Rapid death following undiagnosed stercoral perforation in a chronic opioid user

A case of rapid demise following an undiagnosed stercoral perforation is reported. A 57-year-old woman on chronic opioid replacement therapy presented with constipation and abdominal pain to the hospital. Following an unremarkable abdominal radiograph and admission for laxation and pain therapy, she was found dead only 18 h later. To exclude medical malpractice, a postmortem investigation was ordered. Postmortem computed tomography and autopsy revealed fatal fecal peritonitis based on a stercoral perforation of the rectosigmoid, which had been undiagnosed. This report highlights the need for early cross-sectional imaging and contributes to the data collection concerning this ever-growing, vulnerable group of patients undergoing opioid replacement.     

Predictors of Lung Cancer Screening Utilization in a Population-Based Survey

PurposeAnnual low-dose CT (LDCT) screening in high-risk individuals has been recommended to detect lung cancer earlier and reduce mortality. The objective of this study was to identify demographic, financial, and health care factors associated with screening uptake in a population-based survey.MethodsData from the Lung Cancer Screening Module and core modules of the 2017 Behavioral Risk Factor Surveillance System, a population-based survey administered via cell phone and landline, were analyzed to examine demographic, health, and financial factors associated with screening uptake among the 10 states that administered the screening module. Weighted frequencies and confidence intervals (CIs) were produced, and weighted Wald χ² tests were used to compare differences in screening utilization by patient characteristics. A multivariate logistic mixed-effects model was constructed, in which participant clustering by state was accounted for with a random intercept.ResultsThe uninsured were less likely to undergo LDCT screening (odds ratio [OR], 0.28; 95% CI, 0.12-0.65). LDCT screening uptake was higher for participants with chronic respiratory conditions (OR, 4.14; 95% CI, 2.33-7.35); those who were divorced, separated, widowed, or refused to answer (OR, 1.41; 95% CI, 1.05-1.86); those who had previous cancer diagnoses (OR, 1.90; 95% CI, 1.40-2.56); and those aged 65 to 69 years (OR, 1.23; 95% CI, 1.06-1.44) or 70 to 74 years (OR, 1.17; 95% CI, 1.00-1.37). Utilization also varied significantly across states.ConclusionsHaving a related health condition whereby participants were sensitized to the benefits of early screening (ie, another cancer diagnosis, presence of chronic respiratory conditions) and having insurance coverage were associated with higher LDCT screening uptake. Providers should engage LDCT-eligible patients through informed and shared decision making to increase preference-sensitive screening decisions.     

非那雄胺在慢性中心性浆液性脉络膜视网膜病变患者中的应用

目的评估非那雄胺治疗慢性中心性浆液性脉络膜视网膜病变(central serous chorioretinopathy,CSC)的有效性及安全性。方法选取2017年3月至2019年6月在本院确诊的慢性CSC患者31例40眼,采用单臂试验对患者进行非那雄胺治疗。使用非那雄胺治疗后6个月,对患者的视网膜神经上皮层(retinal neuroepithelial layer,RNL)下积液状况,ETDRS视力以及黄斑中心凹视网膜厚度(central foveal thickness,CFT)进行检查。结果非那雄胺治疗后1个月,有10眼(25.0%)RNL下积液完全消退。持续治疗2个月、3个月、4个月、5个月、6个月,分别有7眼(17.5%)、6眼(15.0%)、7眼(17.5%)、3眼(7.5%)及3眼(7.5%)RNL下积液消退,仅有4眼(10.0%)在治疗后6个月RNL下积液仍存在。患眼EDTRS视力非那雄胺治疗后1个月为(50.00±16.11)个字母,与治疗前(46.16±16.67)个字母差异无统计学意义(P=0.2213);治疗后2个月(53.39±14.67)个字母,较治疗前显著升高(P=0.0003);治疗后3个月、4个月、5个月、6个月,分别为(57.39±12.76)个字母、(58.52±12.39)个字母、(59.13±10.76)个字母及(60.42±10.96)个字母,与治疗前相比差异均有统计学意义(均为P<0.0001)。而患眼CFT自治疗后1个月、2个月、3个月、4个月、5个月、6个月分别为(274.10±22.74)μm、(273.00±17.22)μm、(263.50±12.81)μm、(263.90±10.62)μm、(259.70±12.48)μm及(252.60±11.00)μm,与治疗前(296.60±35.41)μm相比,差异均有统计学意义(均为P<0.05)。所有患者均无服药后身体不适或并发症发生。结论非那雄胺对于慢性CSC的治疗安全且有效,有望成为慢性CSC的治疗选择。     

Comparative analysis of calcification parameters with Agatston Score approximations for ex vivo atherosclerotic lesions

BackgroundThe Agatston Calcium Score is a predictor of major adverse cardiovascular events but it is unable to identify high-risk lesions. Recent research suggests that examining calcification phenotype could be more indicative of plaque stability.ObjectiveTo examine the Agatston score's ability to determine atherosclerotic calcification phenotype.MethodsMicro-Computed Tomography was performed on 20 carotid and 20 peripheral lower limb lesions. ImageJ pixel histogram analysis quantified the non-calcified (≥30HU, <130HU) and calcified (≥130HU) tissue volumes. ImageJ ‘3D Objects Counter’ plugin determined the calcified particle count, volumes and maximum attenuation density of each particle. Image stacks were subsequently downsampled to a resolution of 0.7 × 0.7 × 3 mm and an approximation for the Extra-Coronary Calcium Scores (ECCS) were calculated. Spearman's correlation examined the relationships between ECCS approximations and calcification parameters.ResultsECCS has a strong positive correlation with the Calcified Volume Fraction (CVF) (r_s = 0.865, p < 0.0005), weak positive correlations with Calcified Particle Fraction (CPF) (r_s = 0.422, p = 0.007) and Microcalcification Fraction (micro-CF) (r_s = 0.361, p = 0.022). There is no correlation evident between ECCS and Calcified Particle Index (CPI) (r_s = −0.162, p = 0.318). It is apparent that there is a high prevalence of microcalcifications in both carotid and peripheral lower limb lesions. Additionally, an inverse relationship exists between calcified particle volume and maximum-recorded attenuation density.ConclusionThe density-weighted Agatston calcium scoring methodology needs to be reviewed. Calcium scoring which differentiates between critical calcification morphologies, rather than presenting a density-weighted score, is required to direct high-risk plaques towards tailored treatment.     

Characterization of Moyamoya and Middle Cerebral Artery Diseases by Carotid Canal Diameter and RNF213 p.R4810K Genotype

ObjectivesIt is sometimes difficult to differentiate middle cerebral artery disease from moyamoya disease because the two can present similarly yet have different treatment strategies. We investigated whether the presence of a narrow carotid canal and the RNF213 mutation can help differentiate between the two phenotypes.Population and MethodsWe analyzed 78 patients with moyamoya disease, 27 patients with middle cerebral artery disease, and 79 controls from 2 facilities. The carotid canal diameter was measured using computed tomography. The p.R4810K mutation was genotyped by TaqMan assay. A receiver operating characteristics analysis was performed to assess the significance of the carotid canal diameter for the accurate diagnosis of moyamoya disease.ResultsThe carotid canal diameter was significantly narrower in patients with moyamoya disease than in controls. The optimal cutoff values were 5.0 mm for adult males and 4.5 mm for adult females and children (sensitivity: 0.82; specificity: 0.92). Among the patients with middle cerebral artery disease, 18.5% and 25.0% of the affected hemispheres had the p.R4810K mutation and narrow canal (i.e., below the cutoff), respectively, whereas only 3.1% of those had both. Contrastingly, 68.8% of the affected hemispheres in patients with moyamoya disease had both these characteristics. Among the patients with moyamoya disease, those with the p.R4810K mutation tended to have narrower carotid canals.ConclusionsAlthough the presence of a narrow carotid canal or the p.R4810K mutation alone could not be used to distinguish those with moyamoya disease from those with middle cerebral artery disease, the combination of these factors could better characterize the two phenotypes.     

Myocardial extracellular volume fraction to differentiate healthy from cardiomyopathic myocardium using dual-source dual-energy CT

ObjectiveTo evaluate the feasibility of dual-energy CT (DECT)-based iodine quantification to estimate myocardial extracellular volume (ECV) fraction in patients with and without cardiomyopathy (CM), as well as to assess its ability to distinguish healthy myocardial tissue from cardiomyopathic, with the goal of defining a threshold ECV value for disease detection.MethodsTen subjects free of heart disease and 60 patients with CM (mean age 66.4 ± 9.4; 59 males and 11 females; 40 ischemic and 20 non-ischemic CM) underwent late iodine enhanced DECT imaging. Myocardial iodine maps were obtained using 3-material decomposition. ECV of the left ventricle was estimated from hematocrit levels and the iodine maps using the AHA 16-segment model. Receiver operating characteristic curve analysis was performed, with corresponding area under the curve, along with Youden's index assessment, to establish a threshold for CM detection.ResultsThe median ECV for healthy myocardium, non-ischemic CM, and ischemic CM were 25.4% (22.9–27.3), 38.3% (33.7–43.0), and 36.9% (32.4–41.1), respectively. Healthy myocardium showed significantly lower ECV values compared to ischemic and non-ischemic CM (p < 0.001). From Youden's index analysis, an ECV>29.5% would indicate the presence of CM in the myocardium (sensitivity = 90.3; specificity = 90.3); the AUC for this criterion was 0.950 (p < 0.001).ConclusionThe findings of this study resulted in a statistically significant distinction between healthy myocardium and CM ECVs. This led to the establishment of a promising threshold ECV value that could facilitate the differentiation between healthy and diseased myocardium, and highlights the potential of this DECT methodology to detect cardiomyopathic tissue.     

Subclinical Pulmonary Congestion and Abnormal Hemodynamics in Heart Failure With Preserved Ejection Fraction

ObjectivesThe authors hypothesized that quantitative computed tomography (QCT) imaging would reveal subclinical increases in lung congestion in patients with heart failure and preserved ejection fraction (HFpEF) and that this would be related to pulmonary vascular hemodynamic abnormalities.BackgroundGross evidence of lung congestion on physical examination, laboratory tests, and radiography is typically absent among compensated ambulatory patients with HFpEF. However, pulmonary gas transfer abnormalities are commonly observed and associated with poor outcomes.MethodsPatients referred for invasive hemodynamic exercise testing who had undergone chest computed tomography imaging within 1 month were identified (N = 137). A novel artificial intelligence QCT algorithm was used to measure pulmonary fluid content.ResultsCompared with control subjects with noncardiac dyspnea, patients with HFpEF displayed increased mean lung density (–758 HU [–793, –709 HU] vs –787 HU [–828, –747 HU]; P = 0.002) and a higher ratio of extravascular lung water to total lung volume (EVLWV/TLV) (1.25 [0.80, 1.76] vs 0.66 [0.01, 1.03]; P < 0.0001) by QCT imaging, indicating greater lung congestion. EVLWV/TLV was directly correlated with pulmonary vascular pressures at rest, with stronger correlations observed during exercise. Patients with increasing tertiles of EVLWV/TLV demonstrated higher mean pulmonary artery pressures at rest (34 ± 11 mm Hg vs 39 ± 14 mm Hg vs 45 ± 17 mm Hg; P = 0.0003) and during exercise (55 ± 17 mm Hg vs 59 ± 17 mm Hg vs 69 ± 22 mm Hg; P = 0.0003).ConclusionsQCT imaging identifies subclinical lung congestion in HFpEF that is not clinically apparent but is related to abnormalities in pulmonary vascular hemodynamics. These data provide new insight into the long-term effects of altered hemodynamics on pulmonary structure and function in HFpEF.     

Benefits of positron emission tomography scans for the evaluation of radiotherapy

The assessment of tumour response during and after radiotherapy determines the subsequent management of patients (adaptation of treatment plan, monitoring, adjuvant treatment, rescue treatment or palliative care). In addition to its role in extension assessment and therapeutic planning, positron emission tomography combined with computed tomography provides useful functional information for the evaluation of tumour response. The objective of this article is to review published data on positron emission tomography combined with computed tomography as a tool for evaluating external radiotherapy for cancers. Data on positron emission tomography combined with computed tomography scans acquired at different times (during, after initial and after definitive [chemo-]radiotherapy, during post-treatment follow-up) in solid tumours (lung, head and neck, cervix, oesophagus, prostate and rectum) were collected and analysed. Recent recommendations of the National Comprehensive Cancer Network are also reported. Positron emission tomography combined with computed tomography with (¹⁸F)-labelled fluorodeoxyglucose has a well-established role in clinical routine after chemoradiotherapy for locally advanced head and neck cancers, particularly to limit the number of neck lymph node dissection. This imaging modality also has a place for the evaluation of initial chemoradiotherapy of oesophageal cancer, including the detection of distant metastases, and for the post-therapeutic evaluation of cervical cancer. Several radiotracers for positron emission tomography combined with computed tomography, such as choline, are also recommended for patients with prostate cancer with biochemical failure. (¹⁸F)-fluorodeoxyglucose positron emission tomography combined with computed tomography is optional in many other circumstances and its clinical benefits, possibly in combination with MRI, to assess response to radiotherapy remain a very active area of research.     

Building and Exploitation of Learning Curves to Train Radiographer Students in X-Ray CT Image Postprocessing

IntroductionThis study aims to construct learning curves related to the realization of standardized postprocessing by radiographer students and to discuss their exploitation and interest.Materials and MethodsThis study was carried out in 21 French students in their 3rd year of training. Two postprocessing protocols in CT (#1 traumatic shoulder; #2 petrous bone) were repeated 15 times by each student. Each achievement was timed to obtain overall learning curves. The realization accuracy was also assessed for each student at each repetition.ResultsThe learning rates for the two protocols are 63% and 56%, respectively. The number of repetitions to reach the reference time for each protocol is 11 and 12, respectively. In both protocols, the standard deviations are significantly reduced and stabilized during repetitions. The mean accuracy progresses more quickly in protocol #1.DiscussionThe measured learning rates reflect a rapid learning process for each protocol. The analysis of the standard deviations shows that students have reached a homogeneous level. The average times and accuracies measured during the last repetitions show that the group has reached a high level of performance. Building learning curves helps students measure their progress and motivates them.ConclusionObtaining learning curves allows trainers/supervisors to qualify the learning difficulty of a task while motivating students/radiographers. The use of learning curves is inline with the competency-based training paradigm.