Pseudokidney Sign in Gastric Cancer.

Pseudokidney sign (PKS) is a characteristic sonographic finding of an abnormal mass with a reniform appearance, and a hyperechoic central region surrounded by a hypoechoic area. It has been seldom documented in gastric cancer. A 75-year-old male patient presented with a palpable abdominal resistance in the left upper abdominal quadrant and ultrasound evaluation revealed a well-vascularized mass presenting with PKS. Regional lymphadenopathy was also found, and the working diagnosis of gastric cancer was established. The suspected diagnosis was later verified endoscopically and on pathohistological examinations as gastric adenocarcinoma. Computed tomography staging also revealed distant metastases to the lungs, liver, and adrenal glands and abdominal lymphadenopathy. The PKS often indicates gastrointestinal pathology, and it may be seen in benign and malignant conditions due to gastrointestinal wall thickening. Therefore, additional diagnostic examinations are advised for a more definite diagnosis.

Osteochondritis Dissecans of the Elbow in Overhead Athletes: A Comprehensive Narrative Review.

Osteochondritis dissecans (OCD) of the elbow mainly occurs in overhead athletes (OHAs). This narrative review aimed to comprehensively analyze the epidemiological data, etiological factors, clinical and imaging features, treatment options, and outcomes of OHAs with the diagnosis of elbow OCD. A literature search was performed in PubMed/MEDLINE, Scopus, and Web of Science. Individuals with elbow OCD were usually 10-17 years of age with incidence and prevalence varying between studies, depending on the sport activity of the patients. The etiology of OCD lesions is multifactorial, and the main causes are believed to be repetitive trauma, the biomechanical disproportion of the articular surfaces, poor capitellar vascular supply, and inflammatory and genetic factors. Athletes usually presented with elbow pain and mechanical symptoms. The mainstay for the diagnosis of elbow OCD is MRI. The treatment of elbow OCD lesions should be conservative in cases of stable lesions, while various types of surgical treatment are suggested in unstable lesions, depending mainly on the size and localization of the lesion. The awareness of medical practitioners and the timely diagnosis of OCD lesions in OHAs are key to favorable outcomes.

Fragility spinal fractures among cirrhotic liver transplant candidates in Croatia.

INTRODUCTION: Existing data on fragility spinal fractures prevalence in liver transplant candidates are scarce and inconsistent. This may be due to other comorbidities, besides hepatic osteodystrophy (HO), that contribute to bone loss and fragility fracture prevalence in chronic liver disease (CLD). OBJECTIVES: The aim of this study was to investigate the prevalence of spinal thoracic and lumbar fragility fractures among cirrhotic, non-chronic kidney disease (CKD), non-diabetic liver transplant candidates and to explore their relationship with clinical characteristics, laboratory markers and dual-energy x-ray absorptiometry (DXA) results. MATERIAL AND METHODS: This cross-sectional observational study was conducted at Merkur University Hospital, Croatia, between February 2019 and May 2023. Adult patients with liver cirrhosis referred for liver transplantation were included. Patients with acute infection, CKD, diabetes mellitus, malignancies, inflammatory bone diseases and those on corticosteroid or antiresorptive therapy were excluded. Clinical, laboratory and radiological assessment was carried out and patients were accordingly allocated into non-fractured and fractured group for the purpose of statistical analysis. RESULTS: A total of 90 patients were included in the study. There was 123 fractures, 87 (70.7 %) in the thoracic and 36 (29.3 %) in the lumbar region. Eighty-nine (72.4 %) fractures were grade 1, 31 (25.2 %) were grade 2 and 3 (2.4 %) were grade 3. Patients in the fractured group were significantly older (p < 0.001). No significant differences between fractured and non-fractured group according to laboratory and DXA parameters were noted. Subgroup with lumbar fractures had significantly lower bone mineral density values at L1-L4 region. Statistically significant negative correlation between bone specific alkaline phosphatase (BALP) and hip total BMD (rho = -0.414, p < 0.001) and spine total BMD (rho = -0.258, p = 0.014) values was found. CONCLUSION: Present study confirmed detrimental impact of CLD and HO on bone strength. DXA measurement correlated with the presence of lumbar fragility fractures. A combination of standard X-ray imaging and DXA is needed for adequate bone evaluation in pretransplant period and BALP could be useful for detecting HO in CLD. Searching for other risk factors and implementing bone turnover markers and additional imaging techniques for bone loss evaluation in liver transplant candidates is needed.

Patient's knowledge regarding radiation exposure from various imaging modalities: a pilot study.

To determine patients' knowledge about ionising radiation used in diagnostic imaging and whether they were adequately informed about the procedure they were referred to. A cross-sectional study was conducted at the University Hospital Merkur, Zagreb, Croatia during 2019-20. A questionnaire with 14 questions was given to patients in waiting rooms for imaging examinations. Statistical analysis was conducted using the standard software package. Chi-square with Yates correction was used to determine differences in patients' answers between those who received the explanation about the procedure and those who did not. The differences depending on the educational level were also evaluated. The survey was completed by 374 participants (200 women, 174 men) with a mean age of 55.45 ± 15.92 y. Of all patients, 8.63% had no formal education or only finished elementary school, 52.83% had finished high school and 38.55% had a college or a higher degree. The referring physicians informed 63.66% of participants about the radiological exam they were being referred to, and 226 thought that the given explanation was sufficient. Most patients knew that some radiological procedures use ionising radiation. Only 47.37% of respondents correctly identified MRI as a non-ionising method, whereas 37.40% of participants recognised chest X-ray as the modality with the lowest radiation dose. Higher-educated patients had better knowledge of radiological procedures and the potential risks. The study demonstrated suboptimal patients' knowledge about ionising radiation, and additional efforts in their education are needed.

Retroperitoneal Paraganglioma Treated With Tumor Resection and Replacement of the Inferior Vena Cava.

Retroperitoneal paragangliomas are tumors of neuroectodermal origin rarely appearing in the pediatric population. We report a case of a large paraganglioma infiltrating the right kidney and inferior vena cava in a 16-year-old boy who initially presented with a right-sided varicocele. Right retroperitoneal paraganglioma was embolized preoperatively, followed by total tumor excision, right nephrectomy, inferior vena cava resection, and reconstruction using a prosthetic vascular graft. Retroperitoneal tumors requiring surgery can successfully be treated by radical resection and replacement of the inferior vena cava in experienced centers.

Infrarenal inferior vena cava agenesis presenting as acute abdomen and hydronephrosis - case report.

The inferior vena cava agenesis (IVCA) is a rare and often asymptomatic malformation due to the abundant development of the collateral circulation. However, it is frequently found in young people and carries a significant risk of deep venous thrombosis (DVT). It is estimated that about 5% of patients under 30 years of age presenting with DVT have this condition. We report a case of a previously healthy 23-year-old patient presenting with signs of acute abdomen and hydronephrosis due to the thrombophlebitis of an unusual iliocaval venous collateral, which developed secondary to IVCA. After treatment, the iliocaval collateral and hydronephrosis completely regressed on a 1-year follow-up. To our knowledge, this is the first such case reported in the literature.

Urothelial carcinoma in a urinary bladder diverticulum: A case report and review of the literature.

Bladder diverticula are defined as an outpouching of the mucosa into the muscle layer of the bladder wall. There is a well-known link between urinary bladder diverticula and tumors arising within the diverticula. They are rare with an incidence rate of 0.8%-10%. We report an intradiverticular urothelial carcinoma in a 72-year-old man with a known history of multiple episodes of acute urinary retention and urinary tract infections, followed by transurethral resection of the benign prostatic hyperplasia.

SUCCESSFUL RESOLUTION OF NUTCRACKER SYNDROME WITH 3D PRINTED PEEK EXTRAVASCULAR STENT IN AN ADOLESCENT BOY.

Three-dimensional printed polyetheretherketone (PEEK) extravascular stent was applied to treat a 14-year-old boy with nutcracker syndrome. Digital subtraction angiography revealed a segment of the left renal vein (LRV) with reduced contrast filling immediately before its inflow into the inferior vena cava, and high-pressure gradient. The three-dimensional reconstruction model demonstrated that the LRV and the duodenum were contracted at the aortomesenteric angle, resulting in LRV compression from the abnormal high-level duodenal compartment. When duodenum courses between the abdominal aorta and superior mesenteric artery (duodenal interposition), the LRV entrapment occurs even at <90 aortomesenteric degrees. Three-dimensional printed PEEK extravascular stent was chosen to elevate the superior mesenteric artery and lower the duodenum position, thus relieving LRV compression. This extravascular application has significant advantages over open surgery, endovascular stenting and artificial vessel procedures with expanded polytetrafluoroethylene. It provides better cellular vitality by ensuring soft tissue proliferation. By reducing external acceleration and centrifugal force, a three-dimensional printed PEEK extravascular stent reduces adverse side effects. Such a stent has a distinctive personalized design, good stiffness, and durability that allows blood vessel growth, preventing stent migration and thrombosis. Therefore, it is suitable for both adult and pediatric patients. According to the abdominal ultrasound and multi-slice computed tomography scan, the postoperative follow-up results were satisfactory one year after surgery. The patient felt well, the blood flow in the LRV was not obstructed, and the blood flow velocity was average. The external stent was in place.

Liver transplantation in hepatocellular carcinoma - should we perform downstaging?

AIM: To compare the long-term outcomes between liver transplant (LT) recipients with hepatocellular carcinoma (HCC) who were downstaged with transarterial-chemoembolization (TACE) to the Milan criteria (MC) and those initially meeting the MC. METHODS: This retrospective study enrolled 198 patients with HCC: 38 were downstaged and 160 patients initially met the MC. Post-LT survival and HCC recurrence-free survival were evaluated. We assessed the association of death and HCC recurrence with TACE, baseline (age, sex, disease etiology, Model of End-stage Liver Disease, tumor number and the sum of maximum tumor diameters, waiting time, alpha-fetoprotein level) and explant characteristics (tumor number and the sum of maximum tumor diameters, micro- and macrovascular invasion). RESULTS: The recipient survival rates one, three, and five years after LT were 88.2%, 80.1%, and 75.9%, respectively. HCC recurrence-free probabilities were 92.3%, 87.9%, and 85%, respectively. The outcomes were comparable between the groups. In multivariate analysis, the number of tumors on the explant, age, and tumor recurrence were independent risk factors for death. Only the sum of maximum tumor diameters on the explant was an independent risk factor for HCC recurrence. CONCLUSIONS: Patients successfully downstaged with TACE to the MC can achieve post-LT recipient and HCC recurrence-free survival comparable with patients initially within the MC. Good response to TACE as a criterion for LT may be a method of selecting patients with favorable biological characteristics.

EFFICIENCY OF BREAST SHIELDING DEVICE IN OUT-OF-PLANE COMPUTERIZED TOMOGRAPHY IMAGING OF THE ABDOMEN - PRELIMINARY RESULTS.

The dose absorbed by sensitive breast glandular tissue in abdominal computed tomography examinations, even when the breasts are outside the primary imaging beam, is still significant. Several studies have explored using breast shielding with a protective lead sheet or a bra. Since the source of radiation in computed tomography rotates by 360° around the patient, we made a custom-tailored shielding device that wraps around the entire thorax. The hypothesis is that such a custom-tailored breast shielding device provides significantly better dose reduction. Study participants were female patients with no anatomic anomalies. Entrance surface doses were measured using thermoluminescence dosimeters placed on the skin of the breast in the control group without shielding and on the surface and below the shielding device in the group with anterior shielding and the group with the new device. As expected, according to literature data, doses measured at breast level were above the threshold that epidemiological studies determine as an increased risk of breast cancer development although they were not in the primary imaging plane. Preliminary results of our study showed that average dose reduction was 42% with conventional anterior shielding and 57% with wrapped shielding compared to the doses measured with no shielding.

The role of magnetic resonance imaging and the expression of MMP-9 protein in the analysis of carotid atherosclerotic plaques in patients undergoing carotid endarterectomy: a prospective pilot study.

Components of carotid atherosclerotic plaque can be analysed preoperatively by non-invasive advanced imaging modalities such as magnetic resonance imaging (MRI). The expression of matrix metalloproteinase-9 protein (MMP-9), which has a potential role in remodelling of atherosclerotic plaques, can be analysed immunohistochemically. The aim of the present prospective pilot study is to analyse histological characteristics and expression of MMP-9 in carotid plaques of patients undergoing carotid endarterectomy (CEA) and to investigate the correlation with preoperative clinical symptoms and MRI features. Preoperative clinical assessment, MRI imaging, postoperative histological and immunohistochemical analyses were performed. Fifteen patients with symptomatic (7/15; 47%) and asymptomatic carotid artery stenosis undergoing CEA were included. Among symptomatic patients, 5 (71%) had recent stroke and 2 (29%) had recent transient ischaemic attack with a median timing of 6 weeks (IQR: 1, 18) before the surgery. Both groups did not significantly differ in respect to preoperative characteristics. Prevalence of unstable plaque was higher in symptomatic than asymptomatic patients, although it was not significant (63% vs. 37%, p = 0.077). The expression of MMP-9 in CD68 cells within the plaque by semiquantitative analysis was found to be significantly higher in symptomatic as compared to asymptomatic patients (86% vs. 25% with the highest expression, p = 0.014). The average microvascular density was found to be higher and lipid core area larger among both symptomatic patients and unstable carotid plaque specimens, although this did not reach statistical significance (p = 0.064 and p = 0.132, p = 0.360 and p = 0.569, respectively). Our results demonstrate that MRI is reliable in classifying carotid lesions and differentiating unstable from stable plaques. We have also shown that the expression of MMP-9 is significantly higher among symptomatic patients undergoing CEA.

Provisional focal stenting of complex femoropopliteal lesions using the Multi-LOC multiple stent delivery system - 12-month results from the LOCOMOTIVE EXTENDED study.

Background: This study aimed to evaluate a Multiple Stent Delivery System for provisional focal stenting of the femoropopliteal artery. Patient and methods: The LOCOMOTIVE EXTENDED study (Multi-LOC for flOw liMiting Outcomes after plain old balloon angioplasty and/or drug-coated balloon Treatment in the infrainguinal position with the objectIVE to implant multiple stent segments) is a prospective, single-arm, multicentre observational study. The Multi-LOC Multiple Stent Delivery System (B.Braun, Melsungen, Germany) was used for provisional focal stenting of the femoropopliteal artery. We enrolled 357 patients with 449 femoropopliteal lesions; all had flow-limiting dissections or recoil following angioplasty. Eligibility included Rutherford classification 2 to 5 with a de novo or non-stented restenotic femoropopliteal lesion undergoing plain balloon or drug-coated balloon angioplasty. The 6- and 12-month efficacy endpoints encompassed target lesion revascularisation and primary patency rates. Results: The mean patient age was 71 ± 10 years. The mean lesion length was 16.0 ± 9.7 cm; 44.5% were TASC II C/D lesions and 31.4% were chronic total occlusions. By operator choice, 45% of the patients underwent drug-coated balloon angioplasty. On average, 4.0 stents (each 13 mm long) were placed in each lesion, resulting in a scaffolding proportion of 56% of the total lesion length with a technical success rate of 98.3%. At 6 and 12 months, the freedom from clinically driven target lesion revascularisation was 95.5% and 88.7% and the primary patency rates were 88.7% and 82.3%, respectively. At 12 months, significant improvements were noted in Rutherford categories and ankle-brachial indices. In multiple regression analyses, both diabetes mellitus and no distal run-off vessel showed a trend toward worse TLR, while other factors such as DCB predilation or the lesion length were not predictive. Conclusions: The LOCOMOTIVE EXTENDED study demonstrated the safety and efficacy of the Multi-LOC stent system for focal provisional stenting of complex femoropopliteal lesions.

Acute kidney injury following percutaneous mechanical thrombectomy of subclavian artery stent graft thrombosis: a case report.

BACKGROUND: Percutaneous mechanical thrombectomy (PMT) is a well-established technique for treatment of acute arterial and venous thrombosis which inevitably leads to intravascular erythrocyte hemolysis, resulting in hemoglobinuria. CASE PRESENTATION: We present a case of 66-year-old Caucasian female with subclavian artery aneurysm causing distal embolization and hand ischemia. The aneurysm was treated with stent graft, but with a subsequent graft thrombosis 3 months later. After graft recanalisation, AngioJet PMT was performed which resulted in dialysis-requiring acute kidney injury. CONSLUSION: Only several cases of acute kidney injury following AngioJet PMT have been published in literature. To our knowledge, this is the first reported case of dialysis-requiring AKI after PMT for peripheral arterial thrombosis. Until there is sufficient evidence and recommendation on preventing AKI in this setting, we believe that by being aware of the risk and by monitoring of patient, one might minimize the damage in case it occurs.

Cerebral Neuromonitoring during Carotid Endarterectomy and Impact of Contralateral Internal Carotid Occlusion.

BACKGROUND: The aim of this study was to identify the reliability of carotid artery stump pressure (SP) in predicting the neurologic changes and correlation with contralateral internal carotid artery (ICA) occlusion in patients undergoing eversion carotid endarterectomy (CEA). The optimal method for monitoring cerebral perfusion during CEA, performed under either local or general anesthesia, is still controversial. METHODS: We prospectively analyzed 118 consecutive patients undergoing eversion CEA under local anesthesia. We had 78 symptomatic (66%) and 40 asymptomatic patients (33.9%). Selective shunting was performed in patients who developed neurologic changes after carotid clamping regardless of SP. Correlation of preoperative symptom status, a degree of stenosis, status of contralateral ICA, arterial blood pressure, SP value, and the intraoperative need for shunting due to neurologic changes was evaluated for both groups: shunted and nonshunted. RESULTS: Selective shunting was performed in 12 patients (10%). There was no significant difference among the groups regarding the demographic characteristics. Mean carotid clamping time was 14.57 minutes. We had no perioperative mortality, stroke, or myocardial infarction. None of the patients required conversion to general anesthesia. We found a mean SP of 31 mm Hg as a reliable threshold for shunting (P < .001; sensitivity 92.3%; specificity 91.3%). Contralateral carotid occlusion was correlated with the significantly lower SP (27 ± 13 mm Hg; P = .001) and the higher need for shunt (50%). CONCLUSIONS: SP measurement is a reliable and simple method for monitoring the collateral cerebral perfusion and can predict the need for shunting during CEA. Patients with the contralateral ICA occlusion showed significantly lower SP, although it did not have impact on the outcome.

Embolisation of pulmonary arteriovenous malformations - case series.

PURPOSE: Pulmonary arteriovenous malformations (PAVM) are the direct communications between the pulmonary arteries and veins. These malformations can cause serious complications, and most of these patients should be treated. Herein we present our experience in the treatment of 18 cases of PAVM, treated with endovascular embolisation. MATERIAL AND METHODS: Eighteen patients with PAVMs underwent endovascular embolisation during a five-year period. Eight were male and 10 were female, with ages ranging from 16 to 65 years. Standard steel coils and vascular plug were used for embolisation. RESULTS: Embolisation was successful in 17 of 18 patients. Coiling was used in 10 patients, vascular plug in five, and both materials in two patients. All symptomatic patients with successful embolisation lost all their symptoms after treatment. Control angiography after embolisation showed a closure of AV shunt without migration of embolic material in all patients. Post-embolisation syndrome developed in four patients and late onset of pleural pain in three patients. There was no connection between pleural reaction and type of PAVM and embolic material. CONCLUSIONS: Endovascular PAVM treatment is a minimally invasive, highly successful method with a low rate of only transitory complications.

Heat shock protein 70 and antibodies to heat shock protein 60 are associated with cerebrovascular atherosclerosis.

OBJECTIVES: Heat shock proteins (Hsps) are produced by all cells, including vascular, to ensure stress protection. Damaged cells release Hsps in their local environment and systemic circulation. The aim of this study was to investigate the involvement and prognostic utility of serum Hsp60 and Hsp70, and the respective antibodies anti-Hsp60 and anti-Hsp70 in subjects with advanced atherosclerosis resulting in high degree of cerebrovascular stenosis. DESIGN AND METHODS: Ultrasound Doppler examination of carotid arteries was used to discriminate between control and cerebrovascular atherosclerosis subjects. Twenty eight subjects without carotid obstruction were selected as controls. Fifty patients with obstruction of cerebrovascular blood flow were evaluated for the degree of stenosis of cerebral arteries by digital subtraction angiography. In parallel, serum concentrations of Hsp60, Hsp70, anti-Hsp60 and anti-Hsp70 were measured by ELISA kits. RESULTS: Anti-Hsp60 was significantly higher (P=0.003) in the atherosclerosis group than in the control group (23.62ng/L vs. 15.28ng/L, respectively, expressed as median). Circulating Hsp70 was lower in the atherosclerosis than in the control group (P=0.048), with respective median values of 0.00µg/L vs. 0.22µg/L. Concentrations of Hsp60 and anti-Hsp70 did not differ significantly between the control and atherosclerosis group. CONCLUSIONS: Higher circulating anti-Hsp60 is associated with advanced cerebrovascular atherosclerosis as a consequence of the autoimmunity part of the inflammation and bursting of atherosclerosis. Higher levels of Hsp70 observed in the control group could be protective in the development of atherosclerotic changes.

Safety of Radiographic Imaging in Pregnancy

There are many false assumptions, both in the general population and among physicians, regarding the influence of radiation on pregnant patients and the fetus during diagnostic procedures, in spite of scientific facts based on studies. These false assumptions are mostly based on the idea that every diagnostic procedure using ionizing radiation is a cause for serious concern and that artificial abortion as a possible solution might be considered. We analyzed data from counseling of pregnant patients exposed to ionizing radiation during diagnostic procedures in the Merkur University Hospital during a 4-year period. In this period, 26 patients presented for counseling after exposure to diagnostic ionizing radiation during pregnancy. Results showed most of these patients to have been exposed to radiation between the 2nd and 3rd week of gestation (36%), between the 4th and 5th week 32%, before the 2nd week 24%, and after the 6th week of gestation less than 8%. To provide reasonable estimate of fetal doses, Report No. 174 from the National Council on Radiation Protection and Measurements (NCRP) was used. Data from the Report include estimate of the fetal dose from direct and indirect exposures. Th e mean doses were up to 0.01 cGy in 46.2%, 0.01-0.15 cGy in 19.2%, 0.2-1 cGy in 26.9% and 1 cGy or more in 7.7% of patients. None of the counseled patients had medical indication for abortion, even though in a small percentage of patients abortion was a personal subjective decision. Considering that there are no Croatian guidelines for counseling patients exposed to ionizing radiation during pregnancy, it is recommended to use the International Commission on Radiological Protection guidelines in the management of pregnant patients exposed to ionizing radiation.

Percutaneous Endovascular Treatment for Hepatic Artery Stenosis after Liver Transplantation: The Role of Percutaneous Endovascular Treatment.

BACKGROUND: To retrospectively analyze the outcomes of interventional radiology treatment of patients with hepatic artery stenosis (HAS) after liver transplantation at our Institution. MATERIAL/METHODS: Hepatic artery stenosis was diagnosed and treated by endovascular technique in 8 (2.8%) patients, who underwent liver transplantation between July 2007 and July 2011. Patients entered the follow-up period, during which we analyzed hepatic artery patency with Doppler ultrasound at 1, 3, 6, and 12 months after percutaneous endovascular treatment (PTA), and every six months thereafter. RESULTS: During the 12-month follow-up period, 6 out of 8 patients (75%) were asymptomatic with patent hepatic artery, which was confirmed by multislice computed tomography (MSCT) angiography, or color Doppler (CD) ultrasound. One patient had a fatal outcome of unknown cause, and one patient underwent orthotopic liver retransplantation (re-OLT) procedure due to graft failure. CONCLUSIONS: Our results suggest that HAS angioplasty and stenting are minimally invasive and safe endovascular procedures that represent a good alternative to open surgery, with good 12-month follow-up patency results comparable to surgery.

CIRCADIAN RHYTHM OF BLOOD PRESSURE RESTORATION AND NEPHROTIC PROTEINURIA ALLEVIATION IN A PATIENT WITH CHRONIC KIDNEY DISEASE AFTER RENAL SYMPATHETIC DENERVATION.

Renal sympathetic denervation (RSD) could be an effective antihypertensive treatment of resistant hypertension that triggers additional positive effects on glucose metabolism and insulin sensitivity in type 2 diabetes mellitus. We report the effects of RSD in a patient with chronic kidney disease, type 2 diabetes mellitus and resistant hypertension, manifesting as blood pressure reduction with dipping pattern restoration, followed by nephrotic proteinuria alleviation. The non-dipping blood pressure pattern and proteinuria increase the risk of cardiovascular complications and accelerate kidney disease progression. Thus, further research documenting the frequency and investigating the mechanisms of these effects reported after RSD in chronic kidney disease patients with type 2 diabetes mellitus and resistant hypertension is necessary for the benefit of this high-risk patient population.