The diagnostic value of hepatobiliary scintigraphy for choledochal cysts in the era of magnetic resonance imaging with cholangiopancreatography and contrast-enhanced hepatobiliary phase: a case report and review.

Objective: Choledochal cysts (CCs) represent cystic dilatations of the intra- or extrahepatic biliary tract. The diagnosis of CCs may not always be straightforward particularly for the intrahepatic subtype. Whereas the gold standard for diagnosing CCs is endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP) is commonly used as primary diagnostic tool for delineation of biliary pathologies including CCs. Methods: We report a case of cystic hepatic lesion near the confluence of bilateral intrahepatic ducts. MRCP shows direct anatomical communication between the lesion and the biliary tract, raising suspicion of a CC. Endoscopic ultrasound shows no communication between the lesion and biliary system. 99mTc-hepatic iminodiacetic acid scintigraphy (hepatobiliary scintigraphy) was subsequently performed, showing no tracer uptake in the concerned cystic hepatic lesion despite visualisation of gallbladder and transit of tracer into the intestine. Overall scintigraphic findings speak against a CC. Conclusion: The case showed conflicting anatomical findings of a CC on MRCP and endoscopic ultrasound. Hepatobiliary scintigraphy and hepatobiliary contrast MRI may both functionally demonstrate communication of a hepatic lesion with the biliary tract. But hepatobiliary scintigraphy offers the advantage of much higher hepatic extraction and hence higher resistance to competition from plasma bilirubin compared with hepatobiliary contrast MRI. The better pharmacokinetics of HIDA confer superior lesion contrast that may offset inferior image spatial resolution, in particular for large lesions and patients with hyperbilirubinaemia. Hepatobiliary scintigraphy should be considered a suitable functional diagnostic modality for CCs even in the era of magnetic resonance imaging with cholangiopancreatography and contrast-enhanced hepatobiliary phase.

Long-Term Prognostic Implications of Cerebral Microbleeds in Chinese Patients With Ischemic Stroke.

BACKGROUND: This study was performed to determine the clinical correlates and long-term prognostic implications of microbleed burden and location in Chinese patients with ischemic stroke. METHODS AND RESULTS: We recruited 1003 predominantly Chinese patients with ischemic stroke who received magnetic resonance imaging at the University of Hong Kong. We determined the clinical correlates of microbleeds and the long-term risks (3126 patient-years of follow-up) of recurrent ischemic stroke and intracerebral hemorrhage (ICH) by microbleed burden (0 versus 1, 2-4, and ≥5) and location, adjusting for age, sex, and vascular risk factors and stratified by antithrombotic use. Microbleeds were present in 450 of 1003 of the study population (119/450 had ≥5, 187/450 had mixed location). Having ≥5 microbleeds was independently associated with prior antiplatelet and anticoagulant use, whereas microbleeds of mixed location were independently associated with hypertension and prior anticoagulant use (all P<0.05). Microbleed burden was associated with an increased risk of ICH (microbleed burden versus no microbleeds: 1 microbleed: multivariate hazard ratio: 0.59 [95% confidence interval, 0.07-5.05]; 2-4 microbleeds: multivariate hazard ratio: 2.14 [95% confidence interval, 0.50-9.12]; ≥5 microbleeds: multivariate hazard ratio: 9.51 [95% confidence interval, 3.25-27.81]; Ptrend<0.0001), but the relationship of microbleed burden and risk of recurrent ischemic stroke was not significant (Ptrend=0.054). Similar findings were noted in the 862 of 1003 patients treated with antiplatelet agents only (ICH: Ptrend<0.0001; ischemic stroke Ptrend=0.096). Multivariate analysis revealed that, independent of vascular risk factors, antithrombotic use, and other neuroimaging markers of small vessel disease, having ≥5 microbleeds (multivariate hazard ratio: 6.08 [95% confidence interval, 1.11-33.21]; P=0.037) was identified as an independent predictor of subsequent ICH, but neither microbleed burden nor location was predictive of recurrent ischemic stroke risk. CONCLUSIONS: In Chinese patients with ischemic stroke, a high burden of cerebral microbleeds was significantly associated with an increased risk of ICH; however, neither microbleed location nor burden was associated with recurrent ischemic stroke risk.

Rare presentation of small bowel intussusception in childhood.

Small bowel intussusception complicated simultaneously by volvulus in an older child is rare but clinically significant, necessitating urgent operative management. We report a local case of jejuno-jejunal intussusception complicated by volvulus and bowel infarction in a 9-year-old Chinese girl, with diagnosis made on preoperative computed tomography and confirmed at laparotomy. An intestinal polyp as the lead point for intussusception was identified operatively.

Effects of psychosocial interventions on self-efficacy of dementia caregivers: a literature review.

INTRODUCTION: Self-efficacy plays an important role in mediating stressors and physical and psychological outcomes in dementia caregiving. OBJECTIVES: This literature review aims to identify, summarize, and critically appraise current evidence on the psychosocial interventions used for enhancing the self-efficacy of caregivers of patients with dementia (PWD). METHODS: A database search from two major web gateways was conducted to identify relevant research articles with an intervention for caregivers of patients with any type of dementia that included self-efficacy as an outcome measure. RESULTS: A total of 14 studies met the criteria. The key findings and characteristics of the interventions were summarized and analyzed. The results showed that caregivers' self-efficacy and other aspects could be improved by psychosocial interventions. CONCLUSION: The efficacy of the interventions for self-efficacy and other outcomes for caregivers and PWD were explored. Recommendations on the effects and significance of various psychosocial interventions for caregivers of PWD in enhancing self-efficacy were discussed.

Can pre-operative axial CT imaging predict syndesmosis instability in patients sustaining ankle fractures? Seven years' experience in a tertiary trauma center.

OBJECTIVE: The purpose of this study is to explore the diagnostic accuracy of CT measurements in predicting syndesmosis instability of injured ankle, with correlation to operative findings. METHODS: From July 2006 to June 2013, 123 patients presented to a single tertiary hospital who received pre-operative CT for ankle fractures were retrospectively reviewed. All patients underwent open reduction and internal fixation for fractures and intra-operative syndesmosis integrity tests. The morphology of incisura fibularis was categorized as deep or shallow. The tibiofibular distance (TFD) between the medial border of the fibula and the nearest point of the lateral border of tibia were measured at anterior (aTFD), middle (mTFD), posterior (pTFD), and maximal (maxTFD) portions across the syndesmosis on axial CT images at 10 mm proximal to the tibial plafond. Statistical analysis was performed with independent samples t test and ROC curve analysis. Intraobserver reproducibility and inter-observers agreement were also evaluated. RESULTS: Of the 123 patients, 39 (31.7%) were operatively diagnosed with syndesmosis instability. No significant difference of incisura fibularis morphology (deep or shallow) and TFDs was demonstrated respective to genders. The axial CT measurements were significantly higher in ankles diagnosed with syndesmosis instability than the group without (maxTFD means 7.2 ± 2.96 mm vs. 4.6 ± 1.4 mm, aTFD mean 4.9 ± 3.7 mm vs. 1.8 ± 1.4 mm, mTFD mean 5.3 ± 2.4 mm vs. 3.2 ± 1.6 mm, pTFD mean 5.3 ± 1.8 mm vs. 4.1 ± 1.3 mm, p < 0.05). Their respective cutoff values with best sensitivity and specificity were calculated; the aTFD (AUC 0.798) and maxTFD (AUC 0.794) achieved the highest diagnostic accuracy. The optimal cutoff levels were aTFD = mm (sensitivity, 56.4%; specificity, 91.7%) and maxTFD = 5.65 mm (sensitivity, 74.4%; specificity, 79.8%). The inter-observer agreement was good for all aTFD, mTFD, pTFD, and maxTFD measurements (ICC 0.959, 0.799, 0.783, and 0.865). The ICC for intraobserver agreement was also very good, ranging from 0.826 to 0.923. CONCLUSIONS: Axial CT measurements of tibiofibular distance were useful predictors for syndesmosis instability in fractured ankles. The aTFD and maxTFD are the most powerful parameters to predict positive operative instability.