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A Private Investigation: Radiologic-Pathologic Correlation of Testicular Tumors

Thu, 07/14/2016 - 8:58pm

To review the classification of testicular tumors, describe the sonographic and pathologic features of each tumor type, and discuss the mimics, diagnostic pitfalls, and management of testicular tumors. Method consists of pictorial review. We review sonographic and pathologic findings of several testicular tumors and tumorlike entities. Although ultrasound is the first-line imaging modality to differentiate between intratesticular and extratesticular location of an intrascrotal mass, it is not specific for intratesticular lesion characterization. Therefore, correlation with histology sampling is often necessary.

Improving the Transcription of Patient Information From Image Requisitions to the Radiology Information System

Thu, 07/14/2016 - 8:58pm

PURPOSE: The purpose of this study was to improve the transcription of patient information from imaging study requisitions to the radiology information database at a single institution.

METHODS: Five hundred radiology reports from adult outpatient radiographic examinations were chosen randomly from the radiology information system (RIS) and categorized according to their degree of concordance with their corresponding clinical order indications. The number and types of grammatical errors and types of order forms were also recorded. Countermeasures centered on the education of the technical staff and referring physician offices and the implementation of a checklist. Another sample of 500 reports was taken after the implementation of the countermeasures and compared with the baseline data using a chi2 test.

RESULTS: The number of RIS indications perfectly concordant with their corresponding clinical order indications increased from 232 (46.4%) to 314 (62.8%) after the implementation of the countermeasures (P < .0001). The number of partially concordant matches due to inadequate RIS indications dropped from 162 (32.4%) to 114 (22.8%) (P < .001), whereas the number of partially concordant matches due to inadequate clinical order indications increased from 22 (4.4%) to 57 (11.4%) (P < .0001). The number of discordant pairings dropped from 84 (16.8%) to 15 (3%) (P < .0001). Technologists began to input additional patient information obtained from the patients (not present in the image requisitions) in the RIS after the implementation of the countermeasures.

CONCLUSIONS: The education of technical staff members and the implementation of a checklist markedly improved the information provided to radiologists on image requisitions from referring providers.

MRI Findings of Injury to the Longus Colli Muscle in Patients With Neck Trauma

Thu, 07/14/2016 - 8:58pm

OBJECTIVE: The longus colli muscle (LCM) forms the bulk of the deep flexor muscles of the neck. To our knowledge, very little information on the effects of trauma on this muscle group has been published. We describe MRI findings related to injury of the LCM in patients with a history of neck trauma.

MATERIAL AND METHODS: A radiology department database was searched to identify patient medical records from 2008 to 2013 that included the keywords "longus colli" and "deep flexors." Patients with fractures and ligament injuries were excluded. Patients with other obvious large soft-tissue injuries and nontraumatic conditions were also omitted. A total of 12 patients met the inclusion criterion of having an isolated or predominant injury to the LCM. Five patients had been involved in a motor vehicle accident, and seven patients had fallen. Eleven patients had undergone a CT examination before MRI was performed.

RESULTS: No fractures were noted on CT. MRI examinations of the cervical spine were obtained for the following reasons: for increased prevertebral soft-tissue swelling noted on a CT scan plus neck pain (n = 6), for neck pain only (n = 4), or as part of a routine protocol for assessment of obtunded patients (n = 2). Eight of the 12 patients had isolated injury to the LCM. The remaining four patients also had minor injuries to the other neck muscles. The MR image showed swelling and T2 hyperintensity in the LCM and revealed free fluid in the prevertebral space.

CONCLUSION: Isolated injury to the LCM may occur in neck injuries. The MRI findings indicating such injury include increased T2 signal, swelling of the muscle, and the presence of prevertebral fluid.

Stent-assisted coil embolization of aneurysms with small parent vessels: safety and efficacy analysis

Thu, 07/14/2016 - 8:58pm

BACKGROUND: Stent-assisted coil embolization (SACE) is a viable therapeutic approach for wide-neck intracranial aneurysms. However, it can be technically challenging in small cerebral vessels ( < /=2 mm).

OBJECTIVE: To present our experience with stents approved for SACE in aneurysms with small parent arteries.

METHODS: All patients who underwent stent-assisted aneurysm treatment with either a Neuroform or an Enterprise stent device at our institution between June 2006 and October 2012 were identified. Additionally, we evaluated each patient's vascular risk factors, aneurysm characteristics (ruptured vs non-ruptured, incidental finding, recanalized) and follow-up angiography data.

RESULTS: A total of 41 patients with 44 aneurysms met our criteria, including 31 women and 10 men. Most of the aneurysms were located in the anterior circulation (75%). Stent placement in vessels 1.2-2 mm in diameter was successful in 93.2%. Thromboembolic complications occurred in 6 cases and vessel straightening was seen in 1 case only. Initial nearly complete to complete aneurysm obliteration was achieved in 88.6%. Six-month follow-up angiography showed coil compaction in three cases, one asymptomatic in-stent stenosis and stent occlusion. Twelve to 20-months' follow-up showed stable coil compaction in two patients compared with previous follow-up, and aneurysm recanalization in two patients. Twenty-four to 36-months' follow-up showed further coil compaction in one of these patients and aneurysm recanalization in a previous case of stable coil compaction on mid-term follow-up.

CONCLUSIONS: Our results suggest that SACE of aneurysms with small parent vessels is feasible in selected cases and shows good long-term patency rates of parent arteries.

Successful treatment of a giant pediatric fusiform basilar trunk aneurysm with surpass flow diverter

Thu, 07/14/2016 - 8:57pm

Fusiform aneurysms present a unique challenge to traditional microsurgical and endovascular treatment because of the lack of a discernible neck and the involvement of parent vessel. Flow diversion has increasingly become the treatment of choice for fusiform aneurysms in the anterior circulation, but its results in the posterior circulation are variable. We report successful treatment of a giant fusiform upper basilar trunk aneurysm with the Surpass flow diverter in an adolescent, and discuss the potential advantages of this emerging technology in the treatment of fusiform posterior circulation aneurysms.

Redefining Budd-Chiari syndrome: A systematic review

Thu, 07/14/2016 - 8:57pm

AIM: To re-examine whether hepatic vein thrombosis (HVT) (classical Budd-Chiari syndrome) and hepatic vena cava-Budd Chiari syndrome (HVC-BCS) are the same disorder.

METHODS: A systematic review of observational studies conducted in adult subjects with primary BCS, hepatic vein outflow tract obstruction, membranous obstruction of the inferior vena cava (IVC), obliterative hepatocavopathy, or HVT during the period of January 2000 until February 2015 was conducted using the following databases: Cochrane Library, CINAHL, MEDLINE, PubMed and Scopus.

RESULTS: Of 1299 articles identified, 26 were included in this study. Classical BCS is more common in women with a pure hepatic vein obstruction (49%-74%). HVC-BCS is more common in men with the obstruction often located in both the inferior vena cava and hepatic veins (14%-84%). Classical BCS presents with acute abdominal pain, ascites, and hepatomegaly. HVC-BCS presents with chronic abdominal pain and abdominal wall varices. Myeloproliferative neoplasms (MPN) are the most common etiology of classical BCS (16%-62%) with the JAK2V617-F mutation found in 26%-52%. In HVC-BCS, MPN are found in 4%-5%, and the JAK2V617-F mutation in 2%-5%. Classical BCS responds well to medical management alone and 1(st) line management of HVC-BCS involves percutaneous recanalization, with few managed with medical management alone.

CONCLUSION: Systematic review of recent data suggests that classical BCS and HVC-BCS may be two clinically different disorders that involve the disruption of hepatic venous outflow.

Academic-industry Collaborations in Translational Stroke Research

Thu, 07/14/2016 - 8:57pm

Academic-industry collaborations are an emerging format of translational stroke research. Next to classic contract research models, a multitude of collaboration models has been developed, some of which even allowing for multinational or intercontinental research programs. This development has recently been paralleled by first successful attempts to overcome the translational stroke research road block, such as the unprecedented success of novel endovascular approaches or the advent of the multicenter preclinical trial concept. While the first underlines the role of the industry as a major innovation driver in stroke research, the latter will require enrollment of industrial partners for optimal output. Moreover, academic-industry partnerships are invaluable to bridge the translational "valley of death" as well as funding gaps in times of dwindling public funding and declining high risk capital investments. However, these collaborations are also subject to relevant challenges because interests, values, and aims often significantly differ between cademia and industry. Here, we describe common academic-industry collaboration models as well as associated benefits and challenges in the stroke research arena. We also suggest strategies for improved planning, implementation, guidance, and utilization of academic-industry collaborations to the maximum mutual benefit.

Patient delay in seeking care for heart attack symptoms: findings from focus groups conducted in five U.S. regions

Tue, 07/12/2016 - 3:41pm

BACKGROUND: Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the United States.

METHODS: Investigators conducted focus groups (N = 34; 207 participants) in major U.S. regions (NE, NW, SE, SW, MW) as formative evaluation to develop a multi-center randomized community trial (the REACT Project). Target groups included adults with previous heart attacks, those at higher risk for heart attack, and bystanders to heart attacks. There were also subgroups reflecting gender and ethnicity (African-American, Hispanic-American, White).

FINDINGS: Patients, bystanders, and those at higher risk expected heart attack symptoms to present as often portrayed in the movies, that is, as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. Patients and those at higher risk also unrealistically judge their personal risk as low, understand little about the benefits of rapid action, are generally unaware of the benefits of using EMS/9-1-1 over alternative transport, and appear to need the "permission" of health care providers or family to act. Moreover, participants reported rarely discussing heart attack symptoms and appropriate responses in advance with health care providers, spouses, or family members. Women often described heart attack as a "male problem," an important aspect of their underestimation of personal risk. African-American participants were more likely to describe negative feelings about EMS/9-1-1, particularly whether they would be transported to their hospital of choice.

CONCLUSIONS: Interventions to reduce patient delay need to address expectations about heart attack symptoms, educate about benefits and appropriate actions, and provide legitimacy for taking specific health care-seeking actions. In addition, strategy development must emphasize the role of health care providers in legitimizing the need and importance of taking rapid action in the first place.

Ultrasound-guided Intralesional Bleomycin Injection (IBI) for Treatment of Cutaneous Hemangiomas and Vascular Malformations

Thu, 07/07/2016 - 9:05am

Purpose: To report the therapeutic outcome of ultrasound-guided intralesional injection of bleomycin in the treatment of cutaneous hemangiomas and vascular malformations.

Material & Methods: The medical records of patients with cutaneous hemangiomas and vascular malformations treated with the intralesional injection of bleomycin under ultrasound guidance between August 2009 and June 2013 at the Indus Hospital, Karachi were reviewed retrospectively using a computerized medical record information management system. Data were extracted using a pre-coded performa that included patient demographics, type and location of lesion, number of treatments, presenting/pre- and post-treatment clinical symptoms (pain, swelling, heaviness, size, discoloration), ultrasound appearance and vascularity, and post-treatment side effects. The dose range of bleomycin was 0.5-1.0 mg/kg, but not exceeding 15 mg in a single session. A maximum of four treatments were given in any given patient except for one, who presented with recurrence after a year of complete resolution. Therapeutic outcome was determined using review of ultrasound images and recorded clinical assessment. Treatment response was categorized as: (i) complete resolution [more than 90% reduction]; (ii) substantial reduction [more than 50% reduction]; (iii) mild reduction [25% reduction]; or, (iv) no improvement [ < 10% reduction].

Results: A total of 30 patients (16 female, 14 male), ranging in age from 8 months to 48 years (mean age 10.2 years), were treated from 2009 to 2013. There were 23 hemangiomas. Seven were vascular malformations, of which five were lymphatic malformations and two were venous malformations. Twenty-eight lesions were located in the head and neck region, and two were peripheral.. In 24 of the 30 patients (76%), treatment had been completed. In six patients (21%) treatment was ongoing at the time of this report. Seventeen of the 23 hemangiomas (74%) were completely resolved clinically and on ultrasound, five (22%) showed substantial improvement and one (4%) showed mild improvement. In five of the seven vascular malformations (71%) lymphatic malformations resolved completely, and two (29%) venous malformations showed substantial improvement. Of the 13 patients presenting with discoloration, there was complete resolution in one (7.7%), marked reduction in 11 (84.6%) and mild reduction in one (7.7%). Of seven patients presenting with pain, there was complete resolution in two (28.6%), marked reduction in two (28.6%), mild reduction in two (28.6%), and no improvement in one (14.3%). There were no pulmonary complications.

Conclusion: Ultrasound-guided intralesional injection of bleomycin is an option to consider for the treatment of certain types of cutaneous hemangiomas and vascular malformations. Prospective studies should be undertaken to understand the various factors contributing to therapeutic success.

Promoter-enhancer looping at the PPARγ2 locus during adipogenic differentiation requires the Prmt5 methyltransferase

Wed, 07/06/2016 - 10:05am

PPARγ2 is a critical lineage-determining transcription factor that is essential for adipogenic differentiation. Here we report characterization of the three-dimensional structure of the PPARγ2 locus after the onset of adipogenic differentiation and the mechanisms by which it forms. We identified a differentiation-dependent loop between the PPARγ2 promoter and an enhancer sequence 10 kb upstream that forms at the onset of PPARγ2 expression. The arginine methyltransferase Prmt5 was required for loop formation, and overexpression of Prmt5 resulted in premature loop formation and earlier onset of PPARγ2 expression. Kinetic studies of regulatory factor interactions at the PPARγ2 promoter and enhancer revealed enhanced interaction of Prmt5 with the promoter that preceded stable association of Prmt5 with enhancer sequences. Prmt5 knockdown prevented binding of both MED1, a subunit of Mediator complex that facilitates enhancer-promoter interactions, and Brg1, the ATPase of the mammalian SWI/SNF chromatin remodeling enzyme required for PPARγ2 activation and adipogenic differentiation. The data indicate a dynamic association of Prmt5 with the regulatory sequences of the PPARγ2 gene that facilitates differentiation-dependent, three-dimensional organization of the locus. In addition, other differentiation-specific, long-range chromatin interactions showed Prmt5-dependence, indicating a more general role for Prmt5 in mediating higher-order chromatin connections in differentiating adipocytes.

Comparison of RNA isolation and associated methods for extracellular RNA detection by high-throughput quantitative polymerase chain reaction

Wed, 07/06/2016 - 9:49am

MicroRNAs (miRNAs) are small noncoding RNA molecules that function in RNA silencing and posttranscriptional regulation of gene expression. miRNAs in biofluids are being used for clinical diagnosis as well as disease prediction. Efficient and reproducible isolation methods are crucial for extracellular RNA detection. To determine the best methodologies for miRNA detection from plasma, the performance of four RNA extraction kits, including an in-house kit, were determined with miScript miRNA assay technology; all were measured using a high-throughput quantitative polymerase chain reaction (qPCR) platform (BioMark System) with 90 human miRNA assays. In addition, the performances of complementary DNA (cDNA) and preamplification kits for TaqMan miRNA assays and miScript miRNA assays were compared using the same 90 miRNAs on the BioMark System. There were significant quantification cycle (Cq) value differences for the detection of miRNA targets between isolation kits. cDNA, preamplification, and qPCR performances were also varied. In summary, this study demonstrates differences among RNA isolation methods as measured by reverse transcription (RT)-qPCR. Importantly, differences were also noted in cDNA and preamplification performance using TaqMan and miScript. The in-house kit performed better than the other three kits. These findings demonstrate significant variability between isolation and detection methods for low-abundant miRNA detection from biofluids.

PETS-D (parents education through simulation-diabetes): Parents' qualitative results

Wed, 07/06/2016 - 9:38am

OBJECTIVE: Parents who have a child newly diagnosed with type 1 diabetes (T1D) must quickly learn daily diabetes self-management. An RCT was conducted using human patient simulation (HPS) to enhance parents learning diabetes self-management with children with new-onset T1D. The purpose of this study was to describe parents' perspectives of using HPS to augment diabetes education.

METHODS: A qualitative descriptive design was used with open-ended in-depth interviews of parents (n=49) post-intervention. Qualitative directed content analysis was used.

RESULTS: The majority of parents were positive about learning with HPS. Although a few parents said the HPS was "hokey" or "creepy," most reported the visual and hands-on learning was realistic and very beneficial. Seeing a seizure increased their fear although they would have panicked if they had not had that learning experience, and it helped build their diabetes self-management confidence. Recommendations included teaching others with the HPS (grandparents, siblings, babysitters, and school nurses).

CONCLUSION: HPS-enhanced education is an acceptable and viable option that was generally well-received by parents of children with new-onset T1D.

PRACTICE IMPLICATIONS: The technique should be studied with parents of children with other chronic illnesses to see if the benefits found in this study are applicable to other settings.