Need For Cross-sectional Imaging Research Articles

Fibrosis-Related microRNAs in Crohn's Disease with Fibrostenosis and Inflammatory Stenosis.

Crohn's disease (CD) is frequently complicated by strictures that can be either inflammatory or fibrostenotic. This distinction is important for deciding the best treatment course, but it can be difficult to determine clinically, sometimes even by advanced imaging techniques. We performed miRNA PCR panel screening on pooled samples of ileum with CD fibrostenosis or inflammatory stenosis. Eight miRNAs with profibrotic (miR-93-5p, miR-376c-3p and miR-424-5p), or fibroprotective (miR-133a-3p, miR-133b, miR-193a-5p, miR-335-5p and miR-378a-3p) functions described in the literature were selected for validation on 20 samples each of CD with fibrostenosis or inflammatory stenosis, with a separate sampling of the submucosa and subserosa. The results showed significant differences between the groups in subserosal samples, with upregulation of profibrotic miRNAs and downregulation of fibroprotective miRNAs in fibrostenosis compared to inflammatory stenosis. Only miR-424-5p showed a significant difference in the submucosa. There were significant differences in miRNA expression between subserosa and submucosa. Our results provide further evidence that the major differences between fibrostenosis and inflammatory stenosis are located in the subserosa, which is inaccessible to endoscopic sampling, highlighting the need for cross-sectional imaging or serological markers. We identify several miRNAs previously not connected to fibrosis in CD, which could potentially serve as biomarkers of fibrostenosis.

The Novel Use of Rare Earth Magnets for the Extraction of Metallic Soft Tissue Foreign Bodies in Children.

Metallic foreign bodies (mFB) are common following penetrating injuries in children. The mFB commonly occur in the head and neck region and extremity soft tissues. Removal may be indicated due to morbidity related to pain or migration. Extraction can be challenging to localize, often requiring wide exposure, and may be difficult to achieve in cosmetically sensitive areas. Different technological adjuncts have been used to facilitate foreign body removal including fluoroscopy, ultrasound, and more recently in adults, surgical magnets. The most powerful commercially available magnets are rare earth magnets comprised of neodymium iron and boron (Ndy). With the goal of reducing radiation exposure and the morbidity of mFB removal with associated soft tissue injury in children, a strategy was introduced utilizing Ndy to optimize extraction with minimal soft tissue surgical dissection. Two children with extremity mFB treated with Ndy between January 2021 and July 2021 were analyzed. We utilized commercially available ring type neodymium-iron-boron magnets with dimensions of 1 3/8-inch outer diameter x 1/8-inch inner diameter and 1/16 inch thick with a power of 13200 gauss that were processed for use according to our hospital protocols. Our main clinical indication was for the detection and retrieval of small ferromagnetic foreign bodies embedded in superficial extremity soft tissues. In the operating room under general anesthesia, the mFB were localized utilizing fluoroscopy. A 1.0cm skin incision was made into the subdermal soft tissues overlying the area of the mFB. No surgical tissue dissection was performed. The mFB could not be visualized in the soft tissue. Using fluoroscopy to localize the mFB, the Ndy was then placed into the wound in close proximity to the mFB. The mFB were immediately magnetized to the Ndy and the mFB were extracted from the soft tissues without any further surgical dissection. Two simple interrupted nylon sutures were placed to close the incision. The total operative time was 2 and 2.5minutes respectively. The children recovered uneventfully and are without complication. The use of Ndy to remove extremity soft tissue mFB in children appears to be feasible, safe, and efficient. Use of the Ndy allowed extraction via a small incision, optimizing the aesthetic result and avoiding the need for cross-sectional imaging, extensive surgical dissection, tissue reconstruction and prolonged operative time or x-ray exposure. The development of magnets of increasing energy density may be indicated to further optimize metallic soft tissue foreign body extraction in children in a minimally invasive manner.

Imaging Recommendations for Diagnosis, Staging, and Management of Oral Cancer

AbstractOral cavity cancers contribute to a majority of cancers in India. Clinical examination alone cannot determine the deeper extent of the disease; therefore, need for cross-sectional imaging including computed tomography and magnetic resonance imaging becomes indispensable for pre-treatment evaluation to decide optimal plan of management. Oral cavity squamous cell cancers (OSCC) can be treated with surgery alone, whereas deep muscle, neurovascular, osseous, or nodal involvement on imaging suggests advanced disease that requires a combination of surgery, radiation, and/or chemotherapy. Because of the complex anatomy of the oral cavity and its surrounding structures, imaging is crucial for locoregional staging and early detection of distant metastases. Imaging plays indispensable role not only in diagnosis but also in planning the management. An optimal guideline paper for developing countries like India is lacking that not only helps standardize the management but will also assist oncologists make reasonable decisions and reduce the unnecessary imaging. This imaging guideline paper will discuss the optimal imaging in diagnosis and management OSCC for Indian subcontinent.

LBODP067 Primary Amenorrhea - A Common Referral With An Uncommon Cause

Abstract Introduction Primary amenorrhea is a commonly encountered referral in the endocrine setting. Thorough history and clinical examination are integral in assessment to identify the cause. Although rare, congenital absence of the uterus and vagina constitutes the second most common cause after primary ovarian insufficiency. Once endocrine causes are excluded, anatomical causes must be explored. Case We present the case of a 17-year-old who was referred to our Endocrine unit by primary care with primary amenorrhea. Medical history was significant for acute myeloid leukaemia which was treated with chemotherapy and cranial radiotherapy at the age of 2 years. There was no family history of endocrinopathy. Physical examination revealed no significant abnormalities with a height of 154cm and Tanner staging of 5 in all areas. The patient and her parents were concerned about delayed puberty or hypogonadotropic hypogonadism due to previous oncology treatments. Biochemistry showed normal oestradiol 262 pmol/L, Prolactin 258 mU/L, LH 11.8IU/L, FSH 6.6IU/L, Testosterone 1.1 nmol/L, IGF-1 211 ug/L, TSH 1.7mu/L, T4 12.7 pmol/L, AMH 23.5 pmol/L. Bone age was 17 years 5 months, in keeping with chronological age. Considering normal endocrine investigations and development, anatomical causes of primary amenorrhoea were investigated with ultrasound and then subsequently MRI imaging. This demonstrated the absence of the uterus and upper two thirds of the vagina. Both ovaries were present, and she also had a single pelvic kidney. Results are in keeping with Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome type 2). The patient was counselled on the impact this would have on fertility and sexual functioning and offered psychological support with this diagnosis. Conclusion Mayer-Rokitansky-Küster-Hauser (MRKH) is a rare disorder with prevalence of 1 in 4500 and is usually diagnosed in adolescents with primary amenorrhea as first presentation. Genetic origins have been suggested and further research is required as this could impact fertility choices for patient moving forward. This case highlights many of the differential diagnoses at presentation and the need for cross sectional imaging to fully appreciate anatomical and therefore clinical consequences. Presentation: No date and time listed

An Incidental Discovery of a Serious Complication

An Incidental Discovery of a Serious Complication

Prevalence and risk of progressive aortic aneurysm and dissection in adults with conotruncal anomalies.

Conotruncal anomalies share common embryogenic defects of the outflow tracts and great arteries, which result in a predisposition to aortic aneurysms. The purpose of this study was to describe the prevalence and risk of progressive aortic aneurysms in adults with conotruncal anomalies. Retrospective study of adults with conotruncal anomalies that underwent cross-sectional imaging 2003-20. Aneurysm was defined as aortic root/mid-ascending aorta >2.1 mm/m2/>1.9 mm/m2, progressive aneurysm as increase by >2 mm, and severe aneurysm as dimension >50 mm. Of 2261 patients (38 ± 12 years; male 58%), 1167 (52%) had an aortic aneurysm, and 205 (14%) had a severe aortic aneurysm. Mean annual increase in aortic root/mid-ascending aorta was 0.3 ± 0.1 mm/0.2 ± 0.1 mm. The 3-, 5-, and 7-year cumulative incidence of the progressive aortic aneurysm was 4%, 7%, and 9%, respectively. The rate of aneurysm growth decreased with age, with no significant growth after age 40 years. There was an excellent correlation between aortic indices from cross-sectional imaging and echocardiography. Of 950 females, 184 had ≥1 pregnancy, and 81 (44%) of the 184 patients had aortic aneurysm prior to pregnancy. There was no aortic dissection or progression of the aortic aneurysm during pregnancy. Overall, there was no aortic dissection during 7984 patient-years of follow-up. Aortic aneurysm was common in patients with conotruncal anomalies. However, the risk of progressive aneurysm or dissection was low. Collectively, these data suggest a benign natural history and perhaps a less frequent need for cross-sectional imaging. Further studies are required to determine the optimal timing for surgical intervention in this population.

MP34-19 HEMATURIA REFERRALS AT A SAFETY NET HOSPITAL: A FOCUS ON PATIENT DEMOGRAPHICS AND COMPLIANCE

You have accessJournal of UrologyHealth Services Research: Quality Improvement & Patient Safety II (MP34)1 Sep 2021MP34-19 HEMATURIA REFERRALS AT A SAFETY NET HOSPITAL: A FOCUS ON PATIENT DEMOGRAPHICS AND COMPLIANCE Liz Wang, Remington Lim, Christopher Noyes, Batsheva Rubin, Shaun Wason, and David Wang Liz WangLiz Wang More articles by this author , Remington LimRemington Lim More articles by this author , Christopher NoyesChristopher Noyes More articles by this author , Batsheva RubinBatsheva Rubin More articles by this author , Shaun WasonShaun Wason More articles by this author , and David WangDavid Wang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002043.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Hematuria accounts for over 20% of referrals to urology with completion rates of only 5-18%. Our study characterizes the referral trends for hematuria and analyzes the socioeconomic factors affecting follow-up appointment rates at a safety net hospital. METHODS: We performed a retrospective review of patients referred to urology at an urban safety net hospital for microscopic and gross hematuria from 2018-2019. Demographics of patients were analyzed with an emphasis on gender, race, language, and insurance status. Appropriateness of the referral and completion of the workup, including imaging and cystoscopy, were studied. Univariate analysis was performed using chi-square test, Fisher’s exact test or t-test, and odds ratios were calculated. RESULTS: 333 patients were referred for microscopic or gross hematuria. We excluded 45 patients who did not show for consultation and 53 patients with a known history of genitourinary malignancy or urolithiasis. 59.2% patients had a pre-referral urinalysis with microscopy and 28.9% had a urine culture. 5.5% patients had only a dipstick urinalysis and 16.2% had no urine studies. The majority of patients were non-White (68.5%), publicly insured (75.3%). 40.8% were non-English speaking. Only 150 (63.8%) completed the hematuria workup with both upper tract imaging and cystoscopy. Of the remaining 85, 28 missed cystoscopy, 26 missed imaging, and 31 missed both. Odds of completing a hematuria evaluation was not significantly associated with any factors, including age, gender, BMI, smoking status, race, language, insurance status, or referral center. CONCLUSIONS: Within an urban safety net hospital system, 40% of hematuria referrals were missing the recommended urinalysis with microscopy. Although workup completion rates were higher compared to prior studies, they remain relatively low regardless of socioeconomic factors. Stratified 2020 AUA hematuria guidelines, which obviate the need for cross sectional imaging, may improve hematuria completion rates. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e623-e624 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Liz Wang More articles by this author Remington Lim More articles by this author Christopher Noyes More articles by this author Batsheva Rubin More articles by this author Shaun Wason More articles by this author David Wang More articles by this author Expand All Advertisement Loading ...

A blacksmith's tale: use of a rare earth magnet to facilitate safe removal of a metallic fragment from the face.

A 48-year-old blacksmith presented to A&E after sustaining facial injuries while operating a metal punch press. Radiographs revealed the presence of a metallic foreign body within the cheek, but this was clinically impalpable. By using a neodymium rare earth magnet extraorally, it was possible to identify the position of the fragment several centimetres lateral to the entry wound. Triangulation of the fragment's position allowed retrieval under local anaesthetic through the original penetration wound, without need for cross sectional imaging or extensive exploration under general anaesthetic. This case highlights an application for magnets in detection and removal of impalpable metallic foreign bodies embedded in superficial soft tissues.

The modified percent depth: Another step toward quantifying severity of pectus excavatum without cross-sectional imaging

IntroductionCurrent approaches to quantifying the severity of pectus excavatum require internal measurements based on cross-sectional imaging. This study evaluated the modified percent depth (MPD), a novel index of severity that can be obtained with external measurements, potentially avoiding the need for cross-sectional imaging. MethodsPatients undergoing surgical repair of pectus excavatum (pectus group), and those undergoing cross-sectional imaging for unrelated reasons (control group), between 2010 and 2016 were included. The MPD of the deformity was calculated using external (i.e. skin surface to skin surface) measurements from the radiographic images. The same external measurements were taken using chest calipers on a subset of these patients in the outpatient clinic. The optimal threshold for MPD that defined severe pectus deformity was derived from receiver–operator characteristic (ROC) analysis. Sensitivity and specificity of the MPD was compared with that of the Haller Index (HI) and Correction Index (CI). ResultsThere were 92 children (49 pectus, 43 controls) included. The median MPD was 20.2% and 4.2% for pectus and control patients, respectively (p<0.0001). An MPD cutoff of 10% optimally discriminated between severe pectus patients and controls by ROC analysis. An MPD of >10% had 98% sensitivity and 98% specificity for severe pectus deformity. Sensitivity and specificity were respectively 93% and 93% for HI >3.25, and 100% and 79% for CI >10. ConclusionAn MPD >10% performs slightly better than the HI and CI in distinguishing patients with severe pectus deformities. This novel measurement approach offers distinct advantages over existing indices, in that it does not require cross-sectional imaging and can be done using chest calipers in the office setting. Further studies with larger sample size are needed to verify reproducibility of the technique. Level of evidenceLevel II, Study of Diagnostic Test.

Negative D-dimer testing excludes pulmonary embolism in non-high risk patients in the emergency department.

The purpose of this study was to assess the ability of d-dimer testing to obviate the need for cross-sectional imaging for patients at "non-high risk" for pulmonary embolism (PE). This is a retrospective study of emergency department patients at an academic medical center who underwent cross-sectional imaging (MRA or CTA) to evaluate for PE from 2008 to 2013. The primary outcome was the NPV of d-dimer testing when used in conjunction with clinical decision instruments (CDIs = Wells', Revised Geneva, and Simplified Revised Geneva Scores). The reference standard for PE status included image test results and a 6-month chart review follow-up for venous thromboembolism as a proxy for false negative imaging. Secondary analyses included ROC curves for each CDI and calculation of PE prevalence in each risk stratum. Of 459 patients, 41 (8.9%) had PE. None of the 76 patients (16.6%) with negative d-dimer results had PE. Thus, d-dimer testing had 100% sensitivity and NPV, and there were no differences in CDI performance. Similarly, when evaluated independently of d-dimer results, no CDI outperformed the others (areas under the ROC curves ranged 0.53-0.55). There was a significantly higher PE prevalence in the high versus "non-high risk" groups when stratified by the Wells' Score (p=0.03). Negative d-dimer testing excluded PE in our retrospective cohort. Each CDI had similar NPVs, whether analyzed in conjunction with or independently of d-dimer results. Our results confirm that PE can be safely excluded in patients with "non-high risk" CDI scores and a negative d-dimer.

What is the use of imaging before referral to an orthopaedic oncologist? A prospective, multicenter investigation.

Patients often receive advanced imaging before referral to an orthopaedic oncologist. The few studies that have evaluated the value of these tests have been single-center studies, and there were large discrepancies in the estimated frequencies of unnecessary use of diagnostic tests. (1) Is there regional variation in the use of advanced imaging before referral to an orthopaedic oncologist? (2) Are these prereferral studies helpful to the treating orthopaedic oncologist in making a diagnosis or treatment plan? (3) Are orthopaedic surgeons less likely to order unhelpful studies than other specialties? (4) Are there any tumor or patient characteristics that are associated with the ordering of an unhelpful study? We performed an eight-center prospective analysis of patients referred for evaluation by a fellowship-trained orthopaedic oncologist. We recorded patient factors, referral details, advanced imaging performed, and presumptive diagnosis. The treating orthopaedic oncologist determined whether each study was helpful in the diagnosis or treatment of the patient based on objective and subjective criteria used in prior investigations. We analyzed the data using bivariate methods and logistic regression to determine regional variation and risk factors predictive of unhelpful advanced imaging. Of the 371 participants available for analysis, 301 (81%) were referred with an MRI, CT scan, bone scan, ultrasound, or positron emission tomography scan. There were no regional differences in the use of advanced imaging (range of patients presenting with advanced imaging 66%-88% across centers, p = 0.164). One hundred thirteen patients (30%) had at least one unhelpful study; non-MRI advanced imaging was more likely to be unhelpful than MRIs (88 of 129 [68%] non-MRI imaging versus 46 of 263 [17%] MRIs [p < 0.001]). Orthopaedic surgeons were no less likely than nonorthopaedic surgeons to order unhelpful studies before referral to an orthopaedic oncologist (56 of 179 [31%] of patients referred by orthopaedic surgeons versus 35 of 119 [29%] referred by primary care providers and 22 of 73 [30%] referred by nonorthopaedic specialists, p = 0.940). After controlling for potential confounding variables, benign bone lesions had an increased odds of referral with an unhelpful study (59 of 145 [41%] of benign bone tumors versus 54 of 226 [24%] of soft tissue tumors and malignant bone tumors; odds ratio, 2.80; 95% confidence interval, 1.68-4.69, p < 0.001). We found no evidence that the proportion of patients referred with advanced imaging varied dramatically by region. Studies other than MRI were likely to be considered unhelpful and should not be routinely ordered by referring physicians. Diligent education of orthopaedic surgeons and primary care physicians in the judicious use of advanced imaging in benign bone tumors may help mitigate unnecessary imaging. Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

A Simple Fluoroscopic Approach to Percutaneous Transgastric Cystgastrostomy with Internalized Drainage Catheter for Treatment of Pancreatic Pseudocysts: Report of Two Cases

With the emergence of minimally invasive techniques, percutaneous drainage has been applied to the management of symptomatic pancreatic pseudocysts in lieu of conventional surgical or endoscopic therapy. Percutaneous insertion of internalized drainage catheters represents an attractive method for pseudocyst drainage, but has been limited by the usual need for cross-sectional imaging or endoscopic guidance. Herein, we describe the use of a simple fluoroscopically guided technique for percutaneous transgastric cystgastrostomy with internalized drainage catheter placement in two cases.