Imaging after Pancreatic Surgery: Expected Findings and Postoperative Complications.

Pancreatic surgery is considered one of the most technically challenging surgical procedures, despite the evolution of modern techniques. Neoplasms remain the most common indication for pancreatic surgery, although inflammatory conditions may also prompt surgical evaluation. The choice of surgical procedure depends on the type and location of the pathologic finding because different parts of the pancreas have separate vascular supplies that may be shared by adjacent organs. The surgical approach could be conventional or minimally invasive (laparoscopic, endoscopic, or robotic assisted). Because of the anatomic complexity of the pancreatic bed, perioperative complications may be frequently encountered and commonly involve the pancreatic-biliary, vascular, lymphatic, or bowel systems, irrespective of the surgical technique used. Imaging plays an important role in the assessment of suspected postoperative complications, with CT considered the primary imaging modality, while MRI, digital subtraction angiography, and molecular imaging are considered ancillary diagnostic tools. Accurate diagnosis of postoperative complications requires a solid understanding of pancreatic anatomy, surgical indications, normal postoperative appearance, and expected postsurgical changes. The practicing radiologist should be familiar with the most common perioperative complications, such as anastomotic leak, abscess, and hemorrhage, and be able to differentiate these entities from normal anticipated postoperative changes such as seroma, edema and fat stranding at the surgical site, and perivascular soft-tissue thickening. In addition to evaluation of the primary operative fossa, imaging plays a fundamental role in assessment of the adjacent organ systems secondarily affected after pancreatic surgery, such as vascular, biliary, and enteric complications. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the supplemental material. See the invited commentary by Winslow in this issue.

Accuracy of the American College of Surgeons Minimum Criteria for Full Trauma Team Activation for Children.

OBJECTIVE: Pediatric trauma centers use reports from emergency medical service providers to determine if a trauma team should be sent to the emergency department to prepare to care for the patient. Little scientific evidence supports the current American College of Surgeons (ACS) indicators for trauma team activation. The objective of this study was to determine the accuracy of the ACS Minimum Criteria for Full Trauma Team Activation for children as well as the accuracy of the modified criteria used at the local sites for trauma activation. METHODS: Emergency medical service providers who transported an injured child aged 15 years or younger to a pediatric trauma center in 1 of 3 cities were interviewed after emergency department arrival. Emergency medical service providers were asked if each of the activation indicators were present based on their evaluation. The need for full trauma team activation was determined through a medical record review using a published criterion standard definition. Undertriage and overtriage rates and positive likelihood ratios (+LRs) were calculated. RESULTS: Emergency medical service provider interviews were conducted and outcome data were obtained for 9483 children. There were 202 (2.1%) cases that met the criterion standard for need for trauma team activation. Based on the ACS Minimum Criteria, 299 (3.0%) cases should have received a trauma activation. The ACS Minimum Criteria undertriaged 44.1% and overtriaged 20% (+LR, 27.9; 95% confidence interval, 23.1-33.7). Based on the actual activation status using the local criteria, 238 cases received a full trauma activation, 45% were undertriaged, and 1.4% were overtriaged (+LR, 40.1; 95% confidence interval, 32.4-49.7). There was 97% agreement between the ACS Minimum Criteria and the actual local activation status at the receiving institution. CONCLUSIONS: The ACS Minimum Criteria for Full Trauma Team Activation for children have a high rate of undertriage. Changes that individual institutions have made to improve the accuracy of activations at their institutions seem to have had a limited effect on decreasing undertriage.

The effect of formulation composition and adjuvant type on difenoconazole dislodgeable foliar residue.

Rigorous risk assessments for those exposed to pesticides are carried out to satisfy crop protection regulatory requirements. Non-dietary risk assessments involve estimating the amount of residue which can be transferred from plant foliage to the skin or clothes, known as dislodgeable foliar residues (DFRs). DFR data are less available than crop residue data as studies are costly and limited by seasonality. European regulatory authorities are reticent to allow extrapolation of study data to different scenarios as the contributory factors have hitherto been poorly identified. This study is the first to use a new laboratory DFR method to investigate how one such factor, pesticide formulation, may affect DFR on a variety of crops. The study used the active substance difenoconazole as both an emulsifiable concentrate (EC 10%) and a wettable powder (WP 10%) with and without adjuvants (Tween 20 and organophosphate tris(2-ethylhexyl)phosphate TEHP) on tomato, French bean and oilseed rape. A comparable DFR% was retained from the WP and EC formulation on most crops except for tomato, where lower DFR% was retained in the case of WP (39 ± 4.7%) compared to EC (60 ± 1.2%). No significant effect of adjuvant addition was observed for either formulation except when mixing TEHP (0.1% w/v) to the EC 10% on French bean, resulting in 8% DFR reduction compared to the EC formulation alone. This research demonstrates the value of a unique DFR laboratory technique in investigating the importance of the formulation and in-tank adjuvants as factors that affect DFR.

Effect of urea-treated rice straw, mixed with faba bean straw, on nutrient digestibility, blood metabolites and performance of growing lambs.

The present study aimed to use poor quality roughages, such as rice and faba bean straw, treated with or without urea, and their impacts on digestibility, rumen fermentation, some blood parameters, and growth performance of lambs. Twenty crossbred male lambs (1/4 Finland ×¾ Ossimi, 25±1.13kg live body weight) were chosen and divided into four groups. All lambs were fed rations of concentrated feed mixture at 2% of live weight with the following roughages ad libitum: URS (control group, untreated rice straw), TRS (urea-treated rice straw), FBS (faba bean straw), and TRS+FBS (mixture of TRS and FBS, 1:1). Nutrient digestibility and feeding values improved (P<0.05) with TRS+FBS lambs versus FBS, TRS and URS lambs. The highest numerical values of ruminal total volatile fatty acid (VFA) concentration in TRS lambs were recorded 23.9 ml.eq/dl followed by TRS+FBS, URS and FBS. Regarding to the ruminal parameters, there were no differences (P>0.05) among evaluated groups except for NH3-N, the highest concentration (P<0.05) was recorded in TRS lambs at 3 h post-feeding. Lambs of TRS, FBS and TRS+FBS showed faster growth (P<0.05) than those of the control (i.e., URS). Intakes of dry matter, total digestible nutrients, and digestible crude protein were numerically increased for TRS, FBS, and TRS+FBS. Feed conversion, as kg dry matter/kg gain, was improved for TRS, FBS, and TRS+FBS lambs versus URS. Daily gain of lambs increased (P<0.05) with lambs of TRS, FBS, and TRS+FBS but URS lambs showed a decrease (P<0.05) in daily gain. Feed conversion as kg dry matter intake/kg gain was improved (P<0.05) by feeding on TRS, FBS and TRS+FBS rations versus URS. The TRS+FBS lambs tended to have the highest economic efficiency versus URS, TRS and FBS lambs. It was concluded that urea-treated rice straw could be used as sole roughage or mixed with faba bean straw (1:1) in growing lambs' ration to improve their performance and economic efficiency without adversely affecting their health.The present study aimed to use poor quality roughages, such as rice and faba bean straw, treated with or without urea, and their impacts on digestibility, rumen fermentation, some blood parameters, and growth performance of lambs. Twenty crossbred male lambs (1/4 Finland ×¾ Ossimi, 25±1.13kg live body weight) were chosen and divided into four groups. All lambs were fed rations of concentrated feed mixture at 2% of live weight with the following roughages ad libitum: URS (control group, untreated rice straw), TRS (urea-treated rice straw), FBS (faba bean straw), and TRS+FBS (mixture of TRS and FBS, 1:1). Nutrient digestibility and feeding values improved (P<0.05) with TRS+FBS lambs versus FBS, TRS and URS lambs. The highest numerical values of ruminal total volatile fatty acid (VFA) concentration in TRS lambs were recorded 23.9 ml.eq/dl followed by TRS+FBS, URS and FBS. Regarding to the ruminal parameters, there were no differences (P>0.05) among evaluated groups except for NH3-N, the highest concentration (P<0.05) was recorded in TRS lambs at 3 h post-feeding. Lambs of TRS, FBS and TRS+FBS showed faster growth (P<0.05) than those of the control (i.e., URS). Intakes of dry matter, total digestible nutrients, and digestible crude protein were numerically increased for TRS, FBS, and TRS+FBS. Feed conversion, as kg dry matter/kg gain, was improved for TRS, FBS, and TRS+FBS lambs versus URS. Daily gain of lambs increased (P<0.05) with lambs of TRS, FBS, and TRS+FBS but URS lambs showed a decrease (P<0.05) in daily gain. Feed conversion as kg dry matter intake/kg gain was improved (P<0.05) by feeding on TRS, FBS and TRS+FBS rations versus URS. The TRS+FBS lambs tended to have the highest economic efficiency versus URS, TRS and FBS lambs. It was concluded that urea-treated rice straw could be used as sole roughage or mixed with faba bean straw (1:1) in growing lambs' ration to improve their performance and economic efficiency without adversely affecting their health.

Prevalence of Malignancy in Adrenal Nodules With Heterogeneous Microscopic Fat on Chemical-Shift MRI: A Multiinstitutional Study.

BACKGROUND. Homogeneous microscopic fat within adrenal nodules on chemical-shift MRI (CS-MRI) is diagnostic of benign adrenal adenoma, but the clinical relevance of heterogeneous microscopic fat is not well established. OBJECTIVE. This study sought to determine the prevalence of malignancy in adrenal nodules with heterogeneous microscopic fat on dual-echo T1-weighted CS-MRI. METHODS. We performed a retrospective study of adult patients with adrenal nodules detected on MRI performed between August 2007 and November 2020 at seven institutions. Eligible nodules had a short-axis diameter of 10 mm or larger with heterogeneous microscopic fat (defined by an area of signal loss of < 80% on opposed-phase CS-MRI). Two radiologists from each center, blinded to reference standard results, determined the signal loss pattern (diffuse, two distinct parts, speckling pattern, central loss, or peripheral loss) within the nodules. The reference standard used was available for 283 nodules (pathology for 21 nodules, ≥ 1 year of imaging follow-up for 245, and ≥ 5 years of clinical follow-up for 17) in 282 patients (171 women and 111 men; mean age, 60 ± 12 [SD] years); 30% (86/282) patients had prior malignancy. RESULTS. The mean long-axis diameter was 18.7 ± 7.9 mm (range, 10-80 mm). No malignant nodules were found in patients without prior cancer (0/197; 95% CI, 0-1.5%). Four of the 86 patients with prior malignancy (hepatocellular carcinoma [HCC], renal cell carcinoma [RCC], lung cancer, or both colon cancer and RCC) (4.7%; 95% CI, 1.3-11.5%) had metastatic nodules. Detected patterns were diffuse heterogeneous signal loss (40% [114/283]), speckling (28% [80/283]), two distinct parts (18% [51/283]), central loss (9% [26/283]), and peripheral loss (4% [12/283]). Two metastases from HCC and RCC showed diffuse heterogeneous signal loss. Lung cancer metastasis manifested as two distinct parts, and the metastasis in the patient with both colon cancer and RCC showed peripheral signal loss. CONCLUSION. Presence of heterogeneous microscopic fat in adrenal nodules on CS-MRI indicates a high likelihood of benignancy, particularly in patients without prior cancer. This finding is also commonly benign in patients with cancer; however, caution is warranted when primary malignancies may contain fat or if the morphologic pattern of signal loss may indicate a collision tumor. CLINICAL IMPACT. In the absence of prior cancer, adrenal nodules with heterogeneous microscopic fat do not require additional imaging evaluation.

Paraneoplastic Syndromes from Head to Toe: Pathophysiology, Imaging Features, and Workup.

Patients often have symptoms due to the mass effect of a neoplasm on surrounding tissues or the development of distant metastases. However, some patients may present with clinical symptoms that are not attributable to direct tumor invasion. In particular, certain tumors may release substances such as hormones or cytokines or trigger an immune cross-reactivity between malignant and normal body cells, resulting in characteristic clinical features that are broadly referred to as paraneoplastic syndromes (PNSs). Recent advances in medicine have improved the understanding of the pathogenesis of PNSs and enhanced their diagnosis and treatment. It is estimated that 8% of patients with cancer develop a PNS. Diverse organ systems may be involved, most notably the neurologic, musculoskeletal, endocrinologic, dermatologic, gastrointestinal, and cardiovascular systems. Knowledge of various PNSs is necessary, as these syndromes may precede tumor development, complicate the patient's clinical presentation, indicate tumor prognosis, or be mistaken for metastatic spread. Radiologists should be familiar with the clinical presentations of common PNSs and the selection of appropriate imaging examinations. Many of these PNSs have imaging features that can assist with arriving at the correct diagnosis. Therefore, the key radiographic findings associated with these PNSs and the diagnostic pitfalls that can be encountered during imaging are important, as their detection can facilitate early identification of the underlying tumor, reveal early recurrence, and enable monitoring of the patient's response to therapy. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Curcumin-infused nanostructured lipid carriers: a promising strategy for enhancing skin regeneration and combating microbial infection.

BACKGROUND: Curcumin is a biomolecule that can be extracted from the Curcuma longa that has been shown to have the potential to aid skin wound healing. It has been studied for its anti-inflammatory and antioxidant properties, which may help to reduce swelling and promote tissue repair. However, curcumin has low solubility in water, which can limit its absorption and bioavailability. Encapsulating it in lipid nanoparticles may help to increase its absorption, leading to improved bioavailability. METHODS: Curcumin-loaded nanostructure lipid nanocarriers (CURC-NLCs) were prepared and characterized. Also, the phenolic, flavonoid contents, antioxidant and antimicrobial efficacy against gram-positive and gram-negative bacteria were investigated. Furthermore, in vivo rabbit animal model was used to test its regenerative capacity and wound-healing efficiency. RESULTS: The CURC-NLCs significantly increased the content of phenolic and flavonoid compounds compared to curcumin, resulting in a dramatic increase in antioxidant activity. CURC-NLCs also showed a potent inhibitory effect on Gram-positive, Gram-negative, and fungi, two times higher than curcumin. CURC-NLCs showed a higher potential to fasten the wound healing of full-thickness skin injuries as it resulted in 1.15- and 1.9-fold higher wound closure at the first week of injury compared to curcumin and control, respectively (p < 0.0001). CONCLUSION: These results suggest that CURC-NLCs have an excellent potential to promote skin regeneration, which could be attributed to its antioxidant and broad-spectrum antimicrobial effect.

Concerns about stone free rate and procedure events of percutaneous nephrolithotripsy (PCNL) for 2-4 cm kidney stones by standard-PCNL vs mini-PCNL- comparative randomised study.

BACKGROUND: To compare the efficacy and safety of standard percutaneous nephrolithotomy (PCNL) with mini- PCNL for kidney stones 2-4 cm. METHODS: Eighty patients were enrolled in a comparative study, they were randomly divided into mini-PCNL group (n = 40) and standard-PCNL (n = 40). Demographic characteristics, perioperative events, complications, stone free rate (SFR) were reported. RESULTS: Both groups showed no significant difference in clinical data about age, stone location, back pressure changes, and body mass index. The mean operative time was (95 ± 17.9 min) in mini-PCNL, and (72.1 ± 14.9 min). Stone free rate were 80% and 85% in mini-PCNL and standard-PCNL respectively. Intra-operative complications, post-operative need for analgesia, hospital stay were significantly higher in standard-PCNL compared to mini-PCNL (85% vs. 80%). The study followed CONSORT 2010 guidelines for reporting parallel group randomization. CONCLUSION: Mini-PCNL is an effective and safe treatment of kidney stones 2-4 cm, it has the advantage over standard-PCNL being has less intra-operative events, less post-operative analgesia, shorter hospital stay, while operative time and stone free rate are comparable when considering multiplicity, hardness, and site of stones.

Brain Responses to Propofol in Advance of Recovery from Coma and Disorders of Consciousness: A Preliminary Study.

Rationale: Predicting recovery of consciousness in unresponsive, brain-injured individuals has crucial implications for clinical decision-making. Propofol induces distinctive brain network reconfiguration in the healthy brain as it loses consciousness. In patients with disorders of consciousness, the brain network's reconfiguration to propofol may reveal the patient's underlying capacity for consciousness. Objectives: To design and test a new metric for the prognostication of consciousness recovery in disorders of consciousness. Methods: Using a within-subject design, we conducted an anesthetic protocol with concomitant high-density EEG in 12 patients with a disorder of consciousness after a brain injury. We quantified the reconfiguration of EEG network hubs and directed functional connectivity before, during, and after propofol exposure and obtained an index of propofol-induced network reconfiguration: the adaptive reconfiguration index. We compared the index of patients who recovered consciousness 3 months after EEG (n = 3) to that of patients who did not recover or remained in a chronic disorder of consciousness (n = 7) and conducted a logistic regression to assess prognostic accuracy. Measurements and Main Results: The adaptive reconfiguration index was significantly higher in patients who later recovered full consciousness (U value = 21, P = 0.008) and able to discriminate with 100% accuracy whether the patient recovered consciousness. Conclusions: The adaptive reconfiguration index of patients who recovered from a disorder of consciousness at 3-month follow-up was linearly separable from that of patients who did not recover or remained in a chronic disorder of consciousness on the single-subject level. EEG and propofol can be administered at the bedside with few contraindications, affording the adaptive reconfiguration index tremendous translational potential as a prognostic measure of consciousness recovery in acute clinical settings.

A new laboratory method to study the impact of leaf texture on pesticide dislodgeable foliar residues (DFR).

Pesticides are vital in meeting the challenge of feeding the rapidly increasing world population. However, it is crucial that they are used in a way that does not compromise the safety of humans or the environment. Non-dietary worker risk assessments consider the amount of residue which can be transferred from plant foliage to the skin or clothes, known as dislodgeable foliar residues (DFRs). DFR data scarcity due to the costly and seasonal characteristics of DFR studies is an obstacle to the extrapolation of DFR data to different crops/leaves. This paper validates a new proof-of-concept technique to investigate factors that may affect DFR (leaf texture) using the fungicide difenoconazole EC 10% as an example on various leaves (i.e., French bean, soybean, tomato, oilseed rape, and wheat). DFR was the lowest in the case of oilseed rape (31.0 ± 3.4%) and the highest in French beans (82.0 ± 2.9%). This significant difference in DFR in the findings of this study sheds light on the importance of the leaf surface as a major factor affecting DFR and supports the application of the laboratory method for more extensive data generation. More data generation would enable the extrapolation saving money and resources.

Removal of fenamiphos, imidacloprid, and oxamyl pesticides from water by microalgal Nannochloropsis oculata biomass and their determination by validated HPLC method.

The present study assessed the removal of fenamiphos, imidacloprid, and oxamyl pesticides from water using algal Nannochloropsis oculata biomass. Several factors, such as algal biomass concentration, incubation time, and pesticide concentration, were studied for their impact on pesticide removal. Analysis and quantification of pesticides by rapid HPLC have been developed and validated. The optimum conditions were obtained at 15 min, 50 mg/L of pesticide concentration, and 4,500 mg/L of the algal biomass with 92.24% and 90.43% removal for fenamiphos and imidacloprid, respectively. While optimum parameters of 10 min incubation, 250 mg/L of pesticide concentration, and 2,750 mg/L of the algal biomass exhibited 67.34% removal for oxamyl. N. oculata, marine microalgae, successively removed different concentrations of the tested pesticides from water, and the algal biomass showed a potential reduction of pesticides in polluted water samples.

Effect of acetic acid addition to rice straw pre-treated with urea on performance of dairy ewes.

This experiment was carried out to study the effect of acetic acid addition to rice straws that had been already treated with urea on chemical composition, digestibility, nutritive value, and productive performance of ewes. Thirty ewes with an initial body weight of 44 ± 0.41 kg were chosen 7 days after parturition and divided into 3 groups (10 of each) for 3 months. Each group was assigned randomly to receive one of the three experimental rations composed of concentrate feed mixture and untreated rice straw as a control group (G1), urea-treated rice straw (G2), and urea-acetic acid-treated rice straw (G3). Digestibility coefficients and nutritive value were determined using fifteen mature rams and blood samples were obtained at the end of the collecting period. Findings indicated that the crude protein of rice straw was increased, and crude fiber content was decreased by either urea or urea-acetic acid rations (i.e., G2 and G3). Digestibility of most nutrients was increased (P < 0.05) for animals fed either G2 or G3 rations. There were no significant differences in nutritive value as total digestible nutrients (TDN) among tested groups; however, digestible crude protein (DCP) increased (P < 0.05) for G2 and G3 rations. Plasma total protein, AST, creatinine, and urea were increased (P < 0.05) by feeding on G2 or G3 ration; however, plasma ALT was not affected. The average daily intake of dry matter (DM), TDN, and DCP was higher for G2 and G3 rations. Actual milk yield, fat-corrected milk (FCM), percentages of fat, and total solids and constituents yield were increased (P < 0.05) by feeding on treated rice straw rations (i.e., G2 and G3); however, the percentages of protein, lactose, solids not fat, and ash were not affected. In the 1st month after parturition, the changes in ewes body weight were less (P < 0.05) when they fed on G2 and G3 rations than the control one (G1)). Dams' production and offspring performance were improved (P < 0.05) by feeding on G2 and G3 rations. Feed conversion as kg DMI/kg FCM, kg TDN/kg FCM, and economic efficiency was improved for G2 and G3. In concluded, adding acetic acid to urea-treated rice straw may improve the performance of ewes fed on it and increase their milk production and profitability. The same trend was observed with (G2) which received urea-treated rice straw ration.

Association of Pyuria with Uropathogens in Young Children.

OBJECTIVE: To examine the association between uropathogens and pyuria in children <24 months of age. STUDY DESIGN: A retrospective study of children <24 months of age evaluated in the emergency department for suspected urinary tract infection (UTI) with paired urinalysis and urine culture during a 6-year period. Bagged urine specimens or urine culture growing mixed/multiple urogenital organisms were excluded. Analysis was limited to children with positive urine culture as defined by the American Academy of Pediatrics clinical practice guideline culture thresholds. RESULTS: Of 30 462 children, 1916 had microscopic urinalysis and positive urine culture. Urine was obtained by transurethral in-and-out catheterization in 98.3% of cases. Pyuria (≥5 white blood cells per high-powered field) and positive leukocyte esterase (small or more) on the urine dipstick were present in 1690 (88.2%) and 1692 (88.3%) of the children respectively. Children with non-Escherichia coli species were less likely to exhibit microscopic pyuria than children with E coli (OR 0.24, 95% CI 0.17-0.34) with more pronounced effect on Enterococcus and Klebsiella (OR 0.08, 95% CI 0.03-0.18 and OR 0.18, 95% CI 0.11-0.27 respectively). Similarly, positive leukocyte esterase was less frequently seen in non-E coli uropathogens compared with E coli. CONCLUSIONS: Pyuria and leukocyte esterase are not sensitive markers to identify non-E coli UTI in young children. More sensitive screening biomarkers are needed to identify UTI with these uropathogens.

Characteristics and outcomes of ventricular tachycardia and premature ventricular contractions ablation in patients with prior mitral valve surgery.

BACKGROUND: Data regarding ventricular tachycardia (VT) or premature ventricular complex (PVC) ablation following mitral valve surgery (MVS) is limited. Catheter ablation (CA) can be challenging given perivalvular substrate in the setting of mitral annuloplasty or prosthetic valves. OBJECTIVE: To investigate the characteristics, safety, and outcomes of radiofrequency CA in patients with prior MVS and ventricular arrhythmias (VA). METHODS: We identified consecutive patients with prior MVS who underwent CA for VT or PVC between January 2013 and December 2018. We investigated the mechanism of arrhythmia, ablation approach, peri-operative complications, and outcomes. RESULTS: In our cohort, 31 patients (77% men, mean age 62.3 ± 10.8 years, left ventricular ejection fraction 39.2 ± 13.9%) with prior MVS underwent CA (16 VT; 15 PVC). Access to the left ventricle was via transseptal approach in 17 patients, and a retrograde aortic approach was used in 13 patients. A combined transseptal and retrograde aortic approach was used in one patient, and a percutaneous epicardial approach was combined with trans-septal approach in one patient. Heterogenous scar regions were present in 94% of VT patients and scar-related reentry was the dominant mechanism of VT. Forty-seven percent of PVC patients had abnormal substrate at the site targeted for ablation. Clinical VA substrates involved the peri-mitral area in six patients with VT and five patients with PVC ablation. No procedure-related complications were reported. The overall recurrence-free rate at 1-year was 72.2%; 67% in the VT group and 78% in the PVC group. No arrhythmia-related death was documented on long-term follow-up. CONCLUSION: CA of VAs can be performed safely and effectively in patients with MVS.

Incidental Adrenal Nodules in Patients Without Known Malignancy: Prevalence of Malignancy and Utility of Washout CT for Characterization-A Multiinstitutional Study.

BACKGROUND. Washout CT is commonly used to evaluate indeterminate adrenal nodules, although its diagnostic performance is poorly established in true adrenal incidentalomas. OBJECTIVE. The purpose of this study was to compare, in patients without a known malignancy history, the prevalence of malignancy for incidental adrenal nodules with unenhanced attenuation more than 10 HU that do and do not show absolute washout of 60% or more, thereby determining the diagnostic performance of washout CT for differentiating benign from malignant incidental adrenal nodules. METHODS. This retrospective six-institution study included 299 patients (mean age, 57.3 years; 180 women, 119 men) without known malignancy or suspicion for functioning adrenal tumor who underwent washout CT, which showed a total of 336 adrenal nodules with a short-axis diameter of 1 cm or more, homogeneity, and unenhanced attenuation over 10 HU. The date of the first CT ranged across institutions from November 1, 2003, to January 1, 2017. Washout was determined for all nodules. Reference standard was pathology (n = 54), imaging follow-up (≥ 1 year) (n = 269), or clinical follow-up (≥ 5 years) (n = 13). RESULTS. Prevalence of malignancy among all nodules, nodules less than 4 cm, and nodules 4 cm or more was 1.5% (5/336; 95% CI, 0.5-3.4%), 0.3% (1/317; 95% CI, 0.0-1.7%), and 21.1% (4/19; 95% CI, 6.1-45.6%), respectively. Prevalence of malignancy was not significantly different for nodules smaller than 4 cm with (0% [0/241]; 95% CI, 0.0-1.2%) and without (1.3% [1/76]; 95% CI, 0.0-7.1%) washout of 60% or more (p = .08) or for nodules 4 cm or larger with (16.7% [1/6]; 95% CI, 0.4-64.1%) and without (23.1% [3/13]; 95% CI, 5.0-53.8%) washout of 60% or more (p = .75). Washout of 60% or more was observed in 75.5% (243/322; 95% CI, 70.4-80.1%) of benign nodules (excluding pheochromocytomas), 20.0% (1/5; 95% CI, 0.5-71.6%) of malignant nodules, and 33.3% (3/9; 95% CI, 7.5-70.1%) of pheochromocytomas. For differentiating benign nodules from malignant nodules and pheochromocytomas, washout of 60% or more had 77.5% sensitivity, 70.0% specificity, 98.8% PPV, and 9.2% NPV among nodules smaller than 4 cm. CONCLUSION. Prevalence of malignancy is low among incidental homogeneous adrenal nodules smaller than 4 cm with unenhanced attenuation more than 10 HU and does not significantly differ between those with and without washout of 60% or more; wash-out of 60% or more has suboptimal performance for characterizing nodules as benign. CLINICAL IMPACT. Washout CT has limited utility in evaluating incidental adrenal nodules in patients without known malignancy.

Manifestations of Sickle Cell Disorder at Abdominal and Pelvic Imaging.

Sickle cell disorder (SCD) refers to a spectrum of hematologic disorders that cause a characteristic clinical syndrome affecting the entire body. It is the most prevalent monogenetic hemoglobinopathy worldwide, with a wide range of focal and systemic expressions. Hemoglobin gene mutation leads to the formation of abnormal sickle-shaped red blood cells, which cause vascular occlusion and result in tissue and organ ischemia and infarction. Recurrent episodes of acute illness lead to progressive multisystem organ damage and dysfunction. Vaso-occlusion, hemolysis, and infection as a result of functional asplenia are at the core of the disease manifestations. Imaging plays an essential role in the diagnosis and management of SCD-related complications in the abdomen and pelvis. A thorough understanding of the key imaging findings of SCD complications involving hepatobiliary, gastrointestinal, genitourinary, and musculoskeletal systems is crucial to timely recognition and accurate diagnosis. The authors aim to familiarize the radiologist with the SCD spectrum, focusing on the detection and evaluation of manifestations that may appear at imaging of the abdomen and pelvis. The topics the authors address include (a) the pathophysiology of the disease, (b) the placement of SCD among hemoglobinopathies, (c) the clinical presentation of SCD, (d) the role of imaging in the evaluation and diagnosis of patients with SCD who present with abdominal and pelvic manifestations in addition to extraperitoneal manifestations detectable at abdominal or pelvic imaging, (e) imaging features associated with common and uncommon sequelae of SCD in abdominal and pelvic imaging studies, and (f) a brief overview of management and treatment of patients with SCD. Online supplemental material is available for this article. ©RSNA, 2022.

Extraskeletal Ewing Sarcoma from Head to Toe: Multimodality Imaging Review.

Extraskeletal Ewing sarcoma (EES) is a rare subtype in the Ewing sarcoma family of tumors (ESFT), which also includes Ewing sarcoma of bone (ESB) and, more recently, primitive neuroectodermal tumors. Although these tumors often have different manifestations, they are grouped on the basis of common genetic translocation and diagnosis from specific molecular and immunohistochemical features. While the large majority of ESFT cases occur in children and in bones, approximately 25% originate outside the skeleton as EES. Importantly, in the adult population these extraskeletal tumors are more common than ESB. Imaging findings of EES tumors are generally nonspecific, with some variation based on location and the tissues involved. A large tumor with central necrosis that does not cross the midline is typical. Despite often nonspecific findings, imaging plays an important role in the evaluation and management of ESFT, with MRI frequently the preferred imaging modality for primary tumor assessment and local staging. Chest CT and fluorine 18 fluorodeoxyglucose PET/CT are most sensitive for detecting lung and other distant or nodal metastases. Management often involves chemotherapy with local surgical excision, when possible. A multidisciplinary treatment approach should be used given the propensity for large tumor size and local invasion, which can make resection difficult. Despite limited data, outcomes are similar to those of other ESFT cases, with 5-year survival exceeding 80%. However, with metastatic disease, the long-term prognosis is poor. ©RSNA, 2022.

Nonaccidental Injury in the Elderly: What Radiologists Need to Know.

Elder abuse may result in serious physical injuries and long-term psychological consequences and can be life threatening. Over the past decade, attention to elder abuse has increased owing to its high prevalence, with one in six people aged 60 years and older experiencing some form of abuse worldwide. Despite this, the detection and reporting rates remain relatively low. While diagnostic imaging is considered critical in detection of child abuse, it is relatively underused in elder abuse. The authors discuss barriers to use of imaging for investigation and diagnosis of elder abuse, including lack of training, comorbidities present in this vulnerable population, and lack of communication among the intra- and interdisciplinary care providers. Moreover, imaging features that should raise clinical concern for elder abuse are reviewed, including certain types of fractures (eg, posterior rib), characteristic soft-tissue and organ injuries (eg, shoulder dislocation), and cases in which the reported mechanism of injury is inconsistent with the imaging findings. As most findings suggesting elder abuse are initially discovered at radiography and CT, the authors focus mainly on use of those modalities. This review also compares and contrasts elder abuse with child abuse. Empowered with knowledge of elderly victims' risk factors, classic perpetrator characteristics, and correlative imaging findings, radiologists should be able to identify potential abuse in elderly patients presenting for medical attention. Future recommendations for research studies and clinical workflow to increase radiologists' awareness of and participation in elder abuse detection are also presented. An invited commentary by Jubanyik and Gettel is available online. Online supplemental material is available for this article. ©RSNA, 2022.

Effect of Rythmol (propafenone HCl) administration during pregnancy in Wistar rats.

Propafenone is a well-known Class 1C antiarrhythmic agent that has sodium channel blocking properties as well as the ability to block 13 other channels and a modest calcium antagonistic effect. Propafenone has a profound electrophysiologic effect on auxiliary atrioventricular circuits and in patients with atrioventricular nodal reentry tachycardia can obstruct conduction in the fast conducting pathway. Furthermore, propafenone is less likely than other Class 1C drugs to cause proarrhythmia. However, although this medicine can pass through the placenta, the effects during pregnancy remain unknown. Here, we investigated the potential teratogenic and genotoxic effects of Rythmol during rat development. Pregnant Wistar rats received 46.25 mg/kg body weight of propafenone daily by gavage from Gestation Day (GD) 5 to GD 19. At GD 20, the dams were dissected, and their fetuses were assessed via morphologic, skeletal, and histologic investigation. In addition, a comet assay was used to measure DNA impairment of fetal skull osteocytes and hepatic cells. The study showed that propafenone treatment of pregnant rats led to a marked decrease in gravid uterine weight, number of implants/litter, number of viable fetuses, and bodyweight of fetuses but a clear increase in placental weight and placental index in the treated group. Frequent morphologic abnormalities and severe ossification deficiency in the cranium bones were observed in the treatment group. Various histopathological changes were observed in the liver, kidney, and brain tissues of maternally treated fetuses. Similarly, propafenone induced DNA damage to examined samples. Thus, our study indicates that propafenone may be embryotoxic in humans.

Is JJ Ureteral Stenting Inferior to Percutaneous Nephrostomy as a Drainage Method in Emphysematous Pyelonephritis?

INTRODUCTION: The aim of the study was to examine the efficacy of JJ stenting in comparison with percutaneous nephrostomy (PCN) as a drainage method in patients with emphysematous pyelonephritis (EPN). METHODS: We retrospectively identified patients with EPN between January 2000 and January 2021. Platelet-to-leukocytic ratio (PLR) at the time of hospital admission and discharge, time taken to clear air locules and to normalize leukocytic count, and air locule volume in mm3 were identified. Renal drainage by either PCN or JJ stent was required if symptoms persist for ≥3 days or in obstructed renal units. Failure of drainage method was defined as conversion to another method of drainage, need for intensive care unit admission, salvage nephrectomy, and mortality. RESULTS: Twenty-nine patients were managed by JJ stent. Treatment success was identified in 20 patients and 19 patients who were managed by PCN and JJ stent, respectively. Higher air locule volume ≥16.7 mm3 and lower PLR ≤18.4 increased the risk of drainage failure (p = 0.009 and 0.001, respectively). CONCLUSION: Ureteral JJ stenting is an effective method for EPN drainage with a comparable overall success to the PCN use. Higher air locule volume and lower PLR increased the risk of drainage failure.