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The most common cause of acute right lower quadrant (RLQ) pain requiring surgery is acute appendicitis (AA). This narrative's focus is on imaging procedures in the diagnosis of AA, with consideration of other diseases causing RLQ pain. In general, Computed Tomography (CT) is the most accurate imaging study for evaluating suspected AA and alternative etiologies of RLQ pain. Data favor intravenous contrast use for CT, but the need for enteric contrast when intravenous contrast is used is not strongly favored. Radiation exposure concerns from CT have led to increased investigation in minimizing CT radiation dose while maintaining diagnostic accuracy and in using algorithms with ultrasound as a first imaging examination followed by CT in inconclusive cases. In children, ultrasound is the preferred initial examination, as it is nearly as accurate as CT for the diagnosis of AA in this population and without ionizing radiation exposure. In pregnant women, ultrasound is preferred initially with MRI as a second imaging examination in inconclusive cases, which is the majority.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The Atlanta Classification by the Acute Pancreatitis Classification Working Group recently modified the terminology for the clinical course and the morphologic changes identified on imaging, primarily contrast- enhanced multidetector computed tomography (MDCT). The two distinct clinical courses of the disease are classified as (1) early phase, which lasts approximately 1 week, and (2) late phase, which starts after the first week and can last for months after the initial episode. The two, primary, morphologic changes are acute, interstitial edematous and necrotizing pancreatitis. Timing of imaging, primarily MDCT, is based on the clinical phases and is, therefore, important for these imaging guidelines. Ultrasound's role is to detect gallstones after the first episode. MDCT plays a primary role in the management of acutely ill patients, only after a minimum of 48-72 hours and generally after one week. MR plays a supplementary role to MDCT. Follow-up MDCT guides management and therapy: percutaneous aspiration of fluid collections and/or placement of large caliber catheters in infected necrosis.

Acute right upper quadrant pain is a common presenting symptom in patients with acute cholecystitis. When acute cholecystitis is suspected in patients with right upper quadrant pain, in most clinical scenarios, the initial imaging modality of choice is ultrasound. Although cholescintigraphy has been shown to have slightly higher sensitivity and specificity for diagnosis, ultrasound is preferred as the initial study for a variety of reasons, including greater availability, shorter examination time, lack of ionizing radiation, morphologic evaluation, confirmation of the presence or absence of gallstones, evaluation of bile ducts, and identification or exclusion of alternative diagnoses. CT or MRI may be helpful in equivocal cases and may identify complications of acute cholecystitis. When ultrasound findings are inconclusive, MRI is the preferred imaging test in pregnant patients who present with right upper quadrant pain. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: Morbidity after pancreaticoduodenectomy (PD) is nearly 50%. In this study we analyzed if early enteral nutrition via feeding tube (FT) contributes to better patient outcomes., Materials and Methods: Patients undergoing PD from 2003-2010. FTs were placed routinely before August 2006, and omitted thereafter. Short-term outcome measures included: time to start of oral diet, need for total parenteral nutrition (TPN), morbidity and mortality, pancreatic fistula, complications from FT, hospital length of stay, and disposition. Long-term outcome measures included time to start adjuvant therapy, and survival., Results: N = 59 (25 had FT, 34 did not). Adenocarcinoma was found in 88%. Early institution of tube feeding had no positive impact on any of the outcome measures. There were three FT-related complications., Conclusions: Our results demonstrate that FT placement does not improve short-term or long-term outcomes after PD. Moreover, major complications can result from FT placement. We do not advocate the routine use of FT after PD.

Changes in temperature, precipitation, and other climatic drivers and sea-level rise will affect populations of existing native and non-native aquatic species and the vulnerability of aquatic environments to new invasions. Monitoring surveys provide the foundation for assessing the combined effects of climate change and invasions by providing baseline biotic and environmental conditions, although the utility of a survey depends on whether the results are quantitative or qualitative, and other design considerations. The results from a variety of monitoring programs in the United States are available in integrated biological information systems, although many include only non-native species, not native species. Besides including natives, we suggest these systems could be improved through the development of standardized methods that capture habitat and physiological requirements and link regional and national biological databases into distributed Web portals that allow drawing information from multiple sources. Combining the outputs from these biological information systems with environmental data would allow the development of ecological-niche models that predict the potential distribution or abundance of native and non-native species on the basis of current environmental conditions. Environmental projections from climate models can be used in these niche models to project changes in species distributions or abundances under altered climatic conditions and to identify potential high-risk invaders. There are, however, a number of challenges, such as uncertainties associated with projections from climate and niche models and difficulty in integrating data with different temporal and spatial granularity. Even with these uncertainties, integration of biological and environmental information systems, niche models, and climate projections would improve management of aquatic ecosystems under the dual threats of biotic invasions and climate change.

We report a case of a 20-year-old woman who presented with a 3-year history of a stable cystic nodule on the scalp. Light microscopy of the excised nodule demonstrated a malignant small round cell undifferentiated neoplasm. Immunohistochemical studies suggested a neural crest origin, while ultrastructural examination revealed characteristics of schwannian differentiation. Both of these special techniques were essential in establishing the diagnosis of a malignant epithelioid schwannoma of superficial tissue (neurotropic melanoma, desmoplastic melanoma). We discuss the differential diagnoses and describe the immunohistochemical and ultrastructural characteristics of this tumor. This case illustrates the difficulty of diagnosing this rare malignant tumor, which masqueraded as a benign-appearing scalp lesion.

The surgical treatment for recurrent or incompletely excised benign mixed tumors of the parotid gland is analyzed. In this series no operative procedure proved superior to another. For each patient the type of surgical procedure used must be individually selected. For patients with tumors recently excised or biopsied, superficial parotidectomy with excision of the skin scar is the minimal recommended procedure. Radiation therapy is not used as a primary method of treatment. It is however, recommended postoperatively for patients with very advanced recurrent tumor or inadequate surgical margins.

The operative management of 200 patients with pancreatic and periampullary cancer was reviewed. Patients with metastatic disease and biliary obstruction are best treated by the nonoperative techniques of biopsy and internal biliary drainage if technically feasible. For patients who undergo exploration and are found to be candidates for a bypass procedure, both biliary and gastroduodenal bypass should be performed. Lymph node involvement and age of the patient were found to be significant variables in determining the candidates suitable for curative resection. A definite incidence of multicentricity was found in patients undergoing total pancreatectomy for ductal carcinoma of the pancreas; however, significant problems with diabetic management arose from this procedure. The primary site of the lesion as well as the intelligence and socioeconomic background of the patient should dictate the type of resection employed. Pancreatoduodenectomy (Whipple procedure) is recommended for periampullary cancers other than pancreatic carcinoma, while total pancreatectomy may be appropriate in selected patients. However, there has been no evidence thus far in this early trial with total pancreatectomy that more complete resection of the pancreas leads to longer survival.