Use Of Imaging Studies Research Articles

The use of imaging studies and its association with surgical delays, costs and complications in patients with acute appendicitis: a population-based study in Ontario, Canada

BackgroundAppendicitis is commonly assessed with diagnostic imaging prior to intervention. The study objective was to describe practice patterns of diagnostic imaging for appendicitis and the associations with surgical delays, hospital costs, and complications.MethodsThis was a population-based cohort study of patients with appendicitis between 2009 and 2015. Imaging was categorized into none, ultrasound, computed tomography (CT), or both. The outcomes were: 1) time from triage to surgery, 2) complication rate and 3) hospital costs. Logistic regression and hierarchical linear regression were used to estimate associations between imaging and outcomes.ResultsThere were 50,369 study patients. Time to surgery was highest in patients requiring both CT and ultrasound (mean difference 5.0 h 95%CI 4.6–5.4) followed by patients requiring CT (2.7 h 95%CI 2.4–3.0) and ultrasound (mean difference 0.7 h, 95%CI 0.5–1.0), compared to no imaging. Hospital costs were highest in those with both ultrasound and CT ($256 95%CI $28–483) and CT alone ($234 95%CI $75–394), compared with no imaging. Complications were associated with the use of CT (OR 1.08 95%CI 1.00–1.17) and both CT and ultrasound (OR 1.21 95%CI 1.09–1.35) compared with no imaging, but not with ultrasound alone (OR 1.01 95%CI 0.93–1.09).ConclusionsThis study demonstrated that type of diagnostic imaging is associated with delays to surgery, especially in those requiring CT scan. In addition, complications and hospital costs are increased in this group. Clinicians could consider ultrasound as the first imaging modality to facilitate more timely surgery and reduced costs.

7859 Primary Hyperaldosteronism And Mild Autonomous Cortisol Secretion (MACS) In Adrenal Incidentaloma

Abstract Disclosure: K. Chanturishvili: None. Q. Gvazava: None. N. Zavrashvili: None. An adrenal incidentaloma is a mass lesion greater than 1 cm in diameter, discovered by radiologic examination, performed for another reason. Widespread use of imaging studies in everyday clinical practice has led to the increased rates of adrenal incidentalomas. Two main questions arise after discovering adrenal mass: is it malignant or benign, and is the mass hormonally active?We present a case of a 55 years old male, with a history of obesity (BMI 35).He had no significant past medical history and was not taking any medications.He presented to our clinic with an upper respiratory tract infection and shortness of breath. Chest CT was done to evaluate for possible pneumonia, where 46 x 30 cm adrenal incidentaloma with -5 HU was discovered.He was referred to our department for endocrine evaluation.Initial assessment revealed previously unknown hypertension with left ventricular hypertrophy. Laboratory workup revealed high aldosterone, suppressed renin, low normal ACTH and DHEA-S, positive 1-mg overnight dexamethasone suppression test (DST- 2.66 ug/dL) and 8-mg DST (2.26 ug/dL).Additionally, the metabolic panel showed prediabetes and hyperlipidemia.Diagnosis of adrenal macroadenoma with cortisol and aldosterone co-secretion was made.Unilateral adrenalectomy was planned. Possible postoperative adrenal insufficiency has been established. Recommendation for proper glucocorticoid coverage was given.In conclusion, evaluation of the functional status of adrenal tumors is essential to uncover hidden medical issues, as s well as to properly guide the patient for intra and postoperative management, avoiding the risks of adrenal insufficiency with proper glucocorticoid coverage. Surgical management of hormonally active adrenal incidentalomas, especially larger >2.4 cm, has potential benefit of improving and preventing metabolic abnormalities: hyperglycemia, dyslipidemia as well as comorbidities such as obesity, hypertension and osteoporosis. Presentation: 6/1/2024

A case report on incidentally detected pulmonary sclerosing pneumocytoma: a diagnostic challenge

Introduction and importance: Pulmonary sclerosing pneumocytoma (PSP) is a rare non-cancerous lung tumor that is usually asymptomatic, but may cause respiratory distress if it becomes large. PSPs are often detected incidentally because of their slow growth, lack of symptoms, characteristic radiographic features, and increased use of imaging studies. Although it is not a malignant tumor, it can mimic malignancy on imaging and histology, leading to misdiagnosis and unnecessary surgery. Case presentation: A 23-year-old asymptomatic female was incidentally diagnosed with PSP during evaluation for a breast fibroadenoma. A chest CT revealed a 3 cm lobulated mass in the left upper lobe. Cytology showed malignant cells with necrotic debris. Immunohistochemistry was positive for TTF-1 and EMA, negative for p63 and AE1/AE3. Histopathology confirmed a well-circumscribed benign neoplasm, consistent with pulmonary sclerosing pneumocytoma. There was no mediastinal lymph node invasion, and the post-surgery prognosis was good. Clinical discussion: PSP is a slow-growing tumor that is often asymptomatic until it reaches a significant size. Owing to their well-circumscribed margins and the presence of calcifications, they are often detected incidentally during imaging studies, such as routine chest radiography or CT scans for unrelated conditions. Although these tumors are often incidental, it is important to diagnose and treat them appropriately to prevent potential complications and malignant transformation. Conclusion: The findings of this study contribute to the existing literature, increase awareness of this rare tumor, and provide insights into its diagnosis, treatment, and follow-up.

Acute Myocardial Infarction in COVID-19 Patients-A Review of Literature Data and Two-Case Report Series.

Background/Objectives: The newly emergent COVID-19 pandemic involved primarily the respiratory system and had also major cardiovascular system (CVS) implications, revealed by acute myocardial infarction (AMI), arrhythmias, myocardial injury, and thromboembolism. CVS involvement is done through main mechanisms-direct and indirect heart muscle injury, with high mortality rates, worse short-term outcomes, and severe complications. AMI is the echo of myocardial injury (revealed by increases in CK, CK-MB, and troponin serum markers-which are taken into consideration as possible COVID-19 risk stratification markers). When studying myocardial injury, physicians can make use of imaging studies, such as cardiac MRI, transthoracic (or transesophageal) echocardiography, coronary angiography, cardiac computed tomography, and nuclear imaging (which have been used in cases where angiography was not possible), or even endomyocardial biopsy (which is not always available or feasible). Two-case-series presentations: We present the cases of two COVID-19 positive male patients who were admitted into the Clinical Department of Cardiology in "Sfântul Apostol Andrei" Emergency Clinical Hospital of Galați (Romania), who presented with acute cardiac distress symptoms and have been diagnosed with ST elevation AMI. The patients were 82 and 57 years old, respectively, with moderate and severe forms of COVID-19, and were diagnosed with anteroseptal left ventricular AMI and extensive anterior transmural left ventricular AMI (with ventricular fibrillation at presentation), respectively. The first patient was a non-smoker and non-drinker with no associated comorbidities, and was later discharged, while the second one died due to AMI complications. Conclusions: From this two-case series, we extract the following: old age alone is not a significant risk factor for adverse outcomes in COVID-19-related CVS events, and that the cumulative effects of several patient-associated risk factors (be it either for severe forms of COVID-19 and/or acute cardiac injury) will most probably lead to poor patient prognosis (death). At the same time, serum cardiac enzymes, dynamic ECG changes, along with newly developed echocardiographic modifications are indicators for poor prognosis in acute cardiac injury in COVID-19 patients with acute myocardial injury, regardless of the presence of right ventricular dysfunction (due to pulmonary hypertension).

Analysis of a Case of Airway Hemangioma in a 1-Month-Old Infant with Dyspnea – A Secondary Publication

Infantile hemangiomas are the most common benign tumors of infancy. However, hemangiomas located in the respiratory tract are rare and could cause life-threatening events due to airway obstruction. To date, the best recommended treatment for infantile hemangioma is oral propranolol as it exhibits faster effects with fewer adverse effects as compared to systemic corticosteroid therapy. In this study, we reported a case of a 1-month-old girl who was presented with respiratory symptoms and hemangioma on the scalp. The hemangioma extended from the right base of the skull to the thoracic inlet, causing inspiratory stridor and dyspnea. Treatment with oral propranolol was initiated and her symptoms regressed. Imaging showed regression of the hemangioma. This was a rare case of skin hemangioma found on the scalp, in which the hemangioma extended from the base of the skull to the subglottis, precipitating respiratory symptoms from airway obstruction. Based on this encounter, the presentation of skin hemangioma on the head, coupled with respiratory symptoms, necessitates the use of imaging studies, such as computed tomography, ultrasound, and magnetic resonance imaging to ascertain the extent of hemangioma.

NEIM-07 HARNESSING END-TO-END CLOUD-BASED WORKFLOWS AND MULTI-MODAL DATA ANALYTICS IN PEDIATRIC BRAIN TUMOR IMAGING AT THE CHILDREN’S BRAIN TUMOR NETWORK (CBTN)

Abstract Neuroimaging is an essential component of the standard of care in pediatric brain tumor patients. Developing efficient and agile workflows for image processing and integration of imaging with other data types to perform predictive analytics is an increasing need. At CBTN, we developed user-friendly workflows to support the entire imaging data lifecycle and to bridge access to multi-modal datasets with scalable analytics, to empower researchers to make breakthrough discoveries that will advance patient care. An automated deep learning-based brain extraction and tumor subregion segmentation model based on a multi-institutional dataset was developed that can reliably segment the treatment-naïve MRI scans of children across a variety of brain tumor histologies. This model was subsequently integrated into an end-to-end imaging pipeline for collecting, managing and analyzing clinically acquired radiology exams of the CBTN consortium with processing of 19,975 exams (1,443 subjects) to date. Critically, the constituent software tools enable the preparation of images for downstream AI analytics, from acquisition to feature extraction. A public website was also created to allow users to search and explore the dataset based on sequence labels, and clinical and imaging attributes. In addition, we established a scalable workflow and processes for de-identification, ingestion, quality control, and management of digital pathology slides for CBTN (over 8,000 slides to date). Finally, we evaluated the feasibility of interoperability between imaging (Flywheel) and molecular (CAVATICA) platforms deployed in cloud ecosystems which can allow streamlined, user-friendly workflows to ingest and harmonize files, perform cohort selection, prepare data using standard processing packages and cloud resources, and conduct analysis on extracted multi-modal feature sets. The described workflow lays the foundation for the broad use of imaging studies and access to multi-modal datasets and analytics, with the goal of empowering researchers to make breakthroughs in patient care.

IMG-03. HARNESSING COMPUTATIONAL IMAGING, SCALABLE CLOUD-BASED WORKFLOWS, AND MULTI-MODAL DATA ANALYTICS WITH INTEROPERABLE SOFTWARE PLATFORMS IN PEDIATRIC NEURO-ONCOLOGY; THE ROAD AHEAD FOR CHILDREN’S BRAIN TUMOR NETWORK (CBTN)

Abstract Neuroimaging is acquired as part of the clinical standard of care for treatment of brain tumor patients. Capitalizing on this data and integration of imaging with other data types to perform predictive analytics is an increasing need. Here, we review the efforts at CBTN in the past couple of years to establish user-friendly workflows to support the entire imaging data lifecycle and to bridge access to multi-modal datasets with scalable analytics scale, to empower researchers to make breakthrough discoveries that will advance patient care. An automated deep learning-based brain extraction and tumor subregion segmentation model based on a multi-institutional dataset was developed that can reliably segment the MRI scans of children across a variety of brain tumor histologies. This model was subsequently integrated into an end-to-end imaging pipeline for collecting, managing, and analyzing clinically acquired radiology exams of the CBTN consortium with processing of 12,500 exams to date. A public website was also created to allow users to search and explore the dataset based on sequence labels, and clinical and imaging attributes. In addition, we established a scalable workflow and processes for de-identification, ingestion, quality control, and management of digital pathology slides on CBTN (over 8,000 slides to date). Finally, we established interoperability between imaging (Flywheel) and molecular (CAVATICA) platforms deployed in cloud ecosystems which allows streamlined, user-friendly workflows to ingest and harmonize files, perform cohort selection, prepare data using standard processing packages and cloud resources, and conduct analysis on extracted multi-modal feature sets. The described workflow lays the foundation for broad use of imaging studies and access to multi-modal datasets and analytics, with the goal of empowering researchers to make breakthroughs in patient care. The next step is to apply these tools in the context of clinical trials.

Utility of rapid on-site evaluation in procurement of adrenal gland tissue biopsies.

While the number of adrenal biopsies has increased due to more "incidentalomas" were detected by widespread use of imaging studies, there have been very limited studies to evaluate the utility of rapid on-site evaluation (ROSE) in obtaining adequate core needle biopsy (CNB) tissue for diagnosis of adrenal lesions. We retrospectively reviewed all percutaneous adrenal CNB cases with available ROSE for a 12-year period in our institute in order to assess the usefulness of ROSE in adrenal CNB sampling. A total of 83 cases were identified in our database. The majority of cases (52/83, 63%) were diagnosed as metastatic malignancies with the lung being the most common primary site. Adrenal hyperplasia/adenoma was the most common primary adrenal lesion. The concordance between the ROSE interpretations and CNB final diagnoses is 80%. The interpretation errors accounted for majority (11/17, 65%) of the discordant cases. ROSE assessment during adrenal CNB procedures is a helpful tool for obtaining adequate diagnostic tissue. Pathologists should be familiar with adrenal cytology in order to reduce interpretation errors at ROSE.

Role of imaging in the evaluation of intussusception in adults: A 10-year retrospective study

IntroductionIntussusception is the insertion of a bowel loop segment into an adjacent segment. Unlike in children, where the condition is mainly idiopathic, intussusception in adults is more often associated with severe disease. The growing use of imaging studies to evaluate the abdomen has resulted in a higher rate of detection of cases of intussusception without underlying disease in which it is not possible to determine the cause. This study aimed to review the clinical presentation, evaluation, and treatment of patients in whom abdominal ultrasonography or computed tomography diagnosed intussusception. MethodWe retrospectively reviewed radiology reports of abdominal ultrasound and computed tomography studies done at our hospital in a 10-year period. ResultsIn the 40 cases found, intussusception was an incidental finding in 10%. No underlying cause was identified in 68%, and posterior imaging studies showed spontaneous resolution in 75%. The most common symptom was abdominal pain, being present in 60%. Intussusception affected only the small bowel in 90% of cases (entero-enteric intussusception). Intussusception was attributed to malignancy in only 8% of cases. In 7 patients, intussusception was resolved surgically. ConclusionThe increased use of abdominal imaging has shown that a significant proportion of cases of intussusception are idiopathic and resolve spontaneously.

Usefulness of imaging studies for diagnosing and localizing cerebrospinal fluid rhinorrhea: A systematic review and meta-analysis.

Our aim in this study was to determine the usefulness of diagnosis by imaging studies for the localization of cerebrospinal fluid (CSF) rhinorrhea. PubMed, SCOPUS, Embase, Web of Science, and Cochrane Library databases were searched up to July 2021. True and false positive and negative data were collected along with the characteristics of each study. Methodologic quality was assessed using the QADAS-2 tool. Sixteen studies involving 472 patients were included. The diagnostic odds ratio (DOR) of imaging studies was 13.6195 (95% confidence interval [CI], 7.4756-24.8129; I2 =28.1%). The area under the summary receiver-operating characteristic curve was 0.712. Sensitivity, specificity, negative predictive value, and positive predictive value were 0.8507 (0.7773-0.9029), 72.1%; 0.7827 (0.6865-0.8556), 26.8%; 0.5828 (0.4398-0.7132), 67.4%; and 0.9407 (0.8935-0.9678), 59.1%, respectively. In the subgroup analysis, there were significant differences for sensitivity (computed tomography [CT], 0.7421; computed tomography cisternography [CTC], 0.8872; magnetic resonance imaging [MRI], 0.8365; magnetic resonance cisternography [MRC], 0.8565; intrathecal gadolinium magnetic resonance cisternography [GaMRC], and 0.9307; radionuclide cisteronography [RNC], 0.7097; p=0.0481) and for negative predictive value among imaging modalities (CT, 0.3028; CTC, 0.4848; MRI, 0.4658; MRC, 0.7465; GaMRC, 0.8611; and RNC, 0.5263; p=0.0046). There were no significant differences among imaging modalities for specificity, positive predictive value, or DOR (p>0.05). Imaging studies can be used in the diagnosis of CSF rhinorrhea. Gadolinium magnetic resonance cisternography showed the highest diagnostic accuracy. MRC showed fair diagnostic accuracy without intrathecal injection.

Adult Soft-Tissue Sarcomas of the Extremities.

Soft-tissue sarcomas (STS) in adults comprise a heterogeneous group of tumors of mesenchymal origin that share similar biological patterns of local tumor growth and metastatic dissemination. The judicious use of imaging studies, biopsy techniques, and pathological evaluations is essential for accurate diagnosis and for planning treatment strategy. Wide local resection and radiation therapy form the cornerstone of management of high-grade STS. The role of adjuvant radiation therapy is questionable in the management of small (≤5 cm) superficial lesions that can be resected with negative margins. Chemotherapy given to patients who have nonmetastatic, high-grade STS results in varying benefit in terms of local tumor control and overall survival. Coordinated care by a multidisciplinary team of trained surgeons, medical oncologists, radiologists, radiation oncologists, and pathologists has been documented to improve local tumor control and the overall survival of patients with STS. Although considerable progress in tumor diagnostics and targeted therapies has been made over the past 2 decades, recommendations and controversies relating to tumor imaging and margins of resection have not changed.

EP.FRI.960 USS appraisal in females of child bearing age presented with possible appendicitis

Abstract Aims Appendicitis remains the most common acute surgical condition. No standard guidelines for the use of imaging studies, and there is a discrepancy between the published data regarding accuracy of these modalities and our practical findings. Yet the growing number of USS reported as “appendix not visualized” has led us to rethink about the value of USS in acute appendicitis. Methods A retrospective single centre study for all females (15-45 years) underwent emergency appendectomy for suspected acute appendicitis. Analysis of preoperative clinical, radiographic and postoperative histopathological data was done. Results 632 cases analysed over 18months, out of those 238 (37%) were females (15-45 years). USS was done in 129(54%) cases. 25(10.5) cases had both USS and CTAP. 32(13%) cases had only CTAP. The mean rate of appendix visualization in the USS was 30%(71cases) two thirds reported by radiologist versus one third by sonographers. Our negative appendectomy rate dropped from 25 to 15% after a positive scan. Conclusions Traditional preference for ultrasound in the UK compared to CTAP in young population is mostly due to the potential hazards of irradiation, but USS commonly does not visualise the appendix in our practice (70%), and has low sensitivity and specificity for appendicitis. However, following a positive USS, NAR dropped to 15%. Radiologists had a higher visualization rate of appendix compared to sonographers. Commitment to improve the performance of ultrasonography by allocating adequately timed sessions to the most experienced radiologists and increasing the use of low dose CT scans are possible solutions.

Nuances in the Surgical Management of Thyroid Cancer.

The incidence of thyroid cancer is rapidly rising, primarily due to the increased use of imaging studies and incidentalomas. In the USA, the incidence has quadrupled. The last decades have seen remarkable advances in diagnosis and surgery for thyroid cancer. We will discuss the surgical advances in this manuscript. The American Thyroid Association and many other organizations around the world have been quite instrumental in developing the guidelines for the management of thyroid cancer, which have streamlined the treatment approaches. There have also been advances made in the management of medullary and anaplastic thyroid cancer, which will be a different subject not included in this manuscript. The major surgical advances include the following: impact of molecular markers, risk group stratifications, de-escalation in surgery, nerve monitoring, and endoscopic surgery. We will discuss some of these surgical nuances in this review article.

Prevalence of Venous Thromboembolism in Cancer Patients in the Emergency Department and Associated Healthcare Resource Utilization and Expenditure in the United States

BackgroundVenous thromboembolism (VTE) is one of the leading causes of morbidity and mortality in cancer patients. We investigated VTE prevalence in cancer patients in the emergency department (ED) setting, associated utilization of health care resources and costs.MethodsThe Agency for Healthcare Research and Quality sponsored Nationwide Emergency Department Sample (NEDS) database was used to identify cancer patients and ED utilizations in 2006-12. The NEDS database captures 20% of US ED visits. Cancer types (solid tumor, lymphoma, leukemia, multiple myeloma) and acute venous thromboembolism [VTE, which includes deep vein thrombosis (DVT) and/or pulmonary embolism (PE)] were identified by ICD-9 codes. CPT procedure codes were used to identify any use of computed tomography pulmonary angiography (CTPA), CT chest with contrast (CTC), duplex ultrasound of the veins (DUS), or ventilation-perfusion (VQ) scan. Descriptive statistics were used to present the VTE prevalence, use of imaging study, admission rates and costs incurred. Chi-square test were used to compare death/admission rate and chi-square test for trend was used for trend analysis. Multivariable logistic regression modeling was used to explore the association between VTE diagnosis and hospital admission or death during hospital course after baseline characteristics adjustment.ResultsThere were 6,330,322 ED visits by cancer patients in our study, which represented 3.2 % of total ED visits from 2006-2012 in the NEDS database. Over the study period, 1.6% of patients received either CTPA, CTC, DUS, or V/Q scan during their ED visits (CTPA: 0.56%; CTC: 0.47%; DUS: 0.62%; V/Q: 0.02%). The use of imaging studies had increased from 0.92 to 2.35 per 100 ED visits (Figure 1, p-value for trend<.0001) over time. The overall VTE rate was 2.35 (95% CI: 2.34-2.37) per 100 ED visits [Table 1, DVT: 1.34 (95% CI: 1.33-1.35) per 100 ED visits; PE: 1.30 (95% CI: 1.29-1.31) per 100 ED visits]. Patients with pancreatic cancer had the highest rate (5.84 per 100 ER visits), followed by lung (3.51 per 100 ER visits) and stomach cancers (3.09 per 100 ER visits) (Figure 2). Patients with thyroid, head and neck and prostate cancers had the lowest rates. Cancer patients with VTE had a higher rate of death in the ED (6.5% vs 4% of those without VTE, p-value<.0001) and a higher rate of admission (92% vs 61% of those without VTE, p-value< .0001). From 2006-2012, the total median hospital cost of cancer patients with VTE increased from $26,069 to $34,254 and were consistently higher than those without VTE (costs: $19,013 to $26,768, Table 2). In the subgroup of patients with solid tumor cancer (N=5,349,246), VTE diagnosis was independently associated with higher odds of admission (adjusted odds ratio (AOR):6.7, 95% CI: 6.56-6.84, p-value< .0001) and hospital death (AOR: 1.24, 95% CI: 1.21-1.27, p-value< .0001) after adjusting for age, cancer types, and metastatic status.ConclusionsVTE diagnosed in the ED was associated with higher rate of mortality, hospital admissions, and healthcare-associated costs. Imaging studies for VTE are increasingly frequent, suggesting increased awareness by ED providers. Future clinical trials are warranted to investigate the cost-effectiveness of outpatient VTE prophylaxis among cancer patients in order to reduce VTE-associated burden. [Display omitted] DisclosuresKhorana:Halozyme: Consultancy, Honoraria; Janssen Scientific Affairs, LLC: Consultancy, Honoraria, Research Funding; Sanofi: Consultancy, Honoraria; Bayer: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Amgen: Consultancy, Research Funding; Leo: Consultancy, Honoraria, Research Funding.

Radiation Reduction Strategies in Pediatric Orthopaedics.

Pediatric orthopaedic patients have the potential for significant radiation exposure from the use of imaging studies, such as computed tomography and bone scintigraphy. With the potential for long-term treatment, such as is required for scoliosis or osteogenesis imperfecta, patients are at even greater risk of radiation-induced carcinogenesis. Although an association between radiation and cancer risk is evident, causation is difficult to prove because comorbidities or genetic predispositions may play a role in the higher baseline rates of malignancy later in life. Efforts have been made over the years to reduce exposure using more modern imaging techniques and simple radiation reduction strategies. Educational efforts and clinical practice guidelines are decreasing the rate of computed tomography scan use in pediatrics. Although considerable work is being done on the development of radiation-free imaging modalities, imaging that uses ionizing radiation will, in the near term, be necessary in specific circumstances to provide optimal care to pediatric orthopaedic patients. Knowledge of the ionizing radiation exposure associated with commonly used tests as well as radiation-reduction strategies is essential for the optimal and safe care of pediatric orthopaedic patients.

Escisión transcervical de un adenoma paratiroideo mediastínico gigante

Primary hyperparathyroidism (HPTP) is the third most common neuroendocrine disorder, its main cause is parathyroid adenoma. Within the classification, those adenomas that weigh more than 3.5 g are classified as giant parathyroid adenomas (APG), and are associated with a worse evolution and malignancy. The purpose of this article is to present our diagnostic and therapeutic approach of a patient with HPTP ssociated with a mediastinal APG. A search in the international literature of the last 10 years revealed that only 8 other centers ha ve reported the extraction of an APG of similardimensions to ours and in a similar location. Case presentation: A 66-year-old woman with a history of multinodular goiter, thyroid profile and parathormone (PTH) measurement were requested, with a report of 350.60 pg/mL. A thyroid/parathyroid scintigraphy was performed with 99mTc sestaMIBI which reported persistence of a focal area of the concentration located in the topography of the lower pole of the right thyroid lobe. This study was complemented with SPECT-CT, which reported an image of hyperfunctioning right inferior parathyroid compatible with adenoma and the patient was diagnosed with PTH. Finally, resection was performed, obtaining a tumor measuring 7.0 × 4.5 × 2.0 cm, with a weight of 24.5 g. Conclusions: Our case highlights the use of imaging studies to facilitate localization and achieve diagnosis together with clinical presentation and biochemical profile. Selective treatment was achieved safely through a minimally invasive transcervical technique, combined with the measurement of PTH. Keywords: Parathyroid adenoma; neoplasia; hypercalcemia; primary hyperparathyroidism; case report.

Resource utilisation among patients with syncope presenting to the emergency department.

Syncope is a common problem encountered in the emergency department (ED) and a significant source of ED resource utilisation, including advanced imaging modalities. Current guidelines do not recommend routine Computed Tomography (CT) imaging of the head for patients seen in the ED due to syncope. In this study, we investigate resource allocation in the ED for syncope-related visits, including advanced imaging modalities using a large national database. Data from the CDC's National Hospital Ambulatory Medical Care Survey (NHAMCS) for years 2008-2017 were compiled and analysed. Intrinsic survey and constructed variables were utilised to identify and investigate all syncope-related ED visits in the United States during the study period that met study criteria. Appropriate bivariate and multivariate statistical analyses were applied in order to identify and compare the resource utilisation, demographics, and ED visit dynamics of syncope and non-syncope-related ED visits. During the study period, there were over 15 million ED visits for syncope. A high percentage of syncope visits received head CT compared with non-syncope visits (34% vs. 4.5%, P>.001). When investigated by age-grouping utilisation of head CT ranged from 26.5 (95% CI 18.9-27.5) for ages 18-40 to as high as 40.2% (95% CI 33.8-47.1) for ages 80 and higher. Compared with non-syncope ED visits, syncope-related ED visits were older and more likely to have Medicare or private insurance. Syncope continues to be a large and growing share of visits to US EDs. Despite well-supported, evidence-based recommendations that do not recommend routine utilisation of head CT in syncope-related ED visits, these data suggest that emergency physicians routinely over-utilise this modality. More specific guidelines may be required to help reduce the use of imaging studies for patients who present to the ED with syncope.

Rol de las imágenes en la evaluación de la invaginación intestinal del adulto: un estudio retrospectivo de 10 años

IntroductionIntussusception is the insertion of a bowel loop segment into an adjacent segment. Unlike in children, where the condition is mainly idiopathic, intussusception in adults is more often associated with severe disease. The growing use of imaging studies to evaluate the abdomen has resulted in a higher rate of detection of cases of intussusception without underlying disease in which it is not possible to determine the cause. This study aimed to review the clinical presentation, evaluation, and treatment of patients in whom abdominal ultrasonography or computed tomography diagnosed intussusception. MethodWe retrospectively reviewed radiology reports of abdominal ultrasound and computed tomography studies done at our hospital in a 10-year period. ResultsIn the 40 cases found, intussusception was an incidental finding in 10%. No underlying cause was identified in 68%, and posterior imaging studies showed spontaneous resolution in 75%. The most common symptom was abdominal pain, being present in 60%. Intussusception affected only the small bowel in 90% of cases (entero-enteric intussusception). Intussusception was attributed to malignancy in only 8% of cases. In 7 patients, intussusception was resolved surgically. ConclusionThe increased use of abdominal imaging has shown that a significant proportion of cases of intussusception are idiopathic and resolve spontaneously.

Triggers of thyroid cancer diagnosis: a systematic review and meta-analysis.

Understanding the method of thyroid cancer detection has potential implications on interpreting incidence rates, the diagnosis and management of thyroid cancer. We conducted a systematic review of studies reporting methods of thyroid cancer detection to estimate the frequency of incidentally found cancers and classify triggers of incidental thyroid cancer diagnosis. We searched multiple bibliographic databases from inception to June 2020. A pair of reviewers, working independently and in duplicate selected studies for inclusion, extracted data, and evaluated each trial's risk of bias. Studies enrolling patients older than 18 years with thyroid cancer confirmed histologically were included. In total, 17 cohorts and 1 cross-sectional study, conducted between 1991 and 2018, enrolling 4668 patients with thyroid cancer were included: 88% had papillary thyroid cancer and 23% had papillary thyroid microcarcinoma. The proportion of patients with non-incidental and incidental thyroid cancer was similar: 49% [95% confidence interval (CI): 40-58%]. Subgroup analysis showed that most patients with incidental thyroid cancers had tumor size <10 mm (76%; 95% CI: 56-92%), age >45 (61%; 95% CI: 56-67%), and were detected through imaging (35%; 95% CI: 26-45%), of which ultrasound was the most common modality (27%; 95% CI: 14-43%). The heterogeneity for all the effect sizes was large and significant. About half of thyroid cancers were found incidentally through the use of imaging studies, in particular neck ultrasound. These incidentally found cancers were mostly small papillary thyroid cancer. These results highlight opportunities for interventions aimed at reducing drivers of overdiagnosis.

Modeling and Molecular Dynamic Simulation of F(ab')2 Fragment of Nimotuzumab for Lung Cancer Diagnostics.

Lung cancer is one of the leading causes of cancer-related deaths in the world among both men and women. Several studies in the literature report that overexpression and mutation of the epidermal growth factor receptor (EGFR) are implicated in the pathogenesis of some lung cancers. Nimotuzumab is a humanized monoclonal antibody (mAb) that inhibits EGF binding because it binds to the extracellular domain of the EGFR. Nimotuzumab requires bivalent binding for stable attachment to cellular surface, which leads to nimotuzumab selectively binding to cells that express mAbs of moderate to high EGFR levels, and this could explain its low toxicity. This property has an advantage for development of nimotuzumab as a therapeutic and diagnostic agent. Monoclonal antibodies are large in size (150 kDa), thus penetrating slowly and residing in the blood for extended periods of time (from days to weeks); their use in imaging studies can result in low signal-to-background ratios and poor image quality. A reduction in the size of the immunoglobulin molecule has also been proposed as a means for increasing tumor penetration by mAbs. Nevertheless, it is known that the penetration of mAb into tumor cell is slow, due to its high molecular weight. Therefore, mAb is not very attractive to be used for imaging diagnostic purpose because of its kinetics and potential to elicit antibody response. The objective of this research was to study the homology modeling of a simpler functional molecule based on nimotuzumab, which consists of 2 antigen-binding fragments (Fab), namely, F(ab′)2, using MODELER. The crystal structure of Fab of nimotuzumab from protein data bank was used as a template to construct the model of F(ab′)2. Molecular dynamic simulation was performed to evaluate the stability of F(ab′)2 and conformational changes of F(ab′)2 in simulation. The result showed the dynamic behavior of antigen-binding site region of F(ab′)2 throughout simulation. This result is expected to be useful in the further development of F(ab′)2 fragment nimotuzumab as a lung cancer diagnostic.