The effect of ulnar variance on scapholunate and capitolunate angles.

Background Ulnar variance (UV), which is measured using anteroposterior (AP) X-rays, is associated with the development of multiple wrist pathologies. The scapholunate angle (SLA) and capitolunate angle (CLA) are measured using lateral X-rays, and these can be used in the diagnosis of intercalated segmental instability. Purpose To determine the effect of UV on SLA and CLA. Material and Methods A total of 140 patients (73 women, 67 men; mean age, 37.8 ± 14.6 years; 95% confidence interval [CI], 35.4-40.3) were included in the study. Participants were excluded if they presented with fractures or malunions, any arthritic conditions, avascular necrosis, congenital deformities, or bone and soft tissue tumors. UV, SLA, and CLA were measured using AP and lateral wrist X-rays. Results Patients were grouped as positive, neutral, and negative UV. There was no statistically significant difference in mean ages, sex, and sides (left or right) between the UV groups ( P > 0.05). In addition, there was no statistically significant difference in the mean values of SLA and CLA between the UV groups ( P > 0.05). UV showed no statistically significant association with SLA and CLA (r = -0.064; P = 0.455, and r = 0.059; P = 0.485, respectively). However, there was a statistically significant association between SLA and CLA (r = -0.482; P < 0.001). Conclusion There is higher prevalence of neutral UV and no correlation between UV with respect to age and sex of patients in the local Turkish population. SLA and CLA are not affected by UV. There is a negative correlation between SLA and CLA.

MRI assessment of internal acoustic canal variations using 3D-FIESTA sequences.

Magnetic resonance imaging (MRI) of the internal acoustic canal is the standard diagnostic tool for a wide range of indications in patients. This study aims to investigate the vascular variations and compression of the cranial nerves (CNs) VII and VIII at the cerebellopontine angle in patients with neuro-otologic symptoms using 3D-fast imaging employing steady-state acquisition (FIESTA) MR imaging. One hundred and eighty-seven patients (374 temporal bones) were examined on a 1.5-T MRI. In addition to conventional MR sequences, a 3D-FIESTA MR imaging was acquired. Magnetic resonance images thus obtained were evaluated with special regard to the presence of vascular contact to the CNs VII and VIII, as well as the presence of the vascular variations of the anterior inferior cerebellar artery (AICA) causing the compression of CNs. The Chi-squared test was used for statistical analysis. No statistically significant differences were found between the presence and absence of the AICA loop and/or vascular contact for the clinical symptoms of patients (P > 0.05). The cisternal and canalicular segments of CNs VII and VIII and adjacent vascular variations are well identified using 3D-FIESTA, especially by determining the relationship of the AICA variations between CNs.

Respiratory epithelial adenomatoid hamartoma: a rare nasopharyngeal mass lesion.

Respiratory epithelial adenomatoid hamartoma (REAH) is a rare and nonneoplastic lesion of upper respiratory tract characterized by an abnormal mixture of tissues which are peculiar to the involved anatomic region. The most common site reported is nasal cavity and its nasopharyngeal origin is extremely rare. The lesion can be confused with a variety of benign and malignant entities. In this article, we report a 22-year-old female case of REAH of posterior nasopharyngeal wall. The clinical and radiological features of the lesion are discussed in the light of literature data.

An unusual cause of death: spontaneous urinary bladder perforation.

Spontaneous urinary bladder perforation is a rare and life-threatening condition similar to traumatic and iatrogenic perforation. The connection with the underlying bladder damage due to previous radiotherapy, inflammation, malignancy, obstruction, or other causes can be found in almost all cases. The symptoms are often nonspecific, and misdiagnosis is common. Here, we present a case of spontaneous urinary bladder perforation due to bladder necrosis in a diabetic woman. She presented to the emergency department with abdominal pain. Exploratory laparotomy was performed by surgeons and revealed necrosis of the anterior and lateral walls of the urinary bladder. Microscopic examination revealed necrotic changes throughout the bladder wall. Ghost-like cellular outlines were compatible with coagulative necrosis. Clusters of bacteria were also present in some necrobiotic tissues. Malignant cells were not present. It appears probable that the infection was due to local interference with the blood supply (arterial, capillary, or venous) combined with the systemic metabolic upset that led to the bladder condition. In our case, we observed partial necrosis of the bladder rather than distortion of the entire blood supply to the bladder as consequences of the microvascular effects of diabetes. Urinary bladder perforation must be considered in the differential diagnosis of patients presenting with free fluid in the abdomen/peritonitis, decreased urine output, and hematuria, and in whom increased levels of urea/creatinine are detected in serum and/ or peritoneal fluid aspirate.

The association of patellar maltracking with infrapatellar fat pad edema and chondromalacia patella: A quantitative morphological magnetic resonance imaging analysis.

OBJECTIVES: This study aims to investigate the relationship of patellofemoral joint morphology with infrapatellar fat pad edema and chondromalacia patella (CP) using patellar maltracking parameters on magnetic resonance imaging (MRI). PATIENTS AND METHODS: Between January 2010 and January 2013, 50 patients with edema in the superolateral portion of the infrapatellar fat pad (the study group) and control group (n=50) with a normal infrapatellar fat pad were identified on MRI to compare with regard to five patellar maltracking parameters retrospectively. These parameters were trochlear depth, the trochlear sulcus angle (TSA), patellar translation, the lateral patellofemoral angle (PFA), and the Insall-Salvati ratio. The relationship between patellar maltracking and the CP was also evaluated using the same parameters. RESULTS: In the study group, the Insall-Salvati index and TSA were significantly higher (p=0.001), and the trochlear depth and PFA were low (p=0.001, p=0.01), while patellar translation showed no difference (p=0.957). In the CP group, the Insall-Salvati index and TSA were significantly high (p=0.001), the trochlear depth was low (p=0.001). No statistically significant difference was found in PFA and patellar translation (p=0.292, p=0.446). CONCLUSION: Our study results suggest that edema in the superolateral portion of infrapatellar fat pad and CP are associated with patellar maltracking.

Spinal epidural abscess due to Brucella.

BACKGROUND: Brucellar spinal epidural abscess (SEA) is a rarely encountered clinical entity during the course of the systemic Brucella infection. METHODS: We reported 9 patients diagnosed with Brucellar SEA with a mean follow-up of 20 months. Spinal epidural abscess was detected by magnetic resonance imaging in all cases. Brucella diagnosis was established by specific blood tests. Patients were administered antibiotics for a duration of 6 to 12 weeks. RESULTS: Spinal epidural abscess was localized in lumbar region in 6 patients, dorsal in 2 patients, and cervical in 1 patient. Abscess mimicked disk herniation clinically in 3 patients. Although neurologic examination was normal in 6 patients, we detected motor deficit in 3 patients. Symptoms regressed in all patients but 1 after the institution of antibiotic regimens, and all recovered fully without any sequel. Surgical drainage of abscess was performed in 1 patient. CONCLUSIONS: Proper antibiotic regimens in required doses and duration should be the primary treatment in Brucellar SEA. The criteria for terminating antibiotic therapy are clinical recovery and dissolution of abscess images radiologically. Lastly, should any neurologic deterioration be detected during the course of medical treatment, surgical decompression is to be considered.

Effect of percutaneous biliary drainage on serum levels of tumor markers in patients with obstructive jaundice.

BACKGROUND/AIMS: Some tumor markers such as CA 19-9 are shown to be increased in obstructive jaundice due to either benign or malignant causes. In this study the clinical importance of raised serum levels of tumor markers have been evaluated, with particular reference to obstructive jaundice and percutaneous biliary drainage. METHODOLOGY: We conducted a prospective longitudinal before-after trial. Twenty-one patients with obstructive jaundice were investigated, 5 with benign obstruction and 16 with malignant disease. All patients were examined with abdominal CT prior to biliary drainage. All patients underwent percutaneous transhepatic cholangiography, and 20 of 21 patients underwent percutaneous biliary drainage within 3 days after the CT examination. RESULTS: The mean CA 19-9 at presentation was lower in the group with benign disease (95 +/- 60.9 IU/mL) than those with malignancy (461.9 +/- 331.4 IU/mL). The mean CA 19-9 level in the benign group 1 week after drainage was 12 +/- 11.8 IU/mL. The mean CA 19-9 level in the malignant group after drainage was 249.7 +/- 279.5 IU/mL. CONCLUSIONS: A prominently high serum CA 19-9 level at the presentation and a high serum CA 19-9 level after successful biliary drainage should prompt investigation for a malignant etiology of obstructive jaundice.

Prenatal diagnosis of intracranial pial arteriovenous fistula and endovascular treatment during the neonatal period.

We present a case with prenatal diagnosis of an intracranial high-flow pial arteriovenous fistula that was draining into the vein of Galen in the third trimester of pregnancy. The child was treated by transcatheter embolization with N-butyl 2-cyanoacrylate (NBCA) via the umbilical artery in the early neonatal period due to intractable cardiac failure. Hydrocephalus developed and a ventriculoperitoneal shunt was placed. At the time this report was prepared, the patient was 20 months old and without cardiac failure, but with a delay in neurological development. Prenatal diagnosis and endovascular treatment in the early neonatal period is important in preventing heart failure and resultant mortality due to such high-flow vascular malformations. To the best of our knowledge, the combination of prenatal diagnosis of an intracranial high-flow pial arteriovenous fistula draining into the vein of Galen and endovascular treatment in the early neonatal period is presented here for the first time.

Value of Apparent Diffusion Coefficient Values in Differentiating Malignant and Benign Breast Lesions.

BACKGROUND: Magnetic resonance imaging (MRI) has become a diagnostic and problem solving method for the breast examinations in addition to conventional breast examination methods. Diffusion-weighted imaging (DWI) adds valuable information to conventional MRI. AIMS: Our aim was to show the impact of apparent diffusion coefficient (ADC) values acquired with DWI to differentiate benign and malignant breast lesions. STUDY DESIGN: Diagnostic accuracy study. METHODS: Forty-six women with 58 breast masses (35 malignant, 23 benign) were examined on a 1.5 T clinical MRI scanner. The morphologic characteristics of the lesions on conventional MRI sequences and contrast uptake pattern were assessed. ADC values of both lesions and normal breast parenchyma were measured. The ADC values obtained were statistically compared with the histopathologic results using Paired Samples t-Test. RESULTS: Multiple lesions were detected in 12 (26%) of the patients, while only one lesion was detected in 34 (74%). Overall, 35 lesions out of 58 were histopathologically proven to be malignant. In the dynamic contrast-enhanced series, 5 of the malignant lesions were type 1, while 8 benign lesions revealed either type 2 or 3 time signal intensity curves (85% sensitivity, 56% spesifity). Mean ADC values were significantly different in malignant vs. benign lesions. (1.04±0.29×10(-3) cm(2)/sec vs. 1.61±0.50×10(-3) cm(2)/sec for the malignant and benign lesions, respectively, p=0.03). A cut-off value of 1.30×10(-3) mm(2)/sec for ADC detected with receiver operating characteristic analysis yielded 89.1% sensitivity and 100% specificity for the differentiation between benign and malignant lesions. CONCLUSION: ADC values improve the diagnostic accuracy of solid breast lesions when evaluated with the conventional MRI sequences. Therefore, DWI should be incorporated to routine breast MRI protocol.

Application of scoring systems with point-of-care ultrasonography for bedside diagnosis of appendicitis.

BACKGROUND: Appendicitis is a common disease requiring surgery. Bedside ultrasound (BUS) is a core technique for emergency medicine (EM). The Alvarado score is a well-studied diagnostic tool for appendicitis. This study aimed to investigate the relationship between patients' symptoms, Alvarado score and ultrasound (US) findings, as performed by emergency physicians (EPs) and radiologists, of patients with suspected appendicitis. METHODS: Three EM specialists underwent the BUS course and core course for appendicitis assessment. Patients suspected of having appendicitis were selected and their Alvarado and modified (m) Alvarado scores calculated. The specialists performed the BUS. Then, patients were given a formal US and surgery consultation if necessary. Preliminary diagnoses, admission or discharge from the emergency department (ED) and final diagnosis were documented. The patients were also followed up after discharge from the hospital. RESULTS: The determined cut-off value was 2 for Alvarado and 3 for mAlvarado scores. The sensitivities of the two scores were 100%. Each score was used to rule out appendicitis. The results of EP-performed BUS were as follows: accuracy 70%, sensitivity 0.733, specificity 0.673, + LR 2.24, and - LR 0.40 (95%CI). Radiologists were better than EPs at diagnosing appendicitis and radiologists and EPs were equally strong at ruling out appendicitis by US. When US was combined with Alvarado and mAlvarado scores, EP US+Alvarado/mAlvarado scores <3 and radiology US+Alvarado/mAlvarado scores <4 perfectly ruled out appendicitis. CONCLUSION: BUS performed by EPs is moderately useful in detecting appendicitis. Combined with scoring systems, BUS may be a perfect tool for ruling out decisions in EDs.

A rare case of abdominal infection: Emphysematous pyelonephritis without diabetes.

Emphysematous pyelonephritis (EP) is a rare form of necrotizing pyelonephritis. It is a life-threatening condition that usually affects patients with diabetes, and a small percentage may be due to urinary tract obstruction. Here, we present the case of an EP caused by urinary tract obstruction without diabetes. A 45-year-old woman presented to the emergency department with fever, chills, and abdominal pain. There was no significant past history. Physical examination depicted bilateral lower abdominal and right flank knocking tenderness. Laboratory exams revealed leukocytosis, neutrophilia, a high C-reactive protein level, and pyuria. Abdominal computerized tomography (CT) showed diffuse gas in the right renal collecting system and dilatation of the right renal pelvis compared to the right side, in addition to multiple millimetric stones located in the right kidney and right ureter. After emergent placement of a percutaneous nephrostomy, she was admitted. Control abdominal CT without contrast revealed the absence of gas, hydronephrosis of the right renal pelvis, and the presence of nephrolithiasis. The patient was discharged 10 days of post-procedure with instructions for follow-up. Emergency physicians need to remain alert about this life-threatening disease and the typical CT findings of this disease to make a timely diagnosis and navigate management.

The value of ultrasonographic measurement in carpal tunnel syndrome in patients with negative electrodiagnostic tests.

The diagnosis of carpal tunnel syndrome (CTS) is mainly based on clinical findings and electrodiagnostic tests (EDT). However, EDT results do not support clinical findings in some cases. It has been recently suggested that ultrasonography (US) can be used to diagnose CTS. In this study, we aimed to investigate whether US has a diagnostic value for CTS in patients with negative EDT findings or not. EDT was performed on 319 wrists with clinical CTS findings in electrophysiology laboratory. Median and ulnar nerve conduction velocities were measured in all cases and electromyography was performed in patient with tenar atrophy and having suspicion involvement of brachial plexus as EDT. Fifty-nine wrists with negative EDT (study group) and 30 wrists from 15 healthy individuals (control group) were examined using US. The mean of cross-sectional areas (CSAs) measurements were found 8.83+/-3.05 mm2 by tracing method (TM) and 8.51+/-3.13 mm2 by ellipsoid formula (EF) in study group, and 7.63+/-1.52 mm2 by TM and 7.66+/-1.42 mm2 by EF in control group. The differences between study group and control group according to both TM and EF were significant (t-test p=0.0079, p=0.0460, respectively). In study group, CSAs were larger than 10.5 mm2 in 18 (30.51%) and 16 (27.12%) wrists according to TM and EF findings, respectively, and in only one wrist (3.33%) in control group by both TM and EF. The differences of ultrasonographic CTS numbers between study group and control group were significant (p=0.0024 by TM, p=0.0086 by EF). We confirmed the usefulness of quantitative US assessment in the diagnosis of CTS in the patients with negative EDT findings. If EDT findings are inadequate to confirm the CTS in the patients with clinical CTS, US studies may be helpful to diagnose.

Wassel's Type V Polydactyly with Plain Radiographic and CT Findings.

Duplication of the thumb is the most common polydactyly of the hand. Wassel's classification is frequently used to classify the polydactyly of the hand. His classification was based on the level of duplication and the number of bones in the thumb, and has seven groups (Types I-VII) according to the level of the bifurcation, except for his Type VII. The most common type is the bifurcation at the metacarpophalangeal joint (Type IV). In this paper, we report a very rare case of Type V thumb polydactyly in a 42-year-old man, who presented with swan neck deformity of the radial thumb and discuss the plain radiography and computed tomography (CT) findings. Kumar recently reported plain radiography findings in a case of bifid first metacarpal in a 13-year-old girl, who presented with swan neck deformity of the left thumb. To our knowledge, our case is the second presented case that has a swan neck deformity with bifid metacarpal.

Venous flow volume measured by duplex ultrasound can be used as an indicator of impaired tissue perfusion in patients with peripheral arterial disease.

AIM: In this study, we aimed to investigate the arterial and venous flow volume rate (FV) in order to determine the tissue perfusion using duplex ultrasonography (DU). We hypothesized that FV provides reliable information regarding tissue perfusion in patients with peripheral arterial disease (PAD). MATERIAL AND METHODS: The study comprised 38 patients (72 legs) with PAD. In all patients, common femoral, popliteal, anterior tibial, posterior tibial arteries and veins were examined with DU. Measurements were obtained in the supine position with 15 cm elevation of the foot to neutralise central venous pressure. The diameter, blood flow velocity, and FV of arteries and veins were measured for each patient. RESULTS: The FV of the common femoral artery and vein (p = 0.001), popliteal artery and vein (p=0.003), and posterior tibial artery and vein (p = 0.008) had statistically significant differences. However, there was no statistically significant difference between the FV of the anterior tibial vein and artery (p = 0.408). The mean FV values of all veins were significantly lower than those of homonymous arteries in patients with PAD. CONCLUSIONS: Our study showed that venous FV measured by DU can be used as an indicator of impaired tissue perfusion in patients with PAD.

Stethoscope versus point-of-care ultrasound in the differential diagnosis of dyspnea: a randomized trial.

We aimed to determine the accuracies of point-of-care ultrasound (PoCUS) and stethoscopes as part of the physical examinations of patients with dyspnea. Three emergency medicine specialists in each of two groups of ultrasound and stethoscope performers underwent didactic and hands-on training on PoCUS and stethoscope usage. All the patients enrolled were randomized to one of two predetermined PoCUS or stethoscope groups. The diagnostic performance of ultrasonography was higher than that of the stethoscope in the diagnoses of heart failure (90 vs. 86%, 1.00 vs. 0.89, and 5.00 vs. 4.92, respectively) and pneumonia (90 vs. 86.7%, 0.75 vs. 0.73, and 16.50 vs. 13.82, respectively). No significant differences were observed in the utility parameters of these modalities in these diagnoses. Although some authors argue that it is time to abandon the 'archaic tools' of past centuries, we believe that it is too early to discontinue the use of the stethoscope.

The image of urachus adenocarcinoma on Doppler ultrasonography.

Malignant urachal lesions are exceedingly rare and occur predominantly in adult life. In this case report, an adult patient with urachal carcinoma is presented with abdominal plain film, intravenous urography, gray-scale ultrasonography (US), Doppler US, and computed tomography (CT). Doppler US successfully showed the neovascularity with low resistive index value in the urachus tumor. We believe that Doppler US examination is helpful in the differential diagnosis of urachal carcinoma.

Bilateral and symmetric diaphragmatic crus lipomas: report of a case.

Diaphragmatic crus lipoma is a rare entity and it occasionally occurs bilaterally. In this case, a patient with bilateral and symmetric shape diaphragmatic lipomas that were demonstrated during routine thoraco-abdominal CT examination is presented.

Bilobed gallbladder diagnosed by oral cholecysto-CT.

Morphological anomalies of the gallbladder are rare and are characterized by a large variety of configurations depending on the size and degree of fusion of the lobes, and on the number and position of the cystic ducts. We presented a case of bilobed gallbladder incidentally detected during abdominal ultrasonography. Oral cholecystography and computed tomographic examination after oral cholecystography (Oral Cholecysto-CT) were performed to confirm this abnormality. This is a quite rare anomaly consisted of complete duplication of the fundus and partially duplication of the corpus and separated lobes both of which entered a single infundibulum and cystic duct.