Utility of chest radiograph severity scoring in emergency department for predicting outcomes in COVID-19: A study of 1275 patients.

OBJECTIVE: To measure the reliability and reproducibility of a chest radiograph severity score (CSS) in prognosticating patient's severity of disease and outcomes at the time of disease presentation in the emergency department (ED) with coronavirus disease 2019 (COVID-19). MATERIALS AND METHODS: We retrospectively studied 1275 consecutive RT-PCR confirmed COVID-19 adult patients presenting to ED from March 2020 through June 2020. Chest radiograph severity score was assessed for each patient by two blinded radiologists. Clinical and laboratory parameters were collected. The rate of admission to intensive care unit, mechanical ventilation or death up to 60 days after the baseline chest radiograph were collected. Primary outcome was defined as occurrence of ICU admission or death. Multivariate logistic regression was performed to evaluate the relationship between clinical parameters, chest radiograph severity score, and primary outcome. RESULTS: CSS of 3 or more was associated with ICU admission (78 % sensitivity; 73.1 % specificity; area under curve 0.81). CSS and pre-existing diabetes were independent predictors of primary outcome (odds ratio, 7; 95 % CI: 3.87, 11.73; p < 0.001 & odds ratio, 2; 95 % CI: 1-3.4, p 0.02 respectively). No significant difference in primary outcome was observed for those with history of hypertension, asthma, chronic kidney disease or coronary artery disease. CONCLUSION: Semi-quantitative assessment of CSS at the time of disease presentation in the ED predicted outcomes in adults of all age with COVID-19.

Hearing Rehabilitation After Treatment of Sporadic Vestibular Schwannomas.

Background: Hearing preservation in vestibular schwannoma resection is a much-discussed topic in these times of functional preservation. Irrespective of the mode of treatment of large tumors, this becomes possible only in a lucky few. The overall burden of such deaf patients is on a rising trend, and therefore, it is high time neurosurgeons look into this often-neglected area of hearing rehabilitation. Objectives: In this review, the authors intend to provide a glimpse of available hearing rehabilitation modalities in the present era. Materials and Methods: : This review deals with both immediate and long-term hearing outcomes following both surgery and stereotactic radiosurgery for sporadic vestibular schwannoma and the need for hearing rehabilitation in these patients. Various databases, including PubMed, Medline/Medscape, Scopus, Cochrane, and Google Scholar were searched to find available literature on hearing rehabilitation after treatment of sporadic vestibular schwannoma. The searched MeSH terms were "Hearing", "Vestibular schwannoma", "Rehabilitation", and "Acoustic Neuroma", alone and in various combinations. Results: : The authors were surprised to find a paucity of literature. Even though neurosurgeons are at the forefront in managing vestibular schwannoma, they are not actively involved in hearing rehabilitation techniques possible for those who are rendered deaf following treatment. Conclusions: : The authors strongly believe that this review will be a wake-up call for neurosurgeons on a relatively untouched topic.

Chest imaging in pregnant patients with COVID-19: Recommendations, justification, and optimization.

Evaluation of COVID-19 related complication is challenging in pregnancy, due to concerns about ionizing radiation risk to mother and the fetus. Although there are instances when diagnostic imaging is clinically warranted for COVID-19 evaluation despite the minimal risks of radiation exposure, often there are concerns raised by the patients and sometimes by the attending physicians. This article reviews the current recommendations on indications of chest imaging in pregnant patients with COVID-19, the dose optimization strategies, and the risks related to imaging exposure during pregnancy. In clinical practice, these imaging strategies are key in addressing the complex obstetrical complications associated with COVID-19 pneumonia.

Utility of MRCP in surveillance of primary sclerosing cholangitis associated hepatobiliary malignancy: 15 year experience at a single institution in Ontario, Canada.

OBJECTIVE: Magnetic resonance cholangiopancreatography (MRCP) is used for the surveillance of primary sclerosing cholangitis (PSC) and its associated complications. The time interval gap for subsequent follow-up MRCP is variable depending on clinical practice patterns, therefore this study was done to assess the MRCP follow-up strategy used in our institution for screening PSC-associated hepatobiliary malignancies. MATERIALS AND METHODS: This retrospective observational cohort included MRCP studies in adult patients, with clinical and radiological diagnosis of PSC over the past 15-year period between January 1, 2003 to December 31, 2018. The study population was grouped based on the presence and absence of PSC-associated malignancy. The frequency of MRCP follow-up was compared between the groups to look for MRI ordering trends in surveillance for PSC-associated complications. RESULTS: The overall median interval follow-up with MRCP was 14 months. The median follow-up interval in cases with PSC-associated malignancy was 6.0 months, compared to 13.1 months in the PSC group without malignancy (p 0.013). During the study period, the PSC-associated malignancy group had a median number of 7.5 scans, while the no malignancy group had a median number of 4 scans. Three patients (3/10, 30%) developed hepatobiliary malignancies within the first year of clinical diagnosis of PSC. The most common malignancy associated with PSC was cholangiocarcinoma (4.6%,7/10). Other PSC-associated malignancies included carcinoma gallbladder (1.3%,2/10), and hepatocellular carcinoma (0.6%,1/10). The median age of PSC associated malignancies was 56 (IQR 15) and higher compared to median age of PSC group without malignancies 46 (IQR 25.5), p 0.035. CONCLUSION: The median interval for subsequent follow-up MRCP in our study cohort was 14 months. One-third of PSC-associated hepato-biliary malignancies developed within the first year of clinical diagnosis of PSC, and the risk of PSC-associated hepato-biliary malignancy is constant after the first year.

Abdominal CT manifestations in fish bone foreign body injuries: What the radiologist needs to know.

Fish bone is one of the most common foreign body ingestions encountered in the emergency department. Fish bone perforations occur most commonly in segments with acute angulation like the ileocecal region and rectosigmoid junction and can present acutely with obstruction and free air or with chronic complications like abscess and sepsis. Radiologists should be familiar with the high-risk clinical scenarios, the CT appearance of radiopaque fishbones, and the spectrum of imaging findings related to gastrointestinal (GI) tract so as to direct management and timely referral to GI endoscopists and surgeons.

Diagnostic accuracy and inter-observer agreement with the CO-RADS lexicon for CT chest reporting in COVID-19.

PURPOSE: To measure the diagnostic accuracy and inter-observer agreement with the use of COVID-19 Reporting and Data System (CO-RADS) for detection of COVID-19 on CT chest imaging. METHODS: This retrospective study included 164 consecutive patients with clinical suspicion of COVID-19 in whom a CT chest examination was performed at a single institution between April 2020 and July 2020. Of them, 101 patients was RT-PCR positive for COVID-19. Six readers with varying radiological experience (two each of chest radiologists, general radiologists, and radiologists in training) independently assigned a CO-RADS assessment category for each CT chest study. The Fleiss' K was used to quantify inter-observer agreement. The inter-observer agreement was also assessed based on the duration of onset of symptoms to CT scan. ROC curve analysis was used to determine the diagnostic accuracy of CO-RADS. The area under curve was calculated to determine the reader accuracy for detection of COVID-19 lung involvement with RT-PCR as reference standards. The data sets were plotted in ROC space, and Youden's J statistic was calculated to determine the threshold cut-off CO-RADS category for COVID-19 positivity. RESULTS: There was overall moderate inter-observer agreement between all readers (Fleiss' K 0.54 [95% CI 0.54, 0.54]), with substantial agreement among chest radiologists (Fleiss' K 0.68 [95% CI 0.67, 0.68]), general radiologists (Fleiss' K 0.61 [95% CI 0.61, 0.61]), and moderate agreement among radiologists-in-training (Fleiss' K 0.56 [95% CI 0.56, 0.56]). There was overall moderate inter-observer agreement in early disease (stages 1 and 2), with cumulative Fleiss' K 0.45 [95% CI 0.45, 0.45]). The overall AUC for CO-RADS lexicon scheme to accurately diagnose COVID-19 yielded 0.92 (95% CI 0.91, 0.94) with strong concordance within and between groups, of chests radiologists with AUC of 0.91 (95% CI 0.88, 0.94), general radiologists with AUC 0.96 (95% CI 0.94, 0.98), and radiologists in training with AUC of 0.90 (95% CI 0.87, 0.94). For detecting COVID-19, ROC curve analysis yielded CO-RADS > 3 as the cut-off threshold with sensitivity 90% (95% CI 0.88, 0.93), and specificity of 87% (95% CI 0.83, 0.91). CONCLUSION: Readers across different levels of experience could accurately identify COVID-19 positive patients using the CO-RADS lexicon with moderate inter-observer agreement and high diagnostic accuracy.

Endoscopic-Assisted Microsurgery for Vestibular Schwannomas: Operative Nuances.

Vestibular schwannoma surgery is a challenging operative procedure. Intricate anatomy of vital neurovascular structures demands a meticulous planning and execution. The cerebellopontine angle is an unforgiving area of skull bases surgery which can have grave implications on patient outcome even after a successful tumor removal. As more and more tumors are being detected at early stage, functional preservation of seventh and eighth nerve complex is increasingly being demanded. The key to any minimally invasive approach is to minimize the collateral damage while ensuring complete tumor removal. Binocular microscopy is the workhorse for illumination and dissection via retrosigmoid approach. However, as instrumentation has improved, endoscopic dissections are increasingly being performed. The following video presents the step-by-step nuances for an endoscope-assisted microsurgery for small vestibular schwannomas with stress on endoscopic drilling of the meatal wall to deliver out intracanacular tumor while preserving the labrynthine structures.

Utility of visual coronary artery calcification on non-cardiac gated thoracic CT in predicting clinical severity and outcome in COVID-19.

BACKGROUND: Assessment of visual-coronary artery calcification on non-cardiac gated CT in COVID-19 patients could provide an objective approach to rapidly identify and triage clinically severe patients for early hospital admission to avert worse prognosis. PURPOSE: To ascertain the role of semi-quantitative scoring in visual-coronary artery calcification score (V-CACS) for predicting the clinical severity and outcome in patients with COVID-19. MATERIALS AND METHODS: With institutional review board approval this study included 67 COVID-19 confirmed patients who underwent non-cardiac gated CT chest in an inpatient setting. Two blinded radiologist (Radiologist-1 &2) assessed the V-CACS, CT Chest severity score (CT-SS). The clinical data including the requirement for oxygen support, assisted ventilation, ICU admission and outcome was assessed, and patients were clinically subdivided depending on clinical severity. Logistic regression analyses were performed to identify independent predictors. ROC curves analysis is performed for the assessment of performance and Pearson correlation were performed to looks for the associations. RESULTS: V-CACS cut off value of 3 (82.67% sensitivity and 54.55% specificity; AUC 0.75) and CT-SS with a cut off value of 21.5 (95.7% sensitivity and 63.6% specificity; AUC 0.87) are independent predictors for clinical severity and also the need for ICU admission or assisted ventilation. The pooling of both CT-SS and V-CACS (82.67% sensitivity and 86.4% specificity; AUC 0.92) are more reliable in terms of predicting the primary outcome of COVID-19 patients. On regression analysis, V-CACS and CT-SS are individual independent predictors of clinical severity in COVID-19 (Odds ratio, 1.72; 95% CI, 0.99-2.98; p = 0.05 and Odds ratio, 1.22; 95% CI, 1.08-1.39; p = 0.001 respectively). The area under the curve (AUC) for pooled V-CACS and CT-SS was 0.96 (95% CI 0.84-0.98) which correctly predicted 82.1% cases. CONCLUSION: Logistic regression model using pooled Visual-Coronary artery calcification score and CT Chest severity score in non-cardiac gated CT can predict clinical severity and outcome in patients with COVID-19.

Preoperative ultrasonography for tumor thickness evaluation in guiding management in patients with early oral tongue squamous cell carcinoma.

OBJECTIVES: (1) To assess the statistical correlation between the tumor thickness (TT) by ultrasonography (USG) and microscopic measurement in cases of early oral tongue squamous cell carcinoma (OTSCC). (2) To assess the predictive capacity of TT by ultrasound in detecting nodal metastasis. MATERIALS AND METHODS: Prospective analysis was performed in 24 patients for a period of 2 years from 2012 to 2013. Nodal status and TT measurement was done preoperatively by neck and intraoral USG respectively in cases of early (pT1 & T2, clinically N0) OTSCC. As per the institution protocol after histopathological confirmation of malignancy, all patients underwent resection of primary lesion and ipsilateral elective neck dissection (Level - I to IV). Measurement of TT was obtained intraoperatively from fresh glossectomy specimen and postoperatively from histopathological paraffin section examination. The statistical correlation between TT measured by USG and histopathology was assessed by Pearson's correlation coefficient. Chi-square test was used to find the association of pathological T stage, TT with pathological nodal status. RESULTS: Significant statistical correlation was seen between TT by USG and microscopic measures. Between the two, TT measurements were within 1 mm in 37.5% (9/24) of cases, within 2 mm in 29.16% (7/24), and was greater than 2 mm in 8 cases. The Pearson's correlation r is 0.678 (P < 0.001) and ICC (interclass correlation coefficient) is 0.808. The average difference between microscopic and US thickness (Bias) is -0.14637 and the limits of agreement is (4.717, -4.863) with 95% limits of agreement. The rate of occult nodal metastasis was 16.6% and TT of <4 mm had no incidence of nodal metastasis. CONCLUSION: Ultrasonographic evaluation is reliable and cost-effective tool to measure the TT preoperatively, which will be of help in deciding the management in early OTSCC. TT of 4 mm and above was predictor of occult cervical nodal metastasis.

Hepatic Amyloidosis: Something That Can camouflage and Deceive our Perception!

Amyloidosis is a multi-systemic diffusely infiltrating disease due to extracellular deposition of protein-mucopolysaccharide complexes. The type of protein deposited determines the subgroup of amyloid. Hepatic amyloidosis is a rare infiltrating disease affecting the hepatic parenchyma. A wide range of clinical presentation and atypical imaging findings delay the diagnosis of amyloidosis, while tissue biopsy demonstrating amyloid deposits is vital for a definitive diagnosis.

Role of dual time fluorodeoxyglucose (FDG) positron emission tomography-computed tomography in identifying co-existing inflammatory and malignant disease: Who holds it (FDG) longer?

18-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) is an integral part of imaging in the follow-up of head and neck malignancies. Very often distinguishing inflammatory/infective from malignant recurrence cannot be made confidently with standard uptake value (SUV) alone, as inflammatory lesions have shown to have a very high SUV, and in some cases both can co-exist. In such doubtful cases, dual time PET-CT (3-5 h delayed) is of paramount importance in confidently differentiating inflammatory/infective from a malignant cause.

A novel function of RIP1 in postnatal development and immune homeostasis by protecting against RIP3-dependent necroptosis and FADD-mediated apoptosis.

RIP1 is an adaptor kinase originally identified as being able to associate with TNFR1 and Fas, and is later shown to be involved in signaling induced by TLRs. Major signaling pathways regulated by RIP1 include necroptosis, apoptosis, and pro-survival/inflammation NF-κB activation. Previous studies show that RIP1 deficiency has no effect on mouse embryogenesis, but blocks postnatal development. This phenotype could not readily be explained, since mice lacking TNFR1, Fas, or TLRs show no apparent developmental defect. Certain types of RIP1-deficient cells are hypersensitive to TNF-induced apoptosis. However, in our previous study, deletion of the apoptotic adaptor protein, FADD, provides marginal improvement of postnatal development of rip1 (-/-) mice. Remarkably, the current data shows that haploid insufficiency of RIP3, a known mediator of necroptosis, allowed survival of rip1 (-/-) fadd (-/-) mice beyond weaning age, although the resulting rip1(-/-)fadd(-/-) rip3(+/-) mice were significant smaller in size and weight. Moreover, complete absence of RIP3 further improved postnatal development of the resulting rip1 (-/-) fadd (-/-) rip3 (-/-) mice, which display normal size and weight. In such triple knockout (TKO) mice, lymphocytes underwent normal development, but progressively accumulated as mice age. This lymphoproliferative (lpr) disease in TKO mice is, however, less severe than that of fadd(-/-)rip3 (-/-) double knockout mice. In total, the data show that the postnatal developmental defect in rip1 (-/-) mice is due in part to FADD-mediated apoptosis as well as RIP3-dependent necroptosis. Moreover, the function of RIP1 contributes to development of lpr diseases.

Morel-Lavallée lesion: A closed degloving injury that requires real attention.

Morel-Lavallée lesions are post-traumatic, closed degloving injuries occurring deep to subcutaneous plane due to disruption of capillaries resulting in an effusion containing hemolymph and necrotic fat. Magnetic resonance imaging (MRI) is the modality of choice in the evaluation of Morel-Lavallée lesion. Early diagnosis and management is essential as any delay in diagnosis or missed lesion will lead to the effusion becoming infected or leading to extensive skin necrosis.