Unclear Cases Research Articles

Acute Hematogenous Osteomyelitis of the Rib in 14 Years Old Child: Clinical Case

Background.Rib osteomyelitis is extremely rare in childhood. This localization of purulent focus represents only 1% of all osteomyelitis cases. The typical manifestations of ribs osteomyelitis are fever, chest or back pain. However, these clinical signs are not always present, and the disease can manifest in other way.Clinical Case Description. Mother with 14 years old child K. have applied to the regional children's hospital admission department. The child had complains of right upper quadrant abdominal pain and in right part of the chest, difficulty in breathing. The disease began 2 days before admission with fatigue, weakness, and pyretic fever (39 °C). Complaints remained over time. The patient was hospitalized with the diagnosis: “Chest impact injury with severe pain syndrome? Right lung contusion?". The ultrasound examination of pleural cavities and the right anterior chest surface has revealed osteomyelitic phlegmon in VII intercostal space on the 3rd day of hospitalization. It was lanced and drained under general anesthesia, about 7 ml of liquid pus were obtained. The child received treatment according to clinical guidelines for the management of patients with such nosology. The final diagnosis was: «Acute hematogenous osteomyelitis of the VII rib, local form. Osteomyelitic phlegmon of VII intercostal space. Right pneumonitis. Bilateral mild hydrothorax». The boy was discharged on the 10th day since surgery in satisfactory condition.Conclusion.The described clinical case is interesting for pediatric surgeons, traumatologists, infectious disease specialist. Particular attention should be paid to the clinical features of the disease and anamnestic information in such unclear clinical cases. It will allow to exclude traumatic injuries and assume the local inflammatory process.

Partial annular pancreas in a 12-year-old girl

Introduction. Annular pancreas is a rare congenital anomaly in which a band of the pancreatic tissue, in continuity with the pancreatic head, completely or incompletely surrounds the descending part of the duodenum. An abnormal pancreatic development can cause complete annular pancreas, partial annular pancreas, and pancreas divisum. Complete annular pancreas is diagnosed in newborns, while the diagnosis of the partial annular pancreas is more frequently established in adults. The most reliable diagnostic methods are computed tomography and magnetic resonance cholangiopancreatography. The anomaly is treated surgically, using bypass procedures. Case report. A 12-year-old girl presented malnourished, with occasional feeding problems, vomiting, heartburn, and pain from infancy. The upper gastrointestinal series showed an extremely dilated stomach, the first and the second part of the duodenum. An endoscopic exam revealed the dilated stomach, pylorus, and the first and the second part of the duodenum with retained contrast, while the entrance of the endoscope into the third part of the duodenum was not possible. Computed tomography showed pancreatic tissue encircling the second part of the duodenum and the characteristic "crocodile jaw" sign. Roux-en-Y duodenojejunostomy was performed as a bypass procedure. Conclusion. The complete annular pancreas is a well-known and easily diagnosed anomaly in newborns. The partial annular pancreas is often poorly recognized, especially in patients who do not present with marked duodenal obstruction. Unrevealed, it causes chronic problems in food intake, with possible serious complications. Although a very rare condition in the pediatric population, partial annular pancreas should be taken into consideration in unclear cases of chronic poor oral food intake and vomiting.

Unclear chronic vertigo syndromes-experiences with an interdisciplinary inpatient diagnostic concept

Schwindel ist ein häufiges Leitsymptom. Insbesondere Patienten mit chronischen Schwindelsyndromen erleben eine deutliche Beeinträchtigung der Lebensqualität und bei Berufstätigen eine Einschränkung der Arbeitsfähigkeit. Folgen sind finanzielle und kapazitive Belastungen des Gesundheitssystems aufgrund von häufigen Mehrfachuntersuchungen und Krankschreibungen bis hin zur Erwerbsunfähigkeit der Betroffenen. Bei 150 Patienten mit in der ambulanten Diagnostik unklaren chronischen Schwindelsyndromen wurde auf der Grundlage eines strukturierten interdisziplinären stationären Diagnostikkonzepts bei über 90 % der Fälle mindestens eine die Beschwerden begründende Diagnose erhoben. Chronische Schwindelsyndrome sind häufig multifaktoriell bedingt. Bei mehr als der Hälfte der Patienten fanden sich u. a. psychosomatische (Begleit‑)Diagnosen. Zielführende therapeutische Empfehlungen können nur diagnosespezifisch erfolgen, weshalb in dauerhaft unklaren Fällen auch die Abklärung im Rahmen eines interdisziplinären stationären Diagnostikkonzepts sinnvoll und gerechtfertigt sein kann.

Diverse Manifestation of Acromegaly With Suspicion of Ectopic GHRH Secretion. Report of Two Cases

Introduction: Acromegaly can rarely be caused by an ectopic production of GH or GHRH by various neoplasms, most commonly neuroendocrine tumors of pancreatic or pulmonary origin. Squamous cell carcinoma of the lung has not been associated with ectopic GHRH secretion yet. The authors present two cases of acromegaly with suspicion of GHRH ectopy. Presentation of the Cases: Case 1. A male born in 1945 presenting with typical morphologic features of acromegaly. Pituitary MRI revealed a cuneatic-shaped, hypointense focal lesion (8x7x6 mm) in the right posterior part of the anterior pituitary lobe, radiologically interpreted as either hyperplasia of the intermediate lobe or atypical adenoma in a normal-sized pituitary. IGF-1 and no suppression of GH secretion after oral glucose load were observed. Furthermore, a polycyclic tumor in the 2nd segment of the right lung with pathological metabolic activity in 18FDG- PET/CT was discovered. Ga68- DOTA TATE PET/CT revealed no pathological accumulation of the tracer. After upper right lobectomy, squamous cell carcinoma, non-keratinizing, G3, with a negative immunohistochemical reaction for GH was confirmed. IHC for GHRH and serum GHRH have been scheduled. After surgery and chemotherapy, no biochemical remission of acromegaly was observed and the pituitary MRI showed stable radiological image of the pituitary tumor, suggesting rather a possible metastasis to the pituitary. Due to unfavorable prognosis, the patient was disqualified from neurosurgical resection of the pituitary tumor. Case 2. a male born in 1948 with typical symptoms of acromegaly, elevation of IGF-1 and no suppression of GH in OGTT. Due to MRI contraindications, only CT of the head was performed- it revealed partially empty sella, compressed pituitary with maximal diameter 3 mm and no focal lesions. Treatment with somatostatin analogue was introduced, however, only partial biochemical control was achieved. Ga68- DOTA TATE PET/CT performed after 8 years showed pathological expression of somatostatin receptors in the pancreatic tail. Abdominal CT confirmed a focal lesion in this location, 14x9 mm, with a strong enhancement after contrast administration, suggesting a neuroendocrine tumor. The patient refused to undergo any invasive procedures and remains treated with SRL. Serum GHRH has been scheduled. Conclusion: The authors report two cases of ectopic acromegaly suspicion, with an ambiguous clinical and radiological presentation. In unclear cases of acromegaly, ectopic production of GHRH should be taken into consideration.

ALMA small-scale features in the quiet Sun and active regions

Aims. The main aim of the present analysis is to decipher (i) the small-scale bright features in solar images of the quiet Sun and active regions obtained with the Atacama Large Millimeter/submillimeter Array (ALMA) and (ii) the ALMA correspondence of various known chromospheric structures visible in the Hα images of the Sun. Methods. Small-scale ALMA bright features in the quiet Sun region were analyzed using single-dish ALMA observations (1.21 mm, 248 GHz) and in an active region using interferometric ALMA measurements (3 mm, 100 GHz). With the single-dish observations, a full-disk solar image is produced, while interferometric measurements enable the high-resolution reconstruction of part of the solar disk, including the active region. The selected quiet Sun and active regions are compared with the Hα (core and wing sum), EUV, and soft X-ray images and with the magnetograms. Results. In the quiet Sun region, enhanced emission seen in the ALMA is almost always associated with a strong line-of-sight magnetic field. Four coronal bright points were identified, while other small-scale ALMA bright features are most likely associated with magnetic network elements and plages. In the active region, in 14 small-scale ALMA bright features randomly selected and compared with other images, we found five good candidates for coronal bright points, two for plages, and five for fibrils. Two unclear cases remain: a fibril or a jet, and a coronal bright point or a plage. A comparison of the Hα core image and the 3 mm ALMA image of the analyzed active region showed that the sunspot appears dark in both images (with a local ALMA radiation enhancement in sunspot umbra), the four plage areas are bright in both images and dark small Hα filaments are clearly recognized as dark structures of the same shape also in ALMA.

Comparison of Laser Fluorescence and Digital Radiograph with International Caries Detection and Assessment System in Primary Teeth (In-vivo study)

Background: There has been an increased incidence of dental caries in children due to recent changes in lifestyle. More sensitive and reproducible diagnostic tools for precise caries detection in children are needed because of the complex occlusal anatomy. Aim: To compare the clinical performance and accuracy of international caries detection and assessment system-II (ICDAS II) versus DIAGNOdent pen and digital bitewing radiograph in the detection of occlusal caries in the primary teeth. Materials and Methods: Fifty children aged 6-11 years were assessed of both gender (29 girls and 21 boys) and 377 occlusal surface of primary teeth were examined by visual ICDAS II, DIAGNOdent pen and digital bitewing radiographic examination at D0 (non caries lesions), D1 (lesions limited to enamel) and D2 (lesions limited to dentin) thresholds. Results: Sensitivity at D0 for ICADS II was 14.23% and 95.95% for DIAGNOdent pen and 87.85% for digital bitewing, radiographs while specificity for both ICADS II and bitewing radiographs were 99.23% but 73.85% for DIAGNOdent pen. At D1, threshold sensitivity of ICADS II and digital bitewing radiographs were higher than DIAGNOdent pen but specificity for bitewing radiographs and DIAGNOdent pen 90.69% - 87.99%. were highly significant than ICADS II At D2, threshold specificity for all diagnostic methods was almost similar with better sensitivity for ICADS II and digital bitewing radiographs. Conclusion: This study showed that ICDAS II, Diagnodent pen, and bitewing radiography are effective for the detection of occlusal caries for primary molars. Digital bitewing radiography correlated stronger with ICDASII than Diagnodent pen and proved to be the best method to detect occlusal lesions within the dentin in primary molars while Diagnodent pen and bitewing radiography are better for detecting enamel caries lesion. In addition, the clinical performance of three diagnostic methods was insufficient to detect occlusal caries lesions separately. Consequently, it is advisable to use a combination of diagnostic methods, especially in unclear cases, as well as in cases of initial lesions and their monitoring.

Finger injuries with a focus on ligamentous structures

Ligamentous lesions of the fingers are common everyday injuries and usually the result of distortion or overloading. Numerous examination methods are available for dedicated radiological diagnosis of sometimes complex injury patterns. To review radiological diagnosis of the ligamentous structures of the finger joints including the presentation of anatomical, biomechanical and therapeutic aspects. Presentation of the anatomy and biomechanics as well as the most common trauma mechanisms of the ligamentous structures. Review of the literature, discussion of recent work and diagnostic expert recommendations. The most relevant ligamentous structures are collateral ligaments, pulley ligaments, volar plates and tendons. The goal of radiologic diagnosis is to accurately define the injury pattern and to differentiate between simple and complicated ligamentous lesions. In unclear cases, magnetic resonance imaging (MRI) has become standard for further diagnostics, which may allow depiction of ligamentous structures in submillimetre resolution. Today, differential diagnosis includes all radiological modalities, which ensures the determination of an adequate therapy and prevention of sequel at ahigh standard.

Electrocution Stigmas in Organ Damage: The Pathological Marks.

Background: Diagnostic criteria for electrocution related death are still a challenge in forensic pathology and it seems that the electrical mark is the only reliable evidence. Methods: A comparison of histological and morphological findings of skin and internal organs from an autopsy series of electrocution deaths with those mostly reported in literature as representative for electrocution. Results: The morphological changes of heart, brain and other main internal organs are still unspecific. Organ’s damage observed in electrocution deaths shows a wide variability, not reliable for a certain diagnosis of electrocution. The electrical mark is still the golden standard for diagnosis of electrocution. Conclusions: In electrocution related deaths, pathological findings of the main internal organs are not enough evidence to support with certainty a post-mortem diagnosis that a victim suffered an electrical damage. Although the organ histological changes are undoubtedly the starting point for a better understanding of the fatal even, the diagnosis of death from electrical damage is still a dark and unsolved chapter. The electrical mark still represents a fundamental indicator above all in the medical-legal field, but the identification of pathognomonic elements and signs not limited to the skin alone could be a valid help in the future, especially in unclear cases.

Professional development: Training in ethics

IntroductionSome of the most vulnerable psychiatry patients are children under 18, as they can’t protect themselves and their rights from unethical behaviour of mental health professionals. There is a gap between theoretical knowledge and application of ethics at the workplace. Continuous education in ethics is necessary to address this gap.ObjectivesThe objective of the study was to compare various forms of education in ethics and develop training for mental health practitioners.MethodsThe study had 2 groups (356 participants, aged 23 to 67, average age – 41.3) – staff of the main and oldest children’s mental health clinic in Moscow, Russia. The control group (124 participants) of mental health professionals received written materials on ethics (such as ethical codes and ethical decision-making protocols). The test group (232 people) participated in a several trainings on ethics. The trainings included 3 parts – discussing the code of ethics, creating examples of potential ethical challenges and role-plays. Participants reported that the topics on the quality of care, common ethical dilemmas and relationships between the practitioners, young patients and legal guardians, were the most helpful for them.ResultsThe survey was conducted to evaluate the results. 70.8% of staff members that participated in training shared that they feel confident about applying the Code and the decision-making protocols in unclear cases. Only 32.6% from the control group reported the same level of confidence.ConclusionsHands-on training in ethics for continuing education has shown to be more beneficial, as compared to theoretical instructions

Weichgewebezysten der Kopf-Hals-Region

Soft tissue cysts of the head and neck region usually manifest as slowly enlarging, well defined painless swellings, which may be accompanied by symptoms due to the increasing displacement of surrounding tissues or superinfection. They are often associated with soft tissue fistulas. Diagnosis should always be preceded by thorough evaluation of the medical history, since some cysts (e.g. lateral/medial neck cysts) develop in early childhood, whereas others can be trauma associated with a very short history (e.g., submucous cysts). Clinical examination can be supplemented by ultrasound. In unclear cases or for better therapeutic planning, three-dimensional imaging may be helpful. Treatment of choice is complete extirpation of the cyst; histopathological work-up to confirm the diagnosis and exclude other differential diagnoses is mandatory. Due to the increased risk of recurrence and incomplete histological examination, cystostomy and sclerotherapy should currently be viewed as a therapeutic alternative reserved for exceptional cases only.

ARROSIVE BLEEDING FROM THE APPENDICULAR ARTERY IN ACUTE DESTRUCTIVE APPENDICITIS

Summary. Objective of the study: to present to the surgical community a rather rare complication of severe destructive appendicitis – arrosive bleeding and the cause of its development.
 Material and methods. Published a rare clinical case from prac-tice — the development of perforation of the appendix and arrosive bleeding from the appendicular artery in a patient with acute gangrenous appendicitis.
 Results and its discussion. The atypical course of acute appendicitis of undulating nature under the mask of acute adnexitis and antibacterial therapy has led to a prolonged delay with surgery in the surgical department. Only the appendicular abscess, which spontaneously opened into the abdominal cavity, made it possible to diagnose acute appendicitis and determine indications for emergency surgery, during which arrosive bleeding was diagnosed. The favorable outcome of the disease is due to the local purulent-necrotic process and small hemoperitoneum.
 Findings. Timely diagnosis of acute appendicitis, with the involvement of additional research methods in unclear cases, and subsequent appendectomy, are the prevention of a rather rare complication — arrosive bleeding from the appendicular artery in the development of severe complicated forms of acute destructive appendicitis.

\u201cGuboow\u201d\u2014child abuse or traditional medical treatment? a case report

The examination of children suspected of being abused poses a great challenge for forensic pathologists. The risk of misjudgment is high and can have serious consequences for the child and the family. In unclear cases, an assessment should always be carried out on an interdisciplinary basis with the involvement of the relevant disciplines such as pediatrics, dermatology, or radiology. We present the case of a 2.5-year-old boy who was presented by his parents at the Pediatric Emergency Department of a Swiss University Hospital due to fever and weight loss. During the physical examination, conspicuous findings on the abdomen were present, and the responsible emergency physicians informed the child protective services. A clinical forensic examination occurred on behalf of the child protection services. The abdomen of the child showed several symmetrical scars. The initial questioning of the parents did not provide clear information about the origin of the injuries. Further professional questioning of the family by the child protective services concluded that the injuries were the result of a traditional medical treatment in Somalia, which occurred several weeks before.

Accuracy of hepatobiliary scintigraphy and added value of SPECT/CT versus planar imaging for diagnosing biliary atresia.

Hepatobiliary scintigraphy (HBS) is an important tool in diagnosing biliary atresia in infants. There is limited evidence on the use of single photon emission computed tomography/computed tomography (SPECT/CT) as an additional imaging method to planar imaging. We evaluated the value of SPECT/CT in unclear cases of planar HBS. Consecutive patients with suspected biliary atresia who underwent guideline-compliant HBS from January 2010 until March 2020 were reviewed, and cases with SPECT/CT were identified. Each step within the imaging procedure (dynamic, static [early and late], and SPECT/CT) was blindly reread in consensus by two observers and categorized based on a 5-point scale: 0, definitely no bowel excretion (i.e., atresia confirmed); 1, probably positive; 2,equivocal; 3, probably negative; and 4, definite negative (i.e., atresia not confirmed). In this analysis, categories were dichotomized as negative for biliary atresia (scores 3-4) or positive (scores 0-2, including equivocal scans). Available follow-up information constituted the standard of truth (SoT). Twenty-three infants had HBS, among which ten (4 boys and 6 girls; mean age 36 days; range 8-108) underwent SPECT/CT. Single photon emission computed tomography SPECT/CT was performed as early examination (<8h) in 3 subjects and late (8 to 24 h) in 7 infants. Reread SPECT/CT was categorized as positive for atresia in three infants and negative in seven infants. The SoT showed biliary atresia in one of ten patients. Single photon emission computed tomography/CT was true positive in one case, false positive in two, and true negative in seven. No false negative cases were noted. The diagnostic performance of SPECT/CT showed a sensitivity of 100%, specificity of 78%, positive predictive value (PPV) of 33%, negative predictive value (NPV) of 100%, and accuracy of 90%. For comparison, the diagnostic performance of planar HBS showed a sensitivity of 100%, specificity of 67%, PPV of 25%, NPV of 100%, and accuracy of 70%. In summary, the addition of SPECT/CT to planar HBS improved specificity andaccuracyand marginally improved PPV. Single photon emission computed tomography/CT provided more confidence in the final conclusion in 8/10 patients. In the remaining two cases, SPECT/CT did not improve the level of confidence (one remained equivocal, and one changed from probably no excretion to equivocal). These preliminary data demonstrated increased accuracy of add-on SPECT to planar HBS predominantly due to improved specificity. This finding is consistent with the existing but limited literature and supports the recommendation of routine use of SPECT/CT or SPECT.

Fatal avian malaria in captive Atlantic puffins (Fratercula arctica) in Switzerland.

Avian malaria is a vector-borne disease caused by Plasmodium species, which may affect a broad spectrum of bird families worldwide. In most endemic and migratory birds, Plasmodium infections seem not to cause severe harm; however, non-indigenous species kept in human care such as penguins may experience high morbidity and mortality rates. Fatal avian malaria may also occur in other non-native seabirds such as puffins (Fratercula spp.), but reported cases are scarce.The aim of this study was to analyze seven cases of sudden death in captive Atlantic puffins (Fratercula arctica) at Berne Animal Park in Switzerland between 2010 and 2020, and to determine the involvement of haemosporidian parasites in the fatal outcome. In all cases, lymphoplasmacytic inflammation, necrotic lesions in several organs and presence of protozoan stages within tissues/erythrocytes or accumulation of iron-based pigment were observed histologically. A one-step multiplex PCR designed to simultaneously detect and discriminate haemosporidia belonging to the genera Plasmodium, Haemoproteus and Leucocytozoon, and a nested PCR detecting Plasmodium and Haemoproteus infections were performed on DNA extracted from formalin-fixed and paraffin-embedded (FFPE) or fresh liver and spleen tissues from five and two birds, respectively. Plasmodium spp. DNA was detected in the tissues from six of seven birds by the one-step multiplex PCR and in five of seven individuals by the nested PCR protocol. Direct sequencing of the amplification products allowed the molecular identification of Plasmodium relictum SGS1 as the involved species in three individuals and Plasmodium matutinum LINN1 in two of these fatal cases. In one bird, no haemosporidian DNA could be amplified from FFPE tissues despite of suggestive histopathological findings. These results indicate that avian malaria represents an important cause of death in captive puffins and it should be considered as a differential diagnosis in unclear or fatal cases in this threatened bird species.

Matching Clinical Diagnosis and Amyloid Biomarkers in Alzheimer's Disease and Frontotemporal Dementia.

Background: The aims of this study were to compare the diagnostic accuracy, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of different cerebrospinal fluid (CSF) amyloid biomarkers and amyloid-Positron Emission Tomography (PET) in patients with a clinical diagnosis of Alzheimer’s disease (AD) and Frontotemporal Dementia (FTD); to compare concordance between biomarkers; and to provide an indication of their use and interpretation. Methods: We included 148 patients (95 AD and 53 FTD), who underwent clinical evaluation, neuropsychological assessment, and at least one amyloid biomarker (CSF analysis or amyloid-PET). Thirty-six patients underwent both analyses. One-hundred-thirteen patients underwent Apolipoprotein E (ApoE) genotyping. Results: Amyloid-PET presented higher diagnostic accuracy, sensitivity, and NPV than CSF Aβ1–42 but not Aβ42/40 ratio. Concordance between CSF biomarkers and amyloid-PET was higher in FTD patients compared to AD cases. None of the AD patients presented both negative Aβ biomarkers. Conclusions: CSF Aβ42/40 ratio significantly increased the diagnostic accuracy of CSF biomarkers. On the basis of our current and previous data, we suggest a flowchart to guide the use of biomarkers according to clinical suspicion: due to the high PPV of both amyloid-PET and CSF analysis including Aβ42/40, in cases of concordance between at least one biomarker and clinical diagnosis, performance of the other analysis could be avoided. A combination of both biomarkers should be performed to better characterize unclear cases. If the two amyloid biomarkers are both negative, an underlying AD pathology can most probably be excluded.

Differential diagnosis of acute and chronic pulmonary thromboembolism according to MSCT data

Introduction. One of the important problems of medical imaging is the differential diagnosis of patients with acute and chronic pulmonary embolism. The widely used minimally invasive technique of multispiral computed tomography with intravenous bolus contrast enhancement can serve to solve this problem, in particular, to assess the state of the parenchyma and vascular structures of the lungs.The purpose. To assess the state of bronchial arteries and parenchymal changes in the lungs in pulmonary thromboembolism based on the results of multispiral computed tomography and their role in the more precise diagnosis of this disease.Materials and methods. An analysis of CT-angiopulmonography of 600 patients with suspected PE was performed. 87 patients with confirmed pulmonary thromboembolism were selected and divided into groups according to the final diagnosis: group 1 — acute pulmonary embolism, group 2 — chronic pulmonary embolism. CT data were analyzed for the presence of pathologically changed bronchial arteries, as well as lung's parenchymal changes (including mosaic perfusion, fibrotic changes, bronchial dilatation with or without wall thickening).Results. Bronchial arteries were assessed in patients with acute and chronic pulmonary embolism and the diagnostic value of the detected changes was determined. Acute pulmonary embolism does not lead to such dilatation of the bronchial arteries as chronic pulmonary embolism. In diagnostically unclear cases, secondary parenchymal signs visible on CT (mosaic perfusion and dilated bronchi without wall thickening) can be useful in the differential diagnosis of acute and chronic pulmonary embolism.Conclusions. Most patients with chronic pulmonary embolism demonstrated dilated bronchial arteries, in contrast to patients with acute pulmonary embolism. Lung's parenchymal changes (a mosaic perfusion pattern and bronchial dilation without wall thickening) were more common in patients with chronic pulmonary embolism. These CT-signs can help differentiate acute from chronic pulmonary embolism in unclear clinical situations.

Overnight attending radiologist coverage decreases imaging-related emergency department recalls by at least 90.

Benefits of overnight attending radiologist final reports are debated, often stating low resident discrepancy rates, usually assessed retrospectively. The objective of this study was to assess the impact of overnight final reporting on the recall rates for patients in the emergency department (ED) receiving overnight imaging. Retrospective matched cohorts of two separate years prior (prior-16 and prior-17) and 1year after (post-18) introduction of overnight attending radiologist final reporting. Patients receiving imaging between 22:00 and 07:00h and returned to ED within 48h of initial visit discharge were electronically identified. String matching identified return visits possibly related to imaging completed on first visit. Identified return visit notes were scored by three observers individually. Unclear and discrepant cases were resolved by consensus meeting, using full patient charts where needed. Incidences were provided and logistic regression analysis defined if coverage model was a predictor for recall. Odds ratios were calculated. ED patient count with imaging completed overnight in prior-16 was 9200, in prior-17 was 9543, and in post-18 was 9992. The number of overnight imaging studies performed was respectively 13,883, 14,463, and 15,112. Imaging-related ED recalls were respectively 54, 61, and 7, a decrease with the new coverage model of 89% to true and at least 90% of expected recalls.Logistic regression demonstrated that coverage model was a significant predictor of ED recalls with chi-square of 59.86 and p< 0.001, an R2 of 0.03 (Hosmer and Lemeshow). Compared to post-18, ED patients had an odds ratio of 8.42 (prior-16) and 9.18 (prior-17) to be called back to ED. Overnight final reporting significantly decreases ED recalls for patients receiving diagnostic imaging overnight. While numbers are low even prior to rollout, the number should be minimized wherever possible to diminish patient anxiety and discomfort, reduce ED overcrowding and expedite definitive management. Section 1: What is already known on this subject • Radiology resident preliminary report discrepancy rates are low. • Overnight attending radiologist coverage is a model increasingly applied in academic and large non-academic centers. • Patient recalls to the ED are a burden to the patient and impact patient throughput in (over)crowded EDs. Section 2: What this study adds • First study to look at the impact of overnight attending final reports on the recall rate for ED patients with overnight imaging performed. • While absolute numbers are low, there is a significant decrease in patients returning to ED for imaging related issues after introducing overnight attending coverage. • Resident autonomy can be preserved and training enhanced while increasing patient safety and comfort.

Epidermoid cyst arising in the mandibular ramus: A case report

Introduction: Dermoid and epidermoid cysts are developmental lesions derived from the ectoderm. In acquired elements, trauma and inflammation are hypothesized mechanisms of onset. In the oral region, these cysts mainly develop in the soft tissues such as floor of the mouth, moreover, it is relatively rare in the mandible. Among them, it is extremely rare in the ramus. Case Report: A 48-year-old woman visited dental clinic because of occlusal pain of the left wisdom tooth. The panoramic X-ray film showed an oval-shaped radiolucent area in the left mandibular ramus. Computed tomography revealed radiolucent area in the left mandibular ramus, moreover, there was no bone destruction. Magnetic resonance imaging revealed a lesion measuring 18×17×21 mm in size with mixed moderate and high signal intensity on fat-suppressed T2-weighted imaging in the left mandibular ramus. Gadolinium contrast-enhanced T1-weighted imaging showed no clear enhancement. On the basis of imaging findings, cystic lesion was diagnosed. We performed cystectomy and extraction of the lower wisdom teeth under general anesthesia. Histopathologic examination of the resected specimen revealed the unilocular cyst lined keratinized squamous epithelium. There were no adnexal skin structures such as sweat grand, sebaceous glands, and hair follicles. In addition, the lesions were not associated with teeth and were found only in the mandibular ramus. From these results, it was finally diagnosed as the epidermoid cyst. Three years and six months have passed, but there is no recurrence and a radiolucent area in the panoramic X-ray film shows increased radiopaque. Computed tomography revealed that the defect of the bone is reduced. The postoperative course was uneventful. Conclusion: There is a large amount of literature on jaw diseases; however, we may still come across unique and unclear cases. Clinical examinations, conventional radiography, and surgical experience are not sufficient for the diagnosis of all pathologies. Our case is very rare and is a unique case in the relevant literature because the lesion was limited to the mandibular ramus above the mandibular foramen and was not associated with teeth.

Basophil activation test in the diagnostics of hymenoptera venom allergy.

The aim of the study was to analyse the diagnostic performance of the basophil activation test (BAT), to compare the diagnostic reliability of BATs performed with different types of allergens, which are available in Slovakia and to verify the correlation between the symptom severity and the sensitivity and specificity of the BAT in 114 patients with suspected hymenoptera venom allergy (HVA). Diagnosis of the HVA and the identification of the appropriate venom for immunotherapy are in Slovakia based on detailed patient'medical history, skin tests and detection of sIgE. In unclear cases, where the clinical decision regarding the relevant insect species for immunotherapy is difficult, the cellular tests are recommended in several countries, such as Sweden, Spain, Germany, Denmark and Italy. In Slovakia, BAT is not adapted as s part of routine diagnostic work-up. The identification of the culprit hymenoptera species among 114 patients was based on detailed history, skin tests and detection of sIgE. Obtained results were compared with the results acquired by the BAT. The sensitivity of the BAT was 80.8 % and the specificity was 87.8 %. The sensitivity of the BAT was higher when using Soluprick SQ Allergens, but the specificity was higher with BŰHLMANN CAST Allergens. In the study no correlation between the symptom severity and the sensitivity and specificity of the BAT was observed. The results show that the BAT can be recommended in the identification of the appropriate venom for immunotherapy, the only specific treatment that is currently available for patients with HVA. Allergen source is one of critical factors in diagnostic reliability of the BAT (Tab. 4, Ref. 29) Keywords: hymenoptera venom allergy, allergy diagnosis, basophil activation test, sensitivity, specificity.

Usefulness of Itrace in Diagnosing Unclear Cases of the Deterioration in Visual Acuity. Congenital Lens Dysfunction as a New Disease Entity. Preliminary Reports.

The article analyses 22 cases of severe impairment of vision to far distances for no apparent reason. Visual impairment was observed regardless of patients’ age and type of eye defect diagnosed, with the majority of people suffering from myopia and accompanying astigmatism. The exclusion of causes related to the cornea and retina, optic nerve damage and the lack of visible pathologies of the lens in the physical examination did not allow for the determination of the cause of deterioration in visual acuity to far distances despite good vision to near distances. The results of examinations using iTrace indicated the lens as the cause of visual impairment despite the apparent lack of opacity and other pathologies within it. The results of examinations in the field of Higher Order Aberration, Opacity Map, Modulation Transfer Function™ and their graphical presentation using the Dysfunctional Lens Index™ module were analysed. Low values of visual contrast sensitivity and high values of higher order aberrations for the internal optics were observed, with the correct values for the cornea. The more pathological the results of the visual contrast sensitivity and higher order aberration, the lower the values of visual acuity to far distances. In most cases removing the dysfunctional lens and replacing it with an artificial lens allowed for a significant improvement in vision to far distances while maintaining proper vision to near distances. The procedure was performed on patients over 18 years of age. The medical history in the study group may indicate a congenital nature of the abnormal structure of the lens. Thus, it is necessary to consider verification of the diagnosis made in some patients, pointing to a new disease entity, i.e. congenital lens dysfunction.