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Frostbite is caused by exposure to cold temperatures and can lead to severe injury resulting in amputations. Tissue plasminogen activator (tPA) is a thrombolytic agent that has demonstrated efficacy preventing amputation in frostbite patients. The goal of frostbite management with tPA is to salvage tissue without causing clinically significant bleeding complication. The purpose of this study was to characterize bleeding complications in severe frostbite patients managed with and without tPA. Retrospective chart review of severe frostbite patients admitted to a single ABA verified burn center. Bleeding events were grouped: category 0: no bleed; category 1: bleed not resulting in change or intervention; category 2: bleed resulting in change of management; and category 3: bleed resulting in change of management and intervention. Over a 7-year period, 188 patients were included in the study. Most patients had no documentation suggesting a bleeding complication: 69.7% category 0, 19.1% category 1, 4.8% category 2, and 6.4% category 3. There was no significant difference in category 2 or 3 bleeding complications between patients treated with or without tPA. Overall, 9 of the 143 patients (6.3%) treated with tPA had a category 2 or 3 bleeding complication within 12 hours of tPA completion and 12 of 143 (8.4%) within 24 hours of tPA completion. Based on the low risk of severe bleeding and significant benefit relative to limb or digit salvage demonstrated in this study, we conclude that tPA is safe and effective for the treatment of frostbite in appropriately selected patients.

Acute bowel ischemia is a condition with high mortality and requires rapid intervention to avoid catastrophic outcomes. Swift and accurate imaging diagnosis is essential because clinical findings are commonly nonspecific. Conventional contrast enhanced CT of the abdomen has been the imaging modality of choice to evaluate suspected acute bowel ischemia. However, subtlety of image findings and lack of non-contrast or arterial phase images can make correct diagnosis challenging. Dual-energy CT provides valuable information toward assessing bowel ischemia. Dual-energy CT exploits the differential X-ray attenuation at two different photon energy levels to characterize the composition of tissues and reveal the presence or absence of faint intravenous iodinated contrast to improve reader confidence in detecting subtle bowel wall enhancement. With the same underlying technique, virtual non-contrast images can help to show non-enhancing hyperdense hemorrhage of the bowel wall in intravenous contrast-enhanced scans without the need to acquire actual non-contrast scans. Dual-energy CT derived low photon energy (keV) virtual monoenergetic images emphasize iodine contrast and provide CT angiography-like images from portal venous phase scans to better evaluate abdominal arterial patency. In Summary, dual-energy CT aids diagnosing acute bowel ischemia in multiple ways, including improving visualization of the bowel wall and mesenteric vasculature, revealing intramural hemorrhage in contrast enhanced scans, or possibly reducing intravenous contrast dose.

Introduction Frostbite is caused by exposure to cold temperatures and can be a severe injury leading to hospital admissions, surgeries, or amputations. Disease progression involves endothelial injury, thrombosis, and tissue necrosis; therefore, management of patients involves a process of rewarming and restoration of blood flow to the affected area. Tissue plasminogen activator (tPA) is a thrombolytic agent that has demonstrated efficacy at restoring tissue perfusion in patients with frostbite. The goal of frostbite management with tPA is to salvage tissue without causing clinically significant bleeding, a documented adverse effect of tPA administration. The purpose of this study was to characterize specific bleeding complications associated with tPA administration. The secondary objective was to compare the rate of bleeding complications in frostbite patients treated with intravenous (IV) tPA to frostbite patients that did not receive tPA. Methods This single center retrospective study included all adult patients with severe frostbite who presented between October 2013 and March 2020. tPA was given to patients per institutional protocol. To assess for bleeding events, patient charts were reviewed and any instance of bleeding was categorized based on severity. Bleeding was categorized as: 1) none, 2) mild: not clinically significant (bandage or moved IV site), 3) moderate: change of management (tPA stopped, enoxaparin held, or specialty consult), and 4) severe: included a change and intervention (transfusion, fasciotomy for compartment syndrome). Any change in management or any additional therapies used to control bleeding were documented, as well as the timing of bleeding in relation to tPA administration. Results Over a 7-year period 209 patients were analyzed and 202 patients were included. For patients with bleeding events requiring intervention, the mean time to bleed was 105.5 hours (range 4 to 576 hours). Of these, 4 (3 transfusions and 1 fasciotomy for compartment syndrome) were temporally associated with tPA administration (within 24 hours). Two of the 4 patients had minor to moderate traumatic injury prior to admission, the 3rd patient had incomplete work-up at referring center that initiated tPA prior to transport, and the 4th patient was in restraints. Of the patients who did not receive tPA, 3.39% had a severe bleeding event requiring intervention compared to 6.99% of patients treated with tPA (P=0.516). Conclusions Though there was a higher incidence of bleeding in tPA-treated patients, for the majority of patients studied, tPA was safe for the treatment of severe frostbite. Bleeding events occur in frostbite patients treated with or without tPA and warrant close follow-up for these infrequent complications.

Acute bowel ischemia is a condition with high mortality and requires rapid intervention to avoid catastrophic outcomes. Swift and accurate imaging diagnosis is essential because clinical findings are commonly nonspecific. Conventional contrast enhanced CT of the abdomen has been the imaging modality of choice to evaluate suspected acute bowel ischemia. However, subtlety of image findings and lack of non-contrast or arterial phase images can make correct diagnosis challenging. Dual-energy CT provides valuable information toward assessing bowel ischemia. Dual-energy CT exploits the differential X-ray attenuation at two different photon energy levels to characterize the composition of tissues and reveal the presence or absence of faint intravenous iodinated contrast to improve reader confidence in detecting subtle bowel wall enhancement. With the same underlying technique, virtual non-contrast images can help to show non-enhancing hyperdense hemorrhage of the bowel wall in intravenous contrast-enhanced scans without the need to acquire actual non-contrast scans. Dual-energy CT derived low photon energy (keV) virtual monoenergetic images emphasize iodine contrast and provide CT angiography-like images from portal venous phase scans to better evaluate abdominal arterial patency. In Summary, dual-energy CT aids diagnosing acute bowel ischemia in multiple ways, including improving visualization of the bowel wall and mesenteric vasculature, revealing intramural hemorrhage in contrast enhanced scans, or possibly reducing intravenous contrast dose.

Introduction Frostbite is a high morbidity, high cost injury caused by soft tissue freezing, which can lead to digit or limb necrosis requiring amputation. Many severe frostbite injuries are initially assessed at healthcare facilities outside of dedicated burn centers. Rapid rewarming is the widely accepted first line treatment and is typically performed by placing the affected body parts in a 40–42 C water bath for 15–30 minutes. The aim of this study is to ascertain the clinical practices at the referring facilities before transferring patients with severe frostbite to regional burn centers, as well as any impact on clinical outcomes. Methods Upon IRB approval, retrospective chart review identified severe frostbite patients admitted to our ABA verified burn center between 2014 and 2019. Records were reviewed to identify initial rewarming strategy from referring facilities. Time to thrombolytics after initial admission was also noted. Amputation and salvage rates were calculated. Results Seventy-four severe frostbite patients presented to outside facilities and 96 were direct admissions (N=170). There was no significant difference in age, gender, social and comorbid characteristics between transfer and direct admit groups. We found that a significantly greater number of transfer patients received tPA versus direct admit patients (82.4% v 66.7%, P=0.023). On average, tPA was given 1.5 hours earlier in the direct admit patients (5.8 vs 7.3 hours, P=0.004). There was no significant difference in tissue at risk scores (10.2 v 9.1, P=0.465), percentage of patients requiring amputation (35.1% v 24.0%, P=0.126), or tissue salvage rates (76.8 v 84.2, P=0.207) between the two groups. In the cohort of patients presenting to outside hospitals, 66% received rapid rewarming. Other warming modalities at referring centers included warm intravenous fluids, heated blankets, heated oxygen, catheter-based warming, bladder irrigation, and heat packs. On regression analysis, the use of rapid rewarming was not a significant predictor for poor outcomes for limb salvage (P=0.578). The early use of thrombolytics had a positive outcome on limb salvage (P=0.013). Conclusions Initial rewarming practices for frostbite vary dramatically at outside centers. While rapid rewarming was not statistically associated with improved outcomes, variations in specific treatment modalities and limited sample size decrease the likelihood of identifying differences in a retrospective study. Outreach efforts are needed to educate outside centers about the importance of rapid rewarming and early transfer of severe frostbite patients to burn centers for thrombolytic therapy. Applicability of Research to Practice This study shows the need for outreach and education of frostbite management for non-burn centers.

This article reviews the role of MRI in the evaluation of benign pancreatic disease. Although MRI and magnetic resonance cholangiopancreatography (MRCP) are most often used to evaluate the liver and bile duct, technical advances such as the use of secretin stimulation also allow for high-quality imaging of the pancreas and pancreatic ductal system. Secretin-stimulated MRCP (S-MRCP) can aid the diagnosis of acute and chronic pancreatitis, and delineate ductal pathology such as benign strictures and duct leaks. There seems to be a role for S-MRCP in the assessment of pancreatic function and (possibly) sphincter of Oddi dysfunction. When endoscopic or surgical therapy is planned, S-MRCP can help to establish a diagnosis as well as offer a 'road map' to guide therapy. S-MRCP is noninvasive and almost entirely without risk to the patient, which gives it a distinct advantage over traditional endoscopic methods of diagnosis for conditions such as pancreas divisum and other ductal pathology. The information provided by S-MRCP, obtained before endoscopic or surgical therapy is attempted, can assist the patient and physician in making a fully informed decision with regard to the risks and probable benefits of any planned intervention.

Thymoma may be present in as many as one third of cases of pure red cell aplasia. Presented is a case of pure red cell aplasia with a mediastinal mass seen ,on a plain chest radiograph. A computed tomographic scan showed an anterior mediastinal mass. A Tc-99m tetrofosmin whole-bodyscan and SPECT revealed avid concentration corresponding to the mass. The diagnosis of thymoma was made based on the result of an excisional biopsy.