Ultra-low-dose thoracic CT with model-based iterative reconstruction (MBIR) in cystic fibrosis patients undergoing treatment with cystic fibrosis transmembrane conductance regulators (CFTR).

AIM: To assess the utility of a volumetric low-dose computed tomography (CT) thorax (LDCTT) protocol at a dose equivalent to a posteroanterior (PA) and lateral chest radiograph for surveillance of cystic fibrosis (CF) patients. MATERIALS AND METHODS: A prospective study was undertaken of 19 adult patients with CF that proceeded to LDCTT at 12 and 24 months following initiation of ivacaftor. A previously validated seven-section, low-dose axial CT protocol was used for the 12-month study. A volumetric LDCTT protocol was developed for the 24-month study and reconstructed with hybrid iterative reconstruction (LD-ASIR) and pure iterative reconstruction (model-based IR [LD-MBIR]). Radiation dose was recorded for each scan. Image quality was assessed quantitatively and qualitatively, and disease severity was assessed using a modified Bhalla score. Statistical analysis was performed and p-values of <0.05 were considered statistically significant. RESULTS: Volumetric LD-MBIR studies were acquired at a lower radiation dose than the seven-section studies (0.08 ± 0.01 versus 0.10 ± 0.02 mSv; p=0.02). LD-MBIR and seven-section ASIR images had significantly lower levels of image noise compared with LD-ASIR images (p<0.0001). Diagnostic acceptability scores and depiction of bronchovascular structures were found to be acceptable for axial and coronal LD-MBIR images. LD-MBIR images were superior to LD-ASIR images for all qualitative parameters assessed (p<0.0001). No significant change was observed in mean Bhalla score between 1-year and 2-year studies (p=0.84). CONCLUSIONS: The use of a volumetric LDCTT protocol (reconstructed with pure IR) enabled acquisition of diagnostic quality CT images, which were considered extremely useful for surveillance of CF patients, at a dose equivalent to a PA and lateral chest radiograph.

Hip pain and cauda equina syndrome.

Acute cauda equina syndrome secondary to a spinal epidural abscess as a result of a psoas abscess is very uncommon. We report the case of a 64-year old with a 6-day history of left hip pain, which progressively worsened until she presented to the emergency department with systemic infective symptoms and classical acute cauda equina syndrome. A good clinical outcome was achieved by urgent posterior decompression, followed by CT-guided drainage of the psoas abscess and appropriate antibiotic treatment.

Clinical and Survival Outcomes Using Percutaneous Cholecystostomy Tube Alone or Subsequent Interval Cholecystectomy to Treat Acute Cholecystitis.

BACKGROUND: Percutaneous cholecystostomy (PCT) is a safe method of gallbladder drainage in the setting of severe or complicated acute cholecystitis (AC), particularly in patients who are high-risk surgical candidates. Small case series suggest that PCT aids resolution of acute cholecystitis in up to 90% of patients. However, reluctance is observed in utilising PCT more frequently, due to concerns that we are committing comorbid patients to an interval surgical procedure for which they may not be suitable. AIM: The aim of this study was to assess the clinical and survival outcomes of PCT use, with particular emphasis on a subgroup of patients who did not proceed to cholecystectomy. METHODS: A retrospective analysis was performed of all patients with severe acute cholecystitis who required PCT insertion in a tertiary referral hospital from 2010 to 2015. Patient demographics and clinical data including systemic inflammatory response (SIRS) scores at presentation, readmissions and clinical and survival outcomes were analysed. Statistical analysis was performed using SPSS v.22 and GraphPad Prism v.7. RESULTS: In total, 157 patients (59% males) with AC underwent PCT insertion during the study period. Median age at presentation was 71 years (range 29-94). A median SIRS score of 3 was noted at presentation. Patients required a median of two cholecystostomy tube changes/replacements (range 1-10) during treatment. Transhepatic tube placement was the preferred approach (69%) with 31% of tubes being placed via transabdominal approach. Only 55% proceeded to interval cholecystectomy. Of the 70 patients treated with PCT alone, their median age was 75 years. In this subgroup, only 12.9% (n = 9) developed recurrent biliary sepsis necessitating readmission following initial resolution of symptoms and tube removal. All episodes of recurrent biliary sepsis presented within 6 months of index presentation, and definitive PCT removal in this group was performed at a median of 3 months. No difference in survival was observed between both groups. CONCLUSION: Almost 90% of patients with AC who are managed definitively with a PCT will recover uneventfully without recurrent sepsis following PCT removal. This is a viable option for older, comorbid patients who are unfit for surgical intervention and is not associated with significantly increased mortality.

A phantom study of the performance of model-based iterative reconstruction in low-dose chest and abdominal CT: When are benefits maximized?

INTRODUCTION: The aim of this study was to assess and compare the effects of CT image reconstruction techniques on low-dose CT image quality using phantoms. METHODS: Anthropomorphic torso and spatial/contrast-resolution phantoms were scanned at decreasing tube currents between 400 and 10 mA. CT thorax and abdomen/pelvis series were reconstructed with filtered back projection (FBP) alone, combined 40% adaptive statistical iterative reconstruction & FBP (ASIR40), and model-based iterative reconstruction (MBIR) [(resolution-preference 05 (RP05) and RP20 in the thorax and RP05 and noise-reduction 05 (NR05) in the abdomen)]. Two readers rated image quality quantitatively and qualitatively. RESULTS: In thoracic CT, objective image noise on MBIR RP05 data sets outperformed FBP at 200, 100, 50 and 10 mA and outperformed ASIR40 at 50 and 10 mA (p < 0.001). MBIR RP20 outperformed FBP at 50 and 10 mA and outperformed ASIR40 at 10 mA (p < 0.001). Compared with both FBP and ASIR40, MBIR RP05 demonstrated significantly better signal-to-noise ratio (SNR) at 10 mA. In abdomino-pelvic CT, MBIR RP05 and NR05 outperformed FBP and ASIR at all tube current levels for objective image noise. NR05 demonstrated greater SNR at 200, 100, 50 and 10 mA and RP05 demonstrated greater SNR at 50 and 10 mA compared with both FBP and ASIR. MBIR images demonstrated better subjective image quality scores. Spatial resolution, low-contrast detectability and contrast-to-noise ratio (CNR) were comparable between image reconstruction techniques. CONCLUSION: CTs reconstructed with MBIR have lower image noise and improved image quality compared with FBP and ASIR. These effects increase with reduced radiation exposure confirming optimal use for low-dose CT imaging.

Assessment of isocenter alignment during CT colonography: Implications for clinical practice.

INTRODUCTION: Optimization of image quality and patient radiation dose is achieved in part by positioning the patient at the isocenter of the CT gantry. The aim of this study was to establish whether there was increased isocenter misalignment (IM) in CT colonography (CTC) scans by comparing patient position during the prone part of a CTC to patient position during renal stone protocol CT (CT-KUB) and patient position during the supine part of a CTC to patient position during abdominopelvic CT (CT-AP). METHODS: Two hundred and twenty two consecutive outpatient adult CTC studies performed between January and December 2016 were retrospectively analyzed. Automated dose-tracking software was used to quantify IM in the x and y planes. Renal stone CT-KUB (n = 100) and standard CT-AP (n = 100) were used as comparison studies. RESULTS: IM during CTC was significantly greater in the y-axis compared with the x-axis for both prone (p = 0.002) and supine (p < 0.001) scanning. IM was significantly greater during prone CTC compared with CT-KUB (p = 0.008) and during supine CTC compared with CT-AP (p = 0.0001). IM was shown to be slightly greater in studies performed by more experienced radiographers (p = 0.04). IM was not associated with patient age, gender or size (p > 0.05 for all). CONCLUSION: Isocenter misalignment is greater during CT colonography compared with CT-KUB or CT-AP. Strategies for improving patient positioning could include radiographer education and automated patient centering solutions.

The Diagnostic Accuracy of Contrast-Enhanced CT of the Neck for the Investigation of Sialolithiasis.

BACKGROUND AND PURPOSE: Sialolithiasis is a common benign pathology affecting the salivary glands but it is unclear if contrast-enhanced CT, which is commonly used for investigation of head and neck pathology, can identify calculi as accurately as noncontrast CT. The aim of this study was to assess the diagnostic accuracy of contrast-enhanced CT of the neck in the diagnosis of sialolithiasis compared with noncontrast CT of the neck used as the criterion standard. MATERIALS AND METHODS: This was a retrospective, case-control study of 92 consecutive cases in 90 patients who underwent both noncontrast CT of the neck and contrast-enhanced CT of the neck in 2 tertiary referral centers from January 2011 to December 2015 for investigation of sialolithiasis. Axial 3-mm-section images were assessed by a fellowship-trained diagnostic neuroradiologist and diagnostic neuroradiology fellow in consensus. Blinded assessment of the contrast-enhanced CT of the neck was performed first, followed by noncontrast CT of the neck after a 2-week interval. The presence or absence of a stone and stone location and size were documented. Statistical analysis was undertaken to assess the agreement between CT protocols and calculate the sensitivity and specificity of contrast-enhanced CT of the neck. RESULTS: Fifty calculi were identified on noncontrast CT of the neck in 31 cases; and 48 calculi, in 31 cases on contrast-enhanced CT of the neck. No calculi were identified in the remaining 61 cases. The sensitivity and specificity of contrast-enhanced CT of the neck in the detection of sialolithiasis was 96% (95% CI, 86.3%-99.5%) and 100% (95% CI, 94.1%-100%), respectively. The positive predictive value of contrast-enhanced CT of the neck was 100% (95% CI, 92.6%-100%), and the negative predictive value was 96.8% (95% CI, 89%-99.6%). The accuracy of contrast-enhanced CT of the neck in diagnosing the presence or absence of salivary calculi was 98%. CONCLUSIONS: Contrast-enhanced CT of the neck is accurate in the detection of sialolithiasis, with no difference in diagnostic accuracy compared with noncontrast CT of the neck.

Comparative Effectiveness of Imaging Modalities for the Diagnosis of Intestinal Obstruction in Neonates and Infants:: A Critically Appraised Topic.

RATIONALE AND OBJECTIVES: The purpose of this study was to critically appraise and compare the diagnostic performance of imaging modalities that are used for the diagnosis of upper and lower gastrointestinal (GI) tract obstruction in neonates and infants. METHODS: A focused clinical question was constructed and the literature was searched using the patient, intervention, comparison, outcome method comparing radiography, upper GI contrast study, and ultrasound in the detection of upper GI tract obstruction such as duodenal atresia and stenosis, jejunal and ileal atresia, and malrotation and volvulus. The same methods were used to compare radiography and contrast enema in the detection of lower GI tract obstruction such as meconium plug syndrome, meconium ileus, Hirschsprung disease, and imperforate anus. Retrieved articles were appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-Based Medicine hierarchy of validity for diagnostic studies. RESULTS: There were no sensitivities/specificities available for the imaging diagnosis of duodenal atresia or stenosis, jejunal or ileal atresias, meconium plug, and meconium ileus or for the use of cross-table lateral radiography for the diagnosis of rectal pouch distance from skin in imperforate anus. The retrieved sensitivity for the detection of malrotation on upper GI contrast study is 96%, and the sensitivity for the diagnosis of midgut volvulus on upper GI contrast study is 79%. The retrieved sensitivity and specificity for the detection of malrotation with volvulus on ultrasound were 89% and 92%, respectively. The retrieved sensitivity and specificity for the detection of Hirschsprung disease on contrast enema were 70% and 83%, respectively. The retrieved sensitivity of invertogram for the diagnosis of rectal pouch distance from skin in imperforate anus is 27%. The retrieved sensitivities of perineal ultrasound and colostography for the diagnosis of rectal pouch distance from skin in imperforate anus were 86% and 100%, respectively. CONCLUSIONS: There is limited evidence for the imaging diagnosis of duodenal atresia and stenosis, jejunal and ileal atresias, meconium plug, meconium ileus, and imperforate anus, with recommended practice based mainly on low-quality evidence or expert opinion. The available evidence supports the use of upper GI contrast study for the diagnosis of malrotation and volvulus, with ultrasound as an adjunct to diagnosis. Contrast enema is useful in the investigation of suspected Hirschsprung disease, but a negative study does not outrule the condition. Colostography is the investigation of choice for the work-up of infants with complex anorectal malformations before definitive surgical repair.

The 100 classic papers of pediatric orthopaedic surgery: a bibliometric analysis.

BACKGROUND: Pediatric orthopaedic surgery owes its development to many pioneering individuals, and the studies that these individuals have undertaken form the basis for the clinical decisions made on the modern pediatric orthopaedic service. The aim of our study was to use citation analysis to identify the top 100 papers in pediatric orthopaedic surgery. METHODS: Using the Thomson Reuters Web of Knowledge, we searched for citations of all papers relevant to pediatric orthopaedics. The number of citations, authorship, year of publication, journal of publication, and country and institution of origin were recorded for each paper. RESULTS: The most cited paper was found to be the classic paper from 1963 by Salter and Harris that introduced the now-eponymous classification system for physeal injuries in the skeletally immature patient. The second most cited was Salter's paper describing the widely used osteotomy for the treatment of developmental dysplasia of the hip, and the third most cited was Catterall's description of the natural history of Legg-Calvé-Perthes disease. Most papers originated in the U.S., and most were published in this journal. A number of authors including Salter, Ponseti, Graf, and Loder had more than one paper in the top-100 list. DISCUSSION: This paper's identification of the classic papers of pediatric orthopaedic surgery gives us a unique insight into the development of pediatric orthopaedic surgery in the twentieth and early twenty-first centuries and identifies those individuals who have contributed the most to the body of knowledge used to guide evidence-based clinical decision-making in pediatric orthopaedics today.

Operative techniques for cervical radiculopathy and myelopathy.

Cervical spondylosis is a common problem encountered in modern orthopaedic practice. It is associated with significant patient morbidity related to the consequent radiculopathic and myelopathic symptoms. Operative intervention for this condition is generally indicated if conservative measures fail; however there are some circumstances in which urgent surgical intervention is necessary. Planning any surgical intervention must take into account a number of variables including, but not limited to, the nature, location and extent of the pathology, a history of previous operative interventions, and patient co-morbidities. There are many different surgical options and a multitude of different procedures have been described using both the anterior and posterior approaches to the cervical spine. The use of autograft to achieve cervical fusion is still the gold standard with allograft showing similar results; however fusion techniques are constantly evolving with novel synthetic bone graft substitutes now widely available.