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BackgroundSarcopenia and visceral fat independently predict poor outcomes in Crohn’s disease (CD). However, combined influence of these parameters on outcomes is unknown, and was investigated in the present study.MethodsThis retrospective study evaluated skeletal muscle index (SMI-cross-sectional area of five skeletal muscles normalized for height), visceral and subcutaneous fat area and their ratio (VF/SC) on single-slice computed tomography (CT) images at L3 vertebrae in CD patients (CT done: January 2012-December 2015, patients followed till December 2019). Sarcopenia was defined as SMI < 36.5 cm2/m2 and 30.2 cm2/m2 for males and females, respectively. Disease severity, behavior, and long-term outcomes (surgery and disease course) were compared with respect to sarcopenia and VF/SC ratio.ResultsForty-four patients [age at onset: 34.4 ± 14.1 years, median disease duration: 48 (24–95) months, follow-up duration: 32 (12–53.5) months, males: 63.6%] were included. Prevalence of sarcopenia was 43%, more in females, but independent of age, disease severity, behavior and location. More patients with sarcopenia underwent surgery (31.6% vs 4%, p = 0.01). VF/SC was significantly higher in patients who underwent surgery (1.76 + 1.31 vs 0.9 + 0.41, p = 0.002), and a cutoff of 0.88 could predict surgery with sensitivity and specificity of 71% and 65% respectively. On survival analysis, probability of remaining free of surgery was lower in patients with sarcopenia (59.6% vs 94.1% p = 0.01) and those with VF/SC > 0.88 (66.1% vs 91.1%, p = 0.1), and still lower in those with both sarcopenia and VF/SC > 0.88 than those with either or none (38% vs 82% vs 100%, p = 0.01).ConclusionsCombination of sarcopenia and high visceral fat predict worse outcomes in CD than either.

Pancreatoduodenectomy (PD) also known as Whipple procedure is done for malignant lesions involving the distal CBD, duodenum, ampulla and pancreatic head. In the absence of peritoneal and distant metastases, resectability of the lesion is mainly determined by the relationship of the lesion with the vascular structures in the vicinity. Vascular variations of the celiac artery branches are common and PD, a complex surgical procedure, becomes more challenging if the vascular variations are present. In borderline resectable lesions advances in neoadjuvant therapies and refined surgical techniques are pushing the boundaries of resection. Extended PD is done in borderline resectable lesions when resection and reconstruction of portal vein involved by the primary mass and dissection of extended lymph nodal stations are intended. In this era where more borderline cases are undergoing surgery, it is essential for the radiologist to understand the procedure and the implications of variations in vascular anatomy. Though there are many radiology literatures available on the diagnostic and resectability criteria related to normal vessel anatomy there are very few on the importance of the variant arterial anatomy. The purpose of this review is to familiarize the readers with these variant vessels which can help the surgeons in their intraoperative identification and consequently improve surgical outcomes.

Objective was to assess the precision and reproducibility of spatial penalty-based intravoxel incoherent motion (IVIM) methods in comparison to the conventional bi-exponential (BE) model-based IVIM methods. IVIM-MRI (11 b-values; 0–800 s/mm 2 ) of forty patients (N = 40; Age = 17.7 ± 5.9 years; Male:Female = 30:10) with biopsy-proven osteosarcoma were acquired on a 1.5 Tesla scanner at 3 time-points: (i) baseline, (ii) after 1-cycle and (iii) after 3-cycles of neoadjuvant chemotherapy. Diffusion coefficient (D), Perfusion coefficient (D*) and Perfusion fraction (f) were estimated at three time-points in whole tumor and healthy muscle tissue using five methodologies (1) BE with three-parameter-fitting (BE), (2) Segmented-BE with two-parameter-fitting (BESeg-2), (3) Segmented-BE with one-parameter-fitting (BESeg-1), (4) BE with adaptive Total-Variation-penalty (BE + TV) and (5) BE with adaptive Huber-penalty (BE + HPF). Within-subject coefficient-of-variation (wCV) and between-subject coefficient-of-variation (bCV) of IVIM parameters were measured in healthy and tumor tissue. For precision and reproducibility, intra-scan comparison of wCV and bCV among five IVIM methods were performed using Friedman test followed by Wilcoxon-signed-ranks (WSR) post-hoc test. Experimental results demonstrated that BE + TV and BE + HPF showed significantly (p < 10 –3 ) lower wCV and bCV for D (wCV: 24–32%; bCV: 22–31%) than BE method (wCV: 38–49%; bCV: 36–46%) across three time-points in healthy muscle and tumor. BE + TV and BE + HPF also demonstrated significantly (p < 10 –3 ) lower wCV and bCV for estimating D* (wCV: 89–108%; bCV: 83–102%) and f (wCV: 55–60%; bCV: 56–60%) than BE, BESeg-2 and BESeg-1 methods (D*-wCV: 102–122%; D*-bCV: 98–114% and f-wCV: 96–130%; f-bCV: 94–125%) in both tumor and healthy tissue across three time-points. Spatial penalty based IVIM analysis methods BE + TV and BE + HPF demonstrated lower variability and improved precision and reproducibility in the current clinical settings.

Non-alcoholic fatty liver disease (NAFLD) is a spectrum of disease ranging from simple steatosis, non-alcoholic steatohepatitis (NASH), through to advanced fibrosis and cirrhosis. We assessed the prevalence, spectrum, and determinants of NAFLD among adults in urban and rural North India. A representative sample of adults aged 30-60 years were recruited from urban Delhi and rural Ballabhgarh during 2017-2019. Participants underwent abdominal ultrasonography (USG) and vibration controlled transient elastography (VCTE) with FibroScan to assess fatty liver and fibrosis, respectively. We estimated the age- and sex-standardised prevalence of NAFLD and its spectrum. The factors associated with 'ultrasound-diagnosed NAFLD' were identified using multivariate logistic regression. A total of 828 urban (mean ± SD age: 45.5 ± 8.0 years; women: 52.7%) and 832 rural (mean ± SD age: 45.1 ± 7.9 years; women: 62.4%) participants were recruited. The age- and sex-standardized prevalence of ultrasound-diagnosed NAFLD was 65.7% (95%CI: 60.3-71.2) in the urban and 61.1% (55.8-66.5) in the rural areas, respectively. The prevalence of NAFLD with elevated alanine transaminase (≥40IU/L) was 23.2% (19.8-26.6), and 22.5% (19.0-26.0) and any fibrosis by liver stiffness measurement on transient elastography (≥6.9 kPa) was 16.5% (13.8-19.8) and 5.2% (3.8-6.7) in urban and rural participants, respectively. In both urban and rural areas, diabetes, central obesity and insulin resistance were significantly associated with NAFLD. NAFLD prevalence was high among rural and urban North Indian adults, including fibrosis or raised hepatic enzymes. The strong association of metabolic determinants confirms its linkage with metabolic syndrome.

ObjectiveHistopathological examination (HPE) is the current gold standard for assessing chemotherapy response to tumor, but it is possible only after surgery. The purpose of the study was to develop a noninvasive, imaging-based robust method to delineate, visualize, and quantify the proportions of necrosis and viable tissue present within the tumor along with peritumoral edema before and after neoadjuvant chemotherapy (NACT) and to evaluate treatment response with correlation to HPE necrosis after surgery.MethodsThe MRI dataset of 30 patients (N = 30; male:female = 24:6; age = 17.6 ± 2.7 years) with osteosarcoma was acquired using 1.5 T Philips Achieva MRI scanner before (baseline) and after 3 cycles of NACT (follow-up). After NACT, all patients underwent surgical resection followed by HPE. Simple linear iterative clustering supervoxels and Otsu multithresholding were combined to develop the proposed method—SLICs+MTh—to subsegment and quantify viable and nonviable regions within tumor using multiparametric MRI. Manually drawn ground-truth ROIs and SLICs+MTh-based segmentation of tumor, edema, and necrosis were compared using Jacquard index (JI), Dice coefficient (DC), precision (P), and recall (R). Postcontrast T1W images (PC-T1W) were used to validate the SLICs+MTh-based necrosis. SLICs+MTh-based necrosis volume at follow-up was compared with HPE necrosis using paired t test (p ≤ 0.05).ResultsActive tumor, necrosis, and edema were segmented with moderate to satisfactory accuracy (JI = 62–78%; DC = 72–87%; P = 67–87%; R = 63–88%). Qualitatively and quantitatively (DC = 74 ± 9%), the SLICs+MTh-based necrosis area correlated well with the hypointense necrosis areas in PC-T1W. No significant difference (paired t test, p = 0.26; Bland–Altman plot, bias = 2.47) between SLICs+MTh-based necrosis at follow-up and HPE necrosis was observed.ConclusionThe proposed multiparametric MRI-based SLICs+MTh method performs noninvasive assessment of NACT response in osteosarcoma that may improve cancer treatment monitoring, planning, and overall prognosis.Key Points• The simple linear iterative clustering supervoxels and Otsu multithresholding-based technique (SLICs+MTh) successfully estimates the proportion of necrosis, viable tumor, and edema in osteosarcoma in the course of chemotherapy.• The proposed technique is noninvasive and uses multiparametric MRI to measure necrosis as an indication of anticancer treatment response.• SLICs+MTh-based necrosis was in satisfactory agreement with histological necrosis after surgery.

Aims/Introduction This study aims to evaluate the prevalence of and factors associated with non‐alcoholic fatty liver disease (NAFLD) in Indian women with prior gestational diabetes mellitus (GDM) diagnosed using International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. Materials and Methods This cross‐sectional study (2018–2019) enrolled women with and without prior GDM. Study participants underwent detailed assessments, including relevant medical, obstetric and demographic details; 75‐g oral glucose tolerance test with glucose and insulin estimation at 0, 30 and 120 min; and other relevant biochemical and anthropometric measurements. NAFLD status was defined by ultrasonography. Results We evaluated a total of 309 women (201 and 108 with and without prior GDM, respectively) at a mean age of 31.9 ± 5.0 years and median of 16 months (interquartile range 9–38 months) following the index delivery. The prevalence of NAFLD was significantly higher in women with prior GDM (62.7% vs 50.0%, P = 0.038; grade 2 and 3 disease, 13.9% vs 6.5%). On logistic regression analysis (fully adjusted model), the odds of NAFLD were 2.11‐fold higher in women with prior GDM (95% confidence interval 1.16–3.85, P = 0.014). Overweight/obesity, metabolic syndrome, prediabetes and homeostasis model of assessment of insulin resistance (a measure of insulin resistance) were positively associated with NAFLD, whereas the Matsuda index (a measure of insulin sensitivity) showed a negative association with NAFLD. Conclusions The prevalence of NAFLD is high in women with prior GDM. Such women also have a high burden of cardiometabolic risk factors. Future studies should evaluate the intermediate and long‐term hepatic and cardiovascular risk, and the impact of lifestyle interventions in reducing morbidity in such women. This study evaluated the prevalence and risk factors of non‐alcoholic fatty liver disease in Indian women with prior gestational diabetes mellitus diagnosed using International Association of Diabetes and Pregnancy Study Groups criteria. Ultrasonography of abdomen was used to define non‐alcoholic fatty liver disease status. Prevalence of non‐alcoholic fatty liver disease was significantly higher in women with prior gestational diabetes mellitus (62.7% vs 50.0%, P = 0.038; grade 2 and 3 disease, 13.9% vs 6.5%).

Chest X-ray, the established standard of confirming endotracheal tube (ETT) position, has important drawbacks including radiation exposure. Point-of-care airway ultrasound, which has been insufficiently studied in children, can overcome these problems. This was a prospective cross-sectional study done on children aged 2 months to 17 years undergoing intubation with cuffed ETT in the PICU. The ETT cuff was filled with saline and three ultrasonographic techniques were used– 1) Suprasternal (SS) method 2) Cricoid (CC) metho and 3) Tracheal ring (TR) method. Position of the ETT as determined by ultrasound and X-ray were compared. The main outcomes were sensitivity, specificity, and area under curve (AUC) for ultrasound-based methods vs. X-ray. For the TR method, concordance between the X-ray and ultrasound categories were taken. Total 62 patients were enrolled. The sensitivity and specificity of SS method were 71% (95% CI: 57–83%) and 100% (40–100%). The CC distance method had an AUC of 0.94 (95% CI: 0.86, 1.0). In the TR method, 98% of correct position on X-ray were correctly classified by USG. The agreement between X-ray and ultrasound categories with the cuff between the first and third tracheal rings, was very good [kappa (95% CI): 0.87 (0.70, 1.00), p ≤0.001)]. Bedside ultrasound is a good method to confirm ETT depth in children. The tracheal ring method had the best diagnostic accuracy and is easy to perform. The new method using cricoid cuff distance needs further validation in different ICU settings. •Chest X-ray the current gold standard for confirming correct endotracheal tube (ETT) position is unsafe.•Ultrasonography in comparison is safer, faster to obtain and easily accessible in ICUs.•We conducted this prospective cross-sectional study in 62 patients.•Three techniques of USG: suprasternal, cricoid and tracheal ring methods were studied.•We found USG to reliably confirm ET tube depth at the bedside.•Of the three methods, the tracheal ring method had the best diagnostic accuracy.

Background Perianal fistulas (PF) affect one-third patients with Crohn’s disease (CD) with limited therapeutic options. There is dearth of literature on safety and efficacy of bone marrow-derived mesenchymal stromal cells (BMSCs) in this population. Methods An open-label, phase I/II, single-arm study was conducted involving local administration of human allogeneic bone marrow-derived mesenchymal stromal cells in perianal fistula of patients with Crohn’s disease refractory to standard therapies. Clinical severity and biomarkers were assessed at baseline and periodically until week 104 , and MRI at week 24 and 104. Primary and secondary objectives were to assess safety and efficacy respectively. Fistula remission was complete closure of fistula openings with < 2 cm perianal collection on MRI, and fistula response was decrease in drainage by ≥ 50%. Change in perianal disease activity index, quality-of-life and Van Assche index on MRI over time was assessed using mixed-effect linear regression model. Results Ten patients (male:8, mean age:27.4 ± 12.0years) were recruited. Self-resolving procedure-related adverse events occurred in three patients, with no follow-up adverse events. In intention to treat analysis at week 24, two patients (20%) achieved fistula remission and seven (70%) had fistula response. At week 52, two (20%) patients were in remission and seven (70%) maintained response. At 104 weeks, two (20%) patients maintained response and one (10%) was in remission. Statistically significant decrease in perianal disease activity index ( P  = 0.008), Van Assche Index ( P  = 0.008) and improvement in quality-of-life ( P  = 0.001) were observed over time. Conclusions Allogeneic BMSCs are safe and effective for the treatment of perianal fistulizing CD with significant improvement in clinical severity and radiological healing. Trial registration The study was prospectively registered on Clinical trials registry – India (CTRI), CTRI/2020/01/022743 on 14 January 2020, http://ctri.nic.in .

Choking is a serious yet often overlooked risk among individuals with Down syndrome (DS), primarily due to their anatomical and neuromuscular vulnerabilities. This case report discusses the sudden choking-related death of an 11-year-old child with DS, emphasizing both clinical and forensic perspectives. The child developed respiratory distress while eating and became unresponsive, leading to a medicolegal investigation. A comprehensive postmortem examination, including verbal autopsy, postmortem computed tomography (PMCT), and traditional autopsy, was performed. PMCT revealed a foreign body obstructing the laryngeal inlet, along with pulmonary interstitial emphysema and diffuse pulmonary edema - findings that strongly suggested antemortem choking. The traditional autopsy also confirmed the presence of a soya chunk completely blocking the laryngeal inlet, with all findings aligning with the PMCT results. This case highlights the role of PMCT as a valuable, non-invasive tool in diagnosing choking-related deaths, especially in cases with minimal external indicators. Given that swallowing difficulties in DS persist into adulthood, early screening, caregiver education, and dietary modifications are critical preventive measures. Training caregivers to recognize choking risks, adopt safe feeding practices, and respond promptly to airway obstruction could significantly reduce such fatalities. Forensic pathologists should also consider choking as a differential diagnosis in sudden unexplained deaths, with PMCT aiding in a thorough assessment of airway compromise. Strengthening preventive strategies and improving diagnostic approaches can help mitigate the risk of choking-related deaths in individuals with DS.

Background Early prediction of response to neoadjuvant chemotherapy (NACT) is important to aid personalized treatment in osteosarcoma. Diffusion-weighted Intravoxel Incoherent Motion (IVIM) MRI was used to evaluate the predictive value for response to NACT and survival outcome in osteosarcoma. Methods Total fifty-five patients with biopsy-proven osteosarcoma were recruited prospectively, among them 35 patients were further analysed. Patients underwent 3 cycles of NACT (Cisplatin + Doxorubicin) followed by surgery and response adapted adjuvant chemotherapy. Treatment outcomes were histopathological response to NACT (good-response ≥ 50% necrosis and poor-response < 50% necrosis) and survival outcome (event-free survival (EFS) and overall survival (OS)). IVIM MRI was acquired at 1.5T at baseline (t0), after 1-cycle (t1) and after 3-cycles (t2) of NACT. Quantitative IVIM parameters ( D, D*, f & D*.f ) were estimated using advanced state-of-the-art spatial penalty based IVIM analysis method bi-exponential model with total-variation penalty function (BETV) at 3 time-points and histogram analysis was performed. Results Good-responders: Poor-responders ratio was 13 (37%):22 (63%). EFS and OS were 31% and 69% with 16.27 and 25.9 months of median duration respectively. For predicting poor-response to NACT, IVIM parameters showed AUC = 0.87, Sensitivity = 86%, Specificity = 77% at t0, and AUC = 0.96, Sensitivity = 86%, Specificity = 100% at t1. Multivariate Cox regression analysis showed smaller tumour volume (HR = 1.002, p  = 0.001) higher ADC -25 th -percentile (HR = 0.047, p  = 0.005) & D -Mean (HR = 0.1, p  = 0.023) and lower D*- Mean (HR = 1.052, p  = 0.039) were independent predictors of longer EFS (log-rank p -values: 0.054, 0.0034, 0.0017, 0.0019 respectively) and non-metastatic disease (HR = 4.33, p  < 10 –3 ), smaller tumour-volume (HR = 1.001, p  = 0.042), lower D* -Mean (HR = 1.045, p  = 0.056) and higher D*.f- skewness (HR = 0.544, p  = 0.048) were independent predictors of longer OS (log-rank p -values: < 10 –3 , 0.07, < 10 –3 , 0.019 respectively). Conclusion IVIM parameters obtained with a 1.5T scanner along with novel BETV method and their histogram analysis indicating tumour heterogeneity were informative in characterizing NACT response and survival outcome in osteosarcoma.