Contemporary and Emerging MRI Strategies for Assessing Kidney Allograft Complications: Arterial Stenosis and Parenchymal Injury, From the AJR Special Series on Imaging of Fibrosis.

MRI plays an important role in the evaluation of kidney allografts for vascular complications as well as parenchymal insults. Transplant renal artery stenosis, the most common vascular complication of kidney transplant, can be evaluated by MRA using gadolinium and nongadolinium contrast agents as well as by unenhanced MRA techniques. Parenchymal injury occurs through a variety of pathways, including graft rejection, acute tubular injury, BK polyomavirus infection, drug-induced interstitial nephritis, and pyelonephritis. Investigational MRI techniques have sought to differentiate among these causes of dysfunction as well as to assess the degree of interstitial fibrosis or tubular atrophy (IFTA)-the common end pathway for all of these processes-which is currently evaluated by invasively obtained core biopsies. Some of these MRI sequences have shown promise in not only assessing the cause of parenchymal injury but also assessing IFTA noninvasively. This review describes current clinically used MRI techniques and previews promising investigational MRI techniques for assessing complications of kidney grafts.

An Unusual Presentation: High-Grade Serous Carcinoma of the Fallopian Tube Manifesting With Altered Mental Status Secondary to a Single Brain Metastasis-A Case Report and Review of the Literature.

Epithelial ovarian and fallopian cancers are aggressive lesions that rarely metastasize to the central nervous system. Brain metastases usually occur in the setting of known primary disease or widespread metastatic disease. However, in extremely rare cases, an isolated intracranial neoplasm may be the first presentation of fallopian cancer. To the best of our knowledge, only one such case has been reported previously. We present an illustrative case with multimodality imaging and histopathologic correlation of a fallopian tube carcinoma first presenting with altered mental status secondary to an isolated brain metastasis. A 64-year-old female with no pertinent medical history presented with altered mentation. Initial workup identified a 1.6 cm avidly enhancing, solitary brain lesion at the gray-white junction with associated vasogenic edema concerning for either central nervous system lymphoma or metastatic disease. Additional imaging identified a 7.5 × 3 cm left adnexal lesion, initially thought to be a hydrosalpinx with hemorrhage, but magnetic resonance imaging suggested gynecologic malignancy. No lesions elsewhere in the body were identified. Given the lack of locoregional or systemic disease, the intracranial and pelvic lesions were assumed to represent synchronous but distinct processes. The intracranial lesion was biopsied. Preliminary results were suggestive of lymphoma, but further analysis was consistent with high-grade serous carcinoma of müllerian origin. Positron emission tomography/computed tomography was performed to evaluate for other neoplastic lesions, only highlighting the intracranial and pelvic lesions. At this point, a diagnosis of metastatic fallopian cancer was made. The patient was taken for robot-assisted laparoscopy with surgical debulking of the pelvic neoplasm, pathology demonstrating high-grade serous carcinoma of the fallopian tube, matching that of the intracranial lesion. Even though rare, metastatic fallopian cancer should be considered in patients with isolated brain lesions and adnexal lesions, even in the absence of locoregional or systemic disease.

Does MRI alter management in patients 60 years and older with chronic knee pain: correlation with radiographs and clinical parameters.

OBJECTIVE: To determine if MRI altered management in patients ≥ 60 years old with chronic knee pain. MATERIALS AND METHODS: Consecutive patients ≥ 60 years old with knee MRI and radiographs within 90 days were included. Exclusion criteria included mass/malignancy, recent trauma, and infection. Standing AP and PA flexion views were evaluated using Kellgren-Lawrence (KL) and International Knee Documentation Committee (IKDC) scales. Pertinent clinical history was recorded. MRIs were considered to alter management if subchondral fracture was identified or subsequent arthroscopy was performed due to an MRI finding. RESULTS: Eighty-five knee MRI/radiograph exams were reviewed; mean 68.2 years (60-88), 47:38 F:M. Twenty knee MRIs (24%) had either a subchondral fracture (n = 9) or meniscal tear (n = 11) prompting arthroscopy. On PA flexion view, 0/20 of these studies had KL grade 4 and 70% (14/20) had KL grade 0-1 compared to the remaining MRIs having 15.4% (10/65) KL grade 4 and 38.5% (25/65) KL grade 0-1 (p = 0.03). A 10-pack-year tobacco history, 38% vs 18%, was associated with a subchondral fracture or arthroscopy (p = 0.06). Subchondral fractures were more prevalent in older patients (mean 72.4 vs 67.7 years; p = 0.03). CONCLUSION: In patients ≥ 60 years old with chronic knee pain, MRI altered management in ~ 24% of cases; 70% in patients with KL grade 0-1, and none in patients with KL grade 4. MRI may benefit older patients with minimal osteoarthritis but not those with end-stage disease. Patients with ≥ 10 pack years of smoking may also benefit from MRI.

Beyond the Needle: Unmasking Atypical Mycobacteria in Postvaccination Abscesses in Children.

Introduction: Atypical or nontuberculous mycobacteria (NTM) are an environmental organism responsible for opportunistic infection. Rapid-growing NTM are more commonly associated with hospital-acquired infections. Many of the organisms responsible for diseases in immunocompromised patients and hospital-acquired infections originate from tap water, such as Mycobacterium kansasii, Mycobacterium xenopi, Mycobacterium gordonae, Mycobacterium simiae, Mycobacterium mucogenicum, Mycobacterium fortuitum, Mycobacterium chelonae, and Mycobacterium abscessus. NTM is a rare organism responsible for the injection abscess. Considering low incidents, not much clinical data are available for this condition. Here, we discuss such cases which can be helpful to spread awareness and provide data for future policy makers. Materials and Methods: This was a retrospective study. Data on patients with injection abscess were collected from the last 6 years. Detailed history and clinical examination findings were analyzed. Children with injection abscess were operated and their further management and outcome were studied. Results: A total of 13 cases with confirmed culture of NTM were treated over 6 years. The age ranged from 2½ months to 5¾ years with male:female ratio of 7:6. All patients hailed from the same geographical area. All children were healthy with no history of any long-term or chronic illness, without additional symptoms and had received Bacillus Calmette-Guérin vaccination at birth. The total duration of illness varied from 1 to 5 months, with a mean of 3 months. All patients had a history of intramuscular age-appropriate vaccination as per the national immunization schedule. All patients were followed up to 6 months after intervention and none of our patients developed relapse. Conclusion: Patient who does not respond with optimum treatment should have a high suspicion of such opportunistic infection, which is crucial to their management. Hospital-acquired NTM infections often result from contaminated instruments or fluids. Adherence to strict aseptic precautions, hand hygiene and environmental precautions are the key to preventing these infections. In case of skin and soft tissue infections / abscesses, surgical intervention plays a significant role for managing the patient.

Tuberculosis treatment outcomes and patient support groups, southern India.

Objective: To assess treatment outcomes in tuberculosis patients participating in support group meetings in five districts of Karnataka and Telangana states in southern India. Methods: Tuberculosis patients from five selected districts who began treatment in 2019 were offered regular monthly support group meetings, with a focus on patients in urban slum areas with risk factors for adverse outcomes. We tracked the patients' participation in these meetings and extracted treatment outcomes from the Nikshay national tuberculosis database for the same patients in 2021. We compared treatment outcomes based on attendance of the support groups meetings. Findings: Of 30 706 tuberculosis patients who started treatment in 2019, 3651 (11.9%) attended support groups meetings. Of patients who attended at least one support meeting, 94.1% (3426/3639) had successful treatment outcomes versus 88.2% (23 745/26 922) of patients who did not attend meetings (adjusted odds ratio, aOR: 2.44; 95% confidence interval, CI: 2.10-2.82). The odds of successful treatment outcomes were higher in meeting participants than non-participants for all variables examined including: age ≥ 60 years (aOR: 3.19; 95% CI: 2.26-4.51); female sex (aOR: 3.33; 95% CI: 2.46-4.50); diabetes comorbidity (aOR: 3.03; 95% CI: 1.91-4.81); human immunodeficiency virus infection (aOR: 3.73; 95% CI: 1.76-7.93); tuberculosis retreatment (aOR: 1.69; 1.22-2.33); and drug-resistant tuberculosis (aOR: 1.93; 95% CI: 1.21-3.09). Conclusion: Participation in support groups for tuberculosis patients was significantly associated with successful tuberculosis treatment outcomes, especially among high-risk groups. Expanding access to support groups could improve tuberculosis treatment outcomes at the population level.

A Randomized Control Trial Comparing the Efficacy of Platelet-Rich Plasma and 5% Topical Minoxidil for the Treatment of Androgenetic Alopecia.

Androgenetic alopecia (AGA) is the most common cause of hair loss in men and has limited treatment options. Minoxidil is a common therapeutic option for AGA patients because of its availability. Platelet-rich plasma (PRP) therapy is a newer option in AGA management with promising results that may be suitable for some patients. Despite a great prevalence of AGA outside the United States and Europe, there remains limited studies on the efficacy of PRP for AGA treatment. Our study's objective was to compare the efficacy of PRP and minoxidil therapy for the treatment of AGA in a Pakistani population. 72 patients were included in this randomized control trial and were either treated with PRP or topical minoxidil. After 12 weeks of treatment, the hair pull test was performed and extracted hair was counted. We report a 91.7% negative hair pull rate in the PRP treatment group which was significantly greater than the 69.4% negative hair pull rate in the minoxidil-treated group. Our study suggests that PRP therapy demonstrates a higher efficacy compared to minoxidil for treating AGA, especially in our patient demographic. These results have the opportunity to improve patient compliance and overall satisfaction while offering an improved option in patients unsatisfied with topical minoxidil.  Citation: Shah R, Asim M, Ouellette S, et al. A randomized control trial comparing the efficacy of platelet-rich plasma and 5% topical minoxidil for the treatment of androgenetic alopecia. J Drugs Dermatol. 2023;22(9):905-909. doi:10.36849/JDD.7031.

Total Glans Amputation in a Child following Ritual Circumcision - Report of a Case and Review of Literature.

Ritual circumcision in children remains a trivialized procedure in some countries, especially in rural areas. It is often performed by unqualified paramedical personnel, or even by religious workers whose notions of surgery and asepsis are uncertain. Although it is thought to be a minor procedure, major complications with sexual or even life-threatening prognosis can occur. Amputation of the glans during circumcision is a rare incidence secondary to poor application of operating principles. We report the case of a 1½-year-old boy who underwent a progressive amputation of the glans after a ritual circumcision by a religious worker. The child was brought 10 days after the procedure with totally amputated, nonsalvageable glans. A urethral meatoplasty was performed to enable proper voiding and prevent meatal stenosis. The child has been in follow-up for the past 6 months without any urinary symptoms.

Intraperitoneal Rupture of Urinary Bladder during Micturating Cystourethrography in a Child.

Micturating cystourethrography (MCUG) is a very commonly performed diagnostic procedure in pediatric urology. Although considered to be simple, safe, and cost-effective, it can incur some complications. Bladder rupture during MCUG is a very rare complication and only a handful of cases have been reported in world literature. We report the case of a 2.5-month-old boy who had intraperitoneal bladder rupture during an MCUG needing surgical repair. At operation, the child had a bladder tear at the dome of the bladder which was repaired successfully. The postoperative recovery was uneventful and the child is doing well in follow-up. Although individual management of bladder rupture may differ, a majority of infants need surgery for the same. Thorough vigil and attention to the technique are a must to prevent such incidents in children.

Factors Affecting Domiciliary Non-Invasive Ventilation Compliance.

Few international studies have investigated factors affecting domiciliary non-invasive ventilation (D-NIV) compliance, and data from the UK are limited. We assessed compliance (defined as ≥ 4 h/night for at least 70% of the time) in a retrospective UK population study, at three time points (0-1 month, 3-4 months and 11-12 months), for all patients commenced on D-NIV over a 5-year period. A total of 359 patients were included. Non-compliant vs. compliant patients were significantly younger (median age 64 (IQR 52-72) vs. 67 (58-75) years, p = 0.032) and more likely to have schizophrenia, consistent at both 3-4 months (5% vs. 1%, p = 0.033) and 11-12 months (5% vs. 2%, p = 0.049). Repeated measures ANOVA demonstrated that the minutes [median (IQR)] of D-NIV used significantly increased at the three time points (0-1 month, 3-4 months and 11-12 months) for patients with hypertension [310 (147.5-431) vs. 341 (89-450) vs. 378 (224.5-477.5), p = 0.003]; diabetes [296.5 (132.5-417.5) vs. 342.5 (94.5-438.5) vs. 382 (247.5-476.25), p = 0.002] and heart failure [293 (177-403) vs. 326 (123-398) vs. 365 (212-493), p = 0.04]. In conclusion, younger and comorbid schizophrenic patients have lower D-NIV compliance rates, and our data suggest that persistence with D-NIV over a year may improve overall use.

Cardiac hemangioma mimicking a neuroendocrine tumor on 68 Ga Dotatate PET/CT.

Cardiac hemangioma is a rare, benign primary tumor characterized by endothelial proliferation. While reports of cardiac hemangiomas demonstrating 18 F FDG avidity and other forms of hemangiomas showing 68 Ga Dotatate avidity have been published, we present a rare case of primary cardiac hemangioma demonstrating 68 Ga Dotatate avidity, mimicking a primary neuroendocrine tumor.

Intraperitoneal bladder rupture in a 1 year old: A very unusual accident.

Intraperitoneal bladder rupture is a rare event in the paediatric population. Road traffic accidents (RTA) and seat belt injuries are considered to be the main cause for the same. We report an interesting case of a 1-year-old girl who had a laparoscopic repair of intraperitoneal bladder tear following a non-RTA injury. This is the smallest child where intraperitoneal bladder rupture was repaired laparoscopically. This mechanism of injury-causing bladder rupture has also not been reported across world literature. The child was sleeping on the floor near the bed with her mother. The father who was sleeping on the bed accidentally fell onto this child. Imaging showed large amount of clear intraperitoneal fluid with no organ injury. Laparoscopy showed a 3.5 cm long tear on the posterior wall of the bladder. The tear was repaired using 3 mm instruments.

Measurement of Body Temperature in Postsurgical Children: Comparisons of Infrared Nonskin Contact Digital Thermometer, Skin Contact Digital Thermometer, and Mercury in Glass Thermometer.

CONTEXT: Postoperative fever is known to occur after all surgical procedures irrespective of the type of anesthesia. Thermometry devices that work without touching or disturbing the child seem to be appreciated more than the conventional skin contact thermometers. However, whether this technology is reliable to be adapted for routine pediatric surgical care is debatable. AIMS: The aim of this study was to study the accuracy of infrared nonskin contact digital thermometer (IRT) compared to the skin contact digital thermometer (DT) and mercury in glass thermometer (MT). SETTINGS AND DESIGN: A prospective cross-sectional study was done in postoperative patients at a pediatric surgical center over a period of 3 months. SUBJECTS AND METHODS: The forehead temperature was recorded with IRT. This was followed by recording the temperature in one armpit by DT and the other armpit by MT. Readings were promptly documented. STATISTICAL ANALYSIS USED: A sample t-test was done which gave the P value and mean. Linear regression analysis was carried out to find correlation coefficients. Bland-Altman test was used to access the concordance between all readings. RESULTS: We found a strong correlation between temperature readings taken by DT (mean = -0.03, r = 0.07, slope = -0.04) and IRT (mean = 0.89, r = 0.091, slope = -0.14). However, on comparison of results with the MT, there are wider limits of agreement with the IRT (-0.31-2.09) in comparison to DT (-0.66-0.59). CONCLUSION: Skin contact digital thermometer are more accurate and suitable for checking body temperature as compared to infrared nonskin contact digital thermometer in postoperative pediatric patients.

COVID-19 and pneumothorax: a multicentre retrospective case series.

INTRODUCTION: Pneumothorax and pneumomediastinum have both been noted to complicate cases of coronavirus disease 2019 (COVID-19) requiring hospital admission. We report the largest case series yet described of patients with both these pathologies (including nonventilated patients). METHODS: Cases were collected retrospectively from UK hospitals with inclusion criteria limited to a diagnosis of COVID-19 and the presence of either pneumothorax or pneumomediastinum. Patients included in the study presented between March and June 2020. Details obtained from the medical record included demographics, radiology, laboratory investigations, clinical management and survival. RESULTS: 71 patients from 16 centres were included in the study, of whom 60 had pneumothoraces (six with pneumomediastinum in addition) and 11 had pneumomediastinum alone. Two of these patients had two distinct episodes of pneumothorax, occurring bilaterally in sequential fashion, bringing the total number of pneumothoraces included to 62. Clinical scenarios included patients who had presented to hospital with pneumothorax, patients who had developed pneumothorax or pneumomediastinum during their inpatient admission with COVID-19 and patients who developed their complication while intubated and ventilated, either with or without concurrent extracorporeal membrane oxygenation. Survival at 28 days was not significantly different following pneumothorax (63.1±6.5%) or isolated pneumomediastinum (53.0±18.7%; p=0.854). The incidence of pneumothorax was higher in males. 28-day survival was not different between the sexes (males 62.5±7.7% versus females 68.4±10.7%; p=0.619). Patients aged ≥70 years had a significantly lower 28-day survival than younger individuals (≥70 years 41.7±13.5% survival versus <70 years 70.9±6.8% survival; p=0.018 log-rank). CONCLUSION: These cases suggest that pneumothorax is a complication of COVID-19. Pneumothorax does not seem to be an independent marker of poor prognosis and we encourage continuation of active treatment where clinically possible.

Chest CT and Coronavirus Disease (COVID-19): A Critical Review of the Literature to Date.

OBJECTIVE. Coronavirus disease (COVID-19) is a global pandemic. Studies in the radiology literature have suggested that CT might be sufficiently sensitive and specific in diagnosing COVID-19 when used in lieu of a reverse transcription-polymerase chain reaction test; however, this suggestion runs counter to current society guidelines. The purpose of this article is to critically review some of the most frequently cited studies on the use of CT for detecting COVID-19. CONCLUSION. To date, the radiology literature on COVID-19 has consisted of limited retrospective studies that do not substantiate the use of CT as a diagnostic test for COVID-19.

Is a differentiated care model needed for patients with TB? A cohort analysis of risk factors contributing to unfavourable outcomes among TB patients in two states in South India.

BACKGROUND: TB is a preventable and treatable disease. Yet, successful treatment outcomes at desired levels are elusive in many national TB programs, including India. We aim to identify risk factors for unfavourable outcomes to TB treatment, in order to subsequently design a care model that would improve treatment outcomes among these at-risk patients. METHODS: We conducted a cohort analysis among TB patients who had been recently initiated on treatment. The study was part of the internal program evaluation of a USAID-THALI project, implemented in select towns/cities of Karnataka and Telangana, south India. Community Health Workers (CHWs) under the project, used a pre-designed tool to assess TB patients for potential risks of an unfavourable outcome. CHWs followed up this cohort of patients until treatment outcomes were declared. We extracted treatment outcomes from patient's follow-up data and from the Nikshay portal. The specific cohort of patients included in our study were those whose risk was assessed during July and September, 2018, subsequent to conceptualisation, tool finalisation and CHW training. We used bivariate and multivariate logistic regression to assess each of the individual and combined risks against unfavourable outcomes; death alone, or death, lost to follow up and treatment failure, combined as 'unfavourable outcome'. RESULTS: A significantly higher likelihood of death and experiencing unfavourable outcome was observed for individuals having more than one risk (AOR: 4.19; 95% CI: 2.47-7.11 for death; AOR 2.21; 95% CI: 1.56-3.12 for unfavourable outcome) or only one risk (AOR: 3.28; 95% CI: 2.11-5.10 for death; AOR 1.71; 95% CI: 1.29-2.26 for unfavourable outcome) as compared to TB patients with no identified risk. Male, a lower education status, an initial weight below the national median weight, co-existing HIV, previous history of treatment, drug-resistant TB, and regular alcohol use had significantly higher odds of death and unfavourable outcome, while age > 60 was only associated with higher odds of death. CONCLUSION: A rapid risk assessment at treatment initiation can identify factors that are associated with unfavourable outcomes. TB programs could intensify care and support to these patients, in order to optimise treatment outcomes among TB patients.

Image Guidance in Cranial Neurosurgery: How a Six-Ton Magnet and Fluorescent Colors Make Brain Tumor Surgery Better.

Maximal safe resection can improve patient outcomes for a variety of brain tumor types including low- and high-grade gliomas, pituitary adenomas, and other pathologies. Numerous intraoperative adjuncts exist to guide surgeons with maximizing extent of resection. Three distinct strategies exist including: 1) surgical navigation; 2) intraoperative imaging; and 3) tumor fluorescence. Surgical navigation involves registration of high-resolution three-dimensional imaging to the patient's cranial surface anatomy, allowing real-time localization of tumor and brain structures. Intraoperative imaging devices like intraoperative magnetic resonance imaging (iMRI), intraoperative computed tomography (iCT), 3-D fluoroscopy, and intraoperative ultrasonography (iUS) allow near real time visualization to assess the extent of resection. Intraoperative fluorescence via intravenous fluorescein or oral 5-aminolevulinic acid (5-ALA) causes brain tumors to "light up", which can be viewed through surgical optics using selective filters and specific wavelength light sources. A general overview, as well as implementation and utilization of some of these image guidance strategies at Washington University and by Siteman Cancer Center neurosurgeons at Barnes Jewish Hospital, is discussed in this review.

Generalized Lymphangioma of the Tongue: A Rare Cause of Macroglossia.

Generalized lymphangioma of tongue is a rare cause of macroglossia in children. It causes mechanical discomfort and functional and psychological disturbances. We report a case of macroglossia due to generalized lymphangioma in a 10 year old where partial glossectomy was done to achieve symptomatic relief.

Ultralow Dose Dynamic Expiratory Computed Tomography for Evaluation of Tracheomalacia.

OBJECTIVE: The aim of this study was to determine the average effective radiation dose and feasibility of ultralow dose dynamic expiratory computed tomography (CT) for evaluation of tracheomalacia (ULD) and to evaluate factors that impact image quality. METHODS: This is a retrospective study of 64 consecutive patients from September to October 2016 for the evaluation of tracheomalacia. All studies were performed with routine inspiration chest CT followed by ULD z(kilovoltage peak (kVp) 80, 100, or 120 and fixed milliamperage 10) or typical dose CT (TD) (kVp 100 or 120 with automated milliamperage) dynamic expiration CT. Image quality was considered diagnostic if the trachea area could be accurately measured for tracheomalacia assessment, and diagnostic studies were graded fair, good, or excellent. Scan length, image quality, and effective radiation dose were compared for ULD versus TD and ULD at 100 kVp versus ULD at 80 kVp. For ULD studies, patient factors were compared across image quality. RESULTS: The ULD had a mean effective radiation dose of 0.08 mSv, with all studies of diagnostic image quality. The ULD showed 95% reduction in effective radiation dose (P < 0.001), 14% significant reduction in scan length (P = 0.029), and qualitatively decreased image quality compared w2 ith TD (P < 0.001). The ULD at 100 kVp had significantly better image quality compared with ULD at 80 kVp (P = 0.041) with higher effective radiation dose (0.09 vs 0.05 mSv) (P < 0.001). Body mass index significantly impacted image quality for all ULD studies but not for ULD at 80 or 100 kVp. CONCLUSION: For evaluation of tracheomalacia, ULD showed low effective radiation dose less than 0.1 mSv and maintained diagnostic image quality.