 12 weeks after the 11 patients recovered from the anal defecation function, the average score on the LARS questionnaire was 25.5 ± 1.5 (minor). The average time at which anal function began to recover was 6.2 ± 2.6 weeks after surgery. The recovery was rapid, as the rectal and anal function of all patients generally returned to normal levels within 12 weeks, and the quality of life was close to that before surgery.

Conclusion

Greater omental flap transplantation can significantly improve LARS after Dixon TME in patients with low rectal cancer.

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Omental pedicle flap transplantation is a revised and promising surgical procedure.

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The procedure reconstructing the mesorectum could maintain rectal compliance.

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The procedure can significantly improve low anterior resection syndrome.

Vaginal cuff dehiscence: report of two cases

Vaginal cuff dehiscence is a rare but potentially life-threatening post-hysterectomy complication. Here we report two cases of vaginal cuff dehiscence with distinct imaging features and describe the CT findings of vaginal cuff dehiscence. Both patients underwent repair surgery, and the diagnoses were confirmed. Radiologic features of vaginal cuff dehiscence are uncommonly described in the literature. Vaginal cuff mural discontinuity and omental fat tissue or bowel herniation into the vaginal canal are the most common appearances of vaginal cuff dehiscence. Pelvic hematoma, bowel obstruction, and pneumoperitoneum can accompany. These two cases highlight the CT appearances, potential presentations, and management of vaginal cuff dehiscence in the emergency setting.

Delayed stillbirth by hysterectomy following early-term uterine rupture with fetal demise in secundigravida

Uterine rupture and postterm pregnancy pose a number of life-threatening complications to both mother and child, including severe intra-abdominal bleeding and peritonitis, birth injury, hypoxia, and fetal loss. This report presents a rare case of a 20-year-old female experiencing fetal demise at 60 weeks of pregnancy, with uterine rupture and bone tissue discharge from her vagina without severe intra-abdominal bleeding and peritonitis. The mild clinical course despite complete uterine rupture was due to the firm adhesion of the amniotic sac to the uterus caused by inflammation. The adhesion of the intestines to the rupture site prevented dehiscence of the ruptured wound. Suppuration and bone tissue discharge relieved the pressure on the patient's abdominal cavity and prevented subsequent occurrence of severe peritonitis. Radiologists mistakenly regarded the thick amniotic sac wall on the right side of the uterine wall as a right cornual pregnancy with uterine rupture caused by chronic inflammation. This report aims to bring awareness of this rare condition to medical students and radiologists.

Sarcoidosis or cancer? That is the question

Sarcoidosis is a granulomatous inflammatory disease of unknown etiology. Sarcoid like granuloma may develop concurrently or following cancer. Detection of granuloma in mediastinal lymph nodes biopsy in patient with pulmonary nodules may be a concern for undiagnosed lung cancer. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a diagnostic modality of choice for the lung lesions.

We discussed A 71-year-old man with history of chronic obstructive lung disease (COPD), who presented with a lung nodule and mediastinal lymphadenopathies. The nodule was 9.9 mm when detected and his endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA) of lymph nodes in station 7 & 4R showed normal lymph node structure. Two years later, his surveillance chest CT scan indicated an increase in the size of the nodule to 15 mm, and PET/CT showed Fluorodeoxyglucose (FDG) avid nodule & mediastinal Lymph nodes. He complained of Shortness of breath after 2–3 climbs of stairs, without any history of cough or fever. He quit cigarette smoking recently and smoked 50 pack years before. He underwent another set of EBUS and was referred for sarcoidosis treatment due to finding non-necrotizing granuloma in 4L and 11L lymph nodes. The patient also underwent another biopsy of the nodule concerning the possibility of cancer sarcoid syndrome. A poorly differentiated lung adenocarcinoma positive for GATA3, positive for P63 and CK7, TTF-1 was reported.

Concurrent lung cancer and granulomatous reaction in mediastinal lymph nodes are being reported more often. Recent studies have shown a better survival of patients with diagnosis of cancer and granulomatous findings of sarcoidosis. Performing lung biopsy from any nodular lesion in a patient with sarcoidosis is essential for the differential diagnosis and early therapeutic measures.

Ultrasound delta-radiomics during radiotherapy to predict recurrence in patients with head and neck squamous cell carcinoma

PURPOSE

This study investigated the use of quantitative ultrasound (QUS) obtained during radical radiotherapy (RT) as a radiomics biomarker for predicting recurrence in patients with node-positive head-neck squamous cell carcinoma (HNSCC).

METHODS

Fifty-one patients with HNSCC were treated with RT (70 Gy/33 fractions) (±concurrent chemotherapy) were included. QUS Data acquisition involved scanning an index neck node with a clinical ultrasound device. Radiofrequency data were collected before starting RT, and after weeks 1, and 4. From this data, 31 spectral and related-texture features were determined for each time and delta (difference) features were computed. Patients were categorized into two groups based on clinical outcomes (recurrence or non-recurrence). Three machine learning classifiers were used for the development of a radiomics model. Features were selected using a forward sequential selection method and validated using leave-one-out cross-validation.

RESULTS

The median follow up for the entire group was 38 months (range 7-64 months). The disease sites involved neck masses in patients with oropharynx (39), larynx (5), carcinoma unknown primary (5), and hypopharynx carcinoma (2). Concurrent chemotherapy and cetuximab were used in 41 and 1 patient(s), respectively. Recurrence was seen in 17 patients. At week 1 of RT, the support vector machine classifier resulted in the best performance, with accuracy and area under the curve (AUC) of 80% and 0.75, respectively. The accuracy and AUC improved to 82% and 0.81, respectively, at week 4 of treatment.

CONCLUSION

QUS Delta-radiomics can predict higher risk of recurrence with reasonable accuracy in HNSCC.Clinical trial registration: clinicaltrials.gov.in identifier NCT03908684.

Insights into forsythia honeysuckle (Lianhuaqingwen) capsules: A Chinese herbal medicine repurposed for COVID-19 pandemic

Background

In December 2019, a novel coronavirus, SARS-CoV-2 caused a series of acute atypical respiratory diseases worldwide. However, there is still a lack of drugs with clear curative effects, and the clinical trial research of vaccines has not been completely finished.

Purpose

LH capsules are approved TCM patent medicine that are widely used for the treatment of respiratory tract infectious diseases caused by colds and flu. On April 12, 2020, LH capsules and granules were officially repurposed by the China Food and Drug Administration (CFDA) for patients with mild COVID-19 based on their safety and efficacy demonstrated through multicentre, randomized, controlled clinical trials. We hope to conduct a comprehensive review of it through modern pharmacy methods, and try to explain its possible mechanism.

Methods

Using the full names of LH capsules Lianhuaqingwen, Lianhua Qingwen andSARS-COV-2, COVID-19 as the keywords of the search terms, systemically search for existing related papers in various databases such as Web of Science and PubMed. And completed the collection of clinical data in ClinicalTrials.gov and Chinese Clinical Trial Registry. Last but not least, we have sorted out the anti-inflammatory and antiviral mechanisms of LH capsules through literature and Selleck.

Results

This review systematically sorted out the active ingredients in LH capsules. Furthermore, the related pharmacological and clinical trials of LH capsule on SARS-CoV-2, IAV and IBV were discussed in detail. Moreover, the present review provides the first summary of the potential molecular mechanism of specific substances in LH capsules involved in resistance to SARS-COV-2 infection and the inhibition of cytokine storm syndrome (CSS) caused by IL-6.

Conclusion

This review summarizes the available reports and evidence that support the use of LH capsules as potential drug candidates for the prevention and treatment of COVID-19. However, TCM exerts its effects through multiple targets and multiple pathways, and LH capsules are not an exception. Therefore, the relevant mechanisms need to be further improved and experimentally verified.

Evaluation of image quality of a novel computed tomography metal artifact management technique on an anthropomorphic head and neck phantom

Background and purpose

Artefacts caused by dental amalgam implants present a common challenge in computed tomography (CT) and therefore treatment planning dose calculations. The goal was to perform a quantitative image quality analysis of our Artifact Management for Proton Planning (AMPP) algorithm which used gantry tilts for managing metal artefacts on Head and Neck (HN) CT scans and major vendors’ commercial approaches.

Materials and methods

Metal artefact reduction (MAR) algorithms were evaluated using an anthropomorphic phantom with a removable jaw for the acquisition of images with and without (baseline) metal artifacts. AMPP made use of two angled CT scans to generate one artifact-reduced image set. The MAR algorithms from four vendors were applied to the images with artefacts and the analysis was performed with respective baselines. Planar HU difference maps and volumetric HU differences were analyzed.

Results

AMPP algorithm outperformed all vendors’ commercial approaches in the elimination of artefacts in the oropharyngeal region, showing the lowest percent of pixels outside +− 20 HU criteria, 4%; whereas those in the MAR-corrected images ranged from 26% to 67%. In the region of interest within the affected slices, the commercial MAR algorithms showed inconsistent performance, whereas the AMPP algorithm performed consistently well throughout the phantom’s posterior region.

Conclusions

A novel MAR algorithm was evaluated and compared to four commercial algorithms using an anthropomorphic phantom. Unanimously, the analysis showed the AMPP algorithm outperformed vendors’ commercial approaches, showing the potential to be broadly implemented, improve visualizations in patient anatomy and provide accurate HU information.

Pleurography (thoracography) for pleural fistulas: A case series

Background

Pleurography (PG) has been described previously but has not gained popularity. PG can determine the exact air leak points in the lung, which is important for treating pneumothorax and pleural fistulas. We believe that the usefulness of PG should be reassessed, and here we describe the method, air leak detection rate, and common complications.

Methods

From the 1210 cases of pleural fistulas that were treated at our institution between March 2015 and October 2018, 275 patients with recurrent primary pneumothorax or secondary spontaneous pneumothorax were selected for this study. PG was performed in 127 patients with persistent air leakage during exhalation. In addition, 35 patients with postoperative complications of air leakage persisting for 7 days or longer were included.

Results

Air leak points were detected in 119 patients (73%), in the apex of the lung in 65 cases, in the basal segment in 13 cases, and in the middle lobe or lingular segment in 9 cases. There were 8 cases of hilar lesions, 12 cases of S6 lesions, 8 cases of upper lobe lesions other than apex, and 4 cases of upper mediastinal lesions. Complications within 30 days were observed in 10 cases (6.2%), with 8 grade 2 cases involving fever, 1 grade 3 case involving infection, and one grade 1 case with abdominal distension.

Conclusions

The incidence of grade ≥3 adverse events after PG was 0.6%, which is considered acceptable. Our findings suggest that PG is a safe examination method to identify air leaks before surgery for pleural fistulas.

Development of Innovative Neurosurgical Operation Support Method Using Mixed-Reality Computer Graphics

Background

In neurosurgery, it is important to inspect the spatial correspondence between the preoperative medical image (virtual space), and the intraoperative findings (real space) to improve the safety of the surgery. Navigation systems and related modalities have been reported as methods for matching this correspondence. However, because of the influence of the brain shift accompanying craniotomy, registration accuracy is reduced. In the present study, to overcome these issues, we developed a spatially accurate registration method of medical fusion 3-dimensional computer graphics and the intraoperative brain surface photograph, and its registration accuracy was measured.

Methods

The subjects included 16 patients with glioma. Nonrigid registration using the landmarks and thin-plate spline methods was performed for the fusion 3-dimensional computer graphics and the intraoperative brain surface photograph, termed mixed-reality computer graphics. Regarding the registration accuracy measurement, the target registration error was measured by two neurosurgeons, with 10 points for each case at the midpoint of the landmarks.

Results

The number of target registration error measurement points was 160 in the 16 cases. The target registration error was 0.72 ± 0.04 mm. Aligning the intraoperative brain surface photograph and the fusion 3-dimensional computer graphics required ∼10 minutes on average. The average number of landmarks used for alignment was 24.6.

Conclusions

Mixed-reality computer graphics enabled highly precise spatial alignment between the real space and virtual space. Mixed-reality computer graphics have the potential to improve the safety of the surgery by allowing complementary observation of brain surface photographs and fusion 3-dimensional computer graphics.

Complex space of Retzius lymphocele resulting in iliac compression and submassive pulmonary embolism after robotic Retzius sparing prostatectomy

Lymphoceles are common following prostatectomy with lymph node dissection, but the vast majority are asymptomatic. We present a unique case of a large complex lymphocele tracking into the anterior space of Retzius following Retzius sparing prostatectomy and bilateral pelvic lymphadenectomy. The patient initially presented with shortness of breath and subsequent diagnosis of a submassive pulmonary embolism. Further evaluation revealed compression of the iliac vessels by the fluid collection. Following multiple failed attempts of drainage percutaneously, the patient required return to the operating room for peritoneal marsupialization, drainage of fluid collection, and evacuation of large amounts of clot within the collection.

A case report of inverted Meckel's diverticulum

Inverted Meckel's diverticulum is an entity often discovered incidentally or through a clinical evaluation for gastrointestinal bleeding. While rare, inverted Meckel's diverticulum should be considered in the evaluation of a patient presenting with gastrointestinal bleeding, intestinal obstruction, or intussusception. In this case, a 67-year-old female with a remote history of surgically treated breast cancer presents to an urgent care facility with weakness and fatigue. She was found to be anemic with hemoglobin of 4. Imaging revealed a blind-ending pouch in the mid to distal ileum consistent with an inverted Meckel's diverticulum. Inverted Meckel's diverticulum is identified on computerized tomography as an intraluminal, blind-ending structure in the mid to distal ileum. The possibility of a lead point should be investigated and surgical resection is indicated to prevent intestinal obstruction.