aging

Purpose: To determine the normal value of basal angle measured using the modified MR imaging technique in Thai population compared with the standard value obtained from the Western population. Material and Methods: We retrospectively evaluated midline sagittal SE T1 weighted MR images in 200 adults and 50 children. The basal angle of the skull base was measured using the modified MR imaging technique described by Koenigsberg et al. The angle was formed by a line extending across the anterior cranial fossa to the tip of the dorsum sellae and another line drawn along the posterior margin of the clivus. The mean values of the basal angles among different age groups and sex were calculated and analyzed. Results: The mean skull base angle of our adult population was 115° (range 100.5°-130°, SD=5.7) with an inter-observer agreement of 0.85, slightly smaller than the previous study from the USA which was 117°. There was no significant difference between the male and female groups. The mean skull base angle in our children population was 114.7° (range 102- 130.5°, SD=6.3) with an inter-observer agreement of 0.89, quite similar to the previous USA study which was 114°. There was no significant difference between adult and children. Conclusion: The mean adult skull base angle measured using the modified MR imaging technique in Thai population was slightly smaller than the Western population, while the mean skull base angle of children was quite similar. The basal angle range of 103.6°-126.4° may be used as a guide for the potential range of normal skull base angles in Thai population and possibly also the Southeast Asian population.

Necrotizing fasciitis is a quickly progressing soft tissue infection that can be described with diffuse necrosis of subcutaneous tissue and superficial fascia. The cause of this can be infectious process of odontogenic origin, most commonly caused by mixed gram+ and gram- , aerobic and anaerobic microorganisms that are found in patients that are predisposed to infections. In a case of undiagnosed illness, there is a possibility of life threatening complications. This case analysis introduces the diagnostic criteria of the disease and treatment plan, encouraging doctors to devote more attention to prevention of infections. 

Objective: The primary aim of this study was to measure pressure generated on a Tuohy needle during the epidural procedure in labouring women of varying body mass indices (BMI) with a view of utilising the data for the future development of a high fidelity epidural simulator. High-fidelity epidural simulators have a role in improving training and safety but current simulators lack a realistic experience and can be improved. Methods: This study was approved by the National Research Ethics Service Committee South Central, Portsmouth (REC reference 11/SC/0196). After informed consent epidural needle insertion pressure was measured using a Portex 16-gauge Tuohy needle, loss-of-resistance syringe, a three-way tap, pressure transducer and a custom-designed wireless transmitter. This was performed in four groups of labouring women, stratified according to BMI kg/m2: 18-24.9; 25-34.9; 35-44.9 and >=45. One-way ANOVA was used to compare difference in needle insertion pressure between the BMI groups. A paired t-test was performed between BMI group 18-24.9 and the three other BMI groups. Ultrasound images of the lumbar spine were undertaken prior to the epidural procedure and lumbar magnetic resonance imaging (MRI) was performed within 72h post-delivery. These images will be used in the development of a high fidelity epidural simulator. Results: The mean epidural needle insertion pressure of labouring women with BMI 18-24.9 was 461mmHg; BMI 25-34.9 was 430mmHg; BMI 35-44.9 was 415mmHg and BMI >=45 was 376mmHg, (p=0.52). Conclusion: Although statistically insignificant, the study did show a decreasing trend of epidural insertion pressure with increasing body mass indices.

Background: Leiomyoma itself is not a rare disease, but it is rarely found intravascularly. Case presentation: A 54-year old female sought medical help after noticing her leg being swelling. A diagnosis of deep vein thrombosis (DVT) was made and antithrombotic treatment was given after her initial imaging exam. Several days later, a contrast CT and sequential pathology revealed the real diagnosis was intravascular leiomyoma. The patient was discharged after a successful surgery. Conclusion: Intravascular leiomyoma should not be confused with DVT.

Background: The aim of the study was to evaluate radiographic features of systemic sclerosis-associated interstitial lung disease. Patients and methods: 116 patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD) from 2010 to 2019 comprised our retrospective study. All patients were subject to high resolution computed tomography (HRCT). ILD patterns were classified into 7 patterns as IIPs and analyzed with pathology. We chose two staging method and two semi-quantitative score methods to evaluate the HRCT performance and analyzed with pulmonary function tests. Results: Ground-glass opacities were the most common presentation on HRCT, followed by interlobular septal thickening, reticular opacities, intralobular interstitial thickening; honeycombing, traction bronchiectasis and nodules can also be observed. The most common pattern of SSc-ILD was nonspecific interstitial pneumonia (NSIP), secondly was UIP. There was no difference in ILD pattern between HRCT and pathology, and revealed a high congruence. The four HRCT evaluating methods presented in this study all had significant relationships with PETs. Conclusion: The most common pattern of SSc-ILD was nonspecific interstitial pneumonia (NSIP). The ILD patterns of HRCT coincide very well with histology, and will replace pathology as the gold standard for diagnosis and evaluation of SSc-ILD.

The RNA interference (RNAi) technique is a new modality for cancer therapy, and several candidates are being tested clinically. Nanotheranostics is a rapidly growing field combining disease diagnosis and therapy, which ultimately may add in the development of ‘personalized medicine’. Technologies on theranostic nanomedicines has been discussed. We designed and developed bioresponsive and fluorescent hyaluronic acid-iodixanol nanogels (HAI-NGs) for targeted X-ray computed tomography (CT) imaging and chemotherapy of MCF-7 human breast tumors. HAI-NGs were obtained with a small size of ca. 90 nm, bright green fluorescence and high serum stability from hyaluronic acid-cystamine-tetrazole and reductively degradable polyiodixanol-methacrylate via nanoprecipitation and a photo-click crosslinking reaction. This chapter presents an over view of the current status of translating the RNAi cancer therapeutics in the clinic, a brief description of the biological barriers in drug delivery, and the roles of imaging in aspects of administration route, systemic circulation, and cellular barriers for the clinical translation of RNAi cancer therapeutics, and with partial content for discussing the safety concerns. Finally, we focus on imaging-guided delivery of RNAi therapeutics in preclinical development, including the basic principles of different imaging modalities, and their advantages and limitations for biological imaging. With growing number of RNAi therapeutics entering the clinic, various imaging methods will play an important role in facilitating the translation of RNAi cancer therapeutics from bench to bedside.

Background and Purpose: Injuries for the pre-adolescent female Irish Dancer (FID) are not well recognized. The purpose of this case study is to report imaging assisted diagnosis and management of atypical medial and plantar foot pain (MPFP) in an 8-year-old FID. Description: The patient presented with chief complaint of diffuse left MPFP. The patient was initially evaluated by a Physical Therapist for persistent foot pain. The patient experienced minimal pain in non-weightbearing (NWB). Pain intensified in weightbearing (WB) escalating with a heel raise. The patient experienced pain with resistance testing, ankle passive range of motion (PROM) and first metatarsophalangeal joint (MTPJ) PROM. Diffuse tenderness with palpation over the medial column of the left foot was noted. The patient was unable to complete single leg dynamic activity on the left foot. There was suspicion for a metatarsal stress fracture (MSF). Radiographs were ordered and read as negative. The patient was treated with immobilization in a walking boot, WB as tolerated and relative rest including cessation of dance. The patient returned for re-evaluation 2 weeks after reporting no change in symptoms. Magnetic Resonance Imaging (MRI) was then ordered. Outcome: Results of the MRI identified 2 stress fractures in the first metatarsal. The treatment plan changed to NWB status with immobilization for an additional 6 weeks. The patient returned to full WB status and participated in all dance activity 15 weeks after the initial presentation to the Physician and 27 weeks after the initial onset of MPFP. Discussion/Conclusion: In this pre-adolescent FID, the presentation of MPFP can be misinterpreted as a soft tissue injury. It is important to consider the diagnosis of first MSF in a pre-adolescent FID to allow appropriate management.

Anal melanoma is a rare and highly aggressive mucosal melanocytic malignancy. It is the third most common after melanomas of the skin and retina. The peak incidence in seen in the sixth and seventh decades. The clinical symptoms are pain, anal mass, bleeding per rectum, tenesmus or change in the bowel habits. It affects anal canal, rectum or both with a tendency to spread along submucosal planes. It is mostly beyond complete resection at the time of diagnosis and majority of patients die of metastasis. MR imaging significantly increases the diagnosis of anal melanoma in its early stages.

Background: Proximal humerus fractures (PHFs) are common injuries particularly in older adults. Evidence-based protocols for PHF rehabilitation are lacking and physiotherapists use a variety of interventions. Purpose: To determine practice patterns and perceptions of physiotherapists who treat adults with PHF in Ontario, Canada. Method: A paper and pencil survey asking about respondent demographics and management of Neer Group 1 (minimally/nondisplaced) and complex (displaced 3- and 4-part) PHF was mailed to 875 randomly selected physiotherapists who were registered with the College of Physiotherapists of Ontario in 2013/2014 and working in practice areas likely to be accessed by adults with PHF. Results: The response rate was low (10%); 83 physiotherapists completed the survey - 80% had experience managing PHF. Respondents treated 1-5 individuals with PHF annually; more treated Neer Group 1 PHF (89%) than complex PHF (68%). Most individuals with PHF were older than 60 years (64%), female (76%) and accessed physiotherapy through a doctor’s referral (91%) more than 1 month post injury (33%). Main findings: Physiotherapists manage PHF using multi-component interventions and a minimum of 76% include the following elements: education and progression of passive, active assisted, active range of motion exercises and muscle retraining to build coordination and strength. Use of other elements was variable. The main factors influencing the treatment plan were the ability of the individual with PHF to comply, bone quality, and fracture type. Most respondents were unsure that there is sufficient PHF rehabilitation literature to guide treatment. Conclusions:This environmental scan is the first North American study to document practice patterns and attitudes of physiotherapists providing PHF rehabilitation. Elements used by physiotherapists in Ontario treating small numbers of individuals with Neer Group 1 or complex PHFs each year align well with the limited PHF rehabilitation literature available. Potential implications:Multi-disciplinary collaborations to design and conduct large, high quality, multi-centre prognostic studies and RCTs that evaluate the effectiveness of key aspects of non-surgical PHF rehabilitation in various patient groups are needed. Meanwhile, consensus guidelines should be developed in the context of region-specific physiotherapy service models to inform best practice in PHF rehabilitation management.

Purpose: To investigate the suture-tourniquet technique for haemostasis in patients with acute thrombosis of native arteriovenous fistula (AVF) whom underwent manual aspiration thrombectomy using large-bore venous sheaths and high dose heparin. Methods: Between January 2016 and May 2018, patients with acute AVF thrombosis performed successful manual aspiration thrombectomy by using large bore venous sheaths and high dose heparin were included in this retrospective study. Success rate for haemostasis, procedural complications clinical and imaging follow up was reported descriptively. Results: A total of 52 patients with 64 procedures met the inclusion criteria. In 60(94%) of 64 procedures, successful haemostasis was achieved with suture-tourniquet technique. In 2(3.1%) of the 64 procedures, the suture broke while turning the tourniquet and haematoma occurred in another 3 procedures (4.7%) although suture-tourniquet technique was applied appropriately. Manual compression was performed in these patients. There were 3 major complications unrelated the suture-tourniquet technique. Conclusion: The suture tourniquet technique can achieve haemostasis rapidly and can be safely used with low complication rates without fistulae thrombosis after large-bore venous sheath removal following treatment of AVF thrombosis.

Uterine torsion is a rare life-threatening event that happens at any age or any gestational age. By definition, it consists of a rotation of more than 45 degrees around the long axis of the uterus. The reported cases have variable presentations. The uterine torsion can happen without any sequelae either for the fetus or the mother. However, fetal and maternal mortalities were also reported in such a case. We hereby, report the case of a 29-year-old female patient, with previous four Normal Vaginal Deliveries, pregnant with twins, presenting at 36 weeks gestation with an irreducible uterine torsion at the third trimester of her pregnancy complicated by maternal and fetal deaths. We concluded that the prognosis is improved as long as the management is done rapidly. More data is needed to know about the genetic predilection and the characteristics of imaging workup for a rapid preoperative diagnosis of this condition. 

Endometriosis is a common benign disease in women of reproductive age, it has been associated with an increased risk of various malignancies that is defined by certain histological criteria mainly 80% in ovary and 20% in extragonadal sites such as intestine, rectovaginal septum, abdominal wall, pleura and others; the greatest risk for colorectal cancer is women with adenomyosis or endometriosis; Several genetic alterations have been found in the risk of endometriosis associated with cancer; The symptomatology, imaging and endoscopic characteristics simulate other inflammatory and malignant lesions that make the preoperative diagnosis of extragonadal endometriosis difficult. This is a review of the knowledge about endometriosis and its potential risk of malignancy, particularly with colorectal cancer 

Background: AngioJetTM rheolytic thrombectomy has been used in the treatment of deep vein thrombosis (DVT) to prevent post-thrombotic syndrome. Though not widely appreciated, it has the potential to cause intravascular haemolysis. Report: A 37 year old man with no previous medical history presented to his GP with a three week history of progressive right upper limb swelling. Doppler imaging confirmed right upper limb DVT and CT scan demonstrated thoracic outlet syndrome. The patient underwent AngioJetTM thrombectomy followed by IV heparin infusion. Successful revascularisation of the occluded vein was achieved. Overnight he developed haematuria, which was initially attributed to IV heparin. Urinalysis however revealed no red cells or casts. Apart from an Hb drop from 134 to 117 his blood profile and blood film showed no abnormality. He subsequently developed progressive oliguria with marked oedema and acute kidney injury (AKI). His creatinine peaked at 1070umol/l at 96 hours post procedure and he was started on intermittent dialysis. He remained dialysis dependent for 6 days. Ultrasound imaging excluded urinary obstruction. Autoimmune and vasculitic serology were negative. Intravascular haemolysis and haemoglobinuria was confirmed by raised LDH (1714u/L) and low haptoglobin (<0.1units). Direct Coomb’s test, Cold agglutinin test and paroxysmal nocturnal haemoglobinuria screen were negative. The patient’s renal function normalised over 3 months. Conclusions: The likely cause of this man’s AKI is heme pigment nephropathy from intra-vascular haemolysis. Increased awareness of this condition may allow early identification and intervention to reduce the risk of renal injury from AngioJetTM associated haemolysis.

Obstructive jaundice in children is not uncommon and has diverse etiologies. We report a rare cause of obstructive jaundice, cholangitis and pancreatic mass in a young boy due to eosinophilic cholangiopathy who responded to oral steroids. Presence of peripheral eosinophilia, elevated serum IgE level, radiological imaging and tissue eosinophilia helped in diagnosis. Eosinophilic cholangiopathy with pancreatitis is a benign treatable cause of obstructive jaundice though it can masquerade as malignancy.

Background: Low back pain has recently been reported as the leading cause for disability worldwide. The diagnostic value of imaging has been estimated low. Led by own positive experience, however, we hypothesized that MRI can detect signs of facet joint pain. Methods: 15 patients and 15 controls were retrospectively assessed by two readers. They compared de-identified T2 weighted lumbar spine MRI scans. Facet joint size, shape, angle, joint space signal and degeneration were rated. Pain aetiology was proven with the diagnostic gold standard of medial branch blocks. Results: Facet joint angles and joint diameters were significantly larger in symptomatic patients, who also showed significantly higher grades of degeneration but no difference in joint space distances or shape or signal intensity. The readers were able to correctly identify symptomatic patients with good interrater reliability (kappa 0.5, sensitivity and specificity 0.87-0.93), positive (LR+= 6.7-7.2) and negative likelihood ratios (LR-=0.15). Conclusion: Contrary to recent publications, we could demonstrate differences between asymptomatic and symptomatic subjects showing the latter to have larger joints and more signs of degeneration. One can conclude from the strong LR+ and LR- values that MRI is a useful investigation to rule in or rule out facet pain.

Flexible magnifying endoscopy with narrow band imaging (ME-NBI) has outstanding diagnostic correctness for gastrointestinal metaplsia and is hope for to be highly useful for imaging stage cervixcal metaplsia beginning by imaging the first stage of metaplasia by imaging single layer of subcolmnar reserve cells reserve cells hyperplasia, the reserve cells are round to cuboid with large oval or round nuclei, seen below the surface columnar cells and the columnar

Intraparenchymal cysts without communication to the ventricles or the subarachnoid space are named ependymal or epithelial cysts. The estimated ratio of their incidence compared with arachnoid cysts is 1:10. Neurologic deficit can occur when the cyst exerts mass effect on its surroundings. We report a case of cerebral ependymal cyst in a 75-year-old lady who presented with history of headache, vomiting and left incomplete homonymous hemianopsia. Neuroimaging studies showed a large right occipital cyst. She underwent the neurosurgical procedure of marsupialization. Histologic findings and the immunophenotype was consistent with a diagnosis of ependymal cyst. The patient made an excellent recovery after the procedure.

43-year-old lady presented with incidentally discovered liver lesions while she was being managed for her complaints of menorrhagia. CT and MRI showed hepatomegaly with multiple lesions in both lobes of the liver with vascular element in the background of diffuse fatty infiltration. Patient underwent laparoscopic core biopsy. Histopathology showed extensive steatosis, intracytoplasmic giant mitochondria and absence of portal tracts, features highly suggestive of hepatic adenomatosis. IHC staining showed membranous and cytoplasmic positivity in hepatocytes for B-catenin consistent with multiple hepatic adenomatosis. Hepatic adenomatosis is a new clinical entity in the hepatological practice characterized by the presence of 10 or more nodules in the liver known for its major complication of bleeding. Hepatic adenomatosis is managed by regular imaging and resection of large (> 5cm) superficial and painful adenomas along with liver function tests and tumor markers to rule out malignant transformation. However, the potential cure being the liver transplantation.

Pseudomyxoma peritonei (PMP) or Gelatinous Peritoneal Disease is a rare condition that refers to an anatomo-clinical entity characterized by ascites of variable abundance in the peritoneal cavity, viscous or mucinous, associated or not with neoplastic epithelial cells. It predominates in women. Diagnosis is guided by imaging and confirmed by histology. Prognosis is good in case of early management. We report the case of a male diagnosed with Pseudomyxoma peritonei revealed by isolated ascites.

Objective: To determine the diagnostic accuracy of Magnetic Resonance Imaging (MRI) to differentiate Benign and Malignant Parotid Gland Tumors taking histopathology as gold standard. Design: Cross sectional study. Place and duration of study: Department of Diagnostic Radiology, Lahore General Hospital, Lahore from January till July 2014. Methodology: 200 patients of age between 5 to 80 years of either gender with parotid gland swelling, having radiological evidence and clinical suspicion of parotid tumour like fixation to underlying skin, pain, facial palsy and cervical lymphadenopathy were taken. T1 and T2 plain and contrast enhanced 1.5 Tesla MRI unit using standard imaging coil was then carried out. Imaging was further evaluated for the presence or absence of benign or malignant parotid gland tumours using histopathology as a Gold standard. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of MRI were taken against the gold standard. Results: There were 170 males and 30 females having mean age of 40.27±15.04 and 40.12±12.15 years respectively. Sensitivity, specificity, positive predictive value and negative predictive value of MRI were 90.4%, 89.33%, 93.39% and 84.41% respectively. The diagnostic accuracy of MRI to differentiate benign and malignant parotid gland tumours was 90%. These results were taken against surgery histopathology as a gold standard. Conclusion: MRI is highly accurate in differentiating malignant & benign tumours of parotid glands and can be used as an adjunct to histopathology for pre-operative evaluation of the parotid gland tumours.