A New Proposed Combined CT and MRI Staging System for Covid-19-Associated Rhino-Orbito-Cerebral Fungal Infection: A Multi-center Study with Pathological Correlation.

RATIONALE AND OBJECTIVES: To propose a combined computed tomography (CT) and magnetic resonance imaging (MRI) based classification system in the management of COVID-19-associated rhino-orbito-cerebral (C-ROC) fungal infection and to assess the reliability of such proposed staging system. MATERIALS AND METHODS: This was a multi-center prospective study conducted on 122 adults with previously confirmed COVID-19 infection. CT and contrast-enhanced MRI (CE-MRI) were performed for all patients. Three radiologists (with experience of 8, 10, and 14 years) independently assessed all images. Then, each patient was assigned a radiological stage based on the five stages of the proposed system according to the radiological extent of the fungal infection. The intra-class correlation coefficient (ICC) test assessed the inter-rater agreement. Based on the pathological evaluation of post-operative specimens, a diagnosis of fungal infection was documented. RESULTS: The most prevalent severity stage among all raters was stage IV in 29.5-31.1% patients. The overall inter-rater agreement of the proposed staging system was excellent (ICC 0.971, 95% CI;0.960-0.979). Moreover, the most common detected pathogen was Mucormycosis (n = 87, 71.3%). Furthermore, there was a statistically significant association between the patients' outcome and the severity stage (P value 0.001) and there was no statistically significant association between ethmoid and sphenoid sinus affection and cranial extension (P value 0.081). CONCLUSION: Our proposed combined CT and MRI severity staging system has a high inter-rater agreement. Moreover, it can aid in the early detection of the C-ROC fungal infection, improve preoperative planning, and subsequently improve the patient's outcome.

Nephron index rather than serum FGF 23 predicts endothelial dysfunction in early but not advanced chronic kidney disease patients.

BACKGROUND: Endothelial dysfunction is the primary step for the development of CKD-related cardiovascular disease. Early prediction and management can influence patient survival. Serum testing of FGF 23 hormone and urinary phosphate excretion were studied as predictors of all-cause cardiovascular morbidity in CKD patients; however, their relation to endothelial dysfunction is controversial. A combination of both in one index is hypothesized to increase their sensitivity in detecting endothelial dysfunction, especially in the early stages of CKD before the dominance of hyperphosphatemia, the original risk. METHODS: A cross-sectional comparative analysis between thirty CKD stage 3 patients and sixty stage 4-5 CKD patients was conducted. All patients were tested for markers of mineral bone disorders including serum FGF 23 and 24-h urinary phosphate excretion. A combination of both in one index (nephron index) is calculated and hypothesized to correlate with nephron number. Endothelial dysfunction was assessed by measuring the post-occlusion brachial flow-mediated dilatation (FMD). RESULTS: In univariate and multivariate regression analyses, the nephron index was the only predictor of endothelial dysfunction in individuals with stage 3 CKD (r = 0.74, P 0.01). This was not applied to stage 4-5 CKD patients where serum phosphorus (r = - 0.53, P 0.001), intact PTH (r = - 0.53, P 0.001), uric acid (r = - 0.5, P 0.001), and measured GFR (r = 0.59, P 0.001) were the highest correlates to FMD; the Nephron index had the weakest correlation (r = 0.28, P = 0.02) and is not predictive of endothelial dysfunction. CONCLUSION: Nephron index calculation showed better correlation with endothelial dysfunction than using any of its determinants alone in early stages of CKD when FGF 23 levels are just beginning to rise. In advanced CKD patients, hyperphosphatemia, hyperparathyroidism, hyperuricemia, and measured GFR are more reliable than nephron index.

Multidetector computed tomography (MDCT) angiography in the evaluation of external carotid artery.

BACKGROUND: Knowledge about anatomical variants of the external carotid artery is crucial in head and neck surgery and interventional technique. This work aimed to present the frequency of regular and another variant of the external carotid artery using 128 multidetector computed tomography (MDCT) angiography. MATERIALS AND METHODS: This retrospective study included 120 patients in our university hospital between April 2017 and October 2021. They were 65 men and 55 women (mean age, 45.6 years; range, 18-65 years). They were angiofibroma (10 patients), cerebral stroke (28 patients), partial glossectomy (13 patients), submandibular gland excision (12 patients), parotidectomy (17 patients), mandibulectomy (5 patients), and a thyroidectomy (35 patients). We retrospectively analyzed the level and branches of external carotid arteries on both sides of 120 patients. RESULTS: According to the level of bifurcation; the external carotid artery originated at the level of the upper border of the thyroid cartilage in 164/240 cases (68.3%), and a higher level was detected in 76/ 240 cases (31.7%). The lower level of origin of the external carotid artery was not detected. The superior thyroid, facial, and lingual arteries originated from separate branches of external carotid arteries in 173/240 cases (72.1%). At the same time, the facial arteries originated with lingual arteries in a common trunk in 67/240 cases (27.9%). CONCLUSION: MDCT angiography is a valuable noninvasive diagnostic tool for evaluating the external carotid artery and its branches.

Multi-parametric arterial spin labeling and diffusion-weighted imaging of paranasal sinuses masses.

PURPOSE: To evaluate arterial spin labeling (ASL) and diffusion-weighted imaging (DWI) in discrimination of benign from malignant paranasal sinus (PNS) tumors. MATERIAL AND METHODS: A prospective study was done upon 42 cases of PNS masses that underwent magnetic resonance ASL and DWI of the head. Tumor blood flow (TBF) and apparent diffusion coefficient (ADC) of the masses were calculated by two observers. The pathological diagnosis was malignant (n = 28) and benign (n = 14) cases. RESULTS: For both observers, the malignant PNS masses had significantly higher TBF (P < 0.001, 0.001) and lower ADC (P < 0.001, 0.001) than in benign masses. The ROC curve analysis of TBF, The threshed TBF was (121.45, 122.68 mL/100 g/min) used for differentiation between benign and malignant PNS masses, revealed sensitivity (92.9%, 89.3%), specificity (85.7%, 85.7%), accuracy (90.5%, 88.1%) and the AUC was 0.87 and 0.86 by both observers. the ROC curve analysis of ADC, The threshold ADC (1.215, 1.205 X10-3mm2/s) was used for differentiation between benign and malignant PNS masses, revealed sensitivity (96.4%, 89.3%), specificity (78.6%, 78.6%), accuracy of (90.5%, 85.7%) and the AUC was 0.93 and 0.92 by both observers. Combined analysis of TBF and ADC used for differentiation between benign and malignant PNS masses had revealed sensitivity (96.4%, 89.3%), specificity (92.9%, 85.7%) accuracy of (95.2%, 88.1%) and AUC. (0.995, 0.985) for both observers. CONCLUSION: Combined using of TBF and ADC have a role in differentiation malignant from benign PNS masses.

Characterization of regulatory T cells in SARS-CoV-2 infected hemodialysis patients: relation to clinical and radiological severity.

BACKGROUND: Disordered Treg counts and function have been observed in patients with SARS-Cov-2 and are thought to contribute to disease severity. In hemodialysis patients, scarce data are available on the Treg response to SARS-CoV-2 or its relation to the clinical presentation. METHODS: A cross-sectional study included one hundred patients divided into three groups, thirty SARS-CoV-2-infected hemodialysis patients (COV-HD), and thirty confirmed SARSCoV-2 infected patients (COV), and forty non-infected hemodialysis patients (HD). Flow cytometric analysis of CD4, CD25, FoxP3, and CD39+ Tregs was done for all patients and tested for correlation to in-hospital mortality, clinical, radiological severity indices. RESULTS: COV-HD and COV patients had significantly lower Treg cell count than HD patients (Median value of 0.016 cell/ µl vs 0.28 cell/ µl, respectively- P: 0.001). COV-HD patients had higher CD39+ Tregs (median value of 0.006 cell/ µl vs 0.002 cell/ µl, respectively- P: 0.04). COV-HD patients had significantly lower hospital stay (median value of 3 vs 13 days, P:0.001), ICU admission rates (26.5% vs 46.7%, P:0.005) and in-hospital mortality (20.7% versus 43.3%, P:0.003) than COV patients. Treg and CD39 expressing Treg counts were not correlated to severity indices in both groups. A high neutrophil to lymphocyte ratio is strongly correlated to disease severity in COV-HD patients. CONCLUSIONS: This study provides evidence of T-cell, particularly T-regulatory cell decline in SARS-CoV-2 and suggests that hemodialysis per se does not distinctively impact the T-cell response. COV-HD patients exhibited a higher CD39+ Treg count and a better clinical profile, however, larger studies are needed to extrapolate on these findings.

COVID-19-associated acute invasive fungal sinusitis: Clinical and imaging findings.

BACKGROUND AND PURPOSE: The purpose is to provide a comprehensive report describing the clinical and imaging features of Coronavirus disease 2019 (COVID-19)-related acute invasive fungal sinusitis (AIFS) and associated comorbidities. METHODS: A retrospective study was conducted on 25 patients (12 males and 13 females, mean age of 53.9±9.1 years). All patients had positive polymerase chain reaction test for COVID-19 and histopathological proof of AIFS. Patients underwent computed tomography (CT) and magnetic resonance examinations to assess sinonasal, orbital, and cranial spread. RESULTS: The most prevalent comorbidity among the study cohort was diabetes mellitus (DM). Twenty-one patients (84%) were diagnosed in the post-COVID-19 period after hospital discharge, with a mean interval of 19.1±9.2 days. Steroid treatment was given to 19 patients (76%). Orbital manifestations were the presenting symptoms in all patients, followed by facial edema, nasal discharge, and neurological symptoms. Sinonasal involvement ranged from mucosal thickening to complete sinus opacification by a predominant isodensity on CT, low T1, and high T2 signal intensity with variable enhancement patterns. Twenty-four patients had a unilateral orbital extension, and 12 patients showed signs of intracranial extension. Bone involvement was detected in 16 patients (64%). Follow-up scans in 18 patients (72%) showed rapid progression of the disease. Eight patients (32%) died, six from neurological complications and two from severe respiratory failure. CONCLUSION: Steroids, DM, and severe COVID-19 are the major risk factors of AIFS in the post-COVID-19 era. Imaging scans in all patients revealed different sinonasal, facial, orbital features, and intracranial involvement with rapid progression of the findings on follow-up scans.

Aorta unfolding index as an indicator for coronary artery disease severity.

BACKGROUND: Aortic unfolding index (AUI) is an independent predictor of cardiovascular events, yet there is scarcity in the literature on its association with the severity of coronary artery disease (CAD). PURPOSE: To investigate the correlation between aortic unfolding and coronary artery disease severity score. MATERIAL AND METHODS: The study included 115 patients with various degrees of CAD who underwent invasive coronary angiography and were retrospectively studied. AUI derived from non-contrast computed tomography (CT) of the chest was correlated to the Gensini score describing the CAD severity. Its sensitivity and specificity in the detection of severe stenosis were examined at various cutoff points. RESULTS: CAD severity was significantly correlated with the patient age and AUI. On multivariate regression analysis, AUI was an independent predictor of severe CAD. The best cutoff value was ≥66, with 94.9% sensitivity and 81.6% specificity. CONCLUSION: AUI ≥66 was a predictor of severe CAD independent of the patient age.

The role of multidetector computed tomography enterography in the evaluation of localized malignant small intestinal lesions: retrospective radiological and pathological experience.

PURPOSE: Our purpose is to present our experience in using multidetector computed tomography (MDCT) enterography in the evaluation of localized malignant small intestinal lesions with pathological correlation. MATERIAL AND METHODS: We retrospectively evaluated 53 patients of pathologically proven malignant localized small intestinal tumours, who underwent multidetector CT enterography. RESULTS: In this study, the mean age was 51.39 ± 17.4 years. The most commonly affected age group was from 50 to 59 years. The commonest clinical complaint was abdominal pain. The ileum was the most commonly affected anatomical region, showing 25 lesions (47.16%). Radiologically irregular/asymmetric wall thickening was detected in 42 cases(79.24%). Pathologically the most common malignancy was small intestinal adenocarcinoma, followed by carcinoid tumour, lymphoma, and gastrointestinal stromal tumours (GIST). We found that there was a statistically significant association between the pathological lymphadenopathy (p = 0.005) and absent proximal intestinal dilatation (p = 0.01) with intestinal lymphoma. Also, there was a statistically significant association between the extra-intestinal mesenteric fat changes with carcinoid tumours (p = 0.001). Irregular/asymmetric wall thickening was detected in 14 cases of small intestinal adenocarcinoma with a statistically significant association (p = 0.001) while exophytic pathological mass formation was statistically significant associated (p ≤ 0.001) with small intestinal GIST. CONCLUSIONS: Multidetector CT enterography is a non-invasive and accurate method in the evaluation of focal and localized small intestinal malignant lesions. The accurate detection of these lesions depends to some degree on the experience of the radiologist, lesional size, site and pattern of enhancement, as well as adequate intestinal distension.

Diffusion Tensor Imaging in early prediction of renal fibrosis in patients with renal disease: Functional and histopathological correlations.

AIM: Renal fibrosis (RF) is a well-known marker of chronic kidney disease (CKD) progression. However, renal biopsy is an available tool for evaluation of RF, non-invasive tools are needed not only to detect but also to monitor the progression of fibrosis. The aim of this study is to evaluate the role of diffusion tensor imaging (DTI) in the assessment of renal dysfunction and RF in patients with renal disease. METHODS: Fifty-six patients with renal disorders and 22 healthy controls were recruited. All participants underwent DTI. Renal biopsy was performed for all patients. Mean renal medullary and cortical fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were compared between patients and healthy controls and correlated to serum creatinine (SCr), estimated glomerular filtration rate (eGFR), 24-h urinary protein (24h-UPRO) and renal histopathological scores. RESULTS: Cortical FA values were significantly higher (P = .001), while cortical ADC values were significantly lower in the patients' group (P = .002). Cortical FA values positively correlated to SCr (P = .006) and negatively correlated to eGFR (P = .03), while cortical ADC negatively correlated to percentage of sclerotic glomeruli, atrophic tubules and interstitial fibrosis (P = .001 for all variables). Medullary ADC negatively correlated to tubular atrophy (P = .02). The diagnostic performance of DTI for detecting RF was supported by ROC curve. Multiple linear regression analysis revealed that the mean cortex ADC was significantly decreased by 0.199 mg/dL for patients with >50% glomerulosclerosis in renal biopsy. CONCLUSION: DTI appears to represent a valuable tool for the non-invasive assessment of renal dysfunction and renal fibrosis.