Fatal pulmonary embolism following injectable gluteal filler usage: a case report.

BACKGROUND: Despite the fact that injectable filler usage in the gluteal region has not been recommended in formal medical institutions, illegal procedures are performed in many clinics and beauty centers across Egypt. This case report illustrates the illegal practice culminating in a fatal complication. CASE PRESENTATION: A 26-year-old female with no relevant medical history presented to the ER with acute onset shortness of breath. The complaint started 16 h before, with a rapidly progressive course, shortly after undergoing a gluteal filler injection at a center in Cairo. At ER, the patient was severely distressed, yet fully conscious and oriented. She was shocked (BP 70/40 mmHg), tachycardic (130 BPM), and tachypneic (30/min) with normal temperature. She had congested pulsating neck veins with positive Kussmaul sign. Chest auscultation revealed normal vesicular breathing with equal air entry and no adventitious sounds. Her O2 saturation was 60% on room air that improved to 85% on O2 mask. ECG showed sinus tachycardia. Echocardiography showed dilated right side, D-shaped septum with systolic flattening, dilated IVC, mild tricuspid regurgitation and estimated RV systolic pressure 53 mmHg. Her ABG showed compensated metabolic acidosis with elevated lactate level. At the ICU, CVP was 18 mmHg. Saline infusion was continued along with noradrenaline infusion initiation. A provisional diagnosis of high-risk pulmonary embolism was made, though CT pulmonary angiography was not available. Accordingly, thrombolytic therapy was initiated with alteplase (100 mg) over 2 h. Also, a dose of pulse steroids (methylprednisolone 200 mg) was given. Chest X-ray showed bilateral heterogenous opacity and ABG showed deteriorating hypoxia and combined metabolic and respiratory acidosis. The patient was intubated upon deterioration of conscious level and was put on mechanical ventilation. Her ET tube showed frequent blood-tinged secretions. Echocardiography showed more right-side dilatation that was consistent with deterioration of clinical status. Three hours after admission the patient developed cardiac arrest and died 2 h later. CONCLUSIONS: This case report highlights the dangers associated with injectable filler usage in the gluteal region. Physicians and patients should be aware of the possible complications and how to avoid it.

Intramedullary Kirschner wire fixation of displaced distal forearm fractures in children.

AIM OF THE WORK: This study was designed to highlight internal fixation by intramedullary K-wires for displaced distal forearm fractures among children and analyze the results of this technique. We hypothesize that physis-sparing intramedullary fixation prevents displacement with a lower complication rate. METHODS: This prospective case series involving 47 patients was conducted between February 2018 and December 2019. All patients with open physis presented with recent displaced distal forearm fractures were included, and all of them were treated with an intramedullary k-wire fixation for both bones with the assessment of the union rate, union time, suspected complication, radiographic evaluation, and functional outcome. RESULTS: The study population consisted of 31 boys (66%) and 16 girls (34%). The mean age of the patients was 10.68 ± 2.728 years (range, 7-15 years). All fractures were united in a median of 6 weeks (range, 4-8 weeks), The functional outcome after 12 months was normal in 42 patients (89.4%), whereas, in five patients (10.6%), the functional parameters were minimally reduced. The median preoperative angulation improved from 36° (range, 24°-52°) preoperatively to 4° (range, 0°-10°) on immediate postoperative radiographs. After 12 months, the median angulation was 2° (range, 0°-7°) (p < 0.001). The angulation of the distal radius immediately after surgery and at the final follow-up was statistically correlated with the functional outcome (p < 0.001 and 0.002, respectively). CONCLUSION: This technique provides a good result with less susceptibility to re-displacement and low complication rates. LEVEL OF EVIDENCE: Level IV.

Comparative Evaluation of Arthroscopically Assisted Coracoclavicular Fixation Versus Hook Plate Fixation for Unstable Distal Clavicle Fractures: A Minimum 2-Year Follow-up Study.

Background: Neer type 2 distal clavicular fractures are associated with poor outcomes after nonoperative management. Surgical management is preferred, and various fixation methods have been studied. Purpose: To assess the clinical and radiological outcomes in patients with unstable distal-end clavicular fractures that were treated with hook plate (HP) or arthroscopically assisted coracoclavicular (AAC) fixation. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively compared the clinical and radiological results of HP versus AAC fixation in patients who had unstable lateral-end clavicular fractures and at least 2 years of follow-up. The recorded postoperative Constant score, American Shoulder and Elbow Surgeons score, and shoulder forward flexion were compared between treatment groups using the independent t test. Fracture union was evaluated on routine shoulder radiographs. Results: This study included 34 patients (17 with HP fixation, 17 with AAC fixation) with a mean ± SD age of 36.4 ± 8.3 years for the HP group and 37.2 ± 6.9 years for the AAC group. The mean follow-up period was 30.8 ± 2.8 months for the HP group and 28.8 ± 3.01 months for the AAC group. No statistically significant difference between groups was observed regarding postoperative Constant score (89.7 vs 92.5; P = .07), American Shoulder and Elbow Surgeons score (88.2 vs 91.1; P = .12), or mean time to union (10.1 vs 9.3 weeks; P = .16). Postoperative shoulder forward flexion was better in the AAC group (168.2° ± 4.3°) versus the HP group (161.9° ± 6.6°; P = .002), and the complication rate was lower in the AAC group (5.8% vs 41.1%; P = .03). Conclusion: Both the AAC and HP fixation methods were effective in the surgical fixation of unstable Neer type 2 lateral-third clavicle fractures, with successful functional and radiological outcomes. However, AAC fixation provided an earlier return to work with fewer complications.

The durability of thin superficial circumflex iliac artery perforator flap in sole reconstruction: Clinical experience with 18 cases.

BACKGROUND: The superficial circumflex iliac artery perforator flap's overall success in the reconstruction of the lower limb has been acceptable, but the sole of the foot remains more challenging. The purpose of this article is to report our experience employing the SCIP flap and evaluate its durability in reconstructing different units of the foot's sole, heel, middle, and forefoot. PATIENTS AND METHODS: This retrospective study reviewed 18 patients with sole defect reconstructed with free SCIP flap from 2017 to 2019. 18 free SCIP flaps were harvested depending on the superficial branch of SCIA (n = 16) or deep branch (n = 2). All flaps were thin and elevated above the scrapa's fascia. The heel (n = 10), middle foot sole (n = 5), forefoot sole (n = 2), and combined heel and midfoot in one patient were among the defect locations. Sole defects were caused by trauma in 10 patients (55.5%), while the rest of the causes were melanoma (three patients, 16.7%), diabetic ulcer (three patients, 16.7%), and unstable scar (one patient), and calcaneal osteomyelitis (one patient). The defect size ranged from 24 to 230 cm2 . RESULTS: The flap dimensions ranged from 6 × 4 to 18 × 11 cm. Mean follow-up observations were 42.5 months. 72.2% of our patients developed protective sensation between 12-18 months. No ulcerations were observed, and all of the patients had successful functional recoveries with satisfying cosmetic outcomes. CONCLUSION: The SCIP flap can be an optimal durable skin flap for weight-bearing sole reconstruction. SCIP flap has the advantage of being thin minimizing the problem of shearing, the need for secondary procedures, and the faster recovery of protective sensation that could prevent ulceration.

Determinants of Under-Five Children Body Mass Index in Sudan; Application of Quantile Regression: A Systematic Review.

BACKGROUND: One of the health challenges in Sub-Saharan countries is child malnutrition. Body Mass Index (BMI) can be defined as a measure of nutritional status. Examining the determinants of under-five children's BMI is a significant subject that needs to be studied. For this study, quantile regression was used to identify the determinants of under-five children's BMI in Sudan. METHODS: We used the 2014 Sudan Multiple Indicator Cluster Survey (MICS) conducted by the Central Bureau of Statistics. Quantile regression was used. RESULTS: Place of residence, state, mother's educational level, gender, age of the child, and wealth index were an important effect significantly affecting under-five children's BMI at different quantile levels. CONCLUSION: Taking measures on the nutritional status of mothers will accordingly resolve the nutritional status of their children. Therefore, the focus of policymakers should be on the influential significant factors which were found across all quantile levels to plan and develop strategies to enhance the normal or healthy weight status of under-five children in Sudan.

Core curriculum case illustration: tubo-ovarian abscess.

This is the 47th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC.

Role of Imaging in Diagnosis of a Rare Hepatosplenic Gamma Delta T-Cell Lymphoma during Pregnancy: A Case Report and Review of Literature.

Hepatosplenic γδ T-cell lymphoma (HSTCL) is a very rare peripheral T-cell lymphoma characterized by extranodal infiltration of mature malignant post-thymic T-lymphocytes into sinusoids of the liver and spleen without lymphadenopathy and significant cytopenias. It is an aggressive form of lymphoma, resistant to the conventional chemotherapy. We report a case of HSTCL in pregnancy. Because this condition is an extremely aggressive and rare entity, data from these cases can help confirm the most suitable treatment regimen and timing of initiation. The role of ultrasound and magnetic resonance imaging in the diagnosis has been discussed. HSTCL is a rare entity of T-cell lymphoma, uncommon in female patients and very rarely reported during pregnancy.

Objective Assessment of Arterial Steal Phenomenon in Direct Carotid Cavernous Fistula Using 2D Parametric Parenchymal Blood Flow Analysis / 신경중재치료의학

The aim of the study is to evaluate the hemodynamic changes and the parenchymal perfusion associated with carotid cavernous fistulas before and after embolization using two-dimensional (2D) parenchymal blood flow analysis. A 15-year-old boy presented with 2-month history of progressive right eye proptosis, chemosis, and diplopia after a motor vehicle accident. Intracranial liquid embolization using Onyx-18 through the inferior petrosal approach was done with balloon protection at the opening of the fistula in the internal carotid artery, resulting in complete occlusion of the fistula. Parenchymal blood flow analysis was done before and immediately after embolization. 2D parametric parenchymal blood flow analysis is newly introduced software that can provide data cannot be conveyed by conventional digital subtraction angiography alone. The software allows for objective assessment of the arterial steal and the parenchymal perfusion both pre, and post-embolization. Pre-embolization assessment may influence the therapeutic decision, while post-embolization assessment can evaluate the treatment efficacy.

Diagnosing Polyps on Transvaginal Sonography: Is Sonohysterography Always Necessary?

BACKGROUND: Endometrial polyps are localized overgrowth of glands, stroma, and blood vessels and reported in 13% to 50% of women with dysfunctional uterine bleeding. Transvaginal ultrasound (TVUS) is the initial noninvasive modality of choice for the evaluation of endometrial polyps. The addition of intrauterine contrast by adding saline during saline infusion sonohysterography (SIS) has been reported to improve diagnostic accuracy in detecting of endometrial polyps. Given all the technical advances in ultrasound instrumentation and technology over the last 10 years, we wanted to revisit the diagnostic accuracy and associated confidence level of TVUS and SIS for detecting endometrial polyps. OBJECTIVE: The aims of this study was to determine the diagnostic accuracy of TVUS in detecting endometrial polyps in patients with abnormal uterine bleeding or infertility and to determine if SIS is necessary when the level of confidence that a polyp is present is high. MATERIALS AND METHODS: A total of 144 patients who underwent both TVUS and SIS for the evaluation of abnormal uterine bleeding and infertility were retrospectively identified and independently reviewed by 2 blinded readers. Examinations were graded as polyps absent, equivocal for polyps, and polyps definitely present. Interreader agreement for TVUS grade was assessed using Cohen kappa. Hysteroscopy and histopathology were used as the reference standard for the final diagnosis. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value were calculated, and confidence intervals (CIs) were computed. RESULTS: From the combined assessments of both readers (288 reads), 24.7% were definitively positive for polyps, 47.2% were negative, and 28.1% were equivocal by TVUS. Interreader agreement was good with a kappa of 0.66 (95% CI, 0.56-0.76). Among the 108 reads where hysteroscopy/histopathology results were available, even when diagnostic confidence for the presence of polyps was high, TVUS had a PPV of 65.2% (95% CI, 42.1%-88.9%). This PPV was significantly lower than the corresponding PPV of SIS of 88.5% (95% CI, 77.4-100.0%; P = 0.021 for the difference). CONCLUSION: Saline infusion sonohysterography has better diagnostic accuracy for the detection and exclusion of endometrial polyps than TVUS, even in cases where the diagnostic confidence for the presence of polyps is high. Saline infusion sonohysterography may still be needed to confirm a TVUS diagnosis for polyps to limit the number of negative hysteroscopies.

First Human Evaluation of Endothelial Healing after a Pipeline Flex Embolization Device with Shield Technology Implanted in Posterior Circulation Using Optical Coherence Tomography / 신경중재치료의학

A 64-year-old female presented with an incidentally-discovered right posterior inferior cerebral artery (PICA) aneurysm, initially treated in 2015 by simple coiling. Follow-up demonstrated significant coil compaction that required retreatment. Retreatment was done uneventfully using a Pipeline embolization device (PED) shield deployed starting from the basilar artery and ending at the V4 segment of the vertebral artery. Eight-weeks post-deployment, a follow-up digital subtraction imaging (DSA) and intravascular imaging with optical coherence tomography were obtained. The intravascular imaging demonstrated that the flow diverter had good wall apposition and concentric neointimal growth over the braid with exception to the areas that the PED was not in contact with the endothelial wall, such as at the right PICA ostium and at the vertebrobasilar junction. The entire procedure was safe, and the patient had no complications. In this article, we describe for the first time the assessment of the status of endothelial “healing” of the PED shield at 8-weeks.

Optimization of a genetically encoded biosensor for cyclin B1-cyclin dependent kinase 1.

Fluorescent protein (FP)-based biosensors have revolutionized the ability of researchers to monitor enzyme activities in live cells. While the basic design principles for FP-based biosensors are well established, first-generation biosensor constructs typically suffer from relatively low fluorescence responses that limit their general applicability. The protein engineering efforts required to substantially improve the biosensor responses are often both labour and time intensive. Here we report the application of a high throughput bacterial colony screen for improving the response of kinase biosensors. This effort led to the development of a second-generation cyclin B1-CDK1 biosensor with a 4.5-fold greater response than the first-generation biosensor.