Feasibility of a low-cost magnet tracking device in confirming nasogastric tube placement at point of care, a clinical trial.

An affordable and reliable way of confirming the placement of nasogastric tube (NGT) at point-of-care is an unmet need. Using a novel algorithm and few sensors, we developed a low-cost magnet tracking device and showed its potential to localize the NGT preclinically. Here, we embark on a first-in-human trial. Six male and 4 female patients with NGT from the general ward of an urban hospital were recruited. We used the device to localize the NGT and compared that against chest X-ray (CXR). In 5 patients, with the sensors placed on the sternal angle, the trajectory of the NGT was reproduced by the tracking device. The tracked location of the NGT deviated from CXR by 0.55 to 1.63 cm, and a downward tracking range of 17 to 22 cm from the sternal angle was achieved. Placing the sensors on the xiphisternum, however, resulted in overt discordance between the device's localization and that on CXR. Short distance between the sternal angle and the xiphisternum, and lower body weight were observed in patients in whom tracking was feasible. Tracking was quick and well tolerated. No adverse event occurred. This device feasibly localized the NGT in 50% of patients when appropriately placed. Further refinement is anticipated.ClinicalTrials.gov identifier: NCT05204901.

Imaging mimickers of cholangiocarcinoma: a pictorial review.

Cholangiocarcinoma (CCA) is the second most common primary hepatobiliary malignancy and presents as three separate morphological subtypes; namely mass-forming, periductal-infiltrating, and intraductal-growing patterns. Each of these subtypes have distinct imaging characteristics, as well as a variety of benign and malignant mimics, making accurate diagnosis of CCA on imaging challenging. Whilst histopathological examination is required to arrive at a definitive diagnosis, it is still important for radiologists to be cognizant of these entities and provide reasonable differential diagnoses, as these potentially have a large impact on patient management. This pictorial essay illustrates the three morphological subtypes of CCA, as well as some important mimics for each subtype, that are encountered in clinical practice.

Radiographic features of COVID-19 based on an initial cohort of 96 patients in Singapore.

INTRODUCTION: Chest radiographs (CXRs) are widely used for the screening and management of COVID-19. This article describes the radiographic features of COVID-19 based on an initial national cohort of patients. METHODS: This is a retrospective review of swab-positive patients with COVID-19 who were admitted to four different hospitals in Singapore between 22 January and 9 March 2020. Initial and follow-up CXRs were reviewed by three experienced radiologists to identify the predominant pattern and distribution of lung parenchymal abnormalities. RESULTS: In total, 347 CXRs of 96 patients were reviewed. Initial CXRs were abnormal in 41 (42.7%) out of 96 patients. The mean time from onset of symptoms to CXR abnormality was 5.3 ± 4.7 days. The predominant pattern of lung abnormality was ground-glass opacity on initial CXRs (51.2%) and consolidation on follow-up CXRs (51.0%). Multifocal bilateral abnormalities in mixed central and peripheral distribution were observed in 63.4% and 59.2% of abnormal initial and follow-up CXRs, respectively. The lower zones were involved in 90.2% of initial CXRs and 93.9% of follow-up CXRs. CONCLUSION: In a cohort of swab-positive patients, including those identified from contact tracing, we found a lower incidence of CXR abnormalities than was previously reported. The most common pattern was ground-glass opacity or consolidation, but mixed central and peripheral involvement was more common than peripheral involvement alone.

Teach a man to fillet: gastrointestinal and extra-gastrointestinal complications related to fish bone ingestion.

Accidental ingestion of fish bone is a common occurrence in populations that consume unfilleted fish. Although most ingested foreign bodies pass through the gastrointestinal tract uneventfully within a week, less than 1% of patients unfortunately develop gastrointestinal perforation. Occasionally, some patients who are unaware of an episode of fish bone ingestion may present sub-acutely with symptoms mimicking inflammatory conditions or pyrexia of unknown origin. Computed tomography (CT) is the definitive imaging modality in the diagnosis of fish bone foreign body and its complications. This pictorial essay aims to illustrate the various complications related to fish bone ingestion, broadly divided into gastrointestinal related complications and extra-gastrointestinal complications related to migration of fish bone. Radiologists should be familiar with the myriad of possible complications, and take heed that a relevant history of fish bone ingestion is often absent.

Chest Radiography in Coronavirus Disease 2019 (COVID-19): Correlation with Clinical Course.

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 and was declared a global pandemic by the World Health Organization on 11 March 2020. A definitive diagnosis of COVID-19 is made after a positive result is obtained on reverse transcription-polymerase chain reaction assay. In Singapore, rigorous contact tracing was practised to contain the spread of the virus. Nasal swabs and chest radiographs (CXR) were also taken from individuals who were suspected to be infected by COVID-19 upon their arrival at a centralised screening centre. From our experience, about 40% of patients who tested positive for COVID-19 had initial CXR that appeared "normal". In this case series, we described the temporal evolution of COVID-19 in patients with an initial "normal" CXR. Since CXR has limited sensitivity and specificity in COVID-19, it is not suitable as a first-line diagnostic tool. However, when CXR changes become unequivocally abnormal, close monitoring is recommended to manage potentially severe COVID-19 pneumonia.

Atypical Chest Computed Tomography Finding of Predominant Interstitial Thickening in a Patient with Coronavirus Disease 2019 (COVID-19) Pneumonia.

BACKGROUND Coronavirus disease 2019 (COVID-19) is caused by a novel coronavirus, SARS-CoV-2, and is associated with severe respiratory disease. There are extensive publications on the chest computed tomography (CT) findings of COVID-19 pneumonia, with ground-glass opacities (GGO) and mixed GGO and consolidation being the most common findings. Those with interstitial thickening manifesting as reticular opacities typically show superimposed ground-glass opacities, giving a crazy-paving pattern. CASE REPORT We report the case of a 77-year-old man with a background of asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) who presented with progressive cough and shortness of breath for 2 days. He was in close contact with a confirmed COVID-19 case. Reverse-transcription polymerase chain reaction analysis of a nasopharyngeal swab was positive for SARS-CoV-2. The initial chest radiograph was negative for lung consolidation and ground-glass opacities. During admission, he had worsening shortness of breath with desaturation, prompting a chest CT examination, which was performed on day 14 of illness. The chest CT revealed an atypical finding of predominant focal subpleural interstitial thickening in the right lower lobe. He was provided supportive treatment along with steroid and antibiotics. He recovered well and subsequently tested negative for 2 consecutive swabs. He was discharged after 34 days. CONCLUSIONS Interstitial thickening or reticular pattern on CT has been described in COVID-19 pneumonia, but largely in association with ground-glass opacity or consolidation. This case demonstrates an atypical predominance of interstitial thickening on chest CT in COVID-19 pneumonia on day 14 of illness, which is the expected time of greatest severity of the disease.

High Resolution Computed Tomography (HRCT) Imaging Findings of Oval Window Atresia with Surgical Correlation.

INTRODUCTION: Isolated oval window atresia (OWA) is a rare cause of congenital conductive middle ear deafness and may be overlooked owing to the normal appearance of the external ear. This anomaly has been previously described, although the published numbers with both imaging and surgical findings are few. Our aim is to correlate the imaging features of OWA with intraoperative findings. MATERIALS AND METHODS: This is a single-centre retrospective evaluation of patients who were diagnosed with OWA and who received surgery from January 1999 to July 2006. No new case was diagnosed after 2006 to the time of preparation of this manuscript. High resolution computed tomography (HRCT) imaging of the temporal bones of the patients were retrospectively evaluated by 2 head and neck radiologists. Images were evaluated for the absence of the oval window, ossicular chain abnormalities, position of the facial nerve canal, and other malformations. Imaging findings were then correlated with surgical findings. RESULTS: A total of 9 ears in 7 patients (two of whom with bilateral lesions) had surgery for OWA. All patients had concomitant findings of absent stapes footplate with normal, deformed or absent stapes superstructure and an inferiorly displaced facial nerve canal. HRCT was sensitive in identifying OWA and associated ossicular chain and facial nerve abnormalities, which were documented surgically. CONCLUSION: OWA is a rare entity that can be diagnosed with certainty on HRCT, best visualised on coronal plane. Imaging findings of associated middle ear abnormalities, position of the facial nerve canal, which is invariably mal-positioned, and associated deformity of the incus are important for presurgical planning and consent.

Clinical utility of chest radiography for severe COVID-19.

BACKGROUND: Chest radiography (CXR) is performed more widely and readily than CT for the management of coronavirus disease (COVID-19), but there remains little data on its clinical utility. This study aims to assess the diagnostic performance of CXR, with emphasis on its predictive value, for severe COVID-19 disease. METHODS: A retrospective cohort study was conducted, 358 chest radiographs were performed on 109 COVID-19 patients (median age 44.4 years, 58 males and 30 with comorbidities) admitted between 22 January 2020 and 15 March 2020. Each CXR was reviewed and scored by three radiologists in consensus using a 72-point COVID-19 Radiographic Score (CRS). Disease severity was determined by the need for supplemental oxygen and mechanical ventilation. RESULTS: Patients who needed supplemental oxygen (n=19, 17.4%) were significantly older (P<0.001) and significantly more of them had co-morbidities (P=0.011). They also had higher C-reactive protein (CRP) (P<0.001), higher lactate dehydrogenase (LDH) (P<0.001), lower lymphocyte count (P<0.001) and lower hemoglobin (Hb) (P=0.001). Their initial (CRSinitial) and maximal CRS (CRSmax) were higher (P<0.001). Adjusting for age and baseline hemoglobin, the AUROC of CRSmax (0.983) was as high as CRPmax (0.987) and higher than the AUROC for lymphocyte countmin (0.897), and LDHmax (0.900). The AUROC for CRSinitial was slightly lower (0.930). CRSinitial ≥5 had a sensitivity of 63% and specificity of 92% in predicting the need for oxygen, and 73% sensitivity and 88% specificity in predicting the need for mechanical ventilation. CRS between the 6th and 10th day from the onset of symptoms (CRSD6-10) ≥5 had a sensitivity of 89% and specificity of 95% in predicting the need for oxygen, and 100% sensitivity and 86% specificity in predicting the need for mechanical ventilation. CONCLUSIONS: Adjusting for key confounders of age and baseline Hb, CRSmax performed comparable to or better than laboratory markers in the diagnosis of severe disease. CXR performed between the 6th and 10th days from symptom onset was a better predictor of severe disease than CXR performed earlier at presentation. A benign clinical course was seen in CXR that were normal or had very mild abnormalities.

Variable computed tomography appearances of COVID-19.

The coronavirus disease 2019 (COVID-19) is typically diagnosed by specific assays that detect viral nucleic acid from the upper respiratory tract; however, this may miss infections involving only the lower airways. Computed tomography (CT) has been described as a diagnostic modality in the COVID-19 diagnosis and treatment plan. We present a case series with virologically confirmed COVID-19 pneumonia. Variable CT features were observed: consolidation with ground-glass opacities, ground-glass opacities with subpleural reticular bands, and an anterior-posterior gradient of lung abnormalities resembling that of acute respiratory distress syndrome. Evolution of CT findings was observed in one patient, where there was interval resolution of bilateral lung consolidation with development of bronchiolectasis and subpleural fibrotic bands. While sensitive for detecting lung parenchymal abnormalities in COVID-19 pneumonia, the use of CT for initial diagnosis is discouraged and should be reserved for specific clinical indications. Interpretation of chest CT findings should be correlated with duration of symptoms to better determine the disease stage and aid in patient management.

Methadone-induced Toxic Encephalopathy In Pediatric Patients: Two Case Reports.

Toxic encephalopathy is a wide spectrum of encephalopathy secondary to insult from toxic substances, with variable clinical presentations from minor cognitive impairment to severe neurological dysfunction and death. Methadone-induced toxic encephalopathy is an extremely rare form of toxic encephalopathy which typically demonstrates abnormal imaging findings in the dentate nuclei or cerebellum. This is a report of methadone-induced toxic encephalopathy in two toddlers secondary to accidental ingestion. They were brought in unconscious to the emergency department of a tertiary hospital and were found to be cyanotic and pulseless, requiring cardiopulmonary resuscitation and mechanical ventilation. Magnetic resonance imaging (MRI) of the brain of both patients showed similar findings of symmetrical hyperintense foci in bilateral cerebellar hemispheres on T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences. These areas also demonstrated diffusion restriction on diffusion weighted imaging (DWI). Blood and urine toxicology results confirmed the presence of methadone in both patients. As the exact substance of accidental ingestion may not be known at the time of presentation, early radiological diagnosis of methadone-induced encephalopathy may prompt early initiation of treatment to prevent further life-threatening complications, particularly in vulnerable pediatric population.

Radiologic Findings in Polyarticular Amyloid Arthropathy and Myopathy in Multiple Myeloma: A Case Report.

BACKGROUND Amyloid arthropathy and myopathy are complications of amyloidosis that can be associated with non-specific imaging findings, which may be challenging to interpret. The report is of a case of polyarticular amyloid arthropathy and myopathy in a 56-year-old man with multiple myeloma and includes a description of the radiographic, computed tomography (CT), and magnetic resonance imaging (MRI) findings. CASE REPORT A 56-year-old man with multiple myeloma presented with chronic polyarticular pain and swelling. Soft tissue thickening of the wrist and knee were found on MRI to be of intermediate T1 weighted imaging (T1WI) and low to intermediate T2 weighted imaging (T2WI) signal intensity. Denervation muscle edema seen in the thenar muscles on the MRI of the right wrist were associated with carpal tunnel syndrome secondary to amyloid deposition. Soft tissue lesions in the periarticular regions of both hip joints were contiguous with subchondral bone lesions. Diffusely scattered myeloma lesions were shown as hyperintense on short tau inversion recovery (STIR) MRI imaging throughout the appendicular and axial skeleton, with vertebral compression fractures. Bilateral iliopsoas involvement with hypertrophy and abnormal surrounding fat reticulated signal intensity was consistent with amyloid myopathy. The patient had a pathological fracture of the right femoral neck and underwent surgical fixation. Histology of the right femoral head confirmed amyloid deposits. CONCLUSIONS Because the clinical presentation and imaging findings of musculoskeletal amyloidosis can be nonspecific, they can result in delay in diagnosis and treatment. Early radiologic identification of polyarticular amyloid arthropathy and myopathy should prompt confirmatory biopsy to confirm the diagnosis.

Renal squamous cell carcinoma mimicking xanthogranulomatous pyelonephritis: Case report and review of literature.

Primary renal squamous cell carcinoma (SCC) is a rare primary malignancy of the kidney. Diagnosis is usually delayed because of its lack of characteristic clinical and imaging features and inherent aggressive nature. We present a case of primary renal SCC in a 66-year-old woman with bilateral renal calculi and a complex right lower pole renal mass. The diagnosis of primary renal SCC was established based on the histopathology after right nephrectomy.

Salmonella Typhi Vertebral Osteomyelitis and Epidural Abscess.

Salmonella vertebral osteomyelitis is an uncommon complication of Salmonella infection. We report a case of a 57-year-old transgender male who presented with lower back pain for a period of one month following a fall. Physical examination only revealed tenderness over the lower back with no neurological deficits. MRI of the thoracic and lumbar spine revealed a spondylodiscitis at T10-T11 and T12-L1 and right posterior epidural collection at the T9-T10 level. He underwent decompression laminectomy with segmental instrumentation and fusion of T8 to L3 vertebrae. Intraoperatively, he was found to have acute-on-chronic osteomyelitis in T10 and T11, epidural abscess, and discitis in T12-L1. Tissue and wound culture grew Salmonella Typhi and with antibiotics susceptibility guidance he was treated with intravenous ceftriaxone for a period of six weeks. He recovered well with no neurological deficits.