Expanding the differential diagnosis for transaminitis in patients with anorexia nervosa.

Aminotransferase elevations have been described in patients with anorexia nervosa. Hypothesized etiologies have included ischemic hepatitis, refeeding-induced transaminitis, and the process of autophagy. Supervised enteral nutrition is the mainstay of treatment for severe anorexia, but an increase in aminotransferase levels after initiation of enteral feeding presents clinicians with a diagnostic dilemma. We present a 31-year-old woman with anorexia nervosa (body mass index [BMI] of 13.5 kg/m2) who experienced a worsening of aminotransferase elevations even after the initiation of enteral feeding. Despite nutritional supplementation, the patient's weight continued to fall for 6 days. Peak aminotransferase concentrations correlated with the patient's lowest weight and improved only after an increase in BMI was eventually achieved. Secondary causes of severe transaminitis were investigated, and after no cause was found, a liver biopsy was performed. Pathology was consistent with liver injury secondary to severe malnutrition rather than from refeeding syndrome. This case highlights malnutrition as an important cause of aminotransferase elevations and underscores the need for judicious early weight restoration in patients with anorexia and abnormal liver chemistry.

Does Illicit Drug Use Influence Inpatient Adverse Events, Death, Length of Stay, and Discharge After Orthopaedic Trauma?

Illicit drug use among adults is increasing, but its associated risk following orthopaedic trauma remains largely unexplored. This study assessed the relationship of illicit drug use with inpatient adverse events, in-hospital mortality, prolonged length of stay, and nonroutine discharge. With the use of the Nationwide Inpatient Sample database, 7,118,720 orthopaedic trauma inpatients from 2002 to 2011 were identified and separated into illicit drug users (1.5%) and non-illicit drug users (98.5%). Multivariable regression modeling was used to determine the association between illicit drug use and each outcome variable. Illicit drug use was associated with higher odds of inpatient adverse events, but not greater likelihood of inpatient death. Illicit drug users were also more likely to experience prolonged hospital stay and nonroutine discharge. Prompt recognition and effective treatment interventions for orthopaedic trauma patients with a history of illicit drug use may improve inpatient outcomes.

Tumor exosomes induce tunneling nanotubes in lipid raft-enriched regions of human mesothelioma cells.

Tunneling nanotubes (TnTs) are long, non-adherent, actin-based cellular extensions that act as conduits for transport of cellular cargo between connected cells. The mechanisms of nanotube formation and the effects of the tumor microenvironment and cellular signals on TnT formation are unknown. In the present study, we explored exosomes as potential mediators of TnT formation in mesothelioma and the potential relationship of lipid rafts to TnT formation. Mesothelioma cells co-cultured with exogenous mesothelioma-derived exosomes formed more TnTs than cells cultured without exosomes within 24-48 h; and this effect was most prominent in media conditions (low-serum, hyperglycemic medium) that support TnT formation (1.3-1.9-fold difference). Fluorescence and electron microscopy confirmed the purity of isolated exosomes and revealed that they localized predominantly at the base of and within TnTs, in addition to the extracellular environment. Time-lapse microscopic imaging demonstrated uptake of tumor exosomes by TnTs, which facilitated intercellular transfer of these exosomes between connected cells. Mesothelioma cells connected via TnTs were also significantly enriched for lipid rafts at nearly a 2-fold higher number compared with cells not connected by TnTs. Our findings provide supportive evidence of exosomes as potential chemotactic stimuli for TnT formation, and also lipid raft formation as a potential biomarker for TnT-forming cells.

Fibroid expulsion: a unique presentation of mechanical small bowel obstruction 11 years after uterine artery embolization: a case report.

BACKGROUND: Uterine artery embolization in the treatment of uterine leiomyoma has been rarely associated with dislodgement and expulsion of infarcted uterine fibroids through the vagina, peritoneum, or bowel wall, predominantly occurring within 6 months of uterine artery embolization. CASE PRESENTATION: We present the case of a 54-year-old African American woman who underwent uterine artery embolization 11 years prior and developed mechanical small bowel obstruction from the migration of fibroid through a uteroenteric fistula with ultimate impaction within the distal small bowel lumen. Small bowel resection and hysterectomy were curative. CONCLUSIONS: Uteroenteric fistula with small bowel obstruction due to fibroid expulsion may present as a delayed finding after uterine artery embolization and requires heightened awareness.

Quantifying and Characterizing Trainee Participation in a Major Academic Radiology Department.

OBJECTIVE: Trainees play an important role in the delivery of medical services in academic medical centers, yet the full extent of their contribution in radiology is unknown. The purpose of this study was to quantify trainee involvement in a single large academic radiology department. MATERIALS AND METHODS: In this Institutional Review Board-approved retrospective study performed in a tertiary care academic medical center, we identified the proportion of radiology reports with trainee involvement (by means of report co-signature) between July 2015 and June 2016. For each exam, we documented the modality, whether a trainee co-signed the report, and the division/subspecialty of the attending radiologist. We computed the overall proportion of radiology reports that involved a trainee and compared this proportion between imaging modalities, type of patient setting (Emergency Department, inpatient, outpatient), and across subspecialty divisions using Chi-square tests. RESULTS: Overall, we analyzed 607,074 radiology reports, of which trainees co-signed 239,187 (39.4%) reports. Trainee involvement varied considerably by division, ranging from 7.1% (ultrasound division) to 99.2% (cardiovascular imaging division) of reports, P <0.001. Among diagnostic imaging modalities, trainee participation was highest in CT (67.0%) and MRI (60.9%) examinations, and lowest in ultrasound (15.3%), P < 0.001. Trainees were more involved in the emergency department (58.0%) and inpatient (43.4%) settings than in the outpatient setting (33.9%), P < 0.001. CONCLUSIONS: Less than half of the imaging studies performed in an academic radiology department involved radiology trainees. Similar data and studies at other institutions may be useful to help define, monitor and improve optimal trainee education nationally.

Utility of sagittal MR imaging of the whole spine in cases of known or suspected single-level spinal infection: Overkill or good clinical practice?

OBJECTIVE: Multi-sequence sagittal magnetic resonance imaging (MRI) of the entire spine is performed in patients with known single level spondylodiscitis. Our objective is to determine the frequency of multifocal infection. METHODS: After IRB approval, a retrospective five-year review of all patients with spondylodiscitis was performed. RESULTS: MRI identified 82 patients with single-level infection. All 82 had entire spine imaging performed within 72 h of admission, showing additional non-continuous sites of infection in 19 patients (23%). Remote levels of spondylodiscitis were present in 11 patients (13%). CONCLUSION: Multi-sequence sagittal MRI of the entire spine may be helpful in patients with known single-level spine infection.