Negative CT Research Articles

ODP499 Myxedema Coma: A Challenging Presentation of an Uncommon Disease

Abstract Myxedema coma is a rare diagnosis but if not early recognized, this medical emergency possesses a high mortality rate. Over the years, it has been described predominantly in elderly women with history of hypothyroidism and as a precipitant factor that converges to evolve in a full presentation. We report a case of myxedema coma in a young male without risks for this disease. A 38 y/o Latin-American male with medical history ofhepatitis C virus and intravenous drug abuser that was brought to the emergency department after being found in the streets. The patient was agitated, oriented only to person, had slurred speech and reports last dose of heroin was two days ago. Denied other condition or medications. Vital signs BP 103/90mmHg, pulse: 41 bpm, T: 35.8°C RR: 19 rpm, SPO2: 99% at room air and BMI: 23.9. kg/m 2 . Physical examination pertinent for a disheveled male with anasarca, diffused dry skin with piloerection without surgery scars, non-palpable nor tender thyroid gland, bilateral exophthalmos, decreased bowel sound, positive fluid wave and abdomen diffusely tender to palpation with bilateral lower extremities infected ulcers. Blood workup showed impaired renal function, severe azotemia, hyponatremia, hypoglycemia and normocytic anemia. TSH 147uIU/mL. Imaging studies remarkable for bilateral pleural effusions, intestinal ileus, and negative brain CT scan. Patient was admitted with diagnosis of uremic encephalopathy, drug withdrawal and soft skin tissue infection. Patient was treated with emergent hemodialysis, drug withdrawal measures and IV antibiotics. Despite treatment, patient's clinical condition began to decline. He was found obtunded requiring endotracheal intubation. TSH was persistently elevated in 55.7uIU/mL with suppressed free T4 <0.42ng/dL. Patient noted with persistent sinus bradycardia, hypothermia, ileus, ascites, bilateral pleural effusions, and hypotension. Patient was consulted to endocrinology department who evaluated the overall clinical presentation and myxedema coma was diagnosed. He was treated with levothyroxine 100mg IV for two days, but eventually developed multiorgan failure and unfortunately died. Myxedema coma is a complication of severe hypothyroidism that slows down the functions of multiple organs and directly affects their function. It is an endocrinologic emergency that leads to decline of the clinical presentation of patients. The epidemiology favors this presentation in patients with history of hypothyroidism, more specifically elderly women. Multiple conditions may present with similar signs and symptoms. Physicians must be aware that myxedema coma must be suspected in a patient with altered mental status, hypothermia, hypoglycemia, hypotension, anasarca among others even in the presence of more common conditions and in rare populations like our patient. Opioid Induced Endocrinopathies still remain a complication that is underdiagnosed. The aim of this case is to createmedical awareness on the importanceto consider myxedema coma in patients with Opioid abuse and withdrawal. Presentation: No date and time listed

PSUN43 Anti-phospholipid syndrome presenting with bilateral adrenal hemorrhage in a young female

Abstract Patient is a 29-year-old female with PCOS and morbid obesity and recent admission for abdominal pain is found to have bilateral adrenal hemorrhage and prolonged PTT. Patient was found to be anemic with hemoglobin of 6.1 a week prior to presentation, attributed to dysfunctional uterine bleeding and was treated with subsequent transfusion. She presents a week after her initial presentation with recurrent constant sharp pulsating abdominal pain, and reported pain was worse in mid-epigastric area radiating into her back, with a temperature of 38.2 and heart rate of 135, troponin level 2.64, with a negative CT for PE, but incidental bilateral adrenal hemorrhage absent on CTA from last week, with a CBC showing WBC 21.7 RBC 3.5 Hgb 8.6 MCV 76.9 MCH 24.7 RDW 17.6, with normal folate and B12. Patient was monitored closely and was started on IV hydrocortisone 50 mg every six hours, her PTT was found to be 88 and PT of 17.5, so antiphospholipid syndrome was suspected and confirmed with positive lupus anti-coagulant (LAC) and anticardiolipin IgG ab, and B2 glycoprotein. Patient had no evidence of adrenal infract that could have converted to hemorrhage. Objectives Antiphospholipid syndrome (APS) is an autoimmune systemic disorder characterized by persistent antiphospholipid antibodies including lupus anticoagulant, anticardiolipin or anti B2- glycoprotein I antibodies, presenting with arterial venous or small vessel thrombosis or recurrent early pregnancy loss. Other manifestation including livedo reticularis, cutaneous ulceration, thrombocytopenia, and hemolytic anemia, valvular heart disease and nephropathy. In our case, the patient APS was confirmed by the presence of the markers, but no evidence of adrenal infracts what could have converted to hemorrhage was found. Conclusions Although APS leads to a hypercoagulable state which can lead to adrenal vein thrombosis, leading to adrenal hemorrhage which can be fatal. Screening for antiphospholipid antibodies should be considered in all patients with unknown etiology of adrenal hemorrhage to promote diagnosis and timely management. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

PSOR7 Presentation Time: 12:00 PM: Toxicity and Efficacity of Whole Gland Salvage HDR Brachytherapy After Primary Radiation for Prostate Cancer

<h3>Purpose</h3> Androgen Deprivation Therapy (ADT) is the most common treatment for relapsing prostate cancer after primary radiation therapy. However, an effective local treatment could be used to obtain local control of the disease while limiting the systemic side effects of ADT. We designed a single institution prospective pilot study to assess the efficacy and safety of whole gland prostate HDR brachytherapy. <h3>Materials and Methods</h3> Fifty (50) patients with local relapse after primary radiation therapy were included in this study. A biopsy-proven local relapse, a negative bone scan, and a negative CT scan of the abdomen and pelvis were mandatory. A dose of 32Gy in 4 fractions was delivered to the whole prostate by HDR brachytherapy using CT-based treatment planning. The use of ADT was allowed if deemed clinically indicated by the treating physician. The primary objective was to evaluate early and late gastrointestinal (GI) and genitourinary (GU) toxicities, assessed with CTCAE v5 scale and IPS score. Biochemical disease-free survival (bDFS) was evaluated as a secondary outcome. <h3>Results</h3> Median follow-up was 61,1 months (0.8-106.8 months). Sixteen (16) patients received short-course ADT prior to brachytherapy. GI toxicities were low, with no grade 3 toxicities reported. 4.1% and 14,6% of patients had early and late grade 2 toxicities. Only one patient had a grade 3 GU early toxicity. However, 16,7% of patients experienced late grade 3 toxicities (12.0% at the last follow-up). Interestingly, none of the patient using neoadjuvant ADT developed late grade 3 toxicities although this association was not statistically significant (Chi-Square p-value 0.171). Mean IPSS value presented a predictable rise to 15.9 at 1 month follow-up. A subsequent decline was observed to mean IPSS under 10 after 24 months. A bDFS of 73,5% was observed after 48 months. <h3>Conclusion</h3> Whole gland salvage HDR brachytherapy is an effective treatment with an excellent biochemical disease-free survival. However, it is associated with a significant risk of late GU toxicities. In this perspective, our treatment protocol has been modified to allow for focal therapy using MR guidance. That will allow us to evaluate if a similar local control can be maintained while reducing the incidence of severe toxicities.

Management of Traumatic Brain Injury in Patients with DOAC Therapy-Are the "New" Oral Anticoagulants Really Safer?

(1) Background: In recent years, "new" direct oral anticoagulants (DOAC) have gradually replaced other antithrombotic therapies. The international literature agrees on the increased mortality for traumatic brain injury (TBI) patients using vitamin K antagonists (VKA), but thus far, there are insufficient data on the influence of DOAC on the outcome of TBI. (2) Methods: We retrospectively analyzed data from all patients who presented with head trauma using antithrombotic therapy. Outcome parameters were the presence of pathologies on the initial CT, occurrence of delayed intracranial hemorrhage, surgical intervention, and death. (3) Results: In total, data of 1169 patients were reviewed. Of those, 1084 (92.7%) had a mild TBI, 67 (5.7%) moderate TBI, and 17 (1.5%) severe TBI. In total, 456 patients (39%) used DOAC and 713 patients (61%) used VKA, antiplatelet therapy, or prophylactic doses of low molecular weight heparin at the time of trauma. The groups showed no significant differences in age, injury mechanisms, or GCS at presentation. Overall, the initial cranial CT showed pathologies in 85 patients (7.3%). Twenty-five patients with head trauma and DOAC therapy had pathological findings on CT (5.5%), 11 patients with VKA (4.8%), and 48 patients with antiplatelet therapy (10.6%). There was a statistically significant difference in occurrence of CT pathologies between DOAC alone compared to acetylsalicylic acid (4.9 vs. 10.5%, p = 0.04). Delayed intracranial hemorrhage after an initially negative CT during in-hospital observation occurred in one patient (0.2%) in the DOAC group, two patients (0.9%) in the VKA group, and four patients (0.9%) in the antiplatelet group without statistical significance. Head trauma related surgery was performed in three patients (0.7%) in the DOAC group, two patients (0.9%) in the VKA group, and six patients (1.3%) in the antiplatelet group without statistical significance. Death due to head trauma occurred in four patients (0.9%) of the DOAC group compared to one patient (0.4%) of the VKA group and five patients (1.1%) of the antiplatelet group without statistical significance. (4) Conclusions: Our data suggest a comparable risk of pathological CT findings, delayed intracranial hemorrhage, surgical interventions, and death after blunt head trauma for patients with DOAC compared to VKA, but a lower risk for pathological CT findings compared to platelet inhibitors. As VKA are known to increase mortality, our data suggest that similar caution should be used when treating patients with head trauma and DOAC, but the overall numbers of serious or severe courses after simple falls remain low. We recommend routine CT for all head trauma patients with antithrombotic therapy but the role of in-hospital observation for patients with mild TBI remains a matter of debate.

A Pilot Study of Salvage HDR Brachytherapy in Recurrent Prostate Cancer: 5 Year Toxicity and Outcomes

<h3>Purpose/Objective(s)</h3> Until recently, Androgen Deprivation Therapy (ADT) was the main treatment option for recurrent prostate cancer after primary radiation treatment. However, ADT is not curative and is associated with several side effects. Local ablative therapy can be curative and reduce long-term side effects associated with ADT. We designed a single institution prospective pilot study to evaluate the toxicities and outcomes of HDR brachytherapy as a salvage local therapy. <h3>Materials/Methods</h3> Sixty (60) patients with a biopsy-proven local relapse after a previous treatment with radiation were included in this study. A negative bone scan and CT scan of the abdomen and pelvis at the time of relapse was mandatory. Primary objective was to assess both early and late genitourinary (GU) and gastrointestinal (GI) toxicities. Biochemical disease-free survival (bDFS) was also assessed as a secondary objective. Toxicities were reported using CTCAE v5 scale and the IPSS. Short-course ADT could be used if deemed clinically indicated by the physician. HDR brachytherapy regimen was 32Gy delivered in 4 fractions to the whole prostate and, for the last 10 patients recruited, 27Gy in 2 fractions administered focally, due to concerns with toxicities. CT-based treatment planning using an inverse planning algorithm (IPSA) was performed for patients with whole prostate treatment (n = 50). Real-time ultrasound-based treatment planning was used for patients undergoing focal salvage radiation (n = 10). <h3>Results</h3> Median follow-up was 58.4 months (0.8-106.8 months). GI toxicities were acceptable with 3.6% and 14.5% of patients experiencing early and late grade 2 toxicities. No G3 GI toxicities were reported. Early G2 GU toxicities were overestimated at 100% (all patients used an alpha-blocker in the postoperative setting) and one patient had G3 early toxicity. Late GU toxicities were significant, with 14.5% of patients experiencing late G3 toxicity (10.0% at the last follow-up). Of interest, the use of ADT before HDR brachytherapy (n = 17) was associated with lower GU toxicities (no G3) although the association was not statistically significant (Chi-Square p-value 0.201). Good biochemical control was achieved with a bDFS of 73.9% at 48 months. <h3>Conclusion</h3> Salvage HDR brachytherapy after primary radiation to the prostate offers good biochemical control but at the cost of significant G3 GU morbidities. Patients can benefit from local therapy after primary radiation but whole-gland radiation should be used with caution because of concern with toxicities. Focal therapy to partial gland might be a good alternative to achieve local control and avoid severe toxicities.

From Alpha to Omicron: A Tertiary Care Hospital-Based Radiation Oncology Network's COVID-19 Response Experience

Purpose/Objective(s)The COVID-19 pandemic completely altered access to medical care, severely limiting or halting outpatient procedures over long periods of time. However, it was clear that radiation therapy needed to remain available to patients. We implemented asymptomatic testing algorithms and constructed negative air pressure CT simulator and treatment rooms within our tertiary care hospital-based Radiation Oncology network to accommodate the safe treatment of patients affected by the COVID-19 pandemic.Materials/MethodsOur Radiation Oncology department undertook dedicated construction to convert select CT simulator rooms and treatment vaults into negative pressure environments, including one CT simulator room and photon-based linear accelerator treatment vault at the main campus in 5/2020; and one CT simulator room, two photon-based linear accelerator vaults, and a single proton therapy gantry between two regional campuses in 12/2021. From 5/18/20 to 9/7/21, an asymptomatic screening protocol was implemented for all patients prior to initiation of radiation therapy. Patients with COVID-19 infection and Persons Under Investigation (PUIs) could undergo simulation and/or treatment in the newly constructed biocontainment environments at the discretion of the treating physician with guidance from a predefined priority scale. A biocontainment treatment protocol delineated specific roles within a treatment team of one Nursing Safety Officer, one Direct Contact Radiation Therapist, and one Indirect Contact Radiation Therapist. Safety drills were performed to establish and practice safe pathways for escorting patients directly from their car to the treatment room, and vice versa, for the last treatment slot(s) of the day. Patients who were treated under COVID-19 protocol from 6/2020 to 1/2022 were chart reviewed to assess utilization of our newly constructed and developed biocontainment resources.ResultsA total of 6,525 patients were treated from 6/2020 through 1/2022 across our 5 campuses. During this time, 42 patients were treated under the COVID-19 biocontainment protocol. All but 3 had documented personal COVID-19 positivity, while the others were designated as PUI, typically for COVID-positive household contacts. For 61.9% of patients, these safety measures mitigated the need for extended breaks during treatment courses that had already been initiated. The majority (64.3%) of patients were being treated with curative intent, while 10 patients (23.8%) were treated as a result of an inpatient palliative consult. A third (35.7%) were transferred from a regional campus to the main campus for management prior to expansion of biocontainment resources. The median number of biocontainment sessions required by each patient was 6 (range: 1-15).ConclusionThe construction of negative pressure environments and development of a COVID-19 biocontainment protocol have helped to mitigate the impact of the pandemic on our patients and to maximize efforts in protecting our staff.

Investigating the Extent of Critical Thinking in Field-Dependent and Field-Independent Students’ Critical Thinking and Blogging

Identifying critical thinking and learners’ characteristics is very important in an online learning environment. This study investigated the extent of critical thinking between field-dependent and field-independent students’ critical thinking and blogging. It is a quasi-experimental in which a quantitative method was employed on an intact class of the students to develop their CT skills in their argumentative blog posts. Different aspects of CT skills, such as observation, inference, reasoning, assumption, and credibility were explained to the students. The GEFT developed by Witkin et al. (1971) was applied to evaluate the students' field dependency. Moreover, Newman et al. model (1996) was applied to analyze students’ CT in their blog posts. No significant difference was found in the number of positive and negative CT indicators used by FD and FI students. Therefore, educators who wish to improve the students’ learning may train the students in CT skills by using a pre-planned and systematic procedure without worrying about learners’ cognitive styles, particularly their field dependency.

Usefulness of preoperative extracranial imaging in radiologically suspicious glioblastoma in the West of Scotland and proposal of an imaging diagnostic pathway.

A computed tomography chest, abdomen and pelvis scan (CT CAP) is probably unnecessary if a glioblastoma is detected on the initial CT brain (CTB) before more radiologically definitive magnetic resonance imaging (MRI). We audited its frequency to develop and improve our diagnostic management pathway. Twelve-month retrospective case series from 2018 of patients having an initial CTB suspicious for glioblastoma. We dichotomised patients into two groups: Group 1, tissue proven; and Group 2, non-tissue proven, owing to increased extracranial comorbidity in Group 2, which might influence a medical decision to request a CT CAP despite the radiological diagnosis of a glioblastoma being obvious on an initial CT. We quantified the frequencies of plain and contrast CTBs, CT CAPs and extracranial malignancy. In total, 131 patients had a CTB suspicious for glioblastoma; of these, 72% had a CT CAP and 17% had extracranial malignancy. In Group 1 (n = 84 [mean age 59 years]), 64% had a CT CAP. Plain CTB was undertaken in 24% of patients and contrast CTB in 76%. Extracranial malignancy was present in 8% and 12%. In Group 2 (n = 47 [mean age 73 years]), 85% had a CT CAP. Plain CTB was undertaken in 22% of patients and contrast CTB in 78%. Extracranial malignancy was present in 33% and 23%. Negative CT CAPs were found in ∼88% of CTBs in Group 1 and ∼75% of CTBs in Group 2. Patients having an initial contrast CTB suggestive of glioblastoma, prior to definitive MRI, who are going to be managed surgically, having no history of extracranial malignancy, do not necessarily need a CT CAP unless MRI is non-diagnostic.

Structural and Functional Pulmonary Assessment in Severe COVID-19 Survivors at 12 Months after Discharge.

Long-term pulmonary sequelae in COVID-19 patients are currently under investigation worldwide. Potential relationships between blood sampling and functional and radiological findings are crucial to guide the follow-up. In this study, we collected and evaluated clinical status, namely symptoms and patients’ reported outcome, pulmonary function tests (PFT), laboratory tests, and radiological findings at 3- and 12-months post-discharge in patients admitted between 25 February and 2 May 2020, and who survived severe COVID-19 pneumonia. A history of chronic pulmonary disease or COVID-19-unrelated complications were used as exclusion criteria. Unenhanced CTs were analyzed quantitatively (compromising lung volume %) and qualitatively, with main patterns of: ground-glass opacity (GGO), consolidation, and reticular configuration. Patients were subsequently divided into groups based on their radiological trends and according to the evolution in the percentage of compromised lung volume. At 12 months post-discharge, seventy-one patients showed significantly improved laboratory tests and PFT. Among them, 63 patients also underwent CT examination: all patients with negative CT findings at three months (n = 14) had negative CT also at 12 months; among the 49/63 patients presenting CT alterations at three months, 1/49 (2%) normalized, 40/49 (82%) improved, 7/49 (14%) remained stably abnormal, and 1/49 (2%) worsened. D-dimer values were low in patients with normal CT and higher in cases with improved or stably abnormal CT (median values 213 vs. 329 vs. 1000 ng/mL, respectively). The overall compromised lung volume was reduced compared with three months post-discharge (12.3 vs. 14.4%, p < 0.001). In stably abnormal CT, the main pulmonary pattern changed, showing a reduction in GGO and an increase in reticular configuration. To summarize, PFT are normal in most COVID-19 survivors 12 months post-discharge, but CT structural abnormalities persist (although sensibly improved over time) and are associated with higher D-dimer values.

Locoregional therapy for oligometastatic cervical cancer: a single-center retrospective study

BackgroundOligometastases are limited in number and extent, and therefore, are amenable to locoregional therapy.ObjectiveTo analyze recurrence patterns, survival outcomes, and prognostic factors in patients with cervical cancer receiving locoregional therapy...

S2472 A Case of Functional Bowel Disease Misdiagnosed as Carcinoid Syndrome

Introduction: Carcinoid tumor is a well-differentiated neuroendocrine tumor (NET) that arises from enterochromaffin cells. NETs produce serotonin which is metabolized to the inactive 5-hydroxyindoleacetic acid (5-HIAA) by the liver and the lungs. Carcinoid syndrome results from the secretion of serotonin into the systemic circulation by a metastatic NET that originates from the midgut. The primary screening method for carcinoid syndrome is 24-hour urinary 5-HIAA (U-5HIAA) which has a 90 percent sensitivity and specificity in diagnosing carcinoid syndrome. This case illustrates a unique scenario of a markedly elevated U-5HIAA not due to NET. Case Description/Methods: A 29-year-old female presented to our clinic with abdominal pain, bloating, diarrhea, and weight loss associated with postprandial facial flushing. Medications included Dextroamphetamine and Fremanezumab. Based on her symptoms, U-5HIAA was ordered and was elevated at 148 mg (normal < 6). Carcinoid Syndrome was suspected based on symptoms and markedly elevated U-5HIAA. Imaging studies were ordered to identify primary or metastatic NET. These included negative CT abdomen/pelvis and a negative Ga68 Dotatate NETSPOT PET scan. Upper endoscopy and Colonoscopy were also negative. The patient expressed difficulty in stopping dextroamphetamine for the urine collection but due to the negative evaluation for NET she finally agreed to hold it for 3 days. Repeat U-5HIAA decreased down to 10.4 mg. Her symptoms were then believed to be secondary to functional bowel disease. The patient’s symptoms improved with mirtazapine and dicyclomine, and she regained the weight. Discussion: This is a unique case with a misleading U-5HIAA. While mildly elevated levels of U-5HIAA can be seen with tryptophan rich foods and certain drugs, including amphetamines, marked elevation, like in our case is more specific and usually seen with the carcinoid syndrome. Our patient had symptoms suspicious of carcinoid syndrome and a U-5HIAA of 148 mg, which is 25 times the upper normal. However, there was no evidence for NET on extensive work up, and the levels rapidly decreased with stopping dextroamphetamine. To our knowledge, this is the highest falsely positive U-5HIAA reported. This case shows the importance of a complete drug history, including over-the-counter medications. When the 5-HIAA is elevated, the test needs to be repeated after discontinuing all potentially interfering medications.

The Usefulness of Pre-Operative Extra-Cranial Imaging in Radiologically Suspicious Glioblastoma Multiforme in the West of Scotland: and a Proposal of an Imaging Diagnostic Pathway

Abstract AIMS Objective: a CT chest, abdomen and pelvis (CT CAP) is probably unnecessary if a glioblastoma multiforme (GBM) is detected on initial CT brain (CTB) prior to definitive MRI. We audited its frequency to develop a management pathway METHOD Methods: 12-month retrospective case series from 2018 of patients having an initial CTB suspicious for GBM. We dichotomised patients into two groups a) tissue proven and b) non-tissue proven, due to these representing distinct patient profiles. We quantified frequencies of plain and contrast CTBs, CT CAPs and extra-cranial malignancy. RESULTS Results: Group 1 (total n=84 [mean age 59 years]): 64% had a CT CAP. Plain CTB occurred in 24% and contrast CTB in 76%. Extra-cranial malignancy was 8% and 12%. Group 2 (total n=47 [mean age 73 years]): 85% had a CT CAP. Plain CTB occurred in 22% and contrast CTB in 78%. Extra-cranial malignancy was 33% and 23%. Negative CT CAPs in ~88% of CTBs in Group 1 and ~75% of CTBs in Group 2. CONCLUSION Conclusions: patients having a contrast CTB as their initial imaging modality, being suggestive of GBM, prior to definitive MRI, and managed surgically, having no history of extra-cranial malignancy, do not need a CT CAP unless MRI is non-diagnostic.

A comparison among RIRS and MiniPerc for renal stones between 10 and 20 mm using thulium fiber laser (Fiber Dust): a randomized controlled trial

We performed a prospective randomized comparison among Retrograde IntraRenal Surgery (RIRS) and MiniPerc (MP) for stones between 10 and 20mm to evaluate outcomes with the same laser device: Fiber Dust. Patients with a single renal stone between 10 and 20mm were randomized to RIRS (Group A) versus MP (Group B). Exclusion criteria were age < 18 or > 75, presence of acute infection, coagulation impairments, cardiovascular or pulmonary comorbidities. In both groups, the Fiber Dust laser was used. A CT scan after 3months was performed. A negative CT scan or asymptomatic patients with stone fragments < 3mm and a negative urinary culture were the criteria to assess the stone-free status. A statistical analysis was carried out to assess success, complication and retreatment rates and need for auxiliary treatments. Between January 2021 and January 2022, 186 patients were enrolled (90 in Group A and 96 in Group B). Mean stone size was 15.8mm and 14.9mm in Group A and B, respectively (p = 0.23). The overall stone-free rate (SFR) was 73.3% for Group A and 84.4% for Group B. A higher SFR was reached for upper calyceal stones in Group A (90.4%) lower calyceal stones in Group B (91.6%). Retreatment rate (p = 0.31) and auxiliary procedure rate (p = 0.18) were comparable. Complication rate was 5.5% and 5.2% for Groups A and B, respectively. RIRS and MP are both effective to obtain a postoperative SFR with Fiber Dust. According to the stone position one treatment is superior to the other one.

536 Conservative Management of the Colonic Gallstone

Abstract A 74-year-old woman presents with a 7-day history of increasing lower abdominal pains and reduced bowel movements; resulting in absolute constipation.Twenty-four hours prior to admission she also had symptoms of nauseous and significant abdominal distention. Her past medical history included; diverticulitis, type 2 diabetes, hypercholesterolemia, an ultrasound scan in 2005 confirming gallstones, but no previous abdominal surgery.She was initially treated for bowel obstruction and a CT arranged. CT showed a 4.5 cm gallstone in mid-sigmoid colon and a cholecystocolonic fistula. She was booked for colonoscopy±laparotomy, but on the morning of her planned procedure she repeatedly opened her bowels. Subsequent colonoscopy was negative and repeat CT confirmed the stone was no longer within the gastrointestinal tract. Several case reports have clearly documented the presence of a cholocystocholic fistula leading to sigmorectal bowel obstruction from gallstones. These reports, however, have all implied that management should primarily be with a laparotomy. Although colonoscopy has also been trialled, few cases appear to have been successful and conversion to laparotomy has been high. This case report highlights a role for conservative management in colonic gallstones, avoiding the morbidity and mortality associated with laparotomy +/- bowel resection.

Imaging in the Evaluation of Esophageal Trauma Including Surgery

Esophageal perforation and anastomotic leak of the postsurgical esophagus place patients at significant risk for morbidity and mortality, requiring prompt and accurate diagnosis through imaging. Plain radiographs may be obtained during the initial evaluation of symptoms but have low sensitivity and specificity for esophageal perforation. With clinical suspicion for perforation, CT with oral contrast should be obtained initially due to its high sensitivity, utility in surgical planning, and usefulness in evaluating underlying causes or other etiologies for symptoms. With a negative CT, perforation is ruled out and subsequent fluoroscopic esophagography is unnecessary. In patients with postsurgical anatomy such as esophagectomy, diagnosis is difficult and concurrent review of CT and fluoroscopy is more sensitive than either modality alone.

The effectiveness of the pregnancy adapted YEARS algorithm to safely identify patients for CT pulmonary angiogram in pregnant and puerperal patients suspected of having pulmonary embolism.

BackgroundPulmonary thromboembolism is one of the leading causes of maternal death worldwide. Globally there has been increasing physician reliance on CT pulmonary angiogram for definitive diagnoses and exclusion of pulmonary thromboembolism. The problem, however, arises when considering the high radiation penalty from performing these investigations, highlighted by the low diagnostic yield. Of recent, the pregnancy-adapted YEARS algorithm has shown promise in international studies as a possible alternative for stratifying risk of pulmonary thromboembolism during the pregnancy and puerperal period.ObjectivesTo determine the effectiveness of the pregnancy adapted YEARS algorithm to safely minimise the number of true negative CT pulmonary angiograms for patients suspected of having pulmonary embolism in our clinical setting.MethodA cross-sectional study was performed in a tertiary hospital in Gauteng on puerperal and pregnant patients suspected of having pulmonary embolism. We retrospectively applied the pregnancy adapted YEARS algorithm and reviewed the various outcomes.ResultsThe pregnancy adapted YEARS algorithm proved effective in safely identifying patients for CT pulmonary angiography. By retrospectively applying the algorithm, there could have been a 25.7% scan reduction, whilst maintaining a negative predictive value of 100.0%.ConclusionAs physician reliance on radiological investigations increases, we must remain cognisant of the added radiation exposure and the long-term adverse effects of ionising radiation. The pregnancy-adapted YEARS algorithm provides a safe, reproducible alternative to aid our bid going forward.

The Diagnostic Performance of Multi-Detector Computed Tomography (MDCT) in Depiction of Acute Spondylodiscitis in an Emergency Department.

Background: The diagnosis of acute spondylodiscitis can be very difficult because clinical onset symptoms are highly variable. The reference examination is MRI, but very often the first diagnostic investigation performed is CT, given its high availability in the acute setting. CT allows rapid evaluation of other alternative diagnoses (e.g., fractures), but scarce literature is available to evaluate the accuracy of CT, and in particular of multi-detector computed tomography (MDCT), in the diagnosis of suspected spondylodiscitis. The aim of our study was to establish MDCT accuracy and how this diagnostic method could help doctors in the depiction of acute spondylodiscitis in an emergency situation by comparing the diagnostic performance of MDCT with MRI, which is the gold standard. Methods: We searched our radiological archive for all MRI examinations of patients who had been studied for a suspicion of acute spondylodiscitis in the period between January 2017 and January 2021 (n = 162). We included only patients who had undergone MDCT examination prior to MRI examination (n = 25). The overall diagnostic value of MDCT was estimated, using MRI as the gold standard. In particular, the aim of our study was to clarify the effectiveness of CT in radiological cases that require immediate intervention (stage of complications). Therefore, the radiologist, faced with a negative CT finding, can suggest an elective (not urgent) MRI with relative serenity and without therapeutic delays. Results: MDCT allowed identification of the presence of acute spondylodiscitis in 13 of 25 patients. Specificity and positive predictive value were 100% for MDCT, while sensitivity and negative predictive value were 68% and 50%, respectively, achieving an overall accuracy of 76%. In addition, MDCT allowed the identification of paravertebral abscesses (92%), fairly pathognomonic lesions of spondylodiscitis pathology. Conclusions: The MDCT allows identification of the presence of acute spondylodiscitis in the Emergency Department (ED) with a satisfactory accuracy. In the case of a positive CT examination, this allows therapy to be started immediately and reduces complications. However, we suggest performing an elective MRI examination in negative cases in which pathological findings are hard to diagnose with CT alone.

Weighing the Risk Profile of Cervical Spine MRI in Evaluating Pediatric Cervical Spine Injuries

Objective: Screening for cervical spine injury after blunt trauma is common, but there remains varied practice patterns and clinical uncertainty regarding adequate radiographic evaluation. An oft-cited downside of MRI is the added risk compared to CT in the pediatric population; however, these specific risks have not yet been reported. This study examines the risks of cervical spine MRI in pediatric trauma patients in the context of what value MRI adds. Methods: This was a retrospective observational study of all pediatric blunt trauma patients who were evaluated with a cervical spine MRI over a 4-year period at a level 1 pediatric trauma center. Clinical and radiographic data were abstracted, as well as anesthesia requirements and MRI-related major adverse events. CT and MRI results were compared for their ability to detect clinically unstable injuries – those requiring halo or surgery. Results: There was one major adverse event related to MRI among the 269 patients who underwent cervical spine MRI – a rate of 0.37%. While 55% of children had an airway and anesthesia for MRI, only 57% of these airways were newly placed for the MRI. None of the 85 patients newly intubated for MRI developed aspiration pneumonitis or ventilator-associated pneumonia, and no patients had a significant neurologic event while at MRI. Another area of the body was imaged concurrently with the cervical spine MRI in 64% of patients and 83% of MRIs were performed within 48 h. CT and MRI were both 100% sensitive for injuries requiring halo or operative intervention. Eighty-three patients had an MRI performed after a negative CT, 11% (9/83) of these patients had a clinically stable injury detected on subsequent MRI, and none of these patients presented for delayed cervical spine complications. Conclusions: Overall, the safety profile of MRI in this setting is excellent and less than one-third of patients need new airway and anesthesia solely for MRI. In this clinical scenario, MRIs can happen relatively quickly and many patients require another body part to be imaged concurrently anyway. MRI and CT were both 100% sensitive for clinically unstable injuries. In the appropriate patients, MRI remains a safe and radiation-free alternative to CT.

P-45964498-191 - Comparison of different diagnostic imaging techniques for the detection of bone invasion in oral cancers

<h3>Objectives</h3> To evaluate the ability of different imaging modalities to accurately detect bone invasion in oral squamous cell carcinomas. <h3>Patients and Methods</h3> Patients with oral squamous cell carcinoma, who were scheduled for mandibulectomy or maxillectomy, underwent clinical evaluation using five preoperative imaging diagnosis Methods-contrast-enhanced MRI, CT, 99mTc scintigraphy (Tc scan), FDG-PET CT (PET/CT), and panoramic radiography. The sensitivity and specificity of each modality in detecting bone invasion were calculated by comparing the findings on the images with postoperative histopathological findings. In a subgroup of patients, we further assessed the ability of MRI and CT to detect the accurate extent of bone invasion, including the height, width, and depth in patients with pathological mandibular invasion. <h3>Results</h3> Overall, 50 patients were enrolled in this study, and nine patients with pathological mandibular invasion were included in our subgroup analysis. MRI was found to be the most useful method in detecting bone invasion, showing the highest sensitivity (88.9%) and negative predictive values (92.3%). CT (87.5% specificity and 77.8% sensitivity) was more specific than MRI, though less sensitive. Combined PET/CT was more sensitive (83.3%) and less specific (71.9%) than CT. Tc scan had high sensitivity (88.9%); however, the specificity was relatively low (71.9%). <h3>Conclusion</h3> MRI was the most useful method in detecting bone invasion. A negative MRI result definitively excludes bone marrow invasion. In patients with positive MRI findings, a negative CT may be useful in ruling out bone marrow invasion.

Is routine CT scan after pancreaticoduodenectomy a useful tool in the early detection of complications? A single center retrospective analysis.

The clinical impact of routine CT imaging after pancreaticoduodenectomy (PD) has not been properly investigated. The aim of this study was to investigate the role of routine CT scan after PD for the detection of postoperative complications. Prospectively collected data of consecutive patients undergoing PD and receiving routine postoperative CT imaging were retrospectively analyzed. The primary endpoint was accuracy of CT imaging in identifying major complications. The secondary endpoint was identification of preoperative and intraoperative factors associated with severe complications. A subgroup analysis of CT scan accuracy in identifying severe complications in patients stratified by fistula risk score (FRS) and presence of early clinical alterations was also performed. A total of 145 patients were included. Routine CT scan had low specificity (Sp = 0.36) and high sensitivity (Sn = 0.98) for predicting major complications, with an accuracy of 0.57. At multivariate logistic regression analysis, only fistula moderate-high FRS (p = 0.029) was independently associated with severe complications. In patients with negligible-low FRS, CT scan showed a Sp of 0.63 and a Sn of 1.0 with an accuracy of 0.69. In patients with moderate-high FRS, CT scan had a Sp of 0.19, a Sn of 0.97 and an accuracy of 0.5. In the 20 (14%) patients with negligible-low FRS and no clinical alterations, no deaths or readmissions occurred regardless of CT findings, while one severe complication occurred in the positive CT scan group. In all other groups, no deaths or readmissions occurred in case of negative CT, with only one severe complication in the moderate-high FRS group with clinical alterations. In case of positive CT, the rate of severe complications was 47% in case of negligible-low FRS and clinical alterations, 40% in case of moderate-high FRS with no clinical alterations, and 45% in case of moderate-high FRS and clinical alterations. Routine postoperative CT scan after PD should not be performed in patients with negligible-low FRS and no clinical alterations. In all other patients, a negative CT scan appears to be highly accurate in identifying patients who will have an uneventful course and who could benefit from early discharge.