Efficient management of new patient referrals to a breast service: the safe introduction of an advanced nurse practitioner-led telephone breast pain service

INTRODUCTION

There has been an almost 100% increase in referrals to breast cancer diagnostic clinics in the past decade. Breaching of the two-week cancer referral target is now commonplace, potentially delaying diagnoses of breast malignancy in many women. Almost one in five of these referrals are women with mastalgia, not a symptom linked to breast cancer. The objective of the study was the safe introduction of an advanced nurse practitioner-led telephone service for women with mastalgia to improve the service for women and create capacity for those with "red flag" breast symptoms.

METHODS

Referrals to clinic were triaged, women with mastalgia only were directed to a telephone-based assessment clinic and symptoms evaluated using a multidisciplinary created proforma.

RESULTS

Within 23 months, 1,427 women were assessed in the breast pain telephone assessment clinic: 863 (61%) were aged over 40 and 564 (39%) aged under 40. A total of 1,238 underwent telephone assessment. Reassurance and discharge only was needed for 365 (26%). The aetiology of pain was identified as musculoskeletal in 1,104/1,238 (89%) of patients, with only 39/1,238 (3.2%) identified as having true breast pain. Additional symptoms were mentioned by 264 women (18%) during the consultation; all immediately redirected back to a diagnostic clinic. Mammography was undertaken in 609 women (43%). Seven women (0.6%) were diagnosed with a breast malignancy. Patient survey indicated that 93% of patients were satisfied with the care received and 97% said they would recommend the service to a family member or friend.

CONCLUSIONS

Although face-to-face assessments for breast pain remain the standard practice in many breast units, data indicating the safety of a telephone assessment clinic, along with high levels of patient satisfaction, question whether services can be delivered differently.

Generic approach to assess the measuring performance of total-radiated power quantities by multi-channel resistive bolometer diagnostics on fusion experiments

On present-day magnetic-confinement fusion experiments, the performance of multi-channel bolometer diagnostics has typically evolved over time through experience with earlier versions of the diagnostic and experimental results obtained. For future large-scale fusion experiments and reactors, it is necessary to be able to predict the performance as a function of design decisions and constraints. A methodology has been developed to predict the accuracy with which the volume-integrated total radiated power can be estimated from the measurements by a resistive bolometer diagnostic, considering, in particular, its line-of-sight geometry, étendues of individual lines of sight, bolometer-sensor characteristics, and the expected noise level that can be obtained with its electronics and signal chain. The methodology depends on a number of assumptions in order to arrive at analytical expressions but does not restrict the final implementation of data-processing of the diagnostic measurements. The methodology allows us to predict the performance in terms of accuracy, total-radiated power level, and frequency or time resolution and to optimize bolometer-sensor characteristics for a set of performance requirements. This is illustrated for the bolometer diagnostic that is being designed for the ITER experiment. The reasonableness, consequences, and limitations of the assumptions are discussed in detail.

A contemporary analysis of the pre- and intraoperative recognition of multigland parathyroid disease

BACKGROUND

Despite advances in biochemical and radiological identification of parathyroid gland enlargement, primary hyperparathyroidism (PHPT) due to sporadic multigland parathyroid disease (MGPD) remains a perioperative diagnostic dilemma. Failure to recognise MGPD pre- or intraoperatively may negatively impact surgical cure rates and result in persistent PHPT and ongoing patient morbidity.

METHODS

We have conducted a comprehensive review of published literature in attempt to determine factors that could aid in reliably diagnosing sporadic MGPD pre- or intraoperatively. We discuss preoperative clinical features and examine pre- and intraoperative biochemical and imaging findings concentrating on those areas that give practicing surgeons and the wider multi-disciplinary endocrine team indications that a patient has MGDP. This could alter surgical strategy.

CONCLUSION

Biochemistry can provide diagnosis of PHPT but cannot reliably discriminate parathyroid pathology. Histopathology can aid diagnosis between MGPD and adenoma, but histological appearance can overlap. Multiple negative imaging modalities indicate that MGPD may be more likely than a single parathyroid adenoma, but the gold standard for diagnosis is still intraoperative identification during BNE. MGPD remains a difficult disease to both diagnose and treat.

Spectrum of Posterior Cerebral Artery Dissection: A Retrospective Observational Study and a Critical Review

Background and Aims

Intracranial arterial dissections commonly involve the vertebrobasilar system leading to subarachnoid hemorrhage (SAH) or cerebral infarction attributable to a dissecting aneurysm of the vessel or occlusion of the lumen depending on the depth of dissection. However, isolated posterior cerebral artery dissections (PCADs) are rare and sparsely reported in the literature.

Methodology

A retrospective multicentric observational study was carried out after collecting data from 14 patients admitted with PCAD in three hospitals of Kolkata, Jaipur, and Patna within the period of July 2021 to June 2022.

Results

The median age of the population was 48.5 years, and 64.28% were females. SAH was the most common presentation with dissecting aneurysms in all patients barring one, who presented with a left occipital infarct consequent to ipsilateral PCAD. Among the 14 patients, three patients denied endovascular intervention and were lost to follow-up; one patient with an occipital infarct and another patient with a dissecting left P3 aneurysm, which underwent spontaneous thrombosis, were managed conservatively. Among the nine patients scheduled for endovascular coiling, one patient succumbed before intervention and one patient succumbed to sepsis in the postoperative period. A complete recovery was noted in six patients, whereas residual neurodeficits were present in three patients. Among the six patients who had an uneventful recovery at the end of 3 months, five patients had an endovascular intervention.

Conclusion

PCAD may present with large-scale neurodeficits and is associated with high morbidity and mortality, hence necessitating prompt management. Conservative management is preferable for consequent infarcts, whereas endovascular management is desirable in cases of dissecting aneurysms, which usually tend to have a favorable outcome if intervened early.

Carotid cavernous fistula: Redefining the angioarchitecture

OBJECTIVE

Numerous classification schemes have been used for carotid cavernous fistula (CCF), each describing some aspect of the disease process but none of them provides a complete description of the fistula including its clinical features, natural history, arterial and venous architecture.

METHODS

Retrospective clinical and radiological review was done for all the patients diagnosed with CCF and treated at our institute. The CCF were classified according to the proposed API-ACE classification along with Barrow and Thomas classification.

RESULTS

Overall 28 patients (M=21, F=7) were diagnosed and treated during the 6-year period. 89.2% of CCF developed following an episode of head injury. Orbital symptoms were the most common presenting complaints. Barrows type A was the most predominant subtype (n=24) and most of the patients (n=23) demonstrated decreased ipsilateral carotid filling. Combined anterior and posterior drainage pattern was the most common drainage pattern and anterior drainage was more commonly observed than posterior drainage.

CONCLUSIONS

API-ACE classification helps to better understand and classify the angioarchitecture of CCF which could help better understand the clinical manifestations and guide in appropriate endovascular approach selection for treatment.

Clinico-radiological features of cerebral proliferative angiopathy: A large case series from India

BACKGROUND

Based on angiographic features, a rare subgroup, different from classical brain AVMs, called cerebral proliferative angiopathy (CPA) was suggested by Lasjaunias et al. in 1989. There are only few reports of CPA described from Asia. Liu et al. has described 5 cases of CPA from China. The objective of study was to evaluate the clinico-radiological features of patients with CPA in our cohort and to find out the differences between our study and the study by Lasjaunias and Liu et al.

METHODS

We retrospectively analysed cases of CPA from March 2012 to April 2020. All radiological images of the patients with AVMs were studied and findings suggestive of CPA were identified. We found 10 patients with CPA out of 272 cases of AVM (10/272) and described the various demographic and clinico-radiological features.

RESULTS

The age of the patients with CPA in our series varied from 14 to 53 years and the mean age was 28.6 years. There was male preponderance (60%) with male to female ratio of 3:2. The most common presentation was seizure (70%). Intracranial haemorrhage was present in five patients. One patient had cerebral infarction.

CONCLUSIONS

There were substantial differences in clinico-radiological profile of patients with CPA in our cohort as compared to the study by Lasjaunias et al. and Liu et al. in form of male dominance, higher rate of ICH and seizure. In our knowledge, this is the second largest series of CPA worldwide and the first largest series in Asia.

High-Grade Astroblastoma in a Young Female: An Enigma with a Rare Cautionary Tale

Astroblastoma is an uncommon neuroepithelial primary brain neoplasm with speculative histopathological origin and unpredictable clinical behavior. They can be easily misdiagnosed, as they are rarely encountered in clinical practice and share common radiological and histopathologic appearances with other glial neoplasms. Herein, we report a case of high-grade astroblastoma in a 27-year-old female with complaints of seizures and loss of consciousness, which was misdiagnosed as atypical meningioma on neuroimaging, due to its rarity and superficial cortical location appearing as extra-axial mass. Although intraoperative findings were also of an extra-axial tumor, the histology and immunophenotype was of an astroblastoma; thus, highlighting the role of histopathology and immunohistochemistry.

Assessing the impact of a gynaecomastia assessment and treatment infographic in primary care in Greater Manchester

INTRODUCTION

Men with gynaecomastia are routinely referred to breast clinics, yet most do not require breast surgical intervention. The aim of this study was to assess the impact of a novel point-of-care gynaecomastia decision infographic in primary care on the assessment, management and referral practices to tertiary breast surgical services.

METHODS

A study was carried out of male patient referrals from primary care in Greater Manchester to a tertiary breast centre between January and March in 2018-2020. Referral patterns were compared before and after the infographic went live in general practices in Greater Manchester in January 2020. Data were collected for gynaecomastia referrals, including aetiology, investigation and management.

RESULTS

In total, 394 men were referred to a tertiary breast centre from 163 general practices, of which 271 (68.8%) had a diagnosis of gynaecomastia. Use of the decision infographic by primary healthcare providers was associated with a decrease in male breast referrals with gynaecomastia (79.6% to 62.0%). Fewer gynaecomastia patients were referred with a benign physiological or drug-related cause after implementation of the infographic (52.2% vs 41.8%). Only 10 (3.7%) patients with gynaecomastia underwent breast surgery during the study period.

CONCLUSION

Implementation of a gynaecomastia infographic in primary care in Manchester was associated with a reduction in gynaecomastia referrals to secondary care. We hypothesise that implementation of the infographic into primary care nationally may potentially translate to hundreds of patients receiving more specialty-appropriate referrals, improving overall management of gynaecomastia. Further study is warranted to test this hypothesis.

Coiling Using Dual Microcatheter Technique—A Novel Approach

Posterior circulation aneurysms are difficult to treat, and if an incorporated artery is arising from the neck of aneurysm, management becomes much more challenging. Here, we are describing a novel technique used to treat a patient with a large, wide-necked left vertebral artery (VA)-posterior inferior cerebellar artery (PICA) junctional aneurysm. PICA seems to be arising from the aneurysm neck, but the aneurysm neck was not very clearly defined. So, we placed a second microcatheter into PICA, which not only allowed the coils to be placed in the aneurysm, without disrupting the flow through PICA but also helpful in assessing the aneurysmal occlusion. This technique allowed coils to be placed successfully without compromising flow through PICA.

Point-of-care ultrasound educational interventions in the neonatal intensive care unit: A systematic review

OBJECTIVE

The benefits of point-of-care ultrasound (POCUS) in the neonatal intensive care unit (NICU) have been widely recognized, but education on this area of practice remains variable. We reviewed published educational interventions regarding POCUS use in the NICU and whether they have led to sustainable increases in POCUS use.

METHODS

A systematic search of 6 databases was performed for publications from January 2000 to March 2021. Studies with quantitative data related to POCUS educational interventions in the NICU were included. Data on number of participants and roles, educational intervention, curriculum description, and project outcome measures (including sustainability) was extracted.

RESULTS

The search resulted in 686 articles, of which nine studies met the inclusion criteria. Educational interventions included didactic sessions, simulation practice, animal practice, and practice in real patients. The most common assessment was based on the quality and accuracy of the images. At the participant level, the average time to reach proficiency ranged from eight hours and thirty-six minutes to five months, and none of the studies evaluated sustainability of POCUS use after the intervention.

CONCLUSION

There is a lack of standardized training modules and assessments for POCUS use in the NICU. Given that none of the studies addressed sustainability or standardized training, we recommend that a standardized training protocol and assessment tool is developed and studied longitudinally; and that barriers to sustainable POCUS use in the NICU (such as billing issues and a lack of POCUS machines and instructors) be systematically addressed as part of this work.

A rare case of cerebral proliferative angiopathy with acute cerebral infarction and facial capillary malformation

We are describing a case of a 14-year-old girl who developed acute cerebral infarction which was documented on diffusion-weighted magnetic resonance imaging (DWI). On detailed evaluation, diagnosis of cerebral proliferative angiopathy (CPA) was made. Incidentally, she had capillary malformation on the forehead contralateral to cerebral vascular malformation. To our knowledge, this is the first case of CPA in the literature where DWI abnormality was due to acute cerebral infarction.

QSAR analysis of sodium glucose co-transporter 2 (SGLT2) inhibitors for anti-hyperglycaemic lead development

QSAR (Quantitative Structure Activity Relationship) modelling was performed on a dataset of 90 sodium-dependent glucose cotransporter 2 (SGLT2) inhibitors. The quantitative and explicative evaluations revealed some of the subtle and distinguished structural features that are responsible for the inhibitory potency of these compounds against SGLT2, such as less possible number of ring carbons at 8 Å from the lipophilic atoms in the molecule (fringClipo8A) and more possible value for the sum of the partial charges of the lipophilic atoms present within seven bonds from the donor atoms (lipo_don_7Bc). Multivariate GA-MLR (genetic algorithm-multi linear regression) and thorough validation methodology out-turned a statistically robust QSAR model with a very high predictability shown from various statistical parameters. A QSAR model with r² = 0.83, F = 51.54, Q²_LOO = 0.79, Q²_LMO = 0.79, CCC_cv = 0.88, Q²Fⁿ = 0.76-0.81, r²_ext = 0.77, CCC_ext = 0.85, and with RMSE_tr < RMSE_cv was proposed. This QSAR model will assist synthetic chemists in the development of the SGLT2 inhibitors as the antidiabetic leads.

Patient reported outcome measures in a cohort of patients at high risk of breast cancer treated by bilateral risk reducing mastectomy and breast reconstruction

BACKGROUND

Many women with increased lifetime risk of developing breast cancer, due to pathogenic gene variants or family history, choose to undergo bilateral risk reducing mastectomies (BRRM). Patient reported outcome measures (PROMS) are an increasingly important part of informed consent but are little studied in women undergoing BRRM.

METHODS

We used a validated PROMS tool for breast reconstruction (BREAST-Q) in 297 women who had BRRM and breast reconstruction, 81% of whom had no malignancy (Benign Group, BG) and 19% in whom a perioperative breast cancer was diagnosed (Cancer Group, CG). 128 women also completed a Hospital Anxiety & Depression Score (HADS) questionnaire to test if preoperative HADS score could predict PROMS outcomes.

RESULTS

Women in the CG had lower PROMS scores for satisfaction with their breasts, nipple reconstruction and sexual wellbeing. Both groups reported equal satisfaction with BRRM outcome and psychosocial well-being. Physical well-being PROMS of the abdomen and chest were high in women in both groups as were scores for satisfaction with the care they received. The CG group reported suboptimal quality of patient information. A higher presurgical HADS anxiety score predicted less favourable postoperative psychosocial well-being despite similar levels of satisfaction with aesthetic outcome.

CONCLUSION

We show a high degree of patient reported satisfaction by woman undergoing BRRM and reconstruction. There was a negative association with a cancer diagnosis on quality of life PROMS and higher preoperative anxiety levels negatively affected postoperative psychosocial well-being. These important findings should be part of the informed consent process during preoperative counselling.

Oncoplastic breast surgery: A guide to good practice

Oncoplastic Breast Surgery has become standard of care in the management of Breast Cancer patients. These guidelines written by an Expert Advisory Group; convened by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), are designed to provide all members of the breast cancer multidisciplinary team (MDT) with guidance on the best breast surgical oncoplastic and reconstructive practice at each stage of a patient's journey, based on current evidence. It is hoped they will also be of benefit to the wide range of professionals and service commissioners who are involved in this area of clinical practice.

Neurofibromatosis Type 2: A Pandora’s Box of Variable Presentations

Introduction Neurofibromatosis type 2 (NF2) also known as MISME syndrome stands for multiple inherited schwannomas, meningiomas, and ependymomas in the peripheral and central nervous system. It is a rare disorder of autosomal dominant inheritance due to mutations of a tumor-suppressor gene on the chromosome 22q12. Clinically, it is characterized by multiple benign tumors arising in both the central and peripheral nervous system, particularly from the bilateral vestibular nerve, in more than 90% of the patients, with more than two thirds of them developing spinal tumors.

Materials and Methods Here, we studied the variable presentations of cases of NF2, and thorough evaluation of patients was done by contrast MRI of brain and spine. Also, evaluation of ocular manifestations and cutaneous features was done in cases of NF2, and a follow-up was done for a period of 18 months with monitoring of cranial and spinal lesions.

Conclusion We studied the various presentations of NF2 and found that a significant proportion of the patients presented with nonvestibular tumors as the initial presentation, with bilateral cerebellopontine angle lesions being an incidental finding; also, the age of presentation in half of the patients was less than 30 years, and so we can conclude that in young patients with spinal tumors or multiple meningiomas, a thorough evaluation regarding family history and various features of NF2 should be done, so that early identification of the disease could be done and patients can be benefitted from timely interventions.

Physiological and clinical aspects in COVID-19

There is a new public health crises threatening globally with the emergence and spread of 2019 novel corona virus (COVID-19) or the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2). In very recent decade we have seen endemic outbreaks in the form of Middle East respiratory syndrome coronavirus (MERS CoV) and severe acute respiratory syndrome related coronavirus (SARS-CoV). Now we again see the emergence of another serious outbreak due to a new strain called the SARS-CoV-2 virus. This SARS-CoV-2 initially presented as pneumonia of unknown etiology with group of symptoms including fever, dry cough and shortness of breath in a cluster of patients in December 2019 Wuhan, China. COVID-19 now has quickly became a health emergency now across worldwide. SARS-CoV-2 is a newly emerging human infectious corona virus that causes COVID-19, now this has been recognized as a pandemic by the World Health Organization (WHO) on 11th March, 2020. Because of the pathogenesis and proliferation pathways of COVID-19 are still unknown the development of vaccine was not developed yet and definitive treatment was not implemented. Therefore, in this article, new potential COVID-19 therapies are briefly reviewed. The world is in emergent need for searching of possible medications for COVID-19.

Residual lymph node tumour burden following removal of a single axillary sentinel lymph with macrometastatic disease in women with screen-detected invasive breast cancer

Background

Women with screen-detected invasive breast cancer who have macrometastatic disease on axillary sentinel lymph node biopsy (SLNB) are usually offered either surgical axillary node clearance (ANC) or axillary radiotherapy. These treatments can lead to significant complications for patients. The aim of this study was to identify a group of patients who may not require completion ANC.

Methods

Data from the NHS Breast Screening Programme between 1 April 2012 and 31 March 2017 were interrogated to identify women with invasive breast carcinoma and a single sentinel lymph node (SLN) with macrometastatic disease who subsequently proceeded to completion ANC. Univariable and multivariable analyses were performed to identify patients with a single positive SLN who had no further lymph node metastasis on ANC.

Results

Of the 2401 women included in the cohort, the presence of non-sentinel node disease was significantly affected by: the number of nodes obtained at SLNB (odds ratio (OR) 0.49 for retrieval of more than 1 node), invasive size of tumour (OR 1.63 for size greater than 20 mm), surgical treatment (OR 1.34 for mastectomy), human epidermal growth factor receptor (HER) 2 status (OR 0.71 for HER2 positivity), and patient age (OR 1.10 for age less than 50 years; OR 1.46 for age greater than 70 years). Patients aged less than 70 years, with tumour size smaller than 2 cm, more than one node retrieved on SLNB, and who had breast-conserving surgery had a lower chance of positive non-sentinel nodes on completion ANC compared with other patients.

Conclusion

This study, of a purely screen-detected breast cancer cohort, identified a subset of patients who may be spared completion ANC in the event of a single axillary SLN with macrometastasis.

Endovascular management of intracranial pseudoaneurysm: an institutional experience

Objective

Pseudoaneurysms (PSAs) of the internal carotid artery (ICA) and vertebral artery are rare entities but with varied treatment options. PSAs can be spontaneous or secondary to trauma, infections, malignancies or iatrogenic. To find out the efficacy of various endovascular interventions in the management of ICA and vertebral PSAs.

Methods

The study included 14 patients diagnosed with intracranial PSAs who underwent endovascular interventions in SMS Medical College, Jaipur (Rajasthan) between June 2015 to January 2019. The clinical and radiological findings (computed tomography angiography and digital subtraction angiography) were reviewed and the consequent endovascular intervention carried out and their results were analyzed.

Results

Total 14 patients were studied out of which 8 (57.1%) were anterior circulation PSAs and 6 (42.9%) were posterior circulation PSAs There were 10 (71.4%) females and 4 (28.5%) males between the age of 9 to 65 years. Only 2 patients with PSA had past history of trauma. Coiling was done in 8 patients (57.1%), stenting in 2 patients (14.2%), parent artery occlusion in 1 patient (7.1%), glue embolization in 1 patient (7.1%) while coiling with glue in 1 patient (7.1%) and flow diverter in 2 patients (14.2%). Immediate and complete occlusion was achieved in 11 (78.6%) patients while 3 (21.4%) patients had subtotal occlusion. 11 patients under follow up till June 2019 did not report recurrence or new neurological deficit.

Conclusions

Endovascular interventions is minimally invasive and safe treatment strategy for intracranial PSAs. The ultimate choice of technique depends on clinical and imaging characteristics.

Curious Case of Atypical Hangman’s Fracture: C2–C3 Listhesis without Pars Fracture

Traumatic spondylolisthesis of axis or hangman’s fracture is the second most common C2 vertebra injury. We present a report of a young man presenting with a history of fall from height with C2 to C3 spondylolisthesis without any evidence of injury to pars interarticularis but with associated injury to capsular ligament of facet joint along with posterior spinous ligamentous injury. The patient underwent intraoperative reduction in listhesis with posterior screw fixation. The patient showed uneventful postoperative course with neurological improvement at 6-week follow-up. Hangman’s fracture refers to a diverse group of injury in which the soft tissue injury has an equally important part to play as the bone fracture.

Cushing’s Disease due to ACTH Secreting Pituitary Microadenoma: A Single Institutional Experience of Four Cases

ACTH secreting pituitary adenomas are rare occurrences in autoptical, surgical and neuroradiological series. We herewith describe a series of four patients of Cushing’s disease due to ACTH secreting pituitary microadenoma. All patients presented with signs and symptoms of hypercortisolism. Hormonal testing and bilateral inferior petrosal sinus sampling were indicative of pituitary-dependent Cushing’s syndrome. Dynamic sellar MRI was suggestive of asymmetric pituitary, with suspect pituitary microadenoma in all cases. Three patients were operated for endoscopic endonasal transsphenoidal surgery, while one patient refused surgery and was managed with ketoconazole. During postoperative period, remission of hypercortisolism was ensured in two patients, while one patient continued to have raised levels of cortisol. One patient with raised levels of cortisol during postoperative period was prescribed Ketoconazole for 6 months. Histopathology confirmed the presence of pituitary adenoma. Adenoma displayed ACTH immunoreactivity. Our cases indicate that ACTH secreting pituitary microadenoma may occur in patients with Cushing’s disease. Careful radiological, surgical and pathological examination is necessary to recognize this condition and avoid surgical failure.

Extending the identification of structural features responsible for anti-SARS-CoV activity of peptide-type compounds using QSAR modelling

A quantitative structure-activity relationship (QSAR) model was built from a dataset of 54 peptide-type compounds as SARS-CoV inhibitors. The analysis was executed to identify prominent and hidden structural features that govern anti-SARS-CoV activity. The QSAR model was derived from the genetic algorithm-multi-linear regression (GA-MLR) methodology. This resulted in the generation of a statistically robust and highly predictive model. In addition, it satisfied the OECD principles for QSAR validation. The model was validated thoroughly and fulfilled the threshold values of a battery of statistical parameters (e.g. r ² = 0.87, Q ² _loo = 0.82). The derived model is successful in identifying many atom-pairs as important structural features that govern the anti-SARS-CoV activity of peptide-type compounds. The newly developed model has a good balance of descriptive and statistical approaches. Consequently, the present work is useful for future modifications of peptide-type compounds for SARS-CoV and SARS-CoV-2 activity.

Indentation and Transverse Diameter of the Meckel Cave: Imaging Markers to Diagnose Idiopathic Intracranial Hypertension

BACKGROUND AND PURPOSE

Clinical and imaging manifestations of idiopathic intracranial hypertension should prompt early diagnosis and treatment to avoid complications. Multiple diagnostic imaging criteria are reported to suggest the diagnosis of idiopathic intracranial hypertension with questionable sensitivity and/or specificity. Increased intracranial pressure results in dilation of the perineural cisternal spaces such as the optic nerve sheaths and the Meckel cave. It may also cause protrusion of cisternal structures of the Meckel cave through the skull base foramina, which could result in indentation or a bilobed appearance of the Meckel cave. We investigated the changes in the Meckel cave in patients with proved idiopathic intracranial hypertension versus healthy controls.

MATERIALS AND METHODS

We studied 75 patients with a diagnosis of idiopathic intracranial hypertension and 75 age-and sex-matched healthy controls. The transverse diameter of Meckel cave was measured in the axial and coronal planes of T2-weighted MR imaging sequences, and comparison was made between the 2 groups.

RESULTS

The mean diameters of the Meckel cave on the coronal T2 plane in patients with idiopathic intracranial hypertension were 5.21  ± 1.22 mm on the right side and 5.16  ± 0.90 mm on the left side, while in the control group, they measured 3.89  ± 0.62 mm and 4.09  ± 0.68 mm, respectively (P value < .001). Of 75 patients with an approved diagnosis of idiopathic intracranial hypertension, 57 (76%) showed an indented Meckel cave as opposed to 21 (28%) in the control group.

CONCLUSIONS

Our results confirm for the first time that the shape and size of the Meckel cave can be used as sensitive and specific diagnostic imaging markers for the diagnosis of idiopathic intracranial hypertension.

Evaluating tisagenlecleucel and its potential in the treatment of relapsed or refractory diffuse large B cell lymphoma: evidence to date

Chimeric antigen receptor (CAR) T cells have changed the treatment landscape of relapsed or refractory diffuse large B cell lymphoma. This review focuses on the biology of tisagenlecleucel and the clinical data that support its use in this setting. In addition, we discuss how it compares to other CAR T products, the financial implications for payers, and ongoing trials.

Oyster calcification of infected bone flap: A rare complication

An extremely rare case of chronic epidural empyema after cranioplasty is presented. It derives its extreme rareness from its association with calcification. This patient when presented to our department had a complaint of swelling with on and off discharging sinus for 2 months adjacent to old incision scar mark. The patient had a history of decompressive craniectomy and evacuation of acute subdural hematoma, in some other institution, 8 years back. Following that, the patient underwent cranioplasty with the exteriorized and preserved bone flap. In the meantime, he was asymptomatic. It is a unique interesting case of chronic epidural empyema with calcified walls after 8 years of long duration following cranioplasty.

Pseudo primary abscess of the cavum septum pellucidum due to pus entrapment: A rare case report

The cavum septum pellucidum (CSP) is defined as a crevice-like space of variable width between the left and right transparent septum. In this report, a rare case of pseudo primary abscess formed in the CSP due to ventriculitis is presented.

Endovascular Occlusion of Traumatic Carotid Cavernous Fistula by Using Detachable Balloon in Various Ways: A Case Series

Introduction The detachable balloons are not frequently used nowadays for endovascular occlusion of carotid-cavernous fistula (CCF) because of lack of availability and supposed high risk of recurrence. This study describes the various way of detachable balloon embolization for traumatic CCF.

Materials and Methods We have used endovascular detachable balloon to occlude the traumatic CCF under local anesthesia in various ways in 12 traumatic cases of CCF from March 2013 to April 2015. Clinical and computed tomographic (CT) angiography follow-up was done at 6 and 12 months.

Results Clinical follow-up from 6 to 12 month showed persistent resolution of symptoms in 10 cases; 2 cases had developed slight proptosis and chemosis. CT angiography done in nine cases after 6 to 9 months showed no residual filling in CCF.

Conclusion The detachable balloon either single or double with or without coils can be used in the management of CCF by different methods. Detachable balloon is a cheaper alternative compared with coiling. It is technically easier to perform and can be performed under local anesthesia.

Measurements of the gamma-quanta angular distributions emitted from neutron inelastic scattering on 28Si

The characteristic gamma radiation from the interaction of 14.1 MeV neutrons with a natural silicon sample is investigated with Tagged Neutron Method (TNM). The anisotropy of gamma-ray emission of 1.779 MeV was measured at 11 azimuth angles with a step of ∠15°. The present results are in good agreement with some recent experimental data.

Renal Biopsy in Paroxysmal Nocturnal Hemoglobinuria: An Insight into the Spectrum of Morphologic Changes

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired, potentially life-threatening disease of blood, characterized by complement-induced intravascular hemolytic anemia and thrombosis. PNH can sometimes present directly with renal manifestations, without showing any hematological manifestation. It, therefore, becomes essential for clinicians and pathologists to be aware of the spectrum of renal changes in PNH. The aim of this study was to document the morphologic changes observed in renal biopsies in patients with PNH. This is an observational study. We report three cases that presented with acute or chronic renal insufficiency and were suspected as PNH on viewing their renal biopsy in light of their clinical and laboratory details. All the three cases were confirmed as PNH on the basis of flow cytometric analysis of CD55 and CD59. Renal biopsy in these patients showed a variety of morphologic changes, however the most consistent finding was moderate-to-heavy siderosis in their kidneys. PNH per se may be difficult to diagnose clinically and sometimes present directly with renal manifestations. It is, therefore, prudent for nephrologists and nephropathologists to be aware of the spectrum of renal changes in PNH.