Automated assessment of ischemic core on non-contrast computed tomography: a multicenter comparative analysis with CT perfusion.

BACKGROUND: Application of machine learning (ML) algorithms has shown promising results in estimating ischemic core volumes using non-contrast CT (NCCT). OBJECTIVE: To assess the performance of the e-Stroke Suite software (Brainomix) in assessing ischemic core volumes on NCCT compared with CT perfusion (CTP) in patients with acute ischemic stroke. METHODS: In this retrospective multicenter study, patients with anterior circulation large vessel occlusions who underwent pretreatment NCCT and CTP, successful reperfusion (modified Thrombolysis in Cerbral Infarction ≥2b), and post-treatment MRI, were included from three stroke centers. Automated calculation of ischemic core volumes was obtained on NCCT scans using ML algorithm deployed by e-Stroke Suite and from CTP using Olea software (Olea Medical). Comparative analysis was performed between estimated core volumes on NCCT and CTP and against MRI calculated final infarct volume (FIV). RESULTS: A total of 111 patients were included. Estimated ischemic core volumes (mean±SD, mL) were 20.4±19.0 on NCCT and 19.9±18.6 on CTP, not significantly different (P=0.82). There was moderate (r=0.40) and significant (P<0.001) correlation between estimated core on NCCT and CTP. The mean difference between FIV and estimated core volume on NCCT and CTP was 29.9±34.6 mL and 29.6±35.0 mL, respectively (P=0.94). Correlations between FIV and estimated core volume were similar for NCCT (r=0.30, P=0.001) and CTP (r=0.36, P<0.001). CONCLUSIONS: Results show that ML-based estimated ischemic core volumes on NCCT are comparable to those obtained from concurrent CTP in magnitude and in degree of correlation with MR-assessed FIV.

Seasonality and geography of diabetes mellitus in United States of America dogs.

The diagnosis of type 1 diabetes mellitus (DM) in humans is associated with high altitude, few sunshine hours, cold climate, and winter. The goals of this study were to investigate seasonal and geographic patterns of DM diagnosis in United States of America (USA) dogs with juvenile and mature onset DM. Data were collected by means of an online survey widely distributed in the USA through breed clubs, academic veterinary institutions, private veterinary referral practices, social media outlets, and the American Kennel Club. Juvenile DM (JDM) and mature onset DM were defined as DM with an age of onset <365 days and DM with an age of onset ≥365 days, respectively. Meteorological seasons were defined as: winter from December through February, spring from March through May, summer from June through August, and fall from September through November. Four geographic regions were also defined as the West, North, South, and Central regions of the USA. Nonoverlapping 95% confidence intervals (CI) for season, geographic region, and breed specific proportions of dogs with JDM were considered statistically significantly different. The study included 933 dogs with mature onset DM and 27 dogs with JDM. Dogs were diagnosed with DM significantly more in the winter and northern USA compared to all other seasons and all other geographic regions, respectively. The prevalence of JDM among dogs with DM was 2.8%. The proportion of dogs with JDM among pure breeds was not significantly different than the proportion of JDM in mixed breed dogs. It is concluded that winter and cold climate could be shared environmental factors influencing DM expression in dogs and humans. Additionally, pure breed dogs do not appear to be at increased risk for JDM compared to mixed breed dogs, indicating that factors other than genetics could influence spontaneous JDM development in dogs.

The Risk of Incarceration During Nonoperative Management of Incisional Hernias: A Population-based Analysis of 30,998 Patients.

OBJECTIVE: The aim of the study was to quantify the risk of incarceration of incisional hernias. BACKGROUND: Operative repair is the definitive treatment for incisional ventral hernias but is often deferred if the perceived risk of elective operation is elevated secondary to comorbid conditions. The risk of incarceration during nonoperative management (NOM) factors into shared decision making by patient and surgeon; however, the incidence of acute incarceration remains largely unknown. METHODS: A retrospective analysis of adult patients with an International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis of incisional hernia was conducted from 2010 to 2017 in 15 hospitals of a single healthcare system. The primary outcome was incarceration necessitating emergent operation. The secondary outcome was 30-, 90-, and 365-day mortality. Univariate and multivariate analyses were used to determine independent predictors of incarceration. RESULTS: Among 30,998 patients with an incisional hernia (mean age 58.1 ±â€Š15.9 years; 52.7% female), 23,022 (78.1%) underwent NOM of whom 540 (2.3%) experienced incarceration, yielding a 1- and 5-year cumulative incidence of 1.24% and 2.59%, respectively. Independent variables associated with incarceration included: age older than 40 years, female sex, current smoker, body mass index 30 or greater, and a hernia-related inpatient admission. All-cause mortality rates at 30, 90, and 365 days were significantly higher in the incarceration group at 7.2%, 10%, and 14% versus 1.1%, 2.3%, and 5.3% in patients undergoing successful NOM, respectively. CONCLUSIONS: Incarceration is an uncommon complication of NOM but is associated with a significant risk of death. Tailored decision making for elective repair and considering the aforementioned risk factors for incarceration provides an initial step toward mitigating the excess morbidity and mortality of an incarceration event.

Transradial versus transfemoral arterial access in the uterine artery embolization of fibroids.

Purpose: Transradial arterial access has become more popular in body interventional procedures but has not been ubiquitously adapted. This retrospective study assesses the efficacy of this approach in uterine artery embolization. Aim of the study was to compare transradial to transfemoral arterial access in patients undergoing uterine artery embolization for the treatment of fibroids. Material and methods: A total of 172 patients underwent uterine artery embolization procedures at our institute from October 2014 to June 2020. Of these, 76 patients had their operations performed via transfemoral access while 96 underwent transradial access. The peak radiation dose, fluoroscopy time, procedure time, total contrast volume, and equipment cost for each procedure were all reviewed to evaluate for statistical differences between the 2 groups. Results: All cases were technically successful without major complications. The average peak skin dose was 2281 mGy,with no statistical difference between the transradial or transfemoral cohorts. Average fluoroscopy time was 25 minutes, also with no statistical difference between the subsets. Mean procedure time was 100 min, and mean contrast volume usage was 138 mL with no statistical differences. Similarly, the average equipment cost was $2204, with no significant differences found between transradial and transfemoral access. Conclusions: With respect to many pertinent radiation parameters, transradial access was evaluated as being an equally efficacious alternative to transfemoral access in uterine artery embolization procedures. The results of this study suggest that transradial access should be considered more often, whenever viable, as an option in the uterine artery embolization treatment of fibroids.

Deep Learning Prediction of Voxel-Level Liver Stiffness in Patients with Nonalcoholic Fatty Liver Disease.

PURPOSE: To reconstruct virtual MR elastography (MRE) images based on traditional MRI inputs with a machine learning algorithm. MATERIALS AND METHODS: In this single-institution, retrospective study, 149 patients (mean age, 58 years ± 12 [standard deviation]; 71 men) with nonalcoholic fatty liver disease who underwent MRI and MRE between January 2016 and January 2019 were evaluated. Nine conventional MRI sequences and clinical data were used to train a convolutional neural network to reconstruct MRE images at the per-voxel level. The architecture was further modified to accept multichannel three-dimensional inputs and to allow inclusion of clinical and demographic information. Liver stiffness and fibrosis category (F0 [no fibrosis] to F4 [significant fibrosis]) of reconstructed images were assessed by using voxel- and patient-level agreement by correlation, sensitivity, and specificity calculations; in addition, classification by receiver operator characteristic analyses was performed, and Dice score was used to evaluate hepatic stiffness locality. RESULTS: The model for predicting liver stiffness incorporated four image sequences (precontrast T1-weighted liver acquisition with volume acquisition [LAVA] water and LAVA fat, 120-second-delay T1-weighted LAVA water, and single-shot fast spin-echo T2 weighted) and clinical data. The model had a patient-level and voxel-level correlation of 0.50 ± 0.05 and 0.34 ± 0.03, respectively. By using a stiffness threshold of 3.54 kPa to make a binary classification into no fibrosis or mild fibrosis (F0-F1) versus clinically significant fibrosis (F2-F4), the model had sensitivity of 80% ± 4, specificity of 75% ± 5, accuracy of 78% ± 3, area under the receiver operating characteristic curve of 84 ± 0.04, and a Dice score of 0.74. CONCLUSION: The generation of virtual elastography images is feasible by using conventional MRI and clinical data with a machine learning algorithm.Keywords: MR Imaging, Abdomen/GI, Liver, Cirrhosis, Computer Applications/Virtual Imaging, Experimental Investigations, Feature Detection, Classification, Reconstruction Algorithms, Supervised Learning, Convolutional Neural Network (CNN) Supplemental material is available for this article. © RSNA, 2021.

Heritability and complex segregation analysis of diabetes mellitus in American Eskimo Dogs.

BACKGROUND: Heritability and mode of inheritance of spontaneous diabetes mellitus (DM) in American Eskimo Dogs (AED) are unknown. OBJECTIVE: Investigate the heritability and mode of inheritance of DM in AED. ANIMALS: An extended family of AED including 71 AED without DM, 47 AED with an unknown phenotype, and 38 AED with spontaneous DM. METHODS: Retrospective evaluation of inheritance. A logistic regression model was formulated to evaluate the heritability of DM, including effects of sex and neuter status. Subsequently, complex segregation analysis was employed to investigate the inheritance pattern of DM in AED. Six plausible models were considered, and the Akaike Information Criterion was used to determine the best of the biologically feasible models of inheritance of DM in AED. RESULTS: Heritability of DM in AED is estimated at 0.62 (95% posterior interval 0.01-0.99). Predicted DM probabilities for neutered females (NF), intact females (IF), neutered males (NM), and intact males (IM) were 0.76, 0.11, 0.63, and 0.12, respectively. There was no overlap between the 95% posterior intervals of disease probabilities in NF and IF or in NF and IM. Complex segregation analysis suggested that the mode of inheritance of DM in AED is polygenic, with no evidence for a single gene of large effect. CONCLUSIONS AND CLINICAL IMPORTANCE: The estimated heritability of DM in AED is high but has low precision. Diabetes mellitus transmission in AED appears to follow a polygenic inheritance. Breeders could successfully implement a breeding program to decrease the incidence of DM in AED.

The "Crumple Zone" hypothesis: Association of frontal sinus volume and cerebral injury after craniofacial trauma.

PURPOSE: The paranasal sinuses are complex anatomical structures of unknown significance. One hypothesis theorizes that the sinuses, in the event of a traumatic injury, function as a crumple zone to distribute and absorb energy to protect the brain and other critical structures. The current study investigates the association between frontal sinus (FS) volume and the severity of cerebral insults following craniofacial trauma. METHODS: All patients with FS fracture admitted to a level 1 trauma center from 2011 to 2014 were retrospectively reviewed. FS volumes were measured from computed tomography (CT) on admission using a proprietary region growing segmentation tool. Head injuries were classified based on the presence of specific types of intracranial pathology and their corresponding Marshall Score. RESULTS: FS fracture was identified on the admission CT in 165 patients. Male patients had significantly larger FS volume compared to females (8.4 ± 6.3 vs. 4.0 ± 2.9 cm3, p < 0.001). Smaller FS volume was significantly associated with a worse Marshall Score (p = 0.041) and a higher incidence of cerebral contusion (p = 0.016) independent of age, gender, mechanism, ISS, and admission GCS. The inverse correlation between FS volume and the Marshall Score was also statistically significant (Spearman correlation coefficient r = -0.19, p = 0.015). Smaller FS volume was observed in patients who suffered intracranial insults, underwent neurosurgical interventions, and had worse clinical outcomes and trended towards significance with respect to an association with subarachnoid hemorrhage (p = 0.074) and subdural hematoma (p = 0.080), and had a statistically significant association with longer length of stay (p < 0.001). CONCLUSION: FS volume is inversely correlated with the severity of intracranial pathology following craniofacial trauma. Our findings are consistent with the "crumple zone" hypothesis and suggest that the FS likely plays a role in mitigating intracranial injury. Furthermore, FS volume is significantly different between male and female patients. This is a novel finding that warrants further validation.

Use of negative pressure wound therapy on malignant wounds - a case report and review of literature.

The presence of malignancy is considered a contraindication to the use of negative pressure wound therapy (NPWT) because of concerns that it may promote tumourigenesis and expedite metastasis. This notion is extrapolated from studies evaluating NPWT in normal tissues. Despite the absence of direct evidence, the use of this technology in malignant wounds is widely considered a contraindication. We present the case of a patient with treatment-resistant metastatic colon cancer, who developed a chronic abdominal wound with positive margins. A staged reconstruction using NPWT was performed and wound closure allowed the patient to meet eligibility criteria and enrol in a clinical trial for treatment of his oncological disease. Skin closure remained intact until the patient expired 6 months after the wound closure. This case, as well as others in the literature, demonstrated that the use of NPWT should not be considered an absolute contraindication in malignancy. Individualised approaches taking into account the patient's clinical scenario, the available evidence, as well as the risks and benefits of this technology are recommended.

Migratory stroke-like lesions in a case of adult-onset mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome and a review of imaging findings.

Imaging findings of adult-onset mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome is poorly documented. The authors present a 48-year-old woman with subacute onset of word-finding difficulties and right arm stiffness. Magnetic resonance imaging performed 2 weeks prior revealed left temporal lobe diffusion and fluid-attenuated inversion recovery hyperintensity predominantly involving the cortex. The apparent diffusion coefficient map showed preserved signal in the temporal cortex. Subsequent magnetic resonance imagings demonstrated a new diffusion signal abnormality extending to the left parietal cortex and occipital cortex with resolving diffusion hyperintensity in the temporal lobe. MR spectroscopy showed scattered areas of lactate deposition. Diagnosis of MELAS syndrome was confirmed by genetic analysis. Fluctuating, migratory stroke-like lesions with a predilection for the parietal, temporal, and occipital cortex that do not conform to a vascular territory and a lactate spike at 1.3 ppm on MR spectroscopy are characteristic of MELAS syndrome. Preserved signal intensity on apparent diffusion coefficient is useful to distinguish MELAS syndrome from ischemic infarction where the signal is typically reduced.

A Case Series of Complex Recalcitrant Wounds Treated with Epidermal Grafts Harvested from an Automated Device.

INTRODUCTION: Epidermal grafting has several advantages over full-thickness or split-thickness grafts in the treatment of complex non-healing wounds. These include the low risk of donor site complications, minimal patient discomfort, and abstention from the operating room. Traditionally, the lack of reliable epidermal harvesting techniques has limited its clinical utilization. The development of an automated suction blister epidermal graft (SBEG) harvesting device may facilitate clinical utilization of this technique. The authors present a case series of multimorbid patients who were poor surgical candidates and were treated with this technique. METHODS: A retrospective review of all patients treated with CelluTome™â€‹ Epidermal Harvesting System (KCI, an Acelity company, San Antonio, TX) prior to May 2016 at our institution was conducted. RESULTS: A total of 12 patients underwent 14 epidermal grafting procedures. Multiple comorbidities were identified, including smoking (33%), immunosuppression by immunotherapy or steroids (25%), chronic venous insufficiency (25%), diabetes mellitus (25%), malignancy (25%), polysubstance abuse (17%), HIV/AIDS (17%), and peripheral artery disease (8%). Among the two acute wounds (≤ 3 months) and 10 chronic wounds, the average wound size was 49.1 cm2 (± 77.6 cm2) and the median wound duration was 5.7 months (interquartile range: 4.1 - 15.8 months) before SBEG was attempted. These complex wounds had failed prior therapies, such as local wound care (100%), incision and drainage (58%), vacuum-assisted closure (33%), split-thickness skin graft (16%), and hyperbaric oxygen (8%). Following the procedure, all donor sites healed within one week. Three patients were lost to follow-up. Of the remaining nine patients, four patients had complete resolution of their wounds at a median follow-up of 13.1 weeks (interquartile range: 6.8-17.3 weeks). Among those with partial resolutions, the average wound size was 4.2 cm2 (± 2.1 cm2) with an average wound reduction of 79% (± 23%). No donor or recipient site complications were observed. CONCLUSIONS: The automated SBEG harvesting device is an effective and safe option for treating complex non-healing wounds in multimorbid patients who may be poor surgical candidates. This procedure demonstrates minimal contraindications to its use and donor or recipient site complications.

The role of cardiac troponin I in prognostication of patients with isolated severe traumatic brain injury.

BACKGROUND: Cardiac dysfunction is frequently observed after severe traumatic brain injury (sTBI); however, its significance is poorly understood. Our study sought to elucidate the association of cardiac troponin I (cTnI) elevation with all-cause in-hospital mortality following isolated sTBI (brain Abbreviated Injury Scale score ≥3 and admission Glasgow Coma Scale score ≤8, no Abbreviated Injury Scale score ≥3 to any other bodily regions). METHODS: We retrospectively reviewed all adult patients (aged ≥18 years) with isolated sTBI admitted to a Level I trauma center between June 2007 and January 2014. Patients must have cTnI values within 24 hours of admission. Mortality risks were examined by Cox proportional hazard model. RESULTS: Of 580 patients identified, 30.9% had detectable cTnI in 24 hours of admission. The median survival time was 4.19 days (interquartile range, 1.27-11.69). When adjusted for potential confounders, patients in the highest cTnI category (≥0.21 ng/mL) had a significantly higher risk of in-hospital mortality (hazard ratio, 1.39; 95% confidence interval, 1.04-1.88) compared with patients with undetectable cTnI. Mortality risk increased with higher troponin levels (p < 0.0001). This association was more pronounced in patients aged 65 years or younger (hazard ratio, 2.28; 95% confidence interval, 1.53-3.40; p < 0.0001) while, interestingly, insignificant in those older than 65 years (p = 0.0826). CONCLUSION: Among patients with sTBI, cTnI elevation is associated with all-cause in-hospital mortality via a nonlinear positive trend. Age modified the effect of cTnI on mortality. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Management of Mycobacterium abscessus Infection After Medical Tourism in Cosmetic Surgery and a Review of Literature.

INTRODUCTION: Despite news reports, Food and Drug Administration disclaimers, and warnings from US plastic surgeons against the perils of cosmetic tourism, patients continue to seek care abroad and often present with infectious complications. Recent reports of Mycobacterium abscessus surgical site infection (SSI) is of particularly concern and its management, particularly surgical intervention, has been poorly documented. METHODS: A retrospective review of 2 sisters who presented with M. abscessus SSI after cosmetic surgery in the Dominican Republic was performed. A comprehensive review of the literature was conducted to unveil similar cases after cosmetic tourism. RESULTS: Both patients presented four months after index operation after definitive diagnoses have been reached. They were counselled to undergo immediate, aggressive debridement and antibiotic therapy. Although 1 patient agreed, the other patient opted for local wound care and oral antibiotics in hopes to avoid reoperation. When unsuccessful, she agreed to the initial plan which led to rapid convalescence of her infection. However, aesthetic result was far inferior to the first patient. Review of literature revealed 14 women with an average age of 40 years (range, 19-60 years). Most frequent cosmetic operations that resulted in M. abscessus SSI were abdominoplasty (41%), liposuction (27%), breast augmentation (14%), breast reduction (9%), and rejuvenation surgery (9%). Surgical interventions were performed in all cases except one. Antibiotic therapies focused on macrolides, particularly clarithromycin or azithromycin, with average time to complete recovery of 8 months (range, 2-22 months). CONCLUSIONS: The 2 cases highlighted the importance of multidisciplinary approach of early aggressive surgical intervention and long-term intravenous antibiotics in treating M. abscessus SSI that is highly prevalent among those returning from medical tourism in cosmetic surgery.

Troponin elevations only detected with a high-sensitivity assay: clinical correlations and prognostic significance.

OBJECTIVES: With clinical use of high-sensitivity troponin I (hsTnI), more frequent troponin elevations will occur. However, the burden and implications of these elevations are not well understood. The authors quantified the prevalence of elevated hsTnI in patients presenting with possible acute coronary syndrome (ACS) who do not have elevated troponin with a current generation assay (cardiac troponin I [cTnI]) and determined the association of these newly detected elevations with a composite of all-cause mortality and subsequent cardiac hospitalization. METHODS: This was a prospective observational study of 808 subjects evaluated for possible ACS and followed for up to 1 year. Troponin values were measured with hsTnI (Abbott Laboratories) and cTnI (Abbott and Beckman Coulter). Cardiac hospitalization was defined as hospitalization for ACS, revascularization, acute heart failure (AHF), or tachy/brady arrhythmia that occurred after the index emergency department (ED) visit or hospital discharge. RESULTS: Forty subjects (5%) were diagnosed with ACS (26 myocardial infarction and 14 unstable angina). On the initial sample, the prevalence of elevated hsTnI among subjects with nonelevated cTnI was 9.2% using a gender-neutral cutoff (95% confidence interval [CI] = 7.1% to 11.4%) and 11.1% using a gender-specific cutoff (95% CI = 8.8% to 13.4%). Adjudicated diagnoses for subjects whose initial samples had elevated hsTnI but nonelevated cTnI (gender-neutral cutoff) were as follows: three (4.6%) ACS, 15 (23.1%) AHF, three (4.6%) volume overload etiology unclear/noncardiac, three (4.6%) cardiac (non-ACS), and 41 (63.1%) other. Of the 65 patients whose initial samples had hsTnI but nonelevated cTnI, eight developed cTnI elevation on subsequent serial sampling. After traditional cardiovascular risk factors and renal function were adjusted for, subjects with elevated initial hsTnI but nonelevated cTnI (initial and serial sampling) had a higher risk of all-cause mortality and subsequent cardiac hospitalization than subjects with both nonelevated hsTnI and nonelevated cTnI (hazard ratio [HR] = 1.91, 95% CI = 1.14 to 3.19). CONCLUSIONS: On the initial sample, 9% to 11% of subjects without cTnI elevation had hsTnI elevation. Although the majority of the patients with these newly detected hsTnI elevations did not have ACS, they had a higher risk for all-cause mortality and subsequent cardiac hospitalization.