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The aim of this study was to determine the accuracy of multidetector row CT angiography in the diagnosis of acute mesenteric ischemia. Ninety-three consecutive studies on 91 patients with clinically suspected acute mesenteric ischemia underwent abdominal CT angiography as the first, and usually the sole, diagnostic procedure. CT was performed with a multidetector 16-row CT system from the level of the diaphragm to the pelvis in two phases: early arterial and late portal phase. CT examinations were reviewed by the duty radiologist. Final diagnosis was established by a senior radiologist. CTA was diagnostic in 92 studies. Mesenteric ischemia was diagnosed in 18 patients, 14 of them were of the thromboembolic type and four from the nonocclusive type. Positive CTA findings were confirmed by surgery in 13 patients and by clinical follow-up in three cases. Other reasons for abdominal pain were diagnosed by CT in 38 patients out of the remaining 74. There were two false positive and two false negative CT results, resulting in an overall accuracy of 95.6%. Multidetector CT angiography is a fast and accurate investigation for the diagnosis of acute mesenteric ischemia and in most cases can be used as the sole diagnostic procedure. [ABSTRACT FROM AUTHOR]

Objectives: Severe coagulopathy due to consumption of synthetic cannabinoids adulterated with brodifacoum, a long-acting anticoagulant, is an emerging worldwide hazard. Here, we review the spectrum of imaging findings in adulterated cannabinoid poisoning., Materials and Methods: In this retrospective study, we used the Israeli Poison Information Center database to identify patients with cannabinoid-associated coagulopathy who presented to the Rambam Health Care Campus, where most patients were treated during an outbreak in northern Israel between September 2021 and June 2022. All relevant imaging studies for these patients were reviewed. We estimated the sensitivity of findings for cannabinoid-associated coagulopathy. Associations between a continuous variable and a dichotomous outcome were assessed with the Mann-Whitney U test., Results: We identified 48 patients (mean age 40 years ± 9 [SD], 43 males) with 54 hospitalizations due to cannabinoid-associated coagulopathy. Symptomatic hemorrhage was documented in 50 (93%) cases at presentation, most of whom (78%) had hemorrhage from multiple systems. The most common bleeding site was the genitourinary collecting system, with a characteristic sign of suburothelial bleeding in 16/18 of performed abdominal CTs (sensitivity 89% [CI 65-99%] for cannabinoid-associated coagulopathy). Intramural bowel hematomas were noted in 70% (7/10) of CTs of patients with gastrointestinal bleeding. Incidental bleeding sites were identified on imaging in 24% of patients. An increased number of bleeding sites was associated with need for vasopressors (difference in bleeding sites 3.00 [95% CI 0.99-4.00], p = 0.026)., Conclusion: CT plays a key role in the diagnosis and work-up of adulterated cannabinoid-associated coagulopathy. Characteristic signs include suburothelial hemorrhage and intramural bowel hematomas., Clinical Relevance Statement: Recognition of radiological signs of adulterated synthetic cannabinoid-associated coagulopathy is critical for optimizing outbreak control on the public health level and ensuring timely treatment on the individual patient level., Key Points: • Severe coagulopathy due to consumption of synthetic cannabinoids adulterated with brodifacoum, a long-acting anticoagulant, is an emerging worldwide threat. • Characteristic imaging signs include suburothelial bleeding, intramural bowel hematomas, and rare incidental bleeding sites. • Imaging has a pivotal role in optimizing outbreak control and ensuring timely and appropriate treatment., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

Background: Patient-ventilator asynchrony during mechanical ventilation may exacerbate lung and diaphragm injury in spontaneously breathing subjects. We investigated whether subject-ventilator asynchrony increases lung or diaphragmatic injury in a porcine model of acute respiratory distress syndrome (ARDS)., Methods: ARDS was induced in adult female pigs by lung lavage and injurious ventilation before mechanical ventilation by pressure assist-control for 12 h. Mechanically ventilated pigs were randomised to breathe spontaneously with or without induced subject-ventilator asynchrony or neuromuscular block (n=7 per group). Subject-ventilator asynchrony was produced by ineffective, auto-, or double-triggering of spontaneous breaths. The primary outcome was mean alveolar septal thickness (where thickening of the alveolar wall indicates worse lung injury). Secondary outcomes included distribution of ventilation (electrical impedance tomography), lung morphometric analysis, inflammatory biomarkers (gene expression), lung wet-to-dry weight ratio, and diaphragmatic muscle fibre thickness., Results: Subject-ventilator asynchrony (median [interquartile range] 28.8% [10.4] asynchronous breaths of total breaths; n=7) did not increase mean alveolar septal thickness compared with synchronous spontaneous breathing (asynchronous breaths 1.0% [1.6] of total breaths; n=7). There was no difference in mean alveolar septal thickness throughout upper and lower lung lobes between pigs randomised to subject-ventilator asynchrony vs synchronous spontaneous breathing (87.3-92.2 μm after subject-ventilator asynchrony, compared with 84.1-95.0 μm in synchronised spontaneous breathing;). There were also no differences between groups in wet-to-dry weight ratio, diaphragmatic muscle fibre thickness, atelectasis, lung aeration, or mRNA expression levels for inflammatory cytokines pivotal in ARDS pathogenesis., Conclusions: Subject-ventilator asynchrony during spontaneous breathing did not exacerbate lung injury and dysfunction in experimental porcine ARDS., (Copyright © 2021. Published by Elsevier Ltd.)

Background: For more than a year, health systems all over the world have been combating the global coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease was first described in the city of Wuhan in China, presenting as an atypical infection of the lower respiratory tract., Methods: COVID-19 is characterized by multisystemic involvement, and mortality is attributed mainly to the respiratory system involvement, which may lead to severe acute respiratory distress syndrome and respiratory failure. Several COVID-19-associated complications are being increasingly reported, including arterial and venous thromboembolic events that may lead to amputation of the affected limbs. So far, a large number of reports have described hypercoagulability crises leading to amputation of the lower limbs. However, a search of the National Library of Medicine (MEDLINE) revealed no cases of urgent upper limb amputation in COVID-19 patients., Results: This article describes a novel case of upper limb ischemia in a COVID-19 patient, with rapid progression to hand necrosis, requiring urgent through-arm amputation of the upper limb., Conclusions: This case emphasizes the need for anticoagulant therapy in COVID-19 patients and to maintain a constant awareness of the possible thromboembolic COVID-19-related sequelae., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: Our goal was to discuss the role of Doppler ultrasound (US), combined with clinical features, in the diagnosis of transjugular intrahepatic portosystemic shunt (TIPS) dysfunction in the era of covered stents. In light of the lack of research regarding the accuracy of Doppler US in TIPS dysfunction evaluations when using covered stents and a recent major meta-analysis, which primarily reviewed studies with bare metal stents but few with covered stents, we aimed to provide our single-center case study for further investigation., Methods: All patients from 2010 to 2019 who underwent angiography for a covered stent preceded by a Doppler US examination in our institution were retrospectively reviewed., Results: All of the Doppler US and angiographic examination results showed complete agreement, and 11 of 12 were positive for TIPS dysfunction., Conclusions: Combining the presence of positive clinical signs for TIPS dysfunction with Doppler US may increase its accuracy. Considering our results, there may be a need to reinvestigate Doppler US as a noninvasive, inexpensive, and available tool for the diagnosis of TIPS dysfunction in the era of covered stents, despite recent publications depicting Doppler US as inadequate for evaluating a TIPS., (© 2020 American Institute of Ultrasound in Medicine.)

Objective: The standard of care for the diagnosis and follow-up of urolithiasis is unenhanced CT. The hypothesis of this study was that that by using image fusion of subsequent ultrasound (US) with the initial unenhanced CT, ureteral stones can be precisely localized., Conclusion: Of the 25 stones founds on unenhanced CT studies, 22 (88%) were confidently identified using US-unenhanced CT fusion within 72 hours after the initial CT scan was obtained. US-unenhanced CT fusion might obviate the need for repeated CT scans for monitoring urolithiasis.

Unlabelled: (18)F-FDG PET/CT is of value in the diagnosis of prosthetic vascular graft infection, but potential pitfalls related to tracer uptake in noninfected implants have been described. The current study assesses the incidence and patterns of (18)F-FDG uptake over time in noninfected grafts, in relationship to prosthetic material and location., Methods: A 12-y PET/CT database was retrospectively searched for cancer patients with prosthetic vascular grafts. Data retrieved from patient files included graft location, material, and time from surgery. Images were reviewed by 2 nuclear medicine physicians in consensus, with the presence and patterns (focal, diffuse homogeneous, inhomogeneous) of increased (18)F-FDG uptake in grafts recorded. The mean standardized uptake value in grafts (SUV-G) and mediastinum (SUV-M) was measured. The ratio of SUV-G to SUV-M (SUV-G/SUV-M) was calculated for each graft., Results: One hundred seven prostheses were identified in 102 studies in 43 cancer patients. Sixty-seven prostheses were made of Dacron, 33 of Gore-Tex, and 7 were native veins. No increased (18)F-FDG uptake was found in 9 grafts (native veins, 4; Gore-Tex, 3; Dacron, 2). There was diffuse homogeneous uptake in 68 and inhomogeneous uptake in 30 grafts. The homogeneous pattern was more prevalent in Gore-Tex whereas the inhomogeneous uptake was seen more in Dacron vascular grafts. None of the grafts demonstrated focal uptake. The SUV-G range was 0.4-6.3 (average, 1.9), and SUV-M range was 0.6-2.4 (average, 1.4). The intensity of uptake was significantly higher in Dacron (SUV-G = 2.35 and SUV-G/SUV-M = 1.72) than in Gore-Tex (SUV-G = 1.09, SUV-G/SUV-M = 0.91) and native vein grafts (SUV-G = 1.07, SUV-G/SUV-M = 0.75) (P < 0.005). Native vein grafts showed a significant decrease in (18)F-FDG uptake over time whereas synthetic grafts showed no change in intensity for a follow-up of up to 16 y., Conclusion: Diffuse (18)F-FDG uptake was found in 92% of noninfected vascular prostheses, more in Dacron grafts than with other materials. The intensity of (18)F-FDG uptake of synthetic grafts did not change over time. With knowledge of the presence, patterns, and persistence of (18)F-FDG uptake in noninfected vascular prostheses, misinterpretation of PET/CT studies in patients referred for suspected prosthetic infection and in those assessed for diseases unrelated to their graft status can be avoided.

Introduction: Obscure gastrointestinal bleeding from the small intestine may present the Acute Care Surgeon with a formidable diagnostic and therapeutic challenge. Despite the current array of diagnostic studies, localization of the causative pathology may be elusive, especially when the bleeding is intermittent. When a small intestinal arteriovenous malformation is the responsible lesion, a technique combining super-selective angiography with intra-operative methylene blue injection and focused enterectomy has been described in a number of case series. The current case report utilizes this same approach with emphasis on computed tomography angiography representing a key first step in the diagnostic algorithm., Case Report: In this case report, we describe the diagnosis and treatment of obscure gastrointestinal bleeding emanating from an arteriovenous malformation in the small intestine of a 52 year old male. After an extensive work-up including upper and lower endoscopy, double balloon enteroscopy and capsule endoscopy, he was referred for computed tomography angiography. Though he was not actively bleeding, a jejunal arteriovenous malformation was localized on imaging. This prompted directed transfemoral angiography, placement of a super-selective microcatheter in the 4th jejunal arterial branch, intra-operative methylene blue injection and focused enterectomy with pathological confirmation. The patient was found to be free of gastrointestinal bleeding on 6 month follow-up., Conclusions: A step-wise, rational diagnostic approach should be utilized in the evaluation of obscure gastrointestinal bleeding. In the non-actively bleeding patient, computed tomography angiogram may facilitate the diagnosis of a small intestinal arteriovenous malformation. Methylene blue injection via a super-selective angiographic microcatheter may then allow for focused enterectomy.

Objective: The purpose of this study was to examine the triage role of scrotal Doppler ultrasonography (DUS) as the primary preoperative diagnostic tool in patients presenting to the emergency department (ED) with acute scrotum., Methods: Patients who presented to the ED with acute scrotum and underwent scrotal DUS in the ultrasound unit over a 3-year period (2004-2007) were included in the study. Patient characteristics, DUS findings, and clinical management were retrospectively collected and reviewed. Doppler ultrasonographic diagnoses were compared with histopathologic findings for patients who underwent exploration and with final diagnoses at the time of discharge for patients undergoing medical treatment., Results: A total of 620 consecutive patients with 669 DUS examinations were included. The most common scrotal DUS diagnoses were epididymitis, hydrocele, varicocele, and orchitis. Scrotal trauma was present in 77 cases. Hospitalization followed the initial ED evaluation for 155 patients; 68 underwent surgery. Testicular torsion was ultrasonographically suspected in 20 patients and confirmed in 18. Scrotal malignancy was incidentally diagnosed in 13 patients and testicular hematoma in 8. Doppler ultrasonography for the diagnosis of testicular torsion had 94% sensitivity, 96% specificity, 95.5% accuracy, an 89.4% positive predictive value (PPV), and a 98% negative predictive value (NPV). Doppler ultrasonography for the diagnosis of testicular malignancy had 92% sensitivity, 95% specificity, 94% accuracy, a 78.5% PPV, and a 98% NPV., Conclusions: Scrotal DUS is a highly sensitive preoperative diagnostic tool, thereby validating its routine use in the initial triage of patients with acute scrotum presenting to the ED.

We studied the relocation of newly emerged and fed individuals of three species of desert fleas (Xenopsylla conformis, Xenopsylla ramesis, and Parapulex chephrenis) in response to light and surface angle. We observed flea movements inside of either horizontal or tilted cardboard tubes with different light regime at their ends. Proportion of relocating X. conformis and X. ramesis was significantly higher than that of P. chephrenis. In this species only, adult individuals relocated more frequently than newly emerged individuals, and females relocated more frequently than males. In general, the majority of fleas moved toward light independently of its position in relation to the surface angle. Fleas moved toward light even if it was positioned at the lower end of a tube. When both ends of a tube were darkened, newly emerged Xenopsylla moved randomly toward the upper or lower end of a tube, whereas newly emerged P. chephrenis moved mainly toward the upper end of a tube. Adult P. chephrenis and X. conformis also moved mainly toward the upper end of a tube, whereas adult X. ramesis moved mainly toward the lower end. When both ends of a tube were lighted up, newly emerged females of all species, as well as newly emerged female X. ramesis, randomly relocated toward the upper or lower end of a tube. In contrast, newly emerged males and adults of both sexes of P. chephrenis and X. conformis as well as adult female X. ramesis moved mainly toward the upper end of a tube, whereas adult male X. ramesis moved mainly down. Results of this study suggest that light is a more important abiotic signal for flea orientation than surface angle, and there are species-specific differences in flea responses to light and angle stimuli. These differences are related to spatial ecology and behavior of fleas' main hosts as well as to fleas' environmental preferences.

Purpose: The aim of this study was to assess the value of combined PET/CT compared with PET reviewed side-by-side with CT, in patients with oesophageal cancer, before and after surgery., Methods: Forty-one FDG PET/CT studies were performed in 32 patients with oesophageal cancer, before surgery (n = 18) or during follow-up after resection of the primary tumour (n = 23). One hundred and fifteen sites suspicious for malignancy were evaluated. PET/CT was prospectively compared with PET reviewed side-by-side with CT, for detection, accurate localisation and characterisation of malignant sites. PET/CT performance in different anatomical regions was compared before and after surgery. The impact of fused data on patient management was retrospectively assessed., Results: PET/CT had an incremental value over PET for interpretation of 25 of 115 sites (22%), changing the initial characterisation of ten sites to either malignant (n = 1) or benign (n = 9), and defining the precise anatomical location of 15 sites. PET/CT provided better specificity and accuracy than PET for detecting sites of oesophageal cancer (81% and 90% vs 59% and 83% respectively, p < 0.01). Fusion was of special value for interpretation of cervical and abdomino-pelvic sites, for disease assessment in loco-regional lymph nodes before surgery and in regions of postoperative anatomical distortion. PET/CT had an impact on the further management of four patients (10%), by detecting nodal metastases that warranted disease upstaging (n = 2) and by excluding disease in sites of benign uptake after surgery (n = 2)., Conclusion: PET/CT improves the accuracy of FDG imaging in oesophageal cancer and provides data of diagnostic and therapeutic significance for further patient management.

Multidetector computed tomography (MDCT) and Doppler ultrasound findings of a renal cell carcinoma invading the right ovarian vein are presented. An MDCT study performed for evaluation of macroscopic hematuria showed a heterogeneously enhancing malignant thrombus in the right ovarian vein that was in continuity with inferior vena cava and right renal vein thrombi of identical characteristics. Further investigation with Doppler ultrasound confirmed these findings and showed arterial blood flow of low resistance within the ovarian vein and inferior vena cava thrombi. To the authors' knowledge, this is the first report of MDCT and Doppler ultrasound findings of a renal cell carcinoma invading the right ovarian vein.

The objective of this study was to assess retrospectively the outcome of children with severe Guillain-Barré syndrome (GBS) treated either with intravenous immunoglobulins (IVIG) versus practically untreated cases by a known beneficial agent. Twenty-three children with severe GBS who became bedridden (i.e., Motor Disability Grading Scale [MDGS] grade of at least 4) were analyzed. Fifteen children were treated with IVIG and eight children comprised the nontreatment group: five on supportive therapy and three treated previously with oral steroids found ineffective in GBS. IVIG was administered at a dosage of 1 g/kg daily for 2 days under constant monitoring, with no adverse effects requiring cessation of therapy. Improvement by 1 grade on the MDGS after IVIG therapy was achieved in the IVIG group after a mean of 10.17 days (median, 8 days), and patients started walking independently after a mean of 30.35 days (median, 20.5 days). Improvement by 1 grade on the MDGS was achieved in the nontreatment group after a mean of 22.3 days (median, 20.3 days), and they started to walk independently after a mean of 113.3 days (median, 100 days). A significant difference could not be delineated between both groups, given the rather small number of children in each group. These results indicate a possible beneficial effect of IVIG in severe childhood-onset GBS compared with the nontreated group of children. The authors therefore recommend using IVIG as the first-line drug in such cases, which warrant further approval after double-blind controlled studies of using different IVIG regimens or combined with plasmapheresis and steroids.