Meningeal alveolar soft part sarcoma confirmed by characteristic ASPCR1-TFE3 fusion

Sarcoma metastatic to the brain is uncommon and rarely occurs as the initial manifestation of tumor. Alveolar soft part sarcoma (ASPS) is a rare but well-studied subtype of sarcoma. A 39-year-old man presented with seizures due to a left temporal meningeal-enhancing lesion with striking brain edema on MRI. The patient underwent neurosurgical resection for suspected meningioma. Histology showed large tumor cells clustering and forming small nests, in places with pseudoalveolar pattern. Diastase-resistant periodic acid-Schiff revealed very rare granular and rod-like cytoplasmic inclusions. Immunohistochemistry showed convincing positivity only with vimentin and smooth muscle actin. The histological features were strongly suggestive of ASPS. At the molecular level RT-PCR and sequencing analysis demonstrated ASPCR1-TFE3 fusion confirming the histological diagnosis of ASPS. There was no evidence of primary extracranial tumor by physical examination and on chest and abdominal CT scan 11 months after presentation. ASPS typically arise from the soft tissues of the extremities and develop multiple metastatic deposits usually with a long clinical course. This case may represent primary meningeal ASPS although metastatic deposit from an undiscovered primary site cannot be entirely excluded.

Bespoke Radiology e-Learning

Introduction: Foundation doctors are expected to assess and interpret plain x-ray studies of the chest/abdomen before a definitive report is issued by senior staff. The Royal College of Radiologists have published guidelines (RCR curriculum) on the scope of plain film findings medical students should be familiar with.1 Studies have shown that the x-ray interpretation without feedback does not significantly improve diagnostic ability. 2 Queen’s University, Belfast Trust Radiology and Experior Medical developed an online system to assess individual student ability to interpret X-ray findings. Over a series of assessments each student’s profile is built up, identifying strengths and weakness. The system can then create bespoke individual assessments re-evaluating previously identified weak areas and quantifying interpretative skill improvement. Aim: To determine how readily an online system is adopted by senior medical students, investigating if increasing exposure to x-ray interpretation combined with cyclical formative feedback enhances performance. Methods: The system was offered to all 270 final year medical students as an online resource. The system comprised a series of 20 weekly 30 minute assessments, containing normal and abnormal x-rays within the RCR curriculum. After each assessment students were given formative feedback, including their own result, annotated answers, peer group comparison and a breakdown of areas of strength and weakness. Focus groups of 4-5 students addressed student perspectives of the system, including ease of use, image resolution, system performance across different operating platforms, perceived value of formative feedback loops, breakdown of performance and the value of bespoke personalised assessments. Research Ethics Approval was granted for the study. Data analysis was via two-sided one-sample t-test; initial minimal recruitment was estimated as 60 students, to detect a mean 10% change in performance, with a standard deviation of 20%. Results and Discussion: Over 80% (n = XXX/270) of the student cohort engaged with the study. Student baseline average was 39%, increasing to 62% by the exit test. The steadily sustained improvement (57% relative performance in interpretative diagnostic accuracy) was despite increasing test difficulty. Student feedback via focus groups was universally positive throughout the examined domains. Conclusion: The online resource proved to be valuable, with high levels of student engagement, improving performance despite increasingly difficulty testing and positive learner experience with the system. References: 1. Undergraduate Radiology Curriculum, The Royal College of Ra, April 2012. Ref No. BFCR(12)4 The Royal College of Radiologists, April 2012 2. I Satia, S Bashagha, A Bibi, R Ahmed, S Mellor, F Zaman. Assessing the accuracy and certainty in interpretating chest x-rays in the medical division. Clin Med August 2013 Vol.13 no. 4 349-352

Pneumothorax in the Emergency Room: personal caseload

The aim of this study was to collect information on the incidence, pathophysiology, treatment and mortality of pneumothorax in the Emergency Room. Pneumothorax is classified as spontaneous (primary, secondary or catamenial) or traumatic (iatrogenic or secondary to a blunt or penetrating chest injury). Between January 2007 and December 2009, 102 patients with pneumothorax were seen in our Emergency Room. Their records were examined and their data collected retrospectively. The type and side of the pneumothorax and age, sex, incidence and mortality were analyzed. The cases, involving 93 males and 9 females, broke down as follows: 68 spontaneous (66.7%), 33 traumatic (32.3%) and one iatrogenic (0.98%). The mean age was 47.3 (range 12-99); the incidence was 0.10%. There were no deaths due to pneumothorax in the Emergency Room. Traumatic pneumothorax was associated with blunt chest trauma, pleural effusion, hemothorax, cranial trauma, fractured collarbone, upper and lower limb fracture, pelvic fracture, vertebral and spinal trauma, sternum fracture and abdominal trauma. Pneumothorax is a common clinical problem. A multidisciplinary approach is essential to reduce the risk of morbidity and mortality. The incidence of pneumothorax in the Emergency Room was similar to that reported in the literature, while mortality data cannot be compared due to the lack of published studies.

A method to determine the impact of visual function on lesion detection performance

There are few professions in which visual acuity is as important as it is to radiologists. The diagnostic decision making process is composed of a number of events (detection or observation, interpretation and reporting), where the detection phase is subject to a number of physical and psychological phenomena that are critical to the process. Visual acuity is one phenomenon that has often been overlooked, and there is very little research assessing the impact of reduced visual acuity on diagnostic performance. The aim of this study was to investigate the impact of reduced visual acuity on an observer’s ability to detect simulated nodules in an anthropomorphic chest phantom.

A time bomb in the thorax: the giant ascending aortic aneurysm. Case report

We report the case of a 82-year-old woman, asymptomatic, subject to chest computed tomography for trauma. Then the patient underwent surgery. Before sternotomy, femoro-femoral bypass was starter in order to decompress the aneurysm; using deep hypothermia and circulatory arrest, ascending aorta and hemiarch replacement were performed with a Dacron graft. Post-operative course was uneventful.

Clinical manifestations due to pharmacological interactions in pediatric ophthalmic surgery. Topical drugs and general anaesthesia

Introduction. The authors consider the type and the incidence of the adverse effects due to the interaction between ophthalmic drugs and general anaesthesia in pediatric ophthalmic surgery. Patients and Methods. The experience included 176 general anaesthesia in 100 children aged between 9,2 months and 11,4 years (mean age 4,9 years). Results. In the 100 patients we reported: 4 cases (2.7% general anaesthesias) of sinus tachycardia with heart rhythm varying between 170 and 180 beats per minute (3.6%); 5 cases of sinus bradycardia, varying between 60 and 70 beats per minute (3.3%); 3 cases of bronchospasm (2%); 2 cases of psychomotor agitation/disturbances in pre-convulsive state after anaesthesia (1.3%); 3 cases of arterial hypotension (60-70 mmHg) (2%); 7 cases of skin rush around neck and chest (4.6%); 1 case of prolonged apnoea (0.6%). Conclusions. The clinical manifestations, principally on the cardio-circulatory and nervous system are subjected to critical revision, to foresee the pharmacological interferences and therefore to prepare the necessary measure of medical treatment.

Características clínicas y epidemiológicas del neumotórax en personas de 18 años y más: Hospital Vicente Corral Moscoso y Teófilo Dávila de Machala, 2007-2011

Se realizó un estudio descriptivo- retrospectivo desde enero de 2007 a diciembre del 2011. El universo estuvo constituido por los pacientes de 18 años y más con diagnóstico de Neumotórax, internados en los departamentos de cirugía del Hospital Regional Vicente Corral Moscoso y Hospital Teófilo Dávila. Para el levantamiento de la información se utilizó un formulario previamente diseñado. Los datos se transcribieron de las historias clínicas a los formularios respectivos. Resultados: Se incluyeron 73 pacientes del HTD y 52 del HVCM, el neumotórax de mayor prevalencia fue el traumático con el 85.6% de los casos, izquierdo en el 54.4%; las características clínicas de mayor relevancia fueron: dolor moderado 40.8%; taquicardia 15.2%; desviación de la tráquea hacia la derecha 32.8%; distención de las venas del cuello 38.4%; hipersonoridad 76.8%; murmullo vesicular disminuido 80%; disnea 99.2%; cianosis 22.4%; los método diagnósticos presentaron la siguiente prevalencia: radiografía de tórax 100%; tomografía 27.2% y resonancia en el 0.8% de los casos; el tratamiento fue en el 16% toracocentesis con aspiración de aguja y en el 100% tubo de tórax. La media de días de hospitalización fue de 5 días y la mortalidad fue del 10.4%.- Conclusiones: Se registraron diferencias estadísticamente significativas entre ambas instituciones en las características clínicas en cuanto a la procedencia, intensidad del dolor, frecuencia cardiaca, murmullo vesicular disminuido y presentación de cianosis. Además se evidencia una alta mortalidad.au

Abordagem do paciente com Cardiopatia Isquémica em consulta de Medicina Dentária

Nos últimos anos com a evolução dos sistemas de saúde tem-se verificado uma melhoria na qualidade dos serviços médicos prestados, conduzindo a uma esperança média de vida mais longa. Muitas patologias, apesar de patentes, são tratadas e/ou controladas de modo a permitir que a população possa adquirir um estilo de vida normal. As doenças cardiovasculares com o seu carácter multidimensional, têm consequências graves para o cidadão comum, para a sociedade e para o sistema de saúde, o que determina que sejam encaradas como um dos mais importantes problemas de saúde pública, problema este que urge minorar. Dentro das doenças cardiovasculares, a cardiopatia isquémica tem um significado relevante, uma vez que, engloba condições que necessitam de cuidados médicos especiais, em situações de emergência, como o enfarte agudo do miocárdio e a angina de peito (estável e instável). O médico dentista deve estar atento ao doente com cardiopatia isquémica, tendo em conta os cuidados especiais em consultório dentário que o mesmo necessita. A recolha de uma anamnese detalhada e história clínica atualizada, são fundamentais para o sucesso do tratamento dentário. O médico dentista deverá estar habilitado para atuar em situações de emergência e ter o consultório devidamente equipado, de forma a agir em conformidade com estes possíveis eventos.

Sternal wound dehiscence from intense coughing in a cardiac surgery patient: could it be prevented?

This case report is on a obese patient who underwent a coronary artery bypass. The immediate postoperative phase, on the 8th day, was characterized by sternal dehiscence with diastasis, from intense coughing. At present, for obese patients there are not any guidelines aimed to prevent the sternal diastasis. The use of a sternum support vest after median sternotomy could be a valuable tool in the postoperative care of our patients, in order to avoid chest wall hyperexpansion and to prevent sternal wound dehiscence and diastasis.

Efeito de agentes de controle sobre a qualidade reprodutiva de rainhas de Apis mellifera L. (Hymenoptera: Apidae) africanizadas

The agriculture with the use of products with less environmental impact is expanding. In it, the producers offer their products without the use of synthetic chemical inputs, solving the phytosanitary problems with the use of biological or alternative control agents such as parasites, predators, entomopathogenic, alternative products, plant extracts and essential oils. These products can be considered safe to non-target organisms, but studies are needed to find these features on natural enemies and on the beneficial insects such as bees, common frequenter of cultures. In this sense, this study aims to evaluate the effects of control over reproductive quality queens of Apis mellifera L. (Hymenoptera: Apidae) Africanized. For this, it tested the action of control products on the production of A. mellifera queens, using the commercial entomopathogenic fungus Boveril® 1,0x108 (Beauveria bassiana) and aqueous extract of pomegranate (Punica granatum) at a concentration of 5% sterile distilled water with Tween (0.01%) and sterile distilled water (controls). The treatments were incorporated into a tissue type gauze, wrapped in an acrylic plate and packed inside minirrecrias type colonies for the production of queens on the day before the transfer of larvae. The next day were introduced battens with 30 domes with larvae to produce queens, so the workers have contacted the agent tested. From the emergence of all the queens, they were monitored to determine the measures of body weight (mg), length and width of wing and abdomen, length, width and height of the chest (mm) as well as the time of emergence of queens. The next step was evaluated the influence of the control agents in production creates, performing measurements of creating areas in cm2 for six straight weeks. It was found that the area creates Queens did not differ among the treatments. Histological analysis of hipofaringeanas of workers glands that came into contact with the control agents and the midgut of virgin queens were also held. Histological analysis differences were observed in the tissues when the treatments were compared with the respective controls.

Three-dimensional, in-silico breast phantom for multimodality image simulations

We report on the construction of anatomically realistic three-dimensional in-silico breast phantoms with adjustable sizes, shapes and morphologic features. The concept of multiscale spatial resolution is implemented for generating breast tissue images from multiple modalities. Breast epidermal boundary and subcutaneous fat layer is generated by fitting an ellipsoid and 2nd degree polynomials to reconstructive surgical data and ultrasound imaging data. Intraglandular fat is simulated by randomly distributing and orienting adipose ellipsoids within a fibrous region immediately within the dermal layer. Cooper’s ligaments are simulated as fibrous ellipsoidal shells distributed within the subcutaneous fat layer. Individual ductal lobes are simulated following a random binary tree model which is generated based upon probabilistic branching conditions described by ramification matrices, as originally proposed by Bakic et al [3, 4]. The complete ductal structure of the breast is simulated from multiple lobes that extend from the base of the nipple and branch towards the chest wall. As lobe branching progresses, branches are reduced in height and radius and terminal branches are capped with spherical lobular clusters. Biophysical parameters are mapped onto the complete anatomical model and synthetic multimodal images (Mammography, Ultrasound, CT) are generated for phantoms of different adipose percentages (40%, 50%, 60%, and 70%) and are analytically compared with clinical examples. Results demonstrate that the in-silico breast phantom has applications in imaging performance evaluation and, specifically, great utility for solving image registration issues in multimodality imaging.

The role of microRNA 21 in the development of in-stent restenosis

Coronary heart disease is a major cause of morbidity and mortality worldwide. Percutaneous coronary intervention (PCI) has become the most widely used method of coronary artery revascularisation. The use of stents to hold open atherosclerosis induced arterial narrowing has significantly reduced elastic recoil and acute vessel occlusion following balloon angioplasty. However, bare metal stents have been associated with in-stent restenosis attributed to vascular smooth muscle cell (VSMC) hyperplasia and excessive neointimal formation. The resultant luminal renarrowing may manifest clinically with the return of symptoms such as chest pain or shortness of breath. The development of drug eluting stents has significantly reduced the incidence of in-stent restenosis (ISR). Unfortunately the antiproliferative medications used not only inhibit VSMC proliferation but also re-endothelialisation of the stented vessel. In addition, the drug impregnated polymer coating has been associated with a chronic inflammatory response within the vessel wall predisposing patients to stent thrombosis. Thus the identification of novel therapies which promote vessel healing without excessive proliferative or inflammatory response may improve long term outcome and reduce the need for repeated revascularisation. MicroRNAs (miRs) are short (18-25 nucleotide) non-coding RNAs acting to regulate gene expression. By binding to the 3’untranslated region of mRNA they act to fine tune gene expression either by mRNA degradation or translational repression. Originally identified in coordinating tissue development microRNAs have also been shown to play important roles coordinating the inflammatory response and in numerous cardiovascular diseases. MiR-21 has been identified in human atherosclerotic plaques, arteriosclerosis obliterans and abdominal aortic aneurysms. In addition, its up regulation has been documented in preclinical models of vascular injury. This study sought to identify the role of miR-21 in the development of ISR. Utilising a small animal model of stenting and in vitro techniques, we sought to investigate its influence upon VSMC and immune cell response following stenting. 19 The refinement of a murine stenting model within the Baker laboratory and the electrochemical dissolution of the metal stent from within harvested vascular tissues significantly improved the ability to perform detailed histological analysis. In addition, identification of miRNAs using in situ hybridisation was achieved for the first time within stented tissue. Neointimal formation and ISR was significantly reduced in mice in which miR-21 had been genetically deleted. In addition, neointimal composition was found to be altered in miR-21 KO mice with reductions in VSMC and elastin content demonstrated. Importantly, no difference in re-endothelialisation was observed. In vitro analysis demonstrated that VSMCs from miR-21 KO mice had both reduced proliferative and migratory capacity following platelet derived growth factor stimulation. Molecular analysis revealed that these differences may, at least in part, be due to de-repression of programmed cell death 4 (PDCD4). PDCD4 is a known miR-21 target within VSMCs implicated in the suppression of proliferation and promotion of apoptosis. Unfortunately, initial attempts at antimiR mediated knockdown of miR-21 in vivo, failed to produce a similar change in the suppression of ISR. Furthermore, a significant alteration in macrophage polarisation state within the neointima of miR-21 WT and KO mice was noted. Immunohistochemical staining revealed a preponderance of anti-inflammatory M2 macrophages in KO mice. Analysis of bone marrow derived macrophages from miR-21 KO mice demonstrated an increased level of the peroxisome proliferation activating receptor-γ (PPARγ) which facilitates M2 polarisation. Importantly, significant alterations in numerous pro-inflammatory cytokines, which also have mitogenic effects, were also found following genetic deletion of miR-21. In Summary, this is the first study to look at miRs in the development of ISR. MiR-21 plays an important role in the development of ISR by influencing the proliferative response of VSMCs and modulating the immune response following stent deployment. Further attempts to modulate miR-21 expression following PCI may reduce ISR and the need for repeat revascularisation while also reducing the risk of stent thrombosis.

Imaging in non Traumatic Emergencies: Acute Thrombosis of the Aorta and Pulmonary Embolism

Objectives: To present the possibility of acute arterial and venous thrombosis. Materials and methods: Report of a patient presenting with acute dyspnoea and chest pain. Results: Using a combined medical team and imaging studies, pulmonary embolism and acute arterial thrombosis were diagnosed. The patient was treated medically and surgically. Conclusion: Physicians should be aware of the possibility of combined thrombosis and the diagnosis and management of the condition.