Superior Mesenteric Artery Syndrome: A Potentially Fatal but Reversible Gastrointestinal Manifestation of Systemic Sclerosis.

Superior mesenteric artery syndrome (SMAS) is a rare gastrointestinal disorder characterised by vascular compression of the third part of the duodenum, in the angle between the superior mesenteric artery (SMA) and the abdominal aorta. It presents as an uncommon cause of upper gastrointestinal obstruction. In patients with systemic sclerosis (SSc), gastrointestinal involvement may result in oesophageal dysmotility, gastroesophageal reflux disease (GERD), gastroparesis, small intestinal bacterial overgrowth (SIBO), chronic intestinal pseudoobstruction (CIPO), and fecal incontinence. Malnutrition may thus result in weight loss and reduced mesenteric and retroperitoneal adipose tissue, decreasing the angle between the SMA and aorta causing SMAS. Enteral or parenteral feeding can potentially reverse SMAS in SSc. We report a case of SMAS in an elderly female with SSc and concurrent gastrointestinal involvement, and discuss the important management considerations and potential adverse outcomes when untreated.

Analysis of comparative performance of CEUS and CECT/MR LI-RADS classification: Can CEUS dichotomize LI-RADS indeterminate lesions on CT or MRI?

PURPOSE: To study the comparative performance of contrast-enhanced ultrasound (CEUS) and contrast-enhanced CT or MRI (CECT/MR) in evaluating liver lesions using the LI-RADS guidelines. METHODS: Retrospective analysis of radiology database from July 2010 to April 2017 revealed 228 patients who had CECT/MR and CEUS. Patients at risk of hepatocellular carcinoma (HCC), had contemporaneous CEUS and CECT/CEMR studies within 3 months and adequate follow up were included; reviewed (2 reviewers) and graded according to the 2017 CEUS and 2018 CECT/MR LI-RADS guidelines. Reference standard was multidisciplinary clinical decisions, histology or follow-up imaging. RESULTS: The study cohort consisted of 45 patients with 46 lesions. HCC were significantly larger than non-malignant (mean sizes of 2.5 and 1.4 cm, respectively, p<0.001). Intraclass correlation coefficient for CEUS review (0.941) was higher than of CECT/MR review (0.643). Mean area-under-ROC curve (AUC) for CEUS (0.994) was significantly higher than of CECT/MR (0.760) for all lesions (p=0.01). For lesions scored LR-3 by CECT/MR, the AUC was significantly higher for CEUS (0.978) than CECT/MR (0.500) (p<0.001). Twenty-one (of 27) lesions, classified LR-3 or LR-4 by CECT/MR were upgraded by CEUS and 20 were found to be HCC. Six lesions that were LR-3 on both CECT/MR and CEUS were found to be non-malignant. There was good concordance for LR-5 lesions between both techniques. CONCLUSION: CEUS is useful for reassessment of lesions with intermediate probability (LR-3) or probable for HCC (LR-4) on CECT/MR. Lesions upgraded by CEUS tend to be HCC. Lesions that remain LR-3 on CEUS tend to be non-malignant.

Clinics in diagnostic imaging (198). Small bowel obstruction secondary to a bezoar.

A 60-year-old man presented with abdominal pain. He was later diagnosed on imaging to have high-grade small bowel obstruction. The patient underwent surgery, and a hard, rounded bezoar resembling the endosperm of Nypa fruticans, colloquially known as attap chee, was found at the point of obstruction. Small bowel obstruction is a common acute surgical condition with multiple causes, including bezoars. We discuss the typical imaging features of bezoars causing small bowel obstruction as well as potential pitfalls that can mimic the appearance of a bezoar.

Clinics in diagnostic imaging (198). Small bowel obstruction secondary to a bezoar

A 60-year-old man presented with abdominal pain. He was later diagnosed on imaging to have high-grade small bowel obstruction. The patient underwent surgery, and a hard, rounded bezoar resembling the endosperm of Nypa fruticans, colloquially known as attap chee, was found at the point of obstruction. Small bowel obstruction is a common acute surgical condition with multiple causes, including bezoars. We discuss the typical imaging features of bezoars causing small bowel obstruction as well as potential pitfalls that can mimic the appearance of a bezoar.

Seroprevalence of Toxoplasma gondii among School Children in Pyin Oo Lwin and Naung Cho, Upper Myanmar

Toxoplasma gondii is an apicomplexan parasite that can cause toxoplasmosis in a wide range of warm-blooded animals including humans. In this study, we analyzed seroprevalence of T. gondii among 467 school children living in the rural areas of Pyin Oo Lwin and Naung Cho, Myanmar. The overall seroprevalence of T. gondii among school children was 23.5%; 22.5% of children were positive for T. gondii IgG, 0.4% of children were positive for T. gondii IgM, and 0.6% of children were positive for both T. gondii IgG and IgM. Geographical factors did not significantly affect the seroprevalence frequency between Pyin Oo Lwin and Naung Cho, Myanmar. No significant difference was found between males (22.2%) and females (25.0%). The overall seroprevalence among school children differed by ages (10 years old [13.6%], 11–12 years old [19.8%], 13–14 years old [24.6%], and 15–16 years old [28.0%]), however, the result was not significant. Polymerase chain reaction analysis for T. gondii B1 gene for IgG-positive and IgM-positive blood samples were negative, indicating no direct evidence of active infection. These results collectively suggest that T. gondii infection among school children in Myanmar was relatively high. Integrated and improved strategies including reinforced education on toxoplasmosis should be implemented to prevent and control T. gondii infection among school children in Myanmar.

Ultrasound and MRI features of penile augmentation by "Jamaica Oil" injection. A case series.

Penile paraffinoma is a rare but well-known entity. There have been few studies describing the ultrasound and MRI features of penile paraffinoma. In this case series we describe the imaging findings of 4 patients who self-injected "Jamaica oil" into their penises for the purpose of penile augmentation and discuss the utility of US and MRI in the management of these patients.

Preservation of wild isolates of human malaria parasites in wet ice and adaptation efficacy to in vitro culture.

Wild isolates of malaria parasites were preserved in wet ice for 2-12 days and cultivated by a candle jar method. In four isolates of Plasmodium falciparum collected from Myanmar and preserved for 12 days, all failed to grow. In 31 isolates preserved for 5-10 days, nine were transformed to young gametocytes, but 22 isolates grew well. From Ranong, Thailand, nine isolates preserved for 7 days were examined, and six grew well. On the other hand, all of the 59 isolates collected from eastern Indonesian islands failed to establish as culture-adapted isolates, even most of them were preserved only for 2-3 days: 10 isolates stopped to grow, and 49 isolates were transformed to sexual stages by Day 10. These results indicated that a great difference in adaptation to in vitro culture may exist between wild isolates distributed in continental Southeast Asia and in eastern Indonesia and that gametocytogenesis might be easily switched on in Indonesian isolates. In wild isolates of P. vivax, P. malariae and P. ovale preserved for 2-9 days, ring forms or young trophozoites survived, but adaptation to in vitro culture failed. These results indicate that wild isolates can be preserved in wet ice for 9-10 days.

Effectiveness of an algorithm in reducing the number of unnecessary ultrasound scans for deep vein thrombosis: an evaluation report.

INTRODUCTION: Patients with suspected deep vein thrombosis (DVT) pose a diagnostic dilemma to the Emergency Department (ED) clinician. This study aimed to implement a known algorithm incorporating the modified Wells criteria and D-dimer testing to guide the ED clinician, thus reducing unnecessary ultrasound scans (USS). METHODS: Patients who presented to the ED between August 2008 and April 2009 with suspected DVT underwent Wells scoring. Those with scores < 2 were deemed unlikely to have DVT and underwent D-dimer testing first. Patients with scores ≥ 2 were regarded as likely to have DVT and underwent urgent USS. USS findings were tabulated as positive or negative/indeterminate for DVT. The latter group was followed up for one year to check whether DVT was missed during the initial USS. RESULTS: 75 patients presented with suspected DVT and underwent USS. Of these, 14 results were positive and 61 were negative. 37 patients had Wells scores < 2, with three (8.1%) having DVT. Another 38 patients had Wells scores ≥ 2, with 11 (28.9%) having DVT. D-dimer testing was performed on 27 of the 75 patients. Those with DVT had higher average values compared to those without DVT (1.305 vs. 0.595 µg/ml). The majority of patients with raised D-dimer values had cellulitis, although three also had DVT (with values ≥ 0.99 µg/ml). CONCLUSION: We managed to reduce the number of unnecessary USS and increase the pick-up rate of DVT. A cut-off score ≥ 2 in our algorithm is suitable for use in the ED setting.

Effectiveness of an algorithm in reducing the number of unnecessary ultrasound scans for deep vein thrombosis: an evaluation report

<p><b>INTRODUCTION</b>Patients with suspected deep vein thrombosis (DVT) pose a diagnostic dilemma to the Emergency Department (ED) clinician. This study aimed to implement a known algorithm incorporating the modified Wells criteria and D-dimer testing to guide the ED clinician, thus reducing unnecessary ultrasound scans (USS).</p><p><b>METHODS</b>Patients who presented to the ED between August 2008 and April 2009 with suspected DVT underwent Wells scoring. Those with scores < 2 were deemed unlikely to have DVT and underwent D-dimer testing first. Patients with scores ≥ 2 were regarded as likely to have DVT and underwent urgent USS. USS findings were tabulated as positive or negative/indeterminate for DVT. The latter group was followed up for one year to check whether DVT was missed during the initial USS.</p><p><b>RESULTS</b>75 patients presented with suspected DVT and underwent USS. Of these, 14 results were positive and 61 were negative. 37 patients had Wells scores < 2, with three (8.1%) having DVT. Another 38 patients had Wells scores ≥ 2, with 11 (28.9%) having DVT. D-dimer testing was performed on 27 of the 75 patients. Those with DVT had higher average values compared to those without DVT (1.305 vs. 0.595 µg/ml). The majority of patients with raised D-dimer values had cellulitis, although three also had DVT (with values ≥ 0.99 µg/ml).</p><p><b>CONCLUSION</b>We managed to reduce the number of unnecessary USS and increase the pick-up rate of DVT. A cut-off score ≥ 2 in our algorithm is suitable for use in the ED setting.</p>

Contrast enhanced ultrasound of kidneys. Pictorial essay.

Contrast-enhanced ultrasound has entered the imaging mainstream in the last few years. It is a safe technique with exquisite temporal and spatial resolution and is especially useful for evaluating focal renal mass lesions in patients with renal impairment when iodinated or gadolinium contrast agents are contraindicated. The purpose of this manuscript is to briefly describe our technique, show the normal renal haemodynamics of ultrasound contrast agent and demonstrate a spectrum of renal masses and possible pitfalls.

Fasciola hepatica in a New Zealander traveler.

Fascioliasis is a reemerging zoonosis endemic in many parts of the world. Reports of imported fascioliasis by migrants into nonendemic countries are common, but tourists and business travelers are rarely afflicted. Here, we report a case of a New Zealander traveler who acquired the infection on a business trip.

High Levels of Antibodies to Plasmodium falciparum Liver Stage Antigen-1 in Naturally Infected Individuals in Myanmar

Plasmodium falciparum liver stage antigen-1 (PfLSA-1) is one of the few antigens expressed exclusively in liver stage parasites. In this study, we evaluated the antibody responses against recombinant PfLSA-1 in naturally infected individuals in Myanmar. High levels of antibody responses (70.7%) were detected in 82 serum samples from 116 infected individuals, and IgG responses to PfLSA-1 principally composed of responses of IgG1 and IgG3 subclasses. These results show that PfLSA-1 elicits effective antibody responses in individuals infected with P. falciparum, and thus it could be not only an attractive candidate protein for vaccine development, but also a useful antigen for serodiagnosis of the infection.

Preauricular sinus: clinical course and associations.

OBJECTIVES: To evaluate the clinical course of congenital preauricular sinus (PAS) up until adulthood and to determine its association with congenital ear and renal abnormalities. DESIGN: Cohort survey. SETTING: Medical screening facility at a military base. PARTICIPANTS: All individuals in a cohort of male subjects who were medically assessed for conscription into the army between September 1, 2003, and March 31, 2004. INTERVENTIONS: Subjects identified as having PAS were further evaluated with pure-tone audiometry and renal ultrasonography. MAIN OUTCOME MEASURES: Presence of PAS and associated hearing and renal abnormalities. RESULTS: Of 10 734 male subjects (median age, 19 years; range, 16-26 years) screened, 121 (1.13%) were found to have PAS, all of which were isolated. The point prevalence of PAS in Chinese, Malay, and Indian subjects was 1.36%, 0.69%, and 0.17%, respectively. Of the 29 subjects (24.0%) who developed symptoms (mainly sinus discharge), most had recurrent symptoms, and 7 (24.1%) of the 29 had onset of symptoms after age 16 years. Only 1.7% and 2.6% of the subjects had associated hearing loss (sensorineural) and renal deformity (minor in nature), respectively. CONCLUSIONS: In a study of young adult males with PAS, associations with ear and renal abnormalities were found to be rare, although PAS had widely been acknowledged to be associated with these congenital defects. Up until adulthood, about one quarter of all lesions became symptomatic. Of those who developed symptoms, almost one third did so after age 16 years. The most common symptom was sinus discharge, which tended to be recurrent.

Usefulness of the recombinant liver stage antigen-3 for an early serodiagnosis of Plasmodium falciparum infection

In order to develop tools for an early serodiagnosis of Plasmodium falciparum infection, we evaluated the usefulness of P. falciparum liver stage antigen-3 (LSA-3) as a serodiagnostic antigen. A portion of LSA-3 gene was cloned, and its recombinant protein (rLSA-3) was expressed in Escherichia coli and purified by column chromatography. The purified rLSA-3 and 120 test blood/serum samples collected from inhabitants in malaria-endemic areas of Mandalay, Myanmar were used for this study. In microscopic examinations of blood samples, P. falciparum positive rate was 39.1% (47/120) in thin smear trials, and 33.3% (40/120) in thick smear trials. Although the positive rate associated with the rLSA-3 (30.8%) was lower than that of the blood stage antigens (70.8%), rLSA-3 based enzyme-linked immunosorbent assay could detect 12 seropositive cases (10.0%), in which blood stage antigens were not detected. These results indicate that the LSA-3 is a useful antigen for an early serodiagnosis of P. falciparum infection.