Third-Generation Dual-Source Computed Tomography for Coronary Angiography With Individually Tailored Scan Protocols Can Achieve a Low Radiation Dose With Good Image Quality in Unselected Patients.

OBJECTIVE: To explore the image quality and radiation exposure associated with coronary angiography obtained with a third-generation dual-source computed tomography, using body mass index (BMI)- and heart rate (HR)-adapted protocols in real-world patients. METHODS: Three scan protocols were implemented with regard to HR: prospective turbo high-pitch spiral, sequential, and retrospective spiral modes. We adapted the reference kilovoltage value according to BMI. Image quality was evaluated using a 4-point scale, and effective dose estimates were calculated using the dose-length product. RESULTS: Among the 896 patients, 417 (46.54%), 433 (48.32%), and 45 (5.02%) were imaged using prospective turbo high-pitch spiral, sequential, and retrospective spiral modes, respectively. The median BMI was 27.3 (25-30.4) kg/m2, and the effective dose was 0.65 mSv (interquartile range, 0.33-1.56 mSv). Only 32 of 896 examinations (3.5%) had poor image quality. CONCLUSIONS: Computed tomography angiography with BMI- and HR-tailored protocols offers good image quality with low radiation dose in unselected patients.

Cecum perforation induced by mycophenolate mofetil after hematopoietic stem cell transplantation: A case report and review of literature.

GI perforation after stem cell transplantation is extremely rare and is associated with poor prognosis. In addition, the clinical limitations of MMF are associated with GI intolerance and hematologic suppression. However, the exact mechanism whereby MMF induces changes in GI mucosa is unknown. Currently, there is no definite method to distinguish between GI toxicity associated with MMF and GVHD. It is important to recognize association between MMF and the histologic changes mimicking GVHD, given that GVHD is a significant differential diagnosis in stem cell transplant patients. MMF-induced colitis and GI perforation are extremely rare but should be considered in patients presenting with diarrhea and abdominal pain. Histology and clinical features are helpful to distinguish this condition from ischemic colitis. Early recognition of GI perforation is necessary for proper diagnosis and subsequent intervention. Emergency medical treatment and laparotomy have been shown to reduce the risk of fatal complications in patients presenting with GI symptoms suspected of GI perforation.

Eye Movement Disorders Following Allogeneic Bone Marrow Transplantation on FK506 (Tacrolimus) and Ganciclovir.

FK506 (tacrolimus) is an immunosuppressive drug and more potent than cyclosporine. FK506 is widely used for immunosuppression in the prevention and treatment of graft-versus-host disease after allogeneic bone marrow transplantation and solid organ transplantation. Neurotoxicity is a recognized complication of FK506 therapy, but ptosis and weakness of eye abduction unilaterally has not been reported in association with FK506 administration to date. We discuss a 13-year-old male patient who developed ptosis and weakness of eye abduction unilaterally 90 days after transplantation with bone marrow from an unrelated donor, for acute lymphoblastic leukemia in this case report. FK506 therapy was administered for graft-versus-host disease prophylaxis and CMV infection was treated with ganciclovir. The physical examination findings completely resolved 72 to 96 hours after concomitant FK506 and ganciclovir treatment were terminated.

Intraoperative sonographic guidance for intracavitary brachytherapy of cervical cancer.

BACKGROUND: To describe the role and benefits of intraoperative sonographic (US) guidance in intracavitary brachytherapy of cervical cancer. METHODS: The data of 142 patients who received tandem-based intracavitary brachytherapy for cervical cancer between January 2010 and June 2015 were retrospectively reviewed. US guidance was carried out for tandem selection and appropriate application. The complications and applicator conformity were assessed with planning CT. RESULTS: Intracavitary brachytherapy was performed under US guidance for 412 insertions in 113 consecutive patients with cervical cancer. Before we started to use US guidance, applications were done in 29 patients: uterine perforation occurred in two patients (6.9%), the tandem length was short in two patients (6.9%), the tandem length was long in four patients (13.8%), and tandem was in myometrium in three patients (10.3%). We then decided to use US guidance routinely. With US guidance, only 1 of 113 patients had uterine perforation (0.9%), tandem length was short in only one patient (0.9%), and tandem was in myometrium in one patient (0.9%). CONCLUSIONS: Real-time US provided safe and effective guidance for intracavitary brachytherapy of cervical cancer resulting in decreased rates of perforations and misplacement of applicators. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:8-13, 2018.

Impact of antenatal corticosteroid exposure on thymus size in premature infants.

BACKGROUND: This study examined the effect of corticosteroids on the thymic index (TI) and the thymus/weight index (TWI) in infants exposed to antenatal corticosteroids (ACS). METHODS: This prospective study was conducted between August 2014 and October 2018. A thymus ultrasound was performed to assess thymus size on the second day of life. Thymus size was assessed as TI and TWI. RESULTS: In total, 167 neonates (≤34 weeks gestation)  constituted the study population, including 94 ACS-exposed infants and 73 untreated infants. The treatment group exhibited significantly lower birth weight and significantly shorter birth length than the ACS (-) group. Therefore, TI was smaller in the treatment group than in the untreated group (6.96 ± 4.05 cm3 vs. 5.64 ± 3.39 cm3). The TWI was 3.69 ± 1.8 cm3/kg in the ACS (-) group versus 3.32 ± 1.56 cm3/kg in the ACS (+) group. The median anteroposterior diameter of the right lobe was 1.33 cm (range, 0.45-2.40) in the ACS (-) group compared to 1.15 cm (range, 0.47-2.40) in the ACS (+) group. The median anteroposterior diameter of the left lobe was 1.40 cm (range, 0.43-2.20) in the ACS (-) group and 1.19 cm (range, 0.32-2.36) in the ACS (+) group. The median largest sagittal area was 2.64 cm2 (range, 0.5-5.46) in the ACS (-) group versus 2.20 cm2 (range, 0.55-5.90) in the ACS (+) group. CONCLUSION: We found that TWI was not significantly changed by ACS exposure in premature infants.

Risk Assessment for BK Virus-Associated Hemorrhagic Cystitis After Pediatric Hematopoietic Stem Cell Transplant: A Single-Center Retrospective Cross-Sectional Study.

OBJECTIVES: BK virus-associated hemorrhagic cystitis is a common complication of allogeneic hematopoietic stem cell transplant. It is known to be associated with cyclophosphamide therapy and the intensity of the conditioning regimen as well as infection with the BK virus. Data are limited for BK virus-associated hemorrhagic cystitis in pediatric recipients of allogeneic hematopoietic stem cell transplant. Therefore, we aimed to identify the risk factors and etiology of BK virus-associated hemorrhagic cystitis and determine the factors that may improve the treatment efficacy. MATERIALS AND METHODS: Data from recipients of allogeneic hematopoietic stem cell transplant were retrospectively analyzed. These data included information about age, sex, underlying disease, the details of ablative conditioning, graft-versus-host disease prophylaxis, donor type, stem cell source, history of acute graft-versus-host disease, and cytomegalovirus reactivation. RESULTS: A total of 50 patients developed BK virusassociated hemorrhagic cystitis among 334 patients. Symptoms associated with BK virus-associated hemorrhagic cystitis manifested an average of 45.3 days after transplant. Most of the patients had grade 2 and grade 3 hemorrhagic cystitis. Risk factor analysis revealed that haploidentical donor type, treatment with busulfan and cyclophosphamide as part of conditioning regimen, and history of total body irradiation increased the risk of BK virus-associated hemorrhagic cystitis in the pediatric recipient population. CONCLUSIONS: We found that, despite current conditioning regimens, BK virus-associated infection still leads to a considerable incidence rate of hemorrhagic cystitis in pediatric recipients of allogeneic hematopoietic stem cell transplant. Patients with a haploidentical donor and a history of busulfan and cyclophosphamide treatment or total body irradiation had a higher risk of BK virus-associated hemorrhagic cystitis. Thus, we suggest that patients with these factors should be followed closely after allogeneic hematopoietic stem cell transplant.

Whole-body MRI for preventive health screening: Management strategies and clinical implications.

PURPOSE: To document the diagnostic yields of whole-body MRI (WB-MRI) screening for asymptomatic individuals by using a classification system that categorizes the findings by clinical relevance and provides a flowchart for further investigations, and to determine the influence of WB-MRI findings on clinical decision-making. METHODS: In this institutional review board-approved study, a retrospective review of individuals who underwent WB-MRI between 2009 and 2020 was conducted, and asymptomatic participants who underwent non-contrast-enhanced comprehensive WB-MRI for screening were enrolled. Participants were classified into four categories based on WB-MRI findings, and those with relevant findings (i.e., categories 3 and 4) were referred for further diagnostic workup. The participants' medical records were investigated, and interviews were conducted to reveal false-negative findings and identify the number of WB-MRI-triggered treatments. RESULTS: We included 576 participants (377 [65.4 %] men, 199 [34.6 %] women; mean age, 48.40 ±â€¯10.82 years), of which 266 (46.2 %) and 310 (53.8 %) underwent WB-MRI with 1.5 T and 3.0 T magnets, respectively. Approximately one-third of the participants showed clinically relevant findings, and 65 (11.2 %) received a treatment triggered by WB-MRI. Notably, 15 (2.6 %) and 28 (4.8 %) participants had cancers and intracranial aneurysms, respectively. Of the 576 participants, 16 (2.8 %) had false-negative findings, among which five had cancers. CONCLUSION: WB-MRI yields numerous important findings that trigger therapeutic interventions in a large sample of asymptomatic adults. However, considering its inherent limitations, WB-MRI might be inadequate for detecting malignancies such as colon, thyroid, and breast cancers; thus, it may serve as a complementary screening method for health-conscious individuals.

Impact of the HEAD-US Scoring System for Observing the Protective Effect of Prophylaxis in Hemophilia Patients: A Prospective, Multicenter, Observational Study

Objective: This study aimed to observe the preventive effect of prophylactic treatment on joint health in people with hemophilia (PwH) and to investigate the importance of integration of ultrasonographic examination into clinical and radiological evaluation of the joints. Materials and Methods: This national, multicenter, prospective, observational study included male patients aged ≥6 years with the diagnosis of moderate or severe hemophilia A or B from 8 centers across Turkey between January 2017 and March 2019. Patients were followed for 1 year with 5 visits (baseline and 3th, 6th, 9th, and 12th month visits). The Hemophilia Joint Health Score (HJHS) was used for physical examination of joints, the Pettersson scoring system was used for radiological assessment, point-of-care (POC) ultrasonography was used for bilateral examinations of joints, and the Hemophilia Early Arthropathy Detection with Ultrasound (HEAD-US) score was used for evaluation of ultrasonography results. Results: Seventy-three PwH, of whom 62 had hemophilia A and 11 had hemophilia B, were included and 24.7% had target joints at baseline. The HJHS and HEAD-US scores were significantly increased at the 12th month in all patients. These scores were also higher in the hemophilia A subgroup than the hemophilia B subgroup. However, in the childhood group, the increment of scores was not significant. The HEAD-US total score was significantly correlated with both the HJHS total score and Pettersson total score at baseline and at the 12th month. Conclusion: The HEAD-US and HJHS scoring systems are valuable tools during follow-up examinations of PwH and they complement each other. We suggest that POC ultrasonographic evaluation and the HEAD-US scoring system may be integrated into differential diagnosis of bleeding and long-term monitoring for joint health as a routine procedure.

Analysis of Cavernous Malformations: Experience with 18 Cases.

AIM: To analyze the results of stereotactic radiosurgery (SRS) or surgical treatment of 18 cases with cavernous malformation and report 2 cases with unusual localization and size. MATERIAL AND METHODS: We present 11 and 8 patients who underwent surgery and SRS between 2010 and 2018 respectively. The operated group comprised six men and five women (mean age, 33.6 years). SRS was performed in five men and three women (mean age, 33.3 years). All patients were diagnosed and followed-up with magnetic resonance imaging. Stereotactic navigation was not used for lesion localization. The lesion, including the area with hemosiderin, was easily excised using microsurgical approach. RESULTS: Except for recurrent headache, all symptoms of patients who underwent surgery resolved rapidly. Hemorrhage developed in two of our patients after SRS. One of them refused to undergo surgery and recovered completely with steroid therapy, whereas the other underwent surgery after detection of cavernous malformation at the posterior fossa, with a dimension of 26.8x26.2 mm and occluding the fourth ventricle. CONCLUSION: In patients without significant preoperative morbidity risk, surgical excision is the gold standard of treatment. SRS is performed in surgically inaccessible, deeply located, multiple cavernous malformations in the brain stem and eloquent area. Of note, giant aneurysm is defined as an aneurysm with a diameter of at least 25 mm; however, there is no dimension threshold defined for giant CM, and the size of giant aneurysm can be accepted as a valid criterion for giant CM. Our 2 cases had giant CM and up to our knowledge the case with giant CM at the posterior fossa is the first giant CM at the posterior fossa in the English literature.

Recurrent Chronic Subdural Hematoma: Report of 13 Cases.

Chronic subdural hematoma is a frequent type of hemorrhage, which terminates with mortality if not diagnosed and treated early. The aim of this clinical study is to evaluate the patients with unilateral and bilateral recurrent chronic subdural hematoma. The study group consisted of 13 cases with unilateral and bilateral recurrent chronic subdural hematomas who underwent aggressive wide craniotomy, duraectomy, inner and outer membranectomy, dural border coagulation, incision through cortical vein trace and hang up of dural edge, between 2009 - 2016. All of our patients were diagnosed by preoperative Magnetic Resonance Imaging. We evaluated the age, gender, complaints and neurologic signs, localization and thickness of the hematoma. We can estimate that wide craniotomy, duraectomy and membranectomy is a good option in preventing recurrent chronic subdural hematoma and complications.

Computed tomography based evaluation of prostatic fiducial marker migration between the periods of insertion and simulation.

OBJECTIVE: The aim of this study was to determine whether significant fiducial marker migration occurs between the periods of prostatic marker insertion and computed tomography (CT) performed for radiotherapy planning and if a waiting period is necessary. MATERIAL AND METHODS: Thirty-nine patients with prostate adenocarcinoma underwent fiducial marker insertion before radiotherapy between June 2013 and December 2015. Three markers were inserted by one radiologist under the guidance of transrectal ultrasonography. All patients underwent CT three hours after insertion to confirm the number and position of fiducial markers. Radiotherapy planning CT was performed on an average of 11 days (range 7-20) after insertion. CT images were imported into treatment planning system to analyze the position of fiducial markers. Point- based marker match algorithm was used to find the distance of marker migration. The mean and maximum distances between each fiducial markers were calculated. RESULTS: The mean distance of migration was 1.029±0.42 mm (range 0.23-1.93 mm) and the maximum distance was 1.361±0.59 mm (range 0.25-2.74 mm). The distance of marker migration was not statistically significant for the groups organized according to the timing of marker insertion, prostate volume, patient age, prostate specific antigen level and Gleason score. CONCLUSION: According to our results significant fiducial marker migration did not occur during the interval between insertion and treatment planning CT. It should be taken into consideration that performing simulation on the same day as marker insertion might prevent increased cost and delayed radiation therapy by saving the patients from extra visits to the clinic.

Bilateral recurrent external obturator muscle hematoma: An unusual cause of pelvic pain in hemophilia.

Following joint hemorrhages, intramuscular hemorrhages are the second most prevalent bleeding pattern in hemophiliac patients. Hematomas of the iliopsoas muscle are a well-known complication of hemophilia; however, obturator muscle hematomas are rare. We herein report a case of spontaneous bleeding of the bilateral external obturator muscles, which occured three times within a period of 9 months in a hemophilia patient with factor VIII inhibitors. To the best of our knowledge, this is the first published case of an obturator externus muscle hematoma in hemophilia. In addition to hip hemarthrosis, iliopsoas hematomas and acute appendicitis, obturator muscle hematoma should be considered as one of the diagnostic alternatives for pelvic pain in hemophiliaψ patients. Magnetic resonance imaging enables rapid diagnosis of obturator muscle hematoma.

Spontaneous rupture of the ureter.

Spontaneous rupture of the ureter is a very rare condition and usually results from ureteral obstruction by a calculus. Only theoretical mechanisms have been proposed and no possible explanation has yet been reported in the literature. Intravenous contrast-enhanced computed tomography is the most informative study with high sensitivity. Treatment should be individualised, and depends on the state of the patient. Minimally invasive endourological procedures with double-J catheter placement and percutaneous drainage offer excellent results. Conservative management with analgesics and antibiotic coverage may be an alternative to surgery. Herein, we present a case of spontaneous rupture of the proximal ureter with no evidence of an underlying pathological condition.

Safety, efficacy and outcomes of the new GreenLight XPS 180W laser system compared to the GreenLight HPS 120W system for the treatment of benign prostatic hyperplasia in a prospective nonrandomized single-centre study.

INTRODUCTION: We compare and evaluate the safety, efficacy, and short-term outcomes of the new GreenLight XPS 180W (GL-XPS) laser system with the former generation GreenLight HPS 120W (GL-HPS) system for the treatment of benign prostatic hyperplasia (BPH) in a prospective nonrandomized single-centre study. METHODS: From May 2012 to June 2013, 161 consecutive patients with lower urinary tract symptoms secondary to BPH were included: 88 patients were treated with the GL-HPS system and 73 were treated with the GL-XPS system. The perioperative variables International Prostate Symptom Score (IPSS), quality of life (QOL), and maximum flow rate (Qmax) were recorded at baseline, at one month and 6 months. Serum prostate-specific antigen (PSA) was assessed at baseline. RESULTS: The mean age was 70.2 years in the GL-HPS group and 68.6 years in the GL-XPS group. Prostate volumes were 62.3 mL and 61.3 mL, respectively. Both groups showed significant postoperative improvement in the IPSS, QOL, Qmax variables compared to baseline levels. There were no significant differences in improvement in IPSS and QOL between groups. However, both operating and catheterization times were shorter in patients in the GL-XPS group. The overall postoperative complication rate was similar in both groups. CONCLUSION: Both GreenLight systems provide safe, effective tissue vaporization with significant clinical relief of BPH obstruction. The GL-XPS system appears more favourable with regard to reduced operating and hospitalization time, suggesting more cost-effective and efficient tissue removal.

Primary pericardial extragastrointestinal stromal tumor: A case report and literature review.

Gastrointestinal stromal tumors (GISTs) are the most prevalent mesenchymal tumors of the gastrointestinal tract. GISTs are considered to originate from the interstitial cells of Cajal, the pacemakers of the peristaltic activity of the gastrointestinal tract. More than 95% of GISTs express KIT protein and discovered on GIST-1. GISTs may also be encountered in locations outside the gastrointestinal tract, in which case they are referred to as extra-GISTs (EGISTs) and often behave more aggressively. This is the case report of a primary pericardial EGIST in a 53-year-old male patient, confirmed by immunohistochemistry. To the best of our knowledge, this is the third case of EGIST diagnosed above the diaphragm, without being associated with the esophageal wall. Two cases of primary EGIST arising from the pleura were reported previously. In addition, this is the first reported case of an EGIST originating from the pericardium.

The relationship between presbycusis and mastoid pneumatization.

Presbycusis is defined as the natural hearing loss accompanying aging, caused by degenerative changes in the inner ear. The etiology of presbycusis is uncertain. However, it would appear that a complex genetic cause is most likely. The determinants of mastoid size continue to be controversial. One of the pneumatization theories is the hereditary theory. In this study, the possible relationship between presbycusis and the extent of mastoid pneumatization was investigated. This study was carried out on 21 patients with presbycusis and 21 normal subjects of similar ages. The pneumatized volume was measured by computerized tomography. The temporal bone was scanned at 2 mm thickness intervals. Exposure (kV 130, mA105). The scan plane was parallel to the orbitomeatal line and the CT images covered the entire mastoid region. The average mastoid pneumatization in presbycusis group was 6.08 +/- 2.52 cm(3) in the right ear and 6.19 +/- 2.93 cm(3) in the left ear. However, in the control group it was 4.69 +/- 3.17 cm(3) in the right ear (p=0.12) and 5.10 +/- 3.49 cm(3) in the left ear (p=0.28). No significant difference was found between the presbycusis patients and normal subjects in terms of the volume of mastoid pneumatization.

Bone complications after pelvic radiation therapy: evaluation with MRI.

INTRODUCTION: The purpose of this study was to assess the incidence, distribution and MRI characteristics of pelvic bone complications after radiation therapy. METHODS: The medical charts of 345 patients who received pelvic radiation therapy were retrospectively reviewed. A total of 122 patients, 99 women and 23 men, with a mean age of 57 (range 32-87 years) were included in this study. The MR images were retrospectively reviewed by two radiologists. RESULTS: Fatty replacement of bone marrow was seen in all patients. Pelvic bone complications and focal red marrow changes were identified in a total of 38 patients (31.1%). Pelvic insufficiency fracture was diagnosed in 17 patients (13.9%, with a total of 64 lesions) and radiation osteitis was diagnosed in 5 patients (4.1%, with a total of 13 lesions). Avascular necrosis of the femoral head was detected in one patient (0.8%). Focal red bone marrow changes were seen in 15 patients (12.3%). The median time from the end of radiotherapy to the diagnosis of pelvic bone complications or changes was 25 months (range 2-45 months). The 1-, 2-, and 3-year cumulative incidences were 22%, 41% and 49%, respectively. The distribution of insufficiency fractures was as follows: sacral ala, sacral body, ilium, acetabulum, pubis and lumbar spinal vertebra. The distribution of radiation osteitis was as follows: sacral ala, ilium and pubis. CONCLUSION: Radiation-induced pelvic bone complications are not uncommon, and knowledge of characteristic imaging patterns is essential in order to rule out bone metastases and to avoid inaccurate or excessive treatment.