Volumetric measurement of terminal ileal Crohn's disease by magnetic resonance enterography: a feasibility study.

OBJECTIVES: Magnetic resonance enterography (MRE) interpretation of Crohn's disease (CD) is subjective and uses 2D analysis. We evaluated the feasibility of volumetric measurement of terminal ileal CD on MRE compared to endoscopy and sMARIA, and the responsiveness of volumetric changes to biologics. METHODS: CD patients with MRE and contemporaneous CD endoscopic index of severity-scored ileocolonoscopy were included. A centreline was placed through the terminal ileum (TI) lumen defining the diseased bowel length on the T2-weighted non-fat saturated sequence, used by two radiologists to independently segment the bowel wall to measure volume (phase 1). In phase 2, we measured disease volume in patients treated with biologics, who had undergone pre- and post-treatment MRE, with treatment response classified via global physician assessment. RESULTS: Phase 1 comprised 30 patients (median age 29 (IQR 24, 34) years). Phase 2 included 12 patients (25 years (22, 38)). In phase 1, the mean of the radiologist-measured volumes was used for analysis. The median disease volume in those with endoscopically active CD was 20.9 cm3 (IQR 11.3, 44.0) compared to 5.7 cm3 (2.9, 9.8) with normal endoscopy. The mean difference in disease volume between the radiologists was 3.0 cm3 (limits of agreement -21.8, 15.9). The median disease volume of patients with active CD by sMARIA was 15.0 cm3 (8.7, 44.0) compared to 2.85 cm3 (2.6, 3.1) for those with inactive CD. Pre- and post-treatment median disease volumes were 28.5 cm3 (26.4, 31.2), 11 cm3 (4.8, 16.6), respectively in biological responders, vs 26.8 cm3 (12.3, 48.7), 40.1 cm3 (10, 56.7) in non-responders. CONCLUSION: Volumetric measurement of terminal ileal CD by MRE is feasible, related to endoscopy and sMARIA activity, and responsive to biologics. CLINICAL RELEVANCE STATEMENT: Measuring the whole volume of diseased bowel on MRE in CD is feasible, related to how biologically active the disease is when assessed by endoscopy and by existing MRE activity scores, and is sensitive to treatment response. KEY POINTS: MRE reporting for CD is subjective and uses 2D images rather than assessing the full disease volume. Volumetric measurement of CD relates to endoscopic activity and shows reduced disease volumes in treatment responders. This technique is an objective biomarker that can assess disease activity and treatment response, warranting validation.

Diagnostic performance of sonographic activity scores for adult terminal ileal Crohn's disease compared to magnetic resonance and histological reference standards: experience from the METRIC trial.

OBJECTIVES: The simple ultrasound activity score for Crohn's disease (SUS-CD) and bowel ultrasound score (BUSS) are promising intestinal ultrasound (IUS) indices of CD, but studied mainly in small settings with few sonographers. We compared SUS-CD and BUSS against histological and magnetic resonance enterography (MRE) reference standards in a post hoc analysis of a prospective multicentre, multireader trial. METHODS: Participants recruited to the METRIC trial (ISRCTN03982913) were studied, including those with available terminal ileal (TI) biopsies. Sensitivity and specificity of SUS-CD and BUSS for TI CD activity were calculated with 95% confidence intervals (CI), from the prospective observations of the original METRIC trial sonographers against the histological activity index (HAI) and the simplified magnetic resonance index of activity (sMARIA). RESULTS: We included 284 patients (median 31.5 years, IQR 23-46) from 8 centres, who underwent IUS and MRE. Of these, 111 patients had available terminal ileal biopsies with HAI scoring. Against histology, sensitivity and specificity for active disease were 79% (95% CI 69-86%) and 50% (31-69%) for SUS-CD, and 66% (56-75%) and 68% (47-84%) for BUSS, respectively. Compared to sMARIA, the sensitivity and specificity for active CD were 81% (74-86%) and 75% (66-83%) for SUS-CD, and 68% (61-74%) and 85% (76-91%) for BUSS, respectively. The sensitivity of SUS-CD was significantly greater than that of BUSS against HAI and sMARIA (p < 0.001), but its specificity was significantly lower than of BUSS against the MRE reference standard (p = 0.003). CONCLUSIONS: Particularly when compared to MRE activity scoring, SUS-CD and BUSS are promising tools in a real-world clinical setting. CLINICAL RELEVANCE STATEMENT: When tested using data from a multicentre, multireader diagnostic accuracy trial, the simple ultrasound activity score for Crohn's disease (SUS-CD) and bowel ultrasound score (BUSS) were clinically viable intestinal ultrasound indices that were reasonably sensitive and specific for terminal ileal Crohn's disease, especially when compared to a magnetic resonance reference standard. KEY POINTS: The simple ultrasound activity score for Crohn's disease and bowel ultrasound score are promising intestinal ultrasound indices of Crohn's disease but to date studied mainly in small settings with few sonographers. Compared to histology and the magnetic resonance reference standard in a multicentre, multireader setting, the sensitivity of simple ultrasound activity score for Crohn's disease is significantly greater than that of bowel ultrasound score. The specificity of simple ultrasound activity score for Crohn's disease was significantly lower than that of bowel ultrasound score compared to the magnetic resonance enterography reference standard. The specificity of both indices was numerically higher when the magnetic resonance enterography reference standard was adopted.

Chest radiograph classification and severity of suspected COVID-19 by different radiologist groups and attending clinicians: multi-reader, multi-case study.

OBJECTIVES: To quantify reader agreement for the British Society of Thoracic Imaging (BSTI) diagnostic and severity classification for COVID-19 on chest radiographs (CXR), in particular agreement for an indeterminate CXR that could instigate CT imaging, from single and paired images. METHODS: Twenty readers (four groups of five individuals)-consultant chest (CCR), general consultant (GCR), and specialist registrar (RSR) radiologists, and infectious diseases clinicians (IDR)-assigned BSTI categories and severity in addition to modified Covid-Radiographic Assessment of Lung Edema Score (Covid-RALES), to 305 CXRs (129 paired; 2 time points) from 176 guideline-defined COVID-19 patients. Percentage agreement with a consensus of two chest radiologists was calculated for (1) categorisation to those needing CT (indeterminate) versus those that did not (classic/probable, non-COVID-19); (2) severity; and (3) severity change on paired CXRs using the two scoring systems. RESULTS: Agreement with consensus for the indeterminate category was low across all groups (28-37%). Agreement for other BSTI categories was highest for classic/probable for the other three reader groups (66-76%) compared to GCR (49%). Agreement for normal was similar across all radiologists (54-61%) but lower for IDR (31%). Agreement for a severe CXR was lower for GCR (65%), compared to the other three reader groups (84-95%). For all groups, agreement for changes across paired CXRs was modest. CONCLUSION: Agreement for the indeterminate BSTI COVID-19 CXR category is low, and generally moderate for the other BSTI categories and for severity change, suggesting that the test, rather than readers, is limited in utility for both deciding disposition and serial monitoring. KEY POINTS: • Across different reader groups, agreement for COVID-19 diagnostic categorisation on CXR varies widely. • Agreement varies to a degree that may render CXR alone ineffective for triage, especially for indeterminate cases. • Agreement for serial CXR change is moderate, limiting utility in guiding management.

Recent advances in clinical practice: advances in cross-sectional imaging in inflammatory bowel disease.

Endoscopy remains the reference standard for the diagnosis and assessment of patients with inflammatory bowel disease (IBD), but it has several important limitations. Cross-sectional imaging techniques such as magnetic resonance enterography (MRE) and intestinal ultrasound (IUS) are better tolerated and safer. Moreover, they can examine the entire bowel, even in patients with stenoses and/or severe inflammation. A variety of cross-sectional imaging activity scores strongly correlate with endoscopic measures of mucosal inflammation in the colon and terminal ileum. Unlike endoscopy, cross-sectional techniques allow complete visualisation of the small-bowel and assess for extraintestinal disease, which occurs in nearly half of patients with IBD. Extramural findings may predict outcomes better than endoscopic mucosal assessment, so cross-sectional techniques might help identify more relevant therapeutic targets. Coupled with their high sensitivity, these advantages have made MRE and IUS the primary non-invasive options for diagnosing and monitoring Crohn's disease; they are appropriate first-line investigations, and have become viable alternatives to colonoscopy. This review discusses cross-sectional imaging in IBD in current clinical practice as well as research lines that will define the future role of these techniques.

Are preoperative CT variables associated with the success or failure of subsequent ventral hernia repair: nested case-control study.

OBJECTIVES: Systematic review of CT measurements to predict the success or failure of subsequent ventral hernia repair has found limited data available in the indexed literature. To rectify this, we investigated multiple preoperative CT metrics to identify if any were associated with postoperative reherniation. METHODS: Following ethical permission, we identified patients who had undergone ventral hernia repair and had preoperative CT scanning available. Two radiologists made multiple measurements of the hernia and abdominal musculature from these scans, including loss of domain. Patients were divided subsequently into two groups, defined by hernia recurrence at 1-year subsequent to surgery. Hypothesis testing investigated any differences between CT measurements from each group. RESULTS: One hundred eighty-eight patients (95 male) were identified, 34 (18%) whose hernia had recurred by 1-year. Only three of 34 CT measurements were significantly different when patients whose hernia had recurred were compared to those who had not; these significant findings were assumed contingent on multiple testing. In particular, preoperative hernia volume (recurrence 155.3 cc [IQR 355.65] vs. no recurrence 78.2 [IQR 303.52], p = 0.26) nor loss of domain, whether calculated using the Tanaka (recurrence 0.02 [0.04] vs. no recurrence 0.009 [0.04], p = 0.33) or Sabbagh (recurrence 0.019 [0.05] vs. no recurrence 0.009 [0.04], p = 0.25) methods, differed between significantly between groups. CONCLUSIONS: Preoperative CT measurements of ventral hernia morphology, including loss of domain, appear unrelated to postoperative recurrence. It is likely that the importance of such measurements to predict recurrence is outweighed by other patient factors and surgical reconstruction technique. KEY POINTS: • Preoperative CT scanning is often performed for ventral hernia but systematic review revealed little data regarding whether CT variables predict postoperative reherniation. • We found that the large majority of CT measurements, including loss of domain, did not differ significantly between patients whose hernia did and did not recur. • It is likely that the importance of CT measurements to predict recurrence is outweighed by other patient factors and surgical reconstruction technique.

Quantitative assessment of terminal ileum motility on MR enterography in Crohn disease: a feasibility study in children.

OBJECTIVES: Investigate the relationship between quantified terminal ileal (TI) motility and histopathological activity grading, Crohn Disease MRI Index (CDMI) and faecal calprotectin. METHODS: Retrospective review of children with Crohn disease or unclassified inflammatory bowel disease, who underwent MR enterography. Dynamic imaging for 25 patients (median age 12, range 5 to 16) was analysed with a validated motility algorithm. The TI motility score was derived. The primary reference standard was TI Endoscopic biopsy Assessment of Inflammatory Activity (eAIS) within 40 days of the MR enterography. Secondary reference standards: (1) the Crohn Disease MRI Index (CDMI) and (2) faecal calprotectin levels. RESULTS: MR enterography median motility score was 0.17 a.u. (IQR 0.12 to 0.25; range 0.05 to 0.55), and median CDMI was 3 (IQR 0 to 5.5). Forty-three percent of patients had active disease (eAIS > 0) with a median eAIS score of 0 (IQR 0 to 2; range 0 to 5). The correlation between eAIS and motility was r = - 0.58 (p = 0.004, N = 23). Between CDMI and motility, r = - 0.42 (p = 0.037, N = 25). Motility score was lower in active disease (median 0.12 vs 0.21, p = 0.020) while CDMI was higher (median 5 vs 1, p = 0.04). In a subset of 12 patients with faecal calprotectin within 3 months of MR enterography, correlation with motility was r = - 0.27 (p = 0.4). CONCLUSIONS: Quantified terminal ileum motility decreases with increasing histopathological abnormality in children with Crohn disease, reproducing findings in adults. TI motility showed a negative correlation with an MRI activity score but not with faecal calprotectin levels. KEY POINTS: • It is feasible to perform MRI quantified bowel motility assessment in children using free-breathing techniques. • Bowel motility in children with Crohn disease decreases as the extent of intestinal inflammation increases. • Quantified intestinal motility may be a candidate biomarker for treatment efficacy in children with Crohn disease.

Outcomes of Renal Tumors Treated by Image-Guided Percutaneous Cryoablation: Immediate and 3- and 5-Year Outcomes at a Regional Center.

OBJECTIVE. The purpose of this study was to evaluate the immediate and 3- and 5-year outcomes of patients with clinical stage T1 (cT1) biopsy-proven renal cell carcinoma (RCC) treated by image-guided percutaneous cryoablation at a regional interventional oncology center. MATERIALS AND METHODS. A prospectively maintained local interventional radiology database identified patients with cT1 RCC lesions that were treated by percutaneous cryoablation. Technical success, procedural complications (graded using the Clavien-Dindo classification system), and the residual unablated tumor rate were collated. Local tumor progression-free survival was estimated using Kaplan-Meier estimates. RESULTS. A total of 180 patients with 185 separate cT1 RCC lesions were identified. Mean patient age was 68.4 years (range, 34.1-88.9 years) and 52 patients (28.9%) were women. There were 168 (90.8%) and 17 (9.2%) cT1a and cT1b lesions, respectively, with a mean lesion size of 28.5 mm (range, 11-58 mm). Technical success was achieved in 183 of 185 (98.9%) patients. The major complication rate (Clavien-Dindo classification ≥ grade III) was 2.2% (four out of 185). Residual unablated tumor on the first follow-up scan was identified in four of 183 tumors (2.2%). Estimated local tumor progression-free survival at 3 and 5 years was 98.3% and 94.9%, respectively. No distant metastases or deaths attributable to RCC occurred. Mean estimated glomerular filtration rate (eGFR) before the procedure was 72.4 ± 18.5 (SD) mL/min/1.73 m2 and this was not statistically significantly different after the procedure (69.7 ± 18.8 mL/min/1.73 m2), at 1 year (70.7 ± 16.4 mL/min/1.73 m2), or at 2 years (69.8 ± 18.9 mL/min/1.73 m2) (p > 0.05). CONCLUSION. These data add to the accumulating evidence that image-guided cryoablation is an efficacious treatment for selected cT1 RCC with a low complication rate and ro bust 3- and 5-year outcomes.

Use of Gla-100 in Special Situations.

Insulin therapy is the cornerstone of diabetes management in people with type 2 diabetes mellitus (T2DM). Therefore, its use is recommended even in special populations and situations such as the elderly, pregnant women, obese individuals, people observing religious fasting, and in the presence of comorbidities such as renal insufficiency, and cancer. Since these special situations predispose to complications such as a high risk of hypoglycemia, patients need constant glucose monitoring and insulin dose adjustments, wherever applicable. This review discusses the various considerations that might guide the decision-making process in the special situations alluded to here. It also throws light on how insulin glargine 100 U/mL has emerged as a preferred choice of insulin therapy in most of these situations, on the strength of its inherently low hypoglycemia and weight gain potential, which has found traction even in the recent diabetes guidelines.

Long-term Graft and Patient Survival after Percutaneous Angioplasty or Arterial Stent Placement for Transplant Renal Artery Stenosis: A 21-year Matched Cohort Study.

Purpose To compare long-term graft and patient survival after percutaneous angioplasty (PTA) or stent placement for transplant renal artery stenosis (TRAS) with a control cohort without TRAS. Materials and Methods This is a retrospective matched cohort study of 41 patients (median age, 49 years; range, 18-72 years), including 27 male patients (median age, 48 years; range, 18-67 years) and 14 female patients (median age, 52 years; range, 24-68 years), with TRAS from December 1995 through 2016. Primary end points were death-censored graft and patient survival, compared by using log-rank test and Cox proportional regression. Secondary outcomes were improvement in renal function, blood pressure (BP), and complications. Results Twenty-four patients underwent PTA and 17 received stent placements. Ten-year graft survival was 92.1% (range, 83.2%-100%) versus 81.4% (range, 67.8%-95.3%) (P = .56), and 10-year patient survival was 89.9% (79.1%-100%) versus 84.7% (72.1%-97.5%) (P = .49), for the study and control groups, respectively. Five patients (12%) resumed dialysis in each group and a total of 17 patients died (eight in the study group and nine in the control group). Most patients died with a functioning graft (seven of eight in the study group and seven of nine in the control group). Posttreatment median systolic and diastolic BP improved by 12% and 7.4%, respectively, and serum creatinine improved by 27%. Normal systolic BP and serum creatinine level at 1 year after treatment were associated with better survival for patients (P = .04; hazard ratio [HR], 1.04; 95% confidence interval [CI]: 1.0, 1.075) and grafts (P < .001; HR, 1.02; 95% CI: 1.0, 1.027). Other covariates, including PTA versus renal stent placement, intra-arterial pressure gradient greater than 10%, diastolic BP, age at transplantation, sex, graft type, rejection, and delayed graft function, were not significant. Five patients (12.2%) had a complication (Society of Interventional Radiology class A, two of 41 [4.9%]; class B, two of 41 [4.9%]; and class D, one of 41 [2.4%]); 30-day graft loss and patient mortality were zero. Conclusion Long-term graft and patient survival after endovascular correction of transplant renal artery stenosis (TRAS) was similar to that without TRAS and most patients avoided returning to dialysis. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Dickey and Durrani in this issue.

An ontological approach to identifying cases of chronic kidney disease from routine primary care data: a cross-sectional study.

BACKGROUND: Accurately identifying cases of chronic kidney disease (CKD) from primary care data facilitates the management of patients, and is vital for surveillance and research purposes. Ontologies provide a systematic and transparent basis for clinical case definition and can be used to identify clinical codes relevant to all aspects of CKD care and its diagnosis. METHODS: We used routinely collected primary care data from the Royal College of General Practitioners Research and Surveillance Centre. A domain ontology was created and presented in Ontology Web Language (OWL). The identification and staging of CKD was then carried out using two parallel approaches: (1) clinical coding consistent with a diagnosis of CKD; (2) laboratory-confirmed CKD, based on estimated glomerular filtration rate (eGFR) or the presence of proteinuria. RESULTS: The study cohort comprised of 1.2 million individuals aged 18 years and over. 78,153 (6.4%) of the population had CKD on the basis of an eGFR of < 60 mL/min/1.73m2, and a further 7366 (0.6%) individuals were identified as having CKD due to proteinuria. 19,504 (1.6%) individuals without laboratory-confirmed CKD had a clinical code consistent with the diagnosis. In addition, a subset of codes allowed for 1348 (0.1%) individuals receiving renal replacement therapy to be identified. CONCLUSIONS: Finding cases of CKD from primary care data using an ontological approach may have greater sensitivity than less comprehensive methods, particularly for identifying those receiving renal replacement therapy or with CKD stages 1 or 2. However, the possibility of inaccurate coding may limit the specificity of this method.

Diagnosis and outcome of Clostridium difficile infection by toxin enzyme immunoassay and polymerase chain reaction in an island population.

BACKGROUND AND AIM: Clostridium difficile infection (CDI) is a potentially life-threatening cause of diarrhea. Correct laboratory diagnosis is essential to differentiate CDI from other causes of diarrhea. A positive fecal C. difficile toxin (CDT) is the best indicator of CDI, but the significance of a positive fecal nucleic acid amplification test (NAAT) remains unclear. Our aim was to elucidate the significance of CDI diagnostics in patients in Jersey. METHODS: A retrospective, 5-year study was conducted at an island district general hospital of patients who developed CDI. Patients were grouped according to CDT and NAAT status and their association with outcome (indicators of severity and 30-day case-fatality rate) compared. RESULTS: A total of 207 specimens were toxin positive, 92 NAAT positive and toxin negative, and 39 had a stool sample negative by both toxin and NAAT testing. A positive toxin stool sample was associated with both significantly higher white cell count (14.5 × 109 /L vs 11.3 × 109 /L, P = 0.003) and C-reactive protein (114.7 mg/dL vs 82.9 mg/dL, P = 0.001), but NAAT positivity was not (P = 0.269, 0.728). A positive CDT assay was a significant independent predictor of death (odds ratio [OR]: 1.89 [95% CI: 1.04-3.43], P = 0.046), but a positive NAAT in CDT negative samples was not (OR: 1.02 [95% CI: 0.34-3.12], P = 1.0). CONCLUSIONS: The findings of this study, derived from evolving clinical practice, provide greater clarity in the interpretation of CDI diagnostics. In CDT-negative disease, a positive NAAT neither predicts disease severity nor mortality. NAAT-positive and toxin-negative patients require instigation of infection control measures, but the need for specific treatment remains unclear.

Long-term Graft and Patient Survival after Balloon Dilation of Ureteric Stenosis after Renal Transplant: A 23-year Retrospective Matched Cohort Study.

Purpose To study long-term graft and patient survival after percutaneous ureteroplasty of ureteric stenosis after renal transplantation and to compare the outcomes to those of patients who did not develop ureteric stenosis. Materials and Methods An ethical waiver was obtained for this 23-year retrospective matched cohort study of 52 of 1476 consecutive kidney transplant recipients who developed postoperative ureteric stenosis. Data were collected between January 1990 and December 2012. All patients (mean age, 47 years [range, 23-72 years]; 36 men aged 29-72 years [mean age, 49 years] and 24 women aged 23-68 years [mean age, 42 years]) underwent percutaneous ureteroplasty; recurrent stenosis was managed surgically or by means of long-term ureteric stent placement. Outcomes were compared with those of a matched control group of transplant recipients with no history of ureteric stenosis. Primary outcome measures were death-censored graft failure and all-cause mortality. Secondary outcome measures were the effect of time of stricture onset on graft survival, complications, and risk factors for recurrent stenosis. Kaplan-Meier curves were compared by using log-rank tests, with P < .05 indicative of a statistically significant difference. Results Balloon dilation was technically successful in all 52 strictures, but stenosis recurred in 10 patients and was treated with surgery (n = 5) or long-term stent placement (n = 5). The 10-year graft and patient survival were not significantly different in study versus control groups, with graft survival of 64.5% (95% confidence interval [CI]: 43.4%, 79.4%) versus 76.3% (95% CI: 58.6%, 87.2%), respectively (P = .372), and patient survival of 82.2% (95% CI: 62.9%, 92%) versus 89.9% (95% CI: 74.6%, 96.2%) (P = .632). Subgroup analysis showed that stenosis occurring less than 3 months (10-year graft survival, 59.1%), at least 3 months (10-year graft survival, 67.3%), and at least 6 months (10-year graft survival, 53.0%) after transplantation did not adversely affect graft survival compared with that of the control group (P > .05). Cold ischemia time was longer in those with recurrent stenosis than in control subjects (16.1 vs 8.4 hours, respectively; P = .034). The minor and major complication rates were 13% and 5.7%, respectively, with no 30-day graft loss and patient mortality. Conclusion Long-term graft and patient survival in patients with percutaneous ureteroplasty of transplant ureteric stenosis were not significantly worse than those in a control group. (©) RSNA, 2016.

Thirty-Day Outcomes After Percutaneous Nephrostomy of Renal Transplant Kidneys: 19-Year Experience and Comparison With Existing Practice Parameters.

OBJECTIVE: The purpose of our study was to document the technical success rate, complications, and 30-day outcome after percutaneous nephrostomy catheter insertion into renal grafts. MATERIALS AND METHODS: Radiologic and clinical databases were used to identify all adult patients who underwent renal transplantation from January 1994 through December 2012. Patients who underwent transplant percutaneous nephrostomy catheter insertion for the immediate management of ureteric obstruction or leak were identified, and the 30-day outcomes were recorded. Complications were graded using the Society of Interventional Radiology and Clavien classification systems. RESULTS: Of 1476 consecutive kidney transplants, a total of 73 nephrostomy catheters were successfully inserted into 52 patients (male, 36; age range, 24-72 years), 45 with strictures and seven with strictures with leaks. The median serum creatinine level improved from 276 µmol/L (95% CI, 229-342 µmol/L) to 195 µmol/L (95% CI, 170-223 µmol/L) 7 days after intervention (p = 0.0001). Five complications were seen within 30 days and all were related to bleeding (Society of Interventional Radiology classification: grade A, n = 2; grade B, n = 2; grade D, n = 1; and Clavien classification system: grade I, n = 4; grade IIIa, n = 1). The overall complication rate was 6.8% (5/73), and the major complication rate was 1.4% (1/73). There were no cases of bowel injury or septicemia. The 30-day graft and mortality rates were 0%. CONCLUSION: Transplant percutaneous nephrostomy catheter insertion has a high technical and clinical success rate. The 30-day graft and mortality rates were 0%, the overall complication rate was 6.8%, and the major complication rate was 1.4%.

Small intestinal contrast ultrasonography for the detection of small bowel complications in Crohn's disease: correlation with intraoperative findings and magnetic resonance enterography.

BACKGROUND AND AIMS: In evaluating small bowel Crohn's disease (CD), small intestine contrast-enhanced ultrasonography (SICUS) is emerging as an alternative to magnetic resonance enterography (MRE). This retrospective study compared the diagnostic accuracy of SICUS and MRE with surgical findings, and their level of agreement. METHODS: We identified a cohort of CD patients investigated by either SICUS and/or MRE that subsequently required resective bowel surgery within 6 months. The accuracy and agreement of SICUS and MRE to detect small bowel complications were compared with intraoperative findings using kappa coefficient (κ). Agreement between SICUS and MRE in those undergoing both modalities was also assessed. RESULTS: A total of 67 patients were evaluated; 25 underwent SICUS and 17 underwent MRE prior to surgery. Another 25 patients underwent both SICUS and MRE. When compared with intraoperative findings, the sensitivity of SICUS and MRE was 87.5% and 100%, respectively, in detecting strictures, 87.7% and 66.7% for fistulae, 100% for both in identifying abscesses, 100% and 66.7% for bowel dilatation, and 94.7% and 81.8% in defining bowel wall thickening. When correlating SICUS and MRE with surgery, there was a high level of agreement in localizing strictures (κ = 0.75, 0.88, respectively), fistulae (κ = 0.82, 0.79) and abscesses (κ = 0.87, 0.77). Concordance between SICUS and MRE was substantial or almost complete in identifying stricturing disease (κ = 0.84), their number and location (κ = 0.85), fistulae (κ = 0.65), and mucosal thickening (κ = 0.61). CONCLUSION: SICUS accurately identified small bowel complications and correlated well with MRE and intraoperative findings. SICUS offers an alternative in the preoperative assessment of CD.

5-(3,5-Di-fluoro-phen-yl)-1-(4-fluoro-phen-yl)-3-tri-fluoro-methyl-1H-pyrazole.

In the title compound, C16H8F6N2, the dihedral angle between the pyrazole and di-fluoro-benzene rings is 50.30 (13)°, while those between the pyrazole and fluoro-benzene rings and between the di-fluoro-benzene and fluoro-benzene rings are 38.56 (13) and 53.50 (11)°, respectively. Aromatic π-π stacking inter-actions between adjacent di-fluoro-benzene rings [centroid-centroid separation = 3.6082 (11) Å] link the mol-ecules into dimers parallel to [21-2].

Magnetic resonance enterography and intestinal ultrasound for the assessment and monitoring of Crohn's disease.

Magnetic resonance enterography (MRE) and intestinal ultrasound (IUS) have developed rapidly in the last few decades, emerging as the primary non-invasive options for both diagnosing and monitoring Crohn's disease (CD). In this review, we evaluate the pertinent data relating to the use of MRE and IUS in CD. We summarise the key imaging features of CD activity, highlight their increasing role in both the clinical and research settings, and discuss how these modalities fit within the diagnostic pathway. We discuss how they can be used to assess disease activity and treatment responsiveness, including the emergence of activity scores for standardised reporting. Additionally, we address areas of controversy such as the use of contrast agents, the role of diffusion-weighted imaging, and discuss point-of-care ultrasound. We also highlight exciting new developments including the applications of artificial intelligence. Finally, we provide suggestions for future research priorities.

Nasal Bone Fracture Reduction Under Local Anaesthesia: A Holistic Approach to Nasal Blocks and a Comparison with General Anaesthesia.

To compare the pain scores in closed reduction of nasal bone fractures under local anaesthesia (LA) and general anaesthesia (GA), and to outline the blocks that should be used for the same based on their nerve supply. A prospective study was conducted with 40 patients with Class 1 and 2 nasal bone and septal fracture. 20 patients underwent the procedure under LA and 20 under GA. The local blocks that should be used based on the complete nerve supply of the nose has been tabulated. Pain scores were recorded immediately after the procedure and 6 h later. Additionally, all the patients undergoing reduction under LA were asked, if given the choice again, if they would prefer to undergo the procedure under LA or GA. The overall difference in the pain scores calculated by T-test showed a p-value of 0.08807 (the result was not significant at p < .05) in the immediate post operative period. At the 6 h post operative period, overall difference in the pain scores showed a p-value of 0.384972 (not significant at p < .05). Of the patients who underwent the procedure under LA, 18 of 20 (90%) said that if given a choice again, they would undergo the procedure under LA, while 2 said they would prefer GA. Based on the pain score in the La vs. GA groups, there is no significant difference in the pain scores whether closed reduction is done under local or general anaesthesia. If all the blocks are given keeping the nerve supplies in mind, and both externally, and with pledgets, the entire nerve supply of the nose can be blocked.

Is there a need for "triple therapy"? Role of anticoagulation with dual antiplatelet therapy in acute coronary syndromes (ATLAS Study & TRAP Study).

In the past two decades there has been a succession of advances in the development of anticoagulant and antiplatelet therapies to be used in the treatment of ACS. Despite optimal dual antiplatelet therapy, nearly 10-12 % of patients still face a risk of death or myocardial infarction one year following PCI. This large residual risk provides the impetus for the development of more effective strategies. Dual pathway regimens that combine antiplatelets (aspirin and a thienopyridine), along with an anticoagulant such as rivaroxaban may prove to be a therapeutic option in patients with ACS.

Renal and Urological Disorders Associated With Inflammatory Bowel Disease.

Renal and urinary tract complications related to inflammatory bowel disease (IBD) have been relatively understudied in the literature compared with other extraintestinal manifestations. Presentation of these renal manifestations can be subtle, and their detection is complicated by a lack of clarity regarding the optimal screening and routine monitoring of renal function in IBD patients. Urolithiasis is the most common manifestation. Penetrating Crohn's disease involving the genitourinary system as an extraintestinal complication is rare but associated with considerable morbidity. Some biologic agents used to treat IBD have been implicated in progressive renal impairment, although differentiating between drug-related side effects and deteriorating kidney function due to extraintestinal manifestations can be challenging. The most common findings on renal biopsy of IBD patients with renal injury are tubulointerstitial nephritis and IgA nephropathy, the former also being associated with drug-induced nephrotoxicity related to IBD medication. Amyloidosis, albeit rare, must be diagnosed early to reduce the chance of progression to renal failure. In this review, we evaluate the key literature relating to renal and urological involvement in IBD and emphasize the high index of suspicion required for the prompt diagnosis and treatment of these manifestations and complications, considering the potential severity and implications of acute or chronic loss of renal function. We also provide suggestions for future research priorities.

Renal and urinary tract complications related to inflammatory bowel disease (IBD) are important but have been neglected in the literature. We emphasize the high index of suspicion required for the prompt diagnosis, treatment, and prevention of these manifestations and complications.

A cross-sectional study of coping strategies and resilience and its association with psychological symptoms of doctors working in a dedicated COVID-19 care center.

Context: Health-care professionals who are involved in treating COVID patients use multiple coping strategies to overcome stress. Studies have shown that individuals having poor coping strategies and resilience are more prone toward psychological symptoms. Aims: The study was conducted to assess the coping strategies and resilience and its association with psychological symptoms of frontline doctors working in a COVID care center. Settings and Design: It was a cross-sectional study using convenient sampling conducted among 150 frontline doctors working in a COVID care center. Materials and Methods: The study tools included were sociodemographic questionnaire, Depression, Anxiety, and Stress Scale 21, Brief-COPE Scale, and Connor-Davidson Resilience Scale which was sent using Google Forms to participants after obtaining informed consent. Statistical Analysis Used: Statistical analysis was conducted using Chi-square test for categorical variables, t-test for continuous variables, and Mann-Whitney U test for ordinal data, Spearman correlation for correlations, and backward multiple linear regression to predict psychological symptoms. Results: Doctors with severe stress had higher dysfunctional coping and lower resilience scores (P = 0.001). There was a positive correlation of stress, anxiety, and depression with problem-focused, emotional-focused, and dysfunctional coping, and there was a negative correlation between total resilience scores with stress and depression. Stress and anxiety were predicted by dysfunctional coping and resilience. Depression was predicted by dysfunctional coping (ß = 1.25, P < 0.001), resilience (ß = -0.08, P = 0.005), and duration of working hours per month (ß = -0.008, P = 0.05). Conclusions: There is an urgent need to look at therapeutic strategies and factors which enhance resilience and promote better coping in this population.