Sharp recanalization of CBD occlusion in patient with second orthotropic liver transplant with cocoon syndrome.

Biliary complications after orthotopic liver transplant (OLT) remain one of the primary causes of morbidity and mortality in liver transplant recipients with an approximate incidence between 5% and 32%. Given the limited supply of hepatic grafts, one of the most feared outcomes as a result of biliary complications is acute and or chronic graft failure. Biliary complications include leaks, biliary stasis, and stone formation, sphincter of Oddi dysfunction, recurrence of biliary disease (primary sclerosing cholangitis and primary biliary cirrhosis), and biliary strictures/obstruction. Overwhelmingly, the most common complication in hepatic transplantation is biliary stricture formation accounting for more than 50%. Currently, the mainstay of therapy as it pertains to biliary strictures/obstruction includes endoscopic retrograde cholangiography-guided therapy, percutaneous transhepatic cholangiography-guided therapy, or surgical revision/retransplantation. We present a case of biliary obstruction in a patient with a second liver transplant complicated by Cocoon Syndrome managed via sharp recanalization of CBD occlusion and placement of an endoscopic biliary Viabil stent.

ACR Appropriateness Criteria® Clinically Suspected Vascular Malformation of the Extremities.

Vascular malformations of the extremities represent a wide spectrum of lesions, broadly divided into high-flow and low-flow categories. High-flow lesions include arteriovenous malformations and arteriovenous fistulas, while the more common low-flow lesions consist of venous and lymphatic malformations. The clinical presentation of vascular malformations is variable and can include extremity pain, discoloration, focal mass, or diffuse extremity enlargement. A vascular murmur can also be present and is more typical of high-flow lesions. While vascular malformations can often be diagnosed or strongly suspected by clinical features alone, imaging is often used to confirm the diagnosis, determine lesion characteristics and extent, and/or plan for treatment. Among the imaging options available, those usually appropriate for initial imaging of suspected vascular malformation are MR angiography without and with intravenous contrast, MRI without and with intravenous contrast, CT angiography with intravenous contrast, or US duplex Doppler. 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.

The SLH-domain protein BslO is a determinant of Bacillus anthracis chain length.

The Gram-positive pathogen Bacillus anthracis grows in characteristic chains of individual, rod-shaped cells. Here, we report the cell-separating activity of BslO, a putative N-acetylglucosaminidase bearing three N-terminal S-layer homology (SLH) domains for association with the secondary cell wall polysaccharide (SCWP). Mutants with an insertional lesion in the bslO gene exhibit exaggerated chain lengths, although individual cell dimensions are unchanged. Purified BslO complements this phenotype in trans, effectively dispersing chains of bslO-deficient bacilli without lysis and localizing to the septa of vegetative cells. Compared with the extremely long chain lengths of csaB bacilli, which are incapable of binding proteins with SLH-domains to SCWP, bslO mutants demonstrate a chaining phenotype that is intermediate between wild-type and csaB. Computational simulation suggests that BslO effects a non-random distribution of B. anthracis chain lengths, implying that all septa are not equal candidates for separation.