MRI Reports Research Articles

Negative magnetic resonance imaging cannot be used to omit an initial prostate biopsy - An ambispective study

IntroductionUp to 40% of patients with suspected prostate cancer (PCa) have a negative prebiopsy magnetic resonance imaging (nMRI), and up to 15% of them may have clinically significant PCa (csPCa). The ability to predict the presence of csPCa despite nMRI may help avoid unnecessary biopsies. We aimed to determine the negative predictive value (NPV) of mpMRI, the influence of MRI reporting patterns in clinical practice, and the factors that might predict csPCa among men with an nMRI. MethodologyIn an IRB-approved, ambispective study, men who underwent prostate biopsy from 2016 to 2023 and had a prebiopsy MRI, were included to determine the presence of csPCa. The reporting patterns of institutional and noninstitutional MRI were evaluated. Age, digital rectal examination (DRE) findings, prostate specific antigen (PSA), PSA density (PSAD), and MRI reports were evaluated for their ability to predict csPCa in men with nMRI. Results1660 patients who underwent prostate biopsy were assessed for eligibility, and 685 patients were enrolled in the study. The median age, PSA and PSAD were 60 years, 11.63 ng/ml and 0.23 ng/ml/cm3, respectively. 62 (9%) men had an nMRI, among which csPCa, non-csPCa, and negative biopsy were found in 34%, 5%, and 61% of men, respectively. 61% had an institutional MRI, while 39% had a noninstitutional MRI. The sensitivity and NPV of any MRI for csPCa were 93% and 66%, respectively, which improved to 96% and 81% for institutional MRI. Univariate and multivariate analyses showed abnormal DRE and PSAD ≥0.25 ng/ml/cc as predictive factors for csPCa in men with an nMRI. Conclusion34% of men with negative MRIs were found to harbor csPCa on prostate biopsy. The NPV of institutional MRI was higher than for noninstitutional MRI. Men with an abnormal DRE or PSAD ≥0.25 ng/ml/cc had a higher incidence of csPCa despite an nMRI.

Low-field magnetic resonance imaging of sagittal groove disease of the proximal phalanx in non-racing sport horses.

Injuries of the sagittal groove of the proximal phalanx (P1) in equine athletes are considered to predominantly occur due to chronic bone stress overload. To describe the range of abnormalities that is present in the sagittal groove in a large group of horses diagnosed with sagittal groove disease (SGD) on low-field MRI. Retrospective, cross-sectional. Medical records were searched to identify initial MRI images of horses diagnosed with SGD and these were blindly evaluated using a semi-quantitative grading scheme and novel SGD MRI classification system reflecting potential pathways of pathological progression and severity of stress injury. A total of 132 limbs from 111 horses were included in the study; predominantly warmbloods competing in showjumping (n = 83) and dressage (n = 18). SGD MRI classifications were: 0 (normal, n = 0), 1 (small subchondral defect, n = 2), 2 (osseous densification, n = 28), 3 (subchondral microfissure with osseous densification, n = 7), 4 (bone oedema-like signal within the subchondral ± trabecular bone and ± subchondral microfissure or demineralisation, n = 72), 5 (incomplete macrofissure/fracture, n = 23) and 6 (complete fracture, n = 0). Classification 4c (bone oedema-like signal with demineralisation) and 5 had higher proportions in the plantar third of hindlimbs (3% and 10%, respectively) compared with forelimbs (0% and 0%, respectively). SGD classification and extent of bone oedema-like signal were not significantly different between lame (n = 116) and non-lame limbs (n = 16) (both p > 0.05). Periosteal new bone and oedema-like signal were identified (either confidently or suspected) at the dorsoproximal aspect of P1 in 25% and 39% of limbs, respectively. Inclusion via diagnoses in original MRI reports, variable clinical history, small size of some classification groups. The presence or absence of lameness is not a dependable measure of the severity of SGD. The periosteal oedema-like signal of P1 has not previously been described in MRI of SGD and further supports the concept of bone stress injury.

Abstract 6199: Defining and capturing progression in glioma by harnessing NLP in unstructured electronic health records

Abstract Gliomas exhibit nearly uniform recurrence and poor prognosis. Management of high-grade tumors is surgery followed by chemoirradiation (CRT). Radiographic progression is assessed using contrast-enhanced MRI with reporting captured in Electronic Health Records (EHR). The ability to harness large scale EHR data is limited by the Response Assessment in Neuro-Oncology (RANO) tumor progression criteria, which defines progression as an aggregate of clinical and/or radiographic parameters requiring clinician judgement. As a result, glioma progression is not captured systematically in large data sets, limiting Progression Free Survival (PFS) as an outcome endpoint in data analysis. We developed an AI-based method using natural language processing to capture PFS parameters for analysis of MRI radiology reports. 1088 available brain MRI radiology reports for 81 patients with a pathologically confirmed diagnosis of glioblastoma (GBM) were aggregated in the NIH Integrated Data Analysis Platform. MRI reports were systematically analyzed and PFS manually captured using RANO criteria as ground truth. Common report terms indicating progression were compiled and included in task prompts applied to Large Language Model (LLM) Extraction Tools. The words progression (n=1047) and stable (n=1133) did not necessarily indicate either overall progression or stability in a report. Yet, in the 24 (30%) patients who progressed within 3 months of CRT, recurrence and mass effect occurred in 3.7% and 53% of reports, respectively, which was comparable to the term frequencies of 5.8% and 54% in patients with stable disease. Thus, mass effect and recurrence could not necessarily be used alone as terms to signal overall progression. The analysis identified other commonly employed radiology report terms relevant to determining tumor progression including enhancement (n=2445), perfusion (n=2085), enhancing (n=1785), resection (n=1576), and increased (n=1331), which allowed for experimentation with more detailed LLM extraction task prompts. Our method flagged radiographic progression prior to clinician-coded progression in 43 (53%) patients. Future directions include handling further clinical context such as surgical features, radiation therapy dates, progress notes, and the coadministration of agents such as bevacizumab and steroids. These results indicate the feasibility of LLMs to identify tumor progression dates using EHR text with potential transferability to large glioma data sets pending further optimization and validation. Citation Format: Shreya Chappidi, Hawon Lee, Sarisha Jagasia, Casey Syal, George Zaki, Dylan Junkin, Nathan Golightly, Patrick Chitwood, Kevin Camphausen, Andra Krauze. Defining and capturing progression in glioma by harnessing NLP in unstructured electronic health records [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6199.

The prognosis for return to athletic function for Thoroughbred racehorses in Hong Kong with injuries to the palmaroproximal aspect of the metacarpus diagnosed using low-field magnetic resonance imaging.

To evaluate and compare the prognosis for Thoroughbred racehorses to return to galloping and racing with injuries to the palmaroproximal metacarpus diagnosed with MRI. 29 flat racing Thoroughbreds at the Hong Kong Jockey Club that underwent MRI between 2014 and 2022. Clinical, radiographic, ultrasonographic, and MRI reports were collected from veterinary clinical records, and these were combined with training and racing data. Horses were categorized on the basis of MRI diagnosis: (1) proximal suspensory ligament (PSL) involvement only, (2) PSL and concurrent proximal third metacarpal (MC3) bone involvement, and (3) proximal MC3 bone involvement only. The following were compared for prognosis for return to athletic function: return to galloping or racing, and reinjury. Overall, the prognosis for return to athletic function was fair, with 92% (22/24; P = .53) and 67% (16/24; P = .73) of horses returning to galloping and racing, respectively. There was a relatively low reinjury rate, with 18% (4/22) of horses reinjuring. Horses with concurrent injury to both the PSL and proximal MC3 bone (Category 2) took longer to return to gallop (median, 116; IQR, 100.5 to 160), when compared with horses having only PSL injury (median, 69; IQR, 43 to 80; P = .04). Of the 4 horses that reinjured, 3 (75%) were horses in Category 2. The findings from this study suggest that injuries involving both PSL and proximal MC3 bone concurrently require a longer rehabilitation period than those with PSL involvement alone.

Automatic generation of conclusions from neuroradiology MRI reports through natural language processing.

The conclusion section of a radiology report is crucial for summarizing the primary radiological findings in natural language and essential for communicating results to clinicians. However, creating these summaries is time-consuming, repetitive, and prone to variability and errors among different radiologists. To address these issues, we evaluated a fine-tuned Text-To-Text Transfer Transformer (T5) model for abstractive summarization to automatically generate conclusions for neuroradiology MRI reports in a low-resource language. We retrospectively applied our method to a dataset of 232,425 neuroradiology MRI reports in Spanish. We compared various pre-trained T5 models, including multilingual T5 and those newly adapted for Spanish. For precise evaluation, we employed BLEU, METEOR, ROUGE-L, CIDEr, and cosine similarity metrics alongside expert radiologist assessments. The findings are promising, with the models specifically fine-tuned for neuroradiology MRI achieving scores of 0.46, 0.28, 0.52, 2.45, and 0.87 in the BLEU-1, METEOR, ROUGE-L, CIDEr, and cosine similarity metrics, respectively. In the radiological experts' evaluation, they found that in 75% of the cases evaluated, the conclusions generated by the system were as good as or even better than the manually generated conclusions. The methods demonstrate the potential and effectiveness of customizing state-of-the-art pre-trained models for neuroradiology, yielding automatic MRI report conclusions that nearly match expert quality. Furthermore, these results underscore the importance of designing and pre-training a dedicated language model for radiology report summarization.

Patterns of Access to Radiology Reports and Images Through a Patient Portal.

Access to radiology reports and images through a patient portal offers several advantages. The purpose of this study was to characterize patient's interactions with their radiology results.This was a retrospective study that evaluated radiography, ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography, exams performed between July 2020 and June 2021 for patients aged 12 and older. Exam information, access logs of radiology reports and images, and patient demographics were obtained from the electronic health record and image viewing software. Descriptive statistics were computed.The study included 1,685,239 exams. A total of 54.1% of reports were viewed. MRI and PET reports were viewed with the greatest frequency (70.2% and 67.6%, respectively); 25.5% of exam images were viewed, with the greatest frequency for MRI (40.1%). Exams were shared a total of 17,095 times and downloaded 8409 times; 64% of reports were viewed for patients aged 18-39 and 34% for patients aged 80 and greater. The rate of reports viewed was greater for patients with English as their preferred language (57.1%) compared to other languages (33.3%). Among those viewed, 56.5% of reports and 48.2% of images were viewed multiple times; 72.8% of images were viewed on smartphones, 25.8% on desktop computers, and 1.4% on tablets.Patients utilize a portal to view reports and view and share images. Continued efforts are warranted to promote the use of portals and create patient-friendly imaging results to help empower patients.

(018) Predictors of the Conduct of Nerve Sparing During Radical Prostatectomy

Abstract Introduction The association between nerve-sparing (NS) status at the time of radical prostatectomy (RP) and functional outcomes is well described; however, our profession lacks insight as to whether patient factors such as age and baseline erectile function influence surgeon behavior when it comes to nerve-sparing during RP. Objective We analyzed predictors associated with bilateral nerve damage/resection at the time of RP. Methods The study included patients who underwent RP with surgeon-reported NS scoring. The NS outcome of the right and left sides were independently scored between 1-4: 1 = completely preserved, 2 = partially preserved, 3 = partially damaged, and 4 = completely resected; scores of 1 or 2 indicate nerve-sparing and scores of 3 or 4 indicate non-nerve-sparing. We classified overall NS status as bilateral, unilateral, or not-spared. Demographics, ED-related comorbidities, pre-RP digital rectal exam (DRE), most recent prostate biopsy (bx) results, and pre-RP IIEF Erectile Function Domain (EFD) were analyzed. Pre-RP prostate MRI was used to define prostate volume (PV). EFD score < 24 defined non-functional erections. We created a multivariable (MV) model to define predictors of poorer NS status. The model included patient age, pre-RP EFD, PV, PSA, DRE, noted possible extracapsular extension (ECE) on pre-RP MRI, number of positive bx cores, and predominant Gleason (G) score on bx. Results 3805 men met inclusion criteria. Median age was 64 (57, 67) years. Median pre-RP EFD score was 26 (15, 30); 41% had a pre-RP EFD score < 24. Median PV and PSA were 35 (27, 47) mL and 5.7 (4.2, 8.4) ng/dL, respectively. 64% had a normal pre-RP DRE. Median total bx cores 12 (9, 14). Median positive bx cores 4 (2, 7). Distribution of bx pathology: 17% G6, 64% G7, 10% G8, 8% G9, <1% G10. 65% had predominant G3 and 34% G4 pathology. 26% of MRI reports noted some degree of suspicion for ECE. NS status at RP: bilateral (69%), unilateral (20%), non-spared (11%). Median NS score was 3 (2, 4). On MV analysis, abnormal DRE, number of positive bx cores, and predominance of G4 were predictive of non-NS surgery. Most notably, the non-oncological factors – older patient age and a pre-RP EFD < 24 – were also predictive of non-NS surgery (Table). Conclusions While patient age and baseline erectile function (EF) are not necessarily predictors of a patient’s interest in preserving EF, these non-oncologic factors were identified as predictors of non-NS surgery in this analysis. Surgeons should define the individual patient’s sexual function goals prior to RP. Disclosure No.

Development of a novel genetically encoded hyperpolarized MRI reporter for in vivo cell tracking

Development of a novel genetically encoded hyperpolarized MRI reporter for in vivo cell tracking

Association of multiparametric magnetic resonance imaging findings with oncologic outcomes in non-palpable localized prostate cancer.

281 Background: Multiparametric magnetic resonance imaging (mpMRI) is becoming increasingly integrated into the evaluation and medical decision making for localized prostate cancer. However, mpMRI findings have not been correlated with prostate cancer outcomes and therefore are not currently included in staging. The purpose of this study was to test the association between mpMRI detected extraprostatic extension with oncologic outcomes in patients with non-palpable prostate cancer. Methods: We used the Veterans Affairs Prostate Data Core to identify patients diagnosed with cT1N0M0 prostate cancer between 2000-2021 with an mpMRI prior to definitive treatment. We reviewed MRI reports to identify presence of extracapsular extension (MRI-T3a), seminal vesicle invasion (MRI-T3b), and adjacent organ invasion (MRI-T4). We assessed the impact of mpMRI findings on metastasis free survival with multivariable Fine-Gray competing-risks regression. Results: Overall, 3,142 veterans with cT1N0M0 prostate cancer were included. There were 1,411 (45%) Black patients. By clinical staging, 904 (29%) had low risk, 1,626 (52%) had intermediate risk, and 612 (19%) had high risk disease. The majority of patients were treated with radiation (N=2,267; 72%). There were 217 (7%) patients with MRI-T3a disease, 87 (3%) patients with MRI-T3b disease, and 26 (1%) patients with MRI-T4 disease. The median follow-up time was 5.4 years (90% CI, 1-13 years). The 5-year cumulative incidence of metastases for patients with low, intermediate, and high risk prostate cancer were 3% (95% CI, 2-4%), 7% (95% CI, 6-8%), and 15% (95% CI, 12-18%). The 5-year cumulative incidence of metastases for patients with MRI-T3a, MRI-T3b, and MRI-T4 disease were 15% (95% CI, 10-20%), 29% (95% CI, 29-39%), and 40% (95% CI, 13-66%). After controlling for age, race, risk stratification (which includes prostate specific antigen (PSA) and grade group), local therapy, and co-morbidities, the presence of MRI-T3a (HR 1.58, 95% CI 1.09-2.29, p=0.02), MRI-T3b (HR 3.38, 95% CI 2.31-4.95, p<0.0001), and MRI-T4 disease (HR 4.47, 95% CI 2.32-8.62, p<0.0001) were independently associated with worse metastasis free survival. Similar results were obtained with PSA and grade group as individual variables. Conclusions: Extraprostatic extension observed on mpMRI is independently prognostic of metastasis free survival in patients with non-palpable prostate cancer. mpMRI is a critical imaging modality that should be widely available for patients with prostate cancer, and studies are ongoing to define its role as a standard staging modality.

Generative Large Language Models for Detection of Speech Recognition Errors in Radiology Reports.

This study evaluated the ability of generative large language models (LLMs) to detect speech recognition errors in radiology reports. A dataset of 3233 CT and MRI reports was assessed by radiologists for speech recognition errors. Errors were categorized as clinically significant or not clinically significant. Performances of five generative LLMs-GPT-3.5-turbo, GPT-4, text-davinci-003, Llama-v2-70B-chat, and Bard-were compared in detecting these errors, using manual error detection as the reference standard. Prompt engineering was used to optimize model performance. GPT-4 demonstrated high accuracy in detecting clinically significant errors (precision, 76.9%; recall, 100%; F1 score, 86.9%) and not clinically significant errors (precision, 93.9%; recall, 94.7%; F1 score, 94.3%). Text-davinci-003 achieved F1 scores of 72% and 46.6% for clinically significant and not clinically significant errors, respectively. GPT-3.5-turbo obtained 59.1% and 32.2% F1 scores, while Llama-v2-70B-chat scored 72.8% and 47.7%. Bard showed the lowest accuracy, with F1 scores of 47.5% and 20.9%. GPT-4 effectively identified challenging errors of nonsense phrases and internally inconsistent statements. Longer reports, resident dictation, and overnight shifts were associated with higher error rates. In conclusion, advanced generative LLMs show potential for automatic detection of speech recognition errors in radiology reports. Keywords: CT, Large Language Model, Machine Learning, MRI, Natural Language Processing, Radiology Reports, Speech, Unsupervised Learning Supplemental material is available for this article.

Prevalence, sex differences, and implications of pulmonary hypertension in patients with apical hypertrophic cardiomyopathy.

Apical hypertrophic cardiomyopathy (ApHCM) is a subtype of hypertrophic cardiomyopathy (HCM) that affects up to 25% of Asian patients and is not as well understood in non-Asian patients. Although ApHCM has been considered a more "benign" variant, it is associated with increased risk of atrial and ventricular arrhythmias, apical thrombi, stroke, and progressive heart failure. The occurrence of pulmonary hypertension (PH) in ApHCM, due to elevated pressures on the left side of the heart, has been documented. However, the exact prevalence of PH in ApHCM and sex differences remain uncertain. We sought to evaluate the prevalence, risk associations, and sex differences in elevated pulmonary pressures in the largest cohort of patients with ApHCM at a single tertiary center. A total of 542 patients diagnosed with ApHCM were identified using ICD codes and clinical notes searches, confirmed by cross-referencing with cardiac MRI reports extracted through Natural Language Processing and through manual evaluation of patient charts and imaging records. In 414 patients, echocardiogram measurements of pulmonary artery systolic pressure (PASP) were obtained at the time of diagnosis. The mean age was 59.4 ± 16.6 years, with 181 (44%) being females. The mean PASP was 38 ± 12 mmHg in females vs. 33 ± 9 mmHg in males (p < 0.0001). PH as defined by a PASP value of > 36 mmHg was present in 140/414 (34%) patients, with a predominance in females [79/181 (44%)] vs. males [61/233 (26%), p < 0.0001]. Female sex, atrial fibrillation, diagnosis of congestive heart failure, and elevated filling pressures on echocardiogram remained significantly associated with PH (PASP > 36 mmHg) in multivariable modeling. PH, when present, was independently associated with mortality [hazard ratio 1.63, 95% CI (1.05-2.53), p = 0.028] and symptoms [odds ratio 2.28 (1.40, 3.71), p < 0.001]. PH was present in 34% of patients with ApHCM at diagnosis, with female sex predominance. PH in ApHCM was associated with symptoms and increased mortality.

Presentation and Management of Cerebral Venous Sinus Thrombosis After Supratentorial Craniotomy.

Cerebral venous sinus thrombosis (CVST) after supratentorial craniotomy is a poorly studied complication, for which there are no management guidelines. This study assessed the incidence, associated risk factors, and management of postoperative CVST after awake craniotomy. This is an observational, retrospective, monocentric analysis of patients who underwent a supratentorial awake craniotomy. Postoperative CVST was defined as a flow defect on the postoperative contrast-enhanced 3D T1-weighted sequence and/or as a T2* hypointensity within the sinus. In 401 supratentorial awake craniotomies (87.3% of diffuse glioma), the incidence of postoperative CVST was 4.0% (95% CI 2.5-6.4): 14/16 thromboses located in the superior sagittal sinus and 12/16 located in the transverse sinus. A venous sinus was exposed during craniotomy in 45.4% of cases, and no intraoperative injury to a cerebral venous sinus was reported. All thromboses were asymptomatic, and only two cases were diagnosed at the time of the first postoperative imaging (0.5%). Postoperative complications, early postoperative Karnofsky Performance Status score, and duration of hospital stay did not significantly differ between patients with and without postoperative CVST. Adjusted independent risk factors of postoperative CVST were female sex (adjusted Odds Ratio 4.00, 95% CI 1.24-12.91, P = .021) and a lesion ≤1 cm to a venous sinus (adjusted Odds Ratio 10.58, 95% CI 2.93-38.20, P < .001). All patients received standard prophylactic-dose anticoagulant therapy, and none received treatment-dose anticoagulant therapy. No thrombosis-related adverse event was reported. All thromboses presented spontaneous sinus recanalization radiologically at a mean of 89 ± 41 days (range, 7-171). CVST after supratentorial awake craniotomy is a rare event with satisfactory clinical outcomes and spontaneous sinus recanalization under conservative management without treatment-dose anticoagulant therapy. These findings are comforting to neurosurgeons confronted with postoperative MRI reports suggesting CVST.

ChatGPT yields low accuracy in determining LI-RADS scores based on free-text and structured radiology reports in German language.

To investigate the feasibility of the large language model (LLM) ChatGPT for classifying liver lesions according to the Liver Imaging Reporting and Data System (LI-RADS) based on MRI reports, and to compare classification performance on structured vs. unstructured reports. LI-RADS classifiable liver lesions were included from German written structured and unstructured MRIreports with report of size, location, and arterial phase contrast enhancement as minimum inclusion requirements. The findings sections of the reports were propagated to ChatGPT (GPT-3.5), which was instructed to determine LI-RADS scores for each classifiable liver lesion. Ground truth was established by two radiologists in consensus. Agreement between ground truth and ChatGPT was assessed with Cohen's kappa. Test-retest reliability was assessed by passing a subset of n = 50 lesions five times to ChatGPT, using the intraclass correlation coefficient (ICC). 205 MRIs from 150 patients were included. The accuracy of ChatGPT at determining LI-RADS categories was poor (53% and 44% on unstructured and structured reports). The agreement to the ground truth was higher (k = 0.51 and k = 0.44), the mean absolute error in LI-RADS scores was lower (0.5 ± 0.5 vs. 0.6 ± 0.7, p < 0.05), and the test-retest reliability was higher (ICC = 0.81 vs. 0.50), in free-text compared to structured reports, respectively, although structured reports comprised the minimum required imaging features significantly more frequently (Chi-square test, p < 0.05). ChatGPT attained only low accuracy when asked to determine LI-RADS scores from liver imaging reports. The superior accuracy and consistency throughout free-text reports might relate to ChatGPT's training process. Our study indicates both the necessity of optimization of LLMs for structured clinical data input and the potential of LLMs for creating machine-readable labels based on large free-text radiological databases.

Not Every Anosmia is COVID, a Case of Nasal Mass

Smell and test problems especially anosmia is a frequent symptom for COVID infection. Anosmia was experienced by almost 53% of those affected, in some cases persisting for longer periods after resolution of respiratory symptoms. Nasal blockage is another common symptom for emergency department patients and frequently associated with allergic rhinitis. A 25-year-old male patient presented with persistent bilateral nasal blockage, blood-stained nasal discharge, anosmia, and headache since last 1 year. During the peak of the pandemic, he was diagnosed with COVID. He was complaining of anosmia and nasal blockage and was treated with antihistaminic medicine for allergic rhinitis, but his symptoms persisted. He had breathing, bleeding and smelling problems in the last 2 years and started complaining of left sided proptosis for 3-4 weeks before being admitted to our department and had computerized tomography (CT) imaging at another facility. He was referred by an ophthalmologist to our hospital for advanced imaging with magnetic resonance (MRI) with contrast. He was investigated for exophthalmos in his left eye. He denied any other prior disease or medication. On examination he has nasal voice, left side exophthalmos, no diplopia or vision problem. The right tympanic membrane (TM) was intact, left sided dull TM with effusion. Other system evaluations were unremarkable. The patient was referred to Ear Nose and Throat consultant for further examination. Nasal endoscopy revealed fungating mass with covered blood clots and engorged vessels filling both the nasal cavities. MRI report described soft tissue mass, infiltrating the nasal cavity, paranasal sinuses and clivus with intracranial extension, to involve the left sub frontal region. Also noted associated destruction of the left lamina papyracea, showing orbital extension, compressing the orbital muscle cone, and compressing the medial rectus, with consequent left sided unilateral proptosis. In addition, there was nasopharyngeal extension. The epicenter of the mass was likely to be the ethmoid sinuses. His MRI revealed complete obstruction of the osteomeatal complexes, complete obliteration of the maxillary, ethmoids and frontal sinuses, due to retention of secretions and mass infiltration. Biopsy was taken and patient was followed up for surgical intervention. The differential diagnosis included vascular tumor, meningothelial tumor, undifferentiated carcinoma, and neuroendocrine carcinoma. Smell and taste disorders emerge during COVID infection, seem to be more common than other upper respiratory tract infections. Allergic rhinitis is also common amongst emergency department patients and frequently associated with nasal blockage. Rhinitis can be differentiated from sinus problems by the increased response of nasal obstruction to treatment, clear nasal discharge, and absence of pain or fever. Rhinitis does not lead to ostial obstruction, and patients do not complain of facial pain or headache. For suspected rhinitis or acute sinusitis, routine radiographic examination is not recommended and should be limited to the diagnosis of chronic or recurrent admissions, cases of questionable diagnoses, patients with unresponsive disease, or investigation of complications. Axial and coronal CT is the imaging modality of choice. In this case the patient was investigated for sinusitis complications and additional further imaging was necessary like MRI with contrast for proper diagnosis and management of the patient. Nasal blockage and upper respiratory system findings may be overseen by the patients or even the healthcare workers. Especially repeated admissions and persistence of these symptoms should be suspicious for the emergency physicians. Additional imaging and thorough examination are crucial for differential diagnosis and proper management of these patients. Emergency physicians should be careful on their diagnoses for common symptoms like nasal blockage especially for the patient

Traditional Siddha Approach in Treating Frozen Shoulder (Kumbavatham) by Use of Varmam and Thokkanam Therapy- a Case Study

Adhesive Capsulitis or Frozen shoulder also termed as Kumbavatham in Siddha system of medicine, causes swelling and stiffness in particular shoulder capsule restricting its mobility and ROM. The pain intensity is seen to increase in night times with gradual onset of shoulder stiffness and restriction in movement of the shoulder. Conservatively, it can be treated by analgesics, oral steroids, and intra-articular corticosteroid injections. Sometimes, the symptoms persists despite taking conservative measures, initiating patients to opt for alternative therapies for reducing pain and provide flexibility to the joint. A 34-year male from Bangalore presented with severe pain and restricted movements like abduction, adduction, external rotation and flexion of right shoulder both in active and passive movements for last 6 months. The patient was in distressed condition and even small daily tasks were difficult for him. MRI report confirmed of adhesive capsulitis (kumbavatham), one of the vatha diseases mentioned in Siddha system of medicine. A one-month Siddha vaidyam theraupatic approach incorporating Varmam therapy and thokkanam was administered to him. After 25 days, vast improvement in swelling and stiffness with all movements free in Right shoulder with no pain on moving the right arm. The holistic approach of Siddha medicine has provided the reduction in pain measured on VAS and improved restricted movements which was measured using goniometer and SPADI index. The Siddha system of Medicine is a simple and traditional approach for the treatment of such painful conditions. Conservative management of Adhesive capsulitis through Siddha practices provided significant relief by reducing pain and providing better flexibility in shoulder joints without aid of any analgesics. The paper also gives the details of the method employed and lifestyle modification techniques used to treat the individual.

Mortality Outcomes in a Large Population with and without Covert Cerebrovascular Disease.

Covert cerebrovascular disease (CCD) is frequently reported on neuroimaging and associates with increased dementia and stroke risk. We aimed to determine how incidentally-discovered CCD during clinical neuroimaging in a large population associates with mortality. We screened CT and MRI reports of adults aged ≥50 in the Kaiser Permanente Southern California health system who underwent neuroimaging for a non-stroke clinical indication from 2009-2019. Natural language processing identified incidental covert brain infarcts (CBI) and/or white matter hyperintensities (WMH), grading WMH as mild/moderate/severe. Models adjusted for age, sex, ethnicity, multimorbidity, vascular risks, depression, exercise, and imaging modality. Of n=241,028, the mean age was 64.9 (SD=10.4); mean follow-up 4.46 years; 178,554 (74.1%) had CT; 62,474 (25.9%) had MRI; 11,328 (4.7%) had CBI; and 69,927 (29.0%) had WMH. The mortality rate per 1,000 person-years with CBI was 59.0 (95%CI 57.0-61.1); with WMH=46.5 (45.7-47.2); with neither=17.4 (17.1-17.7). In adjusted models, mortality risk associated with CBI was modified by age, e.g. HR 1.34 [1.21-1.48] at age 56.1 years vs HR 1.22 [1.17-1.28] at age 72 years. Mortality associated with WMH was modified by both age and imaging modality e.g., WMH on MRI at age 56.1 HR = 1.26 [1.18-1.35]; WMH on MRI at age 72 HR 1.15 [1.09-1.21]; WMH on CT at age 56.1 HR 1.41 [1.33-1.50]; WMH on CT at age 72 HR 1.28 [1.24-1.32], vs. patients without CBI or without WMH, respectively. Increasing WMH severity associated with higher mortality, e.g. mild WMH on MRI had adjusted HR=1.13 [1.06-1.20] while severe WMH on CT had HR=1.45 [1.33-1.59]. Incidentally-detected CBI and WMH on population-based clinical neuroimaging can predict higher mortality rates. We need treatments and healthcare planning for individuals with CCD.

Quantification and significance of extraprostatic findings on prostate MRI: a retrospective analysis and three-tier classification

ObjectivesTo quantify extraprostatic findings (EPFs) on prostate MRI, estimate the proportion of reported and unreported EPFs, assess their clinical importance, and propose standardized reporting of EPFs.Materials and methodsProstate 3-T MRI studies, reports, and clinical data from 623 patients (age 67.9 ± 8.2 years) were retrospectively analyzed and re-evaluated for the presence of EPFs and their clinical significance: E1—no finding or findings that have no clinical significance; E2—potentially significant findings; and E3—significant findings.ResultsSecondary reading identified 1236 EPFs in 593 patients (1.98 ± 1.13 EPFs per patient, no EPFs in 30 patients), from which 468 (37.8%) were mentioned in the original report. The most common findings included diverticulosis (44% of patients), hydrocele (34%), inguinal fat hernia (16%), and bladder wall trabecular hypertrophy (15%). There were 80 (6.5%) E2 EPFs and 30 (2.4%) E3 EPFs. From E3 EPFs, 10 (33%) were not originally reported. A workup was suggested in 35 (52%) of the 67 originally reported E2 and E3 findings with follow-up and performed in 20 (30%). Fourteen (21%) EPFs in 11 patients influenced their management. Four experienced radiologists originally reported 1.8 to 2.5 findings per patient (p < 0.0001).ConclusionsEPFs on prostate MRI are frequent, but only 2.4% are clinically significant (E3), and 33% of these are not reported. Only 30% of E2 and E3 findings are further explored, and 21% influence patient management. We suggest that an “E” category should be attached to the PI-RADS system to identify the presence of EPFs that require further workup.Critical relevance statementExtraprostatic findings on prostate MRI are frequent, but only 2.4% are clinically significant (E3), and 33% of these are not reported. We advocate standardized reporting of extraprostatic findings indicating their clinical significance.Key points• Extraprostatic findings on prostate MRI are frequent with an average of two findings per patient.• 2.4% of extraprostatic findings are significant, and 33% of these are not reported.• There is a significant variability among experienced radiologists in reporting extraprostatic findings.Graphical

Charcot Foot Offloading in Stage 0 Is Associated With Shorter Total Contact Cast Treatment and Lower Risk of Recurrence and Reconstructive Surgery: A Pilot Study.

Charcot foot (CF) requires prolonged offloading of the affected foot to decrease the risk of deformity. The earliest phase in active CF (stage 0) is characterized by inflammatory signs without established fractures or skeletal deformity. We investigated whether offloading in stage 0 influences duration of total contact casting (TCC), risk of recurrence, and future need for surgery. All patients treated for active CF at Skåne University Hospital (Lund, Sweden) between 2006 and 2019 were screened for participation in a retrospective cohort study. CF events of included patients were classified as stage 0 or 1 according to X-ray and MRI reports. A total of 183 individuals (median age 61 [interquartile range (IQR) 52-68] years, 37% type 1 diabetes, 62% men) were followed for a median of 7.0 (IQR 3.9-11) years. In 198 analyzed CF events, 74 were treated with offloading in stage 0 and 124 in stage 1. Individuals offloading in stage 0 had significantly shorter TCC duration (median 75 [IQR 51-136] vs. 111.5 [72-158] days; P = 0.001). The difference was sustained when including only MRI-confirmed CF. The risk of developing new ipsilateral CF events >1 year after introduced definitive footwear was lower in those treated with offloading in stage 0 (2.7% vs. 9.7%; P < 0.05). No individual treated with offloading in stage 0 underwent reconstructive surgery, compared with 11 (8.9%) treated with offloading in stage 1 (P < 0.01). Amputation rates were similar. Offloading in stage 0 CF was associated with shorter TCC treatment, lower risk of a new CF event, and diminished need for reconstructive surgery. Future amputation risk was not affected.

Reliability and clinical validity of the Kang MRI grading system for cervical central spinal stenosis

BackgroundThe Kang MRI grading system for central cervical spinal stenosis has been previously explored in literature. The aim of the current study was to re-visit the system before adopting it into our institute’s cervical spine MRI reports and to evaluate its reliability through measuring the degree of agreement between radiologists of different levels of experience. The secondary aim was to evaluate its clinical validity by correlating between the radiological grade and the clinical symptoms as well as the subsequent treatment received by the patients.ResultsA total of 82 patients (21 males and 61 females, mean age = 42.8 years) that underwent cervical spine MRI in our institute were included in the study. Two specialized musculoskeletal radiologists and two radiology residents at different levels of experience independently graded the central cervical spinal stenosis at the narrowest level using the Kang grading system. Substantial agreement was found between all the participating radiologists (K = 0.665–0.799, percentage of agreement = 78.04–86.58%). Correlation between radiological grade and the presence of neuropathic symptoms (upper extremity paresthesias and/or numbness), motor affection (upper extremity weakness and/or weak hand grip), and treatment received by the patients was moderate, with R ranging from 0.325–0.440, 0.420–0.506, and 0.452–0.592 respectively. Correlation between grade and the presence of cervical pain was weak, with R = 0.197–0.253. On subdividing the grade 2 patients into grade 2a (demonstrable spinal cord deformity at the anterior or posterior aspects of the cord only) and grade 2b (demonstrable spinal cord deformity at both the anterior and posterior aspects of the cord), a statistically significant difference was found regarding the prevalence of motor affection among the patients in both sub-groups (P < 0.001).ConclusionDespite being reliable and clinically valid, the Kang grading system needs revision of the use of sagittal T2 images only as well as the definition of grade 2. We showed that the current definition of grade 2 to be rather broad, putting a wide array of patients into a single category. Sub-dividing it might increase the accuracy of the grading system.

Suspected Cauda Equina Syndrome: Can the Presence of an Orthopaedic Doctor in the Emergency Department Reduce Waiting Times for MRI Scans and Inpatient Stays?

Introduction Cauda equina syndrome (CES) is a very rare but devastating surgical emergency that can lead to permanent bowel, bladder or sexual dysfunction and lower limb paralysis. Although it is a clinical syndrome, an MRI scan is a critical diagnostic investigation for these patients and should be done as soon as possible. Our hospital is a district general hospital with no spinal services on site. There is a protocol in place for the management of these patients locally with MRI scanning during daytime hours. However, if the patient presents after 8 pm, they are discussed with the tertiary spinal centre, which then advises if the patient requires transfer overnight for urgent scanning.Considering an MRI scan is a critical diagnostic step for these patients,we introduced a role for an orthopaedic doctor in the Emergency Department (ED) to assess all of these patientsbefore collecting data for the second cycle. The aim of this audit was to see the effect of having an orthopaedic doctor in the ED for the assessment of these patients and its impact on waiting times and admission rates. Methods A closed-loop audit cycle was done looking into all referrals to trauma and orthopaedics with acute back pain and suspected CES in a district general hospital with no spinal services on site. The first cycle was between September 30, 2020, and May 31, 2021, and included 93 patients in total. Following this, a role for an orthopaedic doctor in ED was introduced from December 1, 2021, to January 31, 2022, for assessment of these patients. Data was then collected retrospectively for all patients referred during this period (n=36). Data was extracted from all relevant clinical systems including electronic patient record (EPR), Patient Pass (Patient Pass Ltd, Greater Manchester, England), which is the system used to digitally communicate with regional spinal services, and PACS (picture archiving and communication systems). The data was collated on a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, Washinton, United States) and analysed. Results Data were collected for a total of 36 patients in the second cycle following the introduction of an orthopaedic doctor in the ED. The age of patients referred was 30-89 yearswith a mean age of 51; 44.4% were male (n=16) and 55.5% female (n=20). All the patients who were referred received their MRI scan and report within 24 hours of presentation to the ED. In the first cycle of the audit, the mean waiting time for an MRI scan had been 12.5 hours, which was reduced to eight hours following the introduction of an orthopaedic doctor in the ED during daytime hours. This was stratified further according to the time patients presented to the hospital. From 8 am to 4 pm, the mean waiting time for an MRI scan was 9.5 hours pre-intervention and 5.5 hours after. From 4 pm to 12 am, the mean waiting timewas 18 hours before and 13 hours after, and from 12 am to 8 am, the waiting time for scans improved from 8.5 hours to 6.5 hours. The number of patients discharged on the same day greatly improved from 29% (n=27) in the initial study to 58% (n=21). This decreased unnecessary inpatient stays from 71% (n=66) to 42% (n=15). Conclusion This study showed that an orthopaedic doctor in the ED for the acute assessment of patients referred with possible CES is an effective way of improving their management. This decreases waiting times for MRI scans and therefore allows the patient to be managed more efficiently.