Fecal pulmonary embolism: a case report and literature review.

Pulmonary embolism (PE) is a common cause of death in hospitalized patients. These emboli are usually related to deep venous thrombosis, but other etiologic factors may be the cause. A 60-year-old male was diagnosed with rectal adenocarcinoma and treated by surgical rectal resection. After surgery, he presented with a decreased level of consciousness and hypoxia with no signs of bleeding. PE was ruled out by pulmonary angiography. Given the hemodynamic instability, contrast-enhanced CT was performed, showing a discrete leak related to the rectal anastomosis, which required urgent surgery. The patient suffered cardiorespiratory arrest prior to surgery, and once resolved, the surgical procedure was limited to disconnecting the intestinal anastomosis, leaving the colon and rectal stumps free in the abdomen and keeping the abdominal cavity open with negative-pressure therapy. The patient suffered from another cardiorespiratory arrest after surgery, with abdominal distension and serous-hemorrhagic material discharge through the negative-pressure device. On a new surgical revision, no bleeding was identified, so the symptoms were attributed to coagulopathy. The patient died and autopsy was performed. The autopsy revealed no surgery-related complications. The lungs were increased in weight and showed a normal macroscopic appearance; in contrast, the histological study revealed multiple and bilateral thrombo-embolisms affecting small distal arteries. Those thrombi were composed of intestinal contents, including vegetal particles, mucinous and biliary material, fibrin, and bacterial structures. Fecal PE is an extremely infrequent event. Isolated cases have been described in association with communications between the digestive tract lumen and the systemic circulation, with a generally fatal prognosis.

Immobilized enzymes and cell systems: an approach to the removal of phenol and the challenges to incorporate nanoparticle-based technology.

The presence of phenol in wastewater poses a risk to ecosystems and human health. The traditional processes to remove phenol from wastewater, although effective, have several drawbacks. The best alternative is the application of ecological biotechnology tools since they involve biological systems (enzymes and microorganisms) with moderate economic and environmental impact. However, these systems have a high sensitivity to environmental factors and high substrate concentrations that reduce their effectiveness in phenol removal. This can be overcome by immobilization-based technology to increase the performance of enzymes and bacteria. A key component to ensure successful immobilization is the material (polymeric matrices) used as support for the biological system. In addition, by incorporating magnetic nanoparticles into conventional immobilized systems, a low-cost process is achieved but, most importantly, the magnetically immobilized system can be recovered, recycled, and reused. In this review, we study the existing alternatives for treating wastewater with phenol, from physical and chemical to biological techniques. The latter focus on the immobilization of enzymes and microorganisms. The characteristics of the support materials that ensure the viability of the immobilization are compared. In addition, the challenges and opportunities that arise from incorporating magnetic nanoparticles in immobilized systems are addressed.

Complementary value of electron microscopy and immunohistochemistry in the diagnosis of non-small cell lung cancer: A potential role for electron microscopy in the era of targeted therapy.

With the identification of therapeutic targets for lung adenocarcinoma, it has become mandatory to distinguish it from other entities. Some cases remain classified as non-small cell lung carcinoma, not otherwise specified (NSCLC-NOS) with immunohistochemistry. Electron microscopy (EM) can be useful, allowing the identification of glandular differentiation. The aim of this study was to determine the complementary value of immunohistochemistry and EM.Forty-eight NSCLC-NOS cases were selected (PSMAR-Biobank, Barcelona, Spain). Immunohistochemistry (TTF-1, p40) was performed. Tissue was retrieved from paraffin blocks. Results were compared to the final diagnosis, derived from combination of light microscopy, immunohistochemistry, EM, molecular studies and resection specimen.Immunohistochemistry concurred with final diagnosis in 36 cases (75%, Kappa = 0.517). EM agreed with final diagnosis in 35 (72.9%, Kappa = 0.471). Immunohistochemistry had a sensitivity = 73%, specificity = 100%, positive predictive value (PPV) = 100% and negative predictive value (NPV) = 52.4% for adenocarcinoma. All adenocarcinoma cases not solved by immunohistochemistry (n = 10) were classified by EM, and vice versa. Data from EM were identical to those of immunohistochemistry: sensitivity = 73%, specificity = 100%, PPV = 100% and NPV = 52.4%. Combining both techniques, 47 cases were coincident with final diagnosis (97.9%, Kappa = 0.943).EM can provide valuable information in subtyping NSCLC-NOS, being particularly useful when immunohistochemistry is inconclusive. EM could be considered as a complementary tool for decision-making in NSCLC-NOS.

MRI and Ultrasound Imaging of the Shoulder Using Positional Maneuvers.

OBJECTIVE: The purpose of this article is to review the normal anatomy and pathologic conditions of the shoulder on the basis of the appearance on MR and ultrasound images obtained during performance of abduction external rotation and flexion adduction internal rotation positional maneuvers. CONCLUSION: Positional MRI and ultrasound are highly useful in evaluation of the shoulder. Knowledge of the normal appearance of anatomic structures and pathologic changes in nontraditional imaging planes is necessary to avoid pitfalls in interpretation.

MRI of the annular ligament of the elbow: review of anatomic considerations and pathologic findings in patients with posterolateral elbow instability.

OBJECTIVE: The annular ligament is one of the major stabilizers of the proximal radioulnar joint. However, it is one of the least studied structures in the lateral elbow because of imaging challenges and low pathologic incidence. This article will examine the anatomy of the annular ligament, its biomechanics, and its functional importance. Eight surgically proven cases of annular ligament abnormality in patients with posterolateral and nursemaid elbow, along with the associated findings, are presented. CONCLUSION: Adequate understanding of the anatomy and familiarity with the associated injuries that can be seen in annular ligament displacement or rupture will improve detection of annular ligament abnormality.

Biceps and rotator interval: imaging update.

The rotator interval contains several important anatomical structures that contribute to the stability and normal function of the shoulder joint including the biceps tendon, coracohumeral ligament, superior glenohumeral ligament, rotator interval capsule, anterior fibers of the supraspinatus tendon, and superior fibers of the subscapularis tendon. Rotator interval pathology is associated with biceps instability, glenohumeral instability, and adhesive capsulitis, all of which can be challenging to clinically diagnose and treat. The complex anatomy and orientation of the rotator interval structures within a relatively small space can make it difficult to evaluate by imaging; however, improvements in MR technology have allowed better detection of disease in this region. Furthermore, the rotator interval is not routinely evaluated arthroscopically unless the clinical examination or imaging findings suggest pathology at this level. Imaging, therefore, can play a significant role in helping the clinician make the diagnosis and initiate appropriate treatment. This article discusses the normal anatomy and biomechanics of the rotator interval and its structures as well as the normal and pathologic appearances on imaging and the treatment options of abnormalities of structures in this region.

Imaging of sports ligamentous injuries of the elbow.

Ligamentous injuries of the elbow are common in sports. The diagnosis is usually based on a combination of the assessment of the mechanism of injury during the sporting activity and physical examination. Imaging with radiographs and MR imaging has an important diagnostic role, particularly when the clinical presentation is unclear and to evaluate for other important potential associated injuries such as myotendinous injuries, fractures, dislocations, and osteochondral lesions. Treatment includes conservative and surgical measures depending on the severity of the instability and associated injuries. We provide a detailed review of sports-related injuries of the medial and lateral collateral ligament complexes of the elbow with an emphasis on imaging manifestations of disease and a discussion of the anatomy, biomechanics, and treatment options.

Primary intramuscular and intermuscular Echinococcal disease of the iliopsoas and sartorius muscles: A case report.

Hydatid disease is a parasitic infection caused by the Echinococcus tapeworm. Classically, Echinococcal lesions are slowly growing cystic masses with daughter cysts. The most common sites of disease are the liver in 75% of cases and lungs in 15% of cases. This report covers a case of a patient from Southeast Europe with primary extrahepatic hydatid disease in and along the left iliopsoas and sartorius muscles. Retroperitoneal and soft tissue Echinococcus infection without liver involvement is extremely rare and creates a diagnostic challenge for clinicians and radiologists, especially in nonendemic areas.

[Yellow nail syndrome. A case report with postmortem study]. / Síndrome de las uñas amarillas. Presentación de un caso con estudio autópsico.

Yellow nail syndrome is a rare disease of unknown aetiology. Patients with YNS have a characteristic yellowish-coloured nails, pulmonary alterations and primary lymphedema. To the best of our knowledge, only a few reports of autopsy findings in these patients have been published. Its aetiology possibly involves a primary malformation of larger lymph vessels. We describe autopsy findings not previously associated with yellow nail syndrome, such as expansion of mediastinal lymph-nodes and splenic sinusoids. The present autopsy reveals hitherto unreported findings associated with YNS, such as alterations in splenic sinusoids and mediastinal lymph-node sinuses.

Clinical outcomes of TAVI with the Myval balloon-expandable valve for non-calcified aortic regurgitation.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) in non-calcified aortic regurgitation (NCAR) is an off-label procedure. The balloon-expandable Myval includes extra-large sizes (30.5 mm and 32 mm) of interest in this setting. AIMS: We aimed to evaluate the safety and feasibility of Myval in NCAR. METHODS: This was an international, multicentre, observational study that enrolled all consecutive patients with symptomatic severe NCAR undergoing TAVR with the Myval device. The images were centrally analysed. RESULTS: A total of 113 patients were recruited, 64.6% were men, the mean age was 78.4±7.5 years, and the Society of Thoracic Surgeons score was 2.7±1.7%. Aortic root dilatation was present in 59.3% of patients, 7.1% were bicuspid, and the mean annular area was 638.6±106.0 mm2. The annular area was beyond the recommended range for extra-large sizes in 2.6% of cases, and additional volume was added in 92% (median 4 cc, up to 9 cc). The extra-large sizes were used in 95 patients (84.1%), and the mean oversizing was 17.9±11.0%. The technical success rate was 94.7%; the rate of residual ≥moderate aortic regurgitation was 8.9%, and the pacemaker rate was 22.2%. There were no cases of annular rupture, cardiac tamponade, or aortic dissection, but in 4 patients (3.5%) valve embolisation occurred (1 antegrade and 3 ventricular), all in cases with a tapered left ventricle outflow tract (p=0.007). Thirty-day and 1-year mortality were 5.3% and 9.7%, respectively. Technical success was associated with better survival (97.1% vs 72.7%; p=0.012), and valve embolisation was the main determinant of mortality (p=0.047). CONCLUSIONS: Myval is a feasible and safe option for selected non-operable patients with NCAR and demonstrated good midterm outcomes and lack of impact of oversizing on device durability.

D2-40 immunohistochemical overexpression in cutaneous squamous cell carcinomas: a marker of metastatic risk.

BACKGROUND: Approximately 4% of cutaneous squamous cell carcinomas (cSCCs) develop lymphatic metastases. The value of lymphatic endothelial markers to enhance the detection of lymphatic tumor invasion in cSCC has not been assessed previously. OBJECTIVE: We sought to evaluate the use of the antibody D2-40, a podoplanin immunohistochemical marker, to identify tumor lymph vessel invasion in cSCC and to assess its expression in tumor cells. METHODS: This was a retrospective case-control study. A series of 101 cSCC, including 51 cases that developed lymphatic metastatic spread (metastasizing cSCC [MSCC]) and 50 cases that resolved definitely after surgical excision (non-MSCC) were included in the study. Lymph vessel invasion using D2-40 was evaluated on all primary biopsy specimens. The percentage of tumor cells showing D2-40 positivity and intensity scoring were recorded. All the immunohistochemical findings were correlated with the clinicopathological features. RESULTS: Lymph vessel invasion was observed in 8% of non-MSCCs and in 25.5% of MSCCs (P = .031). D2-40 expression was significantly increased, both in intensity (odds ratio 4.42 for intensity ++/+++) and in area (odds ratio 2.29 for area >10%), in MSCC when compared with non-MSCC. Interestingly, almost half (49%) of the MSCC had moderate to intense D2-40 positivity compared with 16% of non-MSCC. D2-40 immunohistochemical expression was increased in tumors with an infiltrative pattern of extension. In the multivariate analysis, histologically poorly differentiated tumors, recurrent lesions, and cSCC showing D2-40 overexpression (in intensity) were significantly associated with lymphatic metastases development (odds ratios 15.67, 14.72, and 6.07, respectively). LIMITATIONS: This was a retrospective study. CONCLUSION: The expression of podoplanin associates with high metastatic risk in cSCC.

Tibial tunnel and pretibial cysts following ACL graft reconstruction: MR imaging diagnosis.

Tunnel cyst formation is a rare complication after anterior cruciate ligament reconstruction, usually occurring 1-5 years post-operatively, which may occasionally be symptomatic. There are multiple proposed theories regarding the etiology of tunnel cysts. Theories include necrosis, foreign-body reaction, lack of complete graft osteo-integration, and intravasation of articular fluid. It is important to know if the tunnel cysts are communicating or not communicating with the joint, as surgical management may be different. Imaging characteristics on magnetic resonance images (MRI) include tibial tunnel widening, multilocular or unilocular cyst formation in the graft or tibial tunnel, with possible extension into the pretibial space, intercondylar notch, and/or popliteal fossa. The MR imaging differential diagnosis of tibial tunnel cysts includes infection, foreign-body granuloma, or tibial screw extrusion. Importantly, to the best of our knowledge, graft failure or instability has not been reported in association with tibial tunnel cysts.

Use of the V-sign in the diagnosis of bucket-handle meniscal tear of the knee.

OBJECTIVE: Bucket-handle tear is a displaced vertical longitudinal tear of the meniscus. Several signs of the tear have been described on MRI but none in the axial plane. We propose to describe such a sign named the V-sign that is seen at the junction of the displaced fragment and the meniscus, which is in place. MATERIALS AND METHODS: MRI imaging of 25 surgically proven bucket-handle tears was reviewed for presence of the V-sign. Two control groups, one with normal menisci (n = 75) and one with surgically proven non-bucket-handle tears (n = 25), were also evaluated. Comparisons for presence or absence of the V-sign were performed among the three groups, and also for other commonly associated signs such as double PCL sign, double delta sign, and presence of ACL tear. Also, sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Among those with bucket-handle tear, 72% demonstrated the V-sign while no participant in either control group had the V-sign (P ≤ 0.001). The V-sign occurred in 38% of those with double PCL sign, 55.6% with ACL tear, and 66.7% with double delta sign. The V-sign had higher sensitivity and negative predictive values than other signs related to bucket-handle tear. CONCLUSION: The V-sign, when seen on an axial plane image, is highly suggestive of bucket-handle tear. Our data suggest the benefit of using the V-sign for detecting bucket-handle tears, perhaps even above other commonly used approaches.

MRI evaluation of bone marrow changes in the diabetic foot: a practical approach.

One of the most important roles of magnetic resonance (MR) in imaging of the diabetic foot is to differentiate between the common and often comorbid pathologies that present with abnormal bone marrow signal. The primary diagnostic challenges in this setting are to distinguish osteomyelitis from reactive bone marrow edema, neuroarthropathy from osteomyelitis, and the sterile from the superinfected neuropathic joint. Whereas both osteomyelitis and reactive marrow edema share increased T2 signal, osteomyelitis is confirmed by T1 hypointensity in the bone marrow and reactive edema demonstrates isolated T2 signal hyperintensity. In distinguishing osteomyelitis from neuroarthropathy, a localized or contiguously spreading forefoot focus of abnormal bone marrow away from the subchondral surface and adjacent to a skin ulcer, cellulitis, abscess, or sinus tract would be indicative of osteomyelitis. A midfoot, subchondral, periarticular, or polyarticular distribution of findings in the absence of a contiguous focus of skin disruption would strongly support neuroarthropathy. Parameters that have been successfully correlated with acute infection superimposed on neuroarthropathy include diffuse bone marrow signal abnormality, progressive subarticular enhancement, loss of subchondral cysts, and the presence of the MRI "ghost sign."

Entrapment neuropathies III: lower limb.

Clinicians frequently encounter compressive neuropathies of the lower extremity. The clinical history and physical examination, along with electrodiagnostic testing and imaging studies, lead to the correct diagnosis. The imaging characteristics of the compression neuropathies can include acute and chronic changes in the nerves and the muscles they innervate. We provide a detailed review of compression neuropathies of the lower extremity with an emphasis on magnetic resonance (MR) imaging characteristics. We discuss the clinical presentation, etiology, anatomical location, and MR imaging appearance of these neuropathies, including the piriformis syndrome, iliacus syndrome, saphenous neuropathy, obturator neuropathy, lateral femoral cutaneous neuropathy (meralgia paresthetica), proximal tibial neuropathy, common peroneal neuropathy, deep peroneal neuropathy, superficial peroneal neuropathy, tarsal tunnel syndrome, Baxter's neuropathy, jogger's foot, sural neuropathy, and Morton's neuroma.

Histo-morpho-biochemical findings of the residual prostate (III): (undetectable) PSA maintained after retropubic adenomectomy for BPH.

SUMMARY OBJECTIVES: To present 4 cases with "undetectable" PSA levels (PSA <0.15 ng/ml) long-term postoperative follow-up after retropubic adenomectomy for BPH METHODS: They come from a series of 70 consecutive cases of retropubic prostatic adenomectomies, monitored and controlled at the hospital in their biochemical, histological and morphometric analysis for 5 years following the intervention. RESULTS: Four patients have demonstrated PSA levels <0.15 in all controls after surgery. Mean follow-up of the global series: 45.25 months. There is correlation between this determination and histological and morphometric data, when they were achieved. CONCLUSIONS: "Undetectable" PSA after open prostatic adenomectomy could be an equivalent to the expression of "radical cure"of BPH, and a reliable marker for monitoring neo-hyperplasia.

Enhancement of alkaline-oxidative delignification of wheat straw by semi-batch operation in a stirred tank reactor.

This paper compares a semi-batch operation and a conventional one of an alkaline oxidative pretreatment of wheat straw carried out in a stirred tank reactor. For the pretreatment, different concentrations of biomass (6% up to 12% w/v) and two different particle sizes (mesh #40-60 and #>60) were experimented. The performance of processes was evaluated through the analysis of lignocellulosic composition of the biomass, and the enzymatic hydrolysis of pretreated biomass using the Cellic® CTec2 enzyme complex by Novozymes®. The process time of semi-batch operation is significantly lower than the batch one and enables a higher load of biomass, showing a delignification yield between 55 and 60%. In the first 5 h of reaction time, the enzymatic hydrolysis experiments reached their maximum yields of 72 and 66% according to reducing sugars conversion when using the mesh #>60 mesh and #40-60, respectively.

MR imaging of complications of anterior cruciate ligament graft reconstruction.

During the past 3 decades, graft reconstruction of the anterior cruciate ligament (ACL) has become an accepted treatment for symptomatic ACL deficiency. The goal of surgery is to prevent joint instability, which may further damage articular cartilage and menisci. Graft failure is defined as pathologic laxity of the reconstructed ACL. The prevalence of recurrent instability after primary ACL reconstruction ranges from 1% to 8%. Early failures, those that occur within the first 6 months, often are secondary to poor surgical technique, failure of graft incorporation, or errors in rehabilitation. Late failures, those that occur more than 1 year after surgery, likely are related to new trauma and graft tearing. Other complications of ACL reconstruction include roof impingement, postoperative stiffness, tunnel widening due to cyst formation, iliotibial band friction syndrome, hardware failure, and infection. Magnetic resonance imaging is the preferred advanced imaging modality for the evaluation of symptomatic ACL graft reconstructions.

A rare case of right lower quadrant pain.

Endometriosis of the appendix is a very rare entity and commonly affects females in childbearing age. Clinical presentation might be confusing varying from asymptomatic to acute abdominal pain and often mimicks acute appendicitis or chronic pelvic pain. Diagnosis is generally made after pathological examination as operative findings are usually non-specific. This condition poses a diagnostic challenge to radiologists and surgeons altogether and we therefore report a case of a middle aged female who presented with both right lower quadrant and right lower back pain. Recent literature is reviewed and radiological findings discussed.