A rare presentation of small diaphragmatic epidermoid cyst with extremely elevated serum CA19-9 level.

Epidermoid cysts are rare lesions that can occur anywhere in the body. They are associated with elevated serum levels of CA 19-9. The spleen represents the most common site of intra-abdominal localisation. Only two cases of diaphragmatic epidermoid cyst are reported in the literature. We present the case of a 61-year-old woman with a small suprasplenic subdiaphragmatic cyst discovered during the investigation of left flank pain. The establishment of an adequate diagnosis was challenging due to the difficulty in specifying the exact localisation of the cyst, the extremely elevated CA 19-9 level of 19,000 and the high uptake on 18-fluoro-2-deoxy-D-glucose positron emission tomography. The definitive diagnosis followed complete surgical excision. Intra-abdominal epidermoid cysts are usually discovered incidentally on imaging for another reason. The cyst is lined by squamous epithelium responsible for the secretion of CA 19-9. The elevation of serum CA 19-9 is due to small rupture or increased intraluminal pressure followed by diffusion to the bloodstream. Surgery with en-bloc resection represents the optimal treatment to avoid any risk of recurrence. The definitive diagnosis is established by demonstrating positive immunohistopathological staining of epithelial cell to CA 19.9.

Breast sonoelastography: Now and in the future.

PURPOSE: The purpose of this study was to identify practice trends and opinions concerning breast sonoelastography in two different health care systems, one in Europe (France) and the other in North America (Province of Québec/Canada). MATERIALS AND METHODS: We distributed an 11-item online survey among French and Canadian breast radiologists. The survey comprised of four sections: (i) personal practice characteristics, (ii) breast sonoelastography usage in daily practice and evaluation of its usefulness, (iii) limitations and roles of sonoelastogrpahy in their clinical practice, and (iv) types of elastographic technique and interpretation. RESULTS: We found that sonoelastography of the breast appears unpopular among Canadian radiologists, and poorly credible among French radiologists, who perceive it as an unreliable technique. To date, its real impact in clinical practice remains uncertain. CONCLUSION: Continued learning and awareness of the indications, advantages and limitations of breast sonoelastography may motivate breast radiologists to adopt its use.

Breast magnetic resonance imaging: are those who need it getting it?

BACKGROUND: Indications for breast magnetic resonance imaging (mri), a very sensitive but less-specific tool for breast investigation, remain controversial, and accessibility is limited. The purposes of our study were to determine the proportion of breast mri exams performed for various clinical indications, to assess the wait times for breast mri, and to create a list of evidence-based indications for breast mri. METHODS: The indications for breast mri exams performed in September 2013 at our academic centre were audited. A multidisciplinary meeting held in May 2014 established a list of evidence-based indications for breast mri, after which, in September 2014 and 2015, breast mri exams were re-audited for clinical indications, and pending requests were calculated. RESULTS: In September 2013, surveillance of women with a prior diagnosis of breast cancer represented 21% of breast mri exams (24 of 113), with preoperative staging representing 18% of exams (20 of 113) and high-risk screening representing 12% (13 of 113). Of pending mri requests, 230 were within the recommended delay period, and 457 exceeded the recommended delay. After elaboration of evidence-based guidelines, repeat audits in September 2014 and September 2015 showed that mri performed for women with a prior breast cancer diagnosis represented 23% (33 of 141) and 7% (10 of 143) of exams respectively, with preoperative staging having declined to 9% (13 of 141) and 11% (16 of 143) of exams, and high-risk screening having increased to 36% (51 of 141) and 46% (66 of 143) of exams. Overall, wait times were improved for all breast mri indications. CONCLUSIONS: Through multidisciplinary discussion, we actualized a list of breast mri indications, prioritized requests more adequately, and improved wait times.

Use of topical glucocorticoids: a population-based cohort study.

BACKGROUND: Little is known about the prescriptions of topical glucocorticoids in the general population. OBJECTIVES: To report an overall picture of topical glucocorticoid prescriptions in France. METHODS: This study used the Echantillon Généraliste de Bénéficiaires (EGB) database, a 1/97th random sampling of the French population covered by the main national healthcare insurance system (approximately 90% of the whole population). All patients prescribed topical glucocorticoids over a 5-year period (1 January 2011 to 31 December 2015) were identified using a specific code list for topical glucocorticoids. RESULTS: Over the 5-year study period, 662 531 individuals were recorded for at least 1 day in the EGB. Among them, 220 345 (33.3%) were prescribed at least once topical glucocorticoid. The prevalence of topical glucocorticoid prescription increased regularly from 2011 (11.7%) to 2015 (12.5%). A total of 922 026 tubes of topical glucocorticoids were dispensed, mainly high-potency glucocorticoids, and were mainly prescribed by general practitioners (73.1%). A total of 1713 (0.8%) patients were prescribed at least 24 tubes over a calendar year. These patients were more frequently men (P < 0.001) and older (P < 0.001) than the overall population of patients prescribed topical glucocorticoids. The 124 844 tubes prescribed to these patients had stronger potency than those prescribed to the overall population (P < 0.001) and were mostly prescribed by general practitioners (68.1%). The reasons for prescription were available for only 371 patients (21.7%) and were mainly psoriasis, auto-immune bullous dermatoses and eczema. CONCLUSION: About 12% of the French general population is prescribed topical glucocorticoids at least once each year. Most prescriptions are issued by general practitioners, dermatologists being the prescribers in less than one-quarter of cases.

Autochthonous starter cultures and indigenous grape variety for regional wine production.

AIMS: To characterize Oenococcus oeni strains isolated from North-Apulian wines where malic acid degradation is usually achieved by spontaneous fermentations, and to determine the influence of bacterial inoculation time on the malolactic performances in 'Nero di Troia' wine using a complete autochthonous microbial regime. METHODS AND RESULTS: Oenococcus oeni strains from wines produced with the autochthonous (Apulia Region, southern Italy) grape variety 'Uva di Troia' were isolated, selected and characterized. Multilocus sequence typing and variable number tandem repeat analysis were used to investigate intraspecific diversity. Oenococcus oeni strains were tested in co-inoculation and in sequential inoculation, with two autochthonous yeast strains previously isolated from 'Nero di Troia' wine. After a preliminary screening using co-inoculation regime, the O. oeni strains were grouped in reason of the different behaviour in malic acid performances. Results suggested that the efficient degradation of malic acid in co-inoculation is a strain-dependent characteristic. CONCLUSIONS: Autochthonous yeast/bacterium combinations were identified as starter culture, and used in a co-inoculation approach, for vinification of regional wines. SIGNIFICANCE AND IMPACT OF THE STUDY: The 'microbial terroir' of typical fermented food and beverage production represents a dynamic sector of applied research in food microbiology. In this work, we propose the use of autochthonous bacteria and yeast for wine production from an indigenous grape variety.

Values of pathological analysis of lost tissue fragments in the vacuum canister during a vacuum-assisted stereotactic biopsy of the breast.

OBJECTIVE: Determine values of pathological analysis of the canister content during a vacuum-assisted breast biopsy (VABB). METHODS: Approval was obtained from the ethical committee. Prospective radiological and pathological analyses of the canister content collected during 231 VABBs performed on 231 patients were carried out. χ(2) test was used to determine predictors on canister pathology. RESULTS: The canister pathology was reported separately in 212 cases. It showed only blood in 78/212 (37%) cases and benign (including high-risk lesions) and malignant results in, respectively, 113/212 (53%) and 21/212 (10%) cases. Respective specimen analysis was benign, including high-risk lesions in 162/212 cases (76%) and malignant in 50/212 (24%) cases. Microcalcifications were documented on canister X-ray in 70/231 (30%) cases. There was significant association between the canister and the specimen pathology (p<0.0001). In none of the cases was microcalcifications seen exclusively in the canister content or pathological upgrading found in the canister content compared with the specimen. CONCLUSION: Small tissue fragments and microcalcifications may be lost in the canister during a VABB. Nevertheless, our results did not show any significant value for systematic analysis of the canister content. ADVANCES IN KNOWLEDGE: There is no added diagnostic value to retrieval and analysis of tissue lost in the canister during a VABB.

Diabetes supersedes dobutamine stress echocardiography in predicting cardiac events in female patients.

BACKGROUND: The many available choices for testing for coronary artery disease (CAD) brought about several questions regarding suitability of certain tests for different groups of patients and the prognostic value of obtained results in predicting events and mortality. The aim of this study is to describe the prognostic value of dobutamine stress echocardiography (DSE) results in predicting cardiac events and mortality in > or = 60-year-old females. METHODS: 49 women (> or = 60 years old) who were referred for DSE were included in the study. Data including CAD risk factors, and results of tests and a follow-up of events (MI, unstable angina, progression of CHF) and death. RESULTS: Eleven patients were considered to have a positive DSE result. There was no difference between DSE (+) and DSE (-) patients in cardiac events and cardiac death. However when interventions were included to events, analysis showed DSE (+) to have more overall events. Non-cardiac deaths and "all deaths" were 11 and 8 times more common among DSE (+) patients compared with DSE (-) patients p < 0.01. Multivariable logistic regression showed that diabetics and DSE (+) patients were 32 (p = 0.01) and 23 (p = 0.02) times more likely to have an event compared with non-diabetics and DSE (-) patients, respectively. CONCLUSION: DSE is a safe procedure to be used in > or = 60-year-old female patients and can provide informative prognostic information regarding all-cause deaths and cardiac events (including interventions) over a 4-year period. In addition we find that diabetes is a strong predictor of events regardless of DSE result.

Mammographically non-calcified ductal carcinoma in situ: sonographic features with pathological correlation in 35 patients.

AIM: To present the sonographic findings of mammographically non-calcified ductal carcinoma in situ (DCIS) with histopathologic correlation. MATERIALS AND METHODS: The mammographic and ultrasonographic presentations of 47 radiographically non-calcified DCIS lesions in 35 patients were retrospectively analysed. Histological characteristics (architectural appearance, nuclear grade, percent of involved lobules, and presence of necrosis) were reviewed. RESULTS: Seventeen lesions were not mammographically visible (17/47, 36%). Ultrasonographically, these lesions showed an irregular shape (28/47, 60%), microlobulated margins (34/47, 72%) and abrupt interfaces (42/47, 90%). Only 11% (5/47) displayed posterior shadowing. The echotexture of these lesions was most frequently complex (29/47, 62%); therefore, they were divided into two types: type I (24 cases), which were predominantly solid with cystic components, and type II (five cases), which were predominantly cystic with a solid intra-cystic component. A trend to have greater than 50% DCIS cells in cancerous lobules was observed in masses displaying type I echotexture (difference=36%, 95% confidence interval 10.6-62.5) and microlobulated margins (difference=32%, 95% confidence interval 5.1-58.7). CONCLUSION: Ultrasonographically detected radiographically non-calcified DCIS commonly displays an irregular shape, microlobulated margins, and complex echotexture, giving a "pseudomicrocystic" appearance. Microlobulated margins and "pseudomicrocystic" echotexture seem to be associated with a cancerization of the lobules.

[What is the thickness of the normal appendix on MDCT?]. / Quelle est l'épaisseur de l'appendice normal au scanner multibarrette?

OBJECTIVE: To determine the wall thickness and external diameter values of the normal appendix on multidetector computed tomography (MDCT). Materials and methods. A senior radiologist with no knowledge of the patient's surgical history prospectively examined the abdominal-pelvic CT scans of 57 consecutive adult patients with no suspicion for appendicitis. Most of the patients (50/57) received an intravenous iodinated contrast material injection, but none had gastrointestinal studies. All slices (1 and 5 mm) and multiplanar reconstructions were analyzed on a treatment console. The external diameter of the appendix, the thickness of the two appendicular walls, and the presence or absence of intraluminal gas were noted. RESULTS: The appendix was visualized in 82% of the cases (47/57). The mean external diameter was 6.7 mm+/-1.2 (range, 5.0-11.0 mm). The mean thickness of the two walls was 4.8 mm+/-1.0 (range, 2.6-6.4 mm). Intraluminal air was visualized in 87% of cases (41/47). CONCLUSION: Contrary to external diameter, the normal thickness of the appendix's two walls does not go beyond the threshold of 6 mm and therefore seems to be a reliable measurement for identifying a normal appendix using MDCT.

Leiomyosarcoma of the great saphenous vein.

Peripheral vascular leiomyosarcomas are rare. A case of leiomyosarcoma of the great saphenous vein diagnosed pre-surgically by MRI and fine-needle aspiration is presented. Characteristics of the tumour and imaging features are discussed.

[Is appendicolith a reliable sign for acute appendicitis at MDCT?]. / Le stercolithe est-il un signe fiable d'appendicite?

PURPOSE: To determine the frequency of detection of appendicoliths on normal appendix at multidetector row computed tomography (MDCT) with multiplanar reconstructions (MPR). MATERIALS AND METHODS: A senior radiologist, blinded to patient's surgical history, prospectively and independently reviewed abdominopelvic MDCT scans in 57 consecutive adult patients without symptoms suggesting appendicitis. Most patients had IV iodine injection, but no oral contrast. Thick (5 mm) and thin (1 mm) slices were analyzed on a workstation. MPR were available. Localization of the appendix, overall diameter, intraluminal gas and appendicolith were recorded. RESULTS: The appendix was visualized in 47/57 (82%). An appendicolith was found in 13%. Intraluminal gas was identified in 87%. The localization was retrocaecal (47%), mediocaecal (21%) or pelvic (32%). The mean overall diameter of the normal appendix was 6.7 mm +/- 1.2 (SD). CONCLUSION: Appendicolith was found in a significant number of normal patients at MDCT and don't represent a specific sign for appendicitis.

[Local recurrence of ductal carcinoma in situ after conservative breast surgery: mammographic appearance]. / Caractéristiques mammographiques des récidives locales des carcinomes canalaires in-situ après traitement conservateur.

OBJECTIVE: To review the mammographic features of local recurrences of DCIS treated conservatively. MATERIALS AND METHODS: Thirty-five patients treated conservatively for a DCIS have presented subsequently a local recurrence. Three patients had double metachronous and one a bi-focal recurrence. The mammographic appearances of these 39 recurrences were analyzed retrospectively and compared to initial mammograms. RESULTS: Median delay to recurrence was of 47 months (interval 8-240 months). Two-thirds of the recurrent lesions were similar to the initial presentation, of which 90% occurred at the lumpectomy site. In 18/ 35 cases (51%), an intra-ductal component was found at histological diagnosis and among these 11/18 (61%) were strictly intra-ductal. CONCLUSION: Local recurrences of DCIS are proteiform. However, the majority of which, occurring at the lumpectomy site were similar to the primary tumor, raising again the hypothesis of incomplete eradication even when the margins were considered free.

Seroprevalence of toxocariasis in Lebanon: a pilot study.

Toxocariasis is a common helminthic infection that has a worldwide distribution. However, data from Lebanon about the prevalence of this infection are non-existent. We conducted a Toxocara seroprevalence study with 150 subjects attending the outpatient clinics at the American University of Beirut Medical Center between May and June 2004. Serum specimens were tested for anti-Toxocara antibodies by enzyme-linked immunosorbent assay and confirmed by Western blot. Multivariate analysis was performed to identify risk factors for infection. The seroprevalence rate of toxocariasis was 19%. Male gender and below high school education were significantly associated with a positive serological test (odds ratios = 3.1 and 2.8, respectively). Higher numbers of persons in the household, and low family income during childhood, were significant on bivariate analysis only. Toxocariasis is common in Lebanon. A large population-based survey is needed to confirm these results.

Bridging the final gap in stereocontrolled wittig reactions: methoxymethoxy-armed allylic phosphorus ylides affording conjugated dienes with high cis selectivity

After treatment with an appropriate base (butyllithium or sodium amide), 2-alkenyltris(2-methoxymethoxyphenyl)phosphonium salts carrying an allyl, crotyl, or prenyl (3-methyl-2-butenyl) side chain condense with saturated or unsaturated aldehydes to give conjugated dienes with Z/E ratios ranging from 90:10 to > 99:1 and averaging 96:4. Owing to steric congestion, yields are only moderate (on average 41%; extremes 10-79%). The nonvolatile tris(2-methoxymethoxyphenyl)phosphine oxide by-product can be readily isolated and reduced to recover the phosphane starting material, or it may be hydrolyzed to the water-soluble tris(2-hydroxyphenyl)phosphine oxide.