ACR Appropriateness Criteria® Clinically Suspected Adnexal Mass, No Acute Symptoms: 2023 Update.

Asymptomatic adnexal masses are commonly encountered in daily radiology practice. Although the vast majority of these masses are benign, a small subset have a risk of malignancy, which require gynecologic oncology referral for best treatment outcomes. Ultrasound, using a combination of both transabdominal, transvaginal, and duplex Doppler technique can accurately characterize the majority of these lesions. MRI with and without contrast is a useful complementary modality that can help characterize indeterminate lesions and assess the risk of malignancy is those that are suspicious. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update.

This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (ß-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative ß-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive ß-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative ß-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Fibroids.

Uterine fibroids (leiomyomas or myomas) are the most common neoplasm of the uterus. Though incompletely understood, fibroid etiology is multifactorial, a combination of genetic alterations and endocrine, autocrine, environmental, and other factors such as race, age, parity, and body mass index. Black women have greater than an 80% incidence of fibroids by age 50, whereas White women have an incidence approaching 70%. Fibroid symptoms are protean, and menorrhagia is most frequent. The societal economic burden of symptomatic fibroids is large, 5.9 to 34.3 billion dollars annually. There are a variety of treatment options for women with symptomatic fibroids ranging from medical therapy to hysterectomy. Myomectomy and uterine fibroid embolization are the most common uterine sparing therapies. Pelvic ultrasound (transabdominal and transvaginal) with Doppler and MRI with and without intravenous contrast are the best imaging modalities for the initial diagnosis of fibroids, the initial treatment of known fibroids, and for surveillance or posttreatment imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Longitudinal observation of meticillin-resistant Staphylococcus pseudintermedius pulsotypes in six veterinary hospitals in the north-western United States.

Background: Meticillin-resistant Staphylococcus pseudintermedius (MRSP) infections in companion animals are increasing and are difficult to treat. Environmental contamination with MRSP in small animal primary care hospitals may pose an exposure risk to animal patients. Methods: This longitudinal study assessed the genotypic relationships of MRSP isolated from 39 environmental samples collected from six private small animal primary care hospitals, in the north-eastern United States, between August 2018 and April 2019. Results: Of the 39 bacterial isolates, 18 unique pulsotypes were identified based on pulsed-field gel electrophoresis, including six clusters of two or more indistinguishable isolates. Single pulsotypes were frequently detected from multiple hand-contact and animal-contact surfaces within a hospital during a single sampling event, but detection of a single pulsotype within the same hospital on subsequent visits was infrequent. However, one pulsotype was recovered from three separate hospitals, which suggests that either MRSP transmission between hospitals may have occurred via people, animals, or fomites or that there was a dominant community strain. Conclusions: Single strains of MRSP were isolated from various hand-contact and animal-contact surfaces within hospitals, indicating the important role of humans, animals and the environment in MRSP transmission. Additionally, the detection of a single strain between hospitals and over time suggests that either MRSP transmission between hospitals may have occurred via people, animals or fomites or that there was a dominant community strain.

Prevalence of methicillin-resistant Staphylococcus pseudintermedius on hand-contact and animal-contact surfaces in companion animal community hospitals.

Methicillin-resistant Staphylococcus pseudintermedius (MRSP) is an important companion animal pathogen, but few published studies have evaluated its epidemiology in primary care settings. This study determined MRSP prevalence on hand- and animal-contact surfaces in 11 small animal primary care hospitals in Washington and Idaho, USA. Overall, MRSP was isolated from at least 1 sample from 7 of 11 hospitals (64%) and from 36 of 374 total samples (10%) with no difference in prevalence between hand- and animal-contact surfaces (P = 0.51). Strain typing by pulsed-field gel electrophoresis indicated high within-hospital similarity of MRSP strains, but minimal similarity between strains from different hospitals. Indistinguishable MRSP strains were present on handand animal-contact surfaces within individual hospitals. A questionnaire was administered to a representative from each hospital. Respondents reported that animal-contact surfaces were cleaned and disinfected more frequently than hand-contact surfaces (P < 0.001). Improving hand hygiene and disinfection of hand-contact surfaces may decrease exposure of veterinary patients to MSRP.

Prévalence de Staphylococcus pseudintermedius résistant à la méthicilline sur des surfaces en contact avec les mains et des surfaces en contact avec les animaux dans des hôpitaux de première ligne pour animaux de compagnie. Staphylococcus pseudintermedius résistant à la méthicilline (MRSP) est un agent pathogène important chez les animaux de compagnie, mais peu d'études publiées ont évalué son épidémiologie dans les sites de soins de première ligne. Dans la présente étude on détermina la prévalence de MRSP sur les surfaces de contact avec les mains et les surfaces de contact avec les animaux dans 11 hôpitaux de première ligne pour animaux de compagnie dans les états de Washington et de l'Idaho, USA. De manière globale, le MRSP fut isolé à partir d'au moins un échantillon dans 7 des 11 hôpitaux (64 %) et de 36 des 374 échantillons (10 %) sans noter de différence dans la prévalence entre les contacts main-surface ou animal-surface (P = 0,51). Le typage des souches par électrophorèse en champs pulsés indiqua une similarité intra-hôpital élevée des souches de MRSP, mais une similarité minimale entre les souches provenant d'hôpitaux différents. Des souches indistinguables de MRSP étaient présentes sur les surfaces de contact avec les mains et les animaux dans un même hôpital. Un questionnaire fut soumis à un représentant de chaque hôpital. Les répondants rapportèrent que les surfaces de contact avec l'animal étaient nettoyées et désinfectées plus fréquemment que les surfaces de contact avec les mains (P < 0,001). Une amélioration de l'hygiène des mains et de la désinfection des surfaces en contacts avec les mains pourraient diminuer l'exposition de patients vétérinaires au MSRP.(Traduit par Dr Serge Messier).

The Sonographic Spectrum of Pelvic Endometriosis: Pearls, Pitfalls, and Mimics.

Endometriosis is a common disease of reproductive-age women that is often first encountered with ultrasound. Therefore, familiarity with the variety of manifestations of endometriosis is important for appropriate diagnosis and management. The aim of this article is to review the spectrum of appearance of pelvic endometriosis and to discuss potential mimics on ultrasound. Given that magnetic resonance imaging is an important problem-solving tool in female pelvic imaging, magnetic resonance imaging correlation is also provided.

Draft Genome Sequences of 12 Clinical and Environmental Methicillin-Resistant Staphylococcus pseudintermedius Strains Isolated from a Veterinary Teaching Hospital in Washington State.

Methicillin-resistant Staphylococcus pseudintermedius (MRSP) is a globally emergent multidrug-resistant pathogen of dogs associated with nosocomial transmission in dogs and with potential zoonotic impacts. Here, we report the draft whole-genome sequences of 12 hospital-associated MRSP strains and their resistance genotypes and phenotypes.

Molecular Epidemiology of Dairy Cattle-Associated Escherichia coli Carrying blaCTX-M Genes in Washington State.

An increase in the prevalence of commensal Escherichia coli carrying blaCTX-M genes among dairy cattle was observed between 2008 and 2012 in Washington State. To study the molecular epidemiology of this change, we selected 126 blaCTX-M-positive and 126 blaCTX-M-negative isolates for determinations of the multilocus sequence types (MLSTs) and antibiotic resistance phenotypes from E. coli obtained during a previous study. For 99 isolates, we also determined the blaCTX-M alleles using PCR and sequencing and identified the replicon types of blaCTX-M-carrying plasmids. The blaCTX-M-negative E. coli isolates comprised 76 sequence types (STs) compared with 32 STs in blaCTX-M-positive E. coli isolates. The blaCTX-M-positive E. coli isolates formed three MLST clonal complexes, accounting for 83% of these isolates; 52% of blaCTX-M-negative E. coli isolates clustered into 10 clonal complexes, and the remainder were singletons. Overall, blaCTX-M-negative E. coli isolates had more diverse genotypes that were distinct to farms, whereas blaCTX-M-positive E. coli isolates had a clonal population structure and were widely disseminated on farms in both regions included in the study. Plasmid replicon types included IncI1 which predominated, followed by IncFIB and IncFIA/FIB. blaCTX-M-15 was the predominant CTX-M gene allele, followed by blaCTX-M-27 and blaCTX-M-14 There was no significant association between plasmid replicon types and bacterial STs, and neither clonal complexes nor major plasmid groups were associated with two discrete dairy-farming regions of Washington State.IMPORTANCE Infections caused by extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli occur globally and present treatment challenges because of their resistance to multiple antimicrobial drugs. Cattle are potential reservoirs of ESBL-producing Enterobacteriaceae, and so understanding the causes of successful dissemination of blaCTX-M genes in commensal bacteria will inform future approaches for the prevention of antibiotic-resistant pathogen emergence.

The effect of nail characteristics on surface bacterial counts of surgical personnel before and after scrubbing.

OBJECTIVE: To determine the influence of nail characteristics on bacterial counts on the fingers of surgery personnel. STUDY DESIGN: Randomized nonblinded controlled crossover study design. SAMPLE POPULATION: Veterinary students, small animal surgery technicians, small animal surgery interns/residents, and small animal surgery faculty in a veterinary teaching hospital (n = 21). METHODS: Subjects were randomized into one of 2 groups; group 1 wore nail polish (P) for 1 week and group 2 (control) had nonpolished (NP) fingernails. Each subject changed groups the following week. Fingernail lengths were measured each day and fingernail samples were collected before and after presurgical scrub and after surgery. Total bacterial counts (TBC) and suspected staphylococci were counted on blood agar media and mannitol salt agar. The association between bacterial counts and nail biting, position of the volunteer, duration of the surgery, whether the nail polish was chipped, duration of nail polish application, type of surgery, and handedness was tested. Log-transformed CFU counts were compared with a Student's t test and presence or absence of bacteria were compared using Fisher's exact test. RESULTS: TBC, quantities of staphylococci, other gram-positive organisms, and gram-negative bacilli did not differ between P and NP personnel. The only variable associated with higher bacterial counts consisted of nail lengths greater than 2 mm. CONCLUSION: Nail polish did not influence bacterial counts and types of isolates, but nail length is a risk factor for increased bacterial counts. Based on our results, we recommend that nail length be kept under 2 mm.

Surveillance Neck Sonography After Thyroidectomy for Papillary Thyroid Carcinoma: Pitfalls in the Diagnosis of Locally Recurrent and Metastatic Disease.

A sonographic examination of the neck performed 6 to 12 months after thyroid surgery in patients with differentiated thyroid cancer is strongly recommended by the American Thyroid Association and considered mandatory by the European Thyroid Association for locoregional surveillance. The aim of this article is to review the normal anatomic changes expected after thyroid surgery and the pathologic mimics of thyroid carcinoma recurrence in post-thyroidectomy patients as they appear on neck sonography. We hope to offer some pearls to increase diagnostic confidence in this setting.

Can "Tumor-to-Cortex Echogenicity Ratio" Differentiate Angiomyolipomas from Other Hyper-Echoic Renal Masses.

A retrospective study was performed to evaluate the diagnostic value of tumor-to-cortex echogenicity ratio (TCER) in the characterization of hyper-echoic renal masses. The radiology database was queried between 2012 and 2014 for hyper-echoic renal masses on the basis of defined exclusion and inclusion criteria. Each included mass was characterized as either an angiomyolipoma (AML) or a non-AML based on pre-defined criteria. The ratio of renal mass echogenicity to that of adjacent renal cortex (TCER) was calculated for each mass using commercially available software. A total of 70 masses in 65 patients were identified, including 49 AMLs. TCER values >2.26 were associated with a sensitivity and specificity of 81.6% and 71.4%, respectively, for diagnosis of AML. Moreover, TCER values >3.98 resulted in 100% specificity for AML diagnosis with a sensitivity of 28.6%. These findings suggest that the TCER may be a valuable tool for the characterization of hyper-echoic renal masses.

Role of Ultrasound in Complications of Hematopoetic Stem Cell Transplantation.

Hematopoetic stem cell transplantation (HSCT) is an established therapeutic option for both malignant and nonmalignant indications, whose incidence has continued to increase in recent years. Because of its lower cost and lack of radiation exposure, ultrasound examination is often the first-line imaging modality in evaluating patients both before and after HSCT. It is important for radiologists to be aware of sonographic manifestations of the complications that may arise from HSCT. In this study, we will review the basics of HSCT, the role of imaging, and ultrasound examination findings in common and uncommon complications arising from HSCT.

Diagnostic accuracy of hepatorenal index in the detection and grading of hepatic steatosis.

PURPOSE: The objectives of our study were to assess the accuracy of hepatorenal index (HRI) in detection and grading of hepatic steatosis and to evaluate various factors that can affect the HRI measurement. METHODS: Forty-five patients, who had undergone an abdominal sonographic examination within 30 days of liver biopsy, were enrolled. The HRI was calculated as the ratio of the mean brightness levels of the liver and renal parenchymas. The effect of the measurement technique on the HRI was evaluated by using various sizes, depths, and locations of the regions of interest (ROIs) in the liver. The measurements were obtained by two observers. The HRI was compared with the subjective grading of steatosis. RESULTS: The optimal HRI cutoff to detect steatosis was 2.01, yielding a sensitivity of 62.5% and specificity of 95.2%. Subjective grading had a sensitivity of 87.5% and specificity of 62.5%. HRIs of the hepatic steatosis group were statistically different from the no-steatosis group (p < 0.05). However, there was no statistically significant difference between mild steatosis and no-steatosis groups (p value = 0.72). There was a strong correlation between different HRIs based on variable placements of ROIs, except when the ROIs were positioned randomly. Interclass correlation coefficient for measurements performed by two observers was 0.74 (confidence interval: 0.58-0.86). CONCLUSIONS: The HRI is an effective tool for detecting hepatic steatosis. It provides similar accuracy for different methods of ROI placement (except for random placement) and has good interobserver agreement. It, however, is unable to effectively differentiate between absent and mild steatosis. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:580-586, 2016.

US of the Nongravid Cervix with Multimodality Imaging Correlation: Normal Appearance, Pathologic Conditions, and Diagnostic Pitfalls.

The adult uterine cervix may exhibit a wide variety of pathologic conditions that include benign entities (eg, cervicitis, hyperplasia, nabothian cysts, cervical polyps, leiomyomas, endometriosis, and congenital abnormalities) as well as malignant lesions, particularly cervical carcinoma. In addition, lesions that arise in the uterine body may secondarily involve the cervix, such as endometrial carcinoma and prolapsed intracavitary masses. Many of these conditions can be identified and characterized at ultrasonography (US), which is considered the first-line imaging examination for the female pelvis. However, examination of the cervix is often cursory during pelvic US, such that cervical disease may be overlooked or misdiagnosed. Transabdominal US of the cervix may not afford sufficient spatial resolution to depict cervical disease in many patients; therefore, endovaginal US is considered the optimal technique. Use of supplemental imaging techniques, particularly the application of transducer pressure on the cervix, may be helpful. This review describes the normal appearance of the cervix at US, the appearance of cervical lesions and conditions that mimic abnormalities at US, and optimal US techniques for evaluation of the cervix. This information will help radiologists detect and diagnose cervical abnormalities more confidently at pelvic US. Online supplemental material is available for this article.

Evaluation of two multi-locus sequence typing schemes for commensal Escherichia coli from dairy cattle in Washington State.

Multi-locus sequence typing (MLST) is a useful system for phylogenetic and epidemiological studies of multidrug-resistant Escherichiacoli. Most studies utilize a seven-locus MLST, but an alternate two-locus typing method (fumC and fimH; CH typing) has been proposed that may offer a similar degree of discrimination at lower cost. Herein, we compare CH typing to the standard seven-locus method for typing commensal E. coli isolates from dairy cattle. In addition, we evaluated alternative combinations of eight loci to identify combinations that maximize discrimination and congruence with standard seven-locus MLST among commensal E. coli while minimizing the cost. We also compared both methods when used for typing uropathogenic E. coli (UPEC). CH typing was less discriminatory for commensal E. coli than the standard seven-locus method (Simpson's Index of Diversity=0.933 [0.902-0.964] and 0.97 [0.96-0.979], respectively). Combining fimH with housekeeping gene loci improved discriminatory power for commensal E. coli from cattle but resulted in poor congruence with MLST. We found that a four-locus typing method including the housekeeping genes adk, purA, gyrB and recA could be used to minimize cost without sacrificing discriminatory power or congruence with Achtman seven-locus MLST when typing commensal E. coli.

Overview of Conventional Imaging-based Intervention in Clinical Practice.

This article presents an overview of image-guided interventions using conventionally available imaging modalities. It discusses technical and clinical aspects of the interventions, and also focuses on site-specific biopsies such as liver, spleen, renal, and soft tissue biopsies in the abdomen. It briefly discusses the emerging role of PET imaging and other technologies that will improve the diagnostic yield of image-guided biopsies.

Recent Emergence of Escherichia coli with Cephalosporin Resistance Conferred by blaCTX-M on Washington State Dairy Farms.

Enterobacteriaceae-associated blaCTX-M genes have become globally widespread within the past 30 years. Among isolates from Washington State cattle, Escherichia coli strains carrying blaCTX-M (CTX-M E. coli strains) were absent from a set of 2008 isolates but present in a set of isolates from 2011. On 30 Washington State dairy farms sampled in 2012, CTX-M E. coli prevalence was significantly higher on eastern than on northwestern Washington farms, on farms with more than 3,000 adult cows, and on farms that recently received new animals. The addition of fresh bedding to calf hutches at least weekly and use of residual fly sprays were associated with lower prevalence of CTX-M E. coli. In Washington State, the occurrence of human pathogens carrying blaCTX-M genes preceded the emergence of blaCTX-M-associated E. coli in cattle, indicating that these resistance determinants and/or their bacterial hosts may have emerged in human populations prior to their dissemination to cattle populations.

Recent advances in imaging cancer of the kidney and urinary tract.

Modern radiologic imaging is an aid to treatment planning for localized renal cancer, enabling characterization of mass lesions. For patients who present with advanced renal cancer, new imaging techniques enable a functional assessment of treatment response not possible using anatomic measurements alone. Multidetector CT urography permits simultaneous assessment of the kidneys and urinary tract for patients with unexplained hematuria. Both CT and MRI play a significant role in staging and follow up of patients treated for urothelial cancer. Newer imaging methods such as diffusion-weighted MRI have shown promising results for improving accuracy of staging and follow up of urothelial cancer.

Developing an automated database for monitoring ultrasound- and computed tomography-guided procedure complications and diagnostic yield.

Monitoring complications and diagnostic yield for image-guided procedures is an important component of maintaining high quality patient care promoted by professional societies in radiology and accreditation organizations such as the American College of Radiology (ACR) and Joint Commission. These outcome metrics can be used as part of a comprehensive quality assurance/quality improvement program to reduce variation in clinical practice, provide opportunities to engage in practice quality improvement, and contribute to developing national benchmarks and standards. The purpose of this article is to describe the development and successful implementation of an automated web-based software application to monitor procedural outcomes for US- and CT-guided procedures in an academic radiology department. The open source tools PHP: Hypertext Preprocessor (PHP) and MySQL were used to extract relevant procedural information from the Radiology Information System (RIS), auto-populate the procedure log database, and develop a user interface that generates real-time reports of complication rates and diagnostic yield by site and by operator. Utilizing structured radiology report templates resulted in significantly improved accuracy of information auto-populated from radiology reports, as well as greater compliance with manual data entry. An automated web-based procedure log database is an effective tool to reliably track complication rates and diagnostic yield for US- and CT-guided procedures performed in a radiology department.