CT of appendicoliths in adult appendicitis: clinical significance and characteristics of overlooked cases.

OBJECTIVES: Accurate computed tomography (CT) identification of appendicoliths in adults with acute appendicitis is crucial as it may preclude nonoperative management due to high risk of failure and complications. This investigation aimed to identify the significance of appendicoliths in acute appendicitis and to evaluate the performance of portovenous-phase (PVP) CT and the consequences of overlooked appendicoliths. METHODS: CT examinations of 324 consecutive patients (mean age 51.9 years, 112 men) with pathologically confirmed acute appendicitis were retrospectively included. Two radiologists independently reviewed the images, and disagreement was resolved by a consensus. RESULTS: Appendicoliths were identified in 134/324 patients, of which 75 had complicated appendicitis. Among 190 patients without appendicoliths, 52 had complicated appendicitis. An appendicolith was independently associated with complicated appendicitis (adjusted odds ratio 2.289; 95% CI: 1.343-3.902; p = 0.002). The larger minimum diameter was significantly associated with complication. The 4.5-/6.0-mm cutoffs for minimum and maximum diameters of appendicoliths demonstrated 82.7%/85.3% sensitivity and 35.6%/33.9% specificity in predicting complications. The PVP alone had 82.1-88.1% sensitivity, respectively per patient and per appendicolith, and a 100% specificity in the detection of appendicoliths, as compared with combined noncontrast and PVP. PVP overlooked 28/237 appendicoliths (11.8%) corresponding to 24/134 patients (17.9%). Of the 24 patients with overlooked appendicoliths, 16 had complicated appendicitis but 14 were correctly categorized by findings other than appendicoliths. In total, 2/127 patients (1.6%) with complicated appendicitis were misdiagnosed as having uncomplicated appendicitis. CONCLUSIONS: Appendicoliths in acute appendicitis were strongly associated with complications. While PVP overlooked some appendicoliths, only 1.6% of complicated appendicitis were misclassified when considering other CT findings. CLINICAL RELEVANCE STATEMENT: This study found a strong association between appendicoliths and complications. Its presence may preclude conservative management. Although portovenous-phase CT overlooked some appendicoliths, the combination with other CT findings allowed correct classification in a vast majority of cases. KEY POINTS: • Accurate identification of appendicoliths is crucial for nonoperative management decisions in adult acute appendicitis. • Appendicoliths are strongly associated with complications in adult acute appendicitis. • Portovenous-phase CT overlooked some appendicoliths, but only a small percentage of patients with complicated appendicitis were misclassified when considering other CT findings.

Diagnostic yield of esophagogastroduodenoscopy, colonoscopy, and small bowel endoscopy in Thai adults with chronic diarrhea.

BACKGROUND: Gastrointestinal endoscopy is frequently recommended for chronic diarrhea assessment in Western countries, but its benefit in the Southeast Asia region is not well established. METHODS: Medical records of consecutive patients undergoing esophagogastroduodenoscopy (EGD), colonoscopy, and small bowel endoscopy for chronic diarrhea from 2008 to 2018 were reviewed. Small bowel endoscopy included push enteroscopy, balloon-assisted enteroscopy (BAE), and video capsule endoscopy (VCE). The diagnostic yield of each endoscopic modality and predictors for positive small bowel endoscopy were analyzed. RESULTS: A total of 550 patients were included. The mean age was 54 years, and 266 (46.3%) patients were male. The mean hemoglobin and albumin levels were 11.6 g/dL and 3.6 g/dL, respectively. EGD and colonoscopy were performed in 302 and 547 patients, respectively, and the diagnostic yield was 24/302 (7.9%) for EGD and 219/547 (40.0%) for colonoscopy. EGD did not reveal positive findings in any patients with normal colonoscopy. Fifty-one patients with normal EGD and colonoscopy underwent small bowel endoscopy. Push enteroscopy, BAE, and VCE were performed in 28, 21, and 19 patients with a diagnostic yield of 5/28 (17.9%), 14/21 (66.7%), and 8/19 (42.1%), respectively. Significant weight loss, edema, and hypoalbuminemia were independent predictors for the positive yield of small bowel endoscopy. CONCLUSION: Colonoscopy was an essential diagnostic tool in identifying the cause of chronic diarrhea in Thai patients, whereas EGD provided some benefits. Small bowel endoscopy should be performed when colonoscopy and EGD were negative, particularly in patients with significant weight loss, edema, and hypoalbuminemia.

Clinical risk scoring for predicting non-alcoholic fatty liver disease in metabolic syndrome patients (NAFLD-MS score).

BACKGROUND & AIMS: Non-alcoholic fatty liver disease (NAFLD) can progress from simple steatosis to hepatocellular carcinoma. None of tools have been developed specifically for high-risk patients. This study aimed to develop a simple risk scoring to predict NAFLD in patients with metabolic syndrome (MetS). METHODS: A total of 509 patients with MetS were recruited. All were diagnosed by clinicians with ultrasonography-confirmed whether they were patients with NAFLD. Patients were randomly divided into derivation (n=400) and validation (n=109) cohort. To develop the risk score, clinical risk indicators measured at the time of recruitment were built by logistic regression. Regression coefficients were transformed into item scores and added up to a total score. A risk scoring scheme was developed from clinical predictors: BMI ≥25, AST/ALT ≥1, ALT ≥40, type 2 diabetes mellitus and central obesity. The scoring scheme was applied in validation cohort to test the performance. RESULTS: The scheme explained, by area under the receiver operating characteristic curve (AuROC), 76.8% of being NAFLD with good calibration (Hosmer-Lemeshow χ2 =4.35; P=.629). The positive likelihood ratio of NAFLD in patients with low risk (scores below 3) and high risk (scores 5 and over) were 2.32 (95% CI: 1.90-2.82) and 7.77 (95% CI: 2.47-24.47) respectively. When applied in validation cohort, the score showed good performance with AuROC 76.7%, and illustrated 84%, and 100% certainty in low- and high-risk groups respectively. CONCLUSIONS: A simple and non-invasive scoring scheme of five predictors provides good prediction indices for NAFLD in MetS patients. This scheme may help clinicians in order to take further appropriate action.

Alvarado score: can it reduce unnecessary CT scans for evaluation of acute appendicitis?

OBJECTIVE: The objective of the study is to assess the utility of Alvarado score in the diagnosis of acute appendicitis and the utility of computed tomographic (CT) scan for evaluation of acute appendicitis when stratified by Alvarado scores. MATERIALS AND METHODS: Retrospective cohort study comprised adult patients who underwent abdominal CT for suspected acute appendicitis between January 2006 and December 2009. Two abdominal radiologists independently reviewed the CT scans; any discrepancies were resolved by a consensus review. Alvarado scores were calculated and categorized as low (0-3), equivocal (4-6), or high (7-10) probability for appendicitis. The diagnostic utility of CT scans and Alvarado score for acute appendicitis were compared with the criterion standard of combined medical chart review and pathology findings. RESULTS: In a cohort of 158 subjects, 73 (46.2%) had clinical diagnoses of acute appendicitis. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CT scan in the diagnosis of acute appendicitis were 97.5%, 98.6%, 96.5%, 96.0%, and 98.8%, respectively. The mean Alvarado score for subjects with complicated appendicitis was significantly higher (7.95) than subjects with uncomplicated appendicitis (6.67) and those with other diagnoses (5.95). Acute appendicitis was confirmed in 2 (13.3%) of 15 subjects with low probability Alvarado scores, 16 (30.8%) of 52 subjects with equivocal scores, and 55 (60.4%) of 91 subjects with high probability scores. CONCLUSION: The CT scan had high diagnostic utility for acute appendicitis. The Alvarado score was not a reliable independent predictive tool for acute appendicitis and could not replace CT scan.

Intestinal capillariasis in the 21st century: clinical presentations and role of endoscopy and imaging.

BACKGROUND: Intestinal capillariasis is one of the common causes of malabsorption in the East. Reports emphasizing the roles of clinical, endoscopic and radiologic findings of intestinal capillariasis are limited. METHODS: Retrospective review of medical records of 26 patients diagnosed with intestinal capillariasis at Siriraj Hospital, Bangkok, Thailand between 2001- 2013. RESULTS: Clinical manifestations were chronic watery diarrhea (93%), chronic abdominal pain (70%), significant weight loss (92%), hypoalbuminemia (100%; 85% lower than 2.0 g/dL), and anemia (50%). The median duration of symptoms was 5.5 months (1-60 months). Parasites were found in stool in 15 patients (57%). In patients whose stool tests were initially negative, parasites were discovered in tissue biopsy from endoscopy in 1 from 10 esophagogastroduodenoscopies (EGD), 0 from 7 colonoscopies, 3 from 5 push enteroscopies, and 3 from 5 balloon-assisted enteroscopies (BAE). Endoscopic findings included scalloping appearance, mucosal cracking, and redness of mucosa. These endoscopic findings affected mostly at jejunum and proximal ileum. They were similar to celiac disease except duodenal involvement which is uncommon in capillariasis. Three patients underwent video capsule endoscopy (VCE) and typical abnormal findings were observed in all patients. Small bowel barium study showed fold thickening, fold effacement, and increased luminal fluid in 80% of patients, mainly seen at distal jejunum and ileum. CT findings were long segment wall thickening, enhanced wall, and fold effacement. Treatment with either albendazole or ivermectin cured all patients with most responding within 2 months. CONCLUSIONS: In endemic area, intestinal capillariasis should be considered if patients develop chronic watery diarrhea accompanied by significant weight loss and severe hypoalbuminemia. Stool examination had quite low sensitivities in making diagnosis in our study. Deep enteroscopy with biopsy guided by imaging or VCE may improve diagnostic yield. Empirical therapy may also be justifiable due to the very good response rate and less side effects.

Correlation between the severity of hepatitis B cirrhosis and CT volumetry-based hepatic segmental anatomic changes.

OBJECTIVE: To study the correlation between the changes of hepatic segmental volumes and the severity of hepatitis B cirrhosis, classified by Child-Pugh score. MATERIAL AND METHOD: The study cohort comprised viral hepatitis B cirrhotic patients with different severity (Child-Pugh score grade A to C) and control subjects who underwent hepatic computed tomographic (CT) scan between February 2006 and May 2012. The volumes of total liver (TLV), right lobe (RV), left medial segment (LMV), left lateral segment (LLV), and caudate lobe (CV) were measured and compared between the control group and Child-Pugh A, B, and C groups. RESULTS: Among 120 hepatitis B cirrhotic subjects, there were 85 males (70.8%) with the mean age of 59.2 years (range 36-86 years). Sixty-two subjects were Child-Pugh A, 39 were Child-Pugh B, and 19 were Child-Pugh C. Among 62 control subjects, there were 28 males (45.2%) with the mean age of54.5 years (range 19-82 years). The TLVand R Vwere significantly decreased in Child-Pugh B and C subjects when compared with control subjects. LMV was significantly decreased in Child-Pugh A and continually decreased along with the severity of the disease. LLV was significantly increased in Child-Pugh A and B, but relative in Child-Pugh C subjects. CV was not significantly different in these four groups. CONCLUSION: Hepatitis B cirrhotic patients had progressive hepatic atrophy, initially by left medial segment, followed by right lobe and the whole liver Hypertrophy of left lateral segment was evident in early cirrhosis but not significantly shown in severe cirrhosis. Hypertrophy of caudate lobe was not evident in any degrees of hepatitis B cirrhosis.

The CT appearances for differentiating of peripheral, mass-forming cholangiocarcinoma and liver meatastases from colorectal adenocarcinoma.

OBJECTIVE: To evaluate the computed tomographic (CT) appearances for differentiating of primary hepatic adenocarcinoma (peripheral, mass-forming cholangiocarcinoma) and secondary hepatic adenocarcinoma (liver metastases from colorectal carcinoma). MATERIAL AND METHOD: Between January 2004 and December 2010, 45 patients with peripheral, mass-forming cholangiocarcinoma (Group 1) and 45 patients with liver metastases from colorectal adenocarcinoma (Group 2) who underwent abdominal CT scan at the authors' institution were included in the present retrospective study. Two experienced, abdominal radiologists blinded to the participants 'clinical histories and pathological results, separately reviewed the CT findings of each participant (number of liver mass(es), size, margin, internal calcification, hepatic capsule retraction, vascular invasion, peripheral bile duct dilatation, proximal bile duct enhancement, extrahepatic spreading, nearby lymphadenopathy and nearby organ invasion) and gave the presumed diagnosis of each individual case. Any discrepancies were solved by a consensus review. Finally, the authors conducted a stratified analysis of the patients in both groups based on their CT appearances. RESULTS: Ninety participants were 35 (38.9%) female, 55 (61.1%) male, age range from 43 to 88 years (mean 63.4 years, SD = 10.7). There were 28.9% vs. 48.9% female with the mean age (SD) of 61.5 (9.4) vs. 65.4 (11.6) years in Group 1 and 2, respectively. The mean size (SD) were 7.4 (3.7) cm vs. 4.0 (2.1) cm, in Group 1 and 2, respectively (p < 0.001). The presence of hepatic capsule retraction, vascular invasion, peripheral bile duct dilatation, proximal bile duct enhancement, extrahepatic spreading, nearby lymphadenopathy, and nearby organ invasion were significantly higher in Group 1 than Group 2 (p < 0.001). In contrary, the presence of multiple lesions with separated locations, and smooth margin were significantly suggested of Group 2 (p < 0.001 and p = 0.007, respectively). By logistic regression analysis, peripheral bile duct dilatation, extrahepatic spreading, and proximal bile duct enhancement were the sole predictors of peripheral, mass-forming cholangiocarcinoma. The interobserver agreement for the presumed diagnosis of liver mass was good (kappa = 0.76). CONCLUSION: The presence of peripheral bile duct dilatation, extrahepatic spreading, and proximal bile duct enhancement were highly suggestive of peripheral, mass-forming cholangiocarcinoma.

Favorable outcome of immunotherapy in a rare subtype of hepatocellular carcinoma: a case report and literature review.

Scirrhous hepatocellular carcinoma (S-HCC) represents an uncommon subtype of HCC. During radiological evaluation this unique subtype is frequently mistaken as cholangiocarcinoma, fibrolamellar HCC, or metastatic adenocarcinoma. Here, we present the case of a 50-year-old woman with a large hepatic mass. A triple-phase computed tomography of the liver revealed an arterial enhancing lesion without portovenous washout at hepatic segment 4a/8. The liver biopsy showed hepatocellular characteristics and was positive for Hep Par 1, CK7, CK19, Arginase 1 and CEA, indicating atypical S-HCC. This patient had achieved tumor control with combined treatment with atezolizumab plus bevacizumab and was then treated with lenvatinib after tumor progression. The patient died 15 months after the initial diagnosis.

The impact of environmental cleaning protocol featuring PX-UV in reducing the incidence of multidrug-resistant gram-negative healthcare-associated infection and colonization in intensive care units in Thailand.

In this quasi-experimental study, implementing PX-UV to the standard environmental cleaning protocol was associated with a reduction in the overall incidence of multidrug-resistant (MDR) gram-negative organisms (P = .01) and MDR Acinetobacter baumannii (P = .001) in intervention intensive care units. However, the intervention did not reduce patient length of stay and 30-day mortality.

The Patterns of Antifungal Use and Risk Factors Associated with Mortality in Patients with Invasive Candidiasis and Aspergillosis Infections Among Patients Who were Received Infectious Disease Specialist Consultation Prior to and During the COVID-19 Pandemic in A Resource-Limited Setting: A Retrospective Cohort Study.

BACKGROUND: Limited data is available concerning the patterns of antifungal use and invasive fungal infection (IFI)-associated mortality risk factors prior to and during the COVID-19 pandemic in a resource-limited setting. METHODS: A single center retrospective cohort study was conducted to evaluate the patterns of antifungal use and IFI-associated mortality risk factors in a resource-limited setting prior to and during the COVID-19 pandemic. All patients age >18 years diagnosed with IFI were prospectively followed during a 3-year pre-COVID-19 pandemic period (period 1: 1/1/2017-12/31/2019) and a 3-year during COVID-19 pandemic period (period 2: 1/1/2020-12/31/2022). Patient characteristics, patterns of antifungal use, IFI-associated mortality risk factors, and adverse drug events were collected. Multivariate analysis was performed to identify IFI-associated mortality risk factors. RESULTS: There was a total of 133 patients in this study: 60 (45.1%) in period 1 and 73 (54.9%) in period 2. Pre-emptive antifungal therapy was commonly practiced in period 2 (21.7% vs 37%, p=0.05). The presence of a central venous catheter (CVC) (aOR 3.19, p=0.007), hematologic adverse drug events (aOR 17.9, p=0.008) were potentially preventable risks for the overall IFI mortality in both periods. Appropriate antifungal use was protective against the overall IFI mortality in period 2 (aOR 0.09, p=0.009). CONCLUSION: Several preventable IFI-associated mortality risk factors including the presence of CVC and inappropriate antifungal use were identified and served as key target changes for improvement of infection prevention, national policy to access appropriate antifungal agents, and antifungal stewardship in a resource-limited setting during the COVID-19 pandemic.

Timed barium esophagography to predict recurrent achalasia after peroral endoscopic myotomy: a retrospective study in Thailand.

BACKGROUND/AIMS: Achalasia is a rare esophageal motility disease, for which peroral endoscopic myotomy (POEM) has emerged as a promising treatment option; however, recurrence remains a challenge. Timed barium esophagography (TBE) is a useful diagnostic tool and potential outcome predictor of achalasia. This study aimed to determine predictive tools for recurrence after POEM. METHODS: This retrospective study enrolled achalasia patients who underwent POEM between January 2015 and December 2021. Patients were categorized into two groups using the 1-month post-POEM Eckardt scores and TBE: the discordant group (Eckardt score improved >50%, TBE decreased <50%) and the concordant group (both Eckardt score and TBE improved >50%). Recurrence was defined as a reincrease in the Eckardt score to more than three during follow-up. RESULTS: Complete medical records were available in 30 patients who underwent POEM. Seventeen patients (56.7%) were classified into the discordant group, while 13 patients (43.3%) were in the concordant group. The overall recurrence rate was 11.9% at 1-year, increasing to 23.8% during the extended follow-up. The discordant group had a 6.87 fold higher recurrence rate than the concordant group (52.9% vs. 7.7%, p=0.017). CONCLUSIONS: These results strongly suggest that combining the Eckardt score with TBE can effectively predict recurrent achalasia after POEM. Patients in the discordant group had an elevated risk.

Optimizing computed tomography image reconstruction for focal hepatic lesions: Deep learning image reconstruction vs iterative reconstruction.

Background: Deep learning image reconstruction (DLIR) is a novel computed tomography (CT) reconstruction technique that minimizes image noise, enhances image quality, and enables radiation dose reduction. This study aims to compare the diagnostic performance of DLIR and iterative reconstruction (IR) in the evaluation of focal hepatic lesions. Methods: We conducted a retrospective study of 216 focal hepatic lesions in 109 adult participants who underwent abdominal CT scanning at our institution. We used DLIR (low, medium, and high strength) and IR (0 %, 10 %, 20 %, and 30 %) techniques for image reconstruction. Four experienced abdominal radiologists independently evaluated focal hepatic lesions based on five qualitative aspects (lesion detectability, lesion border, diagnostic confidence level, image artifact, and overall image quality). Quantitatively, we measured and compared the level of image noise for each technique at the liver and aorta. Results: There were significant differences (p < 0.001) among the seven reconstruction techniques in terms of lesion borders, image artifacts, and overall image quality. Low-strength DLIR (DLIR-L) exhibited the best overall image quality. Although high-strength DLIR (DLIR-H) had the least image noise and fewest artifacts, it also had the lowest scores for lesion borders and overall image quality. Image noise showed a weak to moderate positive correlation with participants' body mass index and waist circumference. Conclusions: The optimal-strength DLIR significantly improved overall image quality for evaluating focal hepatic lesions compared to the IR technique. DLIR-L achieved the best overall image quality while maintaining acceptable levels of image noise and quality of lesion borders.

Effectiveness of a multimodal strategy to reduce external ventricular drain-associated infection: A quasi-experimental study.

BACKGROUND: Infection is a serious complication in neurosurgical patients who undergo external ventricular drain (EVD) insertion. METHODS: We conducted a quasi-experimental study in patients who underwent EVD insertion to evaluate the impact of a multi-modal strategy to reduce the incidence of external ventricular drain associated infections (EVDAIs). The study was divided into 2 periods; (1) the pre-intervention period when techniques for EVD insertion and maintenance were up to the discretion of the neurosurgeons and (2) the post-intervention after implementation of a multi-modal strategy (cefazolin antibiotic prophylaxis, preoperative chlorhexidine showers, application of postoperative chlorhexidine-impregnated dressing, limited manipulation of the EVD, and meticulous EVD management). The primary outcome was the incidence rate of EVDAIs; secondary outcomes included in-hospital mortality rate, the hospital length of stay. RESULTS: In total, 135 patients were included. The incidence rate of EVDAIs was significantly reduced in the post-intervention period (5.6 cases/1,000 EVD-days) compared with the pre-intervention period (18.2 cases/1,000 EVD-days; P=0.026). There were no differences in all secondary outcomes analyzed. This multi-modal strategy was associated with high satisfaction among health care personnel. CONCLUSIONS: Implementation of a multi-modal strategy was associated with a reduction in the incidence of EVDAIs. This was in line with our goal of promoting a new culture of safety despite being in a resource-limited setting.

Comparison of pasteurized whole milk, UHT whole milk, water, and diluted iodine contrast as computed tomographic enteric contrasts.

OBJECTIVE: To compare four computed tomographic (CT) enteric contrasts (pasteurized whole milk, UHT whole milk, water, and diluted iodine contrast) in various aspects, including gastrointestinal (GI) distension, mural visualization, GI landmark distinction, taste, patients 'satisfaction, adverse effects, and prices. MATERIAL AND METHOD: Sixty patients scheduled for whole abdominal CT at the present institution were randomized to receive 1,000 ml of pasteurized whole milk (n = 15), UHT whole milk (n = 15), water (n = 15) and diluted iodine contrast (n = 15) as CT enteric contrasts. Two radiologists separately assessed the GI distension (using a 4-point scale: poor, partial, good, and full), mural visualization (using a 3-point scale: poor, partial, and good), GI landmark distinction at esophagogastric (EG) junction, ampulla of Vater, and pancreatic head-duodenal loop (using a 3-point scale: poor, partial, and good). The participants graded the taste of received enteric contrasts and their satisfaction using a 4-point scale (unacceptable, unpleasant, acceptable, and pleasant). Adverse effects were evaluated by GI associated symptoms (nausea, vomiting, abdominal cramping/discomfort, and diarrhea). RESULTS: Pasteurized whole milk was superior to other agents in GI distension and tended to be better than other agents in mural visualization and GI landmark distinction. No difference in taste and patients' satisfaction was noted between pasteurized whole milk and other agents. Gallbladder collapse was inevitable in participants with pasteurized and UHT whole milk consumption, due to 4%fat content in whole milk. GI adverse effects were more common in whole milk group than other agents. The prices of pasteurized whole milk, UHT whole milk, water and diluted iodine contrast were about 42, 40, 14, and 36 Baht, respectively. CONCLUSION: Pasteurized whole milk is an attractive oral contrast agent, providing good GI distension, mural visualization, and GI landmark discrimination. Apart from gallbladder collapse, increase of GI adverse symptoms was another major drawback of whole milk when used as CT oral contrast, especially in Thai people.

Detection of recurrent colorectal cancer by 18F-FDG PET/CT comparison with contrast enhanced CT scan.

OBJECTIVE: To evaluate diagnostic performance of 18F-FDG PET/CT in assessment of recurrence colorectal cancer after treatment in Siriraj Hospital. MATERIAL AND METHOD: The authors retrospectively studied 48 treated colorectal cancer patients with suspected recurrence who underwent 18F-FDG PET/CT and contrast-enhanced CT (CECT). Clinical information, image follow-up for at least one year, and pathological reports of the patients were reviewed for gold standard RESULTS: Recurrent or metastatic disease was found in 36 of 48 patients. Calculated sensitivity, specificity and accuracy of 18F-FDG PET/CT were 94.4%, 66.7%, and 87.5%. 18F-FDG PET/CT can reduce false positive results of CECT in six patients, thus specificity of 18F-FDG PET/CT was statistically significantly better than that of CECT. Using lesion-based analysis with 65 recurrent sites and 26 non-recurrent lesion, 18F-FDG PET/CT showed better sensitivity 87.7%, specificity 61.5%, and accuracy 80.2 than CECT without statistical significance. CONCLUSION: 18F-FDG PET/CT overall showed higher sensitivity, specificity, and accuracy than CECT.

Small bowel transmural necrosis secondary to acute mesenteric ischemia and strangulated obstruction: CT findings of 49 patients.

Rationale and objectives: Transmural bowel necrosis (TBN) is an uncommon surgical emergency that represents an endpoint of occlusive acute mesenteric ischemia (AMI), nonocclusive AMI and small bowel obstruction (SBO). According to limited evidence, each etiology of TBN might demonstrate a different CT finding. This investigation aimed to 1) identify overall CT findings of TBN, and 2) compare CT findings of TBN in each etiology. Materials and methods: Forty-nine consecutive adults (mean age, 64.6 years; 26 men) with occlusive AMI, nonocclusive AMI or SBO, and pathologically proven TBN were enrolled. All had a CT scan within 24 h before surgery. Clinical information was compiled from medical records. CT examinations were re-reviewed by two radiologists with disagreements resolved by the third radiologist. Data were analyzed and compared. Results: Transmural bowel necrosis were secondary to arterial AMI, venous AMI, combined arterial and venous AMI, nonocclusive AMI, and SBO in 6, 5, 2, 10, and 26 patients, respectively. The CT findings were ascites (93.9%), abnormal wall enhancement (91.8%), bowel dilatation (89.8%), mesenteric fat stranding (89.8%), abnormal wall thickness (71.5%), pneumatosis (46.9%) and intrinsic hyperattenuation of bowel walls (22.5%). Portovenous gas, mesenteric venous gas, and pneumoperitoneum were present in 4 patients (8.2%). Bowel wall thickness was the only CT findings that showed a statistically significant difference among the 5 etiologies of TBN (P = 0.046). Conclusions: Most common CT findings of TBN were ascites, abnormal bowel wall enhancement, dilatation, and mesenteric fat stranding. Wall thickness differentiated five etiologies, being most thickened in venous AMI and normal in arterial AMI.

Efficacy of Environmental Cleaning Protocol Featuring Real-Time Feedback with and without PX-UV in Reducing the Contamination of Gram-Negative Microorganisms on High-Touch Surfaces in Four Intensive Care Units in Thailand.

Environmental cleaning and disinfection practices have been shown to reduce microorganism bioburden in the healthcare environment. This study was performed in four intensive care units in Thailand. Five high-touch surfaces were sampled before and after terminal manual cleaning and disinfection, and after pulsed xenon UV (PX-UV). Five nursing station sites were collected on a weekly basis before and after terminal manual cleaning. There were 100 patient rooms-50 rooms in the intervention arm and 50 rooms in the control arm-plus 32 nursing station sites. In the intervention arm, rooms with positive Gram-negative microorganisms were reduced by 50% after terminal manual cleaning and disinfection (p = 0.04) and 100% after PX-UV disinfection (p < 0.001). On five nursing station sites, colony counts of Gram-negative contamination decreased by 100% (p < 0.001) in the intervention arm while decreasing by 65.2% (p = 0.03) in the control arm after terminal manual cleaning and disinfection. The in-room time use was 15.6 min per room. A PX-UV device significantly reduced the level of Gram-negative microorganisms on high-touch surfaces in intensive care units. The application of a PX-UV device was practical a in resource-limited setting without compromising cleaning and disinfection times.

Validation of scoring systems for the prediction of complicated appendicitis in adults using clinical and computed tomographic findings.

OBJECTIVES: The study aimed to evaluate scoring systems for predicting complicated appendicitis in adults diagnosed with acute appendicitis on computed tomography. METHODS: Three hundred twenty-five consecutive adult patients (mean age 51.9 ± 19.6 years, 212 women) diagnosed with acute appendicitis on computed tomography were retrospectively included. Clinical and imaging findings were compared between patients with and without complicated appendicitis, and independent associations were identified. As C-reactive protein was not available for most patients, 5 out of 8 scoring systems were modified. They, and a newly proposed system, were compared via area under the receiver operating characteristics (ROC) curve (AUC), Additionally, the latter was internally validated. Pairwise comparison was performed, and diagnostic performance of these scoring systems was obtained. RESULTS: One hundred twenty-seven patients (36.8%) had complicated appendicitis. Significant independent associations were found between complicated appendicitis and duration of symptoms > 12 h, appendicolith, periappendiceal fat stranding, periappendiceal fluid, and extraluminal air (p values < 0.001 to 0.037; AUCs of 0.824-0.829). AUCs of 9 scoring systems ranged from 0.692 to 0.831. Of these, modified Atema, Kim HY, and proposed scores had similarly high and non-significantly different AUCs (0.793-0.831) on pairwise comparison. Their sensitivities, specificities, and accuracies were 73.0-90.6%, 48.5-70.6%, and 64.3-72.3%, respectively. Internal validity test demonstrated high AUCs (0.826-0.844) with one of the proposed scores using odds ratio having 100% sensitivity and 100% negative predictive value. CONCLUSIONS: Few scoring systems, including proposed ones, had high AUCs, sensitivity, and reasonable specificities, which could potentially aid in safely selecting adult patients with acute appendicitis for nonoperative management. CRITICAL RELEVANCE STATEMENT: The study suggests few scoring systems for predicting complicated appendicitis with high AUCs and reasonable sensitivities, potentially aiding in selecting patients for nonoperative management. KEY POINTS: • The study evaluated existing and proposed new scoring systems to predict complicated appendicitis in adults with acute appendicitis on computed tomography. • Several factors were found to be significantly associated with complicated appendicitis, including duration of symptoms, appendicolith, periappendiceal fat stranding, periappendiceal fluid, and extraluminal air. • The modified Atema, Kim HY, and newly proposed scoring systems performed well, potentially aiding in nonoperative management selection.

Performance of computed tomography and its reliability for the diagnosis of transmural gastrointestional necrosis in a setting of acute ingestion of predominantly strong acid substances in adults.

OBJECTIVES: Computed tomography has become a critical component in evaluating adult patients with acute caustic ingestions and an alternative to endoscopy for detecting transmural gastrointestinal necrosis. This study assessed the performance and reliability of computed tomography findings of transmural gastrointestinal necrosis, given that the presence of the disease potentially signifies the need for surgery. METHODS: A retrospective database search was performed to identify consecutive adult patients with acute caustic ingestions who had computed tomography with endoscopy or surgery within 72 h of admission. Eight physicians reinterpreted computed tomography in two separate rounds. Diagnostic performance utilized eight rounds of radiologists' reinterpretations against reference endoscopic or surgical grades. Intra- and interobserver agreements were calculated. RESULTS: Seventeen patients (mean age, 45.6 years; 9 men; 46 esophageal and 34 gastric segments; 16 ingested strong acid substances) met the inclusion criteria. Eight patients (10 esophageal and 13 gastric segments) had transmural gastrointestinal necrosis. The highly differentiating findings between those with and without transmural gastrointestinal necrosis were esophageal wall thickening (100% vs. 42%, P = 0.001; 100% sensitive), gastric abnormal wall enhancement and fat stranding (100% vs. 57%, P = 0.006; 100% sensitive), and gastric absent wall enhancement (46% vs. 5%, P = 0.007; 100% specific). The intra- and interobserver percentage agreements were 47-100%, and 54-100%, which increased to 53-100%, and 60-100%, respectively, when considering only radiologists' reinterpretations. CONCLUSIONS: In a very small sample of adults who primarily ingested acid, contrast-enhanced computed tomography performed well when interpreted by a panel of radiologists.