Assessment of quantitative microflow Vascular Index in testicular cancer.

PURPOSE: Ultrasound (US) is the primary imaging modality when a testicular tumor is suspected. Superb microvascular imaging (SMI) is a novel, highly sensitive Doppler technique that allows quantification of flow signals by determination of the Vascular Index (VI). The aim of the present study is to investigate the diagnostic significance of the SMI-derived VI in normal testicular tissue and testicular cancer. METHODS: This retrospective analysis included patients who underwent testicular US in our department from 2018 to 2022. Inclusion criteria were: i) sufficient image quality of the stored images, ii) US with standardized SMI-default setting (colour gain of 44 ± 5), iii) patient age ≥ 18 years, and iv) normal testicular findings or testicular tumor with histopathological workup. US examinations were performed as part of clinical routine using a high-end ultrasound system (Aplio i800/i900, Canon Medical Systems Corporation, Tochigi, Japan). Statistical analysis included Chi-square test and Mann-Whitney U tests and receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 62 patients (31 each with normal findings and testicular tumors) were included. The VI differed statistically significantly (p < 0.001) between normal testis (median 2.5 %) and testicular tumors (median 17.4 %). Like vascular patterns (p < 0.001), the VI (p = 0.030) was shown to distinguish seminomas (median 14.8 %), non-seminomas (median 17.6 %) and lymphomas (median 34.5 %). CONCLUSIONS: In conclusion, our study has shown the VI to be a quantitative tool that can add information for differentiating testicular tumor entities. While further confirmation in larger study populations is desirable, our results suggest that the VI may be a useful quantitative parameter.

Long-term mortality in patients with pulmonary embolism: results in a single-center registry.

Background: While numerous studies have investigated short-term outcomes after pulmonary embolism (PE), long-term mortality remains insufficiently studied. Objectives: To investigate long-term outcomes in an unselected cohort of patients with PE. Methods: A total of 896 consecutive patients with PE enrolled in a single-center registry between May 2005 and December 2017 were followed up for up to 14 years. The observed mortality rate was compared with the expected rate in the general population. Results: The total follow-up time was 3908 patient-years (median, 3.1 years). The 1- and 5-year mortality rates were 19.7% (95% CI, 17.2%-22.4%) and 37.1% (95% CI, 33.6%-40.5%), respectively. The most frequent causes of death were cancer (28.5%), PE (19.4%), infections (13.9%), and cardiovascular events (11.6%). Late mortality (after >30 days) was more frequent than expected in the general population, a finding that was consistent in patients without cancer (the 5-year standardized mortality ratios were 2.77 [95% CI, 2.41-3.16] and 1.80 [95% CI, 1.50-2.14], respectively). Active cancer was the strongest risk factor for death between 30 days and 3 years (hazard ratio [HR], 6.51; 95% CI, 4.67-9.08) but was not associated with later mortality. Death after >3 years was predicted by age (HR, 1.86; 95% CI, 1.51-2.29 per decade), chronic heart failure (HR, 1.66; 95% CI, 1.02-2.70), and anemia (HR, 1.62; 95% CI, 1.09-2.41). Conclusion: The risk of mortality in patients with PE remained elevated compared with that in the general population throughout the follow-up period. The main driver of long-term mortality during the first 3 years was cancer. After that, mortality was predicted by age, chronic heart failure, and anemia.

Effects of orally administered hormonal contraceptives on the musculoskeletal system of healthy premenopausal women-A systematic review.

Introduction: The musculoskeletal system (MSK) is one of the extragonadal target tissues of sex hormones: osteoblasts and osteocytes express estrogen receptors, while in fibroblasts of the anterior cruciate ligament (ACL) and myocytes of the vastus lateralis muscle (MVL), estrogen and progesterone receptors can be detected by immunoassay. Indeed, upon binding of sex hormones to the extragonadal receptors, the MSK seems to respond to varying levels of sex hormones with structural adaptation. Hormonal contraceptives can affect the musculoskeletal system; however, there is a lack of high-quality studies, and no recommendation for female athletes exists. Material and Methods: This is a systematic review of publications on the effects of oral hormonal contraceptives on the biomechanical properties of tendons, muscles and ligaments, muscle strength, and soft tissue regeneration. A systematic database search was performed using MESH keywords and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology in Pubmed and Cochrane to identify studies investigating the influence of oral hormonal contraceptives on muscles, tendons, and ligaments of healthy, adult, premenopausal women. The risk of bias in the studies included was assessed by two independent researchers using the ROBINS-I Tool. Results: Nine comparative studies were identified that met the inclusion criteria. Endpoints were muscle strength and biomechanical tissue properties. No significant influence of oral hormonal contraceptives on muscle strength was found, although general muscle growth and Type I fiber growth were found to be significantly increased in a dose-dependent manner. There was a negative effect on regeneration of muscle strength after exercise. The stiffness of tendons remained unchanged, while their size adaptation to load increased. Conclusion: The anabolic effect could be beneficial for specific sports, whereas reduced muscle regeneration could be disadvantageous for women exercising with high-performance demands. The different effects on tendons and ligaments and the functional consequences of altered ligament and muscle stiffness, especially with regard to synthetic hormones, should be further investigated.

Contrast-enhanced ultrasound (CEUS) in characterization of inconclusive cervical lymph nodes: a meta-analysis and systematic review.

Lymph node metastases are common in malignant neoplasms of head and neck. Since cervical lymph nodes (cLN) are localized superficially, ultrasound (US) represents the primary imaging modality. The aim of the study is to report the value of US and contrast-enhanced ultrasound (CEUS) and their diagnostic confidence in the characterization of inconclusive cLN. A systematic review was performed using the literature data base PubMed. Results were filtered (published in a peer-reviewed journal, full-text available, published within the last ten years, species human, English or German full-text) and inclusion criteria were clearly defined (cohort with lymphadenopathy or malignancy in head and neck ≥ 50 patients, histological confirmation of malignant imaging findings, performance of CEUS as outcome variable). The results were quantified in a meta-analysis using a random-effects model. Overall, five studies were included in qualitative and quantitative analysis. The combination of non-enhanced US and CEUS enlarges the diagnostic confidence in the characterization of lymph nodes of unclear dignity. The pooled values for sensitivity and specificity in the characterization of a malignant cervical lymph node using US are 76% (95%-CI 66-83%, I2 = 63%, p < 0.01) and 80% (95%-CI 45-95%, I2 = 92%, p < 0.01), compared to 92% (95%-CI 89-95%, I2 = 0%, p = 0.65) and 91% (95%-CI 87-94%, I2 = 0%, p = 0.40) for the combination of US and CEUS, respectively. Consistent results of the included studies show improved diagnostic performance by additional CEUS. Nevertheless, more prospective studies are needed to implement CEUS in the diagnostic pathway of cLN.

Quantitative Multiparametric Ultrasound (mpUS) in the Assessment of Inconclusive Cervical Lymph Nodes.

Background: Enlarged cervical lymph nodes (CLN) are preferably examined by ultrasound (US) by using criteria such as size and echogenicity to assess benign and suspicious CLN, which should be histologically evaluated. This study aims to assess the differentiation of malign and benign CLN by using multiparametric US applications (mpUS). Methods: 101 patients received a standardized US protocol prior to surgical intervention using B-mode−US, shear-wave elastography (SWE) and contrast-enhanced ultrasound (CEUS). SWE was assessed by 2D real-time SWE conducting a minimum of five measurements, CEUS parameters were assessed with post-processing perfusion software. Histopathological confirmation served as the gold standard. Results: B-mode−US and SWE analysis of 104 CLN (36 benign, 68 malignant) showed a significant difference between benign and malignant lesions, presenting a larger long axis and higher tissue stiffness (both p < 0.001). Moreover, tissue stiffness assessed by SWE was significantly higher in CLN with regular B-mode−US criteria (Solbiati Index > 2 and short-axis < 1 cm, p < 0.001). No perfusion parameter on CEUS showed a significant differentiation between benign and malignant CLN. Discussion: As the only multiparametric parameter, SWE showed higher tissue stiffness in malignant CLN, also in subgroups with regular B-mode criteria. This fast and easy application may be a promising noninvasive tool to US examination to ameliorate the sonographic differentiation of inconclusive CLN.

Development of and Gathering Validity Evidence for a Theoretical Test in Contrast-Enhanced Ultrasound.

Contrast-enhanced ultrasound (CEUS) is an imaging modality applied in a broad field of medical specialties for diagnostic uses, guidance during biopsy procedures and ablation therapies and sonoporation therapy. Appropriate training and assessment of theoretical and practical competencies are recommended before practicing CEUS, but no validated assessment tools exist. This study was aimed at developing a theoretical multiple-choice question-based test for core CEUS competencies and gathering validity evidence for the test. An expert team developed the test via a Delphi process. The test was administered to medical doctors with varying CEUS experience, and the results were used to evaluate test items, internal-consistency reliability, ability to distinguish between different proficiency levels and to establish a pass/fail score. Validity evidence was gathered according to Messick's framework. The final test with 47 test items could distinguish between operators with and without CEUS experience with acceptable reliability. The pass/fail score led to considerable risk of false positives and negatives. The test may be used as an entry test before learning practical CEUS competencies but is not recommended for certification purposes because of the risk of false positives and negatives.

Outcomes of Deceased Donor Kidney Transplantation in the Eurotransplant Senior Program with A Focus on Recipients ≥75 Years.

To evaluate the outcomes of kidney transplantations (KTs) in the Eurotransplant Senior Program (ESP) with a focus on the very old, defined as recipients ≥75 years. This retrospective clinical study included 85 patients, who under the ESP protocol underwent deceased donor kidney transplantation from January 2010 to July 2018 at the Charité-Universitätsmedizin Berlin in Germany. Recipients were divided in three age groups, i.e., Group 65-69, Group 70-74, Group ≥75, and compared. Prognostic risk factors for short and long-term outcomes of kidney transplantations were investigated. Graft survival at 1 and 5 years were respectively 90.7% and 68.0% for group 65-69, 88.9% and 76.2% for Group 70-74, and 100% and 71.4% for Group ≥75. Patient survival at 1 and 5 years were respectively 92.9% and 68.0% for Group 65-69, 85.7% and 61.5% for Group 70-74 and 100% and 62.5% for Group ≥75. Serum creatinine did not significantly differ between the three groups, with the exception of serum creatinine at 1 year. Increased recipient age and prolonged time on dialysis correlated with increased occurrence of postoperative complication. An increase in BMI, pretransplant diabetes mellitus and prolonged time on dialysis correlated with the occurrence of delayed graft function (DGF). History of smoking was identified as an independent risk factor for events of rejection. Increased human leukocyte antigen mismatches (HLA-MM) and prolonged cold ischemia time (CIT) correlated with higher rates of intensive care unit (ICU) treatment. This study supports kidney transplantations for the very old. End-stage renal disease (ESRD) patients ≥75 years of age who underwent kidney transplantation experienced comparable results to their younger counterparts. A comprehensive evaluation of ESRD patients with consideration of prognostic risk factor is the most suitable mean of identifying adequate kidney transplant candidates.

Tertiary survey ultrasound has no diagnostic benefit in trauma patients without abdominal injuries on standardised initial whole-body computed tomography.

PURPOSE: The aim of our study was to evaluate the impact of a routine tertiary survey ultrasound (US) on patient management in major trauma patients without trauma-related abdominal findings on standardised initial whole-body CT (WBCT). METHODS: In this retrospective study, all WBCT scans acquired in major trauma patients between 07/2017 and 12/2019 at a university hospital and level I trauma centre were screened. 1,024 patients were included in the final analysis. Results of tertiary survey US and patient information (demographic data, trauma mechanism, imaging findings, clinical course, medical history, and anticoagulative medication) were collected and analysed. RESULTS: Routine tertiary survey US revealed new abdominal findings in six out of 1,024 patients (0.6%). None of the patients had to undergo surgery or minimally invasive intervention, nor did any of the patients die as a result of abdominal injuries. Additional abdominal imaging after tertiary survey US was ordered in 39 patients (38 US, 1 US + CT). None of these patients required further treatment for abdominal injuries. CONCLUSIONS: Routine tertiary survey US after inconspicuous standardised initial WBCT did not change clinical outcome for abdominal trauma patients.

Atypical presentation of a locally advanced hepatocellular carcinoma: Extensive workup of an incidental finding on computed tomography performed for planning of transcatheter aortic valve implantation.

This case report presents the diagnostic workup of liver malignancy incidentally detected in a 72-year-old male patient on routine body computed tomography angiography (CTA) performed for planning transcatheter aortic valve implantation (TAVI). The patient initially presented to an outside hospital with chest discomfort, where routine diagnostic procedures in the emergency room revealed grade III aortic valve stenosis. Routine CTA for TAVI planning in our department then revealed tumor thrombosis of the portal vein suspicious for hepatic malignancy. In contrast-enhanced ultrasound (CEUS) only the left hepatic lobe was inhomogeneously transformed with early arterial contrast enhancement. Magnetic resonance imaging (MRI) confirmed a primary hepatic malignancy involving the left liver. Transcutaneous biopsy with ultrasound guidance established the diagnosis of hepatocellular carcinoma (HCC). Incidental findings may be of prognostic relevance for the patient and in a number of cases, TAVI can be a prerequisite for the appropriate therapy.

Comparison of elution characteristics and mechanical properties of acrylic bone cements with and without superficial vancomycin coating (SVC) in the late phase of polymerization.

INTRODUCTION: Antibiotic-loaded bone cements (ALBCs) are used as spacers in two-stage revision arthroplasty for periprosthetic joint infection. We previously described a new technique applying vancomycin powder coating to custom-made cements. To our best knowledge, this method of superficial vancomycin coating (SVC) has not been assessed before. We therefore performed an in-vitro study to determine: (1) whether manually applied SVC strengthened the cements' antibiotic effect; and (2) whether the mechanical requirements for the cements were fulfilled. HYPOTHESIS: SVC increases the antibiotic effect of cement within the first 24hours. METHODS: Cuboid blocks were produced from two commercially available acrylic ALBCs (Palacos R+G and Copal G+V) with and without SVC. Each block was eluted in phosphate-buffered saline at 37°C. Eluates obtained at 1, 2, 3, 4, 5, 10, 15, 30 and 60minutes and 3, 6 and 24hours were evaluated against Staphylococcus aureus (Palacos, Copal) and methicillin-resistant Staphylococcus aureus (MRSA) (Copal) using zone of inhibition tests. Mechanical test results (bending modulus, bending strength) were compared to ISO requirements (≥1800MPa, ≥50MPa). RESULTS: Palacos with SVC produced significantly greater zones of inhibition against Staphylococcus aureus than Palacos without SVC (p=0.002). Copal with SVC showed greater zones of inhibition against both Staphylococcus aureus and MRSA (p=0.002). The antibiotic effect was enhanced by SVC in both cements at every time point within 24hours. The bending modulus and bending strength of Palacos with SVC (2089±166MPa, 60.8±2.6 MPA) and Copal with SVC (2283±195MPa, 56.9±2.4MPa) were significantly above ISO requirements. CONCLUSION: SVC boosts the antibiotic effect of ALBCs in the first 24hours, while maintaining sufficient stability. These findings endorse SVC as a promising additive in septic revision surgery. LEVEL OF EVIDENCE: III; case control study.

Multiple liver perforations: complication of an outpatient liposuction procedure.

We report on a 29-year-old woman who presented with abdominal right upper quadrant pain after an outpatient liposuction procedure. A contrast-enhanced computed tomography scan revealed 4 hepatic perforation tracts with subcapsular liver hematoma and hematoperitoneum. The patient was treated by intravenous tranexamic acid and isotonic fluids and monitored on an intensive care unit. No intervention or surgery was necessary during her hospital stay. Follow-up imaging after 3 days using contrast-enhanced ultrasound still showed the perforation tracts in the liver but no expansion of subcapsular hematoma. After 7 days, the patient was discharged home with stable hemoglobin and reduced pain. Liver perforation is a rare complication of liposuction procedures. In patients with abdominal pain after liposuction, contrast-enhanced imaging studies should be performed to identify and characterize solid organ injury. Teams with expertise in angiography and visceral surgery need to be on standby.

Contrast-enhanced ultrasound (CEUS) reliably rules out neoplasm in developmental renal pseudotumor.

BACKGROUND: Renal pseudotumors appear as benign cortical hypertrophies and are typically assessed by contrast-enhanced computed tomography or magnetic resonance imaging to rule out malignancy. PURPOSE: To investigate whether contrast-enhanced ultrasound (CEUS) can rule out renal neoplasm and thus potentially reduce cross-sectional imaging and further follow-up in these patients. MATERIAL AND METHODS: Thirty-two patients with presumption of developmental renal pseudotumor on CEUS between June 2011 and July 2019 were retrospectively analyzed. All patients were examined with a standardized renal US protocol including B-mode, color-coded duplex sonography (CCDS), and CEUS by an experienced radiologist (EFSUMB level 3). Images were retrospectively interpreted in consensus by two highly experienced radiologists. Histopathological reports, cross-sectional imaging findings, and clinical course (treatment response, long-term imaging follow-up) were defined as standard of reference. RESULTS: CEUS correctly identified 8/9 neoplastic lesions and missed one oncocytoma within the 32 included patients. Irregular vessel structure (88.9% vs. 13.0%, P = 0.007) and hyperenhancement (66.6% vs. 17.4%, P = 0.031) on CEUS were more common in neoplasm compared to developmental pseudotumors reaching statistical significance. Compared with the standard of reference, CEUS had 89% sensitivity (95% confidence interval [CI] 57-98), 96% specificity (95% CI 80-99), a positive predictive value of 89% (95% CI 57-98), and a negative predictive value of 96% (95% CI 79-99) for ruling out renal malignancy in developmental pseudotumors. CONCLUSION: CEUS is a safe and fast method to rule out neoplasm in the diagnostic work-up of renal pseudotumors. In conjunction with B-mode and CCDS, CEUS has the potential to reduce further (invasive) diagnostic procedures.