Citations

Abstract Background and Aims Perianal fistuliing Crohn’s disease [PFCD] is an aggressive phenotype of Crohn’s disease defined by frequent relapses and disabling symptoms. A novel consensus classification system was recently outlined by the TOpCLASS consortium, which seeks to unify disease severity with patient-centred goals but has not yet been validated. We aimed to apply this to a real-world cohort and to identify factors that predict transition between classes over time. Methods We identified all patients with PFCD and at least one baseline and one follow-up pelvic MRI [pMRI]. TOpCLASS classification, disease characteristics, and imaging indices were collected retrospectively at time periods corresponding with respective MRIs. Results We identified 100 patients with PFCD, of whom 96 were assigned TOpCLASS Classes 1–2c at baseline. Most patients [78.1%] started in Class 2b, but changes in classification were observed in 52.1% of all patients. Male sex [72.0%, 46.6%, 40.0%, p = 0.03] and prior perianal surgery [52.0% vs 44.6% vs 40.0%, p = 0.02] were more frequently observed in those with improved class compared to unchanged and worsened class. Baseline pMRI indices were not associated with changes in classification; however, greater improvements in mVAI, MODIFI-CD, and PEMPAC were seen among those who improved. Linear mixed effect modelling identified only male sex [-0.31, 95% CI -0.60 to -0.02] with improvement in class. Conclusion The TOpCLASS classification highlights the dynamic nature of PFCD over time. However, our ability to predict transitions between classes remains limited and requires prospective assessment. Improvement in MRI index scores over time was associated with a transition to lower TOpCLASS classification.

Purpose: The purpose of this study was to describe the myocardial cut-off sign, assess its ability to distinguish left ventricular pseudoaneurysms (LV PSAs) from true aneurysms (LVAs), and compare its performance with other imaging findings and quantitative measurements used to differentiate LV PSAs from LVAs. Materials and Methods: This retrospective single-center study identified patients with preoperative cardiac computed tomography (CT) or magnetic resonance imaging (MRI) and surgically confirmed LVAs or LV PSAs over a 10-year period. Seventeen LV PSAs (11 MRI, 6 CT) and 18 LVAs (10 MRI, 8 CT) were included. The myocardial cut-off sign was objectively a >50% decrease in aneurysm sac wall thickness measured at 1 cm from the aneurysmal neck (measurements at 2 cm were also assessed) and subjectively an abrupt “cut-off” of myocardium for the aneurysm sac for PSA compared with a gradual tapering of sac wall thickness for LVA. Two radiologists independently evaluated images for the subjective presence of this sign. Results: The myocardial cut-off sign was 91% sensitive and 97% specific when measured 1 cm from the aneurysm neck. When measured at 2 cm from the neck, the sign was 100% sensitive and 69% specific. Subjective analysis of whether the myocardium appeared “cut-off” was 94% to 100% sensitive and 78% to 94% specific with excellent agreement for both PSA (κ=0.94) and LVA (κ=0.83). Conclusions: The myocardial cut-off sign on cardiac CT and MRI is a sensitive and specific finding of LV PSA. Specificity is improved with objective measurements compared with subjective assessment (97% vs. 78% to 94%). This sign may help radiologists distinguish between LV PSAs and LVAs.

Fournier gangrene (FG) is a genitourinary necrotizing fasciitis that can be lethal if not promptly diagnosed and surgically debrided. The diagnosis is often made by physical examination paired with an appropriate clinical suspicion and supporting laboratory values. Imaging, particularly computed tomography (CT), plays a role in delineating involved fascial planes for operative debridement and occasionally in diagnosing FG. Less commonly, the imaging manifestations of FG may also be seen on ultrasound, radiographs, and magnetic resonance imaging. With the ubiquitous use and availability of CT, radiologists have a growing role in recognizing FG. This can be challenging in the absence of fascial gas, but a CT scoring system for necrotizing fasciitis can be helpful in making the diagnosis. Recent series suggest that this predominantly male disease has a rising incidence in women. Women with FG are more likely to be morbidly obese and have vulvar or labial involvement compared to men. Imaging mimics include ulcerative and necrotic tumors, traumatic or iatrogenic fascial gas, and vaginitis emphysematosa. The purpose of this pictorial review is to illustrate the imaging manifestations of FG and its mimics, with emphases on necrotizing fasciitis CT scoring systems and FG in women.

Three-dimensional (3D) printing is an additive manufacturing method that holds great potential in a variety of future patient-specific medical technologies. This project validated a novel crosslinked polyvinyl alcohol (XL-PVA) 3D printed stent infused with collagen, human placental mesenchymal stem cells (PMSCs), and cholangiocytes. The biofabrication method in the present study examined 3D printing and collagen injection molding for rapid prototyping of customized living biliary stents with clinical applications in the setting of malignant and benign bile duct obstructions. XL-PVA stents showed hydrophilic swelling and addition of radiocontrast to the stent matrix improved radiographic opacity. Collagen loaded with PMSCs contracted tightly around hydrophilic stents and dense choloangiocyte coatings were verified through histology and fluorescence microscopy. It is anticipated that design elements used in these stents may enable appropriate stent placement, provide protection of the stent-stem cell matrix against bile constituents, and potentially limit biofilm development. Overall, this approach may allow physicians to create personalized bio-integrating stents for use in biliary procedures and lays a foundation for new patient-specific stent fabrication techniques.

Objective: To compare an expert panel's global assessment of appropriateness of elective surgery for abdominal aortic aneurysms (AAA) with their assessment of the effect of surgery on the probability of 5-year mortality. Methods: Nine expert panel members rated the appropriateness of 120 scenarios for elective AAA repair on a nine-point scale, and also estimated the 5-year probability of AAA-related death and of non-AAA related death among 30-day survivors of AAA surgery and among patients with unoperated AAA. These probabilities were used to determine differences in 5-year probability of mortality of surgery vs. no surgery for each scenario. Three categories of appropriateness were defined based on these differences: inappropriate (< 0%), equivocal (0-5%), and appropriate (>5%). Results: The distribution of scenarios was inappropriate (39%), equivocal (12%), and appropriate (49%) based on probability estimates and inappropriate (43%), equivocal (22%), and appropriate (36%) based on global assessment. There was poor agreement between the two methods, with a Kappa coefficient=0.28 (95% CI: 0.23 to 0.32). Although a higher proportion of scenarios were rated as appropriate using probability estimation rather than global judgment, the level of agreement among members of the panel was similar, Kappa coefficient= 0.07 (95% CI: — 0.07 to 0.72) Conclusions: Experts disagree about the appropriate indications for elective surgery for AAA. Explicit estimates used in a decision analysis may provide a better assessment of appropriate indications than the global judgment of experts. Global assessment of the appropriateness of AAA surgery based on panel members' review of research evidence for increased survival appears to include implicitly their valuation of outcomes.

Clinical risk factors for nephropathy were assessed in a population-based study of Rochester, Minnesota, residents with diabetes mellitus initially diagnosed between 1945 and 1969 (incidence cohort). The 1031 Rochester residents with non-insulin-dependent diabetes mellitus (NIDDM) were followed through their complete medical records in the community to 1 January 1982. The prevalence of persistent proteinuria was 8.2% at the diagnosis of NIDDM. Among those initially free of persistent proteinuria, the subsequent incidence was 15.3/1000 person-yr. Twenty years after the diagnosis of diabetes, the cumulative incidence of persistent proteinuria was 24.6%. A proportional hazards model identified the following risk factors for persistent proteinuria in NIDDM: elevated initial fasting blood glucose (P &lt; .01); older age at onset of diabetes (P &lt; .01); male gender (P = .05); and presence of macrovascular disease (P = .05), diabetic retinopathy (P = .05), or glycosuria (P = .07) at the diagnosis of diabetes. Separate analyses controlling for attained age indicated no association between duration of NIDDM and the incidence of persistent proteinuria. Stratified analysis of the two most significant risk factors (fasting blood glucose and age) indicated that hyperglycemia was a stronger risk factor for proteinuria in younger diabetic subjects, perhaps because of a competing risk of death in the elderly diabetic patient. In contrast to a recently described decreasing secular trend of proteinuria in Danish insulin-dependent diabetes mellitus patients, there was no decrease over the past 40 yr in proteinuria risk in this NIDDM incidence cohort.