Multimodality imaging of acute gynecological emergencies-a pictorial essay.

Gynecological emergencies can often present with a myriad of non-specific signs and symptoms, posing a diagnostic challenge to the clinician. They can be grossly divided into uterine or adnexal pathologies. Uterine pathologies can be secondary to intracavitary accumulation of blood [like in patients with transverse vaginal septum, Robert's uterus, accessory and cavitated uterine mass, unicornuate uterus with contralateral non-communicating functional horn], bleeding per vaginum [like in patients with retained products of conception, enhanced myometrial vascularity], pyometra [secondary to pelvic inflammatory disease, cervical obstruction secondary to benign and malignant causes] or complications of fibroids [like red degeneration, torsion of subserosal fibroid]. The adnexal pathologies can range from ectopic pregnancy in a urine pregnancy test (UPT) positive patient to haemorrhagic ovarian cyst, ovarian torsion, ruptured dermoid cyst and tubo-ovarian abscess in a UPT negative patient. Multimodality imaging including ultrasound (USG), computed tomography (CT) scan and magnetic resonance imaging (MRI) can narrow down the differentials and help in formulating an accurate diagnosis. The objective of this article is to familiarize the readers with multimodality imaging findings in common as well as uncommon acute gynecological emergencies and provide an algorithmic imaging approach for acute gynecological emergencies. USG is typically used as the first line diagnostic modality in diagnosis of acute gynecological emergencies. CT scan & MRI are helpful as a problem-solving tool in acute gynecological emergencies when USG findings are indeterminate.

2D Shear wave elastography for evaluation of renal cortex and medulla: stiffness values in healthy children.

PURPOSE: To evaluate renal cortical and medullary stiffness using 2D Shear-wave elastography (SWE) in healthy children. METHODS: In this IRB approved prospective study, we measured the stiffness of cortex and medulla of children (4 months-17 years) at the upper pole, mid pole, and lower pole in bilateral kidneys. RESULTS: The median (IQR) values of renal cortex in <1 year age group was 8.7 (5.7-11.7) kPa for right and 8.7 (4.2-14.1) kPa for the left side. For 1-5 years age group, it was 7.3 (5.3-10) kPa for the right and 8.9 (6-12.3) kPa for the left side. For >5 years, it was 7.4 (5.3-11.2) kPa for the right and 9.6 (6.2-12.7) kPa for the left side. The median (IQR) values of renal medulla in <1 year age group was 7.1 (5.1-12.5) kPa for right and 6.8 (4-10.6) kPa for the left side. For 1-5 years age group, it was 7.2 (4.9-9.7) kPa for the right and 6.9 (5.6-9.9) kPa for the left side. For >5 years, it was 6.8 (5.1-9.6) kPa for the right and 7 (5-10.2) kPa for the left side. The differences in the elasticity values amongst these groups were statistically insignificant (p>0.05). There was a significant correlation between SWE values of cortex and medulla of right kidney (ρ=0.64) and of left kidney (ρ=0.61), respectively. CONCLUSION: SWE values of renal cortical and medullary stiffness in healthy children do not correlate with age. There is a significant correlation between SWE values of cortex and medulla of the kidneys in healthy children.

Hirayama disease: neutral and flexion magnetic resonance imaging and utility of inter-segmental angle of flexion.

Purpose: Hirayama disease (HD) is a rare disease that was commonly mis-diagnosed in the past. The importance of neutral and flexion magnetic resonance imaging (MRI) in its accurate diagnosis has been emphasized along with utility of the inter-segmental angle of flexion. Aim of the study was to observe MRI findings of HD in neutral and flexion position and measure the inter-segmental angle of flexion. Material and methods: Cervical MR images of 17 patients of suspected HD were evaluated retrospectively for loss of attachment (LOA) of posterior dura, lower cervical cord atrophy, T2 hyperintensity, loss of cervical lordosis, enhancement of posterior epidural venous plexus, and inter-segmental angle of flexion on neutral and flexion MRIs. Results: Flexion MRI showed LOA of posterior dura (most commonly and maximum at C6 vertebral level) and intense enhancement in posterior epidural space in almost all patients. The mean inter-segmental angle of flexion at C5-C6 was 9.2°, and at C6-C7 it was 6°. Neutral MRI revealed LOA in 64.7%, lower cervical cord atrophy in all patients, T2 hyperintensity in the lower cervical cord in 35.2% of patients, and loss of cervical lordosis in 58.8% of patients. Conclusions: Flexion MRI is the gold standard for diagnosis of HD; however, certain imaging attributes, i.e. loss of attachment of posterior dura, asymmetrical lower cervical cord atrophy, T2 hyperintensity, and loss of cervical lordosis, can be seen on neutral MRI as well, which subsequently prompts the radiologist to include flexion MRI for confirmation. The inter-segmental angle of flexion is increased in patients with HD, which plays a role in planning timely surgical intervention.

Dual energy computed tomography in Crohn's disease: a targeted review.

INTRODUCTION: Crohn's disease (CD) is a common chronic inflammatory bowel disease characterized by transmural inflammation and extra-intestinal complications. The diagnosis of CD is made using a combination of clinical, biochemical, endoscopic, imaging and histological features. Among imaging methods, computed tomography enterography (CTE) is the most commonly used. Dual-energy CTE allows objective evaluation of patients with CD. Along with the findings seen in conventional CTE, dual-energy CTE can generate iodine density maps and quantify the iodine content in the involved segments of the bowel, thus providing a measure of the perfusion of the affected bowel. In addition, the virtual monochromatic images generated from dual-energy CTE allow better qualitative evaluation of the mural and extramural findings. AREAS COVERED: We performed a targeted systemic review of all the studies in the literature to understand the role of dual-energy CT in the diagnosis and assessment of the severity of CD. EXPERT OPINION: Dual-energy CTE is superior to conventional CTE in the evaluation of CD. Besides quantifying iodine in the pathological segments, other quantitative parameters like the mural thickness of affected bowel segments, the number of segments involved, ulcerations, comb sign, lymphadenopathy, and the mural heterogeneity can also be assessed in dual-energy CTE.

Wandering spleen: A rare entity and a diagnostic dilemma.

Wandering spleen refers to a spleen that is ectopic in its location contrary to a normal spleen which rests in the left hypochondrium. Although it is a rare clinical entity seen in children, it can also be rarely seen in females of reproductive age group. We present one such case of wandering spleen which was misdiagnosed earlier as a sub-hepatic collection.

From Psychiatry to Neurology and Endocrinology: A Case of Hypoparathyroidism.

A 31-year-old male patient developed extrapyramidal symptoms while on treatment for depression. He was investigated and found to suffer from hypoparathyroidism. He had calcification in the brain, signs and symptoms of neuromuscular irritability, and QT prolongation on electrocardiogram. He was treated with calcium carbonate and calcitriol. Although he had marked improvement, bradykinesia persisted. This report highlights the importance of maintaining a high index of suspicion for hypocalcemia, and the importance of searching for an organic basis for psychiatric symptoms.

Tuberculosis Presenting as Hepatic and Splenic Microabscesses.

Tuberculosis (TB) is a major public health problem in developing countries. It can affect any organ of the body, and can have a multitude of clinical presentations. We present the case of a 22-year-old male who presented with fever, abdominal pain, and weight loss, and was found to have enlarged liver and spleen, both studded with multiple microabscesses. He had deranged liver functions, mild anemia, and elevated acute phase reactants. Examination of the aspirate from the liver did not reveal any organism on microscopy or culture. Based on the demographics, history of contact with a TB patient, positive Mantoux test, and clinical and radiological features, the patient was successfully managed with empirical treatment for TB.

Endometriosis at Cesarean Scar Presenting As an Acute Abdomen.

A 30-year-old female presented to the emergency department with severe abdominal pain and vomitings during her premenstrual period. Abdominal imaging revealed a mass originating from the scar of cesarean section extending into the rectus muscle. The cesarean section was performed four years back. Her history was significant for pain at the site of lesion during menses associated with disproportionate nausea. She was managed conservatively and improved. Fine needle aspiration cytology of the lesion established the diagnosis of scar endometriosis, and there was a permanent resolution of symptoms after its resection.

Performance Feedback Improves Compliance With Quality Measures.

Cirrhotic complications portend high morbidity and mortality and burden the health care system. Established quality measures in management of cirrhotics include screening for esophageal varices (EV), screening for hepatocellular carcinoma (HCC), and hepatitis A and B immunization. A retrospective review was conducted to identify adherence to cirrhosis. Baseline rates were shared with providers. Compliance with quality measures was measured prospectively at 1-month, 2-month, 1-year, and 3-year follow-up after provision of performance feedback. Baseline HCC rate was 60%, EV was 68%, and hepatitis A and B immunization was 51% and 47%, respectively. After performance feedback, HCC, EV, and hepatitis A and B vaccination rates improved to rates ranging from 92% to 100% and remained statistically significant after 3 years. Provider feedback, a simple intervention, achieved significant improvement in compliance with quality measures for management of cirrhotics. This improvement in adherence to quality measures was sustainable over a 3-year time period.

Cardiovascular surgical outcomes in patients with the antiphospholipid syndrome--a case-series.

BACKGROUND: Patients with the antiphospholipid syndrome (APLS) have severe involvement of the cardiovascular apparatus and often need surgical interventions to correct these manifestations. Few studies that have looked at the outcomes of cardiothoracic surgeries in APLS patients have reported high rates of perioperative mortality and thromboembolic events. OBJECTIVE: Our goal was to examine the outcomes of adult APLS patients undergoing coronary artery bypass surgery (CABG) and/or valvular surgery. We also wanted to determine whether aggressive anticoagulation therapy could prevent life threatening thromboembolic complications in these patients. METHODS: We retrospectively reviewed medical records of nine patients with primary APLS undergoing cardiothoracic surgery between 1985 and 2005 at our institution. Patient demographics, operative procedures and one-year clinical outcomes were obtained. RESULTS: Forty-five percent of our patients had more than three cardiovascular risk factors other than APLS. There were no mortalities in our case series. However, 89% of our patients developed major complications. Despite aggressive anticoagulation, 37.5% developed thromboembolic events including cerebrovascular accidents, myocardial infarctions and vena caval thrombosis. Other complications included heparin-induced thrombocytopenia, redo of CABG surgery and sepsis. CONCLUSION: Despite aggressive anticoagulation and lack of significant pre-operative co-morbidities, APLS patients undergoing cardiothoracic surgery appear to have high rates of post-operative clinical events.

A rare case of anomalous left anterior descending artery with a large interarterial communication: an invasive and CT angiographic study.

Recent advances in computed tomography (CT) technology have made this technique useful in evaluating coronary anatomy. Although CT has been the method of choice to evaluate vascular anatomy of the thorax for many years, the coronary arteries, until recently, could not be imaged with diagnostic quality due to cardiac and respiratory motion. The improved temporal and spatial resolution of new-generation multirow detector scanners makes noninvasive evaluation of the coronary arteries possible. Magnetic resonance imaging (MRI) has been the noninvasive method of choice to evaluate proximal coronary anatomy, but is not available in many centers. CT angiography (CTA) is more readily available, has better spatial resolution than MRI, and is quickly becoming an alternate method to evaluate the coronary arteries. Cardiac catheterization is the gold standard in imaging normal and abnormal coronary arteries, but even this technique has limitations. It is occasionally difficult to delineate the course of anomalous vessels, particularly if the anomalous vessel courses between the aorta and pulmonary artery, or if it has an intramyocardial course. We describe a patient with this type of abnormal coronary anatomy in whom CTA supplemented the invasive angiogram.