Imaging Patients with Kidney Failure.

The approach to imaging a patient with kidney failure continues to evolve. Overstatement of the risk of iodinated contrast material-induced (ie, contrast-induced) acute kidney injury and new guidelines for administration of gadolinium-based contrast media affect screening and the choice of contrast material. Treatment of kidney failure requires dialysis or a kidney transplant. Pretransplant imaging includes assessment for the feasibility of performing a transplant and evaluation for underlying malignancy and peripheral vascular disease. Patients with kidney failure are at high risk for renal cell carcinoma. Subtypes that occur exclusively or more commonly in patients with kidney failure, such as acquired cystic kidney disease, renal cell carcinoma, and clear cell papillary renal cell carcinoma, have specific clinical-pathologic characteristics, with indolent behavior. Performing US for dialysis planning increases the success of placement of an arteriovenous fistula, while postoperative US evaluation is essential in assessment of access dysfunction. Systemic manifestations in patients with kidney failure are multifactorial and may relate to the underlying cause of renal failure or may be secondary to treatment effects. Disturbances in mineral and bone metabolism and soft-tissue and vascular calcifications are seen in patients with chronic kidney disease and mineral bone disorder. Neurologic and cardiothoracic complications are also common. The authors provide a comprehensive overview of imaging considerations for patients with kidney failure, including the appropriate use of CT, MRI, and US with their respective contrast agents; the use of imaging in transplant workup and dialysis assessment; and the common renal and extrarenal manifestations of kidney failure. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Fetal Echocardiographic Variables Associated with Pre-Surgical Mortality in Truncus Arteriosus: A Pilot Study.

Truncus arteriosus (TA) is a rare congenital heart defect that can be prenatally detected by fetal echocardiography. However, prognostication and prenatal counseling focus primarily on surgical outcomes due to limited fetal and neonatal pre-surgical mortality data. We aimed to describe the incidence and identify predictors of pre-surgical mortality in prenatally detected TA. This two-center, retrospective cohort study included fetuses diagnosed with TA between 01/2010 and 04/2020. The primary outcome was pre-surgical mortality, defined by fetal or neonatal pre-surgical death or primary listing for transplantation prior to discharge. Univariable regression modeling, Chi-square tests, and t tests assessed for associations between prenatal clinical, demographic, and fetal echocardiographic (fetal-echo) variables and pre-surgical mortality. Of 23 pregnancies with prenatal diagnosis of TA, 4 (17%) were terminated. Of the remaining 19, pre-surgical mortality occurred in 4 (26%), including 2 (11%) fetal deaths and 2 (11%) neonatal pre-surgical deaths. No transplantation listings. Of liveborn fetuses (n = 17), 15 (88%) underwent a neonatal surgery, and 1 (6%) required ECMO. As compared to the survivors, the pre-surgical mortality group had a higher likelihood of having left ventricular dysfunction (0% vs. 40%; p = 0.01), right ventricular dysfunction (0% vs. 60%; p = 0.002), cardiovascular profile score < 7 (0% vs. 40%; p = 0.01), skin edema (0% vs. 40%; p = 0.01), and abnormal umbilical venous (UV) Doppler (0% vs. 60%; p = 0.002). The presence of truncal valve regurgitation or stenosis neared significance. In this cohort with prenatally diagnosed TA, there is significant pre-surgical mortality, including fetal death and neonatal pre-surgical death. Termination rate is also high. Fetal-echo variables associated with pre-surgical mortality in this cohort include ventricular dysfunction, low CVP, skin edema, and abnormal UV Doppler. Knowledge about prenatal risk factors for pre-surgical mortality may guide parental counseling and postnatal planning in prenatally diagnosed TA.

Aortic root dilation in adult patients with Marfan syndrome: Does aortic root stiffness matter?

Objective: Aortic root (AoR) size remains an imperfect predictor of rate of aortic dilation in Marfan syndrome (MFS). Indicators of vascular phenotype such as aortic stiffness have been proposed as additional predictors. In this study we assessed the rate of AoR dilation and stiffness in adult patients with MFS. Methods: We performed a retrospective chart review. We included adult patients with MFS (aged 20-40 years) with at least 2 local echocardiograms 6 months apart (no aortic surgery in-between). A blinded observer analyzed the echocardiograms. AoR dilation rate and stiffness were calculated. Results: Thirty-two patients (53% women; median age, 21.1; interquartile range [IQR], 19-24 years at first echocardiogram) were included. AoR dilation rate in the entire cohort was 0 to 8 mm/year (median, 0.465; IQR, 0.23-1.45 mm/year). Multiple linear regression analysis showed that baseline AoR stiffness was associated with AoR dilation rate (ß = 0.0004; P < .001 for elastic modulus), whereas baseline age and baseline AoR dimension were not. Eighteen of these 32 patients (56%) eventually had AoR surgery (Sx) and 14 did not have surgery (NSx). At baseline, Sx and NSx patients were similar in age. AoR dimension was larger (Sx, 4.27 cm; IQR, 4.05-4.49 cm vs NSx, 3.73 cm; IQR, 3.37-4.09 cm; P = .011) and AoR stiffness was higher in Sx patients (beta stiffness index: median, 23.2; IQR, 17.8-28.6 vs median, 15.6; IQR, 11.6-19.7; P = .024). AoR dilation rate was greater in Sx patients, independent of baseline AoR dimension (1.63 ± 0.41 mm/year vs 0.38 ± 0.08 mm/year; P = .01). Conclusions: Our results showed that AoR dilation rate varies among adult patients with MFS and is associated with baseline AoR stiffness, measured by echocardiography. Further studies are warranted to determine how aortic stiffness can be implemented clinically to refine management in patients with MFS.

Focal Nodular Hyperplasia and Focal Nodular Hyperplasia-like Lesions.

Focal nodular hyperplasia (FNH) is a benign lesion occurring in a background of normal liver. FNH is seen most commonly in young women and can often be accurately diagnosed at imaging, including CT, MRI, or contrast-enhanced US. In the normal liver, FNH frequently must be differentiated from hepatocellular adenoma, which although benign, is managed differently because of the risks of hemorrhage and malignant transformation. When lesions that are histologically identical to FNH occur in a background of abnormal liver, they are termed FNH-like lesions. These lesions can be a source of diagnostic confusion and must be differentiated from malignancies. Radiologists' familiarity with the imaging appearance of FNH-like lesions and knowledge of the conditions that predispose a patient to their formation are critical to minimizing the risks of unnecessary intervention for these lesions, which are rarely symptomatic and carry no risk for malignant transformation. FNH is thought to form secondary to an underlying vascular disturbance, a theory supported by the predilection for formation of FNH-like lesions in patients with a variety of hepatic vascular abnormalities. These include abnormalities of hepatic outflow such as Budd-Chiari syndrome, abnormalities of hepatic inflow such as congenital absence of the portal vein, and hepatic microvascular disturbances, such as those that occur after exposure to certain chemotherapeutic agents. Familiarity with the imaging appearances of these varied conditions and knowledge of their association with formation of FNH-like lesions allow radiologists to identify with confidence these benign lesions that require no intervention. Online supplemental material is available for this article. ©RSNA, 2022.

Impact of Maternal Hyperoxygenation on Myocardial Deformation and Loading Conditions in Fetuses with and without Left Heart Hypoplasia.

BACKGROUND: Maternal hyperoxygenation (MHO) is used in a variety of clinical applications, but its impact on fetal cardiovascular physiology is poorly understood. Our aims were to describe the effects of MHO on myocardial deformation parameters and on ultrasound-based metrics of preload and afterload and to assess the differential effect of MHO on fetuses with left heart hypoplasia (LHH). We hypothesized that the effects of MHO would be modulated by loading conditions and that fetuses with LHH would be more sensitive to changes in preload and afterload induced by MHO. METHODS: We performed a post hoc analysis of 36 fetal echocardiograms performed as part of a pilot study of MHO in LHH (n = 9) and control (n = 9) fetuses. Oxygen was administered via 8 L face mask for 10 minutes. Right ventricular (RV) and left ventricular (LV) longitudinal strain and strain rate, estimated aortic and pulmonary cardiac output, pulmonary vein velocity-time integral (VTI) and pulsatility indices (PI) of the middle cerebral artery (MCA), pulmonary arteries (PA), and umbilical artery (UA) were measured at three time points: baseline, during MHO, and 10 minutes after removal of MHO. RESULTS: Maternal hyperoxygenation induced decreases in LV strain and strain rate and increases in RV strain and strain rate. Pulmonary artery PI decreased and pulmonary vein VTI increased, suggesting decreased pulmonary vascular resistance and increased pulmonary venous return. Most findings did not return to baseline after removal of MHO. We found no significant effect of MHO on MCA or UA PI. Left heart hypoplasia cases demonstrated similar effects of MHO in control cases, with larger changes in pulmonary vein VTI and LV strain rate. CONCLUSION: The effects of MHO on LV and RV mechanics suggest that changes in deformation indices may be explained by increases in LV preload and decreases in RV afterload. The time period for recovery of fetal hemodynamics from MHO is ill-defined.

Multiinstitutional Evaluation of the Liver Surface Nodularity Score on CT for Staging Liver Fibrosis and Predicting Liver-Related Events in Patients With Hepatitis C.

BACKGROUND. In single-institution multireader studies, the liver surface nodularity (LSN) score accurately detects advanced liver fibrosis and cirrhosis and predicts liver decompensation in patients with chronic liver disease (CLD) from hepatitis C virus (HCV). OBJECTIVE. The purpose of this study was to assess the diagnostic performance of the LSN score alone and in combination with the (FIB-4; fibrosis index based on four factors) to detect advanced fibrosis and cirrhosis and to predict future liver-related events in a multiinstitutional cohort of patients with CLD from HCV. METHODS. This retrospective study included 40 consecutive patients, from each of five academic medical centers, with CLD from HCV who underwent nontargeted liver biopsy within 6 months before or after abdominal CT. Clinical data were recorded in a secure web-based database. A single central reader measured LSN scores using software. Diagnostic performance for detecting liver fibrosis stage was determined. Multivariable models were constructed to predict baseline liver decompensation and future liver-related events. RESULTS. After exclusions, the study included 191 patients (67 women, 124 men; mean age, 54 years) with fibrosis stages of F0-F1 (n = 37), F2 (n = 44), F3 (n = 46), and F4 (n = 64). Mean LSN score increased with higher stages (F0-F1, 2.26 ± 0.44; F2, 2.35 ± 0.37; F3, 2.42 ± 0.38; F4, 3.19 ± 0.89; p < .001). The AUC of LSN score alone was 0.87 for detecting advanced fibrosis (≥ F3) and 0.89 for detecting cirrhosis (F4), increasing to 0.92 and 0.94, respectively, when combined with FIB-4 scores (both p = .005). Combined scores at optimal cutoff points yielded sensitivity of 75% and specificity of 82% for advanced fibrosis, and sensitivity of 84% and specificity of 85% for cirrhosis. In multivariable models, LSN score was the strongest predictor of baseline liver decompensation (odds ratio, 14.28 per 1-unit increase; p < .001) and future liver-related events (hazard ratio, 2.87 per 1-unit increase; p = .03). CONCLUSION. In a multiinstitutional cohort of patients with CLD from HCV, LSN score alone and in combination with FIB-4 score exhibited strong diagnostic performance in detecting advanced fibrosis and cirrhosis. LSN score also predicted future liver-related events. CLINICAL IMPACT. The LSN score warrants a role in clinical practice as a quantitative marker for detecting advanced liver fibrosis, compensated cirrhosis, and decompensated cirrhosis and for predicting future liver-related events in patients with CLD from HCV.

The Effect of Exenatide Once Weekly on Carotid Atherosclerosis in Individuals With Type 2 Diabetes: An 18-Month Randomized Placebo-Controlled Study.

OBJECTIVE: Glucagon-like peptide 1 receptor agonists (GLP-1RAs) improved multiple proatherogenic risk factors and reduced cardiovascular events in recent clinical trials, suggesting that they may slow progression of atherosclerosis. We tested whether exenatide once weekly reduces carotid plaque progression in individuals with type 2 diabetes. RESEARCH DESIGN AND METHODS: In a double-blind, pragmatic trial, 163 participants were randomized (2:1) to exenatide (n = 109) or placebo (n = 54). Changes in carotid plaque volume and composition were measured at 9 and 18 months by multicontrast 3 Tesla MRI. Fasting and post-high-fat meal plasma glucose and lipids, and endothelial function responses, were measured at 3, 9, and 18 months. RESULTS: Exenatide reduced hemoglobin A1c (HbA1c) (estimated difference vs. placebo 0.55%, P = 0.0007) and fasting and postmeal plasma glucose (19 mg/dL, P = 0.0002, and 25 mg/dL, P < 0.0001, respectively). Mean (SD) change in plaque volume in the exenatide group (0.3% [2%]) was not different from that in the placebo group (-2.2% [8%]) (P = 0.4). The change in plaque volume in the exenatide group was associated with changes in HbA1c (r = 0.38, P = 0.0004), body weight, and overall plasma glucose (r = 0.29, P = 0.007 both). There were no differences in changes in plaque composition, body weight, blood pressure, fasting and postmeal plasma triglycerides, and endothelial function between the groups. CONCLUSIONS: Exenatide once weekly for up to 18 months improved fasting and postprandial glycemic control but did not modify change in carotid plaque volume or composition. This study raises the possibility that short-term antiatherosclerotic effects may not play a central role in the cardiovascular benefits of GLP-1RAs.

Using qualitative descriptors of chronic liver disease on MRI: A practice prone to error.

PURPOSE: Assess accuracy of qualitative descriptors for chronic liver disease (CLD) in radiology reports compared to histopathological staging. METHODS: Database search for patients with hepatitis B/C (HBV/HCV) CLD, abdominal MRI during 2009-2016, and liver biopsy within 6 months of MRI or prior biopsy showing cirrhosis. Reports reviewed for mention of CLD and associated descriptors. Findings stratified into categories: normal/no mention of CLD; changes of CLD without qualitative descriptor; mild/early; moderate; severe/advanced and cirrhosis. Descriptive ranges categorized to the lesser degree. Percent concordance/discordance of descriptors and Scheuer stage (F0-F4), false positive (FP), false negative (FN) and sensitivity/specificity calculated. RESULTS: 309 patients, median age 54 (24-74). 91% had HCV (282/309), 7% HBV and 2% both HBV/HCV. Biopsy showed 19% without CLD/F0; 8% F1, 15% F2, 15% F3 and 43% F4. 188 MRI reports (61%) stated CLD was present; however, 16 had no fibrosis on histopathology (9% FP). 39% (121/309) did not mention or stated no CLD; however, 78 had CLD on histopathology (64% FN). 59% of FN were early fibrosis (F1 or F2), 27% F3 and 11% F4. Overall sensitivity and specificity was 69% and 73%, respectively. 77% (145/188) of MRI reports used a descriptive qualifier when describing CLD. 10% were concordant with exact histopathology staging. Of discordant reports, 90% identified CLD but under-called severity. CONCLUSION: Abdominal radiologists can detect CLD on MRI but degree of CLD is often under-called compared to histopathology suggesting radiologists should refrain from qualitative descriptors in assessing CLD on MRI and reaffirms the need for quantitative imaging.

An Operational Framework to Study Diagnostic Errors in Emergency Departments: Findings From A Consensus Panel.

OBJECTIVE: To create an operational definition and framework to study diagnostic error in the emergency department setting. METHODS: We convened a 17-member multidisciplinary panel with expertise in general and pediatric emergency medicine, nursing, patient safety, informatics, cognitive psychology, social sciences, human factors, and risk management and a patient/caregiver advocate. We used a modified nominal group technique to develop a shared understanding to operationally define diagnostic errors in emergency care and modify the National Academies of Sciences, Engineering, and Medicine's conceptual process framework to this setting. RESULTS: The expert panel defined diagnostic errors as "a divergence from evidence-based processes that increases the risk of poor outcomes despite the availability of sufficient information to provide a timely and accurate explanation of the patient's health problem(s)." Diagnostic processes include tasks related to (a) acuity recognition, information and synthesis, evaluation coordination, and (b) communication with patients/caregivers and other diagnostic team members. The expert panel also modified the National Academies of Sciences, Engineering, and Medicine's diagnostic process framework to incorporate influence of mode of arrival, triage level, and interventions during emergency care and underscored the importance of outcome feedback to emergency department providers to promote learning and improvement related to diagnosis. CONCLUSIONS: The proposed operational definition and modified diagnostic process framework can potentially inform the development of measurement tools and strategies to study the epidemiology and interventions to improve emergency care diagnosis.

B Cell Responses in the Development of Mammalian Meat Allergy.

Studies of meat allergic patients have shown that eating meat poses a serious acute health risk that can induce severe cutaneous, gastrointestinal, and respiratory reactions. Allergic reactions in affected individuals following meat consumption are mediated predominantly by IgE antibodies specific for galactose-α-1,3-galactose (α-gal), a blood group antigen of non-primate mammals and therefore present in dietary meat. α-gal is also found within certain tick species and tick bites are strongly linked to meat allergy. Thus, it is thought that exposure to tick bites promotes cutaneous sensitization to tick antigens such as α-gal, leading to the development of IgE-mediated meat allergy. The underlying immune mechanisms by which skin exposure to ticks leads to the production of α-gal-specific IgE are poorly understood and are key to identifying novel treatments for this disease. In this review, we summarize the evidence of cutaneous exposure to tick bites and the development of mammalian meat allergy. We then provide recent insights into the role of B cells in IgE production in human patients with mammalian meat allergy and in a novel mouse model of meat allergy. Finally, we discuss existing data more generally focused on tick-mediated immunomodulation, and highlight possible mechanisms for how cutaneous exposure to tick bites might affect B cell responses in the skin and gut that contribute to loss of oral tolerance.

The Natural and Unnatural History of Ventricular Septal Defects Presenting in Infancy: An Echocardiography-Based Review.

BACKGROUND: Ventricular septal defect (VSD), the most common congenital heart defect, accounts for 40% of heart malformations. Despite this prevalence, there remains no consensus on the utility of echocardiography to guide modern-era treatment. In this study, we evaluated patients with isolated VSDs to test the hypothesis that echocardiographic evidence of left ventricular (LV) volume overload and type of VSD are associated with surgical intervention and to identify useful echocardiographic indicators for management of VSDs in infants and children. METHODS: We reviewed 350 patients with VSDs diagnosed during the first year of life. Echocardiographic measurements were made at the time of diagnosis and at the endpoint. The VSD area was calculated using inner edge to inner edge dimensions obtained from two planes and indexed to body surface area. Aortic annulus dimension, left atrium to aortic root ratio, LV end-diastolic diameter, left atrial volume, VSD velocity-time integral, ejection fraction, and pulmonary to systemic blood flow ratio (Qp:Qs) were measured using conventional methods. RESULTS: One hundred seventy-seven muscular (50.5%) and 162 perimembranous (46%) VSDs accounted for the vast majority of defects. Only seven (4%) muscular defects required surgical closure, while 76 (47%) perimembranous defects required surgery. Indexed VSD area, VSD to aortic valve ratio, indexed left atrium volume, LV end-diastolic diameter, VSD velocity-time integral, and Qp:Qs at diagnosis were significantly different between the surgical and nonsurgical groups. Ventricular septal defect area > 50 mm2/m2 at initial diagnosis was independently associated with risk for surgery (P = .0055). CONCLUSIONS: Indexed VSD area is an echocardiographic variable that can be easily measured at diagnosis and can provide insight into the likelihood of requiring surgical intervention regardless of the type and location of the defect.

"Echo pause" for postoperative transthoracic echocardiographic surveillance.

BACKGROUND: No guidelines exist for inpatient postoperative transthoracic echocardiographic (TTE) surveillance in congenital heart disease. We prospectively evaluated indications for postoperative TTEs in patients with congenital heart disease to identify areas to improve upon (Phase 1) and then assessed the impact of a simple pilot intervention (Phase 2). METHODS: We included patients with RACHS-1 (Risk Adjustment for Congenital Heart Surgery) scores of 2 and 3 to keep the cohort homogenous. During Phase 1, we collected data prospectively to identify postoperative TTEs for which there were no new findings and no associated clinical management decisions ("potentially redundant" TTEs). During Phase 2, prior to placement of a TTE order, an "Echo Pause" was performed during rounds to prompt review of prior TTE results and indication for the current order. The number of "potentially redundant" TTEs during Phase 1 vs. Phase 2 was compared. RESULTS: During Phase 1, 98 postoperative TTEs were performed on 51 patients. Potentially "redundant" TTEs were identified in two main areas: (a) TTEs ordered to evaluate pericardial effusion and (b) TTEs ordered with the indication of "postoperative," "follow-up," or "discharge" in the setting of a prior complete postoperative TTE and no apparent change in clinical status. During Phase 2, 101 TTEs were performed on 63 patients. The number of "potentially redundant" TTEs decreased from 14/98 (14%) to 5/101 (5%) (P = .026). CONCLUSION: Our results suggest that the number of "potentially redundant" TTEs during inpatient postoperative surveillance of patients with congenital heart disease can be decreased by a simple intervention during rounds such as an "Echo Pause."

Cutaneous Exposure to Clinically Relevant Lone Star Ticks Promotes IgE Production and Hypersensitivity through CD4+ T Cell- and MyD88-Dependent Pathways in Mice.

Tick-borne allergies are a growing public health concern and have been associated with the induction of IgE-mediated food allergy to red meat. However, despite the increasing prevalence of tick bite-induced allergies, the mechanisms by which cutaneous exposure to ticks leads to sensitization and the production of IgE Abs are poorly understood. To address this question, an in vivo approach was used to characterize the IgE response to lone star tick proteins administered through the skin of mice. The results demonstrated that tick sensitization and challenge induced a robust production of IgE Abs and supported a role for IgE-mediated hypersensitivity reactions in sensitized animals following oral administration of meat. The induction of IgE responses was dependent on cognate CD4+ T cell help during both the sensitization phase and challenge phase with cutaneous tick exposure. In addition, IgE production was dependent on B cell-intrinsic MyD88 expression, suggesting an important role for TLR signaling in B cells to induce IgE responses to tick proteins. This model of tick-induced IgE responses could be used to study the factors within tick bites that cause allergies and to investigate how sensitization to food Ags occurs through the skin that leads to IgE production.

Active Surveillance Versus Nephron-Sparing Surgery for a Bosniak IIF or III Renal Cyst: A Cost-Effectiveness Analysis.

OBJECTIVE: The objective of our study was to evaluate the cost-effectiveness of active surveillance (AS) versus nephron-sparing surgery (NSS) in patients with a Bosniak IIF or III renal cyst. MATERIALS AND METHODS: Markov models were developed to estimate life expectancy and lifetime costs for 60-year-old patients with a Bosniak IIF or III renal cyst (the reference cases) managed by AS versus NSS. The models incorporated the malignancy rates, reclassification rates during follow-up, treatment effectiveness, complications and costs, and short- and long-term outcomes. An incremental cost-effectiveness analysis was performed to identify management preference under an assumed $75,000 per quality-adjusted life-year (QALY) societal willingness-to-pay threshold, using data from studies in the literature and the 2015 Medicare Physician Fee Schedule. The effects of key parameters were addressed in a multiway sensitivity analysis. RESULTS: The prevalence of malignancy for Bosniak IIF and III renal cysts was 26% (25/96) and 52% (542/1046). Under base case assumptions for Bosniak IIF cysts, the incremental cost-effectiveness ratio of NSS relative to AS was $731,309 per QALY for women, exceeding the assumed societal willingness-to-pay threshold, and AS outperformed NSS for both life expectancy and cost for men. For Bosniak III cysts, AS yielded greater life expectancy (24.8 and 19.4 more days) and lower lifetime costs (cost difference of $12,128 and $11,901) than NSS for men and women, indicating dominance of AS over NSS. Superiority of AS held true in sensitivity analyses for men 46 years old or older and women 57 years old or older even when all parameters were set to favor NSS. CONCLUSION: AS is more cost-effective than NSS for patients with a Bosniak IIF or III renal cyst.

An integrated framework using high-dimensional mass cytometry and fluorescent flow cytometry identifies discrete B cell subsets in patients with red meat allergy.

BACKGROUND: B cells play a critical role in the development and maintenance of food allergy by producing allergen-specific IgE. Despite the importance of B cells in IgE-mediated food allergy, the identity of sIgE-producing human B cells and how IgE is regulated are poorly understood. OBJECTIVE: To identify the immunophenotypes of circulating B cells associated with the production of galactose-alpha-1,3-galactose-specific IgE production in patients with red meat allergy. METHODS: B cells in PBMC samples obtained from 19 adults with physician-diagnosed red meat allergy and 20 non-meat allergic healthy controls were assessed by mass cytometry along with a bioinformatics analysis pipeline to identify discrete B cell phenotypes that associated with serum sIgE. Fluorescent flow cytometry was then applied to sort purify discrete B cell subsets, and B cells were functionally evaluated on an individual cell level for the production of sIgE by ELISPOT. RESULTS: Discrete B cell phenotypes abundant in meat allergic subjects compared to non-meat allergic controls were found in peripheral blood that do not share typical characteristics of classical isotype-switched memory B cells that express high levels of CD27. These B cell subsets shared higher IgD and lower IgM expression levels coupled with CXCR4, CCR6 and CD25 expression. In vitro polyclonal stimulation of purified B cell subsets from meat allergic subjects demonstrated that these subsets were enriched for cells induced to secrete sIgE. CONCLUSIONS AND CLINICAL RELEVANCE: Circulating B cells display increased abundance of discrete B cell subsets in meat allergic subjects. This observation, coupled with the capacity of individual B cell subsets to produce sIgE following activation, implicates these novel B cell phenotypes in promoting IgE in meat allergy.

Breastfeeding to 12 mo and beyond: nutrition outcomes at 3 to 5 y of age.

Background: Little is known about nutrition outcomes in preschoolers associated with breastfeeding duration beyond 12 mo of age. Objective: The aim was to examine the association between total breastfeeding duration and nutrition outcomes at 3 to 5 y of age. Design: A cross-sectional study in healthy children, ages 3-5 y, recruited from 9 primary care practices in Toronto was conducted through the TARGet Kids! (The Applied Research Group for Kids) research network. Parents completed standardized surveys, including the Nutrition Screening for Every Preschooler (NutriSTEP) used to assess nutrition risk. Results: A total of 2987 children were included. Ninety-two percent of children were breastfed, and the mean ± SD breastfeeding duration was 11.4 ± 8.4 mo. The prevalence of nutrition risk (score >20) was 17.0%. We examined breastfeeding duration as a continuous variable. With the use of restricted cubic spline modeling, we confirmed a nonlinear relation between breastfeeding duration and NutriSTEP score, dietary intake and eating behavior subscores, and sugar-sweetened beverage and sweet-savory snack consumption. Segmented linear regression was used to examine this nonlinear relation in a piecewise approach. We found a decreasing trend in NutriSTEP score for children who were breastfed for 0-6 mo (ß = -0.14; 95% CI: -0.29, 0.004), a significant decrease in NutriSTEP score for children breastfed for 6-12 mo (ß = -0.20; 95% CI: -0.33, -0.07), and no significant change after 12 mo (ß = 0.09; 95% CI: -0.07, 0.24) and beyond. The mean ± SD NutriSTEP scores were 17.1 ± 7.4 for no breastfeeding, 15.9 ± 6.5 for breastfeeding >0-6 mo, 13.9 ± 6.2 for >6-12 mo, 13.7 ± 6.3 for >12-18 mo, 14.6 ± 6.7 for >18-24 mo, and 14.3 ± 6.8 for >24-36 mo. Conclusions: Breastfeeding for ≤12 mo was associated with decreased nutrition risk and healthier eating behaviors and dietary intake at 3-5 y of age. We found insufficient evidence of additional benefit for breastfeeding beyond 12 mo of age. The TARGet Kids! practice-based research network is registered at www.clinicaltrials.gov as NCT01869530.

Investigating student perceptions at an interprofessional student-run free clinic serving marginalised populations.

Many health profession schools have student-run free clinics (SRFCs), but their educational relevance has not been well studied. The aim of this study was to evaluate the learning experiences and skills developed among interprofessional healthcare students at an SRFC serving marginalised populations, in order to provide data for ongoing programme improvement and recommendations for other SRFCs based on lessons learned. Under 1:1 supervision with a preceptor, interprofessional students completed three clinical shifts at an SRFC and attended a reflection session. A total of 101 out of 105 participants answered semi-structured pre- and post-programme surveys (response rate: 96%). Descriptive statistics and descriptive thematic analyses were used for quantitative and qualitative data, respectively. Numerous skills derived from learning objectives common to many healthcare professions were addressed while participating at the SRFC. Valued programme elements included working with and learning about inner city populations in an interprofessional care model. Interprofessional SRFCs encourage student learning about resources for inner city populations and interprofessional collaboration while providing an opportunity to develop skills related to the formal curriculum. This may provide a workable strategy to address an interprofessional education gap in the healthcare professional curriculum.

Abdominal Imaging Surveillance in Adult Patients After Fontan Procedure: Risk of Chronic Liver Disease and Hepatocellular Carcinoma.

PURPOSE: To assess the prevalence of chronic liver disease (CLD) and hepatocellular carcinoma (HCC) in adult patients who had surveillance imaging after Fontan procedure. METHODS: Institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study evaluated electronic medical records including radiology reports and clinical notes for adult patients after Fontan procedure between January 1993 and January 2016. Abdominal ultrasound, computed tomography, and magnetic resonance imaging reports were reviewed for changes of CLD and HCC. Existence of concomitant viral hepatitis was also recorded. RESULTS: A total of 145 patients (male: 78 and female: 67) had surveillance imaging after Fontan procedure. In all, 78% (113/145) had ongoing imaging surveillance (median follow-up 3.05 years, IQR: 0.75-5.3 years); 19% (21/113) had an initial normal study and remained normal throughout follow-up; 19% (21/113) had an initial normal study with subsequent imaging reporting changes of CLD; and 62% (71/113) had existing changes of CLD on initial study. HCC was identified in 5 patients (median 22 years post-Fontan, IQR: 10-29 years), 4 of which had a normal initial study. Only 1 patient with HCC had concomitant viral hepatitis C infection. CONCLUSION: Radiologists should be aware that CLD is exceedingly common in post-Fontan cardiac physiology, and surveillance imaging is warranted given the risk of HCC.

Paraduodenal pancreatitis: benign and malignant mimics at MRI.

Paraduodenal pancreatitis, also known as groove pancreatitis, is a rare form of chronic pancreatitis that masquerades as pancreatic adenocarcinoma affecting the pancreaticoduodenal groove, a potential space between the head of the pancreas, duodenum, and common bile duct. Two forms of groove pancreatitis have been described. The segmental form involves the pancreatic head with development of scar tissue within the groove, whereas the pure form affects the groove only, sparing the pancreatic head. Imaging findings of groove pancreatitis often overlap with primary duodenal, ampullary, or pancreatic neoplasms, which often results in a diagnostic challenge. In addition, paraduodenal pancreatitis can be mistaken for cystic pancreatic lesions, especially when there is involvement of the duodenal wall. Preoperative recognition of this entity is very important in order to avoid unnecessary procedures, although surgery, such as pancreaticoduodenectomy, may still be required to relieve obstructive symptoms. In this article, the pathophysiology and magnetic resonance imaging characteristics of paraduodenal pancreatitis and important benign and malignant mimics are discussed.