Moderate Edema Research Articles

S1517 Evaluating Obscure GI Bleeding in Pancreatitis

INTRODUCTION: Pancreatic pseudoaneurysm is a rare complication of pancreatitis and occurs in as many as 10% of cases and has a mortality rate ranging from 11-50%. In pancreatitis, pancreatic enzymes cause a necrotizing arteritis of surrounding vessels. Weakened arterial vessel architecture can result in bleeding into a pseudocyst causing rupture and subsequent massive bleeding into the gut lumen or peritoneal cavity. Herein we describe a case involving pancreatitis with pseudocyst complicated by a splenic artery pseudoaneurysm presenting with abdominal pain, anemia, and GI bleeding. CASE DESCRIPTION/METHODS: A 50 year old woman was transferred to our hospital system with acutely worsening abdominal pain and anemia. Her medical history was significant for morbid obesity and recent pancreatitis complicated by necrotizing pancreatitis with large pseudocyst and a right sided pleural effusion. On admission, vitals revealed BP 148/74, HR 79 bpm, RR 20 resp/min, T 36.6 °C, SpO2 100% on room air. Labs revealed WBC 6.58g k/uL, hgb 6.9 g/dL, plts 47, t bili 1.4, alk phos 107, ALT 18, AST 13. CT redemonstrated a moderately sized acute necrotic collection of the pancreas head and neck with no clearly defined wall enclosing the area. A repeat CT scan in 2 weeks was ordered to ensure maturity of the walled off necrosis prior to EUS guided drainage. Shortly after admission the patient developed hematemesis and maroon colored stools. EGD was positive only for moderate edema, erythema, and friability of the entire duodenum, however, a fistula between the pancreatic collection and the stomach/duodenum was not excluded. Ongoing hematemesis prompted an emergent CTA which was notable for a 1.4 cm distal splenic artery pseudoaneurysm (Figure 1). IR performed a successful coil embolization of the splenic artery (Figure 2 A-B). The patient tolerated the procedure well with no complications. DISCUSSION: There is significant mortality associated with rupture of a splenic artery pseudoaneurysm. A high index of suspicion for ruptured splenic artery pseudoaneurysm resulting in GI bleeding through fistulation is required in patients with acute and/or chronic pancreatitis who experience worsening abdominal pain, anemia, and/or overt GI bleed. Early identification and intervention of these pseudoaneurysms is paramount and can be emergently managed with arterial embolization or surgery to prevent life threatening complications.Figure 1.: CT angiogram showing a splenic artery pseudoaneurysm near tail of pancreas.Figure 2.: IR embolization. A) Pseudoaneurysm of the distal splenic artery. B) Successful microcoil embolization of a splenic artery across a pseudoaneurysm with no evidence of active extravasation after embolization with stasis of flow in the splenic artery.

Correlation between Magnetic Resonance Imaging (MRI) Findings with Histological Grading of Patients with Supratentorial Diffusely Infiltrating Astrocytomas

Correlation between Magnetic Resonance Imaging (MRI) Findings with Histological Grading of Patients with Supratentorial Diffusely Infiltrating Astrocytomas

Strategy for Correction of the Whistling Deformity in Secondary Cleft Lip Reconstruction.

Background:Following primary repair of a cleft lip, patients present with many facial deformities. One of the commonly observed sequelae of cleft lip repair is a whistling deformity. This retrospective study was carried out to evaluate the outcomes following correction of whistling deformities in secondary cleft lip reconstruction.Methods:We retrospectively reviewed the hospital records of patients with various whistling deformities who underwent repair from April 1989 to March 2018; 2 surgeons performed the repair using either the double movable mucomuscular complex flaps technique, modified Abbe flap technique, or Abbe flap technique. The postoperative anatomical structure and aesthetic effects of the surgery were evaluated.Results:In total, 136 patients were included in this study. Among these patients, 60 (44.2%) had a grade I whistling deformity and 47 (34.5%) had a grade II deformity and repair was performed using the double movable mucomuscular complex flaps technique and modified Abbe flap transfer technique, respectively, whereas the Abbe flap transfer technique was used in 16 patients (11.8%) and 13 patients (9.5%) with a grade III and grade IV whistling deformity, respectively. All patients were found to have normal postoperative anatomical structures and aesthetic effects of the upper lip, with all patients experiencing mild to moderate postoperative edema of the upper lip, and 29 cases (21.3%) developed an inconspicuous scar.Conclusion:The repair technique should be chosen based on the type of whistling deformity.

Traditional and Advanced Neuroimaging Contributions to the Diagnosis and Differential Diagnosis of Central Nervous System Lymphoma Patients Visiting a Comprehensive Medical Center

Introduction: The diagnosis of Central Nervous System Lymphoma, especially the Primary Central Nervous System Lymphoma is carried out based on brain imaging, thus avoiding an unnecessary extend of surgery. But the traditional imaging techniques, such as Computed Tomography and Magnetic Resonance Imaging, were not satisfactory. Aims: This study was conducted to characterize the spectrum of advanced Neuroimaging, such as the advanced Magnetic Resonance Imaging features in the Central Nervous System Lymphoma patients in a comprehensive medical center in Lebanon, and compare them to what has been described in the literature review. Methods: It is a retrospective exploratory study of the clinical data and imaging features for patients admitted to the emergency and radiology departments with ages above 10 years, and who were diagnosed histopathologically with intracranial lymphoma. This study may be the first to make a Radiological evaluation of Central Nervous System Lymphoma on the local population of patients over 9 years . Results: Results showed that the study of the Computed Tomography and Magnetic Resonance Imaging data of 10 immunocompetent patients with Central Nervous System Lymphoma concurs with the previously described patient populations, except for the gender parameter. Tumors were mostly presented in the fifth or Sixth decade and they could be solitary or multi-focal. Lesions were typically located Preprint submitted to The Open Neuroimaging Journal May 14, 2020 in the supratentorial compartment. On the brain Computed Tomography, the lesions were hyperdense, and in pre-contrast Magnetic Resonance images, the lesions appeared hypointense on T1 and hyperintense on T2-Weighted images, but hypointense with respect to the grey matter. The lesions were also surrounded with a mild to moderate edema as compared to other intracranial neoplasms, such as glioblastomas. Evaluation results showed that on post-contrast Magnetic Resonance images, the majority of lesions exhibited a homogeneous enhancement of 50%. Majority of the lesions also showed a less common heterogeneous ring-like enhancement of 40%, and revealed the uncommon absence of enhancement of 10%. Calcifications, hemorrhage, and necrosis were rare findings and were present in only one patient. Conclusion: As a future prospect, studying whether the advanced imaging techniques may provide not only non-invasive and morphological characteristics but also non-invasive biological characteristics and thus accurate diagnosis could be considered.

High frequency electrical field-ultrashort wave therapy for treatment of cerebral ischemia/reperfusion injury in rats*: Histopathological evaluation

Abstract BACKGROUND Ultrashortwave (USW) therapy may be a new method for treatment of ischemic cerebrovascular diseases. It is necessary to study its treatment time window. OBJECTIVE To observe the effect of USW on reperfusion injury after occlusion of the middle cerebral artery (MCAO) in rats and discuss its acting mechanisms and best occasion. DESIGN Randomized controlled observation, animal experiment. SETTING Laboratory of Department of Rehabilitation Medicine, First Hospital Affiliated to China Medical University. MATERIALS Sixty-six healthy Wistar rats of either gender and of clean grade, aged 18 – 20 weeks, weighing from 250 to 300 g, were provided by the Experimental Animal Center of China Medical University. An USW device (Shanghai Electrical Device Company) with the frequency of 40.68 MHz and the maximum output power of 40 W, and the first channel power controlled at about 11 W was used in this study. Output power was determined by photometry. METHODS Sixty-six rats were randomly divided into 3 groups: Sham-operation group (n = 6): The suture was inserted only 1.0 depth during operation, which did not cause MACO; Model group (n = 12): The USW treatment procedure was performed with the power off on the model rats; USW treatment group (n = 48): The 48 rats were randomly divided into modeling 0, 6, 12 and 18 hours 4 subgroups. USW therapy without heat was used on the head of rats for 10 minutes at each time point. Twelve rats in USW treatment group were decapitated following treatment at each time point, and then their brain tissues were harvested. The rat brain tissues in other groups were harvested by decapitation at 24 hours after modeling. When the rats were awake, the neurologic deficit was scored by Zea-Longa five-point scale (a score of 0 indicated no neurologic deficit, a score of 1 indicated failure to extend left paw fully, a score of 2 indicated circling to the left, and a score of 3 indicated falling to the left, and rats with a score of 4 did not walk spontaneously and has a depressed level of consciousness.) Rats which still survived at 24 hours and was scored 1 and 2 on the neurologic scoring were involved in the analysis. (1) Determination of cerebral water content: Cerebral water contents of healthy and injured hemisphere were determined by wet/dry weighing method. Cerebral water content (100%) = (1 – dry/wet weight) × 100%. (2)Infarction volume: The brain tissue was sliced into 2 mm sections and each section was stained with 20 g/L 2,3,5-triphenyltetrazolium chloride (TTC) by TTC staining technique for 30 minutes in a water bath at 37 °C. Then, the section was fixed in 100 g/L formaldehyde for 10 minutes. The infarction volume was analyzed by using an imaging analyzer. (3) Preparation of light microscopic sample: The rat brain tissue fixed by 100 g/L neutral formaldehyde and stained with TTC, were gradiently dehydrated with alcoholic, embedded with paraffin, sliced and stained by HE, finally, the sections were observed under the light microscope. MAIN OUTCOME MEASURES Cerebral water content, cerebral infarction volume and cerebral histomorphology of rats in each group. RESULTS Sixty-six rats were involved in the final analysis. (1) Cerebral water content: There were no significant differences of cerebral water content in healthy hemisphere among groups (P > 0.05). Cerebral water content of injured hemisphere in the model group and at modeling 0, 6, 12 and 18 hours in the USW treatment group was (81.50±0.74) %, (81.02±0.83) %, (79.78±0.70) %, (79.74±0.84) %, (79.39±1.06) %, respectively, which was significantly higher than that in the sham-operation group [(78.09±0.52) %, P CONCLUSION USW may play a protective effect on cerebral ischemia/reperfusion injury by decreasing brain edema and/or cerebral infarction volume. The treatment action of USW may start at 6 hours after reperfusion, and the best occasion of application may be at 18 hours after reperfusion.

Effect of Piezo1 Overexpression on Peritumoral Brain Edema in Glioblastomas

Previous studies have suggested that increased mortality and disability in patients with brain tumor are associated with peritumoral brain edema. However, the mechanism of peritumoral brain edema in brain tumors is unknown. This study aimed to investigate the effect of Piezo1 overexpression on peritumoral brain edema in glioblastomas. The Piezo1 expression in cell lines and paired samples was detected by quantitative reverse transcription polymerase chain reaction, Western blot, and immunohistochemistry. Sixty-four patients with glioblastomas were analyzed retrospectively. The Piezo1 expression of tumor tissue was detected by immunohistochemistry. The diameters of tumor and edema were measured by preoperative MR imaging, and the edema index value was calculated. Western blot and quantitative reverse transcription polymerase chain reaction showed that Piezo1 expression was higher in 6 glioma cell lines than in the normal astrocyte cell line. Compared with peritumoral tissues, Piezo1 was up-regulated in tumor tissues. Sixty-four patients with glioblastomas were enrolled in further study. Piezo1 was higher in the moderate edema group than in the mild edema group (P < .001), higher in the severe edema group than in the moderate edema group (P < .001), and correlated with the edema index (r = 0.73; P < .001). Receiver operating characteristic curve analysis showed that the edema index yielded an area under the curve of 0.867 (95% CI, 0.76-0.97; P < .001), with a sensitivity of 100% and a specificity of 70%. Piezo1 overexpression is positively correlated with the degree of peritumoral brain edema in glioblastomas. Predicting high Piezo1 expression in tumor tissues based on the edema extent shows good sensitivity and specificity.

Recurrent food impactions

Within 4 years, a 58 (to 62)-year-old man attended the emergency department five times because of acute oesophageal food impaction. Other diagnoses included alcohol and tobacco abuse, arterial hypertension, and...

Performance of deep neural network-based artificial intelligence method in diabetic retinopathy screening: a systematic review and meta-analysis of diagnostic test accuracy.

Automatic diabetic retinopathy screening system based on neural networks has been used to detect diabetic retinopathy (DR). However, there is no quantitative synthesis of performance of these methods. We aimed to estimate the sensitivity and specificity of neural networks in DR grading. Medline, Embase, IEEE Xplore, and Cochrane Library were searched up to 23 July 2019. Studies that evaluated performance of neural networks in detection of moderate or worse DR or diabetic macular edema using retinal fundus images with ophthalmologists' judgment as reference standard were included. Two reviewers extracted data independently. Risk of bias of eligible studies was assessed using QUDAS-2 tool. Twenty-four studies involving 235 235 subjects were included. Quantitative random-effects meta-analysis using the Rutter and Gatsonis hierarchical summary receiver operating characteristics (HSROC) model revealed a pooled sensitivity of 91.9% (95% CI: 89.6% to 94.3%) and specificity of 91.3% (95% CI: 89.0% to 93.5%). Subgroup analyses and meta-regression did not provide any statistically significant findings for the heterogeneous diagnostic accuracy in studies with different image resolutions, sample sizes of training sets, architecture of convolutional neural networks, or diagnostic criteria. State-of-the-art neural networks could effectively detect clinical significant DR. To further improve diagnostic accuracy of neural networks, researchers might need to develop new algorithms rather than simply enlarge sample sizes of training sets or optimize image quality.

Leg Injury - Football

HISTORY: A 12-year old male quarterback sustained a right leg injury while cutting back across the field. He was running across the field and made a lateral cut to change directions, as this happened he tripped over himself and fell without a twisting motion. He landed on his right lateral leg with immediate pain to the fibular head. There was no numbness, tingling, weakness or radiation of pain however he had a noticeable limp. He presented to clinic 2 days later and denied any prior injuries or trauma to the area. PHYSICAL EXAMINATION:2 days post injury (PCP office) — No deformity, normal knee and ankle exams, no bony tenderness, moderate postero-lateral edema of proximal right lower leg, painful/antalgic gait, TTP lateral gastrocnemius and soleus, negative Thompson's.4 days post injury (Sports Medicine Clinic) — Consistent with prior exam, new findings: point TTP just distal to fibular head, decreased edema, negative squeeze test, negative ER test. DIFFERENTIAL DIAGNOSIS: 1. R fibular contusion 2. R knee apophysitis 3. LCL sprain 4. Gastrocnemius contusion/strain 5. Distal Bicep Femoris strain TEST AND RESULTS: XR: R Tib/Fib AP and Lateral radiographs 2 days after injury — Bones/joints/soft tissue appear unremarkable. Repeat XR 13 days post injury — subtle irregularity along the lateral aspect of the proximal fibula physis with associated periostitis. Final XR 20 days post injury — Noted irregularity along the lateral aspect of the proximal fibula physis with increased benign periostitis. FINAL WORKING DIAGNOSIS: Salter-Harris II fracture of R proximal fibula physis TREATMENT AND OUTCOMES: 1. Cam walker boot 3 weeks with weekly exams/XRs 2. 20 days out from injury completely normal RLE exam, no pain, full ROM, XRs suggestive for healing SH2 fracture; patient was able to return to football as tolerated. DISCUSSION: In isolation this is a very rare injury. There was one reported case of a SH-3 fracture that presented with initial knee injury and ROM deficits that was treated non-operatively. Most injuries to the proximal physis of the fibula occur in combination with an interosseous membrane/syndesmotic and distal tibiofibular injury - must rule out a Maisonneuve injury. The presenting complaint was pain and edema in the region of the soleus this may have been a soleus traction injury to the apophysis vs direct trauma from the fall.

Eye Injury- Baseball

HISTORY: A 12 year-old male sustained an injury to left eye during a baseball game. While playing first base, the outfielder threw a ball to him so patient could tag the runner out. When catching the ball, he missed, and instead the ball struck him in the face in the area of the left eye. There was no loss of consciousness, vomiting, hematoma or altered mental status. He initially had difficulty seeing out of the eye, but vision returned soon after and appeared blurry. PHYSICAL EXAMINATION: Normocephalic. With the exception of limitation in upward gaze of left eye, the remaining extraocular movements were intact. Hyphema of left eye noted. Pupils equal, round and reactive to light bilaterally. Moderate left periorbital edema and ecchymosis. Vision intact to left eye. Sensation intact in V1-V3 distribution, facial nerve function intact bilaterally. Normal occlusion, midface stable. Hearing to spoken voice intact and TM’s clear with no evidence of hemotympanum. Remainder of examination was normal. DIFFERENTIAL DIAGNOSIS: 1. Orbital Ridge Fracture 2. Orbital Blowout Fracture 3. Hyphema 4. Retinal detachment 5. Commotio Retinae 6. Globe Rupture TEST AND RESULTS: CT facial bones: -Blowout fracture of left inferior and medial wall of left orbit -Left orbital emphysema with small contusion vs hematoma within the retrobulbar fat -Minimal blood within the left ethmoid and maxillary sinus Ophthalmology Consult: -Visual Acuity 20/30 Right, 20/200 Left -3 mm Hyphema of left eye -Commotio Retinae of left macula -Normal intraocular pressure FINAL/WORKING DIAGNOSIS: Left orbital floor fracture, Traumatic Hyphema, Commotio Retinae involving the macula TREATMENT AND OUTCOMES: 1. CT scan without significant displacement and no ocular muscle entrapment on repeat exam, no operative repair needed; follow-up with plastic surgery 1-2 weeks 2.Per ophthalmology recommendations: a. Ongoing observation for cataract, retinal detachment, and glaucoma due to increased risk from blunt ocular trauma b. Bed rest with bathroom privileges 3-4 days c. Ophthalmic prednisolone and ophthalmic atropine for hyphema with monitoring for absorption and rebleed d. Monitor for macular hole as increased risk secondary to commotio retinae e. Follow-up in 1-2 days

Synthesis, antiinflammatory activity, and molecular docking studies of bisphosphonic esters as potential MMP-8 and MMP-9 inhibitors.

Bisphosphonic acids (or bisphosphonates) have been successfully used in the clinic treatment of bone diseases for over decades. Additionally, the antiinflammatory activity of these compounds has been gaining attention. In our previous work, we synthesized and in vivo evaluated the bisphosphonic esters 1 and 2, finding a moderate edema inhibition upon oral and topical administration on BALB/c mice. Thus, in this work, the bioisosteric replacement of an amide functional group for an ester afforded the new bisphosphonates 3–6, which had a moderate oral edema inhibition (25 mg/kg dose) and a significant topical antiinflammatory activity (2 mg/ear) on BALB/c mice, with 6 being the most active hit (55.9% edema inhibition), comparable to the positive control (55.5% edema inhibition) on a TPA topical model. Next, to assess the acute toxicity of the synthesized derivatives, test animals were administered with 50–100 mg/kg of 3–6, respectively, by an oral route, and after 14 days, neither lethality nor a significative weight loss were observed. Finally, a structure–activity relationship (SAR) and a molecular docking analysis of 3–6 helped us to explain the trend observed in biological tests. Considering all these aspects, we propose the inhibition of MMP-8 and MMP-9 as a possible action mechanism of the synthesized derivatives.

Hayes Yard virus: a novel ephemerovirus isolated from a bull with severe clinical signs of bovine ephemeral fever is most closely related to Puchong virus

Bovine ephemeral fever is a vector-borne disease of ruminants that occurs in tropical and sub-tropical regions of Africa, Asia and Australia. The disease is caused by a rhabdovirus, bovine ephemeral fever virus (BEFV), which occurs as a single serotype globally. Although several other closely related ephemeroviruses have been isolated from cattle and/or arthropods, only kotonkan virus from Nigeria and (tentatively) Mavingoni virus from Mayotte Island in the Indian Ocean have been previously associated with febrile disease. Here, we report the isolation of a novel virus (Hayes Yard virus; HYV) from blood collected in February 2000 from a bull (Bos indicus) in the Northern Territory of Australia. The animal was suffering from a severe ephemeral fever-like illness with neurological involvement, including recumbency and paralysis, and was euthanised. Histological examination of spinal cord and lung tissue identified extensive haemorrhage in the dura mata with moderate perineuronal oedema and extensive emphysema. HYV displayed cone-shaped morphology, typical of rhabdoviruses, and was found to be most closely related antigenically to Puchong virus (PUCV), isolated in 1965 from mosquitoes in Malaysia. Analysis of complete genome sequences of HYV (15 025 nt) and PUCV (14 932 nt) indicated that each has a complex organisation (3′ N-P-M-G-GNS-α1-α2-β-γ-L 5′) and expression strategy, similar to that of BEFV. Based on an alignment of complete L protein sequences, HYV and PUCV cluster with other rhabdoviruses in the genus Ephemerovirus and appear to represent two new species. Neutralising antibody to HYV was also detected in a retrospective survey of cattle sera collected in the Northern Territory.

Diagnostic Value of Magnetic Resonance Imaging in Fibrodysplasia Ossificans Progressiva.

ABSTRACTUsing [18F] Sodium Fuoride (NaF) Positron Emission Tomography (PET) it is not only possible to identify the ossifying potency of a flare‐up, but also to identify an asymptomatic chronic stage of fibrodysplasia ossificans progressiva (FOP). The purpose of this study was to investigate the diagnostic role of a more widely available imaging modality, Magnetic Resonance Imaging (MRI), which is of special interest for studies in pediatric FOP patients. MRI and [18F]NaF PET/CT images at time of inclusion and subsequent follow‐up CT scans of 4 patients were analyzed retrospectively. Presence, location, and intensity of edema identified by MRI were compared with activity on [18F]NaF PET. Occurrence or progression of heterotopic ossification (HO) was examined on the follow‐up CT images. Thirteen different lesions in various muscle groups were identified: five lesions with only edema, five lesions with both edema and increased [18F]NaF uptake, one lesion with only increased [18F]NaF uptake, and two lesions with neither edema nor uptake of [18F]NaF. Mild edema, found in three lesions, was present at asymptomatic sites, which did not show increased [18F] NaF uptake or progression of HO on consecutive CT images. Moderate edema was found in three symptomatic lesions, with increased [18F]NaF on PET and progression of HO on CT. Severe edema was identified in four lesions. Interestingly, two of these lesions did not develop HO during follow‐up; one of these two even gave obvious symptoms of a flare‐up. MRI can identify whether symptoms are the result of an acute flare‐up by the presence of moderate to severe edema. The occurrence of severe edema on MRI was not always related to an ossifying lesion. The additional diagnostic value of MRI requires further investigation, but MRI does not seem to fully replace the diagnostic characteristics of [18F]NaF PET/CT in FOP. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Histopathologic evaluation of experimental murine neurocysticercosis after treatment with albendazole/nitazoxanide combination.

Neurocysticercosis (NCC) is the most common helminthic brain infection related to epilepsy. Only albendazole (ABZ) and praziquantel are used in its treatment. The development of new therapeutics has been encouraged. Taenia crassiceps cysticerci intracranial infection is the experimental model used in NCC studies. This study evaluated the histopathology of the brains of BALB/c mice experimentally infected with T. crassiceps cysticerci after the treatment with the ABZ/nitazoxanide (NTZ) combination. Thirty days after the inoculation the mice received an oral single dose of the ABZ/NTZ combination (40 mg kg-1 each). The control groups were treated with: NaCl 0.9%; ABZ or NTZ. The histopathologic evaluation of the brains was performed 24 h after treatment. The ABZ treatment induced discrete mononuclear inflammatory infiltration, meningitis, gliosis, hyperaemia and hippocampus compression; moderate ependimitis and oedema. The NTZ treatment induced accentuated inflammatory infiltration, foamy macrophages, ependimitis, choroiditis, gliosis and hyperaemia and moderate oedema. The ABZ/NTZ combination treatment induced a significant decrease in the polymorphonuclear inflammatory infiltration, ependimitis, choroiditis, gliosis, hyperaemia and ventriculomegaly in comparison with the other groups. The cysticerci showed destruction of the tegument not observed in other groups. The ABZ/NTZ combination is efficient as the parasite showed signs of destruction and lower damage to the host's tissue.

P112 Muscles in myositis with normal MRI appearance have higher quantitative T2 compared to those in healthy controls

Abstract Background Myositis is an autoimmune disease which can cause a decrease in quality of life and increased mortality, presenting with muscle weakness, raised muscle enzymes and myalgia. Diagnosis is reliant on subjective clinical examinations, blood tests, conventional MRI and invasive muscle biopsies. Quantitative T2 MRI offers a non-invasive measurement of muscle oedema which could help improve the understanding of muscle pathology and potentially inform diagnosis. The aim of this study was to evaluate whether quantitative T2 MRI of muscles is sensitive enough to detect differences in myositis patients compared to healthy controls, and how it compares with current radiologist scoring methods. Methods 16 myositis patients were recruited (10/16 female, 10 polymyositis, 6 dermatomyositis, mean age 50 ± 26), median CK 1000IU/L ± 3100IU/L, and 16 age and gender matched healthy controls were recruited. MRI of the dominant thigh were performed. Imaging was performed using a fat-suppressed turbo-spin echo sequence. Quantitative T2 measurements were obtained from regions of interest (ROI) drawn manually within the individual muscles that make up the quadriceps and hamstrings with no distinction made between affected and unaffected muscles. A mono-exponential fit was used to obtain an estimate of the T2 from each ROI. Two radiologists blinded to the diagnosis, semi-quantitatively scored by consensus the muscles on a 4-point visual scale as either no oedema (0), mild oedema (1), moderate oedema (2) or severe oedema (3). Muscle strength was assessed using an isokinetic dynamometer. Results T2 values were higher in myositis patients compared to healthy controls [mean (SD) hamstring myositis 47.8ms (7.7ms), healthy 39.9ms (1.5ms), p &amp;lt; 0.001; quadriceps myositis 53.8ms (12.1ms), healthy 42.1ms (2.1ms), p &amp;lt; 0.001]. Quantitative T2 correlated with the radiologists’ oedema scores with rs=0.7 in the hamstrings (p &amp;lt; 0.001) and rs=0.6 in the quadriceps (p &amp;lt; 0.001), with an upward trend in T2 as radiologist scored visible oedema increased. Patients who had been classified as normal by the radiologists were compared with matched healthy controls (n = 8), T2 values for patients with ‘normal muscle’ were still higher than those for healthy controls: mean T2 in the hamstrings (myositis 42.2ms, healthy controls 38.7ms, p = 0.004); mean T2 in the quadriceps (myositis 43.9ms, healthy controls 40.1ms, p = 0.001). T2 was inversely correlated with muscle strength in all participants. Conclusion Quantitative T2 measurements can detect muscle differences between myositis patients and healthy control groups, which suggests that this measurement could be used as an objective method to monitor muscles. They are also sensitive to differences that may not be detected by radiologists. This suggests that subtle systemic changes in muscle in myositis patients, which go undetected in semi-quantitative visual scoring, can be detected using quantitative T2 measurements. This shows the potential for T2 measurements to be a diagnostic measure in the diagnosis and management of myositis. Disclosures M. Farrow None. J. Biglands None. A. Grainger None. E. Hensor None. P. O'Connor None. A. Ladas None. S. Tanner None. A. Aslam None. P. Emery None. A. Tan None.

Is a “toxic” death possible with gliclazide, an oral hypoglycemic drug, found at therapeutic concentration?

Summary An unexpected death of a 46-year-old woman presenting a type II diabetes was observed and the Prosecutor requested an autopsy followed by toxicological investigations. Autopsy findings (labial ecchymosis, multiviscera congestion, asphyxia syndrome, moderate cerebral edema) were in accordance with a possible hypoglycemia death. Toxicological analyses revealed the presence of gliclazide in femoral blood at 2.2 mg/L, which is in the range of published therapeutic concentrations. During a meeting with the pathologist, 3 possible explanations were discussed: 1. unknown cause of death (other than a toxic death), 2. death due to gliclazide which could have been degraded due to chemical instability during the 6-weeks interval between death and analysis (at the time of death the blood concentration could have been much higher), and 3. blood concentration was enough to produce fatal hypoglycemia in a non-compliant patient. According to the pathologist, no traumatic cause of death could be established. Testing for gliclazide stability in whole blood over a period that matches the delay of the toxicological analyses demonstrated instability (loss of about 65% after 6 weeks storage at +4 °C), but this was found irrelevant for a massive overdose. Hair tested positive for gliclazide in the 3 × 2 cm segments, at 7, 8 and 3 pg/mg, and were highly indicative of non-compliant use of the medicine. It was therefore concluded by the pathologist that the cause of death of the subject was more likely than not an inappropriate use of gliclazide, which can be responsible of a fatal glycemic disorder.

Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0\xa0T MRI

ObjectiveTo identify abnormalities in asymptomatic sedentary individuals using 3.0 Tesla high-resolution MRI.Materials and methodsThe cohort comprised of 230 knees of 115 uninjured sedentary adults (51 males, 64 females; median age: 44 years). All participants had bilateral knee 3.0 T MRIs. Two senior musculoskeletal radiologists graded all intraarticular knee structures using validated scoring systems. Participants completed Knee Injury and Osteoarthritis Outcome Score questionnaires at the time of the MRI scan.ResultsMRI showed abnormalities in the majority (97%) of knees. Thirty percent knees had meniscal tears: horizontal (23%), complex (3%), vertical (2%), radial (2%) and bucket handle (1%). Cartilage and bone marrow abnormalities were prevalent at the patellofemoral joint (57% knees and 48% knees, respectively). Moderate and severe cartilage lesions were common, in 19% and 31% knees, respectively, while moderate and severe bone marrow oedema in 19% and 31% knees, respectively. Moderate-intensity lesion in tendons was found in 21% knees and high-grade tendonitis in 6% knees—the patellar (11% and 2%, respectively) and quadriceps (7% and 2%, respectively) tendons being most affected. Three percent partial ligamentous ruptures were found, especially of the anterior cruciate ligament (2%).ConclusionNearly all knees of asymptomatic adults showed abnormalities in at least one knee structure on MRI. Meniscal tears, cartilage and bone marrow lesions of the patellofemoral joint were the most common pathological findings. Bucket handle and complex meniscal tears were reported for the first time in asymptomatic knees.

Mechanism of brain swelling in cases of brain evisceration due to catastrophic craniocerebral injury – an autopsy study

Some previously reported cases of brain evisceration in catastrophic craniocerebral injuries showed the presence of brain swelling. The aim of this study was to observe the occurrence of focal or diffuse brain swelling in such cases in order to explain the underlying mechanism. An observational autopsy study included 23 adults, 18 males and 5 females, whose average age was 48 ± 22years (range: 19-89years) and who died as the result of catastrophic craniocerebral injury with brain evisceration. In all the examined cases, either focal (12 cases) or diffuse (11 cases) brain swelling was present. Grossly visible brain contusions (either cortical or deep) were rarely present - only in 6 out of 23 cases, while microscopic brain contusions were observed in 22 out of 23 cases, with 1 remaining case of microscopic subarachnoid bleeding. Blood aspiration in the lungs, as a vital reaction, was noted in 20 out of 23 cases. Microscopic examination showed absence of edema in 20 cases and mild edema in only 3 cases, while microscopic signs of moderate or severe edema were absent. Brain swelling in cases of brain evisceration likely represents a biomechanical reaction (i.e. decompression) due to a sudden decrease in intracranial pressure. The rapidity of death, together with marked absence of microscopic signs of edema, suggests that this is not a form of biological response to injury, but rather a pure physical phenomenon, strictly in a living person. In such cases, the occurrence of brain swelling and parenchymal microbleeding should be considered vital reactions.

Intolerance of preservative-containing eye drops in a glaucoma patient: diagnostic and therapeutic challenges

A patient presented to our clinic with stage Ia open-angle glaucoma of the right eye and stage IIa surgically corrected open-angle glaucoma of the left eye. The condition of the ocular surface was interpreted as toxic/allergic conjunctivitis provoked by brimonidine 0.15 %. Brimonidine was substituted with non-selective 0.5%; additionally, topical steroids were prescribed. After steroids were discontinued, some of the symptoms came back, including moderate hyperemia and conjunctival edema, which was interpreted as intolerance to a preservative contained in the eye drops. A decision was made to switch from the β-blocker to its preservative-free formulation; regular IOP monitoring was continued. IOP measured during the next visit was above tolerated, so a preservative-free form of the ocular hypotensive combination drug (an analog of prostaglandin 0.005% with non-selective β-blocker 0.5%) was introduced to the regimen, with further IOP monitoring. Because the initial diagnosis was wrong, damage to the ocular surface had been aggravated by inadequate therapy. Preservative-free hypotensive eye drops are beneficial for the corneal surface and have a positive effect on a patient’s adherence to the regimen.

Efficacy and safety of sodium zirconium cyclosilicate for hyperkalaemia: the randomized, placebo-controlled HARMONIZE-Global study.

AimsSodium zirconium cyclosilicate (SZC, formerly ZS‐9) is a selective K+ binder to treat adults with hyperkalaemia. HARMONIZE‐Global examined the efficacy and safety of SZC among outpatients with hyperkalaemia from diverse geographic and ethnic origins.Methods and resultsThis phase 3, randomized, double‐blind, placebo‐controlled study recruited outpatients with serum K+ ≥5.1 mmol/L (measured by point‐of‐care i‐STAT device) at 45 sites in Japan, Russia, South Korea, and Taiwan. Following open‐label treatment with thrice‐daily SZC 10 g during a 48 h correction phase (CP), patients achieving normokalaemia (K+ 3.5–5.0 mmol/L) were randomized 2:2:1 to once‐daily SZC 5 g, SZC 10 g, or placebo during a 28 day maintenance phase (MP). The primary endpoint was mean central‐laboratory K+ level during days 8–29 of the MP. Of 267 patients in the CP, 248 (92.9%) entered the MP. During the CP, mean central‐laboratory K+ was reduced by 1.28 mmol/L at 48 h vs. baseline (P < 0.001). During the MP (days 8–29), SZC 5 and 10 g once‐daily significantly lowered mean central‐laboratory K+ by 9.6% and 17.7%, respectively, vs. placebo (P < 0.001 for both). More patients had normokalaemia (central‐laboratory K+ 3.5–5.0 mmol/L at day 29) with SZC 5 (58.6%) and 10 g (77.3%) vs. placebo (24.0%), with the greatest number of normokalaemic days in the 10‐g group. The most common adverse events with SZC were mild or moderate constipation and oedema.ConclusionsNormokalaemia achieved during the CP was maintained over 28 days with SZC treatment among outpatients with hyperkalaemia.