Suspicion Of Pathology Research Articles

Utilization of Whole-Body Magnetic Resonance Imaging in Challenging Diagnoses in Pediatric Rheumatology.

The aim of this study was to investigate the use of whole-body magnetic resonance imaging (WBMRI) in cases where we suspected rheumatic disease in our pediatric rheumatology clinic. We conducted a retrospective analysis of demographic, clinical, laboratory, and imaging data pertaining to pediatric patients who presented at our clinic and underwent WBMRI over the last 5 years. Our investigation targeted children experiencing diffuse musculoskeletal pain, where precise localization was challenging and suspicion of rheumatological pathology persisted despite inconclusive results from conventional diagnostic modalities. A total of 87 patients (33 female) underwent WBMRI at our clinic, with a median age (minimum-maximum) of 11.3 (0.5-18) years. Whole-body magnetic resonance imaging was performed in 4 patients suspected with dermatomyositis (DM) where muscle biopsy was not feasible, revealing muscle involvement and myositis. Additionally, WBMRI was utilized in 4 patients diagnosed with chronic nonbacterial osteomyelitis (CNO) to assess recurrence, identifying new active lesions in 3 patients. Among the remaining 79 patients, 34 received a new diagnosis of CNO. Clinically, supported by additional findings in laboratory and WBMRI, 18 were diagnosed with juvenile idiopathic arthritis (JIA), 5 with protracted febrile myalgia syndrome (PFMS), 5 with acute osteomyelitis, and 1 with viral myositis. The results were normal for 17 patients. Most of the WBMRIs conducted at the clinic under study were primarily performed on patients suspected of having CNO. Additionally, WBMRI was found to be supportive and beneficial in cases of suspected DM, PFMS, and JIA during the diagnosis.

MRI-serum-based score accurately identifies patients undergoing liver transplant without rejection avoiding the need for liver biopsy: A multisite European study.

Serum liver tests (serum tests) and histological assessment for T-cell-mediated rejection are essential for post-liver transplant monitoring. Liver biopsy carries a risk of complications that are preferably avoided in low-risk patients. Multiparametric magnetic resonance imaging (mpMRI) is a reliable noninvasive diagnostic method that quantifies liver disease activity and has prognostic utility. Our aim was to determine whether using mpMRI in combination with serum tests could noninvasively identify low-risk patients who underwent liver transplants who are eligible to avoid invasive liver biopsies. In a multicenter prospective study (RADIcAL2), including 131 adult and pediatric (children and adolescent) patients with previous liver transplants from the Netherlands, Portugal, and the United Kingdom, concomitant mpMRI and liver biopsies were performed. Biopsies were centrally read by 2 expert pathologists. T-cell-mediated rejection was assessed using the BANFF global assessment. Diagnostic accuracy to discriminate no rejection versus indeterminate or T-cell-mediated liver transplant rejection was performed using the area under the receiver operating characteristic curve. In this study, 52% of patients received a routine (protocol) biopsy, while 48% had a biopsy for suspicion of pathology. Thirty-eight percent of patients had no rejection, while 62% had either indeterminate (21%) or T-cell-mediated rejection (41%). However, there was a high interobserver variability (0 < Cohen's Kappa < 0.85) across all histology scores. The combined score of mpMRI and serum tests had area under the receiver operating characteristic curve 0.7 (negative predictive value 0.8) to identify those without either indeterminate or T-cell-mediated rejection. Combining both imaging and serum biomarkers into a composite biomarker (imaging and serum biomarkers) has the potential to monitor the liver graft to effectively risk stratify patients and identify those most likely to benefit from a noninvasive diagnostic approach, reducing the need for liver biopsy.

Etiology and Diagnostic Challenges of Ulnar Wrist Pain in Pediatric and Adolescent Patients

Diagnosing the cause of ulnar-sided wrist pain can be difficult in the pediatric and adolescent age group. While frequently used, the diagnostic accuracy of magnetic resonance image (MRI), as compared with intraoperative arthroscopic findings, is not well-described in this population. This study aimed to determine concordance rates between magnetic resonance and arthroscopic findings depending on the specific ulnar wrist pathology. A retrospective review was performed to identify pediatric and adolescent patients who underwent operative treatment of ulnar wrist pain between 2004 and 2021. Patients were included in the analysis if they were <18 years of age, complained of ulnar-sided wrist pain, underwent MRI of the affected wrist with an available report interpreted by a consultant radiologist, and had a diagnostic arthroscopy procedure within one year of imaging. Ulnar pathologies analyzed included triangular fibrocartilage (TFCC) tears, ulnotriquetral (UT) ligament tears, lunotriquetral ligament abnormalities, and ulnocarpal impaction. A total of 40 patients with a mean age of 15-years-old (range 11 to 17) were included in the analysis. Twenty-four were female, and approximately half had their dominant extremity affected. Most had a history of antecedent trauma (n= 34, 85%), but only 15/40 (38%) had a history of fracture. The mean duration of symptoms prior to presentation was six months (standard deviation, 7). The most common etiologies were Palmer 1B TFCC tears (n= 27, 68%) followed by UT split tears (n= 11, 28%). MRI overall demonstrated high specificity (82% to 94%), but low sensitivity (14% to 71%) for ulnar-sided wrist conditions. Accuracy varied between 70% and 83% depending on the specific injury. While MRI is a useful adjunct for determining the cause of ulnar wrist pathologies, findings are often discordant when compared with diagnostic arthroscopy. Surgeons should have a high degree of suspicion for TFCC-related pathology in the setting of positive provocative clinical examination despite negative MRI findings in young patients. Diagnostic IIb.

Squamoid eccrine ductal carcinoma: clinical, histological and immunohistochemical features.

Squamoid eccrine ductal carcinoma (SEDC) is a cutaneous adnexal malignancy that is histologically challenging to distinguish from squamous cell carcinoma. We report three cases of this rare entity and review the present literature regarding clinical, histological, and immunohistochemical features. Patients presented with a single nodule or plaque lesion on their back and temple. The shave biopsies for Patient A and C were interpreted as SEDC. Patient B's initial shave biopsy was interpreted as probable surface of squamous cell carcinoma, and subsequent excision revealed SEDC. Ductal differentiation was confirmed by positive expression of epithelial membrane antigen and carcinoembryonic antigen immunostains in all three patients. Review of the 67 previously reported cases emphasizes the importance of diagnosing SEDC accurately and promptly given its potential for distant metastasis and mortality. Perineural or lymphatic invasion is associated with higher rate of recurrence or metastasis. There should be high pathologic suspicion for SEDC in an elderly patient presenting with a palpable lesion, even if located outside of the head and neck area, particularly when there is suggestion of ductal differentiation in a sample of a squamous neoplasm.

Differences in cardiac adaptation to exercise in male and female athletes assessed by noninvasive techniques: a state-of-the-art review.

Athlete's heart is generally regarded as a physiological adaptation to regular training, with specific morphological and functional alterations in the cardiovascular system. Development of the noninvasive imaging techniques over the past several years enabled better assessment of cardiac remodeling in athletes, which may eventually mimic certain pathological conditions with the potential for sudden cardiac death, or disease progression. The current literature provides a compelling overview of the available methods that target the interrelation of prolonged exercise with cardiac structure and function. However, this data stems from scientific studies that included mostly male athletes. Despite the growing participation of females in competitive sport meetings, little is known about the long-term cardiac effects of repetitive training in this population. There are several factors-biochemical, physiological and psychological, that determine sex-dependent cardiac response. Herein, the aim of this review was to compare cardiac adaptation to endurance exercise in male and female athletes with the use of electrocardiographic, echocardiographic, and biochemical examination, to determine the sex-specific phenotypes, and to improve the healthcare providers' awareness of cardiac remodeling in athletes. Finally, we discuss the possible exercise-induced alternations that should arouse suspicion of pathology and be further evaluated.

Determination of Factors Associated with Upstage in Atypical Ductal Hyperplasia to Identify Low-Risk Patients Where Active Surveillance May be an Alternative.

Excision is routinely recommended for atypical ductal hyperplasia (ADH) found on core biopsy given cancer upstage rates of near 20%. Identifying a cohort at low-risk for upstage may avoid low-value surgery. Objectives were to elucidate factors predictive of upstage in ADH, specifically near-complete core sampling, to potentially define a group at low upstage risk. This retrospective, cross-sectional, multi-institutional study from 2015 to 2019 of 221 ADH lesions in 216 patients who underwent excision or active observation (≥ 12 months imaging surveillance, mean follow-up 32.6 months) evaluated clinical, radiologic, pathologic, and procedural factors for association with upstage. Radiologists prospectively examined imaging for lesional size and sampling proportion. Upstage occurred in 37 (16.7%) lesions, 25 (67.6%) to ductal carcinoma in situ (DCIS) and 12 (32.4%) to invasive cancer. Factors independently predictive of upstage were lesion size ≥ 10 mm (OR 5.47, 95% CI 2.03-14.77, p < 0.001), pathologic suspicion for DCIS (OR 12.29, 95% CI 3.24-46.56, p < 0.001), and calcification distribution pattern (OR 8.08, 95% CI 2.04-32.00, p = 0.003, "regional"; OR 19.28, 95% CI3.47-106.97, p < 0.001, "linear"). Near-complete sampling was not correlated with upstage (p = 0.64). All three significant predictors were absent in 65 (29.4%) cases, with a 1.5% upstage rate. The upstage rate among 221 ADH lesions was 16.7%, highest in lesions ≥ 10mm, with pathologic suspicion of DCIS, and linear/regional calcifications on mammography. Conversely, 30% of the cohort exhibited all low-risk factors, with an upstage rate < 2%, suggesting that active surveillance may be permissible in lieu of surgery.

The Diagnostic Value of microRNA Expression Analysis in Detecting Intraductal Papillomas in Patients with Pathological Nipple Discharge.

Patients with pathological nipple discharge (PND) often undergo local surgical procedures because standard radiologic imaging fails to identify the underlying cause. MicroRNA (MiRNA) expression analysis of nipple fluid holds potential for distinguishing between breast diseases. This study aimed to compare miRNA expression levels between nipple fluids from patients with PND to identify possible relevant miRNAs that could differentiate between intraductal papillomas and no abnormalities in the breast tissue. Nipple fluid samples from patients with PND without radiological and pathological suspicion for malignancy who underwent a ductoscopy procedure were analyzed. We used univariate and multivariate regression analyses to identify nipple fluid miRNAs differing between pathologically confirmed papillomas and breast tissue without abnormalities. A total of 27 nipple fluid samples from patients with PND were included for miRNA expression analysis. Out of the 22 miRNAs examined, only miR-145-5p was significantly differentially expressed (upregulated) in nipple fluid from patients with an intraductal papilloma compared to patients showing no breast abnormalities (OR 4.76, p = 0.046), with a diagnostic accuracy of 92%. miR-145-5p expression in nipple fluid differs for intraductal papillomas and breast tissue without abnormalities and, therefore, has potential as a diagnostic marker to signal presence of papillomas in PND patients. However, further refinement and validation in clinical trials are necessary to establish its clinical applicability.

Ulnar-Sided Wrist Pain: A Diagnostic Evaluation Guide From 30-Plus Years of Experience.

While multiple ulnar-sided wrist pain (USWP) diagnostic evaluation guides have been presented, none have included original clinical data or statistical analysis. The purpose of this study is to provide a diagnostic evaluation guide derived from original clinical data and analysis to help clinicians arrive at a differential diagnosis for USWP. Using a computer search of patients presenting with sprains, instability, and laxity of the wrist, 385 patient charts were identified. Patient demographics, mechanism of injury, subjective complaints, physical findings, and diagnostic test findings were reviewed. Statistical analysis was performed to determine sensitivity and specificity of diagnostic methods on their ability to identify lunotriquetral ligament tears, triangular fibrocartilage complex (TFCC) tears, and ulnar impaction syndrome. Diagnostic arthroscopy was used as the reference standard. Ninety-three patients, comprising 101 cases of USWP, were included in the study. The onset of injury was traumatic in 83 out of 101 cases with motor vehicle accidents (N=46) being the most common, followed by overuse (N=18), and a fall onto an outstretched hand (N=16). The ulnocarpal tenderness test exhibited sensitivity/specificity of 72%/33%; lunotriquetral ligament laxity test of 42%/62%; bone scan of 80%/33%; radiocarpal arthrogram of 90%/98% for TFCC tears and 50%/91% for lunotriquetral ligament tears; midcarpal arthrogram of 82%/86% for lunotriquetral ligament tears.The mean ulnar variance on standard posteroanterior view radiograph was 0.95 mm, increasing to 2.67 mm on gripping posteroanterior view. Physicians should suspect a lunotriquetral ligament and/or TFCC tear with the acute onset of USWP following a loaded dorsiflexed mechanism of injury. Ulnocarpal tenderness tests and pre-operative ulnar variance measures are effective for increasing suspicion of USW pathology. Bone scans are helpful in diagnosing ulnar impaction syndrome in conjunction with radiographic findings. A combination of midcarpal arthrogram for lunotriquetral ligament tears and radiocarpal arthrogram for TFCC tears should be employed.

Elective one-minute full brain multi-contrast MRI versus brain CT in pediatric patients: a prospective feasibility study

BackgroundBrain CT can be used to evaluate pediatric patients with suspicion of cerebral pathology when anesthetic and MRI resources are scarce. This study aimed to assess if pediatric patients referred for an elective brain CT could endure a diagnostic fast brain MRI without general anesthesia using a one-minute multi-contrast EPI-based sequence (EPIMix) with comparable diagnostic performance.MethodsPediatric patients referred for an elective brain CT between March 2019 and March 2020 were prospectively included and underwent EPIMix without general anesthesia in addition to CT. Three readers (R1–3) independently evaluated EPIMix and CT images on two separate occasions. The two main study outcomes were the tolerance to undergo an EPIMix scan without general anesthesia and its performance to classify a scan as normal or abnormal. Secondary outcomes were assessment of disease category, incidental findings, diagnostic image quality, diagnostic confidence, and image artifacts. Further, a side-by-side evaluation of EPIMix and CT was performed. The signal-to-noise ratio (SNR) was calculated for EPIMix on T1-weighted, T2-weighted, and ADC images. Descriptive statistics, Fisher’s exact test, and Chi-squared test were used to compare the two imaging modalities.ResultsEPIMix was well tolerated by all included patients (n = 15) aged 5–16 (mean 11, SD 3) years old. Thirteen cases on EPIMix and twelve cases on CT were classified as normal by all readers (R1–3), while two cases on EPIMix and three cases on CT were classified as abnormal by one reader (R1), (R1–3, p = 1.00). There was no evidence of a difference in diagnostic confidence, image quality, or the presence of motion artifacts between EPIMix and CT (R1–3, p ≥ 0.10). Side-by-side evaluation (R2 + R4 + R5) reviewed all scans as lacking significant pathological findings on EPIMix and CT images.ConclusionsFull brain MRI-based EPIMix sequence was well tolerated without general anesthesia with a diagnostic performance comparable to CT in elective pediatric patients.Trial registrationThis study was approved by the Swedish Ethical Review Authority (ethical approval number/ID Ethical approval 2017/2424-31/1). This study was a clinical trial study, with study protocol published at ClinicalTrials.gov with Trial registration number NCT03847051, date of registration 18/02/2019.

Intermittent esotropia and ataxia in a child with late diagnosis of empyema in the sphenoid sinus - a case report

Background: Acute bacterial rhinosinusitis is a common condition often affecting children with inflammation of the mucous membrane in one or more nasal sinuses. Isolated sphenoid sinus infections can exhibit atypical or no symptoms before potentially severe suppurative complications develop. Awareness of early signs of complications is crucial to avoid delays in referral, diagnosis, and treatment. We present the first detailed report of a child with sphenoid sinus empyema with the symptoms intermittent unilateral esotropia and limb and gait ataxia. This case emphasizes the need to recognise atypical presentations, aiding early diagnosis and treatment to prevent severe, possibly life-threatening complications. Case presentation: A 7-year-old girl, previously healthy, presented with a months-long decline in health marked by general malaise, significant weight loss, and recurrent upper respiratory infections. Despite multiple primary care visits no antibiotics were prescribed because infection parameters were found to be normal. Subsequently, the emergence of intermittent double vision prompted referral to the pediatric emergency department. Examination revealed a wide-based gait, ataxic finger-nose-finger and knee-heel tests, and intermittent esotropia of the left eye. Neurological examination was otherwise unremarkable. Imaging of the cerebrum was performed on the suspicion of intracranial pathology and found isolated empyema within the left sphenoid sinus. Endoscopic sinus surgery and antibiotic treatment led to a full recovery within a month. The accommodative esotropia, likely triggered by the infection, was identified, and successfully treated with spectacles. Conclusion: This case recognises isolated empyema in the sphenoid sinus as a potential cause of intermittent esotropia and limb and gait ataxia. It serves as a reminder for clinicians to be vigilant for early signs of suppurative complications to commence prompt diagnosis and treatment to prevent delayed recognition and severe complications. It advocates the inclusion of images of the sphenoid sinus to accompany the conventional scans of the cerebrum, as patients risk referral on the suspicion of intracranial pathology on the basis of neurological symptoms.

Substantive approach to ensuring infectious safety in forensic medical expert practice

The objective of the study is to analyze existing measures and identify problematic aspects of ensuring the organization of infectious safety activity in forensic medical expert institutions, to develop ways of their solution. Documents regulating the functional principles of forensic medical expert institutions in cases of detection or suspicion of infectious pathology have been examined. Specific proposals for the development of a system to ensure infectious safety in the organization of work in the bureau of forensic medical expertise have been formulated.

Da Sandifer a Canavan: quando la storia rivela la diagnosi

G., 6 months old, came to our attention for suspected Sandifer syndrome presenting from birth, inconsolable crying, tendency to arch, suspected reflux and ‘hypo-feeding. Comprehensive analysis of the situation, with particular regard to psychomotor developmental trajectories, growth curves, and neurological examination allowed us to raise the suspicion of neurometabolic pathology and, following appropriate examinations, to make the diagnosis of Canavan Disease. The case described here underscores how the comprehensive evaluation of all aspects of a clinical case is essential to reach a diagnosis and that even problems apparently pertaining to the gastroenterological sphere, if placed in the right context, can be indicators of a neurometabolic disease.

Meniscal disruption associated with septic arthritis in three neonatal foals

SummaryThe objective of this study was to report clinical characteristics, surgical management and medium‐term (6–12 months) outcomes of three Arabian neonatal foals with meniscal disruption associated with septic arthritis of the lateral femorotibial joint. The three neonatal Arabian foals with septic arthritis of the lateral femorotibial joint (LFTJ), were diagnosed with disruption of the lateral meniscal (LM). Suspicion of meniscal pathology was based on ultrasonography, computed tomography (in 2 foals) and confirmed during arthroscopy. Treatment included arthroscopic debridement and lavage of the joint with debridement of the meniscal disruption. Postoperative care included systemic and intra‐articular antimicrobials, based on culture and sensitivity results. Two of the foals received intra‐articular injections of autologous mesenchymal stem cells. Marked LM disruption was observed in the LFTJ of the affected joints of all foals, involving the meniscal body (n = 3) and caudal horn (n = 1). Purulent material within the torn tissue was debrided with a synovial resector. Foal 1 was lame‐free as a yearling. Foal 2 was lame at walk at 7.5 months and euthanised due to poor prognosis. Foal 3 showed mild lameness at trot in a straight line at 6 months. Disruption of the LM continued to be visible on US in both foals at these timepoints. It was concluded that meniscal disruption and infection should be considered as a differential in neonatal foals with persistent femorotibial septic arthritis. In such cases, the LM could be the primary nidus of infection.

The value of cytology in diagnosis of body fluids with lymphoma involvement: a report of 29 cases

Abstract Introduction/Objective Lymphoma involving body fluids (pleural, abdominal or pericardial) can be secondary or primary (such as primary effusion lymphoma). The incident rate is variable depending on the hospital setting (general or specialty hospitals), and it is generally low. Due to the large specimen volume, relatively easy collecting sample and stable cellular preservation, body fluids are good sources for diagnosis and classification of lymphoproliferative diseases. Methods/Case Report A retrospective case search from a tertiary academic medical center during 2015 to 2023 were performed for body fluid cytology with diagnosis of lymphoma. The results of cytology, ancillary cellblock, immunohistochemistry and flow cytometry were collected, and the synchronous or follow-up surgical biopsies/resections were cross examined. Results (if a Case Study enter NA) Total 29 cases of body fluids with lymphoma involvement were identified in the study period. There were 22 patients including 9 males and 13 females and age ranged from 16 to 88 years (mean 64.5 years). Only 4 patients (4/22, 18.2%) had history of lymphoma when they presented with body fluids, and the remaining 18 patients (18/22, 81.8%) presented body fluids as the initial or synchronous sign of lymphoma. 26/29 cases had cellblock or flow cytometry done and 13/29 cases had both. All 22 cases had adequate lymphoma diagnosis and classification by combined cytology and ancillary tests and included 5 high grade B cell lymphoma, 3 diffuse large B cell lymphoma, 2 Burkitt, 2 CLL/SLL, 2 small mature B cell lymphoma, NOS, 1 mantel, 1 MYC and BCL-2 double hits lymphoma, 1 primary effusion lymphoma, 1 plasma cell myeloma, 2 T lymphoblastic lymphoma, 1 anaplastic large cell lymphoma, 1 angioimmunoblastic T cell lymphoma. 11 patients had synchronous or follow-up tissue biopsies, and cytology had 100% agreement with the histology diagnosis. Conclusion The majority (81.8%) cases of body fluid involvement with lymphomas presented as the initial or synchronous sign of lymphomas in our study series indicating that high pathologic suspicion and adequate cytomorphological skills for lymphoproliferative disorders are necessary for making the diagnosis. Body fluid samples are excellent sources for diagnosis and classification of lymphomas using the available ancillary tools including immunohistochemistry, flow cytometry and molecular testing.

Evaluation of Neurosurgical Emergencies in the Pediatric Emergency Department: Clinical Warning Signs

BackgroundWe aimed to evaluate the patients who underwent neuroimaging with suspicion of neurosurgery pathology and identify the clinical warning signs for the early recognition of neurosurgical emergencies. MethodsPatients aged one month to 18 years who underwent neuroimaging with a preliminary diagnosis of intracranial pathology requiring emergency surgery and symptom duration less than one month were included in the study. Patients were divided into three groups according to their definitive diagnosis as neurosurgical emergencies, neurological emergencies, and nonurgents. ResultsA total of 140 patients were included in the study (the median age was 8 [interquartile range IQR 3 to 13] years and 52.8% were male). Neurosurgery emergency group and neurological emergency group were significantly younger than the nonurgent group (P < 0.001). Vomiting, meningeal irritation findings, and papilledema (grade 2 and above) were more common in the neurosurgical emergency group (P 0.029, 0.023, and < 0.001, respectively). For neurosurgical emergencies, in the presence of papilledema (grade 2 and above) and focal neurological deficit, the specificity was 99.2%, positive predictive value (PPV) 83.3%, negative predictive value (NPV) 88.1%, and odds ratio (OR) 36.8 (P < 0.001, confidence interval [CI] 4.04 to 336.0); in the presence of altered consciousness and focal neurological deficit, the specificity was 97.5%, PPV 50%, NPV 86.6%, and OR 6.4 (P = 0.014, CI 1.20 to 34.4). ConclusionsYounger age, presence of vomiting, signs of meningeal irritation, papilledema grade 2 and above, and altered consciousness are the crucial “warning signs” of a potential neurosurgical emergency.

THU387 Euglycemic Diabetic Ketoacidosis And SGLT-2 Inhibitor Use

Abstract Disclosure: N. Abrahimi: None. A. Abrahimi: None. N. Terrigno: None. Background: Diabetic ketoacidosis (DKA) is a known adverse effect of SGLT-2 inhibitors. (1) Incidences of euglycemic diabetic ketoacidosis in patients on SGLT-2 inhibitors are reported on less. Clinical Case: A 39-year-old male past medical history of uncontrolled, non-insulin dependent diabetes mellitus and pancreatitis who presented with abdominal pain, nausea and coffee ground emesis. On initial work up, basic metabolic panel showed blood glucose level of 175 mg/dL with an elevated anion gap of 22 mmol/L. Initial differentials included suspicion for euglycemic diabetic ketoacidosis or acute intraabdominal pathology. Venous blood gas showed metabolic acidosis, with a pH of 7.21 and bicarbonate of 9.7 mmol/L, beta hydroxybutyrate was elevated at 7.83 mmol/L. CT abdomen pelvis found a small hiatal hernia, gastric wall thickening, likely gastritis, and was negative for other intraabdominal pathology. Home medications of the patient included dapagliflozin, semaglutide, metformin, gabapentin, and pantoprazole. Patient was admitted with the diagnosis of suspected euglycemic diabetic ketoacidosis and was started on an insulin drip along with D5 0.45 normal saline. Patient’s anion gap was monitored with basic metabolic panel orders every two hours. The insulin drip was discontinued once the patient had two consecutive normal anion gaps and the patient was subsequently started on a subcutaneous insulin regimen. Conclusion: SGLT-2 inhibitors may cause euglycemic diabetic ketoacidosis based on the physiology of the SGLT-2 transporter and the pharmacology of the SGLT-2 inhibitors. (2) Clinical importance of this case report is to consider euglycemic diabetic ketoacidosis in patients on SGLT-2 inhibitors presenting with nausea, vomiting with normal blood glucose to not delay in the diagnosis and treatment of this life-threatening condition.

Red flags to screen for vertebral fracture in people presenting with low back pain.

Red flags to screen for vertebral fracture in people presenting with low back pain.

Role of MRCP in Patients with Jaundice When Biliary Tree Is Normal on Previous Imaging

Background Obstructive jaundice is one of the most frequent and grave form of hepatobiliary disease. It is important for treatment planning to detect level and cause of obstruction. Aim of the Work To assess the role of MRCP in patients presented with jaundice, right hypochondrial pain with the absence of dilated biliary system by ultrasound. Patients and Methods This was cross sectional study that included 38 patients who presented with obstructive jaundice or right hypochondrial pain with normal biliary system by ultrasound referred to the Radio diagnosis Department for MRCP. Results MRCP has high sensitivity reaching 100% and high specificity reaching 93.33% in gall bladder pathology and high specificity 100% in biliary and pancreatic pathology in comparison to ultrasound. Conclusion if there is high clinical suspicion of ductal pathology when patient presented by jaundice or right hypochondrial pain with abnormal liver function tests despite normal biliary tree by ultrasound, an MRCP examination should be strongly considered as next imaging modality of choice

Spontaneous middle meningeal arteriovenous fistula without cortical venous reflux presenting with acute subdural hematoma: illustrative case.

Dural arteriovenous fistula (AVF) without cortical venous reflux (CVR) has a relatively benign course. Here, the authors describe a patient presenting with subdural hematoma due to a middle meningeal AVF without CVR. A 17-year-old male was admitted to the emergency department with acute headache without an episode of head trauma. Computed tomography demonstrated a left acute subdural hematoma (SDH). Because the nontraumatic SDH raised the suspicion of vascular pathology, emergent angiography was performed, which demonstrated an AVF fed by the middle meningeal artery and draining to the diploic vein via the serpentine meningeal vein without CVR. T2-weighted magnetic resonance imaging (MRI) revealed no signs of venous congestion. Given the proximity of the AVF to the SDH and the MRI findings, we suspected that the serpentine meningeal vein was responsible for the SDH. The patient was successfully treated with transarterial Onyx embolization. During the injection, Onyx migrated to the extravascular space following its penetration into the serpentine meningeal vein, suggesting the meningeal vein was a bleeding source of the subdural hematoma. Despite the absence of cortical venous reflux, serpentine meningeal venous drainage of middle meningeal AVF can be a source of subdural hemorrhage.

Introducing Australia's clinical care standard for low back pain.

Introducing Australia's clinical care standard for low back pain.