Multiple Sclerosis Part 1: Essentials and the McDonald Criteria

Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS) characterized by relapsing-remitting or progressive neurologic symptoms and focal white matter lesions. The hallmark of the disease is the dissemination of CNS lesions in space and time, which is defined by the McDonald criteria. MRI is an essential diagnostic and prognostic biomarker for MS which can evaluate the entire CNS. MS mimics must be excluded before a diagnosis of MS is made.

An Ogden hyperelastic 3D micromechanical model to depict Poynting effect in brain white matter

Shear and torsional load on soft solids such as brain white matter purportedly exhibits the Poynting Effect. It is a typical nonlinear phenomenon associated with soft materials whereby they tend to elongate (positive Poynting effect) or contract (negative Poynting effect) in a direction perpendicular to the shearing or twisting plane. In this research, a novel 3D micromechanical Finite Element Model (FEM) has been formulated to describe the Poynting effect in bi-phasic modeled brain white matter (BWM) representative volume element (RVE) with axons tracts embedded in surrounding extracellular matrix (ECM) for simulating brain matter's response to pure and simple shear. In the presented BWM 3D FEM, nonlinear Ogden hyper-elastic material model is deployed to interpret axons and ECM material phases. The modeled bi-phasic RVEs have axons tied to the surrounding ECM. In this proof-of-concept (POC) FEM, three simple shear loading configurations and a pure shear case were analyzed. Root mean square deviation (RMSD) was calculated for stress and deformation response plots to understand the effect of axon-ECM orientations and loading conditions on the degree of Poynting behavior. Variations in normal stresses (S11, S22, or S33) perpendicular to the shear plane underscored the significance of axonal fiber-matrix interactions. From the simulated ensemble of cases, a transitional dominance trend was noticed, as simple sheared axons showed pronounced Poynting behavior, but shear deformation build-up in the purely sheared brain model exhibited the highest Poynting behavior at higher strain % limits. At lower strain limits, simple shear imparted across and perpendicular to axonal tract directions emerged as the dominant Poynting effect configurations. At high strains, the stress-strain% plots manifested mild strain stiffening effects and bending stresses in purely sheared axons, substantiated the strong non-linearity in brain tissues' response.

MicroRNA-21's role in PTEN suppression and PI3K/AKT activation: Implications for cancer biology

MicroRNA-21 (miR-21) was recognized as a key figure in the intricate web of tumor biology, with a prominent role in regulating the PTEN tumor suppressor gene and the PI3K/AKT cascade. This review elucidates the multifaceted interactions between miR-21, PTEN, and the PI3K/AKT signaling, shedding light on their profound implications in cancer initiation, progression, and therapeutic strategies. The core of this review delves into the mechanical intricacies of miR-21-mediated PTEN suppression and its consequent impact on PI3K/AKT pathway activation. It explores how miR-21, as an oncogenic miRNA, targets PTEN directly or indirectly, resulting in uncontrolled activation of PI3K/AKT, fostering cancerous cell survival, proliferation, and evasion of apoptosis. Furthermore, the abstract emphasizes the clinical relevance of these molecular interactions, discussing their implications in various cancer types, prognostic significance, and potential as therapeutic targets. The review provides insights into ongoing research efforts to develop miR-21 inhibitors and strategies to restore PTEN function, offering new avenues for cancer treatment. This article illuminates the critical function of miR-21 in PTEN suppression and PI3K/AKT activation, offering profound insights into its implications for cancer biology and the potential for targeted interventions.

Unravelling the role of long non-coding RNAs in modulating the Hedgehog pathway in cancer

Cancer is a multifactorial pathological condition characterized by uncontrolled cellular proliferation, genomic instability, and evasion of regulatory mechanisms. It arises from the accumulation of genetic mutations confer selective growth advantages, leading to malignant transformation and tumor formation. The intricate interplay between LncRNAs and the Hedgehog pathway has emerged as a captivating frontier in cancer research. The Hedgehog pathway, known for its fundamental roles in embryonic development and tissue homeostasis, is frequently dysregulated in various cancers, contributing to aberrant cellular proliferation, survival, and differentiation. The Hh pathway is crucial in organizing growth and maturation processes in multicellular organisms. It plays a pivotal role in the initiation of tumors as well as in conferring resistance to conventional therapeutic approaches. The crosstalk among the Hh pathway and lncRNAs affects the expression of Hh signaling components through various transcriptional and post-transcriptional processes. Numerous pathogenic processes, including both non-malignant and malignant illnesses, have been identified to be induced by this interaction. The dysregulation of lncRNAs has been associated with the activation or inhibition of the Hh pathway, making it a potential therapeutic target against tumorigenesis. Insights into the functional significance of LncRNAs in Hedgehog pathway modulation provide promising avenues for diagnostic and therapeutic interventions. The dysregulation of LncRNAs in various cancer types underscores their potential as biomarkers for early detection and prognostication. Additionally, targeting LncRNAs associated with the Hedgehog pathway presents an innovative strategy for developing precision therapeutics to restore pathway homeostasis and impede cancer progression. This review aims to elucidate the complex regulatory network orchestrated by LncRNAs, unravelling their pivotal roles in modulating the Hedgehog pathway and influencing cancer progression.

Photoacid-macroion assemblies: how photo-excitation switches the size of nano-objects

Electrostatic self-assembly of photoacids with oppositely charged macroions yields supramolecular nano-objects in aqueous solutions, whose size is controlled through light irradiation. Nano-assemblies are formed due to electrostatic attractions and mutual hydrogen bonding of the photoacids. Irradiation with UV light leads to the deprotonation of the photoacid and, consequently, a change in particle size. Overall, the hydrodynamic radii of the well-defined photoacid-macroion nano-objects lie between 130 and 370 nm. For a set of photoacids, we determine the acidity constants in the ground and excited state, discuss the sizes of photoacid-macroion nano-objects (by dynamic and static light scattering), their composition and the particle shapes (by small-angle neutron scattering), and relate their charge characteristics to size, structure and shape. We investigate the association thermodynamics and relate nanoscale structures to thermodynamics and, in turn, thermodynamics to molecular features, particularly the ionization energy of the photoacid hydroxyl group proton. Structure-directing effects completely differ from those for previously investigated systems, with hydrogen bonding and entropic effects playing a major role herein. This combined approach allows developing a comprehensive understanding of assembly formation and photo-response, anchored in molecular parameters (pKa, ionization energy, substituent group location), charge characteristics, and the association enthalpy and entropy. This fundamental understanding again paves the way for tailoring application solutions with novel photoresponsive materials.

Emerging roles of SnoRNAs in the pathogenesis and treatment of autoimmune disorders

SnoRNAs (small non-coding RNAs) have recently gained prominence in autoimmune diseases, revealing their crucial role in modulating the immune response and contributing to disease pathogenesis. Initially known for their involvement in ribosomal RNA processing and modification, molecular biology and genomics advancements have uncovered their broader impact on cellular function, especially in autoimmune disorders. Autoimmune diseases represent conditions characterized by the immune system's erroneous attacks on self-tissues, encompassing disorders like systemic lupus erythematosus, rheumatoid arthritis, and multiple sclerosis. The complex etiology of these conditions involves a delicate interplay of genetic and environmental factors. Emerging evidence suggests that snoRNAs initially recognized for their housekeeping roles, extend their influence on immune regulation through diverse mechanisms. SnoRNAs have been implicated in epigenetic modification, directly affecting the gene expression profiles of immune cells. Their ability to guide site-specific changes on ribosomal RNAs and other non-coding RNAs can significantly influence the translation of proteins involved in immune response pathways. Moreover, snoRNAs interact with key immune-related proteins, modulating their functions and subsequently impacting immune cell development, activation, and tolerance. Dysregulation of snoRNA expression has been observed in various autoimmune diseases, underscoring their potential as biomarkers for disease diagnosis, prognosis, and therapeutic targets. Manipulating snoRNA expression or activity is a promising therapeutic intervention avenue, offering the potential for personalized treatment strategies in autoimmune diseases. However, there remains a need for comprehensive research efforts to elucidate the precise molecular mechanisms underlying snoRNA-mediated immune modulation. Further investigations in this domain are essential to unravel the potential of snoRNAs in autoimmune disorders.

Controlling the Morphology in Electrostatic Self-Assembly via Light

Electrostatic self-assembly of macroions is an emerging area with great potential in the development of nanoscale functional objects, where photo-irradiation responsiveness can either elevate or suppress the self-assembly. The ability to control the size and shape of macroion assemblies would greatly facilitate the fabrication of desired nano-objects that can be harnessed in various applications such as catalysis, drug delivery, bio-sensors, and actuators. Here, we demonstrate that a polyelectrolyte with a size of 5 nm and multivalent counterions with a size of 1 nm can produce well-defined nanostructures ranging in size from 10-1000 nm in an aqueous environment by utilizing the concept of electrostatic self-assembly and other intermolecular non-covalent interactions including dipole-dipole interactions. The pH- and photoresponsiveness of polyelectrolytes and azo dyes provide diverse parameters to tune the nanostructures. Our findings demonstrate a facile approach to fabricating and manipulating self-assembled nanoparticles using light and neutron scattering techniques.

Double-Wavelength-Switchable Molecular Self-Assembly of a Photoacid and Spirooxazine in an Aqueous Solution

Quadruple-switchable nanoscale assemblies are built by combining two types of water-soluble molecular photoswitches through dipole-dipole interaction. Uniting the wavelength-specific proton dissociation of a photoacid and ring-opening of an anionic spirooxazine results in an assembly that can be addressed by irradiation with two different wavelengths: pH and darkness.

ACR Appropriateness Criteria® Staging and Post-Therapy Assessment of Head and Neck Cancer

Imaging of head and neck cancer at initial staging and as part of post-treatment surveillance is a key component of patient care as it guides treatment strategy and aids determination of prognosis. Head and neck cancer includes a heterogenous group of malignancies encompassing several anatomic sites and histologies, with squamous cell carcinoma the most common. Together this comprises the seventh most common cancer worldwide. At initial staging comprehensive imaging delineating the anatomic extent of the primary site, while also assessing the nodal involvement of the neck is necessary. The treatment of head and neck cancer often includes a combination of surgery, radiation, and chemotherapy. Post-treatment imaging is tailored for the evaluation of treatment response and early detection of local, locoregional, and distant recurrent tumor. Cross-sectional imaging with CT or MRI is recommended for the detailed anatomic delineation of the primary site. PET/CT provides complementary metabolic information and can map systemic involvement. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A New (Digital) Era in Medical Journalism: Leveraging Social Media and Other Online Tools to Increase Reach and Engagement

Social media is a popular communication and marketing tool in modern society, with the power to reach and engage large audiences. Many members of the medical and radiology communities have embraced social media platforms, particularly X (formerly known as Twitter), as an efficient and economic means for performing patient outreach, disseminating research and educational materials, building networks, and promoting diversity. Editors of medical journals with a clear vision and relevant expertise can leverage social media and other digital tools to advance the journal's mission, further their interests, and directly benefit journal authors and readers. For editors, social media offers a means to increase article visibility and downloads, expand awareness of volunteer opportunities, and use metrics and other feedback to inform future initiatives. Authors benefit from broader dissemination of their work, which aids establishment of a national or international reputation. Readers can receive high-quality high-yield content in a digestible format directly on their devices while actively engaging with journal editors and authors in the online community. The authors highlight the multifaceted benefits of social media engagement and digital tool implementation in the context of medical journalism and summarize the activities of the RadioGraphics Social Media and Digital Innovation Team. By enumerating the social media activities of RadioGraphics and describing the underlying rationale for each activity, the authors present a blueprint for other medical journals considering similar initiatives. ©RSNA, 2023.

ACR Appropriateness Criteria® Tinnitus: 2023 Update

Tinnitus is abnormal perception of sound and has many subtypes. Clinical evaluation, audiometry, and otoscopy should be performed before ordering any imaging, as the choice of imaging will depend on various factors. Type of tinnitus (pulsatile or nonpulsatile) and otoscopy findings of a vascular retrotympanic lesion are key determinants to guide the choice of imaging studies. High-resolution CT temporal bone is an excellent tool to detect glomus tumors, abnormal course of vessels, and some other abnormalities when a vascular retrotympanic lesion is seen on otoscopy. CTA or a combination of MR and MRA/MRV are used to evaluate arterial or venous abnormalities like dural arteriovenous fistula, arteriovenous malformation, carotid stenosis, dural sinus stenosis, and bony abnormalities like sigmoid sinus wall abnormalities in cases of pulsatile tinnitus without a vascular retrotympanic lesion. MR of the brain is excellent in detecting mass lesions such as vestibular schwannomas in cases of unilateral nonpulsatile tinnitus. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Enhanced osseointegration of drug eluting nanotubular dental implants: An in vitro and in vivo study

Faster and predictable osseointegration is crucial for the success of dental implants, especially in patients with compromised local or systemic conditions. Despite various surface modifications on the commercially available Titanium (Ti) dental implants, the bioactivity of Ti is still low. Thus, to achieve both biological and therapeutic activity on titanium surfaces, surface modification techniques such as titanium nanotubes have been studied as nanotube surfaces can hold therapeutic drugs and molecules. The main aim of the present research work is to study the early osseointegration around the novel Simvastatin drug eluting nanotubular dental implant. In the present research, the titanium nanotubes were fabricated on the screw-shaped dental implant surface and the Simvastatin drug was loaded into the nanotubes using the ultrasonication dip method. In vitro and In vivo studies were carried out on the modified dental implants. In vitro cell culture study reported enhanced osteogenic activity on the drug-loaded nanotube surface implants. The invivo animal studies were evaluated by micro-CT, histopathology, and reverse torque removal analysis methods. The test results showed faster osseointegration with the strong interface on the Simvastatin drug-loaded implant surface at 4 weeks of healing as compared to the control implants.

New drug discovery of cardiac anti-arrhythmic drugs: insights in animal models

Cardiac rhythm regulated by micro-macroscopic structures of heart. Pacemaker abnormalities or disruptions in electrical conduction, lead to arrhythmic disorders may be benign, typical, threatening, ultimately fatal, occurs in clinical practice, patients on digitalis, anaesthesia or acute myocardial infarction. Both traditional and genetic animal models are: In-vitro: Isolated ventricular Myocytes, Guinea pig papillary muscles, Patch-Clamp Experiments, Porcine Atrial Myocytes, Guinea pig ventricular myocytes, Guinea pig papillary muscle: action potential and refractory period, Langendorff technique, Arrhythmia by acetylcholine or potassium. Acquired arrhythmia disorders: Transverse Aortic Constriction, Myocardial Ischemia, Complete Heart Block and AV Node Ablation, Chronic Tachypacing, Inflammation, Metabolic and Drug-Induced Arrhythmia. In-Vivo: Chemically induced arrhythmia: Aconitine antagonism, Digoxin-induced arrhythmia, Strophanthin/ouabain-induced arrhythmia, Adrenaline-induced arrhythmia, and Calcium-induced arrhythmia. Electrically induced arrhythmia: Ventricular fibrillation electrical threshold, Arrhythmia through programmed electrical stimulation, sudden coronary death in dogs, Exercise ventricular fibrillation. Genetic Arrhythmia: Channelopathies, Calcium Release Deficiency Syndrome, Long QT Syndrome, Short QT Syndrome, Brugada Syndrome. Genetic with Structural Heart Disease: Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia, Dilated Cardiomyopathy, Hypertrophic Cardiomyopathy, Atrial Fibrillation, Sick Sinus Syndrome, Atrioventricular Block, Preexcitation Syndrome. Arrhythmia in Pluripotent Stem Cell Cardiomyocytes. Conclusion: Both traditional and genetic, experimental models of cardiac arrhythmias' characteristics and significance help in development of new antiarrhythmic drugs.

Relationship between cognitive reserve, brain volume, and neuropsychological performance in amnestic and nonamnestic MCI

Cognitive Reserve (CR) is a theoretical construct that influences the onset and course of cognitive and structural changes that occur with aging and mild cognitive impairment (MCI). There is a paucity of research that examines the relationship of CR and brain volumes in amnestic (aMCI) and nonamnestic (naMCI) separately. This study is a retrospective chart review of MCI patients who underwent neuropsychological evaluation and brain MRI with NeuroReader™ (NR). NR is an FDA-cleared software that standardizes MRI volumes to a control sample. Classifications of aMCI and naMCI were based on Petersen criteria. CR was measured as education, occupation, and word reading. Data analysis included bivariate correlations between CR, neuropsychological test scores, and NR-brain volumes by MCI subtype. The Benjamini-Hochberg method corrected for multiple comparisons. The sample included 91 participants with aMCI and 41 with naMCI. Within naMCI, positive correlations were observed between CR and whole brain volume, total gray matter, bifrontal, left parietal, left occipital, and bilateral cerebellum. Within aMCI, no significant correlations were observed between CR and brain volumes. Positive correlations with CR were observed in language, attention, and visual learning in both aMCI and naMCI groups. The current study adds to the minimal literature on CR and naMCI. Results revealed that CR is associated with volumetrics in naMCI only, though cognitive findings were similar in both MCI groups. Possible explanations include heterogeneous disease pathologies, disease stage, or a differential influence of CR on volumetrics in MCI. Additional longitudinal and biomarker studies will better elucidate this relationship.

Unlocking new approaches to Urolithiasis management via Nutraceutical

Urolithiasis, commonly known as kidney stones, is characterized by the formation of hard deposits in the urinary tract. These stones can cause severe pain and discomfort, and their management typically involves a combination of medical interventions and lifestyle modifications. According to the literature, 30% and 50% of urolithiasis cases recur. Between 9 and 12% of persons in industrialised countries are predicted to have urolithiasis at some time. Due to the high frequency of stone formation, recurrent nature, and prevalence in adults, it has a significant impact on society, the person, and the health care system. Adopting the best prophylactic measures is crucial in light of these developments to decrease the impact of urolithiasis on individuals and society. In recent years, there has been growing interest in the potential role of nutraceuticals in the management of urolithiasis. Nutraceuticals, such as herbal extracts, vitamins, minerals, and probiotics, have gained recognition for their potential in promoting urinary health and reducing the risk of urolithiasis. These compounds can aid in various ways, including inhibiting crystal formation, enhancing urine pH balance, reducing urinary calcium excretion, and supporting kidney function. Additionally, nutraceuticals can help alleviate symptoms associated with urolithiasis, such as pain and inflammation. While medical interventions remain crucial, incorporating nutraceuticals into a comprehensive management plan can offer a holistic approach to urolithiasis, improving patient outcomes and quality of life. Therefore, nutraceuticals may be a desirable choice for treating and avoiding recurring urolithiasis for patients and medical professionals. Therefore, the present study has focused on nutraceuticals' role in preventing urolithiasis.

Design, Synthesis, ADME, and Anticancer Studies of Newer N-Aryl-5-(3,4,5-Trifluorophenyl)-1,3,4-Oxadiazol-2-Amines: An Insight into Experimental and Theoretical Investigations

In continuance of our investigation into the anticancer activity of oxadiazoles, we report here the preparation of 10 new 1,3,4-oxadiazole analogues using the scaffold hopping technique. We have prepared the oxadiazoles having a common pharmacophoric structure (oxadiazole linked aryl nucleus) as seen in the reported anticancer agents IMC-038525 (tubulin inhibitor), IMC-094332 (tubulin inhibitor), and FATB (isosteric replacement of the S of thiadiazole with the O of oxadiazole). All of the oxadiazole analogues were predicted for their absorption, distribution, metabolism, and excretion (ADME) profiles and toxicity studies. All of the compounds were found to follow Lipinski's rule of 5 with a safe toxicity profile (Class IV compound) against immunotoxicity, mutagenicity, and toxicity. All of the compounds were synthesized and characterized using spectral data, followed by their anticancer activity tested in a single-dose assay at 10 μM as reported by the National Cancer Institute (NCI US) Protocol against nearly 59 cancer cell lines obtained from nine panels, including non-small-cell lung, ovarian, breast, central nervous system (CNS), colon, leukemia, prostate, and cancer melanoma. N-(2,4-Dimethylphenyl)-5-(3,4,5-trifluorophenyl)-1,3,4-oxadiazol-2-amine (6h) displayed significant anticancer activity against SNB-19, OVCAR-8, and NCI-H40 with percent growth inhibitions (PGIs) of 86.61, 85.26, and 75.99 and moderate anticancer activity against HOP-92, SNB-75, ACHN, NCI/ADR-RES, 786-O, A549/ATCC, HCT-116, MDA-MB-231, and SF-295 with PGIs of 67.55, 65.46, 59.09, 59.02, 57.88, 56.88, 56.53, 56.4, and 51.88, respectively. The compound 6h also registered better anticancer activity than Imatinib against CNS, ovarian, renal, breast, prostate, and melanoma cancers with average PGIs of 56.18, 40.41, 36.36, 27.61, 22.61, and 10.33, respectively. Molecular docking against tubulin, one of the appealing cancer targets, demonstrated an efficient binding within the binding site of combretastatin A4. The ligand 6h (docking score = -8.144 kcal/mol) interacted π-cationically with the residue Lys352 (with the oxadiazole ring). Furthermore, molecular dynamic (MD) simulation studies in complex with the tubulin-combretastatin A4 protein and ligand 6h were performed to examine the dynamic stability and conformational behavior.

Traumatic Brain Injury and Vision

Traumatic brain injury disrupts the complex anatomy of the afferent and efferent visual pathways. Injury to the afferent pathway can result in vision loss, visual field deficits, and photophobia. Injury to the efferent pathway primarily causes eye movement abnormalities resulting in ocular misalignment and double vision. Injury to both the afferent and efferent systems can result in significant visual disability.

Early versus non-early desaturation during 6MWT in COPD patients: A follow-up study

Introduction

Six-minute walk test (6MWT) has a significant prognostic value in chronic obstructive pulmonary disease (COPD). Those who desaturate early during 6MWT are likely to have frequent exacerbations.

Aims and Objectives

To follow-up and compare exacerbations and hospitalisations of COPD patients having early desaturation versus nonearly desaturation determined during baseline 6MWT.

Methods

It was a longitudinal follow-up study conducted in a tertiary care institute from November 1, 2018 to May 15, 2020 involving 100 COPD patients. A decrease in SpO2 by ≥4% in baseline 6MWT was considered a significant desaturation. If the desaturation occurred within first minute of the 6MWT, the patient was called early desaturator (ED); if it occurred later, the patient was called nonearly desaturator (NED). If the saturation did not fall, then the patient was called nondesaturator. During the follow-up, 12 patients dropped out and 88 remained.

Results

Of 88 patients, 55 (62.5%) were desaturators and 33 were nondesaturator. Of 55 desaturators, 16 were ED and 39 were NED. EDs had significantly higher number of severe exacerbations (P <.05), higher hospitalisation (P <.001), and higher BODE index (P <.01) compared to NEDs. The receptor operating characteristic curve and multiple logistic regression analysis showed that previous exacerbations, presence of early desaturation, and distance saturation product during the 6MWT were significant predictors for predicting hospitalizations.

Conclusion

Early desaturation can be used as a screening tool for assessing the risk of hospitalization in COPD patients.

Joining Two Switches in One Nano-Object: Photoacidity and Photoisomerization in Electrostatic Self-Assembly

Multi-switchable supramolecular nano-objects that respond to irradiation of different wavelengths with changes in size and shape have been built from two different water-soluble molecular switches, joined by attachment to the same polyelectrolyte. Accordingly, two wavelength-specific reactions, namely the excited-state proton dissociation of a photoacid and the cis-trans isomerization of an azo dye, are combined in one supramolecular nano-object that is stable in aqueous solution. The concept has potential in the fields of sensors, molecular motors, and transport.

Management of Locally Advanced Unresectable or Metastatic Urothelial Carcinoma: Expert Opinion from an Indian Panel via Delphi Consensus Method

Introduction Currently, there are no guidelines for the management of locally advanced unresectable or metastatic urothelial carcinoma (mUC) from an Indian perspective. There is a lack of consensus on the utility of treatment options in first-line (1L) and second-line (2L) settings, especially in cisplatin- and platinum-unfit mUC patient subgroups.

Objective This articles aims to develop evidence-based practical consensus recommendations for the management of mUC in Indian settings.

Methods Modified Delphi consensus methodology was considered to arrive at a consensus. An expert scientific committee of 15 medical oncologists from India constituted the panel. Twelve clinically relevant questions were grouped into five categories for presentation and discussion: (1) cisplatin and platinum ineligibility criteria; (2) programmed death ligand 1 and fibroblast growth factor receptor (FGFR) testing in mUC patients; (3) treatment options in 1L settings; (4) role of switch maintenance; and (5) treatment options in 2L. Statements that reached high (≥ 80%) and moderate (60–79%) levels of consensus in the first round (electronic survey) did not undergo the second Delphi round. The questions that received a low level of consensus (< 60%) were discussed during the virtual meeting.

Results Renal impairment (creatinine clearance [CrCl] < 60 mL/min) and New York Heart Association class 3 heart failure are important assessment criteria for determining cisplatin ineligibility. Patients are unfit for any platinum-based chemotherapy in case of Eastern Cooperative Oncology Group performance status> 3 or severe renal impairment (CrCl < 30 mL/min). Gemcitabine and platinum with cisplatin over carboplatin were preferred in 1L settings. In patients unfit for cisplatin-based regimens, carboplatin–gemcitabine chemotherapy was preferred over immunotherapy (atezolizumab or pembrolizumab). Selected patients who are platinum ineligible may be considered for immunotherapy. Post-induction chemotherapy, those who do not progress may be strongly considered for avelumab maintenance. Experts recommended erdafitinib in FGFR-positive mUC patients in 2L settings. In FGFR-negative patients, immunotherapy (pembrolizumab, nivolumab, or avelumab) may be preferred over chemotherapy (paclitaxel, docetaxel, or vinflunine). Enfortumab vedotin and sacituzumab govitecan may be considered for further lines of therapy.

Conclusion Expert panel consensus will offer expert guidance to oncologists/clinicians on the management of mUC in Indian settings.

Key Points

Development of a compressed FCN architecture for semantic segmentation using Particle Swarm Optimization

Researchers have adapted the conventional deep learning classification networks to generate Fully Conventional Networks (FCN) for carrying out accurate semantic segmentation. However, such models are expensive both in terms of storage and inference time and not readily employable on edge devices. In this paper, a compressed version of VGG16-based Fully Convolution Network (FCN) has been developed using Particle Swarm Optimization. It has been shown that the developed model can offer tremendous saving in storage space and also faster inference time, and can be implemented on edge devices. The efficacy of the proposed approach has been tested using potato late blight leaf images from publicly available PlantVillage dataset, street scene image dataset and lungs X-Ray dataset and it has been shown that it approaches the accuracies offered by standard FCN even after 851× compression.

Ventral striatal subregional dysfunction in late-life grief: Relationships with yearning and depressive symptoms

Bereaved older adults experiencing high grief in the first year after an attachment loss is at increased risk for prolonged grief disorder (PGD) via unknown mechanisms. Yearning, a core grief symptom, is linked to the ventral striatal (VS) brain function, but the role of this neuronal system in late-life grief is poorly understood. As a first step, we examined the VS subregional abnormalities associated with multidimensional symptoms in bereaved elders during the first year post-loss. Sixty-five bereaved elders completed clinical assessments within 13 months post-loss. Ventral caudate (VCau) and nucleus accumbens (NAcc) functional connectivity (FC) was assessed using seed-based resting-state functional MRI. VCau and NAcc FC differences between high (inventory of complicated grief [ICG] score≥30; n = 35) and low (ICG score<30; n = 30) grief, and the relationships between ventral striatal subregional FC and clinical measures (yearning and depressive symptoms) were assessed after covariate adjustments (α < 0.05; 3dClustSim corrected). Relative to low grief participants, those with high grief showed higher FC between VCau and the medial prefrontal, orbitofrontal, and subgenual cingulate cortices. VCau FC abnormalities positively correlated with yearning (r2 = 0.24, p < 0.001). In contrast, FC between VCau and temporoparietal junction negatively correlated with depressive symptoms, a commonly co-occurring symptom (r2 = 0.37, p < 0.001). The FC between NAcc and insula/striatum positively correlated with yearning (r2 = 0.35, p < 0.001); no other NAcc FC findings were seen in the full sample. In women, higher FC between the NAcc and bilateral posterior cingulate, precuneus, and visual areas were found in those with high, relative to low grief symptoms. Distinct VS subregional abnormalities associate with yearning and depressive symptoms in bereaved elders. Whether ventral striatal dysfunction correlates with PGD development and/or worsening depression remains to be elucidated.

A Gamified Social Media-Based Head and Neck Radiology Education Initiative of the American Society of Head and Neck Radiology: Viewership and Engagement Trends at 3 Years

BACKGROUND AND PURPOSE

Social media has made inroads in medical education. We report the creation and 3-year (2018-2021) longitudinal assessment of the American Society of Head and Neck Radiology Case of the Week (#ASHNRCOTW), assessing viewership, engagement, and impact of the coronavirus disease 2019 (COVID-19) pandemic on this Twitter-based education initiative.

MATERIALS AND METHODS

Unknown cases were tweeted from the American Society of Head and Neck Radiology account weekly. Tweet impressions (number of times seen), engagements (number of interactions), and new followers were tabulated. A social media marketing platform identified worldwide distribution of Twitter followers. Summary and t test statistics were performed.

RESULTS

#ASHNRCOTW was highly visible with 2,082,280 impressions and 203,137 engagements. There were significantly greater mean case impressions (9917 versus 6346), mean case engagements (1305 versus 474), case engagement rates (13.06% versus 7.76%), mean answer impressions (8760 versus 5556), mean answer engagements (908 versus 436), answer engagement rates (10.38% versus 7.87%), mean total (case + answer) impressions (18,677 versus 11,912), mean total engagements (2214 versus 910), and total engagement rates (11.79% versus 7.69%) for cases published after the pandemic started (all P values < .001). There was a significant increase in monthly new followers after starting #ASHNRCOTW (mean, 134 versus 6; P < .001) and significantly increased monthly new followers after the pandemic started compared with prepandemic (mean, 178 versus 101; P = .003). The American Society of Head and Neck Radiology has 7564 Twitter followers throughout 130 countries (66% outside the United States).

CONCLUSIONS

Social media affords substantial visibility, engagement, and global outreach for radiology education. #ASHNRCOTW viewership and engagement increased significantly during the COVID-19 pandemic.

NIMG-56. PHENOTYPIC ANALYSIS OF RADIO-PATHOMIC MAPS IN DE-NOVO GLIOBLASTOMA IDENTIFIES DIFFERENCES IN BEVACIZUMAB TREATMENT RESPONSE

PURPOSE

Bevacizumab (Bev) treatment for recurrent glioblastoma ceases tumor angiogenesis, which changes tumor appearance on Gd enhanced T1-weighted imaging. However, little is known about how non-angiogenic portions of tumor are affected by Bev. Therefore, this study tested the hypothesis that patients with specific tumor appearance phenotypes outside contrast enhancement, as identified using autopsy tissue-based radio-pathomic maps, would show differences in survival benefit from Bev treatment.

METHODS

Previously published methods were used to create machine learning models that generate whole-brain maps of cellularity (Cell), extracellular fluid (ECF) and cytoplasm (Cyt) using glioma autopsy tissue aligned to the patient’s last MRI as ground truth (Bobholz et al. 2022). These maps were then generated for an independent dataset of glioblastoma patients (n=80) using baseline imaging acquired prior to treatment. Patients were then graded for qualitative characteristics of the non-enhancing margin, with phenotypes including Well-Circumscribed (WC) patients with no abnormal tissue surrounding the core, Hypercellular Front (HF) patients with areas of hypercellularity extending from the core, Necrotic Front (NF) patients with areas of necrosis extending from the core, and Hybrid Front (HYF) patients with both hypercellular and necrotic presence beyond the enhancing region. Kaplan Meier analysis was then used to compare survival outcomes between patients who did and did not receive Bev treatment within each phenotype to assess differences in treatment efficacy.

RESULTS

Only patients with NF or HYF showed significant survival increase with bevacizumab treatment (HR=2.35, p=0.02; and HR=2.45, p=0.03, respectively), with no significant or trending difference in survival observed for WC and HF patients.

CONCLUSION

Radio-pathomic phenotypes identify patients who show the greatest survival benefit from Bev treatment, which could be used to direct clinical decision-making.

NIMG-49. RADIO-PATHOMIC MAPS OF DE-NOVO GLIOBLASTOMA IDENTIFY PHENOTYPES OF TUMOR INVASION ASSOCIATED WITH PROGNOSIS

PURPOSE

Although tumor is known to exist beyond the contrast-enhancing margin, a lack of access to pathological information beyond enhancement has hindered the study of non-angiogenic tumor characteristics and their effects on patient prognosis. This study tested the hypothesis that radio-pathomic maps of tumor characteristics developed using autopsy tissue samples can identify phenotypes relevant to patient survival and treatment outcomes.

METHODS

A dataset of autopsy tissue samples aligned to the MRI as ground truth from 65 glioma patients (training set n=43, test set n=22) was used to train machine learning models that predict and map tumor cellularity (Cell), extracellular fluid (ECF), and cytoplasm (Cyt) density following our previously published methodology (Bobholz et al. 2022). Cell, ECF, and Cyt maps were then generated from the pre-surgical MRI scans from an independent dataset of 80 glioblastoma patients. Each patient was separated into groups based on the appearance of tumor characteristics beyond the contrast-enhancing margin. Group phenotypes included Well-Circumscribed (WC) tumors with no tumor activity beyond contrast enhancement, Necrotic Front (NF) tumors with areas of necrosis extending beyond the tumor margin, Hypercellular Front (HF) tumors with areas of increased cellularity surrounding the tumor, and Hybrid Front (HYF) tumors with characteristics of both HF and NF tumors. A Cox regression was used to assess survival differences between phenotypes, controlling for treatment history.

RESULTS

Across the 80 patients, 22 were classified as WC, 14 were classified as HF, 24 were classified as NF, and 20 were classified as HYF. NF, HF, and HYF tumors each showed significant/trending reductions in survival when compared to WC tumors (HR=2.02, p=0.03; HR=2.0, p=0.06; and HR=1.75, p=0.09, respectively).

CONCLUSION

Radio-pathomic phenotypes identify characteristics beyond the contrast-enhancing margin that affect overall survival outcome in glioblastoma.

NCOG-18. OVERALL SURVIVAL VARIATION DUE TO THE TIMING OF POST-SURGICAL RADIATION IN HIGH-GRADE GLIOMAS

PURPOSE

Grade III and IV astrocytomas and glioblastomas are recognized as high-grade gliomas with aggressive heterogenous natures that carry with them a low overall survival (OS). Standard treatment currently involves surgical resection followed by radiation (RT) and concomitant chemotherapy. Despite this standard pathway, there is often disagreement in the optimal timing of radiation initiation post-surgery. In this study, we examined a subset of patients diagnosed with primary high-grade gliomas that underwent radiation following surgery at varying time frames.

METHODS

53 patients from our brain cancer bank with surgical diagnosis of high-grade gliomas were retrospectively analyses for this study. All patients were grouped into three cohorts based on the timing of the initiation of radiation post-surgery. Group 1 RT &lt; 4 weeks, Group 2 RT 4-5 weeks, and Group 3 RT &gt; 5 weeks post-surgery. Overall survival was calculated in days from initial surgical resection to time of death.

RESULTS

Across the three patient cohorts, Group 1 included 9 patients (mean OS 430 days), Group 2 had 18 patients (mean OS 597 days), and Group 3 had 26 patients (mean OS 895 days). Overall survival trended towards a difference between the three radiation timing groups, with Group 3 showing better survival outcomes compared to Group 1 (p=0.07).

CONCLUSIONS

This current study demonstrates a positive outcome with increased time between surgical intervention and initiation of radiation and concomitant chemotherapy. While we did not correct for additional treatment outside of standard clinical care, we would expect to observe similar trends. Despite these promising results for treatment planning, future research in larger cohorts is necessary to investigate possible molecular markers that may also impact treatment response and overall survival.

NIMG-18. A GROUND TRUTH COMPARISON OF PATHOLOGICALLY CONFIRMED GLIOBLASTOMA MARGINS TO CONTRAST ENHANCEMENT AT AUTOPSY

PURPOSE

Glioblastoma is one of the most common and deadly adult brain tumors. Current standard treatment is surgical resection followed by radiation and concomitant chemotherapy (chemoRT). Glioblastoma progression is monitored using MRI, primarily relying on post-contrast T1-weighted imaging (T1C). Unfortunately, tumor invasion is known to extend beyond traditional contrast enhancement. T1-subtraction (T1S) maps have been introduced as a better tumor volume estimate. In this study we compare T1S map derived tumor annotations to a radiologist for identifying histologically confirmed tumor in patients with differing treatment histories at autopsy.

METHODS

Ten patients with autopsy confirmed glioblastoma and MRI within 1 month of death were recruited for this study. Seven patients received chemoRT combined (chemoRT+) and three patients received no treatment beyond surgery (chemoRT-). Patient’s brains were sliced axially in the same orientation as their final MRI using a patient-specific slicing jig. Large tissue samples were taken, processed, embedded in paraffin, stained for hematoxylin and eosin, and digitized at 40x resolution. Digital images were annotated for infiltrative tumor, pseudopalisading necrosis, and necrosis without palisading cells. T1S and radiologist annotations were created for each patient using their final MRI (mean 18 days prior to death). The annotated histology images were aligned and resampled into MRI space using custom software and the overlap of pathologically confirmed tumor and MRI derived annotations was compared.

RESULTS

T1S maps alone were significantly better at identifying areas of histologically confirmed tumor in chemoRT+ patients compared to chemoRT- patients (p=0.043). T1S derived annotations overlapped with 52% of histologically confirmed tumor in the chemoRT- patients and 78% in the chemoRT+. The radiologist drawn tumor masks were more accurate in chemoRT+ patients, identifying 61% confirmed tumor (trending, p=0.097, chemoRT+=61%).

CONCLUSION

These results demonstrate the difficulty of identifying pathologically confirmed tumor outside contrast enhancement in glioblastoma patients, even in the untreated state.

ACR Appropriateness Criteria® Cranial Neuropathy: 2022 Update

Cranial neuropathy can result from pathology affecting the nerve fibers at any point and requires imaging of the entire course of the nerve from its nucleus to the end organ in order to identify a cause. MRI with and without intravenous contrast is often the modality of choice with CT playing a complementary role. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Optimized Dual Fire Attention Network and Medium-Scale Fire Classification Benchmark

Vision-based fire detection systems have been significantly improved by deep models; however, higher numbers of false alarms and a slow inference speed still hinder their practical applicability in real-world scenarios. For a balanced trade-off between computational cost and accuracy, we introduce dual fire attention network (DFAN) to achieve effective yet efficient fire detection. The first attention mechanism highlights the most important channels from the features of an existing backbone model, yielding significantly emphasized feature maps. Then, a modified spatial attention mechanism is employed to capture spatial details and enhance the discrimination potential of fire and non-fire objects. We further optimize the DFAN for real-world applications by discarding a significant number of extra parameters using a meta-heuristic approach, which yields around 50% higher FPS values. Finally, we contribute a medium-scale challenging fire classification dataset by considering extremely diverse, highly similar fire/non-fire images and imbalanced classes, among many other complexities. The proposed dataset advances the traditional fire detection datasets by considering multiple classes to answer the following question: what is on fire? We perform experiments on four widely used fire detection datasets, and the DFAN provides the best results compared to 21 state-of-the-art methods. Consequently, our research provides a baseline for fire detection over edge devices with higher accuracy and better FPS values, and the proposed dataset extension provides indoor fire classes and a greater number of outdoor fire classes; these contributions can be used in significant future research. Our codes and dataset will be publicly available at https://github.com/tanveer-hussain/DFAN.

Detecting Primary Progressive Aphasia Atrophy Patterns: A Comparison of Visual Assessment and Quantitative Neuroimaging Techniques

Background: There are now clinically available automated MRI analysis software programs that compare brain volumes of patients to a normative sample and provide z-score data for various brain regions. These programs have yet to be validated in primary progressive aphasia (PPA). Objective: To address this gap in the literature, we examined Neuroreadertrademark z-scores in PPA, relative to visual MRI assessment. We predicted that Neuroreadertrademark 1) would be more sensitive for detecting left >  right atrophy in the cortical lobar regions in logopenic variant PPA clinical phenotype (lvPPA), and 2) would distinguish lvPPA (n = 11) from amnestic mild cognitive impairment (aMCI; n = 12). Methods: lvPPA or aMCI patients who underwent MRI with Neuroreadertrademark were included in this study. Two neuroradiologists rated 10 regions. Neuroreadertrademark lobar z-scores for those 10 regions, as well as a hippocampal asymmetry metric, were included in analyses. Results: Cohen’s Kappa coefficients were significant in 10 of the 28 computations (k = 0.351 to 0.593, p≤0.029). Neuroradiologists agreed 0% of the time that left asymmetry was present across regions. No significant differences emerged between aMCI and lvPPA in Neuroreadertrademark z-scores across left or right frontal, temporal, or parietal regions (ps >  0.10). There were significantly lower z-scores in the left compared to right for the hippocampus, as well as parietal, occipital, and temporal cortices in lvPPA. Conclusion: Overall, our results indicated moderate to low interrater reliability, and raters never agreed that left asymmetry was present. While lower z-scores in the left hemisphere regions emerged in lvPPA, Neuroreadertrademark failed to differentiate lvPPA from aMCI.

Anatomy and Diseases of the Greater Wings of the Sphenoid Bone

The greater wings of the sphenoid bone (GWS) comprise the components of the sphenoid bone that make up most of the posterior orbital wall and form the anterior and medial parts of the floor of the middle cranial fossa. Many important skull base foramina, which transmit vital neurovascular structures, are present in these paired wings on either side of the central body of the sphenoid bone. A wide variety of diseases can affect the GWS, ranging from benign osseus lesions to malignant primary and secondary bone abnormalities. The complex three-dimensional curved (winged) shape of the GWS and the wide array of pathologic entities that affect this bone can make it challenging for the radiologist to report the imaging findings accurately, especially in relation to the important skull base foramina. The authors describe a systematic approach to understanding the three-dimensional anatomy of the GWS and review important diseases, with the aid of imaging examples. Useful imaging "pearls" that can help in making specific diagnoses are provided throughout the article. ^©RSNA, 2022.

Long-Term Functional Outcome Following Left Hemispherotomy in Adults and Pediatric Participants with Fmri Analysis

Background and Objective

Hemispherotomy surgery in adults is shrouded in doubts regarding the functional outcome. The age at surgery alone should not be the deciding factor for surgery. Language paradigms were used in functional magnetic resonance imaging (fMRI) to confirm the role played by the age at the onset of seizures to predict the postoperative functional outcome. The objective of the study was to formulate an optimal strategy for patient selection for the left-sided hemispherotomy in adults, based on functional outcome analysis.

Materials and Methods

A retrospective analysis of 20 participants (age at surgery 1-26 years) who underwent left hemispherotomy (over a 5-year period) was conducted. The language and motor functional assessments of 18 participants (13 pediatric and five adult participants; attrition of participants- two) were recorded at presentation and during follow-up visits. After approval was obtained from the Institutional Ethics Committee, 13 cooperative participants (eight pediatric and five adult participants) underwent language fMRI. Motor fMRI with both active and passive paradigms was done in 16 participants.

Results

All 18 participants with a mean follow-up of 24 months had class I seizure-free outcome. Of these 18, five were adults (mean age = 21 years, range: 18-22 years) and 13 were in the pediatric age group (mean age = 8 years, range: 2-15 years). Postoperatively, four adults retained both verbal fluency and language comprehension at a mean follow-up period of 38 months (range: 24-48 months). Their pre- and post-op language fMRI showed word generation and regional activations for semantic comprehension in the right hemisphere. The motor area activations were seen in the right hemisphere in two and in the left hemisphere in two participants. Among the pediatric participants, four (group I [n = 4/13]) who had good language outcome showed activations in the right hemisphere. In two participants (group II [n = 2/13]) who deteriorated postoperatively, the activations were in the left hemisphere. Five participants (group III [n = 5/13]) who retained the telegraphic language postoperatively had bilateral activations of semantic comprehension areas in fMRI. All 13 pediatric participants had motor area activations seen in the left hemisphere, similar to controls.

Conclusion

Left hemispherotomy can be advised to adults with comparably good postoperative language and motor outcome as in the pediatric age group, provided the weakness is acquired perinatally or below the age of 7 years. The fMRI is a valuable tool to aid in patient selection.

Eight pruning deep learning models for low storage and high-speed COVID-19 computed tomography lung segmentation and heatmap-based lesion localization: A multicenter study using COVLIAS 2.0

BACKGROUND

COVLIAS 1.0: an automated lung segmentation was designed for COVID-19 diagnosis. It has issues related to storage space and speed. This study shows that COVLIAS 2.0 uses pruned AI (PAI) networks for improving both storage and speed, wiliest high performance on lung segmentation and lesion localization.

METHOD

ology: The proposed study uses multicenter ∼9,000 CT slices from two different nations, namely, CroMed from Croatia (80 patients, experimental data), and NovMed from Italy (72 patients, validation data). We hypothesize that by using pruning and evolutionary optimization algorithms, the size of the AI models can be reduced significantly, ensuring optimal performance. Eight different pruning techniques (i) differential evolution (DE), (ii) genetic algorithm (GA), (iii) particle swarm optimization algorithm (PSO), and (iv) whale optimization algorithm (WO) in two deep learning frameworks (i) Fully connected network (FCN) and (ii) SegNet were designed. COVLIAS 2.0 was validated using "Unseen NovMed" and benchmarked against MedSeg. Statistical tests for stability and reliability were also conducted.

RESULTS

Pruning algorithms (i) FCN-DE, (ii) FCN-GA, (iii) FCN-PSO, and (iv) FCN-WO showed improvement in storage by 92.4%, 95.3%, 98.7%, and 99.8% respectively when compared against solo FCN, and (v) SegNet-DE, (vi) SegNet-GA, (vii) SegNet-PSO, and (viii) SegNet-WO showed improvement by 97.1%, 97.9%, 98.8%, and 99.2% respectively when compared against solo SegNet. AUC > 0.94 (p < 0.0001) on CroMed and > 0.86 (p < 0.0001) on NovMed data set for all eight EA model. PAI <0.25 s per image. DenseNet-121-based Grad-CAM heatmaps showed validation on glass ground opacity lesions.

CONCLUSIONS

Eight PAI networks that were successfully validated are five times faster, storage efficient, and could be used in clinical settings.

ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey

Maxillofacial trauma patients comprise a significant subset of patients presenting to emergency departments. Before evaluating for facial trauma, an emergency or trauma physician must perform a primary survey to ensure patient stabilization. Following this primary survey, this document discusses the following clinical scenarios for facial trauma: tenderness to palpation or contusion or edema over frontal bone (suspected frontal bone injury); pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia (suspected midface injury); visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis (suspected nasal bone injury); and trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth (suspected mandibular injury). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Sinonasal Disease: 2021 Update

This article presents guidelines for initial imaging utilization in patients presenting with sinonasal disease, including acute rhinosinusitis without and with suspected orbital and intracranial complications, chronic rhinosinusitis, suspected invasive fungal sinusitis, suspected sinonasal mass, and suspected cerebrospinal fluid leak. CT and MRI are the primary imaging modalities used to evaluate patients with sinonasal disease. Given its detailed depiction of bony anatomy, CT can accurately demonstrate the presence of sinonasal disease, bony erosions, and anatomic variants, and is essential for surgical planning. Given its superior soft tissue contrast, MRI can accurately identify clinically suspected intracranial and intraorbital complications, delineate soft tissue extension of tumor and distinguish mass from obstructed secretions.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Does pre-diabetes predict the extent of coronary artery disease?

Funding Acknowledgements

Type of funding sources: None.

Background

Extensive coronary artery disease (CAD) is common in diabetes mellitus. This relation between the extent of CAD and prediabetes (pDM)is less well established.

Purpose

To explore whether non-diabetic hyperglycaemia, assessed by HbA1c, is associated with extent of angiographic CAD, independent of traditional cardiovascular risk factors.

Methods

Retrospective cohort analysis of consecutive patients, without known DM undergoing coronary angiography for stable angina, who were screened for hyperglycaemia over 18 months. HbA1c was measured; pre-diabetes was defined as HbA1c 5.7-6.4%.Extent of CAD was assessed using the SYNTAX score. Presence of CAD was defined as visually estimated ≥50% luminal obstruction in arteries ≥1.5 mm diameter. Age, BMI, risk factors for CAD, HbA1c, total and LDL-cholesterol were recorded. The pre-diabetes and normal groups were compared using Mann-Whitney test for continuous variables and chi-squared test for categorical variables. Multiple logistic and linear regressions were used to assess the effect variables on SYNTAX score. Spearman rank correlation was used to assess the relation between HbA1c and SYNTAX score.

Results

1071 patients had angiograms done. 207 had DM, 19 had new diagnosis of DM and 181 missed the screening leaving 664 who had HbA1c measured. 51 poor quality angiograms were excluded from SYNTAX calculation. Data was analysed for 613 (306 normal, 307 pDM) patients. The patients with prediabetes were older, had higher prevalence of risk factors, BMI, fasting glucose and SYNTAX score. HbA1c (OR 2.07, 95% CI 1.32 to 3.25, p=0.002) and the presence of pDM (OR 1.89, 95% CI 1.32 to 2.69, p&lt;0.001) independently predicted the presence of CAD. HbA1c (Coefficient 2.42, SE 1.09, p=0.027) and the presence of pDM (Coefficient 2.25, SE 0.92, p=0.015) independently predicted the SYNTAX score. The correlation between HbA1c and SYNTAX score was weak but significant (Spearman's coefficient 0.206, 95% CI 0.129 to 0.281, p&lt;0.0001).

Conclusion

HbA1c predicts the extent of CAD as measured by SYNTAX score in patients without known diabetes. Presence of pre-diabetes is an independent predictor of extent of CAD.

Radio-Pathomic Maps of Cell Density Identify Brain Tumor Invasion beyond Traditional MRI-Defined Margins

BACKGROUND AND PURPOSE

Currently, contrast-enhancing margins on T1WI are used to guide treatment of gliomas, yet tumor invasion beyond the contrast-enhancing region is a known confounding factor. Therefore, this study used postmortem tissue samples aligned with clinically acquired MRIs to quantify the relationship between intensity values and cellularity as well as to develop a radio-pathomic model to predict cellularity using MR imaging data.

MATERIALS AND METHODS

This single-institution study used 93 samples collected at postmortem examination from 44 patients with brain cancer. Tissue samples were processed, stained with H&E, and digitized for nuclei segmentation and cell density calculation. Pre- and postgadolinium contrast T1WI, T2 FLAIR, and ADC images were collected from each patient's final acquisition before death. In-house software was used to align tissue samples to the FLAIR image via manually defined control points. Mixed-effects models were used to assess the relationship between single-image intensity and cellularity for each image. An ensemble learner was trained to predict cellularity using 5 × 5 voxel tiles from each image, with a two-thirds to one-third train-test split for validation.

RESULTS

Single-image analyses found subtle associations between image intensity and cellularity, with a less pronounced relationship in patients with glioblastoma. The radio-pathomic model accurately predicted cellularity in the test set (root mean squared error = 1015 cells/mm²) and identified regions of hypercellularity beyond the contrast-enhancing region.

CONCLUSIONS

A radio-pathomic model for cellularity trained with tissue samples acquired at postmortem examination is able to identify regions of hypercellular tumor beyond traditional imaging signatures.

Imaging features of cartilaginous tumors of the head and neck

There is a wide spectrum of head and neck cartilaginous lesions which include both neoplastic and nonneoplastic processes. Cartilaginous tumors of the head and neck are uncommon, posing a diagnostic challenge. Benign cartilaginous tumors that may occur in the head and neck include chondroma, chondroblastoma, chondromyxoid fibroma, osteochondroma, and synovial chondromatosis. Chondromesenchymal hamartoma is a rare non-neoplastic cartilaginous lesion that is included for the 1first time in the new WHO classification and radiologically can mimic a tumor. Malignant cartilaginous tumors include chondrosarcoma and chondroid variant of chordoma. Characteristic tumor locations, internal chondroid matrix calcification, and typical T2 hyperintense signal secondary to high-water content within the extracellular matrix of the hyaline cartilage are useful imaging features that narrow the differential diagnosis and help in diagnosing these diseases. This article presents a narrative review of the anatomy of the head and neck cartilaginous structures, discusses the current knowledge and imaging spectrum of benign and malignant cartilaginous tumors and tumor-like lesions of the head and neck.

Long-term oxygen therapy prescription in India: Evaluation of compliance, factors affecting compliance, indications, and survival

Introduction:

The international data shows that long-term oxygen therapy (LTOT) compliance is insufficient and variable. We conducted the first study from India on LTOT compliance, factors affecting compliance, indications, and survival through oxygen concentrator.

Materials and Methods:

Our organization from Delhi had given 378 oxygen concentrators over the last 5 years. We evaluated 120 patients randomly for participating in the study. Compliance was defined as the use of LTOT for at least 15 h/day.

Results:

Ninety-seven patients were included in the final analysis after exclusion criteria. The compliance to LTOT was seen in 45.36% (44/97). The commonest cause of noncompliance was lack of instructions (49.06%) followed by electricity issues, social stigma, and workplace constraints. A higher PaCO₂ was associated with significantly lower compliance (PaCO₂ 53.18 vs. 44.98 mmHg, P = 0.036). Interstitial lung disease was associated with significantly higher compliance. Oxygen prescription was titrated with arterial blood gas analysis in only 4.12%. The indications for LTOT were chronic obstructive pulmonary disease (49.48%), posttuberculous obstructive airway disease (20.6%), and interstitial lung disease (12.37%). We found a significant reduction in the mean number of exacerbations/year from 3.91 to 1.93 (P < 0.0001). 61.86% of the patients were surviving on LTOT with a median survival time of 12 months.

Conclusion:

The adherence to LTOT in Indian patients is suboptimal mainly due to lack of instruction and is associated with a higher PaCO₂. The practice of titration needs to be followed. The development of a national registry to monitor LTOT should be the long-term target.