Traditional teaching methods in radiology education have not kept pace with advances in technology that foster successful transition into independent practice. This deficit has been exacerbated by the COVID-19 pandemic, as the need for social distancing and the introduction of hybrid staffing models have decreased the critical educational interactions at the reading room workstations between staff and trainees. By leveraging interactive, case-based learning, educators have the opportunity to bridge the substantial gap between basic pattern recognition and successfully making a diagnosis in independent practice. For the educator, this signals a shift away from perfect case selection and presenter authority, and toward the role of a guide facilitating an active case-based learning experience. This form of learning is best accompanied by guided interpretation and iterative feedback with the goal of developing similar levels of mastery and autonomy among graduating trainees. In this article, we present the tools and methods for incorporating interactive cases into existing and novel teaching materials to meet the unique challenges educators are facing today.

This case report discusses a diagnosis of uterine torsion in an 84-year-old woman who presented with five days of right lower quadrant abdominal pain, nausea, vomiting, constipation, and poor intake. Computed tomography (CT) imaging demonstrated a whorled configuration at the junction of the cervix and lower uterine segment, with the left gonadal vein crossing midline, and two previously known right leiomyomas now appearing on the left. These findings were consistent with the diagnosis of uterine torsion. She then underwent an urgent exploratory laparotomy, and the uterus was found to be dextroverted 270 degrees, with dark mottled purple tissue and engorged vessels. A supracervical hysterectomy and bilateral salpingo-oopherectomy were performed. Final pathology demonstrated extensive necrosis. This case reviews the classic presentation and imaging findings for the rare diagnosis of uterine torsion and options for management of both non-gravid and gravid patients.

Background: Peristalsis-related streak artifacts on the liver compromise image quality and diagnostic accuracy. Purpose: To assess dual-layer spectral-detector computed tomography (CT) image reconstructions for reducing intestinal peristalsis-related streak artifacts on the liver. Methods: We retrospectively evaluated 220 contrast-enhanced abdominal dual-energy CT scans in 131 consecutive patients (mean age: 68 ± 10 years, 120 men) who underwent routine clinical dual-layer spectral-detector CT imaging (120 kVp, 40 keV, 200 keV, virtual non-contrast (VNC), iodine images). Two independent readers evaluated bowel peristalsis streak artifacts on the liver qualitatively on a five-point Likert scale (1 = none to 5 = severe) and quantitatively by depth of streak artifact extension into the liver and measurements of Hounsfield Unit and iodine concentration differences from normal liver. Artifact severity between image reconstructions were compared by Wilcoxon signed-rank and paired t-tests. Results: 12 scans were excluded due to missing spectral data, artifacts on the liver originating from metallic foreign materials, or oral contrast material. Streak artifacts on the liver were seen in 51/208 (25%) scans and involved the left lobe only in 49/51 (96%), the right lobe only in 0/51 (0%), and both lobes in 2/51 (4%) scans. Artifact frequency was lower in iodine than in 120 kVp images (scans 18/208 vs. 51/208, p < 0.001). Artifact severity was less in iodine than in 120 kVp images (median score 1 vs. 3, p < 0.001). Streak artifact extension into the liver was shorter in iodine than 120 kVp images (mean length 2 ± 4 vs. 12 ± 5 mm, p < 0.001). Hounsfield Unit and iodine concentration differed significantly between bright streak artifacts and normal liver in 120 kVp, 40 keV, 200 keV, and VNC images (p < 0.001, each), but not in iodine images (p = 0.23). Conclusion: Intestinal peristalsis-related streak artifacts commonly affect the left liver lobe at CT and can be substantially reduced by viewing iodine dual-energy CT image reconstructions.

Purpose: To assess the influence of different dual-energy CT (DECT) scanner techniques on the severity of visceral-motion-related artifacts on the liver. Methods: Two independent readers retrospectively evaluated visceral-motion-related artifacts on the liver on 120-kVp(-like), monoenergetic low- and high-keV, virtual non-contrast (VNC), and iodine images acquired on a dual-source, twin-beam, fast kV-switching, and dual-layer spectral detector scanner. Quantitative assessment: Depth of artifact extension into the liver, measurements of Hounsfield Units (HU) and iodine concentrations. Qualitative assessment: Five-point Likert scale (1 = none to 5 = severe). Artifact severity between image reconstructions were compared by Wilcoxon signed-rank and paired t-tests. Results: 615 contrast-enhanced routine clinical DECT scans of the abdomen were evaluated in 458 consecutive patients (mean age: 61 ± 14 years, 331 men). For dual-source and twin-beam scanners, depth of extension of artifacts into the liver was significantly shorter and artifact severity scores significantly lower for 120-kVp-like images compared with the other image reconstructions (p < 0.001, each). For fast kV-switching and spectral detector scanner images, depth of extension of artifacts was significantly shorter and artifact severity scores significantly lower for iodine images (p < 0.001, each). Dual-source 120-kVp-like and spectral detector iodine images reduced artifacts to an extent that no significant difference in HU or iodine concentrations between artifacts (dual-source: 97 HU, spectral detector: 1.9 mg/mL) and unaffected liver parenchyma (dual-source: 108 HU, spectral detector: 2.1 mg/mL) was measurable (dual-source: p = 0.32, spectral detector: p = 0.15). Conclusion: Visceral-motion-related artifacts on the liver can be markedly reduced by viewing 120-kVp-like images for dual-source and twin-beam DECT scanners and iodine images for fast kV-switching and dual-layer spectral detector DECT scanners.

Our studies on novel cyst wall proteins serendipitously led us to the discovery that cyst wall and vacuolar matrix protein MAG1, first identified a quarter of a century ago, functions as a secreted immunomodulatory effector. MAG1 is a dense granular protein that is found in the parasitophorous vacuolar matrix in tachyzoite vacuoles and the cyst wall and matrix in bradyzoite vacuoles. In the current study, we demonstrated that MAG1 is secreted beyond the parasitophorous vacuole into the host cytosol in both tachyzoites and bradyzoites. Secretion of MAG1 gradually decreases as the parasitophorous vacuole matures, but prominent MAG1 puncta are present inside host cells even at 4 and 6 days following infection. During acute murine infection, Δmag1 parasites displayed significantly reduced virulence and dissemination. In the chronic stage of infection, Δmag1 parasites generated almost no brain cysts. To identify the mechanism behind the attenuated pathology seen with Δmag1 parasites, various immune responses were screened in vitro using bone marrow-derived macrophages (BMDM). Infection of BMDM with Δmag1 parasites induced a significant increase in interleukin 1β (IL-1β) secretion, which is a hallmark of inflammasome activation. Heterologous complementation of MAG1 in BMDM cells prevented this Δmag1 parasite-induced IL-1β release, indicating that secreted MAG1 in host cytosol dampens inflammasome activation. Furthermore, knocking out GRA15 (an inducer of IL-1β release) in Δmag1 parasites completely inhibited all IL-1β release by host cells following infection. These data suggest that MAG1 has a role as an immunomodulatory molecule and that by suppressing inflammasome activation, it would favor survival of the parasite and the establishment of latent infection.IMPORTANCEToxoplasma gondii is an Apicomplexan that infects a third of humans, causing encephalitis in AIDS patients and intellectual disabilities in congenitally infected patients. We determined that one of the cyst matrix proteins, MAG1, which had been thought to be an innate structural protein, can be secreted into the host cell and suppress the host immune reaction. This particular immune reaction is initiated by another parasite-secreted protein, GRA15. The intricate balance of inflammasome activation by GRA15 and suppression by MAG1 protects mice from acute death while enabling parasites to disseminate and establish chronic cysts. Our finding contributes to our understanding of how parasites persist in the host and how T. gondii modulates the host immune system.

Objective

Reduction in glucocerebrosidase (GCase; encoded by GBA) enzymatic activity has been linked to Parkinson's disease (PD). Here, we correlated GCase activity and PD phenotype in the Parkinson's Progression Markers Initiative (PPMI) cohort.

Methods

We measured GCase activity in dried blood spots from 1559 samples of participants in the inception PPMI cohort, collected in four annual visits (from baseline visit to Year-3). Participants (PD, n = 392; controls, n = 175) were fully sequenced for GBA variants by means of genome-wide genotyping arrays, whole-exome sequencing, whole-genome sequencing, Sanger sequencing, and RNA-sequencing.

Results

Fifty-two PD participants (13.4%) and 13 (7.4%) controls carried a GBA variant. GBA status was strongly associated with GCase activity. Among noncarriers, GCase activity was similar between PD and controls. Among GBA p.E326K carriers (PD, n = 20; controls, n = 5), activity was significantly lower in PD carriers than control carriers (9.53 µmol/L/h vs. 11.68 µmol/L/h, P = 0.035). Glucocerebrosidase activity was moderately (r = 0.45) associated with white blood cell (WBC) count. Next, we divided the noncarriers with PD to tertiles based on WBC count-corrected enzymatic activity. Members of the lower tertile had higher MDS-Unified Parkinson's Disease Rating Scale motor score in the "off" medication examination at year-III exam. Longitudinal analyses demonstrated slight reduction of activity in samples collected earlier on in the study, likely because of longer storage time.

Interpretation

GCase activity is associated with GBA genotype, WBC count, and among p.E326K variant carriers, with PD status. Reduced activity may also be associated with worse phenotype but longer follow up is required to confirm this observation.

Objective

To determine the feasibility, safety and tolerability of lumbar punctures (LPs) in research participants with early Parkinson disease (PD), subjects without evidence of dopaminergic deficiency (SWEDDs) and healthy volunteers (HC).

Background

Cerebrospinal fluid (CSF) analysis is becoming an essential part of the biomarkers discovery effort in PD with still limited data on safety and feasibility of serial LPs in PD participants.

Design/methods

Parkinson's Progression Marker Initiative (PPMI) is a longitudinal observation study designed to identify PD progression biomarkers. All PPMI participants undergo LP at baseline, 6, 12 months and yearly thereafter. CSF collection is performed by a trained investigator using predominantly atraumatic needles. Adverse events (AEs) are monitored by phone one week after LP completion. We analyzed safety data from baseline LPs.

Results

PPMI enrolled 683 participants (423 PD/196 HC/64 SWEDDs) from 23 study sites. CSF was collected at baseline in 97.5% of participants, of whom 5.4% underwent collection under fluoroscopy. 23% participants reported any related AEs, 68% of all AE were mild while 5.6% were severe. The most common AEs were headaches (13%) and low back pain (6.5%) and both occurred more commonly in HC and SWEDDs compared to PD participants. Factors associated with higher incidence of AEs across the cohorts included female gender, younger age and use of traumatic needles with larger diameter. AEs largely did not impact compliance with the future LPs.

Conclusions

LPs are safe and feasible in PD research participants. Specific LP techniques (needle type and gauge) may reduce the overall incidence of AEs.