Case 295: Pseudomyxoma from Mucinous Adenocarcinoma of the Appendix Extending from the Retroperitoneum into the Thigh.

History A 57-year-old man with no remarkable past medical history presented to an outside institution with painless swelling in his right thigh of 6 months duration. He denied any trauma to the site. At that time, physical examination demonstrated swelling in his right upper thigh. All other work-up, including complete blood count and chest radiography, yielded negative results. The initial diagnosis was lymphangioma of the thigh. He continued to experience worsening swelling in his right upper thigh with no other symptoms over the next year. He was referred to our facility, where he underwent US evaluation of the thigh lesion, an MRI scan encompassing the entire extent of his thigh lesion, and a CT scan of his abdomen and pelvis.

Case 295.

History A 57-year-old man with no remarkable past medical history presented to an outside institution with painless swelling in his right thigh of 6 months duration. He denied any trauma to the site. At that time, physical examination demonstrated swelling in his right upper thigh. All other work-up, including complete blood count and chest radiography, yielded negative results. The initial diagnosis was lymphangioma of the thigh. He continued to experience worsening swelling in his right upper thigh with no other symptoms over the next year. He was referred to our facility, where he underwent US evaluation of the thigh lesion (Fig 1), an MRI scan encompassing the entire extent of his thigh lesion (Fig 2), and a CT scan of his abdomen and pelvis (Fig 3).

Economic and social impact of out-of-pocket expenditure on households of patients attending public hospitals.

BACKGROUND: We aimed to generate evidence on the social and economic impact of out-of-pocket expenses incurred by households on illness. METHODS: We did a hospital-based cross-sectional study including a convenience sample of 374 inpatients and outpatients. RESULTS: The median illness expenditure was the same (₹62 500) for inpatients and outpatients. Of all respondents, 51.3% among the rural and 65.5% among the urban patients were employed before illness, but after illness only 24.4% among the rural and 23.4% among the urban patients remained in employment. The proportion of rural households of different socioeconomic categories that experienced decrease in expenditure on food, education and health, and those who had to sell land or cattle, and the education of whose children suffered was statistically significant. The proportion of indebted families in different socioeconomic classes was also statistically significant among both rural and urban patients. The lowest socioeconomic strata depended mostly upon the financial support of their friends to tide over the financial crisis of an illness. CONCLUSION: Our study shows that out-of-pocket expenses on healthcare are a burden not only for the poor but also the middle classes.

Errors of inclusion and exclusion in income-based provisioning of public healthcare: Problems associated with below poverty line cards.

This study examined the effect of out-of-pocket expenditure of patients on their illness and other household changes impacting on their well-being, and assessed the socioeconomic status and below poverty line (BPL) card status among patients at the All India Institute of Medical Sciences, New Delhi. We did a hospital-based cross-sectional study of 374 inpatients and outpatients. Among the 374 study subjects, more than 69% of poor did not possess a BPL card. On the other hand, 5.5% of the above poverty line patients among the respondents possessed a BPL card. Of those having BPL cards, 84.4% belonged either to the lower middle, upper lower and lower socioeconomic status categories. Our data suggest that the inaccuracies in providing BPL cards limit access of the genuine poor to healthcare. In the light of national-level surveys on accessing healthcare and out-of-pocket expenditure by patients there is a case against 'targeting' in the delivery of public health services and user charges have an adverse impact on access to healthcare by the poor.

Nuclear Medicine to Evaluate Complications of Cerebral Shunts: Two Cases and Review of Literature.

We present two cases of cerebral shunts - a ventriculopleural shunt and a ventriculoperitoneal shunt, with their associated complications. We also hope to provide a comprehensive literature review on various imaging modalities, including nuclear medicine studies in evaluating cerebral shunt complications.

Simplifying size-specific radiation dose estimates in pediatric CT.

OBJECTIVE: Size-specific dose estimates (SSDEs) require manual measurement of torso diameters for individual patients--anteroposterior (hereafter, D(AP)), lateral (hereafter, D(LAT)), and effective (hereafter, D(E))--which can be tedious in clinical settings. We aimed to determine whether body weight can be used as a surrogate for measuring diameter in children. MATERIALS AND METHODS: D(AP) and D(LAT) were measured in 522 consecutive CT examinations (chest, 187 and abdomen-pelvis, 335) performed in 483 (± SD) children (13 ± 7 years). Effective diameter (D(E1)) was calculated as the square root of the product of D(AP) and D(LAT). A second measurement of effective diameter (D(E2)) was obtained using automated software. Correlation coefficients between patient body weight, age, and diameter were measured in addition to 95% prediction interval analysis for diameters corresponding to body weight. RESULTS: Median body weight was 51 kg, and mean D(AP), D(LAT), D(E1), and D(E2) were 207.1 ± 50.8 mm, 289.8 ± 72.6 mm, 243.3 ± 62.0 mm, and 233.6 ± 55.4 mm, respectively. Overall body weight had a strong correlation with diameter (0.88, 0.85, 0.86, and 0.93 respectively; all p < 0.0001). SSDE measured using body weight was statistically not different than SSDE measured using effective diameters (p = 0.9). Children weighing less than 27 kg and between 46 and 100 kg had statistically significant correlations with torso diameters, whereas only anteroposterior and effective diameters were correlated with children weighing between 27 and 45 kg. Children less than 4 years old had strong correlation with all diameters. Adolescents (15-18 years) did not have statistically significant correlation with any of the diameters. CONCLUSION: Body weight, instead of body diameter, can be used as a surrogate to estimate size-specific dose in children, making dose estimation clinically simpler and more rapid.

Use of 18F-FDG PET/CT imaging for evaluation of patients with primary splenic lymphoma.

UNLABELLED: Primary splenic lymphoma (PSL) is a rare disease, and its management differs from other splenic malignancies. The purpose of the present study was to evaluate the role of 18F-FDG PET/CT in patients with PSL. METHODS: We retrospectively evaluated the data of 17 patients with PSL (median age, 46 years; range, 3-64) who had undergone 50 18F-FDG PET/CT studies. Of the 50 PET/CTs, 15 were done for primary diagnosis/staging and 35 were done for restaging. PET/CT images were evaluated both qualitatively and quantitatively [maximum standardized uptake value (SUVmax)]. Combination of clinical/imaging follow-up and/or histopathologic diagnosis was taken as reference standard. RESULTS: Of the total 50 F-FDG PET/CT studies, 27 studies (54%) were positive and 23 (46%) were negative for disease. PET/CT was true positive in 25 studies, true negative in 22 studies, false positive in 2 studies, and false negative in 1 study. Overall, per study-based sensitivity was 96.2%, specificity was 91.7%, and accuracy was 94%. In those studies performed for diagnosis/staging (15/50), PET/CT was true positive in all 15, with an accuracy of 100%. In those studies performed for restaging (35/50), sensitivity was 90.9%, specificity was 91.7%, and accuracy was 91.4%. No significant difference was seen in the accuracy of PET/CT between staging and restaging groups (P=0.601). On 18F-FDG PET/CT, splenic involvement was seen in 24 studies, lymph nodal involvement in 5 studies, liver involvement in 3 studies, and bone marrow involvement in 1 study. More than one site of disease was seen in 9 PET/CT studies. On semiquantitative analysis, the overall mean splenic lesion SUVmax was 6.9±7.9 (median, 4.6; range, 1.3-29). The mean value of ratio of SUVmax of splenic lesions and SUVliver was 4.4±5.5 (median, 2.4; range, 0.9-24.2). On comparison of areas under the curve, the mean value of ratio of SUVmax of splenic lesions and SUVliver was found to be superior to SUVmax alone for this differentiation of involvement from normal spleen (P=0.018). CONCLUSION: 18F-FDG PET/CT seems useful in patients with primary splenic lymphoma and shows high diagnostic accuracy.

Suprasellar non-Langerhans cell histiocytosis (Erdheim-Chester disease)--a case report.

Erdheim-Chester disease (ECD) is an uncommon non-Langerhans cell histiocytosis that affects multiple body systems and can present clinically in a myriad of ways. An adult onset is most common with bony involvement and constitutional symptoms. We report the case of a 52-year-old female presenting with diabetes insipidus and a suprasellar mass on imaging, with no evidence of extracerebral involvement. Histopathology was consistent with ECD.

Positron emission tomography imaging in sarcoidosis.

Sarcoidosis is a chronic granulomatous disease of unknown origin. There are several modalities for diagnosis, staging and therapeutic management of patients with sarcoidosis. Among these, whole-body F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography is found to useful in patients with complex and multisystem forms of sarcoidosis. Other modalities include Gallium scanning, assesment of angiotensin converting enzyme levels in blood, chest radiography, mediastinoscopy etcetera.