Using MRI appendicitis scale and DWI for the diagnosis of acute appendicitis in pregnant women.

OBJECTIVES: To assess the performance of MRI scale for the diagnosis of acute appendicitis in pregnant women and to determine the added diagnostic value of diffusion-weighted imaging (DWI). METHODS: From January 2018 to December 2020, 80 patients were included. All MRI were performed with a 1.5-Tesla scanner with anterior array body coil. This analysis included (1) T2-weighted imaging (T2WI), (2) fat-saturated T2WI, and (3) DWI. Two radiologists blinded to the diagnosis recorded their assessment of four findings: appendiceal diameter, appendiceal wall thickness, luminal mucus, and periappendiceal inflammation. The MRI scale of acute appendicitis which ranged from 0 to 4 was determined from these factors. An additional one point was added to the MRI appendicitis scale in those patients with evidence of appendiceal restricted diffusion on DWI. The diagnostic values and predictive factors were computed. RESULTS: Multivariate analysis demonstrated that the calculated MRI appendicitis scale was a significant independent predictor of acute appendicitis with a sensitivity of 96.6%, specificity of 90.2%, and PPV of 84.8%. The odds ratio of appendicitis is increased by 22.3 times for every increase in one point on the MRI appendicitis scale. Therefore, the addition of one point for restricted diffusion in the appendix on DWI imaging can add substantial value, both positive and negative predictive value, towards making an accurate diagnosis of acute appendicitis. CONCLUSIONS: MRI appendicitis scale is an objective and significant independent predictive factor for acute appendicitis in pregnant women. Incorporation of diffusion weighted imaging to MRI can improve diagnosis of acute appendicitis. CLINICAL RELEVANCE STATEMENT: MRI appendicitis scale is an objective and significant independent predictor of acute appendicitis in pregnant women. Incorporation of DWI/ADC map to MRI examinations can improve diagnosis of acute appendicitis in pregnant women. KEY POINTS: • MRI appendicitis scale is an objective and significant independent predictive factor for acute appendicitis in pregnant women. • The odds ratio of appendicitis can be increased by 22.3 times for every increase of one unit in MRI scale. • Incorporation of diffusion-weighted imaging to MRI examinations can add value to the scale (4.2 ± 0.7 vs. 0.7 ± 1.1; p < 0.001) among pregnant women with appendicitis versus pregnant women without appendicitis.

Contrast-enhanced CT and Acute Kidney Injury: Risk Stratification by Diabetic Status and Kidney Function.

Background Diabetes mellitus may be associated with an increased likelihood of CT contrast material-induced acute kidney injury (CI-AKI), but this has not been studied in a large sample with and without kidney dysfunction. Purpose To investigate whether diabetic status and estimated glomerular filtration rate (eGFR) are associated with the likelihood of acute kidney injury (AKI) following CT contrast material administration. Materials and Methods This retrospective multicenter study included patients from two academic medical centers and three regional hospitals who underwent contrast-enhanced CT (CECT) or noncontrast CT between January 2012 and December 2019. Patients were stratified according to eGFR and diabetic status, and subgroup-specific propensity score analyses were performed. The association between contrast material exposure and CI-AKI was estimated with use of overlap propensity score-weighted generalized regression models. Results Among the 75 328 patients (mean age, 66 years ± 17 [SD]; 44 389 men; 41 277 CECT scans; 34 051 noncontrast CT scans), CI-AKI was more likely in patients with an eGFR of 30-44 mL/min/1.73 m2 (odds ratio [OR], 1.34; P < .001) or less than 30 mL/min/1.73 m2 (OR, 1.78; P < .001). Subgroup analyses revealed higher odds of CI-AKI among patients with an eGFR less than 30 mL/min/1.73 m2, with or without diabetes (OR, 2.12 and 1.62; P = .001 and .003, respectively), when they underwent CECT compared with noncontrast CT. Among patients with an eGFR of 30-44 mL/min/1.73 m2, the odds of CI-AKI were higher only in those with diabetes (OR, 1.83; P = .003). Patients with an eGFR less than 30 mL/min/1.73 m2 and diabetes had higher odds of 30-day dialysis (OR, 1.92; P = .005). Conclusion Compared with noncontrast CT, CECT was associated with higher odds of AKI in patients with an eGFR of less than 30 mL/min/1.73 m2 and in patients with diabetes with an eGFR of 30-44 mL/min/1.73 m2; higher odds of 30-day dialysis were observed only in patients with diabetes with an eGFR less than 30 mL/min/1.73 m2. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Davenport in this issue.

Splenic artery embolization changes the management of blunt splenic injury: an observational analysis of 680 patients graded by the revised 2018 AAST-OIS.

BACKGROUND: This study aimed to evaluate the management of blunt splenic injury (BSI) and highlight the role of splenic artery embolization (SAE). METHODS: We conducted a retrospective review of all patients with BSI over 15 years. Splenic injuries were graded by the 2018 revision of the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS). Our hospital provide 24/7 in-house surgeries and 24/7 in-house interventional radiology facility. Patients with BSI who arrived hypotensive and were refractory to resuscitation required surgery and patients with vascular injury on abdominal computed tomography were considered for SAE. RESULTS: In total, 680 patients with BSI, the number of patients who underwent nonoperative management with observation (NOM-obs), SAE, and surgery was 294, 234, and 152, respectively. The number of SAEs increased from 4 (8.3%) in 2001 to 23 (60.5%) in 2015 (p < 0.0001); conversely, the number of surgeries decreased from 21 (43.8%) in 2001 to 4 (10.5%) in 2015 (p = 0.001). The spleen-related mortality rate of NOM-obs, SAEs, and surgery was 0%, 0.4%, and 7.2%, respectively. In the SAE subgroup, according to the 2018 AAST-OIS, 234 patients were classified as grade II, n = 3; III, n = 21; IV, n = 111; and V, n = 99, respectively.; and compared with 1994 AST-OIS, 150 patients received a higher grade and the total number of grade IV and V injuries ranged from 96 (41.0%) to 210 (89.7%) (p < 0.0001). On angiography, 202 patients who demonstrated vascular injury and 187 achieved hemostasis after SAE with a 92.6% success rate. Six of the 15 patients failed to SAE preserved the spleen after second embolization with a 95.5% salvage rate. CONCLUSIONS: Our data confirm the superiority of the 2018 AAST-OIS and support the role of SAE in changing the trend of management of BSI.

Comparison of outcomes of proximal versus distal and combined splenic artery embolization in the management of blunt splenic injury: a report of 202 cases from a single trauma center.

BACKGROUND: To compare the outcomes of blunt splenic injuries (BSI) managed with proximal (P) versus distal (D) versus combined (C) splenic artery embolization (SAE). METHODS: This retrospective study included patients with BSI who demonstrated vascular injuries on angiograms and were managed with SAE between 2001 and 2015. The success rate and major complications (Clavien-Dindo classification ≥ III) were compared between the P, D, and C embolizations. RESULTS: In total, 202 patients were enrolled (P, n = 64, 31.7%; D, n = 84, 41.6%; C, n = 54, 26.7%). The median injury severity score was 25. The median times from injury to SAE were 8.3, 7.0, and 6.6 h for the P, D, and C embolization, respectively. The overall haemostasis success rates were 92.6%, 93.8%, 88.1%, and 98.1% in the P, D, and C embolizations, respectively, with no significant difference (p = 0.079). Additionally, the outcomes were not significantly different between the different types of vascular injuries on angiograms or the materials used in the location of embolization. Splenic abscess occurred in six patients (P, n = 0; D, n = 5; C, n = 1), although it occurred more commonly in those who underwent D embolization with no significant difference (p = 0.092). CONCLUSIONS: The success rate and major complications of SAE were not significantly different regardless of the location of embolization. The different types of vascular injuries on angiograms and agents used in different embolization locations also did not affect the outcomes.

Intravenous CT Contrast Media and Acute Kidney Injury: A Multicenter Emergency Department-based Study.

Background Although the historical risk of acute kidney injury (AKI) after intravenous administration of contrast media might be overstated, the risk in patients with impaired kidney function remains a concern. Purpose To investigate whether intravenous contrast media administration during CT is associated with a higher risk of AKI and further hemodialysis compared with the risk in patients undergoing unenhanced CT. Materials and Methods This retrospective study evaluated patients who underwent contrast-enhanced or unenhanced CT in five Taiwanese emergency departments between 2009 and 2016. The outcomes were AKI within 48-72 hours after CT, AKI within 48 hours to 1 week after CT, or further hemodialysis within 1 month after CT. The associations between contrast media exposure and outcome were estimated by using an overlap propensity score weighted generalized regression model. Subgroup analyses were performed according to the estimated glomerular filtration rate (eGFR). Results The study included 68 687 patients (median age, 68 years; interquartile range, 53-74 years; 39 995 men) with (n = 31 103) or without (n = 37 584) exposure to contrast media. After propensity score weighting, contrast media exposure was associated with higher risk of AKI within 48-72 hours after CT (odds ratio [OR], 1.16; 95% CI: 1.04, 1.29; P = .007) but no significant risk at 48 hours to 1 week after CT (OR, 1.00; 95% CI: 0.93, 1.08; P = .90). Among patients with eGFR less than 30 mL/min/1.73 m2, exposure to contrast media was associated with a higher AKI risk (48-72 hours after CT: OR, 1.36; 95% CI: 1.09, 1.70; P = .007) (48 hours-1 week after CT: OR, 1.49; 95% CI: 1.27, 1.74; P < .001) and a higher risk of hemodialysis (OR, 1.36; 95% CI: 1.09, 1.70; P = .008). For patients with eGFR greater than 45 mL/min/1.73.m2, contrast media exposure was not associated with higher AKI risk (P > .05). Conclusion Contrast-enhanced CT was associated with higher risk of acute kidney injury and further hemodialysis among Taiwanese patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min/1.73 m2 but not those with an eGFR of more than 45 mL/min/1.73 m2. © RSNA, 2021 Online supplemental material is available for this article.

Transarterial embolization for postpartum hemorrhage: lessons learned.

BACKGROUND: Although transarterial embolization (TAE) can powerfully control postpartum hemorrhage (PPH), clinical failure of TAE is not uncommon. PURPOSE: To discover whether any parameters could predict timely clinical failure of TAE, then whether a supplementary intervention could be promptly initiated. MATERIAL AND METHODS: We retrospectively analyzed 118 TAE procedures in 113 patients with PPH performed at our institution between January 2012 and May 2015. The patients were divided into the following groups: clinically successful TAE and failed TAE. Successful TAE was defined as obviation of supplementary embolization or surgical intervention for hemostasis. Gestational conditions, angiographic factors, maternal vital signs, and laboratory data were compared between the two groups. RESULTS: In total, 100 (84.8%) TAEs were clinically successful. Multivariate logistic regression analyses revealed independent risk factors of TAE clinical failure, including the requirement for augmented embolic agents, placental retention, and international normalized ratio > 1.3 ( P = 0.009, 0.001, and 0.005, respectively). The post-TAE shock index was significantly associated with TAE failure, using a cut-off value of 0.8. CONCLUSION: The discovered independent risk factors of TAE clinical failure existed before or during the TAE procedure and could not reflect the post-TAE conditions. Although the post-TAE shock index was not an independent factor, it reflected the conditions after TAE and could indicate TAE clinical failure timely.

Major pancreatic duct continuity is the crucial determinant in the management of blunt pancreatic injury: a pancreatographic classification.

BACKGROUND: To evaluate the management and outcomes of blunt pancreatic injuries based on the integrity of the major pancreatic duct (MPD). METHODS: Between August 1996 and August 2015, 35 patients with blunt pancreatic injuries underwent endoscopic retrograde pancreatography (ERP). Medical charts were retrospectively reviewed for demography, ERP timing, imaging findings, management, and outcome. RESULTS: Of the 35 patients, 21 were men and 14 were women, with ages ranging from 11 to 70 years. On the basis of the ERP findings, we propose a MPD injury classification as follows: class 1 indicates normal MPD; class 2, partial injury with intact MPD continuity; and class 3, complete injury with disrupted MPD continuity. Both classes 2 and 3 are subdivided into classes a, b, and c, which represent the pancreatic tail, body, and head, respectively. In this report, 14 cases belonged to class 1, 10 belonged to class 2, and 11 belonged to class 3. Of the 14 patients with class 1 injuries, 10 underwent nonsurgical treatment and 4 underwent pancreatic duct stenting. Of the 10 patients with class 2 injuries, 4 underwent nonsurgical treatment and 6 underwent pancreatic duct stenting. Two of the 11 patients with class 3 injuries underwent pancreatic duct stenting; one in the acute stage developed sepsis that led to death even after converting to distal pancreatectomy plus splenectomy. Of the 11 patients with class 3 injuries, spleen-preserving distal pancreatectomy was performed in 6, distal pancreatectomy plus splenectomy in 2, and Roux-en-Y pancreaticojejunostomy after central pancreatectomy in 2. The overall pancreatic-related morbidity rate was 60% and the mortality rate was 2.8%. CONCLUSION: Based on our experience, class 1 and 2 injuries could be treated by nonsurgical means and pancreatic duct stenting could be an adjunctive therapy in class 2b and 2c injuries. Operation is warranted in class 3 injuries.

Timely Antecedent CT or MRI Can Help Predict Hemorrhage Site of Posttreatment Head and Neck Cancer, With Digital Subtraction Angiography Used as the Reference Standard.

OBJECTIVE: We investigated the timing of CT and MRI performed before digital subtraction angiography (DSA) in the prediction of hemorrhage sites in patients with head and neck cancers who present with acute oral or neck bleeding after receiving treatment. MATERIALS AND METHODS: A total of 123 DSA examinations that evaluated 123 oral or neck bleeding events in 85 patients were analyzed. The last CT or MRI examinations performed within a time frame of 0-337 days before transarterial embolization were reviewed retrospectively, with three findings (pseudoaneurysm, air-containing necrotic tissue, and residual tumor) used to predict hemorrhage sites. DSA findings of pseudoaneurysm or active contrast extravasation were used as a reference standard. The sensitivity of CT and MRI for correctly predicting hemorrhage sites was used to determine the optimal timing of CT or MRI examinations performed before DSA. RESULTS: A total of 8.9% of the DSA examinations (11/123) had equivocal findings but were followed by another bleeding event for which DSA findings were positive. CT or MRI was statistically significantly better at predicting hemorrhage sites in patients with bleeding events associated with nonhypopharyngeal cancers (p = 0.019) than in those with bleeding events associated with hypopharyngeal cancers. The sensitivity of CT or MRI in the prediction of hemorrhage sites was statistically significantly higher for the common carotid artery and the internal carotid artery when CT or MRI was performed less than 30 days before bleeding events occurred. Prediction of hemorrhagic sites was better with the use of CT angiography than with the use of enhanced CT or MRI, although it was not statistically significant. CONCLUSION: DSA findings can temporarily be equivocal. CT or MRI examinations performed within 30 days of bleeding events can predict the site of hemorrhage. If no CT or MRI findings from the past 30 days are available, we suggest performing emergent CT angiography for the sake of obtaining better arterial detail.

Performance assessment of the Simplified Acute Physiology Score II, the Acute Physiology and Chronic Health Evaluation II score, and the Sequential Organ Failure Assessment score in predicting the outcomes of adult patients with hepatic portal venous gas in the ED.

OBJECTIVE: This study aims to evaluate the performance of Simplified Acute Physiology Score II (SAPS II), the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and the Sequential Organ Failure Assessment (SOFA) score for predicting illness severity and the mortality of adult hepatic portal venous gas (HPVG) patients presenting to the emergency department (ED). This will assist emergency physicians in risk stratification. METHODS: Data for 48 adult HPVG patients who visited our ED between December 2009 and December 2013 were analyzed. The SAPS II, APACHE II score, and SOFA score were calculated based on the worst laboratory values in the ED. The probability of death was calculated for each patient based on these scores. The ability of the SAPS II, APACHE II score, and SOFA score to predict group mortality was assessed by using receiver operating characteristic curve analysis and calibration analysis. RESULTS: The sensitivity, specificity, and accuracy were 92.6%,71.4%, and 83.3%, respectively, for the SAPS II method; 77.8%, 81%, and 79.2%, respectively, for the APACHE II scoring system, and 77.8%, 76.2%, and 79.2%, respectively, for the SOFA score. In the receiver operating characteristic curve analysis, the areas under the curve for the SAPS II, APACHE II scoring system, and SOFA score were 0.910, 0.878, and 0.809, respectively. CONCLUSION: This is one of the largest series performed in a population of adult HPVG patients in the ED. The results from the present study showed that SAPS II is easier and more quickly calculated than the APACHE II and more superior in predicting the mortality of ED adult HPVG patients than the SOFA. We recommend that the SAPS II be used for outcome prediction and risk stratification in adult HPVG patients in the ED.

The prognostic factors of adult patients with hepatic portal venous gas in the ED.

OBJECTIVES: This study aimed to investigate the prognostic factors of adult patients with hepatic portal venous gas (HPVG) in the emergency department (ED) to facilitate clinical decision making by emergency physicians. METHODS: Data from adult patients with HPVG who visited our ED between December 2009 and December 2013 were analyzed. The computed tomographic scan images were reviewed, and the presence of HPVG with or without pneumatosis intestinalis (PI) was confirmed by a certified radiologist. The study end point was mortality or survival upon discharge. The factors associated with mortality were specifically analyzed with multiple logistic regression models. RESULTS: Among the total of 50 HPVG patients, the overall mortality rate was 56%. No deaths were observed among the patients with neither shock nor PI in the ED. Shock (odds ratio, 17.02; 95% confidence interval, 3.36-86.22) and PI (odds ratio, 5.14; 95% confidence interval, 1.03-25.67) were determined to be significant predictors of patient mortality after adjusting for age and sex. The mortality of the patients with both shock and PI was very high (84%). CONCLUSIONS: Early resuscitation should be initiated for the prevention of shock in adult patients with HPVG in the ED. To enhance the chance for survival, the prompt consultation of surgeons for emergency operations should be considered for adult ED patients exhibiting both shock and PI, which may indicate true ischemic bowel disease.

Esophagography after pneumomediastinum without CT findings of esophageal perforation: is it necessary?

OBJECTIVE: The purpose of our study was to determine the necessity of fluoroscopic esophagography in patients with pneumomediastinum on CT but without CT findings of esophageal perforation. MATERIALS AND METHODS: From January 1, 2006, through December 31, 2010, there were 4305 fluoroscopic esophagography examinations including 533 with CT identified from a search of our PACS. Patients with pneumomediastinum on CT who were subsequently referred for emergent fluoroscopic esophagography to exclude esophageal perforation were enrolled. Fluoroscopic esophagography examinations performed within 3 days of CT were included. Patients with a history of esophageal disease were excluded. As a result, 103 patients were enrolled in the study; patients were divided into groups on the basis of whether there was additional clinical history of esophageal damage (trauma group) or not (nontrauma group). Images were reviewed by two board-certified radiologists blinded to the clinical data and radiologic reports for the presence or absence of esophageal perforation. A positive result on CT was defined as esophageal injury or periesophageal infiltration that coexisted with periesophageal air. A positive fluoroscopic esophagography result was defined as oral contrast medium leakage from the esophagus. RESULTS: Esophageal perforation was diagnosed in 15 of the 103 patients. The CT findings were significantly correlated with esophageal perforation (p < 0.001 in the trauma group, and p = 0.001 in the nontrauma group). The respective sensitivity and negative predictive value (NPV) of CT versus fluoroscopic esophagography in the trauma group were 100% versus 66.7% and 100% versus 87.9%; in the nontrauma group, the sensitivity and NPV were 100% for CT and fluoroscopic esophagography. Thus, the sensitivity and NPV of CT were either superior or equal to those of fluoroscopic esophagography. CONCLUSION: The results of our study suggest that performing fluoroscopic esophagography in patients with pneumomediastinum is unnecessary when CT is negative for esophageal perforation.

Factors associated with the survival of patients with primary small cell carcinoma of the kidney.

BACKGROUND: Primary small cell carcinoma (SCC) of the kidney is rare, and the factors associated with the survival of these patients are yet to be elucidated. PATIENTS AND METHODS: We collected data on patients who were admitted to our hospital for SCC of the kidney in the last 22 years and of those in studies in the literature. Clinical characteristics were summarized using descriptive statistics. The associations of these factors with survival were evaluated using Cox regression models, and the hazard ratio of death was calculated. RESULTS: This study included 45 patients (8 admitted to our hospital and 37 from studies in the literature) with SCC of the kidney. The overall median survival time was 9.9 months (range 6.9-31.6). Data on demographics, clinical symptoms, tumor staging, and tumor characteristics recorded at the time of diagnosis were not associated with survival. Among the different treatment modalities applied, cisplatin-based chemotherapy afforded a strong survival advantage (hazard ratio = 0.35, p = 0.022). However, patients with early local recurrence (hazard ratio = 19.13, p = 0.012) and early distant metastasis (hazard ratio = 10.93, p = 0.003) after primary treatment showed significantly poor survival. CONCLUSIONS: Patients with primary SCC of the kidney generally presented with large, advanced-stage tumors and showed poor survival. Early detection of the tumor, use of cisplatin-based chemotherapy, and careful follow-up for local recurrence or frequent metastasis within 6 months after the primary treatment could be important for improving overall patient survival.

Trans-arterial embolization for intractable primary postpartum hemorrhage caused by arterial aneurysms with arteriovenous fistulas in the lower vagina bilaterally: a case report.

Failure of conservative management for controlling postpartum hemorrhage (PPH) is not uncommon, particularly when PPH is caused by vascular lesions. Awareness of this possibility and initiating timely trans-arterial embolization (TAE) are essential for improving the outcome. Herein, we describe the case of a 34-year-old woman presenting with arterial aneurysms with arteriovenous fistulas in the lower vagina bilaterally, which caused intractable PPH. Conservative management failed to resolve the PPH; however, TAE successfully controlled the bleeding, and the patient recovered smoothly. Knowledge of this possible etiology for intractable PPH is crucial for timely TAE. This case report aims to highlight the pivotal role of TAE in detecting and treating this unusual cause of PPH.

Watch Out for the Early Killers: Imaging Diagnosis of Thoracic Trauma.

Radiologists and trauma surgeons should monitor for early killers among patients with thoracic trauma, such as tension pneumothorax, tracheobronchial injuries, flail chest, aortic injury, mediastinal hematomas, and severe pulmonary parenchymal injury. With the advent of cutting-edge technology, rapid volumetric computed tomography of the chest has become the most definitive diagnostic tool for establishing or excluding thoracic trauma. With the notion of "time is life" at emergency settings, radiologists must find ways to shorten the turnaround time of reports. One way to interpret chest findings is to use a systemic approach, as advocated in this study. Our interpretation of chest findings for thoracic trauma follows the acronym "ABC-Please" in which "A" stands for abnormal air, "B" stands for abnormal bones, "C" stands for abnormal cardiovascular system, and "P" in "Please" stands for abnormal pulmonary parenchyma and vessels. In the future, utilizing an artificial intelligence software can be an alternative, which can highlight significant findings as "warm zones" on the heatmap and can re-prioritize important examinations at the top of the reading list for radiologists to expedite the final reports.

Intra-Arterial Urokinase for Acute Superior Mesenteric Artery Occlusion: A Retrospective 12-Year Report of 13 Cases.

This retrospective study aimed to evaluate the outcomes of 13 patients with acute superior mesenteric artery (SMA) occlusion who underwent intra-arterial urokinase thrombolysis between 2008 and 2020. On angiography, seven presented with complete SMA occlusion versus six with incomplete occlusion. The median time from abdominal pain to attempting urokinase thrombolysis was 15.0 h (interquartile range, 6.0 h). After urokinase therapy, bowel perfusion was restored with bowel preservation in six patients; however, treatment failed in the other seven patients. The degree of SMA occlusion (complete vs. incomplete, p = 0.002), degree of recanalisation (p = 0.012), and length of stay (p = 0.032) differed significantly between groups. Of the seven patients with complete SMA occlusion, six underwent bowel resection, of whom three died, and the remaining patient died of shock due to delayed surgery. Among the six patients with incomplete SMA occlusion, no bowel resection was performed. In our experience, intra-arterial urokinase thrombolysis may serve as an adjunctive treatment modality, being a potential replacement for open thrombectomy that is able to preserve the bowel and obviate surgery in cases of incomplete SMA occlusion; however, its use is unsuitable in cases of complete SMA occlusion, for which surgery is warranted.

Comparing the Clinical Efficacy of Coil Embolization in GDA Stump versus Common Hepatic Artery in Postoperative Hemorrhage after Pancreatoduodenectomy.

BACKGROUND: Hemorrhage after pancreaticoduodenectomy is an uncommon but fatal complication. In this retrospective study, the different treatment modalities and outcomes for treating post-pancreaticoduodenectomy hemorrhage are analyzed. METHODS: Our hospital imaging database was queried to identify patients who had undergone pancreaticoduodenectomy during the period of 2004-2019. The patients were retrospectively split into three groups, according to their treatment: conservative treatment without embolization (group A: A1, negative angiography; A2, positive angiography), hepatic artery sacrifice/embolization (group B: B1, complete; B2, incomplete), and gastroduodenal artery (GDA) stump embolization (group C). RESULTS: There were 24 patients who received angiography or transarterial embolization (TAE) treatment 37 times (cases). In group A, high re-bleeding rates (60%, 6/10 cases) were observed, with 50% (4/8 cases) for subgroup A1 and 100% (2/2 cases) for subgroup A2. In group B, the re-bleeding rates were lowest (21.1%, 4/19 cases) with 0% (0/16 cases) for subgroup B1 and 100% (4/4 cases) for subgroup B2. The rate of post-TAE complications (such as hepatic failure, infarct, and/or abscess) in group B was not low (35.3%, 6/16 patients), especially in patients with underlying liver disease, such as liver cirrhosis and post-hepatectomy (100% (3/3 patients), vs. 23.1% (3/13 patients); p = 0.036, p < 0.05). The highest rate of re-bleeding (62.5%, 5/8 cases) was observed for group C. There was a significant difference in the re-bleeding rates of subgroup B1 and group C (p = 0.00017). The more iterations of angiography, the higher the mortality rate (18.2% (2/11 patients), <3 times vs. 60% (3/5 patients), ≥3 times; p = 0.245). CONCLUSIONS: The complete sacrifice of the hepatic artery is an effective first-line treatment for pseudoaneurysm or for the rupture of the GDA stump after pancreaticoduodenectomy. Hepatic complications are not uncommon and are highly associated with underlying liver disease. Conservative treatment, the selective embolization of the GDA stump, and incomplete hepatic artery embolization do not provide enduring treatment effects.

Quantitative Dynamic Contrast-Enhanced Magnetic Resonance Parameters Could Predict International Society of Urological Pathology Risk Groups of Prostate Cancers on Radical Prostatectomy.

BACKGROUND: The International Society of Urological Pathology (ISUP) grade and positive surgical margins (PSMs) after radical prostatectomy (RP) may reflect the prognosis of prostate cancer (PCa) patients. This study aimed to investigate whether DCE-MRI parameters (i.e., Ktrans, kep, and IAUC) could predict ISUP grade and PSMs after RP. METHOD: Forty-five PCa patients underwent preoperative DCE-MRI. The clinical characteristics and DCE-MRI parameters of the 45 patients were compared between the low- and high-risk (i.e., ISUP grades III-V) groups and between patients with or without PSMs after RP. Multivariate logistic regression analysis was used to identify the significant predictors of placement in the high-risk group and PSMs. RESULTS: The DCE parameter Ktrans-max was significantly higher in the high-risk group than in the low-risk group (p = 0.028) and was also a significant predictor of placement in the high-risk group (odds ratio [OR] = 1.032, 95% confidence interval [CI] = 1.005-1.060, p = 0.021). Patients with PSMs had significantly higher prostate-specific antigen (PSA) titers, positive biopsy core percentages, Ktrans-max, kep-median, and kep-max than others (all p < 0.05). Of these, positive biopsy core percentage (OR = 1.035, 95% CI = 1.003-1.068, p = 0.032) and kep-max (OR = 1.078, 95% CI = 1.012-1.148, p = 0.020) were significant predictors of PSMs. CONCLUSION: Preoperative DCE-MRI parameters, specifically Ktrans-max and kep-max, could potentially serve as preoperative imaging biomarkers for postoperative PCa prognosis based on their predictability of PCa risk group and PSM on RP, respectively.

Effects of High-Resolution CT Changes on Prognosis Predictability in Acute Respiratory Distress Syndrome with Diffuse Alveolar Damage.

Diffuse alveolar damage (DAD) is the pathological hallmark of acute respiratory distress syndrome (ARDS). DAD is independently correlated with higher mortality compared with the absence of DAD. Traction bronchiectasis in areas of ground-glass opacity or consolidation is associated with the late fibroproliferative or fibrotic phase of DAD. This study examined whether the 60-day mortality related to DAD could be predicted using high-resolution computed tomography (HRCT) findings and HRCT scores. A total of 34 patients with DAD who received HRCT within 7 days of ARDS diagnosis were enrolled; they were divided into a 60-day survival group and a nonsurvival group, with 17 patients in each group. Univariate and multivariate binary regression analyses and the receiver operating characteristic curve revealed that only the total percentage of the area with traction bronchiectasis or bronchiolectasis was an independent predictor of 60-day mortality (odds ratio, 1.067; 95% confidence interval (CI), 1.011-1.126) and had favorable predictive performance (area under the curve (AUC): 0.784; 95% CI, 0.621-0.946; cutoff, 21.7). Physiological variables, including age, days from ARDS to HRCT, the sequential organ failure assessment (SOFA) score, the PaO2/fraction of inspired oxygen (FiO2) ratio, dynamic driving pressure, and dynamic mechanical power, were not discriminative between 60-day survival and nonsurvival. In conclusion, the extent of fibroproliferation on HRCT in early ARDS, presented as the total percentage of area with bronchiectasis or bronchiolectasis, is an independent positive predictor with a favorable predictive ability for the 60-day mortality of DAD.

When a Rapid Accurate Diagnosis Changes Therapeutic Approach: Recognizing Acute Abdominal Pain with Ascites as a Possible Presentation of Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is a chronic, multi-organ autoimmune disease which rarely presents with peritoneal involvement. As such, its diagnosis in the emergency department (ED) based on a clinical presentation of gastrointestinal symptoms is extremely challenging. Yet, reaching such a diagnosis in the ED is crucial for avoiding unnecessary surgical intervention and initiating early glucocorticoid therapy to maximise patient outcomes. Here, we report a case of newly diagnosed SLE in a 28-year-old lady who presented atypically and unusually with abdominal pain and ascites. She required extensive but methodical investigations, and was eventually diagnosed with lupus mesenteric vasculitis with underlying newly diagnosed SLE in the ED. The patient was promptly treated with methylprednisolone resulting in marked clinical improvement. Emergency physicians should be mindful of abdominal pain with ascites as an extremely rare but important clinical presentation of SLE. Early diagnosis and commencement of glucocorticoid therapy in these patients are crucial in halting disease progression and averting the need for surgical intervention.

Management of complicated lumbar artery injury after blunt trauma.

STUDY OBJECTIVE: Lumbar artery injury after blunt trauma is not frequently discussed. We review our experience with blunt lumbar artery injury management, especially alternative treatments in which embolization is not feasible. METHODS: We reviewed our trauma registry for 8 years 8 months. We sought all patients who sustained blunt torso trauma and had lumbar artery injury detected by angiography. Variables collected included demographic data, trauma mechanism, vital signs in triage, Injury Severity Score, associated injuries, computed tomography results, angiography results, embolizations, and outcome. RESULTS: Sixteen of the 3,436 patients in the trauma registry system had a blunt lumbar artery injury verified by angiography. For patients with lumbar artery injury, the mean Injury Severity Score was 38.6 (SD 12), and 10 (63%) of these 16 patients were in shock and 12 patients (75%) had closed head injuries. Angioembolization caused bleeding cessation in 11 patients but failed in 5 patients, who were treated conservatively. The overall mortality rate of patients with lumbar artery injury was 50%. CONCLUSION: Lumbar artery injury in multiply injured patients with blunt trauma leads to a high mortality rate, especially if accompanied by head injury. Embolization often stops bleeding, but, if embolization is not feasible, conservative treatment without retroperitoneal surgery can be successful.