Ultrasound shear-wave elastography applicability in estimation of post-mortem time.

Introduction: Post-mortem rigidity of the tissues is one of the basic principles in forensic medicine to estimate the time of death. Qualitative methods to determine the stiffness of the corpse may have some limitations. Methods that provide quantitative values may be useful. We intended to evaluate the applicability of ultrasound shear-wave elastography of the tissues to estimate the post-mortem interval (PMI). Methods: For 80 corpses, shear-wave elastography of the liver, sartorius muscle, testis, thyroid and parotid was performed before autopsy. Based on the forensic reports as the reference method to define post-mortem interval, the corpses were divided into four groups: group 0 (PMI < 24 hours), group 1 (PMI ≥24 hours and <48 hours), group 2 (PMI ≥ 48 hours and <72 hours), and group 3 (PMI ≥ 72 hours). There were 24, 38, 13, and 5 corpses, respectively, in groups 0, 1, 2, and 3. Results: A significant rise in the elasticity values in comparison to elasticity of normal tissues in live adults was seen very early in the post-mortem period. Between-group comparisons showed that a significant difference in the liver elasticity was present among the groups. The mean (SD) liver elasticity was 10.29 (±0.83) in group 0, 14.98 (±1.56) in group 1, 12.49 (±1.09) in group 2, and 15.64 (±1.68) kilopascals (kPa) in group 3 (P = 0.035). Nevertheless, elasticity measurements in other tissues were not helpful in distinguishing post-mortem interval groups. Conclusion: It is possible to use liver quantitative shear-wave elastography to estimate the time of death.

Diagnostic performance of lung ultrasound compared to CT scan in the diagnosis of pulmonary lesions of COVID-19 induced pneumonia: a preliminary study.

Chest CT scan is currently used to assess the extent of lung involvement in patients with the coronavirus disease 2019 (COVID-19). The aim of this study was to evaluate the diagnostic performance of lung ultrasound in the diagnosis of COVID-19 pulmonary manifestations in comparison to CT scan. Thirty-three symptomatic patients with suspected COVID-19 pneumonia were evaluated by lung ultrasound and then, at a short interval, chest CT scan. In the anterior chest, each hemithorax was divided into four areas. In the posterior chest, eight zones similar to the anterior part were examined. The axillary areas were also divided into upper and lower zones (20 zones were determined per patient). Mean age of the patients was 58.66 years. The sensitivity (95% CI) and specificity (95% CI) of lung ultrasound for the diagnosis of parenchymal lesions were 90.5% (69.6-98.8%) and 50% (21.1-78.9%), respectively. In the evaluation of pleural lesions, the sensitivity (95% CI) and specificity (95% CI) of lung ultrasound were 100% (71.5-100%) and 22.7% (7.8-45.4%), respectively. Owing to the high sensitivity of ultrasound in identifying lung lesions in patients with COVID-19 pneumonia, it can be recommended to use lung ultrasound as a tool for initial screening of patients with high clinical suspicion for SARS-CoV-2 infection during the pandemic. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s13337-021-00736-w.

Parenteral Anticoagulation and Retroperitoneal Hemorrhage in COVID-19: Case Report of Five Patients.

Since coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state, especially in critical patients, anticoagulation is used for thromboprophylaxis. Hemorrhagic complications, even uncommon ones such as retroperitoneal hemorrhage, can occur following anticoagulant administration. We present 5 patients with COVID-19 whose clinical course was complicated by spontaneous retroperitoneal hemorrhage. The patients were initially presented with respiratory manifestations of the infection. There was no history or evidence suggestive for traumatic injury. After hospitalization, the patients received supplemental oxygen, antibiotics, enoxaparin or heparin, interferon beta-1b (in three patients), and anticoagulation with subcutaneous injection of enoxaparin (three patients) or heparin (two patients). During the course of hospitalization, the patients showed sudden-onset abdominal pain (three cases), hypotension (three cases), and an acute drop in hemoglobin level. CT scan of the abdomen and pelvis revealed retroperitoneal hemorrhage. For one patient, owing to unstable vital signs and an expanding hematoma, surgical intervention was performed. Others were managed conservatively with discontinuation of anticoagulants, intravenous (IV) fluid resuscitation, and packed red blood cells transfusion. Three patients died due to worsening of the infection and respiratory failure. Retroperitoneal hemorrhage could be a potential complication in COVID-19 patients receiving anticoagulation. Careful monitoring of the vital signs and blood tests like hemoglobin level of such patients is essential.

Diagnostic performance of apparent diffusion coefficient (ADC) for differentiating endometrial carcinoma from benign lesions: a systematic review and meta-analysis.

To determine the diagnostic performance of mean ADC values in the characterization of endometrial carcinoma (EC) from benign lesions by systematic review of the literature and performing meta-analysis. A systematic search of major electronic bibliographic databases was performed to find studies that used ADC values for differentiating EC from benign lesions. Two reviewers independently screened the titles and abstracts of the search results and then by reading the full texts selected the pertinent studies for final analyses. A bivariate random-effects model with pooled sensitivity and specificity values with 95% CI (confidence interval) was used. Summary receiver operating characteristic (SROC) curve and area under curve (AUC) were created. Between-study heterogeneity was measured using I squared (I2) index. Eleven studies including 269 ECs and 208 benign lesions were analyzed. Pooled average (95% CI) ADC in EC and benign lesions groups were, respectively, 0.82 (0.77-0.87) × 10-3 mm2/s and 1.41 (1.29-1.52) × 10-3 mm2/s. The combined (95% CI) sensitivity and specificity of mean ADC values for differentiating EC from benign lesions were 93% (87-96%; I2 = 41.19%) and 94% (88-97%; I2 = 46.91%), respectively. The AUC (95% CI) of the SROC curve was 98% (96-99%). ADC values had good diagnostic accuracy for differentiating EC from benign lesions. In order to recommend ADC measurement for detecting endometrial lesions in routine clinical practice, more primary studies, especially trials and comparative studies including hysteroscopically-guided biopsy method, with larger sample sizes are still required.

Risk Factors for Poor Outcome in Patients with Severe Viral Pneumonia on Chest CT during the COVID-19 Outbreak: a Perspective from Iran.

We investigated significant predictors of poor in-hospital outcomes for patients admitted with viral pneumonia during the COVID-19 outbreak in Tehran, Iran. Between February 22 and March 22, 2020, patients who were admitted to three university hospitals during the COVID-19 outbreak in Tehran, Iran were included. Demographic, clinical, laboratory, and chest CT scan findings were gathered. Two radiologists evaluated the distribution and CT features of the lesions and also scored the extent of lung involvement as the sum of three zones in each lung. Of 228 included patients, 45 patients (19.7%) required ICU admission and 34 patients (14.9%) died. According to regression analysis, older age (OR = 1.06; P < 0.001), blood oxygen saturation (SpO2) < 88% (OR = 2.88; P = 0.03), and higher chest CT total score (OR = 1.10; P = 0.03) were significant predictors for in-hospital death. The same three variables were also recognized as significant predictors for invasive respiratory support: SpO2 < 88% (OR = 3.97, P = 0.002), older age (OR = 1.05, P < 0.001), and higher CT total score (OR = 1.13, P = 0.008). Potential predictors of invasive respiratory support and in-hospital death in patients with viral pneumonia were older age, SpO2 < 88%, and higher chest CT score.

Complementary and alternative medicine use among Iranian patients attending urban outpatient general practices.

OBJECTIVE: To determine the frequency of use of different types of CAM among patients who attended outpatient general practices (GP). METHODS: CAM use, type, reason, administration, satisfaction, and disclosure to physician were documented by interviewing 360 patients. RESULTS: A total of 192 individuals (53.3%) reported that they were using or had used at least one form of CAM therapy (a total of 343 CAM therapies). The five most commonly used CAM therapies were, respectively, vitamin supplements (105 subjects, 54.7%), traditional herbal products (80 cases, 41.7%), mineral supplements (58 cases, 30.2%), herbal medicines (49 cases, 25.5%) and dietary therapies (18 cases, 9.4%); 240 therapies (70%) were self-prescribed. CONCLUSION: A substantial number of the patients had used CAM on their own; one-third of these patients did not have sufficient knowledge about the therapies used. Health care providers should be aware of this practice by the patients and seek information about CAM usage.

Brainstem glioma: Prediction of histopathologic grade based on conventional MR imaging.

Objective The objective of this article is to investigate the association between specific MR imaging findings and histopathologic grading (low-grade vs. high-grade) of brainstem gliomas (BSGs). Methods Sixty-two males and 34 females (mean (standard deviation, SD) age of 24.61 (17.20) years, range = 3 to 70 years) with histologically diagnosed BSG underwent conventional 1.5 T MR imaging, which included T1-weighted (T1W), T2W, and post-contrast T1W sequences. There were 39 children (mean age of 9.38 years) and 57 adults (mean age of 35 years). A binary logistic regression analysis was used to explore associations between MRI features and histopathological grade of the BSG. Results Binary logistic regression revealed that necrosis (adjusted odds ratio (OR) = 16.07; 95% confidence interval (CI) = 3.20 to 80.52; p = 0.001) and inhomogeneous contrast enhancement (adjusted OR = 8.04; 95% CI = 1.73 to 37.41; p = 0.008) as significant predictors of high-grade BSG. The equation (Nagelkerke R2 = 0.575) is Logit ( p high-grade BSG) = (2.77 × necrosis) + (2.08 × heterogeneous contrast enhancement) - 3.13. Sensitivity and specificity values were respectively 66.7% and 96.0% for necrosis and 85.7% and 65.9% for inhomogeneous contrast-enhancing lesions. In the pediatric age group, only inhomogeneous contrast enhancement (adjusted OR = 40; 95% CI = 3.95 to 445.73; p = 0.002) was a significant predictor for high-grade BSG. Conclusion Conventional MR imaging features such as necrosis and inhomogeneous contrast enhancement in adults and heterogeneous contrast enhancement in children suggest high-grade BSG.

Association between common bile duct diameter and abdominal aorta calcium score.

BACKGROUND AND OBJECTIVE: There is evidence of association between aging and increase in the normal upper limit of the common bile duct (CBD) diameter. As aging is a documented risk factor for atherosclerosis, and the possible effect that atherosclerosis can have on the CBD diameter via affecting its smooth muscle contractility and blood flow, we decided to determine the association between CBD diameter and atherosclerosis in the abdominal aorta (AA). METHODS: A total of 99 asymptomatic patients (53 males and 46 females; age range of 18-88 years) without history of cholecystectomy who underwent abdominal contrast-enhanced CT scan were included. The CBD diameter was measured. The atherosclerosis of AA was quantified by Agatston score. RESULTS: Mean (± SD) CBD diameter was 6.14 (± 1.95) mm; range = 2.4-12.7 mm. Agatston score was 0 in 59 patients. In the remaining 40 patients, median (interquartile range, IQR) Agatston score was 497.5 (2026.3). Mean (± SD) CBD diameter in patients with Agatston score > 0 was 7.39 (± 2.07) mm compared to 5.29 (± 1.32) mm in patients without calcification plaque (P < 0.001). A moderate correlation was seen between CBD diameter and Agatston score (ρ = 0.43; P = 0.005). CONCLUSION: Although the exact cause of increased CBD diameter with advancing age is not understood, a general atherosclerotic process which occurs with aging may affect smooth muscle of the CBD. Whether an upper limit for normal CBD should be defined or not when evaluating dilated CBD for patients with subclinical or clinical atherosclerosis needs further studies.

Zinc phosphide poisoning with unusual radiologic findings.

Accidental/suicidal ingestion of metal phosphides (e.g., zinc phosphide found in rodenticides) should be suspected in patients with sudden-onset abdominal pain, refractory hypotension, and metabolic acidosis. CT angiography may show radiopaque substance in the stomach and early enhancement of the inferior vena cava and contrast in right side of the heart.

Adherence to Antihypertensive Medications in Iranian Patients.

Introduction. Appropriate adherence to medication is still a challenging issue for hypertensive patients. We determined adherence to antihypertensive(s) and its associated factors among 280 Iranian patients. Methods. They were recruited consecutively from private and university health centers and pharmacies in four cities. The validated Persian version of the 8-item Morisky Medication Adherence Scale (MMAS-8) was administered to measure adherence. Results. Mean (±SD) overall MMAS-8 score was 5.75 (±1.88). About half of the sample (139 cases, 49.6%) showed low adherence (MMAS-8 score < 6). There was a negative linear association between the MMAS-8 score and systolic BP (r = -0.231, P < 0.001) as well as diastolic BP (r = -0.280, P < 0.001). In linear regression model, overweight/obesity (B = -0.52, P = 0.02), previous history of admission to emergency services due to hypertensive crisis (B = -0.79, P = 0.001), and getting medication directly from drugstore without refill prescription in hand (B = -0.51, P = 0.04) were factors recognized to have statistically significant association with the MMAS-8 score. Conclusion. Antihypertensive adherence was unsatisfactory. We suggest that health care providers pay special attention and make use of the aforementioned findings in their routine visits of hypertensive patients to recognize those who are vulnerable to poor adherence.

Primary multifocal myxopapillary ependymoma of the filum terminale.

BACKGROUND: Myxopapillary ependymoma (MPE) is a rare variant of ependymoma usually occurring in the conus medullaris or the filum terminale. It is usually a single encapsulated lesion. The aim of this study was to describe patients with primary multifocal MPE of the filum terminale. METHODS: In this retrospective study, medical records of 22 patients with spinal MPE who underwent surgical treatment in our hospital between January 2003 and January 2010 were enrolled. The study included 14 males and 8 females with age range from 11 to 66 years. There were 14 adult patients and 8 pediatric patients. The clinical presentation was low back pain (LBP), radiculopathy, focal neurological deficit and cranial nerve palsy. RESULTS: Four cases presented with primary multifocal MPE at the filum terminale. All of them had chronic LBP for at least 2-3 years. Three patients had lower extremity radiculopathy and one had urinary incontinence upon presentation. On magnetic resonance imaging (MRI), three patients presented with two lesions and one patient presented with three lesions at different spinal levels (a total of 9 MPEs). All lesions showed enhancement following gadolinium administration on MRI. For 6 tumors en bloc resection was performed. Three lesions were removed gross totally in a piece-meal fashion. Following the surgical management, no postoperative complication occurred. Three patients underwent radiotherapy (RT. On an average follow-up of 6 years with clinical and MRI imaging, no recurrence was detected and symptoms of LBP and neurologic findings improved after 2 months. CONCLUSIONS: Primary multifocal MPE is an extremely rare event occurring in the conus medullaris or filum terminale. The exact pathogenesis of this condition is unclear. Multifocal MPE may be due to multifocal growth of tumors, early stage of growth of a giant tumor or drop metastasis of tumor in the subarachnoid space. En bloc resection or piecemeal resection with radiotherapy were associated with satisfactory outcome without recurrence.

Controlled Blood Pressure in Iranian Patients: A Multi-Center Report.

We decided to determine the percentage of hypertensive patients whose blood pressure (BP) measurements were within recommended controlled range and to identify predictive factors for controlled BP. In this study carried out in 2014, 280 patients were included consecutively through sampling from both university and private medical centers/pharmacies in four Iranian cities. Demographic data as well as information about duration of HTN and prescribed medications, admission to emergency department (ED) because of HTN crisis, comorbidities, and control of HTN during the last 6 months by a healthcare provider were gathered. Adherence to anti-hypertensives was also determined using the validated Persian version of the 8-item Morisky Medication Adherence Scale (MMAS-8). Controlled BP was defined as systolic BP< 140 and diastolic BP< 90 mmHg in non-diabetics and < 130/80 mmHg in diabetics. Of 280 patients, 122 subjects (43.6%) had controlled BP. Among 55 diabetics, only two patients (3.6%) had controlled BP. Multiple logistic regression revealed the following variables as significant predictors of controlled BP: higher MMAS-8 score (adjusted odds ratio (OR)= 1.19, P= 0.03), fewer number of comorbid conditions (adjusted OR= 0.71, P = 0.03), having occupation as clerk/military personnel (adjusted OR= 1.03, P= 0.04), and not having history of ED admission during the last 6 months because of HTN crisis (adjusted OR= 2.11, P= 0.01). Considerable number of the studied patients had uncontrolled BP. Regarding the dramatic consequences of uncontrolled high BP in long term, it is advisable that careful attention by health care providers to the aforementioned factors could raise the likelihood of achieving controlled BP.

Validation of the Persian Version of the 8-Item Morisky Medication Adherence Scale (MMAS-8) in Iranian Hypertensive Patients.

The reliability and validity of the 8-item Morisky Medication Adherence Scale (MMAS-8) was assessed in a sample of Iranian hypertensive patients. In this multi-center study which lasted from August to October 2014, a total of 200 patients who were suffering from hypertension (HTN) and were taking anti-hypertensive medication(s) were included. The cases were accessed through private and university health centers in the cities of Tehran, Karaj, Kermanshah, and Bafgh in Iran and were interviewed face-to-face by the research team. The validated Persian translation of the MMAS-8 was provided by the owner of this scale. This scale contains 7 questions with "Yes" or "No" response choices and an additional Likert-type question (totally 8 questions). The total score ranges from 0 to 8 with higher scores reflecting better medication adherence. Mean (±SD) overall MMAS-8 score was 5.57 (±1.86). There were 108 (54%), 62 (31%), and 30 (15%) patients in the low, moderate, and high adherence groups. Internal consistency was acceptable with an overall Cronbach's ? coefficient of 0.697 and test-retest reliability showed good reproducibility (r= 0.940); P< 0.001. Overall score of the MMAS-8 was significantly correlated with systolic BP (r= - 0.306) and diastolic BP (r= - 0.279) with P< 0.001 for both BP measurements. The Chi-square test showed a significant relationship between adherence level and BP control (P= 0.016). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the scale were 92.8%, 22.3%, 52.9%, and 76.7%, respectively. The Persian version of the MMAS had acceptable reliability and validity in Iranian hypertensive patients. This scale can be used as a standard and reliable tool in future studies to determine medication adherence of Persian-speaking patients with chronic conditions.

Calcified Mass on Brain CT in a Teenager with Refractory Seizures.

Cerebral echinococcosis is very rare, representing 2% of all cystic echinococcosis (CE) cases. Primary echinococcal cysts of the brain are extremely rare in pediatric patients. We report on a 16-year-old boy referred to our tertiary center with intractable epilepsy for the previous three years despite receiving full doses of three antiepileptic medications. Brain computed tomography (CT) showed a left frontal calcified mass. Magnetic resonance imaging (MRI) of the brain revealed a well-defined spherical mass in the left frontal lobe, slightly hypointense on T1-weighted and heterogeneous hyperintense on T2-weighted images with no contrast enhancement. With a broad differential list in mind, a surgical intervention was planned. During surgery, a primary calcified cerebral echinococcal cyst with severe adhesion to the adjacent dura of the frontal region was discovered and removed intact. Histopathology examination confirmed the diagnosis. Only phenobarbital was continued and no medical therapy for CE was administered. Two years after surgery, the patient remained free of seizures. In areas endemic for CE, cerebral echinococcal cyst should be included in the differential list of patients with intractable seizures. Though rare, this entity can present itself as a calcified mass on neuroimaging. Surgical removal of the calcified cyst is necessary for control and treatment of the epilepsy.

Fatal intratumoral hemorrhage in tectal plate glioblastoma multiforme following ventriculoperitoneal shunt.

Ventriculo-peritoneal (V-P) shunting is an accepted procedure before a direct approach to large tumors producing obstructive hydrocephalus. However, it has been associated with some complications. Intratumoral hemorrhage is an uncommon but fatal complication of V-P shunt insertion. The exact mechanism of this complication is unknown, but several mechanisms have been proposed including rapid lowering of intracranial pressure following V-P shunt placement or cerebrospinal fluid (CSF) drainage and sudden decrease in CSF volume and pressure after V-P shunting. We report an 8-year-old girl who presented with severe headache, double vision, and bilateral papilledema. Brain magnetic resonance imaging with and without gadolinium administration revealed a large tectal plate tumor compressing the aqueduct which caused hydrocephalus. Due to progressive decline in consciousness level, an emergency CSF diversion was planned and she underwent left side posterior parietal V-P shunt placement. Eight hours after V-P shunt insertion, she suddenly developed tonic-clonic seizures and collapsed into deep coma with dilated pupils and stopped breathing and died 1-day later. Histological examination of the autopsy specimen showed the tumor was a glioblastoma multiforme with massive intratumoral hemorrhage. The possible pathophysiological mechanisms of this fatal complication are discussed here and the pertinent literature is reviewed. It seems that endoscopic third ventriculostomy is the procedure of choice for CSF diversion in patients with tectal plate gliomas and decreases the occurrence of intratumoral hemorrhage.

Gradenigo's syndrome as first presentation of solitary osseous plasmacytoma of the petrous apex.

Plasma cell tumors of the skull base are rare in neurosurgical practice. True solitary osseous plasmacytoma of the skull base without development of multiple myeloma is extremely rare. We report a case of typical Gradenigo's syndrome, including left abducens nerve palsy, left facial pain and paresthesia in V1 and V2 distribution of trigeminal nerve caused by solitary osseous plasmacytoma of the left petrous apex. The patient was a 46-year-old man who presented with diplopia for two days. Magnetic resonance imaging (MRI) of the brain showed a hyperintense mass on T1-weighted images and slightly hypointense mass on T2-weighted images in the left petrous apex and left parasellar area. Through a left subtemporal middle fossa approach, subtotal resection of the lesion was performed. Histopathological examination of the lesion revealed plasmacytoma. The patient received 54 Gy radiation for the local tumor. Four months after radiation, the abducens palsy improved. Four years after treatment, the patient remained well with no symptoms or signs of local recurrence or progression to multiple myeloma.

Brown tumor of the spine in patients with primary hyperparathyroidism.

STUDY DESIGN: Retrospective case series and literature review. OBJECTIVE: To describe our experience in diagnosis and management of patients with spine brown tumor (osteitis fibrosa cystica) as the initial manifestation of primary hyperparathyroidism and also to review the pertinent literature. SUMMARY OF BACKGROUND DATA: The spine can be involved through reparative processes such as giant cell reparative granuloma and brown tumor, which lead to formation of lesions that can simulate tumors on neuroimaging. Brown tumor, an uncommon focal giant cell lesion, is a nonneoplastic and reactive process due to bone resorption and localized osseous lesion caused by primary or secondary hyperparathyroidism. METHODS: Among the cases of spine giant cell lesions treated surgically by the authors (2000-2013), there were 4 cases of spine brown tumor in patients with primary hyperparathyroidism. Clinical, radiological, histopathologic, and surgical data of these 4 cases were collected, and the patients were followed from 5 to 7 years after the surgical intervention. RESULTS: There were 2 male and 2 female patients with age range of 16 to 52 years. The lesions were located in cervical (1 case), thoracic (1 case), and lumbar (2 cases) spine regions. Clinical presentations included neck and low back pain, radicular pain, paraparesis, and sphincter dysfunction. Surgical removal of the spine lesions was achieved in all cases. Spine fusion and instrumentation was done in 3 cases. Parathyroidectomy was performed in all 4 cases. CONCLUSION: Spine involvement with brown tumor in patients with primary hyperparathyroidism is rare and may be the first manifestation of hyperparathyroidism. Brown tumor should be differentiated from other giant cell lesions involving the spine. Long-term surgical outcome was satisfactory with no recurrence. LEVEL OF EVIDENCE: 4.

Myxopapillary ependymoma of the conus medullaris presenting with intratumoral hemorrhage during weight lifting in a teenager.

Intratumoral hemorrhage within a myxopapillary ependymoma of the conus medullaris and cauda equina is rare. Most patients with myxopapillary ependymoma present insidiously, but they may present with hemorrhage or cauda equina syndrome. Limited number of case reports available has described this condition only in adult patients. We report our experience with intratumoral hemorrhage of myxopapillary ependymoma of the conus medullaris during weight lifting in a 15-year-old boy.

Primary cerebral myxopapillary ependymoma presenting with intratumoral hemorrhage.

Myxopapillary ependymoma (MPE), a benign histological variant of ependymoma, is found most commonly in the cauda equina region. Primary intracranial MPE is very rare, and most cases are a metastatic deposit from a spinal lesion. Primary cerebral MPEs are usually well-defined solid or cystic lesions without hemorrhage. We report the first case of primary cerebral MPE with intratumoral hemorrhage.