Utilizing ultrasound in suspected necrotizing enterocolitis with equivocal radiographic findings.

BACKGROUND: To examine the use of abdominal ultrasound (AUS) as a diagnostic adjunct in the diagnosis of necrotizing enterocolitis (NEC) in cases where abdominal radiography (AXR) is equivocal in order to reduce unnecessary antibiotic use in neonates. METHODS: Retrospective study (2017-2019) of infants undergoing NEC evaluation with equivocal AXR findings (n = 54). Paired AXR and AUS were reviewed with respect to presence or absence of pneumatosis. Concordance of AUS findings with decision to treat for NEC was evaluated. RESULTS: Among 54 infants where AXR was equivocal, AUS demonstrated presence of pneumatosis in 22 patients (41%), absence of pneumatosis in 31 patients (57%), and was equivocal in 1 patient. All patients with pneumatosis on AUS were treated for NEC. Of 31 patients without pneumatosis on AUS, 25 patients (78%) were not treated for NEC. Patients without pneumatosis on AUS received a significantly shorter mean duration of antibiotics compared to those with pneumatosis (3.3 days (+/- 4.8 days) vs 12.4 days (+/- 4.7 days)); p < 0.001). Of those patients not treated, none required treatment within 1 week following negative AUS. CONCLUSION: AUS is a valuable tool for evaluating the presence or absence of pneumatosis in the setting of equivocal AXR. Absence of pneumatosis on AUS informs clinical decision making and reduces unnecessary treatment and antibiotic usage.

Radiopaque rodenticide.

BACKGROUND: Rodenticide poisoning is common in developing countries. Patients may be unwilling or unable to provide a history on presentation. CASE HISTORY: A 34-year-old man was referred to the emergency department three hours after the intentional ingestion of five packs of a black powdered rodenticide containing zinc phosphide. Radiopaque material was detected in the stomach on an abdominal radiograph. CONCLUSION: Abdominal radiography may be a useful tool in identifying the ingestion of metal phosphides when a history is not obtainable.

Inter and Intraobserver Variation in Interpretation of Fecal Loading on Abdominal Radiographs.

OBJECTIVES: The current gold standard for the diagnosis of functional constipation is the ROME IV criteria. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and North American Society for Pediatric Gastroenterology, Hepatology & Nutrition (NASPGHAN) guidelines do not support the use of abdominal X-rays in establishing the diagnosis of constipation. Despite these recommendations, abdominal radiography is frequently performed to diagnose constipation. The objective of our study is to evaluate inter and intraobserver variation in interpretation of fecal loading on abdominal radiographs. METHODS: Electronic records of 100 children seen in the emergency room for gastrointestinal symptoms who had an abdominal radiograph performed were included. Four physicians from each specialty including gastroenterology, radiology, and emergency medicine interpreted the radiographs independently. Initially, subjective interpretations, followed by interpretations for intraobserver variation were obtained. Subsequently, all physicians were trained and asked to score the X-rays objectively using Barr and Blethyn scoring systems. Consistency between inter and intraobserver ratings of radiographic interpretation was evaluated using the Kappa coefficient ( k ) which ranges from 0 (no agreement) to 1.0 (perfect agreement). RESULTS: For subjective interpretations, k values showed a fixed margin k of 0.18 indicating poor agreement among 12 observers. Intraobserver k to look for reproducibility showed significant variability ranging from 0.08 (poor) to 0.61 (fair) agreement. Objective scoring results for Blethyn showed a k of 0.14 indicating poor agreement among 12 providers. CONCLUSIONS: Reliability and reproducibility of X-rays for diagnosis and grading of constipation is questionable given poor to fair agreement for both inter and intraobserver comparisons. Our study supports the current recommendation of ESPGHAN and NASPGHAN to not use abdominal X-rays to diagnose constipation.

The Society of Abdominal Radiology at 10 years: Reflections, status report, and look to the future.

In 2012, the Society of Abdominal Radiology (SAR) was formed by the merger of the Society of Gastrointestinal Radiologists (SGR) and the Society of Uroradiology (SUR). On the occasion of SAR's ten year anniversary, this commentary describes important changes in society structure, the growth and diversity of society membership, new educational and research initiatives, intersociety and international outreach, and plans for the future.

ERPs responses to dominance features from human faces.

Social dominance is an important feature of social life. Dominance has been proposed to be one of two trait dimensions underpinning social judgments of human faces. Yet, the neural bases of the ability to identify different dominance levels in others based on intrinsically facial cues remains poorly understood. Here, we used event-related potentials to determine the temporal dynamics of facial dominance evaluation based on facial features signaling physical strength/weakness in humans. Twenty-seven participants performed a dominance perception task where they passively viewed faces with different dominance levels. Dominance levels did not modulate an early component of face processing, known as the N170 component, but did modulate the late positive potential (LPP) component. These findings indicate that participants inferred dominance levels at a late stage of face evaluation. Furthermore, the highest level of dominant faces and the lowest level of submissive faces both elicited higher LPP amplitudes than faces with a neutral dominance level. Taken together, the present study provides new insights regarding the dynamics of the neurocognitive processes underlying facial dominance evaluation.

Retención de cápsula endoscópica en divertículo de Zenker

Caso clínico de paciente con cápsula endoscápica retenida en divertículo de Zenker, recuperada 2 años después de que se sometió al estudio. (AU)

Supine and erect abdominal radiography: A comparison of radiation dose and image quality.

Abdominal radiographs are often the first diagnostic imaging tool for patients with acute abdominal pain. In most cases, a supine X-ray is sufficient, but in some cases, an erect abdominal radiograph may be warranted and can provide additional benefits. The aim of this study was to compare erect and supine projections in terms of radiation dose and image quality. Body mass index (BMI), sagittal body thickness, dose area product (DAP)and effective dose (ED) data were collected for 81 patients referred for digital abdominal radiography in both the supine and erect positions. The ED was estimated by inserting the dose area product (DAP) for each projection into the dose modelling computer software PCXMC 2.0. Image quality was assessed by both visual and quantitative methods. The mean ± standard deviation (SD) ED was 0.4 ± 0.3 and 0.2 ± 0.1 mSv for erect and supine projections, respectively (p < 0.001). The estimated ED in the erect position was 102% higher compared to the supine position. The mean ± SD visual image quality was reduced (27%) when using an erect position 1.9 ± 0.5 when compared with supine 2.6 ± 0.7. The calculated signal to noise ratio (SNR) was higher in erect position by 14%. Contrast to noise ratio (CNR) was reduced by 16% when using an erect position. Study findings support the continued use of the supine position as the preferred method due to significant reductions in radiation dose when compared to erect imaging. A single projection is likely to be sufficient but in certain situations, for example in case of absence of a computed tomography (CT) scanner or ultrasound, then an additional erect abdominal radiograph may be warranted. The erect abdomen radiograph increases the radiation dose and decreases the image quality. Further research is required to define more holistically evaluation optimisation strategies to reduce the patient dose, such as using an increase source-to-image distance or the development of patient-specific exposure parameters for evaluating different clinical indications and patient sizes.

Imaging manifestations of neonatal necrotizing enterocolitis to predict timing of surgery.

BACKGROUND: To find the predictor of optimal surgical timing for neonatal necrotizing enterocolitis (NEC) patients by analyzing the risk factors of conservative treatment and surgical therapy. METHODS: Data were collected from 184 NEC patients (Surgery, n=41; conservative treatment, n=143) between the years 2015 and 2019. Data were analyzed by univariate analysis, and multivariate binary logistic regression analysis. RESULTS: Univariate analysis showed that statistically significant differences between the surgery and conservative treatment groups. The results of multivariate Logistic regression analysis indicated intestinal wall thickening by B-ultrasound and gestational age were independent factors to predict early surgical indications of NEC (p < 0.05). The true positive rate, false positive rate, true negative rate and false negative rate in the diagnosis of necrotic bowel perforation guided by DAAS (Duke abdominal X-ray score) ≥7 and MD7 (seven clinical metrics of metabolic derangement) ≥3 were 12.8%, 0.0%, 100.0% and 87.2%, respectively. CONCLUSIONS: In summary, the ultrasound examination in NEC children showing thickening intestinal wall and poor intestinal peristalsis indicated for early operation.

Evaluation of the predictability of clinical and radiological findings in the diagnosis of malrotation.

BACKGROUND: To evaluate the predictability of clinical and radiological findings in the diagnosis of malrotation. METHODS: Between 2010 and 2020, children with presumptive diagnosis of malrotation were included. The demographic features, clinical and radiological findings, operative findings and outcome were recorded. The upper gastrointestinal series (UGIS) were evaluated by two radiologists. All parameters were correlated with surgical findings to evaluate the predictability. RESULTS: Seventy patients were included. The presenting symptom was bilious vomiting in 29 cases (41.4%), and atypical symptoms (non-bilious vomiting, food refusal, etc.) in 40 cases (57%). One of the cases (1.6%) was asymptomatic and diagnosed incidentally during UGIS. 52 cases had abdominal X-ray and 14 (26.9%) of them were normal. Doppler ultrasonography (US) (n=20) revealed evidence of malrotation in 13 cases (65%). The location of duodenojejunal junction (DJJ) in UGIS was compatible with malrotation in 33 cases. 48 (61%) cases underwent surgical exploration; 35 cases had malrotation and seven cases had midgut volvulus. Median followup time was one year (0.5-7 years). Volvulus has recurred in one case and another case operated for volvulus died because of short bowel syndrome. The statistical analysis for predictability revealed that bilious vomiting (sensitivity: 57.1%, specificity: 82.1%), Doppler US (sensitivity: 92.3%, specificity: 75%) and right-sided DJJ in UGIS (sensitivity: 96.8%, specificity: 75%) have highest predictability. CONCLUSIONS: The bilious vomiting, Doppler US findings and right-sided DJJ have the highest predictability to confirm the diagnosis. However, presenting with atypical symptoms and having atypical or normal findings in UGIS do not rule out malrotation.

[Functional MRI of the pelvic floor]. / Funktionelle MRT des Beckenbodens.

Due to the complexity of pelvic floor dysfunctions and the frequent interdisciplinary findings, dynamic magnetic resonance imaging (MRI) can provide valuable (additional) information for the clinical examination in other disciplines through a comprehensive morphological and functional representation of the pelvic floor. It has therefore largely replaced conventional defecography under fluoroscopy in clinical practice. In order to increase the effectiveness and communication between radiology and the other specialist disciplines, recommendations for the standardized implementation and results of dynamic MRI were published by the European Society for Urogenital radiology (ESUR) in 2016 and based on these the Society for Abdominal Radiology (SAR) published simplified recommendations in 2019 for routine clinical use.

Delays in imaging diagnosis of acute abdominal pain in the emergency setting.

Acute abdominal pain is a common cause of ED visits and often requires imaging to identify a specific diagnosis. Prompt and appropriate imaging plays a crucial role in patient management and leads to improved patient outcomes, decreased hospital stay, and improved ED workflow. There are many cases of abdominal pain in the ED with delayed diagnosis and management secondary to a combination of institutional policies and knowledge deficits in current imaging guidelines. Inappropriate use of abdominal radiographs, use of oral contrast for CT abdomen and pelvis, and concern for iodinated contrast-induced acute kidney injury are three of the more commonly encountered roadblocks to prompt imaging diagnosis of abdominal pain. The purpose of this review is to discuss why these potential causes of delayed diagnosis occur and how radiologists can help improve both imaging and ED workflow by utilizing the most up-to-date imaging guidelines such the American College of Radiology (ACR) Appropriateness Criteria and ACR Manual on Contrast Media to assist clinicians working in the emergency setting.

A Quality Improvement Initiative to Reduce Abdominal X-ray use in Pediatric Patients Presenting with Constipation.

OBJECTIVE: To decrease the percentage of patients undergoing an abdominal radiograph for evaluation of constipation within 24 hours of their initial gastroenterology visit. STUDY DESIGN: In January 2015, we implemented a quality improvement, evidence-based guideline (EBG) aimed at standardizing the initial assessment of patients presenting for a new outpatient gastroenterology visit with a primary complaint of constipation. Over the subsequent 5 years, we followed the clinical impact of this guideline initiation with the goal of decreasing unnecessary abdominal radiograph use by 10% within 1 year of EBG launch. Patients older than 6 months and younger than 19 years were included. RESULTS: In total, 6723 patients completed new patient gastroenterology visits for a primary diagnosis of constipation between 2013 and 2019. Of these, 993 (14.8%) patients had abdominal radiographs taken within 24 hours of their initial visit. Over the 7 years of this project, a mean frequency of abdominal radiograph use decreased from 24% to less than 11%. In addition, a 57% decrease in hospital charges related to decreased radiograph use for constipation was found. No increases in subsequent emergency department visits or hospitalization for constipation within 30 days of patients' initial visits were seen. CONCLUSIONS: Through local adoption of an EBG, routine use of abdominal radiographs taken during a patient's initial outpatient gastroenterology visit for constipation decreased by more than 50%. This reduction was maintained over a subsequent 5-year period without any detrimental side effects.

Rehabilitation towards functional independence in patient with abdominal tuberculosis undergone abdominal surgery: a case report.

A small bowel obstruction is one of the most prevalent life-threatening situations. The most common clinical signs are vomiting, stomach discomfort, abdominal distension, and severe constipation. A 23-year-old girl presented to the multispecialty hospital with stomach pains that had persisted for two days. The patient experienced identical issues two months earlier and was treated conservatively. Radiography in the manner of abdominal X-ray and ultrasound were used to appropriately diagnose intestinal blockage. She underwent exploratory laparotomy for the same. Numerical pain rating scale, Incentive Spirometer (IS), mobility scale, anxiety and depression scale, independence measure were used as an outcome measure. Medical management was successful, but to return the patient to her normal daily routine activities without signs of dyspnea or early fatigue following abdominal surgery, a comprehensive rehabilitation program incorporating various respiratory techniques was developed, which proved to be effective and correlated with medically substantial gains in physical functioning and wellbeing.

Multi-Institutional Variation in Performance of Low-Dose Computed Tomography for the Evaluation of Suspected Nephrolithiasis.

Introduction and Objective: Guidelines from the American Urological Association (AUA) and American College of Radiology (ACR) recommend that patients with suspected nephrolithiasis undergo low-dose CT of the kidney, ureter, and bladder (LD CT KUB) as opposed to higher dose conventional imaging. We hypothesized that even at institutions with established LD protocols, higher dose imaging is common. Materials and Methods: We identified four academic medical centers where LD CT KUB protocols were implemented to yield an effective dose (EDose) consistent with national guidelines. Fifty consecutive adult patients who underwent CT KUB specifically for the evaluation of nephrolithiasis were retrospectively reviewed at each site. Patient age, sex, body mass index (BMI), imaging location, and EDose (millisieverts [mSv]) were recorded. Results: Two hundred patients with a mean age of 54 years were identified. Forty-six patients (23%) underwent CT KUB with an EDose ≤4 mSv, accounting for 10% to 48% of each institution's cohort. One hundred sixteen patients had a BMI <30, and would have been expected to receive LD CTs by the AUA criteria for LD CT KUB. Within this subset, only 37 patients (32%) actually underwent LD CT KUB. The highest dose CT KUB at each institution resulted in an EDose of 33.8 to 44.6 mSv, exceeding the recommended exposure of LD CT KUB by 10-fold. Conclusions: At academic institutions where LD CT KUB was implemented for the evaluation of nephrolithiasis, a minority of patients with BMI <30 received guideline-concordant imaging. Differences in patient BMI did not account for the variation in radiation exposure. Further research is necessary to elucidate barriers to LD CT implementation.

The appropriateness of abdominal X-ray requests in the acute medical initial admissions unit.

BACKGROUND/AIMS: Abdominal X-rays are frequently requested by clinicians in the Aberdeen Royal Infirmary acute medical initial assessment unit. METHOD: The proportion of indicated abdominal X-rays requested within 24 hours of admission was retrospectively examined. This process was repeated after displaying an educational poster with the Royal College of Radiologists guidelines (cycle 2) and a graded assertive communication poster (cycles 3 and 4); a tool to enable junior doctors to challenge inappropriate requests for abdominal X-rays from seniors. RESULTS: Only 47.2% of abdominal X-ray requests were deemed appropriate in cycle 1. A 1.54% reduction in abdominal X-ray requests and an 11.5% increase in indicated abdominal X-rays were noted after cycle 2. Cycle 3 led to a statistically significant improvement with 2.6% fewer patients undergoing an abdominal X-ray and a 24.6% increase in indicated abdominal X-rays. This improvement was sustained in cycle 4. CONCLUSIONS: Promoting graded assertive communication is an effective means of helping junior doctors to challenge seniors requesting non-indicated abdominal X-rays.

Multi-contrast computed tomography healthy kidney atlas.

The construction of three-dimensional multi-modal tissue maps provides an opportunity to spur interdisciplinary innovations across temporal and spatial scales through information integration. While the preponderance of effort is allocated to the cellular level and explore the changes in cell interactions and organizations, contextualizing findings within organs and systems is essential to visualize and interpret higher resolution linkage across scales. There is a substantial normal variation of kidney morphometry and appearance across body size, sex, and imaging protocols in abdominal computed tomography (CT). A volumetric atlas framework is needed to integrate and visualize the variability across scales. However, there is no abdominal and retroperitoneal organs atlas framework for multi-contrast CT. Hence, we proposed a high-resolution CT retroperitoneal atlas specifically optimized for the kidney organ across non-contrast CT and early arterial, late arterial, venous and delayed contrast-enhanced CT. We introduce a deep learning-based volume interest extraction method by localizing the 2D slices with a representative score and crop within the range of the abdominal interest. An automated two-stage hierarchal registration pipeline is then performed to register abdominal volumes to a high-resolution CT atlas template with DEEDS affine and non-rigid registration. To generate and evaluate the atlas framework, multi-contrast modality CT scans of 500 subjects (without reported history of renal disease, age: 15-50 years, 250 males & 250 females) were processed. PDD-Net with affine registration achieved the best overall mean DICE for portal venous phase multi-organs label transfer with the registration pipeline (0.540 ± 0.275, p < 0.0001 Wilcoxon signed-rank test) comparing to the other registration tools. It also demonstrated the best performance with the median DICE over 0.8 in transferring the kidney information to the atlas space. DEEDS perform constantly with stable transferring performance in all phases average mapping including significant clear boundary of kidneys with contrastive characteristics, while PDD-Net only demonstrates a stable kidney registration in the average mapping of early and late arterial, and portal venous phase. The variance mappings demonstrate the low intensity variance in the kidney regions with DEEDS across all contrast phases and with PDD-Net across late arterial and portal venous phase. We demonstrate a stable generalizability of the atlas template for integrating the normal kidney variation from small to large, across contrast modalities and populations with great variability of demographics. The linkage of atlas and demographics provided a better understanding of the variation of kidney anatomy across populations.