Left Upper Extremity Pain, Right Coronary Artery Culprit: A Puzzling Path to Aneurysm Discovery.

Giant coronary artery aneurysm (GCA) is a rare disease afflicting 0.2% of the population. It is primarily attributed to atherosclerosis in adults and Kawasaki disease in children. Other uncommon etiologies include Takayasu arteritis and post-percutaneous coronary intervention.1,2 GCA lacks a universally accepted definition, with proposed criteria including a diameter exceeding 2 cm, 5 cm, or four times the normal vessel size.3 While the majority of GCAs are asymptomatic, a subset of patients present with angina, myocardial infarction from embolization or compression, heart failure due to fistula formation, or even sudden death.1 We report a case of an adult harboring a GCA involving the right coronary artery.

Case report: Transcatheter closure of a giant and tortuous right coronary artery to right ventricle fistula in an infant.

Congenital coronary artery fistulas (CAFs) are an uncommon congenital anomaly. While most patients are asymptomatic, life-threatening events including sudden death, myocardial ischemia, heart failure, infective endocarditis, and rupture of aneurysm may occur. Surgical ligation was once the standard choice of management of CAFs in the past. However, transcatheter closure of CAFs has become an emerging alternative to surgery in patients with suitable anatomy. We reported a 7-month-old infant with a giant and tortuous CAF that originated from the distal right coronary artery and drained into the right ventricle, and was successfully treated by transcatheter closure with an Amplatzer ductus occluder.

The role of postprandial very-low-density lipoprotein in the development of atrial remodeling in metabolic syndrome.

BACKGROUND: Negatively charged very-low-density lipoprotein (VLDL-χ) in metabolic syndrome (MetS) patients exerts cytotoxic effects on endothelial cells and atrial myocytes. Atrial cardiomyopathy, manifested by atrial remodeling with a dilated diameter, contributes to atrial fibrillation pathogenesis and predicts atrial fibrillation development. The correlation of VLDL-χ with atrial remodeling is unknown. This study investigated the association between VLDL-χ and remodeling of left atrium. METHODS: Consecutively, 87 MetS and 80 non-MetS individuals between 23 and 74 years old (50.6% men) without overt cardiovascular diseases were included in the prospective cohort study. Blood samples were collected while fasting and postprandially (at 0.5, 1, 2, and 4 h after a unified meal). VLDL was isolated by ultracentrifugation; the percentile concentration of VLDL-χ (%) was determined by ultra-performance liquid chromatography. The correlations of left atrium diameter (LAD) with variables including VLDL-χ, LDL-C, HDL-C, triglycerides, glucose, and blood pressure, were analyzed by multiple linear regression models. A hierarchical linear model was conducted to test the independencies of each variable's correlation with LAD. RESULTS: The mean LAD was 3.4 ± 0.5 cm in non-MetS subjects and 3.9 ± 0.5 cm in MetS patients (P < 0.01). None of the fasting lipid profiles were associated with LAD. VLDL-χ, BMI, waist circumference, hip circumference, and blood pressure were positively correlated with LAD (all P < 0.05) after adjustment for age and sex. Significant interactions between VLDL-χ and blood pressure, waist circumference, and hip circumference were observed. When adjusted for obesity- and blood pressure-related variables, 2-h postprandial VLDL-χ (mean 1.30 ± 0.61%) showed a positive correlation with LAD in MetS patients. Each 1% VLDL-χ increase was estimated to increase LAD by 0.23 cm. CONCLUSIONS: Postprandial VLDL-χ is associated with atrial remodeling particularly in the MetS group. VLDL-χ is a novel biomarker and may be a therapeutic target for atrial cardiomyopathy in MetS patients. TRIAL REGISTRATION: ISRCTN 69295295 . Retrospectively registered 9 June 2020.

Automatic assessment of bone age in Taiwanese children: A comparison of the Greulich and Pyle method and the Tanner and Whitehouse 3 method.

Proper bone age assessment is crucial for the clinical diagnosis and evaluation of treatment responses. We investigated the applicability of Greulich and Pyle (GP), and Tanner and Whitehouse 3 (TW3) methods for children in modern Taiwan, using computer-aided diagnosis. Hand and wrist radiographs were obtained from 611 children (3-17 years) who came to our emergency department due to trauma. Ages 0 to 2 years old were excluded because of a limited number of cases. Skeletal maturation was assessed using the BoneXpert (version 2.5.4.1 automated software), which determines GP and TW3 bone age. The two scoring systems were evaluated for comparing the chronological ages in each subgroup. In boys, mean GP bone age vs mean chronological ages were delayed for ages 3 to 11 and advanced for age 12 to 17. In girls, mean GP bone age vs mean chronological ages was delayed for ages 4 to 8 and 17, and advanced for ages 3 and 9 to 17. In boys, the mean TW3 bone ages vs mean chronological ages were delayed for ages 5 to 10 except age 8, and advanced for ages 3 to 4, 8, and 11 to 15. In girls, the mean TW3 bone ages vs mean chronological ages were delayed for ages 4 to 12, and advanced for ages 3 and 13 to 14. By using the BoneXpert automatic software, we established bone age reference standards for children in Taiwan. Clinical application of GP and TW3 scoring methods can be adjusted according to our results to better assess bone age.

Cost-effectiveness of stereotactic vacuum-assisted biopsy for nonpalpable breast lesions.

PURPOSE: To examine the potential cost-savings of stereotactic vacuum-assisted biopsy (SVAB) over open surgical biopsy (OSB) in diagnosis of nonpalpable lesions on mammography and to estimate the cost-saving effect on lesions at different levels of malignant probability. METHODS: This retrospective study was approved by our Institutional Review Board. We retrospectively reviewed 276 (33.8 %) SVAB and 541 (66.2 %) OSB medical records at a medical center. Direct costs included patients' self-paid and national health insurance claim charges. Indirect costs were calculated using sick days, average salary, and age-adjusted employment rate. One-way and two-way sensitivity analyses were conducted. Lesion classification was determined by the assessment categories of Breast Imaging Reporting and Data System (BI-RADS), 4th or 5th editions. RESULTS: SVAB decreased the direct cost by $90.3 (10.1 %) per diagnosis. The indirect cost was decreased by $560.2 (96.0 %). Overall, SVAB saved 43.9 % of resource utilization for each biopsy. Taking the cost of the subsequent malignant surgery into account, from the healthcare providers' perspective, SVAB was cost-effective if a lesion had less than 19 % likelihood of malignancy. From the societal perspective, SVAB reduced productivity loss for all the lesions. Based on the positive predictive value of the BI-RADS categories, SVAB was more suitable for the lesions of category 4A and category 3, resulting in greater savings in both medical and societal resources. CONCLUSIONS: SVAB is a cost-effective diagnostic option for nonpalpable breast lesions. The cost-saving effect is greater for the lesions of category 4A and category 3.

Accuracy and outcomes of stereotactic vacuum-assisted breast biopsy for diagnosis and management of nonpalpable breast lesions.

Stereotactic vacuum-assisted biopsy (SVAB) is an alternative method of breast biopsy for nonpalpable lesions detected by mammography. Considering the diagnostic effectiveness, a direct comparison of SVAB and open surgical biopsy (OSB) is lacking. We performed a retrospective review of 276 (33.8%) SVAB and 541 (66.2%) OSB to compare the diagnostic accuracy and the total number of procedures the patients underwent. The negative predictive values of OSB and SVAB were 99.77% and 99.61%, and their false-negative rates were 0.96% and 4.76%, respectively. SVAB, as the first-line biopsy method, obviated 92.3% of operations. All malignancies diagnosed using SVAB could be treated with single therapeutic surgery. By contrast, 48% of malignancies of OSB group received two operations. Breast Imaging Reporting and Data System (BI-RADS) category used at the study correlated well with the percentage of malignancy and can thus be used to predict biopsy results. Our study concluded that SVAB is reliable for diagnosing nonpalpable breast lesions and is the better biopsy method for categories 3 and 4A lesions, which reduces the benign surgery rate. For lesions with a higher likelihood of malignancy, BI-RADS 4B, 4C and 5, SVAB has an advantage over OSB, which lowers the total number of operations for malignancy treatment.

Atypical teratoid/rhabdoid tumor of lumbar spine in a toddler child.

BACKGROUND: Atypical teratoid/rhabdoid tumor (AT/RT) is a rare pediatric central nervous system malignancy with poor outcome. AT/RT is infrequently located in the spinal cord. CLINICAL PRESENTATION: A 16-month-old boy presented with progressive urinary retention and weakness of the lower extremities. Magnetic resonance imaging of the spine revealed an intradural extramedullary mass occupying the spinal canal at the level of T10-L3. The tumor was successfully resected by using neuroendoscopy. Histopathology demonstrated rhabdoid cells with eccentric nuclei and eosinophilic cytoplasmic hyaline inclusions. Immunohistologically, the tumor cells showed positive for epithelial membrane antigen, vimentin and neuron-specific enolase, and negative for integrase interactor 1. After surgery, the patient showed significant improvement in sitting and other neurological signs but presenting with flaccid neurogenic bladder. Intrathecal chemotherapy under European Rhabdoid Registry (EU-RHAB) protocol with Doxorubicin, Carboplatin, Etoposide, Ifosfamide, Vincristine, Cyclophosphamide and Actinomycin-D was given. However, recurrent intradural extramedullary tumor at the level of T11-L2 developed in 3 months. CONCLUSION: We report a young Asian case of AT/RT in thoracolumbar spine with recurrent tumor shortly after complete surgical resection of the tumor.

Diagnostic Performance of Split-Bolus Portal Venous Phase Dual-Energy CT Urography in Patients With Hematuria.

OBJECTIVE: The purpose of this study is to evaluate the diagnostic performance of split-bolus portal venous phase dual-energy CT (DECT) urography in patients with hematuria. MATERIALS AND METHODS: True unenhanced and split-bolus portal venous phase contrast-enhanced weighted-average images were obtained in 171 patients with hematuria. Virtual unenhanced and iodine-overlay images were reconstructed from contrast-enhanced 80-kVp and tin-filtered 140-kVp scans. Images were independently reviewed by two radiologists who were blinded to the final diagnoses in two separate reading sessions: virtual unenhanced and iodine-overlay images (single phase) in the first session and true unenhanced and contrast-enhanced weighted-average images (dual phase) in the second session (mean ± SD, 52 ± 8 days later). Sensitivity, specificity, and accuracy of mass detection were calculated from the data of both reading sessions. The number of calculi detected on virtual unenhanced images was compared with the number detected on true unenhanced images. The difference in radiation dose between the single- and dual-phase protocols was calculated. The statistical significance was determined by ANOVA. RESULTS: The sensitivity, specificity, and accuracy were 98.7%, 98.9%, and 98.8%, respectively, for the single-phase approach to malignant mass detection and 98.7%, 97.9%, and 98.3%, respectively, for the dual-phase approach (p > 0.05 for all comparisons). The overall sensitivity of stone detection was 86.7% (39/45) for virtual unenhanced images. Omitting the unenhanced scan reduced the mean radiation dose from 15.4 to 6.7 mSv. CONCLUSION: The diagnostic performance of both the single- and dual-phase approaches of portal venous phase split-bolus DECT urography is equally good in patients with hematuria, and single-phase acquisition has the added benefit of radiation reduction.