Automated tube potential selection for standard chest and abdominal CT in follow-up patients with testicular cancer: comparison with fixed tube potential

Objective: To evaluate prospectively, in patients with testicular cancer, the radiation dose-saving potential and image quality of contrast-enhanced chest and abdominal CT with automated tube potential selection. Methods: Forty consecutive patients with testicular cancer underwent contrast-enhanced arterio-venous chest and portal-venous abdominal CT with automated tube potential selection (protocol B; tube potential 80-140kVp), which is based on the attenuation of the CT topogram. All had a first CT at 120kVp (protocol A) using the same 64-section CT machine and similar settings. Image quality was assessed; dose information (CTDIvol) was noted. Results: Image noise and attenuation in the liver and spleen were significantly higher for protocol B (P < 0.05 each), whereas attenuation in the deltoid and erector spinae muscles was similar. In protocol B, tube potential was reduced to 100kVp in 18 chest and 33 abdominal examinations, and to 80kVp in 5 abdominal CT examinations; it increased to 140kVp in one patient. Image quality of examinations using both CT protocols was rated as diagnostic. CTDIvol was significantly lower for protocol B compared to protocol A (reduction by 12%, P < 0.01). Conclusion: In patients with testicular cancer, radiation dose of chest and abdominal CT can be reduced with automated tube potential selection, while image quality is preserve

Der Ileus - ein Findling in der modernen Medizin?

Zusammenfassung: Kaum einem Krankheitsbild liegt ein so breites differenzialdiagnostisches Spektrum zugrunde wie dem Ileus. Insbesondere die hochgradige Obstruktion und der komplette Ileus können über eine bakterielle Translokation und Mikroperfusionsstörungen des dilatierten Darmes zu intestinalen Perforationen und einer Kreislaufinstabilität führen. Klare Algorithmen zur schnellen Kategorisierung des Ileus sind deshalb unabdingbar. Dabei sind insbesondere die Lokalisation des Kalibersprungs beim mechanischen Ileus als auch der Grad der Obstruktion wichtige Kriterien. Die Anamnese, klinische Untersuchung und das konventionelle Röntgenbild des Abdomens sind elementare Bestandteile der Basisdiagnostik. Als Goldstandard der erweiterten bildgebenden Diagnostik hat sich die Computertomographie etabliert. Während für die meisten hochgradigen mechanischen Obstruktionen des Dünndarms, die in drei Vierteln der Fälle durch Adhäsionen und Briden bedingt sind, eine explorative Laparotomie indiziert ist, stehen beim obstruierenden Dickdarmileus auch endoskopische Optionen zur Verfügung. Das Stenting von malignen kolorektalen Tumoren aboral der linken Flexur als überbrückende oder palliative Intervention hat sich ebenso wie die koloskopische Detorquierung des Volvulus etablier

Laparoscopic Ureteroureterostomy vs. Common Sheath Ureteral Reimplantation in Children With Duplex Kidney Anomalies

Purpose: Laparoscopic ureteroureterostomy (LUU) has been proposed as an alternative to common sheath ureteral reimplantation (CSUR) in children with symptomatic duplex kidneys. However, data is limited for LUU in the pediatric population. The aim of this study was to analyze our experience with LUU and to compare the results with those after CSUR to assess whether a less invasive surgical approach could be a valid alternative. Patients and methods: The data of all children with duplex kidneys who underwent either LUU or CSUR at our center from 2006 to 2018 were reviewed retrospectively. After parental counseling, the option of LUU was provided as an alternative to CSUR for unilateral procedures and in the absence of vesicoureteral reflux to the receiving ureter. Baseline characteristics, indication for surgery, hospitalization and operative times, and intraoperative, post-operative, and late complications were analyzed. Preoperative and 1-year post-operative sonographies were reviewed by a pediatric radiologist. Increasing renal pelvic diameter (Δ >5 mm) was regarded as a sign of ureteral obstruction. Results: Forty children were included in this study, with 16 children receiving LUU and 24 children receiving CSUR. The children had a mean age of 2.7 years (7 months-9.8 years) and were followed up in our outpatient clinic for an average of 3.9 years (3 months-10.6 years) after surgery. The median hospital stay was 2 days shorter after LUU. Initially, a considerably longer time was needed for LUU, but after more experience was gained, similar operative times were observed for both procedures. Complications were encountered in both groups. After LUU, two patients developed anastomotic leakage: one was managed conservatively, and one required temporary nephrostomy. In the CSUR group, one patient developed vesicoureteral obstruction during follow-up and required reoperation with LUU. The occurrence of post-operative urinary tract infections was similar in both groups. No complications related to the ureteral stump after LUU arose. Conclusion: LUU is a safe and efficacious treatment option for children with duplex kidney anomalies and can be used as an alternative to CSUR. All children receiving LUU showed a non-obstructive, patent anastomosis and no signs for stenotic compromise of the receiving ureter

Whole-body CT in polytrauma patients: effect of arm positioning on thoracic and abdominal image quality

The purpose of this study is to assess the influence of different arm positioning techniques on thoracic and abdominal image quality and radiation dose of whole-body trauma CT (wbCT). One hundred and fifty polytrauma patients (104 male, mean age 47 ± 19) underwent wbCT with arms elevated above the head (group A, n = 50), alongside the abdomen (group B, n = 50), and on a pillow ventrally to the chest with both arms flexed (group C, n = 50). Two blinded, independent observers measured image noise and rated image quality (scores 1-3) of the liver, aorta, spleen, spine, and lower lungs. Radiation dose parameters were noted, and the abdomens' anterior-posterior diameter and scan lengths were measured. Interreader agreements for image noise (r = 0.86; p < 0.001) and subjective image quality (k = 0.71-0.84) were good. Noise was lower (p < 0.05), image quality of the liver, aorta, spleen, and spine was higher, and radiation dose lower in group A than in groups B and C (p < 0.001, each). Image quality of the spleen, liver, and aorta were higher in group C than in group B (p < 0.05, each). No significant differences in scan length (p = 0.61) were found among groups. Abdominal anterior-posterior diameter correlated significantly with noise (r = 0.82; p < 0.01) and dose (r = 0.47; p < 0.001). Estimated effective radiation doses were significantly (p < 0.001) higher in groups B (21.2mSv) and C (21.9mSv) as compared to A (16.1mSv). In wbCT for polytrauma patients, positioning of the arms above the head results in better image quality and lower radiation dose. Placing the flexed arms on a large pillow ventrally to the chest significantly improves image quality as compared to positioning alongside the abdome

Clinical Impact of Chronic Venous Changes Induced by Central Lines in Children: A Cohort with Abnormal Venograms

PURPOSE To explore the hypothesis that central venous stenosis/obstructions (CVS/O) in children are influenced by prior central venous access devices (CVADs) and are associated with future risk for thromboses. MATERIAL AND METHODS A convenience sample of 100 patients with abnormal venography (stenosis, collaterals, occlusions) documented during peripherally inserted central catheter (PICC) placements were identified from consecutive PICC placements (January 2008 to November 2012). The patients (41 males, 59 females, median age 2.7 years, median weight 11 kg) were categorized based on venographic presence (Group A, n = 53) or absence (Group B, n = 47) of visible connection to the superior vena cava. Each patient's CVAD history, before and after venography, was analyzed (until October 2016). RESULTS Before venogram, Group B patients were associated with a higher number of previous CVADs, larger diameter devices, greater incidence of malposition, and more use of polyurethane catheters than Group A patients (P < .001). An ipsilateral PICC was successfully placed in 98% of Group A, compared to 32% of Group B (P < .001). After venogram, significantly more Doppler ultrasounds (DUS) were performed and thromboses diagnosed in Group B (57% and 36%) compared to Group A (21% and 8%) (P < .003; P = .001), respectively. CONCLUSIONS Previous catheter characteristics influenced the severity of venographic changes of CVS/O (Group B). Group B was associated with more subsequent symptomatic thromboses. This information may assist parents and referring physicians to anticipate potential adverse sequelae from CVS/O on the child's venous health

Paediatric fractures of carpal bones other than the scaphoid

OBJECTIVES Fractures of carpal bones other than the scaphoid are rare in children. The aim of this study was to analyze results and identify risk factors for an unfavorable outcome. MATERIAL AND METHODS Children and adolescents up to the age of 16 years who sustained a carpal fracture other than in the scaphoid between 2004 and 2021 were reviewed in this single-center retrospective study. RESULTS In a series of 209 children and adolescents with carpal fractures, 22 had fractures other than the scaphoid. Mean age was 13 years (range 8-16) years, with a total of 41 fractures, with highest incidences for the capitate (10), trapezium (6), triquetrum (4) and pisiform (4). Twenty-nine of these 41 fractures were missed on initial X-ray. Non-displaced fractures were treated with a short arm spica cast including the thumb. Four patients were operated on for displacement fracture or carpometacarpal subluxation. All fractures united, and patients returned to full activities. At the final consultation at a median 14 months (range 6-89) post-injury, all patients with non-displaced fractures were free of symptoms, with excellent Mayo Wrist Scores (MWS). However, three patients with operated trapezium fractures developed early radiological signs of osteoarthritis, two of them with residual pain and MWS rated only good. CONCLUSION Non-displaced pediatric carpal fractures treated by forearm cast have excellent prognosis. Fractures of the trapezium with displacement or first carpometacarpal subluxation incur a risk of osteoarthritis despite anatomical reduction and internal fixation

Automated tube potential selection for standard chest and abdominal CT in follow-up patients with testicular cancer: comparison with fixed tube potential

OBJECTIVE: To evaluate prospectively, in patients with testicular cancer, the radiation dose-saving potential and image quality of contrast-enhanced chest and abdominal CT with automated tube potential selection. METHODS: Forty consecutive patients with testicular cancer underwent contrast-enhanced arterio-venous chest and portal-venous abdominal CT with automated tube potential selection (protocol B; tube potential 80-140 kVp), which is based on the attenuation of the CT topogram. All had a first CT at 120 kVp (protocol A) using the same 64-section CT machine and similar settings. Image quality was assessed; dose information (CTDI(vol)) was noted. RESULTS: Image noise and attenuation in the liver and spleen were significantly higher for protocol B (P < 0.05 each), whereas attenuation in the deltoid and erector spinae muscles was similar. In protocol B, tube potential was reduced to 100 kVp in 18 chest and 33 abdominal examinations, and to 80 kVp in 5 abdominal CT examinations; it increased to 140 kVp in one patient. Image quality of examinations using both CT protocols was rated as diagnostic. CTDI(vol) was significantly lower for protocol B compared to protocol A (reduction by 12%, P < 0.01). CONCLUSION: In patients with testicular cancer, radiation dose of chest and abdominal CT can be reduced with automated tube potential selection, while image quality is preserved

Microsurgical central lymphatic reconstruction-the role of thoracic duct lymphovenous anastomoses at different anatomical levels

INTRODUCTION In recent years advances have been made in the microsurgical treatment of congenital or acquired central lymphatic lesions. While acquired lesions can result from any surgery or trauma of the central lymphatic system, congenital lymphatic lesions can have a variety of manifestations, ranging from singular thoracic duct abnormalities to complex multifocal malformations. Both conditions may cause recurrent chylous effusions and downstream lymphatic congestion depending on the anatomical location of the thoracic duct lesion and are associated with an increased mortality due to the permanent loss of protein and fluid. METHODS We present a case series of eleven patients undergoing central lymphatic reconstruction, consisting of one patient with a cervical iatrogenic thoracic duct lesion and eleven patients with different congenital thoracic duct lesions or thrombotic occlusions. RESULTS Anastomosis of the thoracic duct and a nearby vein was performed on different anatomical levels depending on the underlying central lymphatic pathology. Cervical (n = 4), thoracic (n = 1) or abdominal access (n = 5) was used for central lymphatic reconstruction with promising results. In 9 patients a postoperative benefit with varying degrees of symptom regression was reported. CONCLUSION The presented case series illustrates the current rapid advances in the field of central microsurgical reconstruction of lymphatic lesions alongside the relevant literature

Split-bolus dual-energy CT urography: protocol optimization and diagnostic performance for the detection of urinary stones

Purpose: Prospective protocol optimization, determination of image quality and diagnostic performance of virtual non-enhanced images (VNEI) derived from split-bolus dual-energy computed tomography (DECT) urography in patients with urinary stones. Methods: IRB-approved, prospective study of 100 patients who, after written informed consent, underwent single-energy, non-enhanced CT and split-bolus, contrast-enhanced DECT (30+50mL of contrast media; combined nephro-urographic acquisition). DECT was performed using setting A (80/140kVp) in the first 20, and setting B (100/140kVp) in the second 20 patients. Tin filtration was used in all patients. After a pre-analysis of VNEI quality, 60 additional patients were examined using setting B. Two readers qualitatively and quantitatively determined image quality of all weighted-average DECT images regarding urinary tract opacification (n=100), and all VNEI regarding quality of iodine subtraction and urinary stone detection (n=80). True nonenhanced (TNEI) images were the standard of reference for statistical analysis (inter-reader variability and diagnostic performance characteristics). Results: The urinary tract was completely opacified in 94% (94/100) of patients. Iodine subtraction was improved (p<0.01) and image noise of VNEI was lower (p<0.05) in DECT setting B. On VNEI, 83% (86/104) of urinary stones were correctly identified and 17% (18/104) were missed. Stones missed (2.5mm, 1-4) were significantly smaller than stones correctly identified (5mm, 2-27; p<0.001). Diagnostic accuracy was 98% on a per-renal-unit basis and 96% on a per-patient basis. Inter-reader agreements were excellent (κ=0.91-1.00; ICC=0.86-0.99). Conclusions: Split-bolus DECT urography was technically feasible and quality of VNEI was improved with the 100/140kVp setting. Detection of urinary stones <4mm on VNEI was limite

Complication rates of peripherally inserted central catheters vs implanted ports in patients receiving systemic anticancer therapy: A retrospective cohort study

While implanted port catheters ("PORTs") have historically been the standard device for intravenous systemic anticancer therapy, the use of peripherally inserted central catheters (PICCs) has increased continuously and reliable catheter selection guidelines are lacking. We compare complication rates of PORTs and PICCs in cancer treatment in a retrospective study of 3365 patients with both solid organ (n = 2612) and hematologic (n = 753) malignancies, between 2001 and 2021. 26.4% (n = 890) of all patients were treated via PICCs and 73.6% (2475) via PORTs. 20.7% (578) experienced a major catheter-related complication with a higher rate in PICCs than in PORTs (23.5% vs 14.9%, P < .001). Among major complications, infections and mechanical complications were more common in PICCs than in PORTs (11.9% vs 6.4%, P = .001, 7.3% vs 4.2%, P = .002), whereas the rate of thrombosis was similar (3.4% vs 3.0%, P = .9). While PORTs had a higher rate of periprocedural complications (2.7% vs 1.1%, P < .05), PICCs overall complication rate exceeded PORTs within 3 days from implantation. Median follow-up was 49 (PICC) and 60 weeks (PORT). PORTs are safer and therefore should be preferred in this setting regardless of catheter dwell time