Wunderlich Syndrome: Comprehensive Review of Diagnosis and Management.

Wunderlich syndrome (WS), which was named after Carl Wunderlich, is a rare clinical syndrome characterized by an acute onset of spontaneous renal hemorrhage into the subcapsular, perirenal, and/or pararenal spaces, without a history of antecedent trauma. Patients may present with a multitude of symptoms ranging from nonspecific flank or abdominal pain to serious manifestations such as hypovolemic shock. The classic symptom complex of flank pain, a flank mass, and hypovolemic shock referred to as the Lenk triad is seen in a small subset of patients. Renal neoplasms such as angiomyolipomas and clear cell renal cell carcinomas that display an increased proclivity for hemorrhage and rupture contribute to approximately 60%-65% of all cases of WS. A plethora of renal vascular diseases (aneurysms or pseudoaneurysms, arteriovenous malformations or fistulae, renal vein thrombosis, and vasculitis syndromes) account for 20%-30% of cases of WS. Rare causes of WS include renal infections, cystic diseases, calculi, kidney failure, and coagulation disorders. Cross-sectional imaging modalities, particularly multiphasic CT or MRI, are integral to the detection, localization, and characterization of the underlying causes and facilitate optimal management. However, large-volume hemorrhage at patient presentation may obscure underlying causes, particularly neoplasms. If the initial CT or MRI examination shows no contributary causes, a dedicated CT or MRI follow-up study may be warranted to establish the cause of WS. Renal arterial embolization is a useful, minimally invasive, therapeutic option in patients who present with acute or life-threatening hemorrhage and can help avoid emergency radical surgery. Accurate diagnosis of the underlying cause of WS is critical for optimal patient treatment in emergency and nonemergency clinical settings. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Fecal Microbiota Transplantation and Medical Therapy for Clostridium difficile Infection : Meta-analysis of Randomized Controlled Trials.

GOALS: The aim was to assess the effectiveness of fecal microbiota transplantation (FMT) against medical therapy (MT). BACKGROUND: FMT has shown good outcomes in the treatment of Clostridium difficile infection (CDI). We aimed to conduct a systematic review and meta-analysis to compare the effectiveness of FMT versus MT for CDI. STUDY: We performed a comprehensive search to identify randomized controlled trials comparing FMT against MT in patients with CDI. Outcomes of interest were clinical cure as determined by the resolution of diarrhea and/or negative C. difficile testing. Primary CDI is defined as the first episode of CDI confirmed endoscopically or by laboratory analysis. Recurrent C. difficile infection (RCDI) is defined as laboratory or endoscopically confirmed episode of CDI after at least 1 course of approved antibiotic regimen. RESULTS: A total of 7 studies with 238 patients were included in meta-analysis. Compared with MT, FMT did not have a statistically significant difference for clinical cure of combined primary and RCDI after first session [risk ratio (RR): 1.52, 95% confidence interval (CI): 0.90, 2.58; P =0.12; I2 =77%] and multiple sessions of FMT (RR: 1.68; CI: 0.96, 2.94; P =0.07; I2 =82%). On subgroup analysis, FMT has statistically higher rate of response than MT (RR: 2.41; CI: 1.20, 4.83; I2 =78%) for RCDI. However, for primary CDI there is no statistically significant difference between FMT and MT (RR: 1.00; CI: 0.72, 1.39; I2 =0%). CONCLUSION: As per our analysis, FMT should not be utilized for every patient with CDI. It is more effective in RCDI, but the results were not significant in patients with primary CDI.

Clinical Importance of Incidental Homogeneous Renal Masses That Measure 10-40 mm and 21-39 HU at Portal Venous Phase CT: A 12-Institution Retrospective Cohort Study.

BACKGROUND. Incidental homogeneous renal masses are frequently encountered at portal venous phase CT. The American College of Radiology Incidental Findings Committee's white paper on renal masses recommends additional imaging for incidental homogeneous renal masses greater than 20 HU, but single-center data and the Bosniak classification version 2019 suggest the optimal attenuation threshold for detecting solid masses should be higher. OBJECTIVE. The purpose of this article is to determine the clinical importance of small (10-40 mm) incidentally detected homogeneous renal masses measuring 21-39 HU at portal venous phase CT. METHODS. We performed a 12-institution retrospective cohort study of adult patients who underwent portal venous phase CT for a nonrenal indication. The date of the first CT at each institution ranged from January 1, 2008, to January 1, 2014. Consecutive reports from 12,167 portal venous phase CT examinations were evaluated. Images were reviewed for 4529 CT examinations whose report described a focal renal mass. Eligible masses were 10-40 mm, well-defined, subjectively homogeneous, and 21-39 HU. Of these, masses that were shown to be solid without macroscopic fat; classified as Bosniak IIF, III, or IV; or confirmed to be malignant were considered clinically important. The reference standard was renal mass protocol CT or MRI, ultrasound of definitively benign cysts or solid masses, single-phase contrast-enhanced CT or unenhanced MRI showing no growth or morphologic change for 5 years or more, or clinical follow-up 5 years or greater. A reference standard was available for 346 masses in 300 patients. The 95% CIs were calculated using the binomial exact method. RESULTS. Eligible masses were identified in 4.2% of patients (514/12,167; 95% CI, 3.9-4.6%). Of 346 masses with a reference standard, none were clinically important (0%; 95% CI, 0-0.9%). Mean mass size was 17 mm; 72% (248/346) measured 21-30 HU, and 28% (98/346) measured 31-39 HU. CONCLUSION. Incidental small homogeneous renal masses measuring 21-39 HU at portal venous phase CT are common and highly likely benign. CLINICAL IMPACT. The change in attenuation threshold signifying the need for additional imaging from greater than 20 HU to greater than 30 HU proposed by the Bosniak classification version 2019 is supported.

Quantification of residual cetyltrimethylammonium bromide (CTAB) and sodium deoxycholate (DOC) in Haemophilus influenzae type b (Hib) polysaccharide using NMR.

CTAB and DOC are used as reagents in the purification of Hib polysaccharide. Polysaccharide is purified by precipitation with CTAB from fermented broth followed by solvent extraction and DOC is used to remove the protein impurities. The reagents used in the purification process should be removed from the product as per regulatory requirements. These two residual reagents can be easily identified and quantified in purified Haemophilus influenzae type b polysaccharide by NMR. The LOD of these residual reagents is 0.1% (10 µg/mL) and LOQ is 0.5% (50 µg/mL) with respect to polysaccharide determined from the spectrum. The absence of the peaks corresponding to CTAB and DOC in the NMR spectrum of purified polysaccharide confirms either they are absent or present at less than 0.1%. The present study provides supporting data from the regulatory viewpoint, which can help in circumventing the time-consuming studies for the vaccine manufacturers to develop different analytical methods for identification and quantification of CTAB and DOC as per regulatory requirements.

Outcomes of percutaneous coronary interventions in patients with liver transplant.

OBJECTIVE: Our aim is to describe characteristics of liver transplant patients undergoing percutaneous coronary interventions (PCI) as well as in-hospital outcomes including the mortality and peri-procedural complications from the largest publicly available inpatient database in the United States from 2002 to 2014. BACKGROUND: Outcomes of PCI are well studied in patients with end-stage liver disease but not well studied in patients who receive liver transplant (LT). METHODS: Data derived from Nationwide Inpatient Sample (NIS) were analyzed for years 2002-2014. Adult Hospitalizations with PCI were identified using ICD-9-CM procedure codes. LT status and various complications were identified by using previously validated ICD-9-CM diagnosis codes. Endpoints were in-hospital mortality and peri-procedural complications. Propensity match analysis was performed to compare the endpoints between two groups. RESULTS: During the study period, 8,595,836 patients underwent PCI; 4,080 (0.04%) patients had prior LT status. 93% of patients were above age 59 years, 79% were males and 69% were nonwhites. Out of the total patients with LT status, 73% had hypertension, 57% had diabetes mellitus, and 47% had renal failure. Post-PCI complications were studied further in both liver and non-LT patients after 1:1 propensity match which showed the incidence of acute kidney injury (AKI) was higher in LT group (12.3 vs 10.7%, p = .024) but dialysis requiring AKI was similar. CONCLUSION: Among the LT recipients undergoing PCI, majority were nonwhite males. Almost more than half of the recipients had diabetes mellitus and renal failure. Incidence of AKI was higher in LT group, but other peri-procedural complications were comparable.

Comparability studies of hemin from two different origins porcine and bovine in the production of Haemophilus influenzae type b (Hib) polysaccharide.

Hemin is one of the critical components of medium required for growth of Haemophilus influenzae type b (Hib) organisms. It is important to have different sources of critical components to ensure continuous supply for commercial production. Regulatory bodies also recommend having multiple sources for critical components. Hemin is produced from animal blood and the main sources are porcine and bovine origin. The approved Hib vaccine of SIIPL used for immunization is produced using hemin obtained from porcine origin. The present work focuses on the comparison of the growth of organisms on a large scale using hemin from bovine or porcine origin. Purified polysaccharide obtained using bovine source is tested with respect to the set WHO specifications as recommended by regulatory bodies and compared with commercial lots of PRP obtained from using hemin of porcine source. Identical product profile and quality attributes were obtained for PRP produced using bovine hemin and the regular commercial product suggests that there is no change in the product. Hemin from bovine source can be used as a replacement for hemin from porcine source in the fermentation medium for country specific requirement of Hib conjugate vaccine as long as it meets the guidelines on TSE/BSE risk.

Use of NMR as an analytical tool in the process development of conjugate vaccines against Haemophilus influenzae type b (Hib) and meningococcal serogroup A (MenA).

The native structure of the bacterial polysaccharide is the key immunogenic component of conjugate vaccines and antibodies raised against the polysaccharide structure are responsible for providing protection against the corresponding pathogen. The manufacturing process of conjugate vaccines is very complex and has various biological and chemical steps. It is important to monitor the process to ensure that the structural identity of the polysaccharide is maintained throughout the process. NMR spectroscopy can be used as a versatile analytical tool to monitor the structural integrity of the polysaccharide component from isolated polysaccharide to conjugate vaccine and for identifying different impurities generated during the process.

Potential Applications and Impact of ChatGPT in Radiology.

Radiology has always gone hand-in-hand with technology and artificial intelligence (AI) is not new to the field. While various AI devices and algorithms have already been integrated in the daily clinical practice of radiology, with applications ranging from scheduling patient appointments to detecting and diagnosing certain clinical conditions on imaging, the use of natural language processing and large language model based software have been in discussion for a long time. Algorithms like ChatGPT can help in improving patient outcomes, increasing the efficiency of radiology interpretation, and aiding in the overall workflow of radiologists and here we discuss some of its potential applications.

Annealing-induced interfacial toughening using a molecular nanolayer.

Self-assembled molecular nanolayers (MNLs) composed of short organic chains and terminated with desired functional groups are attractive for modifying surface properties for a variety of applications. For example, organosilane MNLs are used as lubricants, in nanolithography, for corrosion protection and in the crystallization of biominerals. Recent work has explored uses of MNLs at thin-film interfaces, both as active components in molecular devices, and as passive layers, inhibiting interfacial diffusion, promoting adhesion and toughening brittle nanoporous structures. The relatively low stability of MNLs on surfaces at temperatures above 350-400 degrees C (refs 12, 13), as a result of desorption or degradation, limits the use of surface MNLs in high-temperature applications. Here we harness MNLs at thin-film interfaces at temperatures higher than the MNL desorption temperature to fortify copper-dielectric interfaces relevant to wiring in micro- and nano-electronic devices. Annealing Cu/MNL/SiO2 structures at 400-700 degrees C results in interfaces that are five times tougher than pristine Cu/SiO2 structures, yielding values exceeding approximately 20 J m(-2). Previously, similarly high toughness values have only been obtained using micrometre-thick interfacial layers. Electron spectroscopy of fracture surfaces and density functional theory modelling of molecular stretching and fracture show that toughening arises from thermally activated interfacial siloxane bridging that enables the MNL to be strongly linked to both the adjacent layers at the interface, and suppresses MNL desorption. We anticipate that our findings will open up opportunities for molecular-level tailoring of a variety of interfacial properties, at processing temperatures higher than previously envisaged, for applications where microlayers are not a viable option-such as in nanodevices or in thermally resistant molecular-inorganic hybrid devices.

Partial Small Bowel Obstruction and Volvulus Due to B-cell Lymphoma in a Common Variable Immunodeficiency Patient.

This case report presents a 43-year-old female with a history of common variable immunodeficiency (CVID) and a recent diagnosis of mesenteric volvulus. The patient presented with symptoms of partial small bowel obstruction and was diagnosed with obstruction and mesenteric volvulus primarily affecting the proximal jejunum. During the exploratory laparotomy, a probable polyposis syndrome and a possible adenocarcinoma of the small bowel were identified. Pathological examination confirmed the presence of B-cell lymphoma in the proximal jejunum. The patient underwent treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (RCHOP) chemotherapy and showed improvement in symptoms. The case highlights the increased risk of malignancies, particularly lymphomas, in individuals with CVID and the challenges in diagnosing and treating lymphoid neoplasms in this population.

Thyrotoxic Crisis in the Absence of Risk Factors: A Case Report.

Thyrotoxic crisis is a severe, life-threatening form of thyrotoxicosis characterized by elevated circulating thyroid hormone that can lead to profound complications. Early diagnostic interventions include a thorough physical examination, laboratory assessments of thyroid hormone levels, and the utilization of quantifying assessment tools to grade the severity of the condition. A targeted therapeutic regimen involving a combination of thioamides, beta-blocking agents, and iodide therapies is administered to combat each stage of the physiological process involved in a thyroid storm. The prompt recognition of clinical manifestations and systemic complications of thyrotoxic crisis is of paramount significance to prevent therapeutic delay and reduce patient mortality. Here, we report an atypical case of a new-onset thyrotoxic crisis in a patient without apparent underlying predisposing factors.

Von Hippel-Lindau Disease (VHL): Characteristic Lesions with Classic Imaging Findings.

Von Hippel-Lindau disease (VHL) is a multisystem cancer syndrome caused by the inactivation of the VHL tumor suppressor gene and involves various organ systems including the central nervous system (CNS), endocrine system, and the kidneys. Tumors seen in patients with VHL disease can be benign or malignant and are usually multifocal, bilateral, and hypervascular in nature. As most lesions associated with VHL are asymptomatic initially, early diagnosis and the institution of an evidence-based surveillance protocol are of paramount importance. Screening, surveillance, and genetic counseling are key aspects in the management of patients diagnosed with VHL disease and often require a multidisciplinary approach and referral to specialized centers. This article will discuss the characteristic lesions seen with VHL disease, their diagnosis, screening protocols and management strategies, as well as an illustrative case to demonstrate the natural progression of the disease with classic imaging findings.

Challenges in hyperglycemia management in critically ill patients with COVID-19.

Hyperglycemia is commonly associated with adverse outcomes especially in patients requiring intensive care unit stay. Data from the corona virus disease 2019 (COVID-19) pandemic indicates that individuals with diabetes appear to be at similar risk for COVID-19 infection to those without diabetes but are more likely to experience increased morbidity and mortality. The proposed hypothesis for hyperglycemia in COVID-19 include insulin resistance, critical illness hyperglycemia (stress- induced hyperglycemia) secondary to high levels of hormones like cortisol and catecholamines that counteract insulin action, acute cytokine storm and pancreatic cell dysfunction. Diabetic patients are more likely to have severe hyperglycemic complications including diabetic ketoacidosis and hyperosmolar hyperglycemic state. Management of hyperglycemia in COVID-19 is often complicated by use of steroids, prolonged total parenteral or enteral nutrition, frequent acute hyperglycemic events, and restrictions with fluid management due to acute respiratory distress syndrome. While managing hyperglycemia special attention should be paid to mode of insulin delivery, frequency of glucose monitoring based on patient and caregiver safety thereby minimizing exposure and conserving personal protective equipment. In this article we describe the pathophysiology of hyperglycemia, challenges encountered in managing hyperglycemia, and review some potential solutions to address them.

Adult Wilms tumor: An unusual case report with dedicated literature review.

Wilms tumor is the most common primary renal malignancy in pediatric age group, however, is rare in adults accounting for 0.5% of all adult renal malignancies. The histopathology is similar in both age groups, however the prognosis in adults is poor with tumor being at advanced stage at presentation with increased incidence of metastasis. Due to rare occurrence in adults and lack of differentiating clinical and imaging features its diagnosis is delayed or often misdiagnosed as adult renal cell cancer. Pre surgical or early post-surgical chemotherapy has shown significantly better surgical outcome and survival rate, however, delayed or misdiagnosis precludes or delays the chemotherapy. Lack of standardized treatment guidelines for adults also adds to the poor prognosis. Presurgical biopsy of renal masses in young adults can be suggested for early diagnosis as well as inclusion of presurgical chemotherapy for overall better outcome.

Artificial intelligence in gastrointestinal and hepatic imaging: past, present and future scopes.

The use of technology in medicine has grown exponentially because of the technological advancements allowing the digitization of medical data and optimization of their processing to extract multiple features of significant clinical relevance. Radiology has benefited substantially from technical developments and innovations, such as artificial intelligence (AI). This article describes the subsets of AI methods relevant to gastrointestinal and hepatic imaging with examples. We also discuss the evolution of AI, the current challenges, and prospects for further development in the field.

Gastrointestinal duplication cysts: what a radiologist needs to know.

Gastrointestinal tract duplication cysts are rare congenital malformations which can be diagnosed as early as the prenatal period but are frequently found in infancy or incidentally in adulthood. They can be seen throughout the alimentary tract with the most common involving the distal ileum and second most common the esophagus. Many duplication cysts are asymptomatic and thus discovered as an incidental imaging finding, though they can also be symptomatic with an array of clinical presentations dependent largely on their location. The vast majority of duplication cysts are benign; however, there are rare instances of malignant transformation reported. The aim of this review is to show how multimodality imaging can help in the diagnosis of duplication cysts at various anatomical locations. Duplication cyst can become symptomatic and in rare cases undergo malignant transformation; therefore, they are typically managed with surgical excision, particularly if found prenatally or during infancy. Given the diversity of anatomic locations, multiple differential diagnoses, and the need for surgical intervention, it is valuable to comprehend the role of multimodality imaging role in diagnosing duplication cysts.

Clinical Outcomes and Predictors of Thirty-Day Readmissions of Hypertriglyceridemia-Induced Acute Pancreatitis.

Background: Hypertriglyceridemia (HTG) is a well-established cause of acute pancreatitis often leading to significant morbidity, mortality, and healthcare burden. This study aimed to describe the rate, reasons, and predictors of HTG-induced acute pancreatitis (HTG-AP) in the USA. Methods: This retrospective study analyzed the Nationwide Readmissions Database (NRD) for 2018 to determine all adults (≥ 18 years) readmitted within 30 days of an index hospitalization of HTG-AP. Hospitalization characteristics and adverse outcomes for 30-day readmissions were highlighted and compared with index admissions of HTG-AP. Furthermore, independent predictors for 30-day readmissions of HTG-AP were also identified. P values ≤ 0.05 were considered statistically significant. Results: In 2018, the rate of 30-day readmission of HTG-AP was noted to be 13.5%. At the time of readmission, AP (45.2%) was identified as the most common principal diagnosis, followed by chronic pancreatitis (6.3%) and unspecified sepsis (4.8%). Compared to index admissions, 30-day readmissions of HTG-AP had a higher proportion of patients with Charlson Comorbidity Index (CCI) scores ≥ 3 (48.5% vs. 33.8%, P < 0.001). Furthermore, we noted higher rates of inpatient mortality (1.7% vs. 0.7%, odds ratio (OR): 2.55, 95% confidence interval (CI): 1.83 - 3.57, P < 0.001), mean length of stay (LOS) (5.6 vs. 4.1 days, OR: 1.5, 95% CI: 1.2 - 1.7, P < 0.001), and mean total healthcare charge (THC) ($56,799 vs. $36,078, OR: 18,702, 95% CI: 15,136 - 22,267, P < 0.001) for 30-day readmissions of HTG-AP compared to index admissions. Independent predictors for 30-day all-cause readmissions of HTG-AP included hypertension, protein energy malnutrition (PEM), CCI scores ≥ 3, chronic kidney disease and discharge against medical advice. Conclusions: AP was the principal diagnosis on presentation in only 45.2% patients for 30-day readmissions of HTG-AP. Compared to index admissions, 30-day readmissions of HTG-AP had a higher comorbidity burden, inpatient mortality, mean LOS and mean THC.

Imaging Review of Pediatric Benign Osteocytic Tumors and Latest Updates on Management.

Pediatric benign osteocytic tumors include osteoma, enostosis, osteoid osteoma, and osteoblastoma. In pediatric populations, benign bone tumors are more common than malignancies. Benign osteocytic tumors may have a unique clinical presentation that helps narrow the differential diagnosis. A systemic imaging approach should be utilized to reach the diagnosis and guide clinicians in management. Radiographs are the most prevalent and cost-effective imaging modality. Cross-sectional imaging can be utilized for tissue characterization and for evaluation of lesions involving complex anatomical areas such as the pelvis and spine. Computed Tomography (CT) is the modality of choice for diagnosis of osteoid osteoma. CT scan can also be utilized to guide radiofrequency ablation, which has been found to be highly effective in treating osteoid osteoma and osteoblastoma. Enostosis is a no-touch lesion. Osteoma is commonly located in the paranasal sinuses. Osteoma needs an excision if it causes complications due to a mass effect.

Post-traumatic intrathoracic splenosis and role of Tc-99m Sulfur colloid scintigraphy in confirmation.

Splenosis is acquired ectopic splenic tissue, usually a sequela of trauma. Its imaging appearance is can be deceiving, and at unusual locations may be mistaken for an alternate cause mass lesion. We present one such unusual case of splenosis in a 53 year-old man with history of heart failure involving the thoracic cavity identified as splenosis on nuclear medicine imaging and suspicion was raised given the remote history splenectomy after splenic rupture during trauma. We will discuss the imaging appearances of splenosis on CT, MRI and nuclear medicine studies, with emphasis on using nuclear medicine as a modality of choice to avoid biopsy. We will also go on to include a brief review of literature on this topic in this article. The key facts are role of detailed clinical history and requirement of high index of suspicion to avoid unnecessary intervention in the case of splenosis.