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Osteoporosis is characterized by reduced bone strength predisposing to an increased risk of fracture. Biomechanical computed tomography (BCT), predicting bone strength via CT-based finite element analysis (FEA), is now clinically available in the USA for diagnosing osteoporosis or assessing fracture risk. However, it has not been previously validated using a cohort of only Chinese subjects. Additionally, the effect of various modeling approaches on BCT outcomes remains elusive. To address these issues, we performed DXA and QCT scanning, compression testing, and BCT analyses on thirteen vertebrae derived from Chinese donors. Three BCT models were created (voxBCT and tetBCT: voxel-based and tetrahedral element-based FE models generated by a commercial software; matBCT: tetrahedral element-based FE model generated by a custom MATLAB program). BCT-computed outcomes were compared with experimental measures or between different BCT models. Results showed that, DXA-measured areal bone mineral density (aBMD) showed weak correlations with experimentally-measured vertebral stiffness (R2 = 0.28) and strength (R2 = 0.34). Compared to DXA-aBMD, BCT-computed stiffness provided improved correlations with experimentally-measured stiffness (voxBCT: R2 = 0.82; tetBCT: R2 = 0.77; matBCT: R2 = 0.76) and strength (voxBCT: R2 = 0.55; tetBCT: R2 = 0.57; matBCT: R2 = 0.53); BCT-computed mechanical parameters (stiffness, stress and strain) of the three different models were highly correlated with each other, with coefficient of determination (R2) values of 0.89–0.98. These results, based on a cohort of Chinese vertebral cadavers, suggest that BCT is superior over aBMD to consistently predict vertebral mechanical characteristics, regardless of the modeling approaches of choice. • Biomechanical computed tomography (BCT) was validated on a cohort of Chinese cadaveric vertebrae. • The effect of various modeling approaches (voxel vs tetrahedral element, commercial software vs custom program) was examined • BCT is superior over aBMD to predict vertebral mechanical characteristics, regardless of the modeling approaches of choice [ABSTRACT FROM AUTHOR]

Introduction: Sleeve gastrectomy is the most common surgical procedure to reduce weight and treat metabolic complications in patients with moderate-to-severe obesity; however, it affects the musculoskeletal system. Dual-energy X-ray absorptiometry (DXA), which is commonly used to measure bone mineral density (BMD), may be affected by excess fat tissue around the bones, interrupting BMD measurement. Due to the strong correlation between DXA and the Hounsfield units (HU) obtained from computed tomography (CT) scans, BMD assessment using clinical abdominal CT scans has been useful. To date, there has been no report of detailed CT evaluation in patients with severe obesity after sleeve gastrectomy., Objective: This study investigated the effect of sleeve gastrectomy in severely obese patients on bone and psoas muscle density, and cross-sectional area using retrospective clinical CT scans., Methods: This was a retrospective observational study that included 86 patients (35 males and 51 females) who underwent sleeve gastrectomy between March 2012 and May 2019. Patients' clinical data (age at the time of surgery, sex, body weight, body mass index (BMI), comorbidities, and preoperative and postoperative blood test results, HU of the lumbar spine and psoas muscle and psoas muscle mass index (PMI)) were evaluated., Results: The mean age at the time of surgery was 43 years, and the body weight and BMI significantly reduced ( p  < 0.01) after surgery. The mean hemoglobin A1c level showed significant improvement in males and females. Serum calcium and phosphorus levels remained unchanged before and after surgery. In CT analysis, HU of the lumbar spine and psoas muscle showed no significant decrease, but PMI showed a significant decrease ( p  < 0.01)., Conclusions: Sleeve gastrectomy could dramatically improve anthropometric measures without causing changes in serum calcium and phosphorus levels. Preoperative and postoperative abdominal CT revealed no significant difference in the bone and psoas muscle density, and the psoas muscle mass was significantly decreased after sleeve gastrectomy., Competing Interests: All authors have no conflict of interests related to this study., (© 2023 The Authors.)

Nontraumatic splenic rupture is a rare pancreatitis complication. We present a 61-year-old chronic alcoholic male with acute on chronic pancreatitis, which progressed to pseudocyst, splenic vein thrombosis, splenic rupture, and eventually hemoperitoneum. Later, the patient required an emergency laparotomy and splenectomy. Early detection and treatment of pancreatitis and pseudocyst can help prevent a rare but potentially fatal complication like an acute rupture., (© 2023 The Authors.)

We report a case of hypothermic death that resulted from extreme freezing, with characteristic postmortem computed tomography (PMCT) findings. A 75-year-old man died in a deeply frozen state. In PMCT, there was a lack of increase in the bilateral lung-field attenuation. Urinary retention, with a hypodense area of frozen urine, was observed in the bladder. Changes that appeared to involve the crystallization of serum in frozen blood were observed in the aorta. Based on the scene and his circumstances, it was speculated that he died of hypothermia. Present case and our review revealed that although PMCT findings from hypothermic death that resulted from deep freezing are very rare, the characteristic PMCT findings may help determine the cause of death., (© 2023 The Authors.)

Rationale and Objectives: Selecting region of interest (ROI) for left atrial appendage (LAA) filling defects assessment can be time consuming and prone to subjectivity. This study aimed to develop and validate a novel artificial intelligence (AI), deep learning (DL) based framework for automatic filling defects assessment on CT images for clinical and subclinical atrial fibrillation (AF) patients., Materials and Methods: A total of 443,053 CT images were used for DL model development and testing. Images were analyzed by the AI framework and expert cardiologists/radiologists. The LAA segmentation performance was evaluated using Dice coefficient. The agreement between manual and automatic LAA ROI selections was evaluated using intraclass correlation coefficient (ICC) analysis. Receiver operating characteristic (ROC) curve analysis was used to assess filling defects based on the computed LAA to ascending aorta Hounsfield unit (HU) ratios., Results: A total of 210 patients (Group 1: subclinical AF, n = 105; Group 2: clinical AF with stroke, n = 35; Group 3: AF for catheter ablation, n = 70) were enrolled. The LAA volume segmentation achieved 0.931-0.945 Dice scores. The LAA ROI selection demonstrated excellent agreement (ICC ≥0.895, p < 0.001) with manual selection on the test sets. The automatic framework achieved an excellent AUC score of 0.979 in filling defects assessment. The ROC-derived optimal HU ratio threshold for filling defects detection was 0.561., Conclusion: The novel AI-based framework could accurately segment the LAA region and select ROIs while effectively avoiding trabeculae for filling defects assessment, achieving close-to-expert performance. This technique may help preemptively detect the potential thromboembolic risk for AF patients., Competing Interests: The authors declare no competing interests., (© 2023 The Authors.)

Background: Total hip arthroplasty (THA) for hip disorders helps to alleviate pain and improve active daily life. When determining the effects of medical therapy and the subsequent clinical results, patient quality of life (QOL) also needs to be assessed. Recently, patient-reported outcomes (PRO) have become important as evaluation criteria. This study aimed to evaluate patient QOL and various PRO between different types of cementless stems and to clarify the relationship between PRO and stem-cortical bone contact., Methods: The study comprised 138 consecutive patients undergoing cementless THA for hip osteoarthritis. We assessed three different types of PRO: the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), patient's joint perception, and peri-hip articular joint pain (PHAP). We measured the state of contact between femur and implant by density mapping., Results: No significant difference was noted in PRO between stem types based on the JHEQ and patient's joint perception. PHAP occurred more frequently in the patients with a taper wedge stem versus a fit-and-fill stem. In both groups, distal contact was associated with PHAP but not with JHEQ results and patient's joint perception., Conclusion: The difference in PHAP between the two stem types groups was significant, with postoperative PHAP being higher with the taper wedge stem because of the more distal contact between the taper wedge stem and femur cortical bone., Competing Interests: All authors declare that they have no conflict of interest or competing interest., (© 2022 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Objective: To clarify whether intersegmental pulmonary veins are always located on the intersegmental plane and determine the division from which blood flows into them., Methods: We analyzed representative intersegmental veins located between the upper/lingular and superior/basal division of the lungs using preoperative chest computed tomography (CT) DICOM data from 22 patients who underwent lobectomy or segmentectomy during 2020. The location and blood flow of V 3 a+b and V 6 b+c were assessed using REVORAS (Ziosoft), a novel volume-rendering 3-dimensional (3D) image reconstruction software dedicated to lung segmentectomy., Results: The V 3 a+b was in the upper division and on the intersegmental plane between the upper and lingular divisions of the left lung in 11 patients (50%) each. A main root of V 3 a+b was not found in the lingular division, but some peripheral flow in the V 3 a+b was derived from it in 14 patients (64%). The V 6 b+c was found in the superior division of the right lower lobe in 13 patients (59%) and the left lower lobe in 10 patients (45%), and on the intersegmental plane between the superior and basal division of the right lower lobe in 6 patients (27%) and the left lower lobe in 10 patients (45%). A main root of V 6 b+c was imperceptible in the basal division. Some peripheral blood flow was derived from the basal division in 6 patients (27%) with V 6 b+c veins located in the right lower lobe and in 8 patients (36%) with V 6 b+c veins located in the left lower lobe., Conclusions: Precise evaluation of intersegmental veins using preoperative volume-rendering 3D reconstructed CT images provides useful anatomic information for separating intersegmental pulmonary parenchyma., (© 2022 The Author(s).)

Introduction: Micro-computed tomography (μCT) is a valuable imaging modality for longitudinal quantification of bone volumes to identify disease or treatment effects for a broad range of conditions that affect bone health. Complex structures, such as the hindpaw with up to 31 distinct bones in mice, have considerable analytic potential, but quantification is often limited to a single bone volume metric due to the intensive effort of manual segmentation. Herein, we introduce a high-throughput, user-friendly, and semi-automated method for segmentation of murine hindpaw μCT datasets., Methods: In vivo μCT was performed on male ( n  = 4; 2-8-months) and female (n = 4; 2-5-months) C57BL/6 mice longitudinally each month. Additional 9.5-month-old male C57BL/6 hindpaws ( n  = 6 hindpaws) were imaged by ex vivo μCT to investigate the effects of resolution and integration time on analysis outcomes. The DICOMs were exported to Amira software for the watershed-based segmentation, and watershed markers were generated automatically at approximately 80% accuracy before user correction. The semi-automated segmentation method utilizes the original data, binary mask, and bone-specific markers that expand to the full volume of the bone using watershed algorithms., Results: Compared to the conventional manual segmentation using Scanco software, the semi-automated approach produced similar raw bone volumes. The semi-automated segmentation also demonstrated a significant reduction in segmentation time for both experienced and novice users compared to standard manual segmentation. ICCs between experienced and novice users were >0.9 (excellent reliability) for all but 4 bones., Discussion: The described semi-automated segmentation approach provides remarkable reliability and throughput advantages. Adoption of the semi-automated segmentation approach will provide standardization and reliability of bone volume measures across experienced and novice users and between institutions. The application of this model provides a considerable strategic advantage to accelerate various research opportunities in pre-clinical bone and joint analysis towards clinical translation., Competing Interests: The authors have no conflict of interest to disclose., (© 2022 The Author(s).)

Background/aims: Multiple definitions of sarcopenia exist and the acceptable criterion that best predicts outcome is lacking. We estimated the prevalence of sarcopenia based on four criteria and assessed their utility in predicting mortality in cirrhotics., Methods: In a prospective observational study, consecutive Asian patients with cirrhosis underwent testing for handgrip strength (HGS) and estimation of skeletal muscle index (SMI) using computed tomography at the third lumbar vertebra. Sarcopenia was defined based on the Western cut-off (WC; SMI < 50 cm 2 /m 2 for men and <39 cm 2 /m 2 for women), Asian cut-off (AC; SMI < 36.5 cm 2 /m 2 for men and 30.2 cm 2 /m 2 for women), European Working Group on Sarcopenia in Older People-2nd meeting (EWGSOP2) definition incorporating low HGS (<27 kg for men and <16 kg for women) with low SMI (defined by the WC), and EWGSOP2 definition with low HGS and low SMI (defined by AC). Risk factors for mortality were assessed using multivariate Cox-proportional hazards., Results: We included 219 patients with cirrhosis (168 men; mean age 42.6 years) with 50.2% patients having decompensation. Alcohol was the commonest aetiology (33.3%). The prevalence of sarcopenia was highest with the WC (men: 82.1%; women: 62.7%). There was a weak concordance among all criteria (Fleiss' kappa 0.23, 95% confidence interval [CI] 0.10-0.37). Overall, 12-month survival was 86.1% (81.1-91.3%) over a median (interquartile range) follow-up of 12 (6-15) months. Ascites (hazards ratio [HR] 6.27 [95% CI 1.6-24.1]; P < 0.007) and SMI (HR 0.92 [0.85-0.98]; P  = 0.021) were independent predictors of mortality. The 12-month mortality rate was higher in patients with sarcopenia, irrespective of criteria (log rank P  < 0.05). Low HGS and low SMI (defined by AC) was the best for predicting mortality (HR 3.04 [1.43-6.43]; P  = 0.004)., Conclusion: A weak concordance exists amongst various diagnostic definitions of sarcopenia. Sarcopenia diagnosed by a combination of low HGS and population-specific SMI cut-off (AC) best predicts mortality., (© 2021 Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Background and Purpose: Magnetic resonance imaging (MRI)-only treatment planning is gaining in popularity in radiation oncology, with various methods available to generate a synthetic computed tomography (sCT) for this purpose. The aim of this study was to validate a sCT generation software for MRI-only radiotherapy planning of male and female pelvic cancers. The secondary aim of this study was to improve dose agreement by applying a derived relative electron and mass density (RED) curve to the sCT., Method and Materials: Computed tomography (CT) and MRI scans of forty patients with pelvic neoplasms were used in the study. Treatment plans were copied from the CT scan to the sCT scan for dose comparison. Dose difference at reference point, 3D gamma comparison and dose volume histogram analysis was used to validate the dose impact of the sCT. The RED values were optimised to improve dose agreement by using a linear plot., Results: The average percentage dose difference at isocentre was 1.2% and the mean 3D gamma comparison with a criteria of 1%/1 mm was 84.0% ± 9.7%. The results indicate an inherent systematic difference in the dosimetry of the sCT plans, deriving from the tissue densities. With the adapted RED mod table, the average percentage dose difference was reduced to -0.1% and the mean 3D gamma analysis improved to 92.9% ± 5.7% at 1%/1 mm., Conclusions: CT generation software is a viable solution for MRI-only radiotherapy planning. The option makes it relatively easy for departments to implement a MRI-only planning workflow for cancers of male and female pelvic anatomy., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Author(s).)

Gestational choriocarcinoma is a malignant trophoblastic tumor arising from any gestational event, even with a long latency period, generally in the reproductive female. It is associated with a high level of beta-human chorionic gonadotropin. Its primary site is usually the uterus but not all patients have a detectable lesion in this site. Regression of the primary tumor after it has metastasized is not uncommon, and one-third of cases manifest as complications of metastatic disease. In this report we present an uncommon case of gestational choriocarcinoma with lung, liver and jejunal metastases at the time of diagnosis without evidence of pelvic disease, in 34-year-old woman. The main points of interest of our case were the development of the ovarian hyperstimulation syndrome with massive multicystic ovarian enlargement induced by high level of beta-human chorionic gonadotropin and the bleeding of jejunal and liver metastases, due to the high vascularity of the tumor tissue, a condition known as "Choriocarcinoma Syndrome". We will focus on the radiological findings of metastases, bleeding complications and ovarian hyperstimulation syndrome., (© 2021 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Background & Aims: Retrospective cross-sectional studies linked sarcopenia and myosteatosis with metabolic dysfunction-associated fatty liver disease (MAFLD). Here, we wanted to clarify the dynamic relationship between sarcopenia, myosteatosis, and MAFLD., Methods: A cohort of 48 obese patients was randomised for a dietary intervention consisting of 16 g/day of inulin (prebiotic) or maltodextrin (placebo) supplementation. Before and after the intervention, we evaluated liver steatosis and stiffness with transient elastography (TE); we assessed skeletal muscle index (SMI) and skeletal muscle fat index (SMFI) (a surrogate for absolute fat content in muscle) using computed tomography (CT) and bioelectrical impedance analysis (BIA)., Results: At baseline, sarcopenia was uncommon in patients with MAFLD (4/48, 8.3%). SMFI was higher in patients with high liver stiffness than in those with low liver stiffness (640.6 ± 114.3 cm 2 / Hounsfield unit [HU] vs . 507.9 ± 103.0 cm 2 /HU, p  = 0.001). In multivariate analysis, SMFI was robustly associated with liver stiffness even when adjusted for multiple confounders (binary logistic regression, p <0.05). After intervention, patients with inulin supplementation lost weight, but this was not associated with a decrease in liver stiffness. Remarkably, upon intervention (being inulin or maltodextrin), patients who lowered their SMFI, but not those who increased SMI, had a 12.7% decrease in liver stiffness (before = 6.36 ± 2.15 vs . after = 5.55 ± 1.97 kPa, p  = 0.04)., Conclusions: Myosteatosis, but not sarcopenia, is strongly and independently associated with liver stiffness in obese patients with MAFLD. After intervention, patients in which the degree of myosteatosis decreased reduced their liver stiffness, irrespective of body weight loss or prebiotic treatment. The potential contribution of myosteatosis to liver disease progression should be investigated., Clinical Trials Registration Number: NCT03852069., Lay Summary: The fat content in skeletal muscles (or myosteatosis) is strongly associated with liver stiffness in obese patients with MAFLD. After a dietary intervention, patients in which the degree of myosteatosis decreased also reduced their liver stiffness. The potential contribution of myosteatosis to liver disease progression should be investigated., Competing Interests: The authors declare that they have no conflict of interest related to this study. Please refer to the accompanying ICMJE disclosure forms for further details., (© 2021 The Authors.)

The coexistence of pannus and thrombus is not uncommon. Accurate diagnosis of the etiology of prosthetic valve dysfunction (PVD) is of utmost importance in guiding adequate and rational therapy. We present a case of PVD in which computed tomography played a decisive role in guiding treatment. ( Level of Difficulty: Intermediate. )., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2021 The Authors.)

Background and Purpose: Artefacts caused by dental amalgam implants present a common challenge in computed tomography (CT) and therefore treatment planning dose calculations. The goal was to perform a quantitative image quality analysis of our Artifact Management for Proton Planning (AMPP) algorithm which used gantry tilts for managing metal artefacts on Head and Neck (HN) CT scans and major vendors' commercial approaches., Materials and Methods: Metal artefact reduction (MAR) algorithms were evaluated using an anthropomorphic phantom with a removable jaw for the acquisition of images with and without (baseline) metal artifacts. AMPP made use of two angled CT scans to generate one artifact-reduced image set. The MAR algorithms from four vendors were applied to the images with artefacts and the analysis was performed with respective baselines. Planar HU difference maps and volumetric HU differences were analyzed., Results: AMPP algorithm outperformed all vendors' commercial approaches in the elimination of artefacts in the oropharyngeal region, showing the lowest percent of pixels outside +- 20 HU criteria, 4%; whereas those in the MAR-corrected images ranged from 26% to 67%. In the region of interest within the affected slices, the commercial MAR algorithms showed inconsistent performance, whereas the AMPP algorithm performed consistently well throughout the phantom's posterior region., Conclusions: A novel MAR algorithm was evaluated and compared to four commercial algorithms using an anthropomorphic phantom. Unanimously, the analysis showed the AMPP algorithm outperformed vendors' commercial approaches, showing the potential to be broadly implemented, improve visualizations in patient anatomy and provide accurate HU information., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Authors.)

Background and Objectives: Fat infiltration of multifidus muscle is an important parameter to assess the efficacy of spinal stabilization training in chronic low back pain (LBP) patients. As a CT scan shows a specific attenuation value for fat, it can be used as a ratio to evaluate fat infiltration of the muscle relative to its cross-sectional area. This study aims to compare the fat infiltration ratio of multifidus muscle between subjects with and without chronic LBP in Indonesia., Methods: Comparative cross-sectional study of 20 subjects with chronic LBP and 20 subjects without LBP. Fat infiltration ratio calculation of the multifidus muscle was obtained from the database of abdominal CT at the level of the superior and inferior endplate of L4 and L5 vertebral body., Results: The fat infiltration ratio of multifidus muscle in the chronic LBP subjects group was significantly higher than the subjects group without NPB (p < 0.05). The cut-off value of the fat infiltration ratio at the level of the inferior endplate of L4 was 0.125 (75 % sensitivity and 80 % specificity)., Conclusion: The calculation of the multifidus muscle fat infiltration ratio at the inferior endplate L4 using CT is a potential method to evaluate multifidus muscle quality in chronic LBP patients., Competing Interests: The authors report no declarations of interest., (© 2020 The Author(s).)

Purpose: To determine the accuracy of quantitative CT to diagnose pulmonary edema compared to qualitative CT and CXR and to determine a threshold Hounsfield unit (HU) measurement for pulmonary edema on CT examinations., Method: Electronic medical records were searched for patients with a billing diagnosis of heart failure and a Chest CT and CXR performed within three hours between 1/1/2016 to 10/1/2016, yielding 100 patients. CXR and CT examinations were scored for the presence and severity of edema, using a 0-5 scale, and CT HU measurements were obtained in each lobe. Polyserial correlation coefficients evaluated the association between CT HUs and CXR scores, and receiver operating characteristic (ROC) curve analysis determined a cutoff CT HU value for identification of pulmonary edema., Results: Correlation between CT HU and CXR score was moderately strong (r = 0.585-0.685) with CT HU measurements demonstrating good to excellent accuracy in differentiating between no edema (grade 0) and mild to severe edema (grades 1-5) in every lobe, with AUCs ranging between 0.869 and 0.995. The left upper lobe demonstrated the highest accuracy, using a cutoff value of -825 HU (AUC of 0.995, sensitivity = 100 % and specificity = 95.1 %). Additionally, qualitative CT evaluation was less sensitive (84 %) than portable CXR in identifying pulmonary edema. However, quantitative CT evaluation was as sensitive as portable CXR (100 %) and highly specific (95 %)., Conclusions: Quantitative CT enables the identification of pulmonary edema with high accuracy and demonstrates a greater sensitivity than qualitative CT in assessment of pulmonary edema., (© 2020 Published by Elsevier Ltd.)

Background: Liver transplantation (LT) is a game changer in cirrhosis. Poor muscle mass defined as sarcopenia may potentially upset the LT scoreboard., Aim: To assess the prevalence and impact of sarcopenia on the intraoperative and early postoperative outcomes in Indian patients undergoing LT., Methods: Pre LT, single-slice routine computed tomography images at L3 vertebra of 115 LT recipients were analyzed, to obtain cross-sectional area of six skeletal muscles normalized for height in m 2 - skeletal muscle index (SMI; cm 2 /m 2 ). SMI< 52.4 in males and <38.5 in females was called sarcopenia. The intraoperative, postoperative outcome parameters and 90-day mortality were compared between sarcopenics and nonsarcopenics., Results: Sarcopenia was found in 47.8% of patients [M (90.4%); age, 46.3 ± 10; BMI, 24.5 ± 4.3 kg/m2; child A:B:C = 1%:22%:77%; MELD, 20.6 ± 6.3; etiology alcohol: nonalchohol = 53%:47%; Charlson Comorbidity Index (CCI) > 3:≤3 = 56.5%:43.5%]. Sarcopenics vs. Nonsarcopenics; early postoperative complications: [sepsis, 49(89%) vs. 33(55%), P  = 0.001; neurologic complications, 16(29.6%) vs. 5(8.8%), P  = 0.040; Clavien-Dindo Classification ≥3-24 (43.6%):15 (25.4%), P  = 0.041; ancillary parameters (days), duration of ventilation [median (range)] 1.5(1-3) vs. 1 (1-2), P  = 0.021; intensive care unit (ICU) stay 12 (8-16) vs. 10 (8-12), P  = 0.024; time to ambulation 9 (7-11) vs. 6 (5-7), P  = 0.001; drain removal 18.7 ± 7.3 vs. 14.4 ± 6.2, P  = 0.001; need for tracheostomy 5 (9%) vs. 0 (%), P  = 0.017; preoperative prevalence of acute kidney injury, comorbidities and requirement for dialysis, intraoperative blood loss & inotropic support were significantly higher in sarcopenics. Ninety-day mortality was comparable between sarcopenics 5 (9.09%) and nonsarcopenics 4 (6.6%) P  = 0.63. SMI (OR: 0.83; 95% CI: 0.71-0.97, P  = 0.016; Acute on chronic liver failure (ACLF) presentation 12.5 (1.65-95.2), P  = 0.015 and intraoperative blood loss 3.74 (0.96-14.6), P  = 0.046 were predictors of 90-day mortality., Conclusion: Almost 50% of LT recipients had sarcopenia, who had a higher incidence of postoperative sepsis, neurological complications, longer ICU stay and ventilatory support. Low SMI, ACLF presentation, and intraoperative blood loss were the independent predictors of early mortality., (© 2019 Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Neglected DJ stent is a challenging case, due to the procedures required, using fluoroscopy, as seen in ESWL, URS, and PCNL. This study presents the case of a 54 years old woman with pyelum and ureter stones, alongside neglected DJ stent for about a year. Treatment was started with cystoscopy, URS lithotripsy, which was continued with kidney puncture, and the subsequent dilatation with Alken Metal Telescopic Dilator. All steps were performed under the guidance of ultrasonography without fluoroscopy. The result showed a successful removal of DJ stent, which was achieved percutaneously, and no remaining stone was found., Competing Interests: None., (© 2020 The Author(s).)

The goal of assessing tumour response on imaging is to identify patients who are likely to benefit - or not - from anticancer treatment, especially in relation to survival. The World Health Organization was the first to develop assessment criteria. This early score, which assessed tumour burden by standardising lesion size measurements, laid the groundwork for many of the criteria that followed. This was then improved by the Response Evaluation Criteria in Solid Tumours (RECIST) which was quickly adopted by the oncology community. At the same time, many interventional oncology treatments were developed to target specific features of liver tumours that result in significant changes in tumours but have little effect on tumour size. New criteria focusing on the viable part of tumours were therefore designed to provide more appropriate feedback to guide patient management. Targeted therapy has resulted in a breakthrough that challenges conventional response criteria due to the non-linear relationship between response and tumour size, requiring the development of methods that emphasize the appearance of tumours. More recently, research into functional and quantitative imaging has created new opportunities in liver imaging. These results have suggested that certain parameters could serve as early predictors of response or could predict later tumour response at baseline. These approaches have now been extended by machine learning and deep learning. This clinical review focuses on the progress made in the evaluation of liver tumours on imaging, discussing the rationale for this approach, addressing challenges and controversies in the field, and suggesting possible future developments., Competing Interests: The authors declare that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript. Please refer to the accompanying ICMJE disclosure forms for further details., (© 2020 The Author(s).)

Rationale and Objectives: To evaluate the frequency and relevance of hypodense myocardium (HM) encountered in patients undergoing chest-pain CT in the emergency department (ED)., Material and Methods: In this IRB-approved retrospective study, ECG-gated chest-pain CT examinations of 300 consecutive patients (mean age 60 ± 17 years) presenting with acute chest-pain to our ED were evaluated. Once ST-segment elevation infarction was excluded, chest-pain CT including the coronary arteries (rule-out acute coronary syndrome (ACS), pulmonary embolism (PE) and acute aortic syndrome (AAS): chest-pain CT coronary , n = 121) or not including the coronary arteries was performed (rule-out PE and AAS: chest-pain CT w/o coronary , n = 179). Each myocardial segment was assessed for the presence of HM; attenuation was measured and compared to normal myocardium., Results: HM was identified in 27/300 patients (9%): 12/179 in chest-pain CT w/o coronary (7%) and 15/121 in chest-pain CT coronary (12%). Mean attenuation of HM (40 ± 17 HU) was significantly lower than that of healthy myocardium (103 ± 18 HU, p < 0.001), with a mean difference of 61 ± 19 HU. In 15/27 patients (55.6%) with HM, the final diagnosis was acute MI, and in the remaining 12/27 patients (44.4%) previous MI was found in the patients' history. Chest-pain CT w/o coronary identified HM in 10/15 patients (66.6%) with a final diagnosis of acute MI., Conclusion: HM indicating acute MI are often encountered in chest pain CT in the ED, also in chest-pain CT w/o coronary when MI is not suspected. This indicates that the myocardium should always be analyzed for hypodense regions even when MI not suspected.

Purpose: To investigate effects of radiotherapy (RT) and erlotinib on pulmonary glucose uptake using 2-deoxy-2-(18F)fluoro-D-glucose ( 18 F-FDG) positron emission tomography (PET) during and after treatment of non-small cell lung cancer (NSCLC) and to identify associations between serum cytokine levels and lung glucose uptake., Material and Methods: Twenty-seven patients with advanced NSCLC, receiving RT alone or concomitant RT and erlotinib therapy, were examined by 18 F-FDG PET before, during, and after treatment. A total of 57 18 F-FDG PET scans were analyzed. Pulmonary 18 F-FDG uptake and radiotherapy dose mapping were used to acquire dose-response curves for each patient, where subsequent linear regression gave a glucose uptake level in the un-irradiated parts of the lungs (SUV 0 ) and a response slope (ΔSUV). Serum cytokine levels at corresponding time points were assessed using a multiplex bioassay. Correlations between the most robust cytokines and lung 18 F-FDG dose response parameters were further investigated., Results: From the dose response analysis, SUV 0 at post-therapy was significantly higher (P < 0.001) than at mid- and pre-therapy (45% and 58%, respectively) for the group receiving RT + erlotinib. Also, SUV 0 at post-therapy was higher for patients receiving RT + erlotinib compared to RT alone (42%; P < 0.001). No differences in ΔSUV were seen with treatments or time. SUV 0 was positively associated (r = 0.47, P = 0.01) with serum levels of the chemokine C-C motif ligand 21 (CCL21) for patients receiving RT + erlotinib., Conclusions: Concomitant RT and erlotinib causes an elevation in pulmonary 18 F-FDG uptake post treatment compared to RT alone. Pulmonary glucose uptake is associated with an upregulation of a chemokine (CCL21) involved in inflammatory reactions.

Objective: To prospectively compare the Guy's Stone Score (GSS), S.T.O.N.E. [stone size (S), tract length (T), obstruction (O), number of involved calices (N), and essence or stone density (E)] score and the Clinical Research Office of the Endourological Society (CROES) nephrolithometric nomogram to predict percutaneous nephrolithotomy (PCNL) success rate and assess the correlation with perioperative complications., Patients and Methods: We prospectively evaluated all consecutive PCNL patients at our institute between 1 November 2013 and 31 May 2015. The above scoring systems were applied to preoperative non-contrast computed tomography and the practical difficulties in such applications were noted. Perioperative complications and the stone-free rate (SFR) were also recorded. Receiver operating characteristic curves were drawn and the areas under curves were compared and appropriate statistical analysis done., Results: In all, 48 renal units were included in the study. The overall SFR was 62.2%. The presence of staghorn stones ( β  = 27.285, 95% confidence interval 1.19-625.35; P  = 0.039) was the only significant variable associated with the residual stones on multivariate analysis. Stone-free patients had significantly lower median GSS (2 vs 4) and S.T.O.N.E. scores (6 vs 10) and higher median CROES scores (83% vs 63%) (all P  < 0.001) compared to residual-stone patients. All scoring systems were significantly associated with SFR (all P  < 0.001). There was no significant difference in the areas under curves of the scoring systems (0.858, 0.923, and 0.931, respectively). Furthermore, all scoring systems had weak correlations with Clavien-Dindo classified complications ( r  = 0.29, P  = 0.045; r  = 0.40, P  = 0.005 and r  = -0.295, P  = 0.04, respectively). We found no standardisation for the measurement of stone dimensions, tract length, Hounsfield units, and staghorn definition., Conclusions: All scoring systems equally predicted SFR and had a weak correlation with Clavien-Dindo complications. Standardisation is needed for the variables in which they have been found deficient.

We report the case of a 62-year-old man with chronic pancreatitis who presented with increasing abdominal pain. Sonography, magnetic resonance imaging, contrast-enhanced computed tomography, and ultimately catheter angiography demonstrated a pancreatic pseudocyst that had eroded into the splenoportal venous confluence, mimicking an arterial aneurysm. The diagnostic was confirmed at the time of surgical treatment. This case demonstrates the use of imaging to diagnose complications of pancreatitis, and the difficulty of distinguishing an eroding pseudocyst from an arterial aneurysm.

Introduction: Radiation exposure is one of the major limitations of computed tomographic coronary angiography (CTA). The purpose of this study was to compare the objective and subjective image quality and radiation dose using prospective ECG gating (PGA) versus ECG-controlled tube current modulation (ECTCM) scanning techniques., Methods: A prospective, single-center study was performed at Prince Sultan Cardiac Centre, Qassim, Saudi Arabia. A total of 104 patients with low-to- intermediate probability of coronary artery disease (CAD) underwent CTA with either PGA or ECTCM acquisition. PGA was performed during the study period and compared with the last 50 CTAs previously done using ECTCM. A 4-point scale was used to assess the image quality subjectively. Objective image quality was assessed using image signal, noise, and signal-to-noise ratio (SNR)., Results: Patient's Baseline characteristics were not different between the two scanning protocols. The 4-point score of subjective image quality showed no significant differences between the PGA and ECTCM scans (2.9 ± 0.7, 2.96 ± 0.7, respectively; p = 0.87). The objective image quality showed significantly higher noise and lower SNR with PGA compared with ECTCM (31 ± 9, 27 ± 9, respectively; p < 0.001 for noise) and (15 ± 5, 17 ± 7, respectively; p < 0.001 for SNR), with no statistical difference in the image signal (434 ± 123, 425 ± 103 HU, respectively, p = 0.7). Radiation exposure was significantly lower with PGA than with ECTCM. The dose-length product (DLP) for PGA was 334 ± 130 mGy, compared with 822 ± 286 mGy for the ECTCM. This corresponds to a 59% reduction in radiation exposure (p < 0.0001)., Conclusions: Although prospective ECG-triggered axial scanning increased image noise, it maintained subjective image quality and was associated with a 59% reduction in radiation exposure when compared with ECTCM.

Introduction: The goal of percutaneous nephrolithotomy (PCNL) is to ensure complete stone clearance with minimal morbidity. The key to complete clearance is accurate technique, expertise and instrumentation., Methods: We systematically reviewed available reports that were identified using a PubMed/Medline search. The keywords used were 'PCNL' and 'advances in PCNL'. The findings were reviewed under the topics of newer developments in imaging, techniques and a review of outcomes with an emphasis on stone clearance and complications., Conclusion: The newer developments in imaging methods, such as cone-beam computed tomography and staghorn morphometry, help the surgeon to plan the procedure for a safe and better outcome. The highlight of these newer developments is the miniaturisation of instruments. This has translated into developing newer techniques such as the 'microperc' and 'miniperc'. The data-collection initiative by the Clinical Research Office of the Endourological Society has helped in obtaining a high level of evidence.

Objective: To review the current role and outcome of laparoscopic adrenalectomy (LA) in the management of adrenal tumours., Methods: A Medline search using the keywords (adrenalectomy, laparoscopy, adrenal masses/tumours) was done for reports published between 1990 and 2011. Key articles were used to find more relevant references on the evaluation and laparoscopic management of adrenal masses., Results: The hormonal evaluation is not standardised, but initial screening tests are recommended and followed with confirmatory ones when positive, equivocal or the clinical presentation suggest adrenal hyperfunction. The imaging studies had, and continued to, advance, especially computed tomography (CT), magnetic resonance imaging and positron-emission tomography/CT. These advances have increased the accuracy of the diagnosis of adrenal masses, with a reported high sensitivity and specificity of 95-100%. The introduction of laparoscopy has resulted in more adrenal lesions being removed, especially incidental lesions smaller than the 5-6 cm that was previously the indication for surgical excision. The technique has developed and larger lesions of >6 cm are now considered for LA in the proper setting. The transperitoneal and retroperitoneal approaches are currently widely practised, with minor differences in the outcome. The reported outcome, although mostly retrospective, is excellent and with fewer complications. The role of LA for adrenal malignancy should be considered cautiously. Preoperative imaging signs of invasion into surrounding structures should be considered a contraindication for LA., Conclusion: LA is the standard procedure for most adrenal lesions of appropriate size and no signs of surrounding tissue invasion, giving an excellent outcome.