Refractory chylothorax after severe vomiting and coughing in a 4-year-old child

Chylothorax is the accumulation of lymphatic fluid in the pleural space. It is a rare condition with potentially life-threatening disorders. In children, the etiology of chylothorax can be mainly attributed to idiopathic factors, congenital, miscellaneous, trauma and malignancies. Conservative treatments can solve most chylothorax, but refractory chylothorax can be challenging to manage. We herein present the case of a 4-year-old girl with no previous medical history who was admitted to our institution after severe vomiting and right chylothorax. The etiological assessment could not identify specific causes. Initial treatment was conservative but after 14 days, the patient showed no improvement. An exploratory thoracoscopy using indocyanine green showed no active leaks. Pleurodesis was performed and, later on, ligation of the ductus thoracicus. Hereafter, the patient progressed favorably. Even though conservative treatments of chylothorax show a high success rate, the efficacy of additional therapies and the benefits between surgical procedures need further investigation.

Redefining the vascular anatomy of the medial gastrocnemius muscle: A computed tomography angiography study

BACKGROUND

The medial gastrocnemius (GN) muscle flap is a historical reconstructive option in lower limb reconstruction. The flap is proximally based on the medial sural artery, and it is assumed not possible to harvest a distally based flap because of the absence of other minor pedicles. The aim of this study is to investigate the presence and the anatomy of a distal secondary pedicle given off by the posterior tibial artery (PTA).

METHODS

A retrospective CTA study was performed of 120 limbs between April 2018 and June 2020. 3D reconstruction was performed to delineate the anatomy of the distal secondary pedicle, if present. The distance of the pedicle, if found, from the intermalleolar line to the patella was noted. The number of pedicles, if multiple, was documented, as well as branches to the soleus muscle and the skin.

RESULTS

A distal pedicle to the gastrocnemius muscle was found in 64% of limbs. The average location from the intermalleolar line is 168 mm. The branching pattern from the PTA showed an isolated vessel going to the distal medial gastrocnemius (32.8%), two branches to the medial gastrocnemius and skin (39.3%), two branches to the medial gastrocnemius and soleus (24.6%), and three branches to the medial gastrocnemius, soleus, and the skin (3.3%).

CONCLUSIONS

This study confirms the presence of the secondary axial distal pedicle of the GN muscle. Furthermore, this study confirms that there is a likely association between the distal medial gastrocnemius pedicle and the PTA skin perforators.

The correlation of muscle quantity and quality between all vertebra levels and level L3, measured with CT: An exploratory study

Introduction

In patients with cancer, low muscle mass has been associated with a higher risk of fatigue, poorer treatment outcomes, and mortality. To determine body composition with computed tomography (CT), measuring the muscle quantity at the level of lumbar 3 (L3) is suggested. However, in patients with cancer, CT imaging of the L3 level is not always available. Thus far, little is known about the extent to which other vertebra levels could be useful for measuring muscle status. In this study, we aimed to assess the correlation of the muscle quantity and quality between any vertebra level and L3 level in patients with various tumor localizations.

Methods

Two hundred-twenty Positron Emission Tomography (PET)-CT images of patients with four different tumor localizations were included: 1. head and neck (n = 34), 2. esophagus (n = 45), 3. lung (n = 54), and 4. melanoma (n = 87). From the whole body scan, 24 slices were used, i.e., one for each vertebra level. Two examiners contoured the muscles independently. After contouring, muscle quantity was estimated by calculating skeletal muscle area (SMA) and skeletal muscle index (SMI). Muscle quality was assessed by calculating muscle radiation attenuation (MRA). Pearson correlation coefficient was used to determine whether the other vertebra levels correlate with L3 level.

Results

For SMA, strong correlations were found between C1-C3 and L3, and C7-L5 and L3 (r = 0.72-0.95). For SMI, strong correlations were found between the levels C1-C2, C7-T5, T7-L5, and L3 (r = 0.70-0.93), respectively. For MRA, strong correlations were found between T1-L5 and L3 (r = 0.71-0.95).

Discussion

For muscle quantity, the correlations between the cervical, thoracic, and lumbar levels are good, except for the cervical levels in patients with esophageal cancer. For muscle quality, the correlations between the other levels and L3 are good, except for the cervical levels in patients with melanoma. If visualization of L3 on the CT scan is absent, the other thoracic and lumbar vertebra levels could serve as a proxy to measure muscle quantity and quality in patients with head and neck, esophageal, lung cancer, and melanoma, whereas the cervical levels may be less reliable as a proxy in some patient groups.

Anatomic study of the profunda artery perforators by multidetector CT scanner and clinical use of the banana-shaped flap design for breast reconstruction

BACKGROUND

The profunda artery perforator (PAP) flap is a well-known free flap for breast reconstruction. However, a reproducible perforator mapping system has yet to be developed.

METHODS

The PAP perforators were localized by CTA using a novel X-Y axis system. Flap dimensions were based on the CTA images and localized PAP-perforators. Perioperative findings and postoperative outcomes were analyzed.

RESULTS

A total of 70 lower limbs and 180 PAP perforators were evaluated. An average of 2.78 ± 1.22 and 2.22 ± 0.96 perforators were seen, in the right and left legs, respectively, and were divided in five clusters (PAP1-PAP5) based on their location on the Y-axis. The course of the perforators was noted as well as the average diameter at the origin. The overall average diameter was 1.99 ± 0.86 mm. A banana-shaped PAP-flap was harvested in 10 patients. The mean operative time was 278 min, pedicle length 76 ± 12 mm, and mean flap weight 247 g. No major complications were seen.

CONCLUSION

The PAP flap can be mapped by CTA in a reproducible way. The X and Y axes are based on fixed anatomic landmarks and may form the basis for a banana-shaped flap design of the PAP-flap.

Repeatability and reproducibility of ADC measurements: a prospective multicenter whole-body-MRI study

OBJECTIVES

Multicenter oncology trials increasingly include MRI examinations with apparent diffusion coefficient (ADC) quantification for lesion characterization and follow-up. However, the repeatability and reproducibility (R&R) limits above which a true change in ADC can be considered relevant are poorly defined. This study assessed these limits in a standardized whole-body (WB)-MRI protocol.

METHODS

A prospective, multicenter study was performed at three centers equipped with the same 3.0-T scanners to test a WB-MRI protocol including diffusion-weighted imaging (DWI). Eight healthy volunteers per center were enrolled to undergo test and retest examinations in the same center and a third examination in another center. ADC variability was assessed in multiple organs by two readers using two-way mixed ANOVA, Bland-Altman plots, coefficient of variation (CoV), and the upper limit of the 95% CI on repeatability (RC) and reproducibility (RDC) coefficients.

RESULTS

CoV of ADC was not influenced by other factors (center, reader) than the organ. Based on the upper limit of the 95% CI on RC and RDC (from both readers), a change in ADC in an individual patient must be superior to 12% (cerebrum white matter), 16% (paraspinal muscle), 22% (renal cortex), 26% (central and peripheral zones of the prostate), 29% (renal medulla), 35% (liver), 45% (spleen), 50% (posterior iliac crest), 66% (L5 vertebra), 68% (femur), and 94% (acetabulum) to be significant.

CONCLUSIONS

This study proposes R&R limits above which ADC changes can be considered as a reliable quantitative endpoint to assess disease or treatment-related changes in the tissue microstructure in the setting of multicenter WB-MRI trials.

KEY POINTS

• The present study showed the range of R&R of ADC in WB-MRI that may be achieved in a multicenter framework when a standardized protocol is deployed. • R&R was not influenced by the site of acquisition of DW images. • Clinically significant changes in ADC measured in a multicenter WB-MRI protocol performed with the same type of MRI scanner must be superior to 12% (cerebrum white matter), 16% (paraspinal muscle), 22% (renal cortex), 26% (central zone and peripheral zone of prostate), 29% (renal medulla), 35% (liver), 45% (spleen), 50% (posterior iliac crest), 66% (L5 vertebra), 68% (femur), and 94% (acetabulum) to be detected with a 95% confidence level.

Deep inferior epigastric artery perforator flap harvest after full abdominoplasty

Abdominal scars are no longer a contra-indication for abdominal perforator flap harvesting. Few research data exists about the regeneration potential of the abdominal wall's perforator system. Therefore, previous abdominoplasty with umbilical transposition is an absolute contra-indication for a DIEaP-flap (deep inferior epigastric artery perforator flap). A 50-year-old patient required a breast reconstruction of the right breast, 10 years after an abdominoplasty with undermining of the superior abdomen and umbilical transposition. The patient was scheduled for a free lumbar artery perforator (LaP) flap. The preoperative computed tomography-angiography mapping showed nice lumbar perforators and to our surprise a good-sized DIEa perforator in the peri-umbilical region. The DIEa perforator on the right hemi-abdomen, consisting of two veins and one artery, was pulsatile and found suitable in size. A classical flap harvest and transfer was further performed. This case report is the first in which a dominant perforator is found in the area of undermining after a full abdominoplasty with umbilical repositioning. Further investigations regarding the nature and timing of re-permeation or regeneration of perforators after abdominoplasty are to be done. Nevertheless, we are convinced that with appropriate perforator mapping and a suitable plan B, previous abdominoplasty is no longer an absolute but a relative contra-indication for performing DIEaP-flap.

A focused 35-minute whole body MRI screening protocol for patients with von Hippel-Lindau disease

BACKGROUND

Von Hippel-Lindau (VHL) disease is an autosomal dominantly inherited tumor syndrome. Affected patients develop central nervous system hemangioblastomas and abdominal tumors, among other lesions. Patients undergo an annual clinical screening program including separate magnetic resonance imaging (MRI) of the brain, whole spine and abdomen. Consequently, patients are repeatedly subjected to time-consuming and expensive MRI scans, performed with cumulative Gadolinium injections. We report our experience with a 35-min whole body MRI screening protocol, specifically designed for detection of VHL-associated lesions.

METHODS

We designed an MRI protocol dedicated to the typical characteristics of VHL-associated lesions in different imaging sequences, within the time frame of 35 min. Blank imaging of the abdomen is carried out first, followed by abdominal sequences with Gadolinium contrast. Next, the full spine is examined, followed by imaging of the brain. A single dose of contrast used for abdominal imaging is sufficient for further highlighting of spine- and brain lesions, thus limiting the Gadolinium dosage. We used 1.5 Tesla equipment, dealing with fewer artifacts compared to a 3 Tesla system for spine- and abdominal imaging, while preserving acceptable quality for central nervous system images. In addition, imaging on a 1.5 Tesla scanner is slightly faster.

RESULTS

From January 2016 to November 2018, we performed 38 whole body screening MRIs in 18 VHL patients; looking for the most common types of VHL lesions in the abdomen, spine, and brain, both for new lesions and follow-up. The one-step approach MRI examinations lead to 6 surgical interventions for clinically significant or symptomatic hemangioblastomas in the brain and spine. One renal cell carcinoma was treated with radiofrequency ablation. In comparison with previous conventional MRI scans of the same patients, all lesions were visible with the focused protocol.

CONCLUSIONS

Annual screening in VHL disease can be done in a rapid, safe and sensitive way by using a dedicated whole body MRI protocol; saving MRI examination time and limiting Gadolinium dose.

MR lymphography in patients with upper limb lymphedema: The GPS for feasibility and surgical planning for lympho-venous bypass

BACKGROUND AND OBJECTIVES

Lymphedema is caused by insufficient lymphatic drainage leading to abnormal accumulation of interstitial fluid within soft tissues. Lympho-venous anastomosis (LVA), as a surgical option for selected patients, is widely applied. Through preoperative localization of functional lymphatics with indocyanine green, real time visualization of functioning lymphatic vessels is possible. This examination is time consuming and operator dependant and is not suitable to differentiate the ratio of fat hypertrophy to liquid edema. We investigated whether MR lymphangiography is accurate for imaging functional lymphatics and adjacent veins in arms. Furthermore, we investigated the accuracy and predictability of preoperative mapping for the feasibility of performing LVA and the preoperative decision making in lymphedema surgery.

METHODS

A prospective study was performed in which 25 patients suffering from lymphedema of the upper extremity were examined. MR lymphography with contrast agent injection in a deep dermal plane was performed.

RESULTS

Precise localization of lymphatic vessels crossing a vein was achieved in 18 of 25 arms. In 16 of the 18 patients in whom functional lymphatics were localized with an adjacent vein on MRI an LVA was performed successfully.

CONCLUSIONS

MR lymphangiography is an accurate and reproducible method for imaging and mapping of lymphatic channels in the lymphedemateous limb.

Central nervous system gadolinium accumulation in patients undergoing periodical contrast MRI screening for hereditary tumor syndromes

Background

Patients with hereditary tumor syndromes undergo periodical magnetic resonance imaging (MRI) screening with Gadolinium contrast. Gadolinium accumulation has recently been described in the central nervous system after repeated administrations. The prevalence and rate of accumulation in different subgroups of patients are unknown. Neither are the mechanism nor clinical impact. This may cause uncertainty about the screening. To explore the prevalence and rate of Gadolinium accumulation in different subgroups, we retrospectively analyzed MRIs of patients with von Hippel-Lindau disease (VHL) and Tuberous Sclerosis Complex (TSC).

Methods

We determined the prevalence and rate of accumulation in the dentate nucleus and globus pallidus on unenhanced T1-weighted MRI from VHL and TSC patients. We compared the signal intensities of these regions to the signal intensity of the pons. We evaluated the impact of number of MRIs, kidney function and liver function on Gadolinium accumulation.

Results

Twenty eight VHL patients and 24 TSC patients were included. The prevalence of accumulation in the dentate nucleus and globus pallidus increased linearly according to number of Gadolinium enhanced MRIs and was higher in the VHL group (100%). A significant linear correlation between number of MRIs and increased signal intensity was observed in the VHL group.

Conclusions

Gadolinium accumulation occurs in almost all patients undergoing contrast MRI screening after >5 MRIs. We advocate a screening protocol for patients with hereditary tumor syndromes that minimizes the Gadolinium dose. This can be accomplished by using a single administration to simultaneously screen for brain, spine and/or abdominal lesions, using an MRI protocol focused on either VHL- or TSC-specific lesions. Higher prevalence and rate of accumulation in VHL patients may be explained by the typical vascular leakage accompanying central nervous system hemangioblastomas.

Whole-body MRI (WB MRI) including diffusion weighted (DW) imaging for the surveillance of melanoma patients at high risk for recurrence following surgery or systemic therapy

e21072

Background: Patients (pts) with locally advanced melanoma have a high risk of recurrence following complete surgical resection of macrometastases. Recent therapeutic progress has led to a growing number of stage IV pts achieving a durable complete remission (CR). For both populations no standards are established for surveillance with medical imaging. This prospective study explored the usefulness of surveillance by WB MRI for the early detection of melanoma recurrences. Methods: Pts with advanced melanoma (AJCC stages IIIb/-c or -IV) who were disease free following resection of macrometastases (cohort 1) and pts in CR following immunotherapy (cohort 2) were included. All pts underwent WB MRI, includingT1, Short Tau Inversion Recovery and DW imaging, Q4 mths the first 3 years of follow-up and Q6 mths in the following 2 years. Results: From Oct 2014 to Jan 2017, 43 pts were included (26 pts in cohort 1; 17 in cohort 2). 4 Pts were excluded (pacemaker [1pt], claustrophobia [1 pt], clinical recurrence before the first MRI [2 pt]). Mean follow-up was 103 wks (range 14–127). In total, 182 WB MRIs were performed (median number per pt: 4.5 [range 3-7]). A total of 16 pts were diagnosed with suspected lesions on WB MRI. Of these, 8 pts were diagnosed with melanoma recurrences (7 pts in cohort 1 and 1 pt in cohort 2). A total of 8 suspected lesions (8 Pts) identified on MRI (4 lymph node, 1 muscle, 1 bone, and 2 liver lesion) were considered to be of non-neoplastic origin based on additional diagnostic imaging and follow-up. No invasive procedures resulting in a false negative result were triggered by MRI. In 2 pts from cohort 2 a solitary subcutaneous metastasis was first detected by clinical examination (1 could be identified on MRI retrospectively, 1 was found in between MRIs). WB MRI was safe without any clinically meaningful ( > gr1) adverse event. Conclusions: Exploration of WB MRI for the surveillance of melanoma patients following resection of melanoma macrometastases or CR on systemic therapy indicates that it is a safe and sensitive imaging technique sparing patients cumulative exposure to x-rays and contrast media. Clinical trial information: NCT02907827.

[A patient with high creatinine levels but no renal failure: reversed autodialysis in a patient with a ruptured bladder]

BACKGROUND

In case of a ruptured bladder with urine leakage into the peritoneal cavity 'reversed autodialysis' can occur, in which urea and creatinine diffuse back into the bloodstream via the peritoneum. This causes clinical signs of pseudorenal failure, with raised concentrations of creatinine and urea. The urea/creatinine ratio does not change.

CASE DESCRIPTION

A 34-year-old female patient experienced increasing abdominal pain 3 days after laparoscopic myomectomy. Acute renal failure was suspected because of increased serum concentrations of creatinine and urea, but no cause could be found. There was a build-up of fluid in the abdominal cavity, which proved to be urine originating from an iatrogenic rupture of the bladder. Serum levels normalised following repair of the rupture.

CONCLUSION

If serum creatinine levels rise rapidly following abdominal surgery or blunt abdominal trauma the bladder should be examined for possible perforation, particularly if the abdominal dimension increases. A ruptured bladder leading to pseudorenal failure is an indication for rapid surgical intervention.

Enumeration of phytoplankton, bacteria, and viruses in marine samples

For many years, a small but dedicated group of scientists have been using flow cytometry for the evaluation of marine microorganisms. One of these scientists now provides us with a detailed series of protocols in this area, spelling out the variations in method and instrument operation that are crucial to the successful extraction of quality flow data from marine organisms. In addition, the use of a number of less frequently employed fluorescent probes gives some insight into alternative staining procedures. As our collection of microbiologically oriented techniques increases, this knowledge database becomes invaluable.

(18)FDG-PET-scan in staging of primary malignant melanoma of the oesophagus: a case report

Primary malignant melanoma of the oesophagus is a rare disease, only 262 cases being reported up to June 2005. In general, the prognosis is dismal because of its tendency to present as an advanced neoplasm with aggressive biological behaviour. (18)FDG-PET-scan is a useful tool for evaluation of metastatic disease and locoregional lymph node metastasis. We present herein a case of a young adult with primary malignant melanoma of the oesophagus, followed by a literature review on the subject.

Computed tomography of the brain in unipolar depression

Several authors have reported enlarged lateral brain ventricles in major depressive patients as compared to healthy controls. Also, the enlargement of brain lateral ventricles has been related to delusions, psychomotor retardation and some biochemical data such as cortisol secretion and L-tryptophan serum levels. The present study was undertaken to investigate if melancholic depressives are characterised by a higher degree of brain atrophy than normal controls and minor depressives, the origin of any brain atrophy, and whether measures of brain atrophy are related to cortisol secretion and L-tryptophan serum levels. We investigated 10 healthy controls and 35 depressive patients categorised according to DSM-III. In contrast to previous studies, we determined a combination of indices which makes it possible to differentiate between central and cortical diffuse atrophy. We found no evidence for the existence of abnormal atrophy of the brain in melancholics; nor did we find any correlation between CT scan measurements and cortisol or tryptophan.

Ultrasonography and computer tomography of the salivary glands in the evaluation of Sjögren's syndrome. Comparison with parotid sialography

Ultrasonography (US) and computed tomography (CT) were studied as noninvasive methods to determine salivary gland involvement and compared with parotid sialography in patients with Sjögren's syndrome (SS) and patients with only objective xerostomia and/or xerophthalmia. Patients with complaints of dry eyes and dry mouth but with no objective abnormalities served as controls. CT was not discriminative between the 2 groups. In contrast, US revealed decreased parotid gland echogenicity in most of the patients with SS, compared with only 1 patient in the group with sicca complaints only (p = 0.005). Our study suggests that US can be a useful, noninvasive method in the diagnostic investigation of patients with sicca complaints.