Concurrent thyrolipomatosis and thymolipoma in a patient with myasthenia gravis: a case report and review of the literature.

We present a case of a man with a background of myasthenia gravis who presented with a neck lump, which was diagnosed as thyrolipomatosis in continuity with a very large thymolipoma. Following removal of these lesions, the patient's myaesthenic symptoms improved. While thymolipomas are often seen in the context of myasthenia gravis, thyrolipomatosis is a rare entity and to our knowledge the concurrent finding of both lesions with myasthenia gravis has never been reported. We highlight the important imaging features of both entities and the clinical importance of recognising them.

Brain Imaging of Patients with COVID-19: Findings at an Academic Institution during the Height of the Outbreak in New York City.

BACKGROUND AND PURPOSE: A large spectrum of neurologic disease has been reported in patients with coronavirus disease 2019 (COVID-19) infection. Our aim was to investigate the yield of neuroimaging in patients with COVID-19 undergoing CT or MR imaging of the brain and to describe associated imaging findings. MATERIALS AND METHODS: We performed a retrospective cohort study involving 2054 patients with laboratory-confirmed COVID-19 presenting to 2 hospitals in New York City between March 4 and May 9, 2020, of whom 278 (14%) underwent either CT or MR imaging of the brain. All images initially received a formal interpretation from a neuroradiologist within the institution and were subsequently reviewed by 2 neuroradiologists in consensus, with disputes resolved by a third neuroradiologist. RESULTS: The median age of these patients was 64 years (interquartile range, 50-75 years), and 43% were women. Among imaged patients, 58 (21%) demonstrated acute or subacute neuroimaging findings, the most common including cerebral infarctions (11%), parenchymal hematomas (3.6%), and posterior reversible encephalopathy syndrome (1.1%). Among the 51 patients with MR imaging examinations, 26 (51%) demonstrated acute or subacute findings; notable findings included 6 cases of cranial nerve abnormalities (including 4 patients with olfactory bulb abnormalities) and 3 patients with a microhemorrhage pattern compatible with critical illness-associated microbleeds. CONCLUSIONS: Our experience confirms the wide range of neurologic imaging findings in patients with COVID-19 and suggests the need for further studies to optimize management for these patients.

FLAIR* to visualize veins in white matter lesions: A new tool for the diagnosis of multiple sclerosis?

OBJECTIVE: To explore the potential of a post-processing technique combining FLAIR and T2* (FLAIR*) to distinguish between lesions caused by multiple sclerosis (MS) from cerebral small vessel disease (SVD) in a clinical setting. METHODS: FLAIR and T2* head datasets acquired at 3T of 25 people with relapsing MS (pwRMS) and ten with pwSVD were used. After post-processing, FLAIR* maps were used to determine the proportion of white matter lesions (WML) showing the 'vein in lesion' sign (VIL), a characteristic histopathological feature of MS plaques. Sensitivity and specificity of MS diagnosis were examined on the basis of >45% VIL+ and >60% VIL+ WML, and compared with current dissemination in space (DIS) MRI criteria. RESULTS: All pwRMS had >45% VIL+ WML (range 58-100%) whilst in pwSVD the proportion of VIL+ WML was significantly lower (0-64%; mean 32±20%). Sensitivity based on >45% VIL+ was 100% and specificity 80% whilst with >60% VIL+ as the criterion, sensitivity was 96% and specificity 90%. DIS criteria had 96% sensitivity and 40% specificity. CONCLUSION: FLAIR* enables VIL+ WML detection in a clinical setting, facilitating differentiation of MS from SVD based on brain MRI. KEY POINTS: • FLAIR* in a clinical setting allows visualization of veins in white matter lesions. • Significant proportions of MS lesions demonstrate a vein in lesion on MRI. • Microangiopathic lesions demonstrate a lower proportion of intralesional veins than MS lesions. • Intralesional vein-based criteria may complement current MRI criteria for MS diagnosis.

The spectrum of injuries in buttock stab wounds.

Buttock stab wounds are a surprisingly common and increasing source of presentations to emergency departments. These injuries can have a significant impact on quality of life, and there are a number of often subtle, but significant, injuries that the radiologist must be alert to when interpreting computed tomography examinations in these patients. In this review, we will examine briefly the sociological reasons for the increase in these injuries, discuss appropriate imaging techniques, and provide imaging examples of the clinically important injuries that may be encountered in this region. These injuries include rectal or colonic perforation; genito-urinary trauma, for example urethral injury; injury to the sciatic nerve; and a spectrum of vascular trauma including transection and pseudoaneurysm or arteriovenous fistula formation.

Imaging features and diagnosis of tuberculosis of the breast.

AIM: To outline the pathophysiology, clinical presentation, imaging features, and relevant investigations of the different subtypes of breast tuberculosis (TB). MATERIALS AND METHODS: A review was undertaken of all cases (33 in total) of breast TB presenting to Barts Health NHS Trust within a 10-year period, including patient demographics, imaging features, and route of diagnosis. RESULTS: Thirty-three cases of proven granulomatous TB of the breast were identified (11 mastitis obliterans, 10 nodular caseous form, five sclerosing form, four disseminated disease, and three abnormal axillary lymph nodes). No cases of miliary breast TB were identified. Fine-needle aspiration cytology aided diagnosis in six patients (<20% of cases); however, the majority of patients required further investigation; namely core biopsy. Over a third of patients (12/33) had multiple clinic attendances prior to diagnosis. Mean delay in diagnosis was 3.7 months (median 0 months, IQR= 3). CONCLUSION: Breast TB is a rare challenging diagnosis with a wide range of imaging features. Core biopsy is essential for definitive diagnosis. A multidisciplinary approach involving surgeons, radiologists, TB consultants, and microbiologists is required, coupled with a high index of clinical suspicion in order to aid timely diagnosis, and initiate prompt treatment to reduce complications.

Association between use of a health information exchange system and hospital admissions.

OBJECTIVE: Relevant patient information is frequently difficult to obtain in emergency department (ED) visits. Improved provider access to previously inaccessible patient information may improve the quality of care and reduce hospital admissions. Health information exchange (HIE) systems enable access to longitudinal, community-wide patient information at the point of care. However, the ability of HIE to avert admissions is not well demonstrated. We sought to determine if HIE system usage is correlated with a reduction in admissions via the ED. METHODS: We identified 15,645 adults from New York State with an ED visit during a 6-month period, all of whom consented to have their information accessible in the HIE system, and were continuously enrolled in two area health plans. Using claims we determined if the ED encounter resulted in an admission. We used the HIE's system log files to determine usage during the encounter. We determined the association between HIE system use and the likelihood of admission to the hospital from the ED and potential cost savings. RESULTS: The HIE system was accessed during 2.4% of encounters. The odds of an admission were 30% lower when the system was accessed after controlling for confounding (odds ratio = 0.70; 95%C I= 0.52, 0.95). The annual savings in the sample was $357,000. CONCLUSION: These findings suggest that the use of an HIE system may reduce hospitalizations from the ED with resultant cost savings. This is an important outcome given the substantial financial investment in interventions designed to improve provider access to patient information in the US.

Physical, chemical, and microbiological characteristics of microbial mats (kopara) in the South Pacific atolls of French Polynesia.

Microbial mats that develop in shallow brackish and hyposaline ponds in the rims of two French polynesian atolls (Rangiroa and Tetiaroa) were intensively investigated during the past three years. Comparative assessment of these mats (called kopara in polynesian language) showed remarkable similarities in their composition and structure. Due to the lack of iron, the color of the cyanobacterial pigments produced remained visible through the entire depth of the mats (20-40 cm depth), with alternate green, purple, and pink layers. Profiles of oxygen, sulfide, pH, and redox showed the anoxia of all mats from a depth of 2-3 mm. Analyses of bacterial pigments and bacterial lipids showed that all mats consisted of stratified layers of cyanobacteria (mainly Phormidium, Schizothrix, Scytonema) and purple and green phototrophic bacteria. The purple and green phototrophic bacteria cohabit with sulfate reducers (Desulfovibrio and Desulfobacter) and other heterotrophic bacteria. The microscopic bacterial determination emphasized the influence of salinity on the bacterial diversity, with higher diversity at low salinity, mainly for purple nonsulfur bacteria. Analyses of organic material and of exopolymers were also undertaken. Difference and similarities between mats from geomorphological, microbiological, and chemical points of view are discussed to provide multicriteria of classification of mats.

Management of chronic pain and control of long-term disability.

Chronic pain has become a major public health problem. Often, the availability of entitlement programs as well as psychosocial, occupational, and other nonmedical factors-rather than objective pathophysiology-are major contributors to disability. In this chapter, the authors discuss the relationship between impairment and disability and detail factors likely to predict or contribute to adverse clinical outcome and disability. Guidelines for disability prevention also are examined.

Reverse tapered vs. straight PTFE (Gore-Tex) grafts in dogs.

Reversed Autogenous Saphenous Vein (RASV) remains the material of choice in infrainguinal arterial bypass. A characteristic of RASV not seen in other grafts is its reverse tapered (RT) configuration. The purpose of this study was to investigate this geometric configuration. Straight 6 mm PTFE (gore-tex) grafts (SG) and 4-7 mm reverse tapered PTFE (gore-tex) grafts (RTG) were both implanted in the aorto-iliac position in 16 mongrel dogs. Specimens of surviving dogs were examined by the usual methods. In terms of absolute patency, 9 of 14 RTG (64%) and 5 of 14 SG (36%) P = 0.05, anastomotic thrombus formation 6 of 14 (43%) RTG vs. 10 of 14 (71%) SG P = 0.05 and in midgraft thrombus deposition P = 0.025 the RTG performed significantly better than the SG. In light of these results and other considerations, the reverse tapered configuration merits clinical investigation with other materials and in other species.

Melorheostosis: two case presentations and review of the literature.

Two cases are presented. Case #1, a 27-year-old Caucasian male presented with chronic right leg pain. Case 2 was a 23-year-old Caucasian female with right fifth finger pain. The clinical examination was benign except for mild tenderness of many years duration. No deformities were present in the male patient, the female patient did exhibit mild clinodactyly. The pain was described as constant, low grade, and dull. Plain roentgenograms of both patients demonstrated a hyperostotic process typical of melorheostosis and the bone scans demonstrated increased bone activity. A CAT scan demonstrated both endosteal and periosteal hyperostosis in our male patient. The biopsies of both patients were consistent with the clinical diagnosis of melorheostosis. A discussion and review of the literature covering this process is presented.

Effects of prostacyclin injections and infusions on canine femoral hemodynamics.

The use of prostacyclin (PGI2) infusions has been recommended in the management of patients with severe distal arteriopathy, who are not candidates for conventional bypass procedures. Further clarification regarding the route of administration and the optimal dose of this potent vasodilator, however, is needed before controlled clinical trials are initiated. We measured bilateral femoral arterial blood flow electromagnetically in seven anesthetized adult mongrel dogs. Systemic arterial pressure and cardiac output were also measured. Central venous and femoral arterial injections of PGI2 were administered in five doses ranging from 10(-4) to 10(0) micrograms X kg-1 to study the dose response. PGI2 was also infused intravenously and intra-arterially for 20 minutes at a dose of 10(-1) micrograms X kg-1 X min-1. Femoral arterial injections of PGI2 in doses from 10(-4) through 10(0) micrograms X kg-1 caused significant (p less than 0.05) and dose-dependent increases in ipsilateral femoral arterial blood flow. Intravenous injections of PGI2 caused no significant changes in the dose range from 10(-4) to 10(-2) micrograms X kg-1 but resulted in a significant (p less than 0.05) reduction in femoral arterial flow and systemic arterial pressure at doses of 10(-1) and 10(0) micrograms X kg-1. The femoral arterial infusion of PGI2 produced a significant and sustained increase in femoral arterial flow that was not observed during the intravenous infusion. Arterial pressure was unchanged with intra-arterial PGI2 but was significantly reduced during the intravenous infusion. The beneficial hemodynamic effects of intra-arterial PGI2 suggest that further clinical trials should employ this route of administration.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of prostacyclin on distribution of canine femoral blood flow.

Prostacyclin (PGI2) has been used clinically in the treatment of ischemic peripheral vascular disease. While intravenous infusions have been reported to be beneficial, the preferred route of administration (intravenous or intraarterial) and the influence of PGI2 on distribution of femoral blood flow have yet to be established. Bilateral femoral arterial blood flow was measured electromagnetically in 10 anesthetized adult mongrel dogs. The distribution of femoral arterial blood flow (FAQ) to skin, muscle, bone, and arteriovenous anastomoses (AVA) was determined by using femoral intraarterial injections of radioactively labeled microspheres before, during, and 30 min after 20-min intravenous (n = 5) and intraarterial (n = 5) infusions of PGI2 at 0.1 microgram kg-1 min-1. Control FAQ was 76 +/- 15 (mean +/- SEM) ml/min and its distribution to skin, muscle, bone, and AVA was 13 +/- 3%, 43 +/- 8%, 17 +/- 4%, and 26 +/- 7%, respectively. Arterial pressure was 127 +/- 7 mm Hg. Intraarterial infusions of PGI2 significantly (P less than 0.05) increased FAQ to 240 +/- 43 ml/min which was sustained throughout the infusion. Distribution of FAQ to skin increased significantly (P less than 0.05) to 47 +/- 8%, while that to the muscle of the thigh decreased to 17 +/- 4% (P less than 0.05). During intravenous infusion of PGI2 at the same concentration, FAQ did not change significantly and its distribution remained unchanged; however, there was a significant (P less than 0.05) reduction in arterial pressure to 78 +/- 6 mm Hg. No significant changes occurred in cardiac output, pulmonary arterial pressure, arterial blood gases, paw or core body temperatures.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of frostbite with intra-arterial prostaglandin E1.

Prostaglandin E1 (PGE1) is a vasodilator that inhibits platelet aggregation. Its use has been effective intra-arterially in treating ischemic peripheral vascular disease. Its potentially beneficial effect in treating frostbite injuries has not been studied and prompted this investigation. A standard frostbite injury was induced by immersing the hindlimbs of New Zealand white rabbits in an ethylene glycol bath maintained at -15 C. Forty animals were separated into eight equal groups (N = 5). Groups I through V were allowed to slowly rewarm at room temperature (21-22 C), while Groups VI through VIII underwent rapid rewarming in a water bath at 42 +/- 1 C. Groups I and VI received no further treatment. Groups II and VII received intra-arterial bolus injections of saline. Group III received intra-arterial bolus injections of reserpine (2.5 X 10(-3) mg/kg-1). Group IV received intra-arterial bolus injections of PGE1 (10(-1) micrograms/kg-1). Groups V and VIII received 3-hour intra-arterial infusions of PGE1 (10(-1) micrograms/kg-1 min-1). Tissue loss was graded numerically after 30 days. Group V (slow rewarming plus 3-hour PGE1 infusion) had significantly (P less than 0.5) less tissue loss than Group I (slow rewarming alone) and Group II (slow rewarming plus saline). Group V was not significantly different from Groups VI through VIII (rapid rewarming). Group III (slow rewarming plus bolus reserpine) and Group IV (slow rewarming plus bolus PGE1) were not significantly different from Group I (slow rewarming alone). The data suggest a clinical application for the use of PGE1 in frostbite patients who have not undergone rapid rewarming.

Ingredients of a psychiatric malpractice lawsuit.

This is a review by two trial lawyers of the practical problems in trying a psychiatric malpractice lawsuit. The substantive rules of law which receive a good deal of attention are found to be most significant in the day-to-day suit than gathering together the facts and medical opinions and presenting them to the jury in a persuasive fashion.