Inguinal Bladder Hernia Indirectly Treated With Prostate Artery Embolization.

An inguinal bladder hernia (IBH) is an abnormal protrusion of the bladder into the inguinal canal accompanied by a peritoneum sheath that creates the hernia sac. Clinical presentations vary greatly from lower urinary tract symptoms (LUTS) and reduction in scrotal size after voiding to being entirely asymptomatic. Since inguinal bladder hernias are uncommon and often accompanied by varied and nonspecific symptoms, it is challenging to diagnose and rarely included in differentials. Currently, computerized tomography (CT) imaging with contrast or voiding cystourethrography is recommended for diagnosis. There is no consensus on the best treatment for inguinal bladder hernias, with options ranging from laparoscopic repair to catheterization. In this study, we report the case of inguinal bladder hernia in an 86-year-old male presenting with symptoms of recurrent hematuria and two failed voiding trials after a Foley catheter placement from prostatomegaly resulting in bladder diverticula, and IBH. He was treated with prostate artery embolization (PAE) to address LUTS related to benign prostatic hyperplasia (BPH). The resultant decreased prostatic volume resolved his symptoms of IBH, hematuria, and urinary retention.

Hematoma Disguised as Cancer.

Hematomas are often associated with benign processes such as sport-related injuries, postsurgical complications, and medications such as blood thinners. Rarely, hematomas can occur spontaneously without any identifiable cause or recollection of an inciting event. Such events can lead to inaccurately diagnosing a patient, which could delay or alter treatment and worsen the patient's prognosis. This patient reported sudden-onset abdominal pain with radiation to her back and denied any recent medication use or trauma while at home. The case highlights the key radiographic findings of magnetic resonance imaging (MRI) and contrast-enhanced ultrasound to eventually confirm an obscure case of hepatocellular carcinoma and help guide management.

Ultrasound evaluation of intraluminal magnets in an ex vivo model.

PURPOSE: The management of foreign body ingestion proves to be a challenge. Magnets pose a unique set of risks when ingested due to their attractive forces and subsequent risk of adherence, pressure necrosis, and perforation complications. Radiographs only provide a limited snapshot in the setting of multiple magnet ingestion when the risk of complication is highest. We hypothesize that abdominal ultrasound (US) has the potential to supplement radiographs in assessing ingested magnets by determining the presence of bowel loop entrapment and of any extraluminal fluid. METHODS: We recreated various scenarios of magnet configurations using animal cadaveric bowel models. X-ray and US images were obtained in various bowel-magnet orientations. RESULTS: We identified several key US features to suggest bowel wall tethering. These include direct visualization of bowel wall entrapment between magnets (what we term the "dangerous V sign"), anti-dependent positions of the magnets, and inability to separate loops of bowel with compression. CONCLUSION: These findings could potentially provide valuable information when directing the urgency of intervention in foreign body ingestion. Ultrasound may supplement and improve the current guidelines in management of magnet ingestion.

Imaging of Hepatobiliary Cancer.

The liver and biliary tree are common sites of primary and secondary malignancies. MRI followed by CT is the mainstay for the imaging characterization of these malignancies with the dynamically acquired contrast enhanced phases being the most important for diagnosis. The liver imaging reporting and data system classification provides a useful framework for reporting lesions in patents with underlying cirrhosis or who are at high risk for developing hepatocellular carcinoma. Detection of metastases is improved with the use of liver specific MRI contrast agents and diffusion weighted sequences. Aside from hepatocellular carcinoma, which is often diagnosed noninvasively, other primary hepatobiliary tumors may require biopsy for definite diagnosis, especially when presenting with nonclassic imaging findings. In this review, we examine the imaging findings of common and less common hepatobiliary tumors.

Are There Ultrasound Features to Distinguish Small (<3 cm) Peripheral Renal Angiomyolipomas From Renal Cell Carcinomas?

BACKGROUND: Small echogenic renal masses are usually angiomyolipomas (AMLs), but some renal cell carcinomas (RCCs) can be echogenic and confused with an AML. OBJECTIVES: This is a study to evaluate any distinguishing demographic and sonographic features of small (<3 cm) peripheral AMLs versus peripheral RCCs. METHODS: This is a HIPAA-compliant retrospective review of the demographics and ultrasound features of peripheral renal AMLs compared with a group of peripheral RCCs. All AMLs had confirmation of macroscopic fat as noted on thin-cut CT or fat-saturation MRI sequence images. All RCCs were pathologically proven. Statistical analysis was used to compare findings in the two groups. RESULTS: There were a total of 52 patients with 56 AMLs, compared with 42 patients with 42 RCCs. There were 42 females in the AML group versus 10 females in the RCC group (P < .0001). The AML diameters (15.7 mm × 12.0 mm) were statistically significantly smaller (Plargest = .0085, Psmallest < .001) than the diameters of the RCCs (19.9 mm × 18.5 mm). Ultrasound features found to be statistically different between the two groups were the ratio of the largest dimension to the smallest dimension (P < .001), a lobulated versus smooth margin of the AML (26 vs 30) compared with the RCC group (3 vs 39) (P = .0012), and an "unusual" versus a round shape (P < .001) of the AML group (45 vs 11) compared with the RCC group (9 vs 33). In the multivariable model, the patient sex, margin, and mass shape were predictive of AML, with an area under the receiver operating characteristic curve of 0.92. CONCLUSION: For a small (<3 cm) peripheral echogenic mass in a female patient, a lobulated lesion with an unusual shape is highly predictive of being an AML.

Using FDA-approved drugs as off-label fluorescent dyes for optical biopsies: from in silico design toex vivoproof-of-concept.

Optical biopsies bring the microscope to the patient rather than the tissue to the microscope, and may complement or replace the tissue-harvesting component of the traditional biopsy process with its associated risks. In general, optical biopsies are limited by the lack of endogenous tissue contrast and the small number of clinically approvedin vivodyes. This study tests multiple FDA-approved drugs that have structural similarity to research dyes as off-labelin situfluorescent alternatives to standardex vivohematoxylin & eosin tissue stain. Numerous drug-dye combinations shown here may facilitate relatively safe and fastin situor possiblyin vivostaining of tissue, enabling real-time optical biopsies and other advanced microscopy technologies, which have implications for the speed and performance of tissue- and cellular-level diagnostics.

Centrifugation Removes a Population of Large Vesicles, or "Macroparticles," Intermediate in Size to RBCs and Microvesicles.

Microparticles or microvesicles (MPs/MVs) are sub-cellular vesicles with a growing number of known biological functions. Microvesicles from a variety of parent cells within the vascular system increase in numerous pathological states. Red blood cell-derived MVs (RMVs) are relatively less studied than other types of circulating MVs despite red blood cells (RBCs) being the most abundant intravascular cell. This may be in part due the echoes of past misconceptions that RBCs were merely floating anucleate bags of hemoglobin rather than dynamic and responsive cells. The initial aim of this study was to maximize the concentration of RMVs derived from various blood or blood products by focusing on the optimal isolation conditions without creating more MVs from artificial manipulation. We found that allowing RBCs to sediment overnight resulted in a continuum in size of RBC membrane-containing fragments or vesicles extending beyond the 1 µm size limit suggested by many as the maximal size of an MV. Additionally, dilution and centrifugation factors were studied that altered the resultant MV population concentration. The heterogeneous size of RMVs was confirmed in mice models of hemolytic anemia. This methodological finding establishes a new paradigm in that it blurs the line between RBC, fragment, and RMV as well as suggests that the concentration of circulating RMVs may be widely underestimated given that centrifugation removes the majority of such RBC-derived membrane-containing particles.

Calcium-phosphate microprecipitates mimic microparticles when examined with flow cytometry.

There are increased levels of circulating microparticles (MPs) in several disease states. Flow cytometry is a common method to examine MPs, but their small size necessitates the use of markers to distinguish specifically MPs from artifact. Annexin V, which binds phosphatidylserine, is a commonly used marker for MP detection. Annexin V requires millimolar calcium ion for optimum binding. Ca(++) can precipitate with phosphate in phosphate-buffered saline (PBS). Calcium-phosphate microprecipitates were formed by titrating Ca(++) into PBS and examined using flow cytometry. Calcium-phosphate microprecipitates were compared with MPs derived from aged donor blood units. Microprecipitates were ∼0.7-0.9 µm in diameter compared with standard beads of known size. The microprecipitates disappeared with the addition of Ca(++) chelator. When we added fluorescently labeled antibodies to microprecipitates, the median fluorescent signal increased with increasing Ca(++) concentration regardless of specificity of the antibody. When repeated with a biological sample, there was an apparent increase in the fluorescent signal that returned to baseline after Ca(++) chelation. The flow cytometry signal of calcium-phosphate microprecipitates overlaps with the MP signal. Since Ca(++) is essential for annexin V binding, it is essential to avoid artifacts from calcium-phosphate microprecipitates when using any buffer or biological fluid containing phosphate. This also highlights the potential utility of flow cytometry for the analysis of crystals in biological fluids.

Phosphatidylethanolamine is externalized at the surface of microparticles.

Microparticles (MPs) are membrane-bound vesicles shed normally or as a result of various (pathological) stimuli. MPs contain a wealth of bio-active macromolecules. Aminophospholipid phosphatidylserine (PS) is present on the surface of many MPs. As PS and phosphatidylethanolamine (PE) are related, yet distinct aminophospholipids, the purpose of this study was to systematically and directly assess PE exposure on MPs. We examined MPs from various human cellular sources (human breast cancer, endothelial, red and white blood cells) by flow cytometry using a PE-specific probe, duramycin, and two PS-specific probes, annexin V and lactadherin. PS and PE exposure percentage was comparable on vascular and blood cell-derived MPs (80-90% of MP-gated events). However, the percentage of malignant breast cancer MPs exposing PE (~90%) was significantly higher than PS (~50%). Thus, while PS and PE exposure can result from a general loss of membrane asymmetry, there may also be distinct mechanisms of PE and PS exposure on MPs that vary by cellular source.