How many times should we repeat measurements of the ultrasound-guided attenuation parameter for evaluating hepatic steatosis?

Purpose@#This retrospective study aimed to determine the number of times the ultrasound-guided attenuation parameter (UGAP) should be measured during the evaluation of hepatic steatosis. @*Methods@#Patients with suspected nonalcoholic fatty liver disease who underwent two UGAP repetition protocols (six-repetition [UGAP_6] and 12-repetition [UGAP_12]) and measurement of the controlled attenuation parameter (CAP) using transient elastography between October 2020 and June 2021 were enrolled. The mean attenuation coefficient (AC), interquartile range (IQR)/median, and coefficient of variance (CV) of the two repetition protocols were compared using the paired t test. Moreover, the diagnostic performances of UGAP_6 and UGAP_12 were compared using the area under the receiver operating characteristic (AUROC) curve, considering the CAP value as a reference standard. @*Results@#The study included 160 patients (100 men; mean age, 50.9 years). There were no significant differences between UGAP_6 and UGAP_12 (0.731±0.116 dB/cm/MHz vs. 0.734±0.113 dB/cm/MHz, P=0.156) and mean CV (7.6±0.3% vs. 8.0±0.3%, P=0.062). However, the mean IQR/median of UGAP_6 was significantly lower than that of UGAP_12 (8.9%±6.0% vs. 9.8%±5.2%, P=0.012). In diagnosing the hepatic steatosis stage, UGAP_6 and UGAP_12 yielded comparable AUROCs (≥S1, 0.908 vs. 0.897, P=0.466; ≥S2, 0.883 vs. 0.897, P=0.126; S3, 0.832 vs. 0.834, P=0.799). @*Conclusion@#UGAP had high diagnostic performance in diagnosing hepatic steatosis, regardless of the number of repetitions (six repetitions vs. 12 repetitions), with maintained reliability. Therefore, six UGAP measurements seem sufficient for evaluating hepatic steatosis using UGAP.

Arterio-Biliary Fistula as a Rare Life-Threatening Complication of Transjugular Intrahepatic Portosystemic Shunt: A Case Report

A 46-year-old male with alcoholic liver cirrhosis underwent a transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites. On the 9th day after the procedure, he presented with melena and decreasing hemoglobin levels. Hemobilia due to fistula formation between the right intrahepatic bile duct and right hepatic artery was suspected on computed tomography. Angiography revealed a fistula of the small branches of the hepatic segmental arteries, and right intrahepatic bile duct was confirmed; embolization was successfully performed with a coil for the eighth segmental hepatic artery, a glue-lipiodol mixture for the fifth segmental hepatic artery, and gelfoam slurry for the right anterior hepatic artery. However, 2 days after embolization, the patient died owing to aggravated disseminated intravascular coagulopathy. When gastrointestinal bleeding occurs after TIPS, careful evaluation is immediately required, and hemobilia should be considered.

Impact of respiratory motion on liver stiffness measurements according to different shear wave elastography techniques and region of interest methods: a phantom study

Purpose@#This study quantified the impact of respiratory motion on liver stiffness measurements according to different shear wave elastography (SWE) techniques and region of interest (ROI) methods, using liver fibrosis phantoms. @*Methods@#Three operators measured stiffness values in four phantoms with different stiffness on a moving platform with two SWE techniques (point-SWE [pSWE] and 2-dimensional SWE [2D-SWE]), three types of motion (static mode and moving mode at low and high speeds), and four ROI methods in 2D-SWE (circle, point, box, and multiple). The circular ROI method was used to compare the two SWE techniques. The occurrence of technical failure and unreliable measurements, stiffness values, and measurement time were evaluated. @*Results@#Technical failure was observed only in moving mode for pSWE and 2D-SWE (n=1 for both). Unreliable measurements were also only observed in moving mode and were significantly less common in 2D-SWE (n=1) than in pSWE (n=12) (P<0.001). No statistically significant differences in the technical failure rate or stiffness values were noted between the static and moving modes for both SWE techniques. The technical failure and unreliable measurement rates were not significantly different among the ROI methods for 2D-SWE. Stiffness values did not differ significantly according to the ROI method used in any moving mode. However, the multiple ROI method had significantly shorter measurement times than the circular ROI method for all moving modes. @*Conclusion@#2D-SWE may be preferable for evaluating liver fibrosis in patients with poor breath-hold. Furthermore, 2D-SWE with multiple ROIs enables rapid measurements, without affecting liver stiffness values.

Computed Tomography Findings Associated with Treatment Failure after Antibiotic Therapy for Acute Appendicitis

Objective@#To identify the CT findings associated with treatment failure after antibiotic therapy for acute appendicitis. @*Materials and Methods@#Altogether, 198 patients who received antibiotic therapy for appendicitis were identified by searching the hospital’s surgery database. Selection criteria for antibiotic therapy were uncomplicated appendicitis with an appendiceal diameter equal to or less than 11 mm. The 86 patients included in the study were divided into a treatment success group and a treatment failure group. Treatment failure was defined as a resistance to antibiotic therapy or recurrent appendicitis during a 1-year follow-up period. Two radiologists independently evaluated the following CT findings: appendix–location, involved extent, maximal diameter, thickness, wall enhancement, focal wall defect, periappendiceal fat infiltration, and so on. For the quantitative analysis, two readers independently measured the CT values at the least attenuated wall of the appendix by drawing a round region of interest on the enhanced CT (HUpost) and non-enhanced CT (HUpre). The degree of appendiceal wall enhancement (HUsub) was calculated as the subtracted value between HUpost and HU pre. A logistic regression analysis was used to identify the CT findings associated with treatment failure. @*Results@#Sixty-four of 86 (74.4%) patients were successfully treated with antibiotic therapy, with treatment failure occurring in the remaining 22 (25.5%). The treatment failure group showed a higher frequency of hypoenhancement of the appendiceal wall than the success group (31.8% vs. 7.8%; p = 0.005). Upon quantitative analysis, both HU post (46.7 ± 21.3 HU vs. 58.9 ± 22.0 HU; p = 0.027) and HUsub (26.9 ± 17.3 HU vs. 35.4 ± 16.6 HU; p = 0.042) values were significantly lower in the treatment failure group than in the success group. @*Conclusion@#Hypoenhancement of the appendiceal wall was significantly associated with treatment failure after antibiotic therapy for acute appendicitis.

Comparison of point and 2-dimensional shear wave elastography for the evaluation of liver fibrosis

Purpose@#This study aimed to assess the technical performance of ElastQ Imaging compared with ElastPQ and to investigate the correlation between liver stiffness (LS) values obtained using these two techniques. @*Methods@#This retrospective study included 249 patients who underwent LS measurements using both ElastPQ and ElastQ Imaging equipped on the same machine. The applicability, repeatability (coefficient of variation [CV]), acquisition time, and LS values were compared using the chi-square or Wilcoxon signed-rank tests. In the development group, the correlation between the LS values obtained by the two techniques was assessed with Spearman correlation coefficients and linear regression analysis. In the validation group, the agreement between the estimated and real LS values was evaluated using a Bland-Altman plot. @*Results@#ElastQ Imaging had higher applicability (94.0% vs. 78.3%, P<0.001) and higher repeatability, with a lower median CV (0.127 vs. 0.164, P<0.001) than did ElastPQ. The median acquisition time of ElastQ Imaging was significantly shorter than that of ElastPQ (45.5 seconds vs. 96.5 seconds, P<0.001). The median LS value obtained using ElastQ Imaging was significantly higher than that obtained using ElastPQ (5.60 kPa vs. 5.23 kPa, P<0.001). The LS values between the two techniques exhibited a strong positive correlation (r=0.851, P<0.001) in the development group. The mean difference and 95% limits of agreement were 0.0 kPa (-3.9 to 3.9 kPa) in the validation group. @*Conclusion@#ElastQ Imaging may be more reliable and faster than ElastPQ, with strongly correlated LS measurements.

Risk Factors for Sudden Infant Death Syndrome and Sleeping Practices in Korea

Sudden infant death syndrome (SIDS) in Korea remains a poorly-understood subject for both professionals and the public. Recent reports have emphasized ethnic differences in SIDS rates, suggesting that making adjustments in child-rearing practices may contribute substantially to SIDS reduction. Two of the three major risk factors for SIDS-vulnerability of the infant and exogenous factors-need to be understood in particular depth due to their broad scope and sociocultural grounding. This paper presents substantial issues regarding preterm birth and male gender on infants’ vulnerability to SIDS in Korea. Practices of caring for healthy infants are addressed in the context of sleeping practices, including sleeping position, bedding arrangements, sleeping on the floor, the back-to-sleep position, high indoor temperatures and ondol floor heating, and swaddling. Professional and social awareness about how to reduce SIDS should be raised by promoting a better understanding of risk factors in the context of ethnic and cultural variations in child-rearing practices.

Measurement of Pancreatic Fat Fraction by CT Histogram Analysis to Predict Pancreatic Fistula after Pancreaticoduodenectomy

OBJECTIVE: To evaluate the effectiveness of computed tomography (CT) Hounsfield unit histogram analysis (HUHA) in postoperative pancreatic fistula (PF) prediction. MATERIALS AND METHODS: Fifty-four patients (33 males and 21 females; mean age, 65.6 years; age range, 37–89 years) who had undergone preoperative CT and pancreaticoduodenectomy were included in this retrospective study. Two radiologists measured mean CT Hounsfield unit (CTHU) values by drawing regions of interest (ROIs) at the level of the pancreaticojejunostomy site on preoperative pre-contrast images. The HUHA values were arbitrarily divided into three categories, comprising HUHA-A ≤ 0 HU, 0 HU < HUHA-B < 30 HU, and HUHA-C ≥ 30 HU. Each HUHA value within the ROI was calculated as a percentage of the entire area using commercial 3-dimensional analysis software. Pancreas texture was evaluated as soft or hard by manual palpation. RESULTS: Fifteen patients (27.8%) had clinically relevant PFs. The PF group had significantly higher HUHA-A (p < 0.01) and significantly lower mean CTHU (p < 0.01) values than those of the non-PF group. The HUHA-A value had a moderately strong correlation with PF occurrence (r = 0.60, p < 0.01), whereas the mean CTHU had a weak negative correlation with PF occurrence (r = −0.27, p < 0.01). The HUHA-A and mean CTHU areas under the curve (AUCs) for predicting PF occurrence were 0.86 and 0.65, respectively, with significant difference (p < 0.01). The HUHA-A and mean CTHU AUCs for predicting pancreatic softness were 0.86 and 0.64, respectively, with significant difference (p < 0.01). CONCLUSION: The HUHA-A values on preoperative pre-contrast CT images demonstrate a strong correlation with PF occurrence.

Multicenter Phase II Study of Oxaliplatin, Irinotecan, and S-1 as First-line Treatment for Patients with Recurrent or Metastatic Biliary Tract Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Although gemcitabine plus cisplatin has been established as the standard first-line chemotherapy for patients with advanced biliary tract cancer (BTC), overall prognosis remains poor. We investigated the efficacy of a novel triplet combination of oxaliplatin, irinotecan, and S-1 (OIS) for advanced BTC. MATERIALS AND METHODS: Chemotherapy-naive patientswith histologically documented unresectable or metastatic BTC were eligible for this multicenter, single-arm phase II study. Patients received 65 mg/m2 oxaliplatin (day 1), 135 mg/m2 irinotecan (day 1), and 40 mg/m2 S-1 (twice a day, days 1-7) every 2 weeks. Primary endpoint was objective response rate. Targeted exome sequencing for biomarker analysis was performed using archival tissue. RESULTS: In total, 32 patients were enrolled between October 2015 and June 2016. Median age was 64 years (range, 40 to 76 years), with 24 (75%) male patients; 97% patients had metastatic or recurrent disease. Response rate was 50%, and median progression-free survival and overall survival (OS) were 6.8 months (95% confidence interval [CI], 4.8 to 8.8) and 12.5 months (95% CI, 7.0 to 18.0), respectively. The most common grade 3-4 adverse events were neutropenia (32%), diarrhea (6%), and peripheral neuropathy (6%). TP53 and KRAS mutations were the most frequent genomic alterations (42% and 32%, respectively), and KRAS mutations showed a marginal relationship with worse OS (p=0.07). CONCLUSION: OIS combination chemotherapy was feasible and associated with favorable efficacy outcomes as a first-line treatment in patients with advanced BTC. Randomized studies are needed to compare OIS with gemcitabine plus cisplatin.

Ultrasound features of secondary appendicitis in pediatric patients

PURPOSE: The purpose of this study was to evaluate the ultrasonographic findings of secondary appendicitis (SA) and to discuss the differential findings compared with primary appendicitis. METHODS: In this study, we analyzed the ultrasonographic findings of 94 patients under 15 years old of age treated at our institution from May 2005 to May 2014 who had bowel inflammation and an inflamed appendix with a maximal outer diameter >6 mm that improved with nonsurgical treatment (the SA group). Ninety-nine patients with pathologically proven acute appendicitis (the primary appendicitis [PA] group) from June 2013 to May 2014 and 44 patients with pathologically negative appendectomy results from May 2005 to May 2014 were also included to compare the ultrasonographic features of these conditions. A retrospective review of the ultrasonographic findings was performed by two radiologists. The clinical and laboratory findings were also reviewed. The results were statically analyzed using analysis of variance, the Pearson chi-square test, and the two-tailed Fisher exact test. RESULTS: Compared with PA, cases of SA had a smaller diameter (9.8 mm vs. 6.6 mm, P < 0.001), and were less likely to show periappendiceal fat inflammation (98% vs. 6%, P < 0.001) or an appendicolith (34% vs. 11%, P < 0.001). SA showed mural hyperemia on color Doppler ultrasonography as frequently as PA (P=0.887). CONCLUSION: The ultrasonographic features of SA included an increased diameter compared to a healthy appendix and the same level of hyperemia as in PA. However, the diameter was commonly in the equivocal range (mean diameter, 6.6 mm), and periappendiceal fat inflammation was rarely present in SA.

A Case of Spontaneous Isolated Dissection of Left Gastric Artery

No abstract available.

Ultrasonographic Evaluation of Acute Appendicitis Superimposed on the Non-rotational Anomaly of the Gastrointestinal Tract

We report on the case of a 29-year-old male with acute appendicitis superimposed on the non-rotational anomaly of the gastrointestinal tract not detected on the computed tomography (CT) scan but correctly diagnosed on ultrasonography (US). This case suggested an additional role of US on the acute abdomen even underlying malrotation of the gastrointestinal tract.

Multidetector CT Findings of Bowel Transection in Blunt Abdominal Trauma

OBJECTIVE: Though a number of CT findings of bowel and mesenteric injuries in blunt abdominal trauma are described in literature, no studies on the specific CT signs of a transected bowel have been published. In the present study we describe the incidence and new CT signs of bowel transection in blunt abdominal trauma. MATERIALS AND METHODS: We investigated the incidence of bowel transection in 513 patients admitted for blunt abdominal trauma who underwent multidetector CT (MDCT). The MDCT findings of 8 patients with a surgically proven complete bowel transection were assessed retrospectively. We report novel CT signs that are unique for transection, such as complete cutoff sign (transection of bowel loop), Janus sign (abnormal dual bowel wall enhancement, both increased and decreased), and fecal spillage. RESULTS: The incidence of bowel transection in blunt abdominal trauma was 1.56%. In eight cases of bowel transection, percentage of CT signs unique for bowel transection were as follows: complete cutoff in 8 (100%), Janus sign in 6 (100%, excluding duodenal injury), and fecal spillage in 2 (25%). The combination of complete cutoff and Janus sign were highly specific findings in patients with bowel transection. CONCLUSION: Complete cut off and Janus sign are the unique CT findings to help detect bowel transection in blunt abdominal trauma and recognition of these findings enables an accurate and prompt diagnosis for emergency laparotomy leading to reduced mortality and morbidity.

Compression of the Main Pancreatic Duct by the Intrapancreatic-Replaced Common Hepatic Artery

We describe a unique case of a patient who presented with a linear, transverse, and incidentally-detected main pancreatic duct dilatation that was caused by the intrapancreatic-replaced common hepatic artery, detected on the MDCT, MRCP and endoscopic retrograde cholangiopancreatography. We believe this case to be the first of its kind reported in the literature.

Fatal Inhalation Injury by Sulfuric Acid Fumes: Case Report / 대한법의학회지

Sulfuric acid can cause local or systemic effects after exposure by inhalation, ingestion, or topical application. Direct ingestion is the main exposure route for fatal sulfuric acid injury. Fatal accidents involving the inhalation of toxic sulfuric acid vapors are rare. Inhalation of sulfuric acid fumes causes severe irritation or corrosive damage to the upper respiratory tract. Consequently, severe congestion, edema, and inflammation of the mucous membranes of the upper respiratory passages hinder the entry of air into the lungs, possibly leading to fatalities in victims. A 35-year-old man died at his home after complaining of a severe sore throat. One day earlier, he had worked in a sulfuric acid tank in a copper-smelting plant while wearing an ordinary gas mask that offered no protection against sulfurous acid vapors. Upon autopsy, the larynx and epiglottis showed pronounced edema, congestion, and inflammation that histologically mimicked an acute bacterial suppurative inflammation, accompanied by severe pulmonary edema. A field analysis of the air inside the sulfuric acid tank revealed SO4(2-) positivity and a 40% sulfuric acid concentration.

A Forensic Autopsy Case of Lissencephaly for Evaluating the Possibility of Child Abuse / 대한법의학회지

A 9-year-old Korean boy with lissencephaly was found dead at home. He had previously been diagnosed with lissencephaly that presented with infantile spasm on the basis of magnetic resonance imaging and electroencephalogram results. Antemortem chromosomal banding revealed a normal karyotype. A legal autopsy was requested to eliminate the possibility of neglect or abuse by his parents. The autopsy findings revealed type I lissencephaly with the associated microcephaly. No external wounds or decubitus ulcers were noted. Postmortem fluorescence in situ hybridization for the LIS1 locus and nucleotide sequence analysis of the whole coding regions of the LIS1 gene did not reveal any deletions. The antemortem and postmortem findings revealed that lissencephaly syndrome was associated with isolated lissencephaly sequence. External causes of death were excluded by the full autopsy and toxicology test results. Because patients with mental retardation are frequently victimized and suffer neglect or abuse, thorough external and internal examinations should be conducted at the time of autopsy.

Laparoscopic treatment for post-cholecystectomy Mirizzi syndrome

The remnant cystic duct or gallbladder neck calculus may rarely result in post-cholecystectomy Mirizzi syndrome. Various managements have been proposed for the treatment of post-cholecystectomy Mirizzi syndrome. Some previous cases of post-cholecystectomy Mirizzi syndrome have been managed with open cholecystectomy and endoscopically. We report a case of a laparoscopic stone removal of post-cholecystectomy Mirizzi syndrome that developed 7 months after laparoscopic cholecystectomy. To our knowledge, this is the first case of laparoscopic management of post-cholecystectomy Mirizzi syndrome. The mechanism, diagnosis and treatment of post-cholecystectomy Mirizzi syndrome are discussed.

Head and Neck Vascular Lesions: Characterization of the Flow Pattern by the Use of Three-Phase CT

OBJECTIVE: This study was designed to evaluate the usefulness of three-phase CT to characterize the hemodynamics of vascular lesions in the head and neck area. MATERIALS AND METHODS:We analyzed vascular malformations of head and neck regions in 21 patients with the use of three-phase CT, including pre-contrast phase, vascular phase (scan delay: 20-35 seconds after intravenous contrast material injection) and equilibrium phase (scan delay: 3-5 minutes) imaging. The flow characteristic of each lesion was determined and categorized as either a high- or a low-flow lesion according to findings on selective arteriography and/or direct puncture venography. The CT number was acquired from two areas in a vascular lesion, sorted by the enhancement pattern: area 1, a highly enhanced area seen on the vascular phase; area 2, a delayedly enhanced area seen on the equilibrium phase. The CT numbers of each phase were compared between high- and low-flow lesions with use of the unpaired t-test. The flow patterns of high- and low-flow lesions were analyzed by assessment of time-density curves of three phase CT. RESULTS: High-flow lesions were detected in nine patients and low-flow lesions were detected in 12 patients. On the vascular phase, the CT number of areas 1 and 2 of high-flow lesions was significantly higher than for low-flow lesions (p < 0.05). Contrary to early peaks seen in time-density curves of high-flow lesions, low-flow lesions showed a delayed peak. CONCLUSION: Three-phase CT seems to be a valuable non-invasive method to differentiate a high-flow lesion from a low flow lesion of head and neck vascular lesions.

Measurement of Kidney Volume with Multi-Detector Computed Tomography Scanning in Young Korean

PURPOSE: Kidney volume is regarded as the most precise indicator of kidney size. However, it is not widely used clinically, because its measurement is difficult due to the complex kidney shape. We attempted to evaluate the normal kidney volume in young Korean men by using multi-detector computed tomography (MDCT). MATERIALS AND METHODS: We retrospectively reviewed MDCT data of young Korean men (113 patients). After data processing, we measured the volume and length of the kidneys. Body parameters (height, body weight, body-surface area, and total body water) and laboratory data were collected. Glomerular filtration rate (GFR) was calculated using Cockcroft-Gault (CG) equation. RESULTS: The mean kidney volume was 205.29 +/- 36.81 cm3; and mean kidney length was 10.80 +/- 0.69 cm. The former correlated significantly with height, body weight, body-surface area, and total body water (p < 0.05, correlation coefficient : gamma = 0.328, 0.649, 0.640, and 0.638, respectively). The latter also correlated significantly with all body indexes, however the correlation was weaker, except with height (p < 0.05, correlation coefficient : gamma = 0.457, 0.473, 0.505, and 0.503, respectively). Only kidney volume significantly predicted estimated GFR (adjusted R2 = 0.431, F = 85.90 and p < 0.05). CONCLUSION: The kidney volume measured with MDCT is correlated well with body parameters, and is useful to predict renal function.

Unexpected Sudden Death due to Post-traumatic Apoplexy of Preexisting Pituitary Adenoma; Blunt Force to the Face / 대한법의학회지

Pituitary adenomas are frequent intracranial tumors with generally benign prognosis but acute hemorrhage into tumor with necrosis is a severe complication and can potentially result in fatal outcome, if not diagnosed or treated early. While many precipitating factors have been known, even a mild blunt force shown in this case could play a role in the catastrophic complication of the pituitary adenoma. We report a rare forensic case of post-traumatic apoplexy sustained in a preexisting pituitary adenoma with a mild blunt force to the face.

Description of the Surface Findings with Use of the Revised Korean Surface Anatomical Terms / 대한법의학회지

Forensic medicine doctors in NISI(National Institute of Scientific Investigation) have traditionally used handed-down or old anatomical terms when they put into words the external findings of dead body. And we have had no any traditional rule or accepted guide relevant to the description about the surface anatomy, especially in terms of our practice of forensic pathology and medicine. Korean association of anatomists has taken the head to revise the old anatomy terms mostly occupied with the old Japanese and banal Chinese types, and we have come to see the Hangeul anatomy terms. These new Hangeul anatomy terms are now used by younger forensic pathologists, newcomer forensic doctors, and present medical students. Present more experienced and older pathologists, however, still use the old terms. It is, therefore, no wonder that investigators, policemen, attorneys, judges and even laymen coming in contact with our autopsy reports might be confused with the terms expressed in that official and publicly trusted documents. We felt that it is time for appropriate guideline about describing the surface anatomy to emerge with the viewpoint of forensic medicine. So we explained and depicted what to designate the region which an external finding lies in and how to use the surface anatomy terms.