Determining the Best Thyroid Imaging Reporting and Data System: A Prospective Study Comparing the Diagnostic Performance of ACR, EU, and K TIRADS in the Evaluation of Thyroid Nodules.

Background Many different risk stratification systems have been formulated for thyroid nodules, differing in their fine-needle aspiration cytology (FNAC) indication, suggesting a lack of consensus around the world. Purpose This prospective study was conducted to find the best guideline for risk stratification, for a better malignancy yield, and with reduced rates of negative FNACs among three Thyroid Imaging, Reporting, and Data System (TIRADS) guidelines. Materials and Methods A total of 625 thyroid nodules with conclusive FNAC or histopathological diagnosis were included in the study. Various sonographic parameters were recorded. They were classified into categories as per the three guidelines and compared with FNAC diagnosis. The guidelines were evaluated in terms of sensitivity, specificity, predictive values, and diagnostic accuracy. Sensitivity and specificity were compared by McNemar's test. Results American College of Radiology (ACR) TIRADS had the highest diagnostic accuracy (56.8%), specificity (50.75%), positive predictive value (23.92%), lowest rates of negative FNACs (76.08%), and high negative predictive value (97.84 %). Korean (K) TIRADS had the maximum sensitivity (97.75%), highest negative predictive value (98.44%), and gross malignancy yield. European TIRADS was between the two other guidelines in most parameters with specificity like K TIRADS. Conclusion All the three guidelines are very good screening tools, with comparable high sensitivity. ACR TIRADS is better in terms of specificity and reduced rates of negative FNACs. Including the presence of a suspicious cervical lymph node as a criterion and more frequent follow-up might further improve the diagnostic performance of the guideline.

Plasmacytoid urothelial carcinoma with duodenal metastasis-A rare tumor with unusual site of metastasis with grim outcome.

Plasmacytoid urothelial carcinoma (PUC) is a newly recognized rare variant of urothelial carcinoma, which is now being increasingly diagnosed prospectively as well as by retrospective analysis of cases with a poor prognosis. Morphologically, these tumors simulate plasma cell neoplasms and pose a diagnostic challenge. Identifying this variant is essential in two aspects: therapy and prognosis. Here, we present a case who underwent multiple transurethral resection of bladder tumor (TURBT) procedures, each with a diagnosis of urothelial carcinoma, the plasmacytoid type which was confirmed on radical cystectomy, and after 1 year, the patient presented with duodenal metastasis. We discuss the morphological aspects of differentiating this tumor from variants of urothelial carcinoma and other tumors with a plasmacytoid appearance. Despite the recognition and aggressive treatment, the patient expires within 2 years of the first diagnosis of bladder carcinoma.

Multidetector Computed Tomography (MDCT) Angiography Evaluation of Total Anomalous Pulmonary Venous Connection.

Total anomalous pulmonary venous connection (TAPVC) is a rare congenital cardiovascular malformation in which all four pulmonary veins anomalously drain into the right atrium (RA) either directly or indirectly. There are four main types based on the site of connection. Any type of TAPVC may be associated with obstruction and presents early in the neonatal period with cyanosis, tachycardia, or respiratory distress. We present four cases of all types of TAPVC and its imaging findings in multidetector computed tomography (MDCT) angiography. Cardiac CT and magnetic resonance imaging (MRI) are very useful in delineating the anatomy and drainage pathway of anomalous pulmonary veins. MDCT angiography is noninvasive and easily available, and rapid image acquisition is possible with high spatial resolution. Since early diagnosis and surgical correction are necessary for the survival of these neonates, rapid image acquisition using MDCT angiography can be preferred over MRI.

Comparing Sensitivity and Specificity of Ultrasonography With Chest Radiography in Detecting Pneumothorax and Hemothorax in Chest Trauma Patients: A Cross-Sectional Diagnostic Study.

Background Thoracic trauma accounts for 20-25% of all traumas and is the third most frequent cause of death, after abdominal injury and head trauma. In the Emergency Department (ED), shifting an unstable patient to the X-ray room for detecting pneumothorax and hemothorax is always risky and bedside X-ray causes radiation exposure not only to the particular patient but also to the surrounding patients in a congested and busy ED. This can be avoided by using bedside ultrasonography (USG) as the initial imaging modality in chest trauma patients. Objective To compare the sensitivity and specificity of ultrasonography and chest radiography in detecting pneumothorax and hemothorax in chest trauma patients. Methods This cross-sectional diagnostic study was conducted for a period of one year at Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, a tertiary care centre. All consecutive patients (n=255) with a suspected history of chest trauma were included in the study. The patients were evaluated bedside using USG by point of care ultrasonography trained emergency medicine physician and subsequently underwent chest radiography for documentation of pneumothorax and hemothorax. Sensitivity and specificity were calculated for ultrasonography and chest X-ray (CXR) compared with the composite gold standard (chest radiography and computed tomography thorax). Results Of the 255 patients, 89% were males. The mean age of the patients was 43.46 (standard deviation 16.3). Road traffic accident (RTA) was the most common mode of injury (81%). The median (interquartile range) time interval between injury and arrival at the hospital was four hours (2.5-7). About 16.1% of the patients had subcutaneous emphysema. About 88.2% of the patients were hemodynamically stable and 78% of the patients had associated other system injuries. The sensitivity and specificity of USG in detecting pneumothorax were 85.7% and 95.3% respectively and that of CXR were 71.4% and 100% respectively. Our study found that the sensitivity and specificity of USG in detecting hemothorax were 79% and 97.9% respectively and that of CXR were 62.9% and 100% respectively. Even in the subset of patients in whom a computed tomography scan was done, the sensitivity of USG was higher than that of CXR in detecting pneumothorax and hemothorax. The specificity of USG in detecting pneumothorax was the same as that of CXR and the specificity of USG in detecting hemothorax was higher than that of CXR in that subset of patients. Conclusion The sensitivities of USG in detecting pneumothorax and hemothorax were higher than that of CXR. The specificities of USG in detecting pneumothorax and hemothorax were comparable to that of CXR. Hence bedside USG performed by emergency physician during resuscitation helps in rapid diagnosis and early management of chest trauma patients.

Randomized Double-Blind Placebo-Controlled Study of Olanzapine for Chemotherapy-Related Anorexia in Patients With Locally Advanced or Metastatic Gastric, Hepatopancreaticobiliary, and Lung Cancer.

PURPOSE: Anorexia occurs in 30%-80% of patients with advanced malignancies, which may be worsened with chemotherapy. This trial assessed the efficacy of olanzapine in stimulating appetite and improving weight gain in patients receiving chemotherapy. METHODS: Adults (≥18 years) with untreated, locally advanced, or metastatic gastric, hepatopancreaticobiliary (HPB), and lung cancers were randomly assigned (double-blind) to receive olanzapine (2.5 mg once a day for 12 weeks) or placebo along with chemotherapy. Both groups received standard nutritional assessment and dietary advice. The primary outcomes were the proportion of patients with weight gain > 5% and the improvement in appetite (assessed by the visual analog scale [VAS] and the Functional Assessment of Chronic Illness Therapy system of Quality-of-Life questionnaires Anorexia Cachexia subscale [FAACT ACS]). Secondary end points were change in nutritional status, quality of life (QOL), and chemotherapy toxicity. RESULTS: We enrolled 124 patients (olanzapine, 63 and placebo, 61) with a median age of 55 years (18-78 years), of whom 112 (olanzapine, 58 and placebo, 54) were analyzable. The majority (n = 99, 80%) had metastatic cancer (gastric [n = 68, 55%] > lung [n = 43, 35%] > HPB [n = 13, 10%]). The olanzapine arm had a greater proportion of patients with a weight gain of > 5% (35 of 58 [60%] v 5 of 54 [9%], P < .001) and improvement in appetite by VAS (25 of 58 [43%] v 7 of 54 [13%], P < .001) and by FAACT ACS (scores ≥37:13 of 58 [22%] v 2 of 54 [4%], P = .004). Patients on olanzapine had better QOL, nutritional status, and lesser chemotoxicity. Side effects attributable to olanzapine were minimal. CONCLUSION: Low-dose, daily olanzapine is a simple, inexpensive, well-tolerated intervention that significantly improves appetite and weight gain in newly diagnosed patients on chemotherapy.

Prevalence and Risk Factors for Resistant Hypertension: Cross-Sectional Study From a Tertiary Care Referral Hospital in South India.

Background Around 10% patients with hypertension have resistant hypertension (RH). Older age, Black race, obesity, diabetes mellitus (DM) and chronic kidney disease (CKD) are the common risk factors for RH. The present study was done to find out the prevalence and factors associated with RH. Methods This cross-sectional study was done between December 2018 and February 2020. Adult patients registered with the hypertension clinic and on care for more than three months were included in the study. History was noted and blood pressure (BP) was measured using standard precautions. The patients were divided into two groups - resistant and non-resistant hypertension. Chi-square test was done to check the significance of the differences between the two groups. Binary logistic regression was done for the risk factors with a p-value < 0.2 in the Chi-square test. Results A total of 275 patients were included. The mean age was 56 ± 10 years and 61% were females. The mean duration of hypertension was 7 ± 5 years; 77% of patients were overweight or obese. A family history of hypertension was present in 30% and 18% had diabetes mellitus. History suggestive of secondary hypertension was present in 13%. BP was controlled (<130/80 mm of hg) in 145 (53%), uncontrolled in 130 (47%) and resistant hypertension was seen in 31 [(11%) 95% CI 8-16%] patients. Duration of hypertension, obesity, and elevated fasting blood sugar were significantly associated with RH.  Conclusions RH was found in 11% of hypertensive patients. Longer duration of hypertension, obesity, and higher fasting blood glucose were associated with RH.

Management dilemmas in pineoblastoma recurrence diagnosed during pregnancy.

Pineoblastoma is an extremely rare intracranial neoplasm, with increased risk of craniospinal metastasis. There is only one case reported in the literature who presented during pregnancy. Described here is a woman who presented at five months of gestation with recurrence of pineoblastoma, who had previously defaulted adjuvant therapy following surgical decompression. The challenges in the diagnosis and treatment of pineoblastoma and its effects on pregnancy are also discussed.

Cardiac tamponade as an initial presentation of papillary carcinoma with psammoma bodies and intranuclear grooves-A diagnostic dilemma.

Involvement of body fluids by adenocarcinoma is a common phenomenon. However, metastasis to the pericardial fluid by adenocarcinoma is a rare occurrence. The most common malignancies associated with malignant pericardial effusion are carcinoma of the lung, breast, esophagus, melanoma, lymphoma, and leukemia. Here, we discuss a case of a 36-year-old female with hemorrhagic pericardial effusion presenting with cardiac tamponade and psammoma bodies which was suspected and reported as metastatic papillary carcinoma of thyroid on cytomorphology; however, the immunocytochemical and radiological features confirmed metastatic papillary adenocarcinoma of lung contrary to the thyroid which is more common and expected.

Role of Ultrasound to Monitor Patients With Carpal Tunnel Syndrome Treated With a Local Corticosteroid.

OBJECTIVES: Carpal tunnel syndrome (CTS) is an entrapment neuropathy resulting from compression of the median nerve at the carpal tunnel (CT). We assessed the role of high-resolution ultrasound (US) in monitoring patients with CTS treated with corticosteroid injection. METHODS: We performed high-resolution US evaluations of the wrists of patients with CTS before and after treatment with local corticosteroid. Thirty-nine and 17 wrists were included for analysis at the end of 1 and 3 months, respectively. The cross-sectional area (CSA) and anteroposterior diameter (APD) of the median nerve at the CT and clinical and electrophysiologic data were recorded. We assessed whether changes in US measurements before and after the treatment correlated with clinical and electrophysiologic parameters. RESULTS: The Boston symptom severity scale (p < .01), Boston functional status scale (p < .01), median nerve motor latency (p = .017), median nerve sensory velocity (p = .003), and difference in motor latencies (p = 0.03) and difference in sensory latencies (p = .03) between median and ulnar nerves showed significant changes over 1 or/and 3 months compared to baseline values. Changes in the CSA and APD correlated with changes in some clinical and electrophysiologic parameters. However, measurements of the CSA and APD at 1 or 3 months were not significantly different from baseline values. CONCLUSIONS: High-resolution US parameters such as the APD and CSA of the median nerve at the CT inlet were not useful to monitor patients with CTS treated with corticosteroid injections.

Isolated hepatobiliary tuberculosis: a diagnostic challenge.

Hepatobiliary system involvement is frequently seen as part of disseminated tubercular infection. But primary isolated hepatobiliary tuberculosis with no evidence of tuberculosis elsewhere in the body is extremely rare. Isolated hepatobiliary tuberculosis can cause diagnostic dilemma as the clinical, laboratory and imaging features are non-specific in majority of the cases. We report the case of a 50-year-old woman who presented with hepatobiliary tuberculosis with no pulmonary or extra hepatic involvement. Liver function tests were abnormal and ultrasonography (USG), CT and MR cholangiopancreatography showed multiple focal lesions in the liver. The diagnosis of tuberculosis was confirmed by a USG-guided biopsy of the liver lesions. In endemic regions with the presence of supportive imaging findings, in the appropriate clinical setting, the possibility of hepatic tuberculosis should be considered and diagnosis has to be confirmed with histopathological examination.

Portal Annular Pancreas: Case Report of a Rare Anomaly.

Portal annular pancreas is a rare congenital anomaly in which the portal vein and/or the splenoportal confluence are completely encircled by aberrant pancreatic parenchyma. It is an asymptomatic condition and is usually an incidental finding. It is, however, important to a surgeon because the postoperative pancreatic fistula (POPF) rates following pancreatic resection are higher in patients with this anomaly. A 47-year-old male presented with features of obstructive jaundice. He was diagnosed to have periampullary carcinoma, and pancreatoduodenectomy was planned. During surgery, uncinate process was seen extending posterior to the portal vein and was communicating with the body of pancreas to the left of the portal vein. After transection, there were two pancreatic stumps. The pancreatic duct was identified in the stump anterior to the portal vein. No duct was present in the posterior pancreatic stump. We closed the posterior pancreatic stump with interrupted polypropylene sutures and performed a duct to mucosa pancreaticojejunostomy in the anterior stump. On reviewing the preoperative computed tomography (CT) scan, we were able to identify the pancreatic tissue encasing the portal vein superior to the splenic vein. Circumportal pancreas is classified based on the orientation of pancreatic duct to the portal vein and the relationship of the aberrant pancreatic tissue with the splenoportal confluence. Following pancreatoduodenectomy, the surgeon has to manage two pancreatic stumps, one anterior and the other posterior to the portal vein. No standardised technique has been described for management of the pancreatic stumps. Every surgeon planning pancreatic surgery should be aware of this rare anomaly, and look for the same in the preoperative CT scan so that appropriate plan can be made regarding the type of pancreatic anastomosis.

Diagnosis of pseudo-gout (calcium pyrophosphate deposition disease) clinched on cytology.

Calcium pyrophosphate dihydrate (CPPD) deposition disease is a metabolic arthropathy which results from deposition of calcium pyrophosphate crystals in and around joints especially the hyaline cartilage and disc material. This metabolic disease in uncommon in the smaller joints and multiple diagnostic modalities along with biochemical investigations would be necessary for definite diagnosis. We highlight the case of a 48 year old male who presented with a painful mass at the base of left thumb and was clinic-radiologically suspected as malignancy. Cytological examination (fine needle aspiration cytology [FNAC]) showed numerous extracellular rods shaped and rhomboid blunt-ended crystals along with foreign body type of giant cells. The main emphasis here is on the pivotal role played by FNAC in accurately diagnosing the disease where other modalities like radiology and histopathology failed to do so. The exact categorization of crystals is important from treatment point of view to avoid any major deformities in the joints/systemic manifestation.

CT pleurogram for diagnosing an occult diaphragmatic tear.

A 27-year-old man road traffic accident victim, in his initial CT, showed fractures in left lower ribs, pleural effusion and splenic and pancreatic lacerations. The left pleural effusion, drained with an intercostal tube, did not show any significant reduction in size and pleural fluid amylase was abnormally high. A diaphragmatic tear was suspected. Contrast was injected through the intercostal tube and a CT was performed, which revealed a small diaphragmatic tear and communication of the pleural space with peritoneum and the pancreatic laceration site.