¿Supuración crónica o pseudoquiste infectado? Una complicación de la eventroplastia con malla / Chronic suppuration or infected pseudocyst? A complication of incisional hernia repair with mesh

RESUMEN Las infecciones crónicas posteriores a reparaciones de la pared abdominal pueden presentarse como colecciones que involucran a la malla y suelen obligar a su extracción, mientras que los pseudoquistes son colecciones estériles con una gruesa pared fibrótica que debe ser extirpada para lograr la curación. Presentamos una paciente de 75 años con antecedente de eventroplastia, que consultó por un tumor abdominal de 6 meses de evolución, con características imagenológicas de pseudoquiste parietal. Durante la operación se encontró una malla preperitoneal no integrada a los tejidos y rodeada de "biofilm" y líquido turbio. La prótesis se retiró fácilmente y la aponeurosis, muy engrosada, se cerró borde a borde. El posoperatorio transcurrió sin incidentes y el cultivo desarrolló estafilococo aureus sensible a trimetoprima-sufametoxazol. Seis meses después, la evolución fue favorable y sin signos de recidiva.

ABSTRACT Chronic infections after abdominal wall repairs may present as collections involving the mesh which usually require removing the mesh, while pseudocysts are sterile collections with a thick fibrotic wall that must be removed to achieve healing. We report the case of a 75-year-old female patient with a history incisional hernia repair who sought medical advice due to an abdominal tumor which appeared 6 months before consultation with imaging tests suggestive of an abdominal wall pseudocyst. Surgery revealed a preperitoneal mesh without tissue integration surrounded by biofilm and cloudy fluid. The mesh was easily removed and the edges of the thick aponeurosis were sutured. The postoperative period evolved uneventful and the fluid culture was positive for staphylococcus aureus sensitive to trimethoprim-sufamethoxazole. Six months later the patient evolved with favorable outcome without recurrence.

Síndrome de abscesos múltiples invasivos en paciente inmunocompetente / Multiple invasive abscesses syndrome in immunocompetent patient

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Computed tomography imaging characteristics help to differentiate pyogenic spondylitis from brucellar spondylitis.

PURPOSE: Both pyogenic spondylitis (PS) and brucellar spondylitis (BS) can cause deformities and permanent neurologic deficits without prompt diagnosis and treatment. However, differential diagnosis is challenging. The aim of this study was to compare the computed tomography (CT) imaging features of PS with those of BS. METHODS: Thirty-two patients with PS and 44 with BS were enrolled in the study. CT images were obtained in all cases. Data on bone destruction and formation, vertebral wall destruction, and osteosclerotic changes were collected and compared using the Chi-square test or t test. A P value < 0.01 was considered statistically significant. Positive predictive values (PPV) for detecting PS or BS were reported. RESULTS: Involvement of the lumbar vertebrae and multiple spinal levels was more common in the BS group than in the PS group. Bone destruction was significantly greater in the PS group than in the BS group (30.8 vs 18.0%; t = 3.920, P = 0.000), with more extensive destruction of the vertebral body (35.8 vs 12.5%, χ2 = 12.672, P = 0.002, PPV = 63.16%). In the BS group, there was more osteosclerosis around erosions (70.5 vs 43.3%, χ2 = 11.59, P = 0.001, PPV = 67.74%) and fan-shaped osteosclerosis (27.3 vs 19.4%, χ2 = 18.556, P = 0.006, PPV = 64.86%), more bone formation around the vertebra (77.2 vs 34.3%, χ2 = 33.608, P = 0.000, PPV = 76.83%), more bone formation under the anterior longitudinal ligament (63.6 vs 19.4%, χ2 = 30.133, P = 0.000, PPV = 76.09%), more longer anterior bone formation (3.55 vs 0.78 mm, t = 3.997, P = 0.000), and more anterior and closed-bone formation with local erosion (42.0 vs 9.0%, χ2 = 74.243, P = 0.000, PPV = 74.36%). CONCLUSIONS: CT images have unique advantages of revealing the morphology of erosions, osteosclerosis, and bone formation around the vertebra and help to differentiate PS from BS. These slides can be retrieved under Electronic Supplementary Material.

Unilateral acute cervical lymphadenitis in children: can we predict the need for surgery?

INTRODUCTION: Paediatric acute cervical lymphadenitis is a frequent diagnosis in the emergency department. Traditionally, suppurative cervical lymphadenitis (SCL) is associated with a higher need of surgical drainage. However, a great variability in the management of this suppurative infections can be observed. Moreover, the clinical distinction between non-suppurative cervical lymphadenitis (NSCL) and SCL is not an easy task and there are, currently, no guidelines defining which patients are eligible for imaging study. OBJECTIVES: To assess the determinants and benefits in the surgical management of SCL in children. As secondary outcome, to determine differences in epidemiological characteristics, clinical, biochemical and radiological features between NSCL and SCL. MATERIAL AND METHODS: A retrospective survey was carried out in a tertiary university hospital between January 2007 and December 2016. Forty-two children with a diagnosis of acute cervical lymphadenitis (ACL) were included and categorized according to the presence of suppuration, resulting in two groups: NSCL and SCL. The latter group was further categorized into surgical and non-surgical groups, according to the need of surgical drainage. RESULTS: No significant differences were found between SCL and NSCL groups in gender, age and previous antibiotics intake (p > 0.05). According to clinical presentation, odynophagia was significantly more frequent in NSCL patients (p = 0.01), with no differences found in other clinical parameters (p > 0.05). Patients presenting acute cervical lymphadenitis involving the submandibular region have 16 times the odds of a suppurative process (p = 0.029). In a SCL subgroup analysis, no association was observed between lymphadenitis size or location and the need for surgical drainage (p > 0.05). Children included in the SCL surgical group presented a trend to an increased in the hospitalization length (p = 0.01), when comparing to those in which treatment was limited to intravenous antibiotics. One death was observed in the SCL non-surgical group. CONCLUSIONS: Predictive factors for the need of surgery were not found. Furthermore, surgical drainage was not associated with better outcomes. Surgery could be considered in selected stable patients, when alternative medical treatments do not seem to work, in a case-to-case basis.

Uterine disease and its effect on subsequent reproductive performance of dairy cattle: a comparison of two cow-side diagnostic methods.

The aim of this study was to compare vaginal mucus scoring and ultrasonographic assessment of uterine content as predictors of future reproductive performance of dairy cows. Holstein-Friesian cows (n = 493) from seven commercial dairy farms were enrolled in this study. All cows received one prebreeding examination (PBE) between 21 and 38 days after parturition. During the PBE, vaginal mucus was scored (MS) and the transrectal ultrasonographic examination of the uterus to assess content (UTS) took place. The MS was scored on a scale of 0 to 3 using a Metricheck device and appearance of the uterus on transrectal ultrasound was scored on a scale of 0 to 4 based on the presence and consistency of intraluminal fluid. Other data collected from each cow included the farm ID (F_ID), conception rate to first service, length of breeding window, lactation number, calving month, body condition score (BCS) at calving, BCS loss after calving, BCS at PBE, days in milk at PBE, 305 day milk yield, economic breeding index (EBI), EBI fertility subindex and EBI health subindex. For each cow these parameters were analyzed using univariate Cox proportional hazard model to evaluate the effect of variables on the reproductive performance, measured as positive pregnancy status (PS) at the end of the breeding season. Receiver-operating characteristic analysis of the diagnostic tests compared with each other took place as well. Cows with positive UTS were 7.75 times more likely to have a positive MS as well (P < 0.01). The PS hazard ratios for cows with UTS0, 1, 2, 3, and 4 were 1; 0.84; 0.53; 0.78; 0.28, respectively (P < 0.001). For the cows with MS0, 1, 2, and 3, the PR hazard ratios were 1; 1.02; 0.51; 0.75; respectively (P = 0.01). Conception rate to first service, breeding window, and PS were significantly better for the cows with UTS0, 1 and 2 compared with the cows with UTS3-4 and MS2+3 (68%; 18%, [P = 0.020]; 29; 75 days, [P = 0.001]; 95%; 55%; [P = 0.010], respectively). There was a significant effect of days in milk at PBE in relation to the subsequent PS (P = 0.04). Cows in lactation number 5 or more were less likely (r = 0.69) to get in calf before the end of the breeding season than cows in their first lactation. Cows that calved later in the season were less likely to become pregnant before the end of the breeding season (P < 0.03). Younger cows (lactation <5) and cows with MS and UTS scores of 0 and -1 had significantly better reproductive performance (P < 0.04). Receiver-operating characteristic analysis showed that MS did not always reflect UTS, but cows with positive UTS were 7.75 times more likely to have a positive MS (P < 0.01) and a high UTS had a larger negative effect on time to PS than a high MS (P < 0.05). In conclusion, both prebreeding vaginal mucus evaluation with the Metricheck device and an ultrasound scan of the uterus serve as a good predictor of the subsequent PS. There is overlap between the two systems, but the best predictor for future reproductive outcome of the cow is a combination of both.

High-Resolution Computed Tomography Examinations for Chronic Suppurative Lung Disease in Early Childhood: Radiation Exposure and Image Quality Evaluations With Iterative Reconstruction Algorithm Use.

PURPOSE: High radiosensitivity of children undergoing repetitive computed tomography examinations necessitates the use of iterative reconstruction algorithms in order to achieve a significant radiation dose reduction. The goal of this study is to compare the iDose iterative reconstruction algorithm with filtered backprojection in terms of radiation exposure and image quality in 33 chest high-resolution computed tomography examinations performed in young children with chronic bronchitis. METHODS: Fourteen patients were scanned using the filtered backprojection protocol while 19 patients using the iDose protocol and reduced milliampere-seconds, both on a 64-detector row computed tomography scanner. The iDose group images were reconstructed with different iDose levels (2, 4, and 6). Radiation exposure quantities were estimated, while subjective and objective image qualities were evaluated. Unpaired t tests were used for data statistical analysis. RESULTS: The iDose application allowed significant effective dose reduction (about 80%). Subjective image quality evaluation showed satisfactory results even with iDose level 2, whereas it approached excellent image with iDose level 6. Subjective image noise was comparable between the 2 groups with the use of iDose level 4, while objective noise was comparable between filtered backprojection and iterative reconstruction level 6 images. CONCLUSIONS: The iDose algorithm use in pediatric chest high-resolution computed tomography reduces radiation exposure without compromising image quality. Further evaluation with iterative reconstruction algorithms is needed in order to establish high-resolution computed tomography as the gold standard low-dose method for children suffering from chronic lung diseases.

Indications and limitations of conservative treatment for pyogenic spondylitis.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To elucidate the indications and limitations of conservative treatment for pyogenic spondylitis (PS). SUMMARY OF BACKGROUND DATA: The optimal strategy for treating PS, conservative or surgical, remains controversial. METHODS: Sixty-eight consecutive patients (44 males, 24 females; 62.6±13.8 y) suffering from PS were enrolled. Forty-three were successfully treated with conservative therapy including immobilization and administration of antibiotics [conservative treatment success (CTS) group]. Twenty-five patients underwent surgical intervention because of ineffective conservative treatment [conservative treatment failure (CTF) group]. Clinical parameters such as duration of symptoms, C-reactive protein (CRP) at admission, durations of hospital stay, and Frankel score, and radiologic parameters such as the presence of epidural abscess, were investigated in both groups. RESULTS: The duration of symptoms, CRP at admission, and the duration of hospital stay were 1.72±1.02 months, 5.89±6.29 mg/dL, and 85.7±46.0 days, respectively, in the CTS group compared with 7.92±16.9 months, 2.22±3.08 mg/dL, and 95.0±28.0 days in the CTF group. Differences were significant. At follow-up, 100% of the CTS group and 84% of the CTF group were ambulatory. A total of 86.1% of the CTS group lesions occurred at the lumbosacral region, whereas the majority (52%) of those in the CTF group were in the thoracic region. The incidence of epidural abscess was higher in the CTF group (84.0%) than in the CTS group (30.2%), and their greatest likelihoods were at the cervical/thoracic regions and lumbosacral region, respectively. CONCLUSIONS: The early phase of PS, in which the duration of disease between onset and admission was short and CRP at admission was active, was a good indication for conservative treatment regardless of the sites if there was neither paralysis nor worsening of kyphosis, and can even be an option for cases with mild paralysis due to epidural abscess occurring at the lumbosacral region.

Ultrasound-guided procedures in the emergency department-diagnostic and therapeutic asset.

Bedside ultrasound is an extremely valuable and rapidly accessible diagnostic and therapeutic modality in potentially life- and limb-threatening situations in the emergency department. In this report, the authors discuss the role of ultrasound in quick assessment of pathologic conditions and its use to aid in diagnostic and therapeutic interventions.

Relapsing suppurative neck abscess after chemocauterization of pyriform sinus fistula.

We report a case of relapsing suppurative neck abscess due to a pyriform sinus fistula ever treated by chemocauterization. Pyriform sinus fistula is rare, and chemocauterization is an alternative microinvasive procedure. This case indicates that the possibility of recurrence following management of chemocauterization exists even after a long time and that clinical radiological assessments are necessary.

The art and science of straight lines in radiology.

OBJECTIVE: The purpose of this article is to review the physical basis for straight radiographic lines, identify the possible components that may form a straight line interface in the body, provide illustrative examples across multiple organ systems and modalities, and explore how the detection of these interfaces can support specific diagnoses. CONCLUSION: Detection of a straight line interface can help the radiologist recognize otherwise difficult or subtle pathologic processes, and identification of its components can provide valuable clues to diagnosis.

Clinical presentation and outcome of hepatic subcapsular fluid collections.

BACKGROUND/PURPOSE: Bile, blood or pus may rupture into or extend to the hepatic subcapsular space, but most descriptions in the literature are from isolated case reports. When fluid collections are limited by the size of the subcapsular space, they rarely present with abrupt symptoms and signs. We reviewed our experience with hepatic subcapsular fluid collections, including diagnostic studies and outcome. METHODS: Two radiologists independently assessed imaging database from computed tomography (CT) with the letter strings "subcapsule", "subcapsular", "liver" or "hepatic". Subcapsular fluid collection was defined as fluid deep in the liver capsule and superficial to the liver parenchyma without rupture into the peritoneum. The demographic data, clinical presentation, laboratory and imaging results, length of hospital stay, final diagnosis, and outcome were reviewed and recorded. RESULTS: From January 2002 to December 2004, 60 patients (33 males, 27 females; age range, 4-92 years) were diagnosed by CT to have a subcapsular fluid accumulation in liver. Etiologies included traumatic hematoma in 10, tumor-related hematoma in 18, ruptured liver abscess in 20, biloma in 8, and 4 miscellaneous causes. CT typically showed a lenticular-shaped fluid collection compressing the liver parenchyma. The fluid accumulation was connected in over half the cases to an intrahepatic lesion with a visible tract. Conservative management was adequate in 32 patients, while 9 had surgery and 19 underwent either percutaneous drainage (by CT or ultrasound guidance) or transarterial therapy. Of the 60 patients, 49 (82%) survived the episode, including all 10 with traumatic hematoma. The shortest mean length of hospital stay was 7.8 +/- 6.7 days in the tumor-related hematoma group, and the longest was 50.7 +/- 41.7 days in the abscess group. The international normalized ratio for coagulation for those who died and those who survived was 1.8 +/- 1.4 and 1.4 +/- 0.2 respectively (p = 0.027). CONCLUSION: If these fluid collections are limited in the subcapsular space, they are rarely associated with abrupt hemodynamic instability and usually not lethal. The only characteristic that differed significantly between those who died and those who survived was the international normalized ratio, meaning that good liver function and normal coagulation has the ability to recover from this dismal episode.