Radiologists' Rating for Comparative Qualitative Assessment of Intravoxel Incoherent Motion Using Novel Analysis Methods.

OBJECTIVE: The objective was to assess qualitative interpretability and quantitative precision and reproducibility of intravoxel incoherent motion ( IVIM) parametric images evaluated using novel IVIM analysis methods for diagnostic accuracy. METHODS: Intravoxel incoherent motion datasets of 55 patients (male/female = 41:14; age = 17.8 ± 5.5 years) with histopathology-proven osteosarcoma were analyzed. Intravoxel incoherent motion parameters-diffusion coefficient ( D ), perfusion fraction ( f ), and perfusion coefficient ( D* )-were estimated using 5 IVIM analysis methods-(i) biexponential (BE) model, (ii) BE-segmented fitting 2-parameter (BESeg-2), (iii) BE-segmented fitting 1-parameter (BESeg-1), (iv) BE model with total variation penalty function (BE + TV), and (v) BE model with Huber penalty function (BE + HPF). Qualitative scoring in a 5-point Likert scale (uninterpretable: 1; poor: 2; fair: 3; good: 4; excellent: 5) was performed by 2 radiologists for 4 criteria: (a) tumor shape and margin, (b) morphologic correlation, (c) noise suppression, and (d) overall interpretability. Interobserver agreement was evaluated using Spearman rank-order correlation ( rs ). Precision and reproducibility were evaluated using within-subject coefficient of variation (wCV) and between-subject coefficient of variation (bCV). RESULTS: BE + TV and BE + HPF produced significantly ( P < 10 -3 ) higher qualitative scores for D (fair-good [3.3-3.8]) than BE (poor [2.3]) and for D* (poor-fair [2.2-2.7]) and f (fair-good [3.2-3.8]) than BE, BESeg-2, and BESeg-1 ( D* : uninterpretable-poor [1.3-1.9] and f : poor-fair [1.5-3]). Interobserver agreement for qualitative scoring was rs = 0.48-0.59, P < 0.009. BE + TV and BE + HPF showed significantly ( P < 0.05) improved reproducibility in estimating D (wCV: 24%-31%, bCV: 21%-31% improvement) than the BE method and D* (wCV: 4%-19%, bCV: 5%-19% improvement) and f (wCV: 25%-49%, bCV: 25%-47% improvement) than BE, BESeg-2, and BESeg-1 methods. CONCLUSIONS: BE + TV and BE + HPF demonstrated qualitatively and quantitatively improved IVIM parameter estimation and may be considered for clinical use further.

Limb salvage of an infant with infantile fibrosarcoma using TRK inhibitor larotrectinib.

Infantile fibrosarcoma (IFS) is an extremely rare locally aggressive soft tissue tumour of childhood. Primary therapy involves complete surgical resection with or without chemotherapy. However complete surgical resection might not be feasible in all cases and so requires other modalities for further management. We report the case of a male infant from Bangladesh with a locally advanced IFS of the leg which was partially resected. The patient received adjuvant chemotherapy which was complicated by the development of chemotherapy-related veno-occlusive disease and had to be discontinued. Thereafter he was referred to our dedicated sarcoma oncology clinic in India for further management. The parents of the child refused amputation of the limb. The tumour tested positive for NTRK3-ETV6 gene fusion and after discussion in multidisciplinary clinic, targeted therapy using oral NTRK inhibitor larotrectinib was started. The patient had complete response at the end of 8 months of treatment with larotrectinib. This is the first report from the Indian subcontinent and we encourage that these children should be referred to specialist clinics for appropriate multidisciplinary management for best outcomes.

Mesenteric lipoblastomatosis: an uncommon fat-containing childhood tumour diagnosed on imaging.

Lipoblastomatosis of mesentery is an extremely rare benign fat-containing mesenchymal tumour in infants and young children. On imaging, it appears as a solid infiltrating mass interspersed with macroscopic fat. We describe the distinctive imaging features of a large mesenteric Lipoblastomatosis, corroborated with intraoperative and histopathological features. We hope the case report and short review about this rare entity will increase the diagnostic confidence of reading radiologists while formulating differentials for lesions of similar appearance in the paediatric age group.

Windsock or Cobra Head Sign: A Distinctive Imaging Sign to Differentiate Type 1 Colonic Atresia From Hirschsprung's Disease.

Colonic atresia is a rare cause of congenital low-type intestinal obstruction in the neonatal age group and may present as a surgical emergency if not diagnosed early. Clinically, it can pose a diagnostic dilemma for Hirschsprung disease, which involves a different treatment strategy. Therefore, an early and accurate diagnosis is paramount from a management and prognosis perspective. The contrast enema plays a crucial role in the diagnosis of the disease. The "Windsock or Cobra head sign" on the contrast enema, typically seen only in type 1 colonic atresia, can help radiologists and surgeons identify this disease. We report a case of a two-day-old neonate, including a clinical feature of low-grade intestinal obstruction with distinctive imaging signs of type 1 colonic atresia, which can help make a definitive diagnosis.

Posttraumatic Corpus Luteal Cyst Rupture: A Diagnostic Enigma for Massive Hemoperitoneum.

In the case of trauma, the presence of free fluid in the abdominal cavity on the focused assessment with sonography for trauma scan usually indicates the possibility of hemoperitoneum caused by injury to the abdominal organs. However, on rare occasions, isolated injuries to gynecologic organs can also result in hemoperitoneum, especially among women of reproductive age. Thus, the rupture of a corpus luteal cyst may be one of the myriad causes of massive hemoperitoneum and carries a risk of misdiagnosis for patients with trauma. In this case report, we highlight the characteristic imaging findings of a case of apoplexy of the corpus luteum cyst that presented to the emergency department as a cause of massive hemoperitoneum after blunt abdominal trauma.

Respiratory triggered diffusion-weighted imaging with a single diffusion sensitising gradient to reduce image acquisition time - A feasibility study in the workup of hepatocellular carcinoma.

PURPOSE: We evaluated respiratory triggered unidirectional single-shot echo-planar imaging (u-SSEPI) as a time-saving measure in diffusion imaging of the upper abdomen. Specifically, we compared the ADC values obtained from unidirectional DWI (u-SSEPI) and routine DWI (4t-SSEPI) and also the diagnostic accuracies of unidirectional and routine DWI sequences in the identification of focal liver lesions in the setting of chronic liver disease (CLD). MATERIALS AND METHODS: This prospective, IRB approved study, included 48 patients of CLD who underwent-DCE-MRI on a 1.5 T scanner for hepatocellular carcinoma (HCC) workup. In addition to 4t-SSEPI, u-SSEPI was acquired with the diffusion sensitising gradient being applied in only one direction; keeping all other parameters same as 4t-SSEPI. Two blinded radiologists evaluated the DWI studies for image quality and detection of liver lesions. A composite gold standard was established using DCE-MRI, follow-up imaging and patient clinical details. The apparent diffusion coefficients (ADCs) of the liver, spleen and the lesions were compared between the two sequences. ROC analysis evaluated the diagnostic accuracy of ADC from both the sequences in identifying HCC. RESULTS: Eighty-eight lesions were identified using the composite gold standard. u-SSEPI resulted in 3 times faster image acquisition. No statistically significant differences were demonstrated between the unidirectional and routine DWI sequences for image quality parameters and lesion detection rates. Lesion wise comparison of the ADC values from both the sequences was not statistically different (p = 0.8) with a coefficient of variation = 12-14 %. The Bland- Altman plots and the Passing-Bablock regression analysis demonstrated a systematic and proportional bias between the ADC values obtained. The AUC of the ROC curve, however, was 0.63-observer1; 0.62-oobserver2 for routine DWI and 0.65; 0.62 for unidirectional DWI when ADC was used to identify HCC (the AUCs were not statistically different (p =  0.6-0.8)). CONCLUSION: No significant differences were demonstrated in the diagnostic accuracies of unidirectional and routine DWI in the diagnosis of HCC. Unidirectional diffusion may be further evaluated in other organs where diffusion is isotropic, especially in respiratory triggered sequences where the imaging time dividend is significant.

Innovation in Community Psychiatry for the Delivery of Mental Health Services: The Sawangi Model.

Objectives Can undergraduate medical students (UGs) adopt a village model to identify mentally ill persons in an adopted village successfully? Materials and Methods UGs during their first year adopt a village, and each student adopts seven families in the villages. During the visit, they look after immunization, tobacco and alcohol abuse, nutrition, hygiene, and sanitation. They help in identifying the health needs (including mental health) of the adopted family. The Indian Psychiatric Survey Schedule containing 15 questions covering most of the psychiatric illnesses were used by UGs to identify mental illness in the community. Persons identified as suffering from mental illness were referred to a consultant psychiatrist for confirmation of diagnosis and further management. Statistical Analysis Calculated by percentage of expected mentally ill persons based on prevalence of mental illness in the rural community and is compared with actual number of patients with mental illness identified by the UGs. True-positive, false-positive, and true predictive values were derived. Results In Umri village, UGs were able to identify 269 persons as true positives and 25 as false positives, whereas in Kurzadi village, UGs were able to identify 221 persons as true positives and 35 as false positives. It suggests UGs were able to identify mental illnesses with a good positive predictive value. In Umri village, out of 294 mentally ill patients, it gave a true positive value of 91.49% and a false positive value of 8.5%, whereas in Kurzadi village, out of the 256 mentally ill patients, it gave a true positive value of 86.3% and a false positive value of 13.67%. Conclusion The ratio of psychiatrists in India is approximately 0.30 per 100,000 population due to which psychiatrists alone cannot cover the mental health problems of India. Therefore, we need a different model to cover mental illness in India, which is discussed in this article.

Automatic segmentation and RECIST score evaluation in osteosarcoma using diffusion MRI: A computer aided system process.

PURPOSE: Accuracy and consistency in RECIST (Response evaluation criteria in solid tumors) measurements are crucial for treatment planning. Manual RECIST measurement is tedious, prone-to-error and operator-subjective. Objective was to develop a fully automated system for tumor segmentation and RECIST score estimation with reasonable accuracy, consistency and speed. METHODS: Diffusion weight images (DWI) of forty patients (N = 40; Male:Female = 30:10; Age = 17.7 ±â€¯5.9years) with Osteosarcoma was acquired using 1.5 T MRI scanner before (baseline) and after neoadjuvant chemotherapy (follow-up). 3D tumor volume was segmented applying Simple-linear-iterative-clustering Superpixels (SLIC-S) and Fuzzy-c-means-clustering (FCM) separately. Connected-component-analysis was performed to identify image-slice with maximum tumor-burden (Max-burden-sliceno) and measure tumor-sizes (Tumor-diameter(cm) & Tumor-volume(cc)). Relative-percentage-changes in tumor-sizes across time-points were scored using RECIST1.1 and Volumetric-response criterion. Segmentation accuracy was estimated by Dice-coefficient (DC), Jaccard-Index (JI), Precision (P) and Recall (R). Evaluated Apparent-diffusion-coefficient (ADC), Tumor-diameter, Max-burden-sliceno and Tumor-volume in segmented tumor-mask and ground-truth tumor-mask were compared using paired-t-test (p < 0.05), Pearson-correlation-coefficient(PCC) and Bland-Altman plots. Misclassification-error-rate (MER) was evaluated for automated RECIST1.1 and Volumetric-response scoring methods. RESULTS: Automated SLIC-S and FCM produced satisfactory tumor segmentation (DC:∼70-83%;JI:∼55-72%;P:∼64-85%;R:∼73-83%) and showed excellent correlation with ground-truth measurements in estimating ADC (p > 0.05; PCC=0.84-0.89), Tumor-diameters (p > 0.05; PCC=0.90-0.95; bias=0.3-2.41), Max-burden-sliceno (p > 0.05; PCC=0.87-0.96) and Tumor-volumes (p > 0.05; PCC=0.89-0.94; bias=15.19-131.81) at baseline and follow-up. MER for SLIC-S and FCM were comparable for RECIST1.1 (15-18 %) and Volumetric-response (18-20 %) scores and assessment times were 2-3s and 4-6s per patient respectively. CONCLUSIONS: Proposed method produced promising segmentation and RECIST score measurements in current bone tumor dataset and might be useful as decision-support-tool for response evaluation in other tumors.

Spine radiograph in dysplasias: A pictorial essay.

Spine radiograph is an essential component of a skeletal survey. It provides important diagnostic clues to various types of skeletal dysplasia. In some conditions, a spine radiograph alone may be diagnostic and characteristic; but mostly, it yields more value as a part of the complete skeletal survey. In this article we will discuss about a few common lethal and non-lethal skeletal dysplasias and their characteristic imaging findings; primarily focusing on the spine radiograph.

Percutaneous Management of Persistent Urine Leak After Partial Nephrectomy: Sealing the Leak Site with Glue.

Background: Localized urinary extravasation is a known complication after partial nephrectomy; however, rarely it forms a nephrocutaneous fistula. Nephrocutaneous fistula after partial nephrectomy is a management challenge for the treating surgeon. It is typically managed with indwelling ureteral stent placement. Persistent fistula after indwelling ureteral stent can be managed with percutaneous nephrostomy drainage. However, persistence after all these measures is a real therapeutic dilemma. Few reports are available on effective management of persistent urine leak by percutaneous obliteration of leak site using glue. Case Presentation: We report one such rare case of persistent nephrocutaneous fistula in a 41-year-old man of Indo-Aryan ethnicity. He was managed effectively with percutaneous cyanoacrylate glue application, when all the conservative methods failed. At 6 months follow-up he is doing well clinically and radiologically. Conclusion: Persistent nephrocutaneous fistula after partial nephrectomy is a rare and highly morbid condition, which leads to multiple intervention and prolonged hospital stay. Percutaneous glue application is a potential therapeutic approach to tackle such cases with good results.

Solid variant ABC of long tubular bones: A diagnostic conundrum for the radiologist.

Solid variant of aneurysmal bone cyst (sABC) is an extremely rare, reactive and non-neoplastic osseous lesion. On imaging it presents as a diaphyseal aggressive, eccentrically placed lytic and expansile lesion. However, differentiating this entity from the other possible malignant differentials is confounded by the histopathology mimicking several commoner lesions. We describe the distinctive MRI features of sABC of long bones from a series of four cases and briefly review the literature. We hope this review will educate all radiologists about this rare entity increasing their diagnostic confidence while formulating differentials for similar appearing lesions.

Synthesis, characterization, and supramolecular architectures of two distinct classes of probes for the visualization of endogenously generated hypochlorite ions in response to cellular activity.

Two distinct classes of compounds, (E)-2-(((3-amino-4-nitrophenyl) imino) methyl)-5-(diethylamino) phenol (SB) and 5-(diethylamino)-2-(5-nitro-1H-benzo[d]imidazol-2-yl) phenol (IM) were synthesized. SB, a bright red colored compound was crystallized in acetonitrile as a triclinic crystal system while IM, yellow colored compound crystallized as a monoclinic crystal system in dimethylformamide by vapor diffusion of diethylether. These compounds were characterized using spectroscopic techniques (IR, UV-visible, 1H, and 13C NMR), and X-ray crystallography. SB and IM displayed classical and non-classical H-bonding involving C-H…O and π…π interactions. These compounds detected hypochlorite ions in aqueous DMSO (1: 9, v/v, HEPES buffer, pH 7.4), and detection was visible via color changes by naked eye. We also performed UV-visible and fluorescence titrations, showing detection limits of 8.82 × 10-7 M for SB and 2.44 × 10-7 M for IM. The fluorometric responses from SB and IM were also studied against different ROS and anions. DFT calculations were performed to strengthen the proposed sensing mechanisms of both SB and IM. Hypochlorite, which is endogenously generated by myeloperoxidase in endosomes, was specifically visualized using SB and IM in lipopolysaccharide-treated RAW264.7 cells. These probes were also used to image the generation of hypochlorite by RAW264.7 cells during phagocytosis of non-fluorescent polystyrene beads.

The Role of Crush Cytology in the Diagnosis of Large-Intestine Lesions with Correlation on Histopathology.

OBJECTIVE: To study the efficacy of colonoscopic crush cytology as a convenient and near-accurate method to evaluate colonic neoplasms. STUDY DESIGN: Retrospective and cross-sectional. The original cytologic diagnoses were correlated with a histology report on 100 cases sent to the cytology laboratory over 2 years. RESULTS: Of the 100 cases, 25 were nonmalignant. Of the 75 malignant lesions, 72 could be identified as positive for malignancy on cytology. The false-positives consisted of 6 adenomas and 1 case of ulcerative colitis. Thus, sensitivity and specificity of cytology are 96 and 63.2%, respectively. Of the 6 adenomas diagnosed as malignant, 4 showed high-grade dysplasia, and the other 2 showed superficial ulceration with low-grade dysplasia on histopathology. The ulcerative colitis case showed widespread ulcers and regenerative/reparative features on biopsy. The 3 adenocarcinomas diagnosed s benign on cytology showed an occasional malignant cell with thickened nuclear borders and prominent central nucleoli. CONCLUSIONS: With careful attention to the cytomorphology, coupled with good clinical and endoscopic correlation, crush cytology of the large intestine is a reliable diagnostic tool. It categorizes lesions as malignant and benign with a high sensitivity, positive predictive value, and negative predictive value. Adenomas and reparative/regenerative changes seen in inflammatory bowel disease are major pitfalls in the cytology diagnosis of malignancy that may be averted by informing the endoscopic findings and clinical history. Cytology diagnosis saves time and gives proper feedback to the gastroenterologist.