Use Of Additional Imaging Research Articles

Diffusion tensor transformation for personalizing target volumes in radiation therapy

Diffusion tensor imaging (DTI) is used in tumor growth models to provide information on the infiltration pathways of tumor cells into the surrounding brain tissue. When a patient-specific DTI is not available, a template image such as a DTI atlas can be transformed to the patient anatomy using image registration. This study investigates a model, the invariance under coordinate transform (ICT), that transforms diffusion tensors from a template image to the patient image, based on the principle that the tumor growth process can be mapped, at any point in time, between the images using the same transformation function that we use to map the anatomy. The ICT model allows the mapping of tumor cell densities and tumor fronts (as iso-levels of tumor cell density) from the template image to the patient image for inclusion in radiotherapy treatment planning. The proposed approach transforms the diffusion tensors to simulate tumor growth in locally deformed anatomy and outputs the tumor cell density distribution over time. The ICT model is validated in a cohort of ten brain tumor patients. Comparative analysis with the tumor cell density in the original template image shows that the ICT model accurately simulates tumor cell densities in the deformed image space. By creating radiotherapy target volumes as tumor fronts, this study provides a framework for more personalized radiotherapy treatment planning, without the use of additional imaging.

Isolated dextrogastria with eventration of right hemidiaphragm and hiatal hernia in an adult male

BackgroundType 2 isolated dextrogastria in conjunction with protrusion of the right hemidiaphragm and hiatal hernia is an uncommon anomaly among all transpositions of the viscera. Clear diagnosis is not straightforward in such cases both clinically and with various imaging techniques leaving often only laparotomy for diagnosis.Case presentationHere, we discuss the case of a so far asymptomatic 19-year-old male, who had a 3-month history of abdominal pain and 2 days of vomiting with absolute constipation, and reduced air entry in the base of the right lung. A large air fluid level was found in the right lower hemithorax, furthermore, a loss of the normal diaphragmatic outline, and paucity of the bowel gases in the rest of the abdomen. Computer tomography with contrast was suggestive of loss of right lung volume, with stomach and bowel loops herniating into the right hemithorax and compressive atelactatic changes in the adjacent lung alongside an enlarged liver. A barium test showed the stomach fundus and body posteriorly positioned, while both duodenal bulb loops and the duodeno-jejunal junction alongside the small and large bowels were detected in their normal positions.ConclusionIn case of visceral transpositions, routine diagnostic blood and radiological tests may lead the health care provider to misdiagnosis. It is necessary, in particular when surgery is required, to carefully elucidate the organ anomaly. The use of additional imaging and radiological methods may be called for; CT scan and a barium test were critical here. This is the first case of isolated dextrogastria with eventration of right hemidiaphragm and hiatal hernia reported from Pakistan providing insights for diagnostic procedures.

Sonographic assessment of inflammatory bowel disease in the emergency department: A case series and review of the literature.

The use of sonography for diagnosing inflammatory bowel disease (IBD) has been reported in the radiology literature but is not common practice in the hands of emergency physicians (EPs). We present a series of three cases where IBD was managed by an EP using point-of-care ultrasonography (POCUS), and discuss the sonographic features of IBD including bowel wall thickening, increased blood flow on color Doppler, infiltration of surrounding fatty tissue, and presence of intraperitoneal fluid. Complications such as bowel strictures and peri-colic abscess are also described. We suggest that the use of POCUS for the assessment of IBD patients in the ED may expedite both diagnosis and treatment, as well as minimize the use of additional imaging.

Reducing length of stay for patients presenting to general surgery with acute non-surgical abdominal pain.

Acute abdominal pain is a common surgical presentation. We previously found that over the last decade, more patients were admitted to hospital with non-surgical diagnoses (e.g. gastroenteritis, constipation and non-specific abdominal pain) and length of stay and use of imaging (mainly computed tomography scan) for these patients increased. This study aimed to reduce length of stay and use of imaging for patients admitted with non-surgical abdominal pain. A prospective study was undertaken in a tertiary centre evaluating length of stay and use of additional imaging in patients with a non-surgical diagnosis after a quality improvement intervention was implemented. A total of 454 patients were included; 204 (44.9%) presented with non-surgical abdominal pain. During the study period, a significant reduction in computed tomography scan requests was observed (38.5-25.0%, P = 0.037) and an increasing proportion of these patients were discharged within 12 h (33.3-57.1%, P = 0.018). The number of re-presentations remained unchanged (P = 0.358). The study intervention increased the proportion of patients with non-surgical diagnoses that were successfully discharged within 12 h and reduced the use of additional imaging in this group. This may lead to improved use of health care resources for patients with more urgent diagnoses.

Çocuklarda Akut Apandisit Tanısında Pediatrik Apandisit Skoru ve Ultrasonografi Bulgularının Güvenilirliğinin Değerlendirilmesi

Objective: Acute appendicitis is the most common surgical emergency in childhood. Early diagnosis is essential to prevent perforation-related morbidity. In this study, we aimed to evaluate the effectiveness of pediatric appendicitis score (PAS) and ultrasonography (USG) findings in the diagnosis of acute appendicitis. Materials and Methods: Patients who presented with acute abdominal pain and who were followed up or operated with a pre-diagnosis of appendicitis were analyzed retrospectively. The patients were divided into two groups as operated (n = 288) and non-operated (n = 161). PAS value of all patients was calculated and 1-4 negative (low risk), 5-6 suspect (moderate risk), 7 and above were considered positive (high risk). Patients who underwent USG were included in the study. The definitive diagnosis of the patients undergoing surgery was confirmed by histopathological evaluation. Results: With the pre-diagnosis of acute appendicitis, 449 patients (171 girls, 278 boys) were hospitalized. Appendectomy was performed in 288 (64 %) of the patients. The remaining 161 patients (36 %) who recovered after the observation were discharged without any surgery. Histopathological diagnosis of patients undergoing appendectomy was acute appendicitis in 217 patients (75.3 %), perforated appendicitis in 67 patients (23.2 %) and normal appendix in 4 patients (1.4 %). Patients undergoing appendectomy had a significantly higher PAS value (p < 0.001). PAS value was significantly higher in the patients diagnosed with perforated appendicitis (p < 0.05). The sensitivity of USG and PAS were 81.59 % and 82.98 %, and their specificity was 88.81 % and 95.03 %, respectively, in the diagnosis of appendicitis. The sensitivity decreased significantly (67.70 %), and the specificity increased (100 %) when the patients with appendicitis in USG and PAS 7 and above were evaluated together. The sensitivity was 32.29 % and the specificity was 83.85 % when USG positivity or high-risk PAS value was used alone. Conclusion: PAS is a useful clinical guide in determining the risk group for appendicitis and the use of additional imaging, and supports the diagnosis even in the high-risk group without additional imaging. However, in cases of incompatibility between USG and PAS values, we believe that close observation, repeated physical examination and, if necessary, further imaging are necessary to reduce the rate of negative appendectomy.

Predictive risk factors for sentinel lymph node nonvisualization on planar lymphoscintigraphy using an intratumoral injection in patients with primary breast cancer.

Lymphoscintigraphy is considered a useful tool to optimize sentinel lymph node (SLN) identification. Nonvisualization of the SLN is associated with a lower SLN identification rate. The aim of this study was to identify preoperative factors associated with SLN nonvisualization on lymphoscintigraphy. A total of 2050 consecutive SLN procedures were evaluated from clinically node-negative breast cancer patients. Planar lymphoscintigraphy was performed at 3 h after an intratumoral injection of technetium-99m-nanocolloid. This technique was used for extra-axillary SLN identification. Patient, tumor, and treatment characteristics were analyzed for association with SLN nonvisualization. Factors with a P-value less than 0.1 in univariate analysis were included in a multivariate logistic regression model. The SLN visualization rate was 86.7%. In multivariate logistic regression, age of at least 70 years [odds ratio (OR): 3.24; 95% confidence interval (CI): 2.14-4.91)], BMI of at least 30 (OR: 1.93; 95% CI: 1.39-2.69), T3/T4-tumors (OR: 2.70; 95% CI: 1.37-5.32), medially/centrally located tumors (OR: 1.52; 95% CI: 1.17-1.99), previous mantle field radiation (OR: 4.04; 95% CI: 1.74-9.35), nonpalpable tumors (OR: 1.88; 95% CI: 1.36-2.60), and presence of iodine seeds (OR: 1.35; 95% CI: 1.02-1.78) were associated significantly with nonvisualization on lymphoscintigraphy. Nonvisualization was the strongest independent predictor of unsuccessful intraoperative SLN identification (P<0.001). Overall, the SLN identification rate was 97.7% because of the use of additional imaging and blue dye. This study reports new tumor and treatment-related risk factors for nonvisualization on lymphoscintigraphy by using an intratumoral injection in primary breast cancer. We recommend a periareolar subcutaneous injection to improve SLN visualization in patients with limited prognostic and therapeutic relevance of internal mammary chain SLN identification.

Fine-needle aspiration to diagnose primary thyroid lymphomas: a systematic review and meta-analysis.

Primary thyroid lymphoma (PTL) is a rare malignancy, and its prognosis depends significantly on its early diagnosis. While fine-needle aspiration (FNA) represents the gold standard to identify differentiated thyroid carcinoma, its reliability for the detection of PTL is still unclear. Here, we conducted a systematic review and meta-analysis to evaluate the diagnostic performance of FNA in PTL. A comprehensive literature search of PubMed/MEDLINE and Scopus databases was conducted to retrieve papers reporting histologically proven PTL undergone FNA. The last search was performed in February 2018 without language and time restrictions. Thirty-two studies describing 593 PTL were included and the pooled FNA sensitivity was 0.48 (95% CI = 0.38-0.58). FNA sensitivity was 0.51 in 20 studies published before 2010 and 0.39 in those published later, 0.50 in six articles with at least 20 cases and 0.44 in nine series enrolled after 2000. This performance was similar in 12 articles including diffuse large B-cell lymphoma (0.54) and those six on marginal zone lymphoma (0.56). Remarkably, FNA sensitivity increased to 0.72 when considering also FNA reports suspicious for PTL reported in 14 articles. Heterogeneity among the series was found. Publication bias was not always detected. The present meta-analysis demonstrated that FNA has low sensitivity in diagnosing PTL. However, this rate increased when considering also FNA reports suspicious for PTL, which is relevant from a clinical standpoint. This result could support indirectly the use of additional imaging and/or core biopsy when PTL is suspected.

Does the use of adjunct urine lipopolysaccharide lipoarabinomannan in HIV-infected hospitalized patients reduce the utilization of healthcare resources? A post hoc analysis of the LAM multi-country randomized controlled trial

BackgroundThe World Health Organization (WHO) recommends the use of adjunctive urine lipopolysaccharide lipoarabinomannan (LAM) testing in hospitalized HIV-infected persons with suspected tuberculosis (TB) and a CD4 count <100cells/ml. However, the recommendation is conditional, and uptake by individual treatment programmes depends on perceived additional benefit. The aim of this study was to determine whether adjunctive LAM testing has additional clinical benefits including a reduction in healthcare-related use of resources. MethodsA post hoc analysis was performed of a published multicentre, multi-country, randomized controlled trial that showed an approximate 20% mortality benefit in HIV-infected hospitalized patients who underwent adjunctive LAM testing as part of their diagnostic workup. In that parent study, adult HIV-infected hospitalized patients with suspected TB (n=2528) were randomly allocated to either routine diagnostics (smear microscopy, Xpert MTB/RIF, and culture; n=1271), or routine diagnostics plus adjunctive urine LAM testing (n=1257). Data were further analyzed to determine whether there were other potential benefits of LAM usage based on CD4 count and illness severity. Aspects evaluated included: (1) the reduction in number of diagnostic sputum samples tested, (2) the utilization of additional imaging, (3) disease resolution based on follow-up signs and symptoms of illness severity, and (4) the reduction in hospital readmission. ResultsAdjuvant LAM did not reduce the number of diagnostic sputum samples requested, the need for additional imaging, or the hospital readmission rate. However, adjunctive LAM was associated with a more rapid rate of disease resolution (dyspnoea) in the severely ill subgroup. Higher LAM grade (grades 4 and 5), compared to lower grade positivity (≤3), was associated with lower use of ultrasound, lower Karnofsky performance score, lower CD4 cell count, and shorter time to culture positivity. ConclusionsAlthough, adjunct LAM was associated with a mortality benefit in the parent study, no benefit could be demonstrated in the secondary analysis with respect to the number of diagnostic sputum samples requested, the use of additional imaging, or hospital readmission rates. However, given the limitations of the present study, further appropriately designed studies are required to determine the effect of adjunct urine LAM on the utilization of healthcare resources.

Penumbra and re-canalization acute computed tomography in ischemic stroke evaluation: PRACTISE study protocol.

Rationale Multimodal imaging, including computed tomography angiography and computed tomography perfusion imaging, yields additional information on intracranial vessels and brain perfusion and can differentiate between ischemic core and penumbra which may affect patient selection for intravenous thrombolysis. Hypothesis The use of multimodal imaging will increase the number of patients receiving intravenous thrombolysis and lead to better treatment outcomes. Sample size 400 patients. Methods and design PRACTISE is a prospective, multicenter, randomized, controlled trial in which patients presenting within 4.5 h of symptom onset are randomized to either the current evidence-based imaging (NCCT alone) or additional multimodal computed tomography imaging (NCCT + computed tomography angiography + computed tomography perfusion). Clinical decisions on intravenous recombinant tissue plasminogen activator are documented. Total imaging time in both arms and time to initiation of treatment delivery in those treated with intravenous recombinant tissue plasminogen activator, is recorded. Follow-up will include brain imaging at 24 h to document infarct size, the presence of edema and the presence of intra-cerebral hemorrhage. Clinical evaluations include NIHSS score at baseline, 24 h and day 7 ± 2, and mRS at day 90 to define functional outcomes. Study outcomes The primary outcome is the proportion of patients receiving intravenous recombinant tissue plasminogen activator. Secondary end-points evaluate times to decision-making, comparison of different image processing software and clinical outcomes at three months. Discussion Multimodal computed tomography is a widely available tool for patient selection for revascularization therapy, but it is currently unknown whether the use of additional imaging in all stroke patients is beneficial. The study opened for recruitment in March 2015 and will provide data on the value of multimodal imaging in treatment decisions for acute stroke.

Decision making in third molar surgery: a survey of Brazilian oral and maxillofacial surgeons

This study was designed to evaluate the variations in decision making among Brazilian oral and maxillofacial surgeons (OMFS) and trainees in relation to third molar surgery. A survey on 18 diverse clinical situations related to the assessment and treatment of the third molar surgeries was conducted during the 20th Brazilian National OMFS meeting. Participants were divided into three groups according to their level of training. Another variable studied was length of experience. Correlation between the question answers and the variables was analysed using the chi-square test and the f test. The mean age of participants was 32.68 years, and their mean length of experience was 5.24 years. There were no statistical differences between the level of training and number of years of experience and the responses to 15 of the 18 questions on clinical situations. However, differences were found in responses to prophylactic extraction of asymptomatic third molars, use of non-steriodal anti-inflammatory drugs (NSAIDs) during the preoperative surgical period and the use of additional imaging to plan extractions. The group with shorter time of experience (3.8 ± 3.94 years) tended to recommend extractions of asymptomatic third molars more frequently compared with the more experienced surgeons (P = 0.041). More experienced surgeons used NSAIDs in the preoperative surgical period, whereas the majority of the youngest surgeons (4.1 ± 5.96 years of experience) did not (P = 0.0042). The certificated trained and in practice group tended to treat deep lower third molar impactions based on the findings of a panoramic radiograph, without obtaining additional imaging [cone beam computed tomography (CBCT)] before treatment (P = 0.0132). Decision making regarding third molar treatment differs according to the level of training and is influenced by the number of years of experience. Therefore, further continuous education programmes in this area are warranted to make recommendations regarding third molars consistent with the current literature.

Percutaneous interventions in cardiology in Poland in the year 2014. Summary report of the Association of Cardiovascular Interventions of the Polish Cardiac Society AISN PTK.

IntroductionThe Board of the Association of Cardiovascular Interventions of the Polish Cardiac Society (AISN PTK) publishes annual data from the National PCI Registry (ORPKI) operated by the Jagiellonian University Medical College in Krakow.AimFor the first time the AISN PTK report is based on the new electronic database implemented in Poland on January 1st, 2014.Material and methodsIn 2014, there were 155 invasive cardiology centers registered in the ORPKI database (an increase by 1 center in comparison to 2013) and 92% of them had 24/7 percutaneous (PCI) duty. For the first time the number of catheterization laboratories (cath labs) in Poland remained stable, and even though there was an increase by 1 in absolute numbers, 2 cath labs ceased to admit patients in 2014. This means that the number of active cath labs per 1 million inhabitants is similar to last year and equals 4.ResultsIn comparison to 2013, there was a significant increase in the total number of coronary angiographies. There were 226 713 angiographies in 2014. The total number of PCI procedures was 126 241, which is 5.1% more than in 2013.ConclusionsThere was a significant increase in the overall number of coronary angiographies and PCIs in Poland in 2014. The use of attributes of modern interventional cardiology such as drug-eluting stents and bioabsorbable vascular stents is growing as well as more frequent choice of a radial access site by PCI operators even in ST-elevation myocardial infarction patients. One should also note a significant rise in the use of additional imaging or diagnostic tools such as fractional flow reserve, intravascular ultrasound and optical coherent tomography.

Variation in position of the L4/5 disc inter-space from the anatomical landmark: review of 450 radiographs and clinical applications

The L4/5 disc inter-space is commonly believed to be represented by a line drawn between the two highest points of the iliac crests. This line is frequently used as a pre-operative guide for incision placement, in patients undergoing spinal surgery. We reviewed the antero-posterior and lateral lumbar spine films of 450 patients, ranging in age from 20 to 90 years, measuring the distance from the supracristal plane to the midpoint of the L4/5 disc interspace. The plane intersected the spine at the L4/5 interspace in only 31.9% of cases and was found to lie at the lower half of the body of L4 or above in 49.5% of cases. There was significant variation in the position of the supracristal plane between the different patient age groups studied (P≤0.05). The use of additional imaging, along with plain radiography is advised when attempting identification of this spinal level, as reliance on palpation of the iliac crests alone to identify this landmark may lead to unintentional cranial placement of a surgical incision during spinal procedures, or cannulation at a level above the intended interspace, during epidural and spinal anaesthesia.

The use of additional imaging increased specificity and decreased sensitivity in screening mammography

Background and Objectives To examine the use of additional imaging after standard mammographic screening views to better understand the value of these additional testing in improving accuracy. Materials and Methods Statewide population data on screening mammography were used to report accuracy measures at screening and after additional imaging tests. Pathology data from biopsies performed within 1 year following the screening mammogram were used to determine cancer outcome (489 in situ and invasive cancers). Pathologic and population characteristics of women receiving different types of imaging were assessed by chi-square or t-tests. Similar tests compared women with the same imaging and differing outcomes. Results Of 77,799 women with screening mammograms 9.9% had additional imaging. Additional imaging reduced false positives from 7,765 (100/1,000 mammograms) to 1,112 (14/1,000 mammograms). The majority of false negatives (82%) occurred in women receiving only screening views, and additional imaging increased the number of false negatives from 82 (1/1,000 mammograms) to 115 (1.5/1,000 mammograms). Conclusion Additional imaging can reduce unnecessary biopsy but at the cost of some additional false negatives. Additional imaging's potential for improving the sensitivity of screening is limited because most missed cancers occur in women who do not have additional imaging.

Minimally invasive biopsy of parasellar lesions: Safety and clinical applications of the endoscopic, transnasal approach

The base of the skull can be affected by a variety of tumours requiring a wide range of treatment modalities. In formulating a management plan, histological diagnosis can play an essential role. Existing methods of skull base biopsy, especially in the anatomically critical parasellar region, include either prolonged open skull base approaches or image-guided needle biopsies. The latter methods can be time-consuming and cannot reliably avoid surrounding critical neurovascular structures. The experience with an endoscopic, transnasal biopsy of parasellar tumours in selected patients is presented. A preliminary series of 11 patients harbouring parasellar lesions with some degree of extension to the sphenoid or maxillary sinus underwent endoscopic, transnasal biopsy. The procedure was diagnostic in all cases. There was no operative mortality and minimal morbidity only recorded. The biopsy results affected the patients' management and, based on these results, major skull base surgery was avoided in four cases. Direct endoscopic visualization prompted avoidance of a vascular catastrophe of an atypical vascular lesion. The endoscopic, transnasal biopsy appears to offer a number of advantages over existing methods in selected patients. It is minimally invasive as it employs the use of natural osseous corridors. Tissue sampling under direct visualization minimizes the risks of negative biopsies or damage to critical neurovascular structures. The use of additional imaging employed by image-guided needle biopsies in not necessary. When planning treatment of parasellar tumours, the endoscopic, transnasal route should be considered.