Incidental Findings In Patients Research Articles

The Predictive Role of Prostate-Specific Antigen Changes Following Transurethral Resection of the Prostate for Patients with Localized Prostate Cancer.

Simple SummaryA part of localized prostate cancer (PC) was an incidental finding in patients who received transurethral resection of the prostate (TURP) for urinary symptoms. The present study examined whether changes in prostate-specific antigen (PSA) levels after TURP possess a predictive value for localized PC. Our data revealed that patients at intermediate risk who are associated with tumor involvement ≤5% in TURP specimens, PSA_TURP ≤ 4 ng/mL, and ≥68% PSA reduction following TURP might be suitable for conservation management instead of immediate local therapy. Moreover, for patients with no pre-TURP PSA, Gleason score (GS) < 7, and low PSA_TURP could potentially be utilized to select which patients could be considered for conservative management after TURP. The findings suggest the pathologic finding of TURP and changes in PSA could be used as adjuvant markers to guide a risk-adaptive strategy for patients with localized PC.Regarding localized prostate cancer (PC), questions remain regarding which patients are appropriate candidates for conservative management. Some localized PC was an incidental finding in patients who received transurethral resection of the prostate (TURP) for urinary symptoms. It is known that TURP usually affects the level of prostate-specific antigen (PSA). In the present study, we examined whether changes in PSA levels after TURP possess a predictive value for localized PC. We retrospectively reviewed the clinical data of 846 early-stage PC patients who underwent TURP for urinary symptoms upon diagnosis at our hospital. Of 846 patients, 687 had tumor involvement in TURP specimens, and 362 had post-TURP PSA assessment. Our data revealed that, in addition to low GS and PSA levels at diagnosis, ≤5% tumor involvement in TURP specimens, greater PSA reduction (≥68%) following TURP, and post-TURP PSA ≤ 4 were significantly associated with better progression-free survival (PFS). Survival analysis revealed that the addition of prostate-directed local therapy significantly improved PFS in intermediate- and high-risk groups, but not in the low-risk group. Moreover, in the intermediate-risk group, local therapy improved PFS only for patients who were associated with post-TURP PSA > 4 ng/mL or <68% PSA reduction following TURP. We also found that local therapy had no obvious improvement in PFS for those with post-TURP ≤ 4 ng/mL regardless of pre-TURP PSA. In conclusion, conservative management is considered for patients at low or intermediate risk who have greater PSA reduction following TURP and low post-TURP PSA. Therefore, the levels of PSA following TURP might be helpful for risk stratification and the selection of patients for conservative management.

The frequency of thyroid incidental findings and risk of malignancy detected by 68Ga-labeled prostate-specific membrane antigen PET/CT in prostate cancer.

Gallium-68-prostate-specific membrane antigen positron emission tomography/computed tomography (68Ga-PSMA PET/CT) has become a well-established imaging method for the evaluation of patients with prostate cancer. However, several cases have revealed PSMA uptake in a large variety of conditions other than prostate cancer. Prostate-specific membrane antigen uptake in thyroid cancer has also been reported. The aim of the present study was to systematically investigate the prevalence and clinical significance of thyroid incidental findings in patients undergoing 68Ga-PSMA PET/CT. We retrospectively identified all patients referred for 68Ga-PSMA PET/CT at the Department of Nuclear Medicine, Aalborg University Hospital, Denmark between May 2015 and May 2019. Patients with increased PSMA uptake in the thyroid gland were included in the analysis. Follow-up included imaging, biochemical, and/or histopathological collected over six months. A total of 341 patients were included. Increased 68Ga-PSMA uptake in the thyroid gland was observed in 13 patients (4%). Focal uptake was observed in seven patients, diffuse uptake in five patients and mixed focal and diffuse uptake in one patient. Malignancy was verified in two patients (2/13 patients, 15%), both patients with focal PSMA uptake. Gallium-68-PSMA thyroid incidental findings are rare in prostate cancer patients. However, cases of focal PSMA uptake in the thyroid gland should be further investigated, as these findings may represent metastatic or primary malignancy of the thyroid gland.

Frequency of potential causes of lower back pain and incidental findings in patients with suspected sacroiliitis: retrospective analysis of 886 patients with negative sacroiliac MRI examination for sacroiliitis.

In a majority of patients with suspected sacroiliitis (SI) who underwent sacroiliac magnetic resonance imaging (MRI), imaging studies may be normal, may depict other causes for pain, or may show clinically irrelevant incidental findings. To determine the prevalence of possible etiologies other than SI and frequency of incidental findings demonstrated on sacroiliac MRI examinations in a cohort of patients with lower back pain and suspected SI. Sacroiliac MRI examinations of 1421 patients with suspected SI were retrospectively reviewed. In patients without SI findings, other potential causes for lower back pain and incidental findings were documented. SI was present in 535 of 1421 patients (37.6%). In 886 of the patients whose MRI studies were negative for SI, other possible causes for lower back pain or incidental findings were seen in 386 (43.5%). The most common musculoskeletal (MSK) finding was lumbosacral transitional vertebra (8.6%) followed by findings suggesting piriformis syndrome (4.2%), spondylosis (3.7%), and sacral insufficiency fractures (1.8%). The most common non-MSK findings were follicular cysts (15.3%) and uterine fibroids (4.9%). In patients with suspected SI but negative MRI examinations for SI, some other possible causes for lower back pain and several incidental findings can be seen on imaging. The presence of these findings may explain the patient's symptoms, and awareness of these conditions may be helpful in patient management and individualizing treatment.

COVID-19 in the act: incidental 18F-FDG PET/CT findings in asymptomatic patients and those with symptoms not primarily correlated with COVID-19 during the United Kingdom coronavirus lockdown.

PurposeThe emergence of the novel SARS-CoV-2 pathogen and lethal COVID-19 disease pandemic poses major diagnostic challenges. The study aims to describe the spectrum and prevalence of thoracic and extrathoracic incidental findings in patients who have undergone 18F-FDG PET/CT during the first 3 weeks of the COVID-19 UK lockdown.MethodsThis is a single-centre retrospective controlled observational study. 18F-FDG PET/CT scans (n = 160) acquired from 23/3/2020 to 9/4/2020 were retrospectively reviewed for incidental findings in the lungs and extrapulmonary sites (heart, nasal sinuses, parotid and salivary glands, colon, large vessels, renal cortex, brain, spleen and testes). A date-matched control group (n = 205) of patients from 2019 was used for comparison.ResultsThe total prevalence of suspicious findings was 26/160 (16.25%). Fifteen patients presented with incidental findings in the lungs, while eleven patients had only non-pulmonary incidental findings. There was a significant increase in the appearance of incidental 18F-FDG PET/CT findings during the 2nd week (OR = 3.8) and 3rd week (OR = 7.6) in relation to the 1st week. There was a significant increase in the average maximum standardised uptake values (SUVmax) in the parotid/salivary glands of patients scanned during week 2 in relation to week 1 (p = 0.036). There was no significant difference in the prevalence of incidental findings compared to the control group, but the number of pulmonary vs. extrathoracic findings was different between the two populations.ConclusionThe study provides a novel base of evidence to identify asymptomatic patients and those without symptoms strongly associated with COVID-19 with incidental 18F-FDG PET/CT findings suspicious of SARS-CoV-2 infection during the initial stages of the pandemic.Electronic supplementary materialThe online version of this article (10.1007/s00259-020-04972-y) contains supplementary material, which is available to authorized users.

Unusual Brain MRI Findings in Patients Imaged for Headache: a Case Series.

We describe a series of cases with unusual brain MRI findings in patients who present with headache disorders. Incidental findings in patients imaged for headache include the following: aneurysm, arachnoid cyst, cerebral vascular malformations, Arnold-Chiari malformations, empty sella turcica, gray matter heterotopias, mastoiditis, mega cisterna magna, meningioma, normal variants of cerebral circulation, paranasal sinus disease, pineal cyst, pituitary tumor, Rathke's cleft cyst, skull hyperostosis, and vestibular schwannoma. The most common abnormal MRI findings encountered in migraine are nonspecific white matter lesions. The current 2019 guidelines from the American College of Radiology and American Headache Society recommend against ordering neuroimaging in patients with a high probability of a primary headache disorder not typically associated with diagnostic imaging findings and who have normal neurologic exam in addition to no red flags in history. Often, unnecessary neuroimaging yields incidental findings, and this typically results in patient anxiety and further unnecessary testing. Detailed below are a series of cases in which unusual findings were found in patients presenting to our clinic for further evaluation of headache disorders. Imaging may have been done prior to presentation to us or by us due to concern for secondary causes.

Lower Urinary Tract Symptoms Due to Xanthoma of the Prostate After Kidney Transplantation: A Case Report

BackgroundProstatic xanthoma is a lesion of unknown cause that is often an incidental finding in patients undergoing needle biopsy or transurethral resection. To the best of our knowledge, we report on a unique case of a pure xanthoma without benign prostatic hyperplasia of the prostate in a patient with lower urinary tract symptoms manifested after kidney transplantation. MethodsA 62-year-old man was submitted for a kidney transplant in April 2018. He had no urinary complaints previous to the transplant. Since July 2019, he had complained of lower urinary tract symptoms. In October 2019, he had acute urinary retention being submitted to a transurethral resection of an estimated 47 g prostate. All measures of cholesterol, high-density lipoproteins (HDL), and low-density lipoproteins (LDL) were within the normal range—except triglycerides, which were mildly elevated in 2 measures. ResultsThe pathologic examination of the resected prostate showed pure xanthoma without benign prostatic hyperplasia. A similar lesion with a xanthomatous cell component is verruciform xanthoma. It is a rare benign lesion of unknown etiology not associated with underlying disorders of lipid metabolism that has been reported in patients with bone marrow, kidney, and liver transplant. ConclusionsWe report a unique case of prostate enlargement caused by pure xanthoma in a patient with renal transplant. In absence of any apparent infection, normal cholesterol measures, and appearance of symptoms after the transplant and considering the morphologic similarity with verruciform xanthoma, a lesion also reported in transplanted patients, we speculate that the pathogenesis of the lesion in this particular patient may be related to immunosuppression.

P014: Incidental findings in trauma whole-body CT scans: a systematic review

Introduction: Whole-body computed tomography scans (WBCT) are a mainstay in the work-up of polytrauma or multiple trauma patients in the emergency department. While incredibly useful for identifying traumatic injuries, WBCTs also reveal incidental findings in patients, some of which require further diagnostic testing and subsequent treatment. Although the presence of incidental findings in WBCTs have been well documented, there has been no systematic review conducted to organize and interpret findings, determine IF prevalence, and document strategies for best management. Methods: A systematic review was conducted using MEDLINE, PUBMED, and EMBASE. Specific journals and reference lists were hand-mined, and Google Scholar was used to find any additional papers. Data synthesis was performed to gather information on patient demographics, prevalence and type of incidental findings (IFs), and follow-up management was collected. All documents were independently assessed by the two reviewers for inclusion and any disagreements were resolved by consensus. Results: 1231 study results were identified, 59 abstracts, and 12 included in final review. A mean of 53.9% of patients had at least one IF identified, 31.5% had major findings, and 68.5% had minor findings. A mean of 2.7 IFs per patient was reported for articles that included number of total IFs. The mean age of patients included in the studies were 44 years old with IFs more common in older patients and men with more IFs than women. IFs were most commonly found in the abdominal/pelvic region followed by kidneys. Frequency of follow-up documentation was poor. The most common reported mechanisms of injury for patients included in the study were MVA and road traffic accidents (60.0%) followed by falls from &gt;3m (23.2%). Conclusion: Although there is good documentation on the mechanism of injury, patient demographics, and type of IF, follow-up for IFs following acute trauma admission lacks documentation and follow-up and is an identified issue in patient management. There is great need for systematic protocols to address management of IFs in polytrauma patients.

A study on the prevalence of type 2 diabetes mellitus as an incidental finding in patients with pterygium

To study the prevalence of type 2 diabetes mellitus as an incidental finding in patients with pterygium. A cross-sectional study was conducted in a tertiary care eye hospital among patients with pterygium, who had been posted for pterygium excision surgery. The study was conducted over a period of three months. 25 patients were enrolled under the study. All cases of operable pterygium were taken up for surgery and studied. Only patients with primary pterygium were included in the study. The random blood sugar levels were monitored, and if found deranged, patients were further investigated for fasting blood sugar levels, post-prandial blood sugar levels and glcosylated hemoglobin levels. Previously diagnosed diabetics and patients with other systemic comorbidities were excluded from the study. Out of the 25 patients enrolled under the study, the mean age was 43 years. 15 patients (60%) were males, and rest were females. Of these, 10 patients (40%) had deranged random blood sugar levels (&amp;#62;130 mg/dl), which were further investigated by fasting blood sugar levels, post-prandial blood sugar levels and glycosylated hemoglobin levels. After these investigations, 6 patients (24%) were newly detected type 2 diabetes mellitus patients, and they were referred to physician for further management of the condition. The etiology of pterygium is multifactorial, though, none can explain the development or the recurrence of pterygium. Though the relationship between pterygium and diabetes is not significant, the role of oxidative stress in these patients needs further investigations.

Histopathologic features of colchicine toxicity in the gastrointestinal tract, a review of 6 cases

Background: Colchicine is an alkaloid drug predominantly used in the treatment and prevention of gout. It has a narrow therapeutic index and toxicity may be associated with gastrointestinal symptoms. Characteristic histopathologic features may be identified in gastrointestinal biopsies. Aim: To describe the histopathologic features of colchicine toxicity in the gastrointestinal tract. Methods: Cases were identified using a database search at Envoi Pathology (2007–2019). Demographic data, clinical history, endoscopic features and histopathologic findings (presence of acute and chronic inflammation, ring mitoses and apoptosis) were documented. Results: Thirteen gastrointestinal biopsies from six patients on oral colchicine therapy were included for analysis. Five patients were male and one was female. The mean patient age was 66 years (range 31–79). Treatment was for gout (n=5) and pericarditis (n=1). Two patients presented with symptoms of colchicine toxicity, including severe diarrhoea (n=1), nausea and abdominal pain (n=1). Four patients did not have clinically suspected colchicine toxicity. Histopathologic features included ring mitoses and chronic inflammation with eosinophils in all biopsies. Crypt apoptosis was present in four cases with associated neutrophils in one case. Conclusion: Colchicine toxicity is characterised by distinct histopathologic features in gastrointestinal biopsies and may be an incidental finding in patients without clinical symptoms.

Incidental findings in patients who underwent cone beam computed tomography for implant treatment planning

The aim of this study is to determine the type, frequency, and location of incidental findings in the maxillofacial region in patients undergoing cone beam computed tomography (CBCT) scan for implant treatment.[5]. In this study, 300 patients who underwent CBCT imaging for implant treatment planning were evaluated retrospectively. Patients were evaluated in four different categories, namely, maxillary sinus pathologies, temporomandibular joint (TMJ) findings, dentoalveolar findings, and soft-tissue calcifications. In maxillary sinus pathologies, we categorized patients by mucosal thickening, polypoidal lesion, air-liquid level, total opacification, oroantral fistula, periapical lesion related with maxillary sinus, antrolith, hypoplasia, and foreign body presence. In the TMJ findings category, we evaluated patients for erosion, osteophyte, sclerosis, flattening, and bifid condyle. For dentoalveolar findings, we looked for the residual root and impacted tooth. In soft-tissue calcifications, we examined patients for tonsillolith, sialolith, lymph node calcification, styloid ligament calcification, carotid artery calcifications, and osteoma cutis. Mucosal thickening was mostly seen in maxillary sinus pathology. One hundred and forty-eight (49.3%) of the patients had at least one TMJ incidental finding. We detected at least one impacted tooth in 17 (5.7%) patients' maxilla and 14 (4.7%) patients' mandibles. The most frequently seen calcification was styloid ligament calcification. There was no statistically significant relationship between the age groups and incidental findings (P > 0.05). Oral radiologists should be aware of incidental findings and evaluate the possibilities of underlying diseases in a comprehensive way, and if there is a concern about the finding, they should refer the patient to the relevant specialist.

The Efficiency of Routine Histopathological Examination for Bilateral Nasal Polyposis.

The necessity to routinely carry out histopathologic examinations of surgically removed polyps in patients with chronic rhinosinusitis with bilateral nasal polyps (CRSwNP) is uncertain. The aim of this study was to describe the histopathology of polyps from a large series of patients who underwent endoscopic sinus surgery for CRSwNP and the rate of neoplasms. This is a retrospective study of the histopathological result of all patients with CRSwNP who underwent functional endoscopic nasal surgery and in whom histologic examination was performed, from 2006 to 2015, in a tertiary medical center. Data on demographics and whether a nasal lesion was suspected for neoplasm prior to surgery were analyzed. Two hundred thirty-five patients underwent bilateral nasal polypectomy and histopathologic examinations of the surgical specimens. The rate of neoplasms in nonsuspicious cases was 2.3% (5 cases) and all were inverted papilloma. To conclude, inverted papilloma and other neoplasms are considered rare incidental findings in patients presenting with bilateral nasal polyps. This study demonstrated a higher rate of the latter than that reported in the literature. Our study further emphasizes that despite the low incidence of these pathologies, a histopathologic examination of every nasal polypectomy is warranted so as not to miss potential serious pathologies. We stress that a routine histopathological examination should be practiced at least in the elderly population.

Incidences and reporting rates of incidental findings on lumbar, thoracic, and cervical spinal magnetic resonance images and extra-neuronal findings on brain magnetic resonance imagesö

Objective: This study aimed to evaluate the incidence rates, reporting rates, and the best imaging plane and sequence for incidental findings in patients undergoing spinal and brain magnetic resonance (MR) imaging. Methods: Three experienced radiologists retrospectively re-evaluated the MR images of 1056 consecutive patients. Results: The incidence rates for extraspinal incidental findings for the images of the lumbar, thoracic, and cervical spine, and extra-neuronal incidental findings on MR images of the brain were 35.47%, 32.25%, 29.16%, and 54.35%; respectively, with reporting rates of incidental findings for these examinations of 31.47%, 8.33%, 29.50%, and 59.62%; respectively. For all examination types, the T2-weighted sequence and the axial plain were the best to reveal the incidental findings of MR examinations, other than that of the cervical spine. Conclusions: Incidental findings, which are commonly detected during routine spinal and brain MR evaluations, are occasionally omitted from formal radiological reports in daily practice. We strongly recommend checking the T2-weighted axial plane for MR imaging of the lumbar, thoracic spine and brain and taking a second look at the T2-weighted sagittal plane MR images of the cervical spine during radiological evaluations.

SUN-390 A Rare Case of Bilateral Macronodular Adrenal Hyperplasia Discovered Incidentally

Introduction: Asymptomatic adrenal masses are often discovered incidentally while testing for unrelated conditions. A very uncommon finding is thickening and increased nodularity of both adrenal glands, which can lead to the patient being diagnosed with subclinical Cushing's syndrome, Conn's syndrome, or both. Case presentation: A 45-year-old African-American man presented to the hospital with a one-month history of increased abdominal girth, bilateral lower extremity edema and shortness of breath, with progressive epigastric abdominal pain which prompted admission. His medical history was relevant for obesity, coronary artery disease and heart failure with reduced ejection fraction. On examination he had a blood pressure of 152/99 mmHg, was diaphoretic, and complained of constant epigastric pain. Multiple purple and pale striae were visible along his abdomen, and he had pitting edema in both lower extremities. His initial laboratory studies showed a potassium of 2.6 mEq/L. A CT scan of the abdomen was relevant for bilaterally enlarged and tortuous adrenal glands, which the patient had no previous knowledge of. Diuresis greatly improved his edema and shortness of breath. Additional laboratory tests showed persistent hypokalemia, normal plasma renin activity and aldosterone, elevated fasting cortisol, normal metanephrines in 24-hour urine collection, and low ACTH level. A suppression test done by administering dexamethasone 0.5 mg every 6 hours for 2 days, was able to suppress the elevated cortisol levels. He was started on spironolactone, and underwent MRI of the abdomen, which confirmed bilateral multinodular adrenal hyperplasia with no imaging characteristics of pheochromocytoma. The patient was discharged home once his clinical status improved. Laboratory studies done at follow-up appointments showed persistently elevated cortisol, normal aldosterone to renin ratio, normal levels of plasma metanephrines and suppressed levels of ACTH. He was also referred to surgery for eventual bilateral adrenalectomy. Discussion: Primary bilateral macronodular adrenal hyperplasia (BMAH) is a very rare cause of endogenous Cushing's syndrome, representing less than 2% of cases. It is characterized by enlarged adrenal glands containing pigmented nodules that secrete excess cortisol and/or aldosterone (1). BMAH is often an incidental finding in patients with subclinical hyper-cortisolism. A low level of plasma ACTH along with bilaterally enlarged adrenal glands on imaging suggest the diagnosis, and this is confirmed with a dexamethasone suppression test. Accurate detection is important for guiding management, which includes pharmacological therapy and bilateral adrenalectomy. Reference: 1. De Venanzi A, Alencar GA, Bourdeau I, Fragoso MCBV, Lacroix A. Primary bilateral macronodular adrenal hyperplasia. Curr Opin Endocrinol Diabetes Obes. 2014 Jun;21(3):177-84.

Prevalence of clinically significant incidental findings by whole-body fludeoxyglucose F 18 positron emission tomography/computed tomography scanning in moderate-to-severe psoriasis patients participating in clinical trials

There has been an increase in the number of psoriasis treatments being investigated in clinical trials. Patients may have undiagnosed issues at the start of a study which may become identified during follow-up as incident medicinal conditions. The prevalence of incidental findings in patients with moderate-to-severe psoriasis presenting for clinical trials is unknown. Determine the prevalence of incidentalomas and rate of malignancy identified by fludeoxyglucose F 18 (FDG) positron emission tomography/computed tomography (PET/CT) imaging in clinical trial patients with moderate-to-severe psoriasis. A cross-sectional secondary analysis of patients with moderate-to-severe psoriasis who underwent FDG PET/CT scans at the baseline visit, before randomization, for 3 phase 4 clinical trials on vascular inflammation in psoriasis. Only patients without active infection, malignancy, or uncontrolled comorbidities were eligible for the clinical trials. A total of 259 healthy patients with moderate-to-severe psoriasis underwent an FDG PET/CT scan as part of the study procedures. In all, 31 patients (11.97%) (95% confidence interval [CI], 8.28-16.56) had clinically significant incidentalomas on the baseline FDG PET/CT scan. Univariate logistic regression demonstrated that with every increase of 10years of age, there was an approximate 30% increased risk of discovery of an incidentaloma (odds ratio, 1.30; 95% CI, 1.01-1.68). Of those patients with findings suggestive of malignancy (n=28), 6 were confirmed to have cancer, resulting in a 2.31% (95% CI, 0.9-5.0) prevalence of malignancy. The positive predictive value of a true cancer was 31.58% (range, 21%-54%). Generalizability and lost to follow-up. Incidentalomas on FDG PET/CT imaging are common in otherwise healthy, asymptomatic patients with moderate-to-severe psoriasis in clinical trials. Our results can help inform interpretation of clinical trial safety data and emphasize the importance of compliance with cancer screening recommendations.

Magnetic resonance imaging of the lumbar spine in adult: Evaluation of spinal incidental findings in patients with low back pain

Aim: We aimed to incidental findings discovered in patients with suspected low back pain disease undergoing MRI of the lumbar spine and the clinical importance of those findings. Material and Methods: One thousand seven hundred fourteen patients included who were admitted to our hospital with a preliminary diagnosis of low back pain were examined. The duration of low back pain complaints of the patients was ranging from 1 week to 4 years. MRI examinations were interpreted by academic neuroradiologists who had 7 years of experience, at the time of the study. Results: Overall, 358 patients (20.9%) had incidental findings. Transitional vertebrae was the most common (134 cases, 7.8%) incidental finding, followed by vertebral hemangioma (65 cases, 3.8%) and Tarlov cyst (54 cases, 3.2%). The incidence of fatty filum terminale, compact bone island, spina bifida, synovial cyst and sacral meningocele was 2.1%, 1.5%, 1%, 0.8% and 0.7% respectively. Of these 1714 patients, 329 patients (92.06%) had one finding, 22 patients (5.95%) had two findings, and 7 patient (1.98%) had three findings. The conus medullaris was terminated in 1710 (99.7%) of the patients (L1-2) .This level were considered normal. In four cases, the spinal cord was determined to be below the required level. The prevalence of transitional vertebra was 7.8%. The prevalence of sacralization and lumbalization was 5.1% and 2.7%, respectively. Conclusion: In this study we showed that incidental findings are mostly benign but interestingly there were no malignant or potentially malignant incidental lesions.

160 Inappropriate Follow-Up of Abdominopelvic Imaging Findings Indeterminate or Suspicious for Malignancy in Emergency Department and Admitted Patients

To evaluate the effects of social determinants of health and health system factors as well as communication on the follow-up of abdominopelvic imaging findings indeterminate or suspicious for malignancy in ED and admitted patients. Our radiology department uses standardized codes to categorize abdominopelvic imaging findings as benign, indeterminate, or suspicious for malignancy on all ultrasound, CT and MRI reports. We assessed ED and inpatients with imaging findings indeterminate or suspicious for malignancy over 7 randomly selected weeks between October 2015 and January 2017. Social determinants of health (age, sex, race, primary language, median household income by zip code, insurance status at the time of index imaging, and physical and psycho-cognitive comorbidities), health system factors (primary care provider [PCP] location, type of follow-up visits within our system, and prior as well as subsequent encounters within our health system), and communication of the incidental finding to the provider in the radiology report impression or to the patient in the discharge instructions were gathered from the electronic health record (EHR). Potentially inappropriate follow-up was defined as no completed relevant pathology, imaging, or clinical follow-up within our health system or other hospitals in our health information exchange (HIE), and no documented rationale for lack of follow-up. Univariate analysis evaluated the association between inappropriate follow-up and the included covariates. Among 210 patients with 235 abdominal imaging findings indeterminate or suspicious for malignancy, 37% of patients (78/210) and 35% of imaging findings (83/235) received potentially inappropriate follow-up; 31% (24/78) of patients without appropriate follow-up had no subsequent encounters within our health system. Potentially inappropriate follow-up was higher among patients with no prior health-system visits (p=.000), no known PCP (p=.000), PCP outside our health system (p=.001), commercial insurance (p = .001), no psycho-cognitive comorbidities (p = .009), and radiologist categorization of a finding as indeterminate for malignancy as opposed to suspicious (p=.000). Communication of the incidental finding to the provider in the radiology report impression or to the patient in the discharge instructions was not correlated with appropriate follow-up (p = .658 and p=.255). Nearly 4 out of 10 patients with imaging findings indeterminate or suspicious for malignancy detected during an ED visit or inpatient admission are at risk for inappropriate follow-up. Lack of documented PCP, PCP outside of health system, commercial insurance, and no documented psycho-cognitive comorbidities were correlated with inappropriate lack of follow-up within our system or other hospitals in our HIE. These findings suggest that better protocols are necessary to ensure adequate follow-up for incidental findings in patients with fragmented access to health care. Communication of imaging findings indeterminate or suspicious for malignancy to providers through the radiology report impression or directly to patients is insufficient to ensure appropriate follow-up.

Unexpected Cardiac MRI Findings in Patients Presenting to the Emergency Department for Possible Acute Coronary Syndrome.

Stress cardiac magnetic resonance imaging (CMR) has become increasingly used in patients presenting to the emergency department (ED) with symptoms concerning for acute coronary syndrome (ACS). We hypothesized that CMR detects a number of alternative diagnoses (diagnoses other than ACS that could explain symptoms) and incidental findings in patients presenting to the ED for potential ACS. We prospectively enrolled adult patients who presented to an academic ED from 2011 to 2015 for possible ACS and subsequently had an adenosine stress perfusion CMR as part of their diagnostic evaluation. All medical charts were reviewed to verify accurate prospective data collection and to collect follow-up data. A total of 391 patients were included. On stress CMR, abnormalities attributable to coronary artery disease (CAD) were found in 106 (27.1%) of patients. Previously undiagnosed moderate to severe valvular disease was the most common non-CAD cardiac finding, occurring in 20 (5.1%) cases. Other alternative diagnoses were rare with 7 cases of cardiomyopathy, 1 case of aortic aneurysm, 1 case of aortic dissection, 1 case of acute myocarditis, 3 cases of pericarditis, and 2 cases of moderate pleural effusion. Cardiac incidental findings were rare. Extracardiac incidental findings were found in 79 patients (20.2%). Only 18.6% of the patients recommended for follow-up imaging had this completed within 1 year after CMR. This experience suggests that stress CMR is useful in not only diagnosing symptomatic CAD but also potentially important non-CAD-related disease. These factors may impact their use in ED-based ACS workups.

Scrotal Calculi A Rare Ultrasonography Finding

Scrotal calculi correspond to the presence of freely floating or located calcifications between the layers of the tunica vaginalis of the testes. It’s a rare discovery with a reported incidence ranging between 1,5 % and 3 %. They are mostly incidental finding in patients during scrotal ultrasound examination and easily recognized due to the hyperechoic nature of the calcification which causes a discrete acoustic shadow. The etiology of scrotal calculi is unclear. literature data report a high association between hydrocele and scrotal calculi suggesting its role in the genesis of scrotal calculi by crystallization of contains of the scrotal fluid.

Scrotal Calculi: A Rare Ultrasonography Finding

Abstract: Scrotal calculi, also known as scrotal pearls, are benign incidental extra testicular macro-calcifications within the scrotum. Hydrocele and repeated micro-trauma may be risk factors for development of scrotal calculi. They are usually of no clinical significance but literature data suggest their role in scrotal pain. Keywords: Scrotal calculi; Ultrasonography; Hydrocele Introduction Scrotal calculi correspond to the presence of freely floating or located calcifications lying between the layers of the tunica vaginalis of the testes [1]. It’s a rare discovery with a reported incidence ranging between 1.5% and 3% [1,2]. Intrascrotal calculi was first found by Kickham during surgery in 1935 and he described it as a “fibrinoid loose body” or “scrotal pearl” Case Presentation: We report the case of a 38 years old patient with no specific medical history complaining about an intermittent scrotal pain. Clinical examination found a swelling of the right spermatic cord without cough impulse. No other abnormalities of genitalia were noticed. Scrotal ultrasonography found both testis of normal size with the presence of 0.73 × 0.32 cm mobile scrotal calculi in the right hemiscrotum associated a small hydrocele (Figure 1A and 1B). A right epidydimal cyst of 0.83 × 0.66 × 1.16 cm was also found (Figure 2). The patient received analgesic treatment with good evolution and was kept under close follow-up. Discussion: Scrotal calculi are mostly incidental finding in patients during scrotal ultrasound examination and easily recognized given the hyper echoic nature of the calcification which causes a discrete acoustic shadow. Detection rate of scrotal calculi is gradually increasing since they are well visualized with the application of high-frequency ultrasound. They can also be detected during surgery, on self-palpation of the testis by patients. The etiology of scrotal calculi is unclear. They may develop as a sequela to trauma or inflammatory diseases affecting the scrotum or from detached portions of the appendices testis or epididymis after torsion or infarction [1,4]. Literature data reports a high association between hydrocele and scrotal calculi suggesting its role in the genesis of scrotal calculi by crystallization of contains of the scrotal fluid. Tan et al. reported an association of hydrocele and scrotal calculi exceeding. Hydrocele was the most common additional scrotal abnormality (29.8%) in Aslan et al. study. Frauscher et al. reported scrotal calculi as the most common diagnosed scrotal abnormality with a high incidence of 81% suggesting the role of repeated chronic micro-trauma of the scrotal contents in the genesis of scrotal calculi. Patients with an association of hydrocele and scrotal calculi exceeded 50% in Tan et al. study. Hydrocele was the most common additional scrotal abnormality (29.8%) in Aslan et al. study. Clinical significance of scrotal calculi is uncertain but some authors suggested their participation in scrotal pain given the presence of scrotal pain in patients with scrotal calculi who had no know additional scrotal abnormalities [2-5]. This pain has been explained by the movement of calculi in the fluid between the layers of the tunica vaginalis which may irritate the surrounding soft tissue, resulting in occasional pain. To date, no information is available in the literature about the results of chronic irritation due to scrotal calculi.

A case control series for the effect of photobiomodulation in patients with low back pain and concurrent depression.

To present incidental findings in patients with low back pain (LBP) who received photobiomodulation (PBM) administered to the back and thighs as an adjunct to physical therapy (PT) and then experienced improvement in concurrent depression. Five outpatients with LBP and concurrent self-reported depression were treated for LBP over five weeks with PT (5-sessions) and concurrent PBM (final 3-sessions), and retrospectively matched to five control patients treated with PT alone (5-sessions). The PBM device emitted light at 850nm and 660 nm with an irradiance of 100 mW/cm2 and fluence of 3 J/cm2 on 12 symmetrical posterior sites (thoracic, lumbar and thighs) for 30 sec/site. Both groups had non-significant differences in all baseline scores, except for higher functional status (ARGS) in the PBM-group (33.6 ± 12.2 vs.18.6 ± 3.6, t(8) = 2.638, p = 0.030). After treatment, the mean decrease in depression scores (OMSQ-12 item #6) was significantly larger in the PBM-group (43.0 ± 22.0 vs. 8.0 ± 5.7, t(8) = 3.449, p = 0.009). Improvement in functional status (ARGS) in the PBM-group was similar to that in the controls (42.0 ± 13.5 vs. 43.4 ± 11.1, t(8) = 0.179, p = 0.862), suggesting group differences in antidepressant effect were independent of functional status improvement. This preliminary investigation suggests that an antidepressant effect may result from PBM to the back and thighs in patients with LBP and concurrent depression.