Myofibroblastoma in the Liver: A Case Report and Review of Literature

Myofibroblastoma is a rare benign mesenchymal tumor first described in the breast. It is also known as mammary-type myofibroblastoma outside of the breast, more frequently located along the embryonic milk line. Exceptionally, myofibroblastoma can occur at visceral locations. We present a case of myofibroblastoma detected incidentally in the liver. A well-circumscribed mass, grossly measuring 6.2 cm in the liver parenchyma, was found on imaging studies. Histologically, the lesion is characterized by benign spindle cells in a hyalinized collagenous stroma, with positive staining for SMA and ER, focal positivity for CD34, negative for desmin, and loss of RB1. This rare tumor at such an unusual location makes it diagnostically challenging, especially on core biopsy of the lesion. To our knowledge, this is the second case of myofibroblastoma in the liver reported in the English literature and the first such case with a detailed pathology description.

Outcomes in Enteral Access Based on Specialty and Approach: A Single-Center Three-Year Experience

INTRODUCTION

Interventional radiologic, endoscopic, and surgical approaches are commonly utilized to establish durable enteral access in adult patients. The purpose of this study is to examine differences in nutritional outcomes in a large cohort of patients undergoing enteral access creation.

METHODS

Adult patients who underwent enteral access procedures by interventional radiologists, gastroenterologists, and surgeons between 2018 and 2020 at a single institution were reviewed. Included access types were percutaneous endoscopic gastrostomy (PEG), open or laparoscopic gastrostomy, laparoscopic jejunostomy, and percutaneous gastrostomy (perc-G), percutaneous jejunostomy , or primary gastrojejunostomy.

RESULTS

912 patients undergoing enteral access cases met the criteria for inclusion. PEGs and perc-Gs were the most common procedures. PEGs had higher Charlson scores (4.5 [3.0-6.0] versus 2.0 [1.0-2.0], P = 0.007) and lower starting albumin (3.0 [2.6-3.4] versus 3.6 [3.5-3.8] g/dL, P < 0.0001). Time to goal feeds (4 [2-6] vs 4 [3-5] d, P = 0.970), delta prealbumin (3.6 [0-6.5] versus 6.2 [2.3-10] mg/L, P = 0.145), time to access removal (160 [60-220] versus 180 [90-300] d, P = 0.998), and enteral access-related complications (19% versus 16%, P = 0.21) between PEG and perc-G were similar and differences were not statistically significant. A greater percent change in prealbumin was noted for perc-G (10 [-3-20] versus 41.7% [11-65], P = 0.002).

CONCLUSIONS

Despite having higher Charlson scores and worse preoperative nutrition, there is a similar incidence of enteral access-related complications, time to goal feeds, delta prealbumin, or time to access removal between PEG and perc-G patients. Our data suggest that access approach should be made on an individual basis, accounting for anatomy and technical feasibility.

Endovascular management of traumatic pseudoaneurysms

Background

Pseudoaneurysms (PAs) caused by traumatic injury to the arterial vasculature have a high risk of rupture, leading to life-threatening hemorrhage and mortality, requiring urgent treatment. The purpose of this study was to determine the technical and clinical outcomes of endovascular treatment of visceral and extremity traumatic pseudoaneurysms.

Methods

Clinical data were retrospectively collected from all patients presenting for endovascular treatment of PAs between September 2012 and September 2018 at a single academic level one trauma center. Technical success was defined as successful treatment of the PA with no residual filling on post-embolization angiogram. Clinical success was defined as technical successful treatment with no rebleeding throughout the follow-up period and no reintervention for the PA.

Results

Thirty-five patients (10F/25M), average age (± stdev) 41.7 ± 20.1 years, presented with PAs secondary to blunt (n = 31) or penetrating (n = 4) trauma. Time from trauma to intervention ranged from 2 h - 75 days (median: 4.4 h, IQR: 3.5–17.1 h) with 27 (77%) of PAs identified and treated within 24 h of trauma. Average hospitalization was 13.78 ± 13.4 days. Ten patients underwent surgery prior to intervention. PA number per patient ranged from 1 to 5 (multiple diffuse). PAs were located on the splenic (n = 12, 34.3%), pelvic (n = 11, 31.4%), hepatic (n = 9, 25.7%), upper extremity/axilla (n = 2, 5.7%), and renal arteries (n = 1, 2.9%). Technical success was 85.7%. Clinical success was 71.4%, for technical failure (n = 5), repeat embolization (n = 1) or post-IR surgical intervention (n = 4). There was no PA rebleeding or reintervention for any patient after discharge over the reported follow-up periods. Three patients died during the trauma hospitalization for reasons unrelated to the PAs.

Conclusions

Endovascular treatment of traumatic visceral and extremity PAs is efficacious with minimal complication rates and low reintervention requirements.

Electroencephalography Measures are Useful for Identifying Large Acute Ischemic Stroke in the Emergency Department

BACKGROUND

Early diagnosis of stroke optimizes reperfusion therapies, but behavioral measures have incomplete accuracy. Electroencephalogram (EEG) has high sensitivity for immediately detecting brain ischemia. This pilot study aimed to evaluate feasibility and utility of EEG for identifying patients with a large acute ischemic stroke during Emergency Department (ED) evaluation, as these data might be useful in the prehospital setting.

METHODS

A 3-minute resting EEG was recorded using a dense-array (256-lead) system in patients with suspected acute stroke arriving at the ED of a US Comprehensive Stroke Center.

RESULTS

An EEG was recorded in 24 subjects, 14 with acute cerebral ischemia (including 5 with large acute ischemic stroke) and 10 without acute cerebral ischemia. Median time from stroke onset to EEG was 6.6 hours; and from ED arrival to EEG, 1.9 hours. Delta band power (P = .004) and the alpha/delta frequency band ratio (P = .0006) each significantly distinguished patients with large acute ischemic stroke (n = 5) from all other patients with suspected stroke (n = 19), with the best diagnostic utility coming from contralesional hemisphere signals. Larger infarct volume correlated with higher EEG power in the alpha/delta frequency band ratio within both the ipsilesional (r = -0.64, P = .013) and the contralesional (r = -0.78, P = .001) hemispheres.

CONCLUSIONS

Within hours of stroke onset, EEG measures (1) identify patients with large acute ischemic stroke and (2) correlate with infarct volume. These results suggest that EEG measures of brain function may be useful to improve diagnosis of large acute ischemic stroke in the ED, findings that might be useful to pre-hospital applications.

Arrhythmokinesis is evident during unimanual not bimanual finger tapping in Parkinson's disease

BACKGROUND

Arrhythmokinesis, the variability in repetitive movements, is a fundamental feature of Parkinson's disease (PD). We hypothesized that unimanual repetitive alternating finger tapping (AFT) would reveal more arrhythmokinesis compared to bimanual single finger alternating hand tapping (SFT), in PD.

METHODS

The variability of inter-strike interval (CVISI) and of amplitude (CVAMP) during AFT and SFT were measured on an engineered, MRI-compatible keyboard in sixteen PD subjects off medication and in twenty-four age-matched controls.

RESULTS

The CVISI and CVAMP of the more affected (MA) and less affected (LA) sides in PD subjects were greater during AFT than SFT (P < 0.05). However, there was no difference between AFT and SFT for controls. Both CVISI and CVAMP were greater in the MA and LA hands of PD subjects versus controls during AFT (P < 0.01). The CVISI and CVAMP of the MA, but not the LA hand, were greater in PDs versus controls during SFT (P < 0.05). Also, AFT, but not SFT, detected a difference between the MA and LA hands of PDs (P < 0.01).

CONCLUSIONS

Unimanual, repetitive alternating finger tapping brings out more arrhythmokinesis compared to bimanual, single finger tapping in PDs but not in controls. Arrhythmokinesis during unimanual, alternating finger tapping captured a significant difference between both the MA and LA hands of PD subjects and controls, whereas that during a bimanual, single finger tapping task only distinguished between the MA hand and controls. Arrhythmokinesis underlies freezing of gait and may also underlie the freezing behavior documented in fine motor control if studied using a unimanual alternating finger tapping task.