Recurrence of Thrombin-Injected Pseudoaneurysms Under Ultrasound Guidance: A 10-Year Retrospective Analysis.

OBJECTIVES: Ultrasound-guided thrombin injection has become standard treatment for extremity pseudoaneurysms. Our specific aims were to determine the procedural success rate, the procedural complication rate, and the factors associated with pseudoaneurysm recurrence. METHODS: A total of 262 consecutive cases of ultrasound-guided thrombin repair of pseudoaneurysms were identified between January 1, 2006, and March 20, 2016. The procedural and follow-up ultrasound studies were reviewed. Outcomes of interest included procedural success (defined as complete thrombosis at the time of injection and on a follow-up examination), incomplete pseudoaneurysm thrombosis, and postprocedural recurrence. Postprocedural pseudoaneurysm recurrences were compared to procedural successes with regard to patient demographics, pseudoaneurysm characteristics, amount of thrombin injected, and periprocedural laboratory values. RESULTS: Procedural success occurred in 85.7% of cases. Complications occurred in 3.0% of cases. The mean patient age ± SD was 72.3 ± 11.3 years. The median amount of thrombin injected was 500 U (interquartile range, 400 U). The median follow-up time was 1 day (interquartile range, 0 days). A pseudoaneurysm size of 2 cm or larger and thrombocytopenia were significant independent predictors of pseudoaneurysm recurrence (P = .003 and .03, respectively). The odds ratios for pseudoaneurysm recurrence were 2.29 for pseudoaneurysm size of 2 cm or larger (P = .03) and 1.04 for thrombocytopenia (P = .04). CONCLUSIONS: Thrombin injection of pseudoaneurysms is an off-label procedure with few complications and a high success rate. Follow-up imaging is recommended in all pseudoaneurysms that are 2 cm or larger and in patients with thrombocytopenia.

Unexpected Findings During Evaluation of Acute Pelvic Pain With Transvaginal Sonography.

Transvaginal sonography is the first-line imaging modality used to evaluate acute female pelvic pain in the emergency setting because of its accessibility, lack of ionizing radiation, and excellent ability to identify reproductive tract disorders. Although the intent of transvaginal sonography is to evaluate the reproductive organs, imaging of adjacent pelvic structures is an important part of every transvaginal sonographic examination. Gastrointestinal, urologic, and vascular disorders incidentally scanned on transvaginal sonography may explain the pain for which the examination is being performed. In such cases, transvaginal sonography may play an important role in the diagnostic process if the clinician is aware of the transvaginal sonographic appearance of these entities.

Hypertrophic cardiomyopathy - phenotypic variations beyond wall thickness.

Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular hypertrophy (LVH) in the absence of another causal disease. Several morphologic and histologic changes have been described. Given the morbidity and mortality associated with HCM, understanding these anatomic variations is key to interpreting imaging. This is especially important since many patients exhibit these associated findings in the absence of LVH and prompt early detection of these variations may lead to early diagnosis and treatment. This article describes the appearance of morphologic variations seen in HCM beyond myocardial thickening including: papillary muscle and mitral valve variants, myocardial crypts, left ventricular myocardial bands, and dystrophic calcification related to increased wall tension.

Splenic sequestration in the adult: cross sectional imaging appearance of an uncommon diagnosis.

Acute splenic sequestration crisis, the sudden pooling of red blood cells in the spleen, is an emergent process typically seen in children with homozygous sickle cell disease. Splenic sequestration has rarely been reported in adults with heterozygous sickle cell conditions, including sickle cell beta(+)-thalassemia disease (HbS/ß+-thalassemia). Here we present a case of a 32-year-old man with HbS/ß+-thalassemia who suffered an acute splenic sequestration crisis. We review the CT and ultrasound appearance of splenic sequestration, which include splenic enlargement and an irregular rim of hypoenhancing or hypoechoic tissue at the periphery of the spleen, and discuss imaging differential considerations. To our knowledge, this is only the nineteenth case of acute splenic sequestration to be reported in an adult with HbS/ß+-thalassemia in the English literature, and only the second case in which ultrasound findings are reported.

Foxl1 promotes liver repair following cholestatic injury in mice.

Cholangiocyte proliferation is one of the hallmarks of the response to cholestatic injury. We previously reported that the winged helix transcription factor Foxl1 is dramatically induced in cholangiocytes following bile duct ligation. In this study, we investigated the function of Foxl1 in the bile duct ligation model of cholestatic liver injury in Foxl1(-/-) and control mice. We found that Foxl1(-/-) livers exhibit an increase in parenchymal necrosis, significantly impaired cholangiocyte and hepatocyte proliferation, and failure to expand bile ductular mass. Wnt3a and Wnt7b expression was decreased in the livers of Foxl1(-/-) mice along with reduced expression of the beta-catenin target gene Cyclin D1 in Foxl1(-/-) cholangiocytes. These results show that Foxl1 promotes liver repair after bile-duct-ligation-induced liver injury through activation of the canonical wnt/beta-catenin pathway.

Incidental myocardial perfusion defect detected on ECG-gated CT aortogram.

We report the case of a 49-year-old man with a history of diabetes and hypertension who presented to the emergency room with intermittent chest pain radiating to the back for one day. An electrocardiogram-gated CT aortogram excluded the emergency department's primary consideration of aortic dissection, but incidentally revealed a myocardial perfusion defect and corresponding coronary artery stenosis. Cardiac catheterization performed the following day confirmed the CT findings and the patient underwent angioplasty and stent placement. We show that despite a different protocol than coronary CTA or myocardial perfusion CT, a gated CTA for dissection (CT aortogram) is capable of detecting resting perfusion abnormalities in patients presenting to the emergency room with chest pain.

Ovarian dermoid cyst complicated by small bowel obstruction, entero-ovarian fistula formation, and malignant degeneration.

Dermoid cysts, or mature cystic teratomas, are complicated by malignant degeneration in only 1-2% of cases. Rarely, dermoid cysts result in complications of small bowel obstruction or entero-ovarian fistula formation. In the current report we present the case of a 59-year-old female with a known dermoid cyst who presented with leukocytosis and was discovered to have a small bowel obstruction at the level of an ileo-ovarian fistula. The patient was taken to the operating room and was treated with total abdominal hysterectomy, bilateral salpingo-oopherectomy, and short segment small bowel resection. Review of the surgical pathology revealed areas of malignant degeneration within the dermoid cyst to squamous cell carcinoma. To our knowledge, this is only the second reported case of an ovarian dermoid cyst complicated by small bowel obstruction, entero-ovarian fistula formation, and malignant degeneration.

Radiologic Imaging in Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis.

The article reviews the multimodality (ultrasound, computed tomography, and magnetic resonance [MR]) imaging appearance of nonalcoholic fatty liver disease (NAFLD) and discusses the radiologic diagnostic criteria as well as the sensitivity and specificity of these imaging methods. The authors review the role of both ultrasound and MR elastography for the diagnosis of fibrosis and for the longitudinal evaluation of patients following therapeutic intervention. Lastly, the authors briefly discuss the screening and diagnosis of hepatocellular carcinoma in patients with NAFLD, as there are special considerations in this population.

Plain radiography may underestimate the burden of body packer ingestion: A case report.

Body packing refers to the intracorporeal concealment of illicit drugs. Here we report the case of a 55-year-old body packer who presented with palpitations, visual hallucinations, and a sense of impending death. Abdominal radiography demonstrated five ovoid foreign bodies overlying the rectum. At subsequent gastrotomy and cecotomy, thirty-eight cocaine-containing packets were retrieved from the stomach and ascending colon as well as from the rectum. As the contraband market evolves new techniques to evade detection, evaluation of the burden of body packer ingestion has become increasingly challenging. As demonstrated in this case, plain radiography can grossly underestimate the burden of ingestion.

Appendiceal ganglioneuroma in neurofibromatosis type 2.

Here we report the case of a 30-year-old woman with a history of neurofibromatosis type 2 (NF2) who presented with an incidentally discovered pelvic mass on an ultrasound. The identity of the mass remained indeterminate following a CT and MRI, although appendiceal pathology was suspected. An elective laparoscopy and appendectomy were performed without complication and pathology on the specimen demonstrated an appendiceal ganglioneuroma. To our knowledge, there has been no prior documented case of an appendiceal ganglioneuroma in a patient with NF2. Furthermore, the current case is the first to report the MR characteristics of appendiceal ganglioneuromas.

Clues to vascular disorders at non-contrast CT of the chest, abdomen, and pelvis.

Non-contrast chest CT scans are commonly performed while CT scans of the abdomen and pelvis are performed in a select subset of patients; those with limited renal function, an allergy to iodinated contrast, in the setting of suspected renal calculus, retroperitoneal hematoma, common duct calculus, abdominal aortic aneurysm with or without rupture, and in patients undergoing a PET-CT scan. In the absence of intravenous contrast, vascular structures may prove challenging to evaluate, yet their assessment is an important component of every non-contrast CT examination. We describe the key imaging features of both arterial and venous pathology, and review clues and common associated non-vascular findings, which can help the radiologist identify vascular disorders at non-contrast CT. Briefly, alternative imaging options are discussed.

Small bowel volvulus in pregnancy with associated superior mesenteric artery occlusion.

Here we report the case of a pregnant 28-year-old who presented with acute upper abdominal pain. CT demonstrated midgut volvulus with short segment occlusion of the superior mesenteric artery (SMA). Emergent detorsion of the small bowel was performed, at which time underlying intestinal malrotation was discovered. Following detorsion, the SMA had a bounding pulse and did not require thrombectomy or revascularization. Fewer than 25 cases of midgut volvulus during pregnancy have been reported over the past 20years. To our knowledge, this is the first report of maternal midgut volvulus in which imaging captures the resultant occlusion of the SMA.

A case of bronchial granular cell tumor in a pediatric patient.

Only nine cases of bronchial granular cell tumor have previously been reported in pediatric patients. We present a 15-year-old girl with acute-onset right shoulder pain, discovered to have a granular cell tumor causing bronchial stenosis and a cavitating post-obstructive right upper lobe pneumonia. The patient was treated with lobectomy. Bronchial granular cell tumors are benign neoplasms that typically present with recurrent pneumonia. Imaging may demonstrate an endobronchial lesion or an associated post-obstructive opacity, but diagnosis requires tissue sampling. To our knowledge, this is the tenth case of bronchial granular cell tumor in a pediatric patient to be reported since 1926.

Central Regulation of Glucose Production May Be Impaired in Type 2 Diabetes.

The challenges of achieving optimal glycemic control in type 2 diabetes highlight the need for new therapies. Inappropriately elevated endogenous glucose production (EGP) is the main source of hyperglycemia in type 2 diabetes. Because activation of central ATP-sensitive potassium (KATP) channels suppresses EGP in nondiabetic rodents and humans, this study examined whether type 2 diabetic humans and rodents retain central regulation of EGP. The KATP channel activator diazoxide was administered in a randomized, placebo-controlled crossover design to eight type 2 diabetic subjects and seven age- and BMI-matched healthy control subjects. Comprehensive measures of glucose turnover and insulin sensitivity were performed during euglycemic pancreatic clamp studies following diazoxide and placebo administration. Complementary rodent clamp studies were performed in Zucker Diabetic Fatty rats. In type 2 diabetic subjects, extrapancreatic KATP channel activation with diazoxide under fixed hormonal conditions failed to suppress EGP, whereas matched control subjects demonstrated a 27% reduction in EGP (P = 0.002) with diazoxide. Diazoxide also failed to suppress EGP in diabetic rats. These results suggest that suppression of EGP by central KATP channel activation may be lost in type 2 diabetes. Restoration of central regulation of glucose metabolism could be a promising therapeutic target to reduce hyperglycemia in type 2 diabetes.

A systematic review of innovative diabetes care models in low-and middle-income countries (LMICs).

BACKGROUND: Over 70% of the world's patients with diabetes reside in low-and middle-income countries (LMICs), where adequate infrastructure and resources for diabetes care are often lacking. Therefore, academic institutions, health care organizations, and governments from Western nations and LMICs have worked together to develop a variety of effective diabetes care models for resource-poor settings. METHODS: A focused search of PubMed was conducted with the goal of identifying reports that addressed the implementation of diabetes care models or initiatives to improve clinical and/or biochemical outcomes in patients with diabetes mellitus. RESULTS: A total of 15 published manuscripts comprising nine diabetes care models in 16 locations in sub-Saharan Africa, Latin America, and Asia identified by the above approach were systematically reviewed. The reviewed models shared a number of principles including collaboration, education, standardization, resource optimization, and technological innovation. The most comprehensive models used a number of these principles, which contributed to their success. CONCLUSIONS: Reviewing the principles shared by these successful programs may help guide the development of effective future models for diabetes care in low-income settings.

Insulin sensitizing and anti-inflammatory effects of thiazolidinediones are heightened in obese patients.

OBJECTIVE: The American Diabetes Association has called for further research on how patients' demographics should determine drug choices for individuals with type 2 diabetes mellitus (T2DM). Here, using in-depth physiology studies, we investigate whether obese patients with T2DM are likely to benefit from thiazolidinediones, medications with a known adverse effect of weight gain. MATERIALS AND METHODS: Eleven obese and 7 nonobese individuals with T2DM participated in this randomized, placebo-controlled, double-blind, crossover study. Each subject underwent a pair of "stepped" pancreatic clamp studies with subcutaneous adipose tissue biopsies after 21 days of pioglitazone (45 mg) or placebo. RESULTS: Obese subjects demonstrated significant decreases in insulin resistance and many adipose inflammatory parameters with pioglitazone relative to placebo. Specifically, significant improvements in glucose infusion rates, suppression of hepatic glucose production, and whole fat expression of certain inflammatory markers (IL-6, IL-1B, and inducible nitric oxide synthase) were observed in the obese subjects but not in the nonobese subjects. Additionally, adipose tissue from the obese subjects demonstrated reduced infiltration of macrophages, dendritic cells, and neutrophils as well as increased expression of factors associated with fat "browning" (peroxisome proliferator-activated receptor gamma coactivator-1α and uncoupling protein-1). CONCLUSIONS: These findings support the efficacy of pioglitazone to improve insulin resistance and reduce adipose tissue inflammation in obese patients with T2DM.

Fatty acid-induced production of plasminogen activator inhibitor-1 by adipose macrophages is greater in middle-aged versus younger adult participants.

BACKGROUND: Human aging is associated with heightened risk of diabetes and cardiovascular disease. Increased fat mass may contribute to age-related diseases by harboring inflammatory macrophages that produce metabolically important proteins such as plasminogen activator inhibitor-1 (PAI-1). Elevated PAI-1 concentrations have been implicated in the pathogenesis of such aging-related conditions as insulin resistance, obesity, and atherosclerosis. We have previously reported that increased plasma free fatty acid (FFA) concentrations augment both circulating PAI-1 concentrations and PAI-1 production by adipose tissue macrophages (ATMs). METHODS: Because increasing age is associated with increased infiltration and reactivity of adipose macrophages, we performed euglycemic-hyperinsulinemic clamp studies and adipose tissue biopsies with and without elevated FFA concentrations in 31 nondiabetic participants stratified by age, to determine whether middle-aged individuals manifest heightened insulin resistance and PAI-1 production by ATMs in response to elevated nutrient signals relative to their young adult peers. RESULTS: We observed that elevating FFA concentrations under euglycemic-hyperinsulinemic clamp conditions induced the same degree of insulin resistance in both middle-aged and younger body mass index-matched adults, whereas systemic PAI-1 concentrations were significantly increased in the middle-aged group. Likewise, elevated FFA and insulin concentrations induced larger increases in PAI-1 gene expression in the whole fat and ATMs of middle-aged compared with younger adult participants. CONCLUSIONS: These studies reveal a heightened adipose inflammatory response to increased FFA and insulin availability in middle-aged individuals relative to younger adults, suggesting that increased susceptibility to the effects of fatty acid excess may contribute to the pathogenesis of age-related diseases.

Activation of K(ATP) channels suppresses glucose production in humans.

Increased endogenous glucose production (EGP) is a hallmark of type 2 diabetes mellitus. While there is evidence for central regulation of EGP by activation of hypothalamic ATP-sensitive potassium (K(ATP)) channels in rodents, whether these central pathways contribute to regulation of EGP in humans remains to be determined. Here we present evidence for central nervous system regulation of EGP in humans that is consistent with complementary rodent studies. Oral administration of the K(ATP) channel activator diazoxide under fixed hormonal conditions substantially decreased EGP in nondiabetic humans and Sprague Dawley rats. In rats, comparable doses of oral diazoxide attained appreciable concentrations in the cerebrospinal fluid, and the effects of oral diazoxide were abolished by i.c.v. administration of the K(ATP) channel blocker glibenclamide. These results suggest that activation of hypothalamic K(ATP) channels may be an important regulator of EGP in humans and that this pathway could be a target for treatment of hyperglycemia in type 2 diabetes mellitus.