Aberrant Right Subclavian Artery: Demographics, Morphological Features and Follow up CT Scans Dynamics.

Introduction: Aberrant right subclavian artery (ARSA) is the most common of the aortic arch anomalies, occurring in .5% to 1% of the population. There is no standardized follow up protocol, especially in the asymptomatic cases. The purpose of the present study was to evaluate the natural history of ARSA and the role of serial CT scans. Methods: This is a single-center retrospective study of patients with ARSA depicted on chest computed tomography (CT) scans between February 2013 and July 2022. Data were collected from their medical records. Measurements of the aorta at different segments including the aortic diameter at the orifice of ARSA, and ARSA at ostium followed by 1 cm intervals were collected, as well as for follow-up CT scans. Results: 65 patients were diagnosed with ARSA, 70.8% of whom were women. The average age for the cohort was 58.569 ± 16.99 years. The median follow up time was 4 years (range 0-10 years), KM estimated survival after ARSA diagnosis at 1 and 5 years as 97% and 93%, respectively. Nineteen patients had a second CT scan and were included in the morphological CT dynamic analysis, on average of 29 ± 27 months apart (range 7-108). The mean ARSA diameter at origin was larger in the second scan 16.91 ± 4.31 mm compared to the initial scan 16.31 ± 4.96 mm, (P = .04).The mean aortic arch diameter in the first and second CT were 28.54 ± 4.24 and 29.64 ± 5.14 (P = .10), respectively. All other measurements did not disclose any significant enlargement over time. Conclusions: Our cohort demonstrate a benign natural history of ARSA with slow growth rates. However, due to our small sample size we can't draw a clinically sound recommendation on the need for imaging follow up, and further larger cohort with longer follow up interval are required.

SMAD genes are up-regulated in brain and blood samples of individuals with schizophrenia.

Schizophrenia is a severe psychiatric disorder, with heritability around 80%, but a not fully understood pathophysiology. Signal transduction through the mothers against decapentaplegic (SMADs) are eight different proteins involved in the regulation of inflammatory processes, cell cycle, and tissue patterning. The literature is not consistent regarding the differential expression of SMAD genes among subjects with schizophrenia. In this article, we performed a systematic meta-analysis of the expression of SMAD genes in 423 brain samples (211 schizophrenia vs. 212 healthy controls), integrating 10 datasets from two public repositories, following the PRISMA guidelines. We found a statistically significant up-regulation of SMAD1, SMAD4, SMAD5, and SMAD7, and a tendency for up-regulation of SMAD3 and SMAD9 in brain samples of patients with schizophrenia. Overall, six of the eight genes showed a tendency for up-regulation, and none of them was found to have a tendency for down-regulation. SMAD1 and SMAD4 were up-regulated also in blood samples of 13 individuals with schizophrenia versus eight healthy controls, suggesting the SMAD genes' potential role as biomarkers of schizophrenia. Furthermore, SMAD genes' expression levels were significantly correlated with those of Sphingosine-1-phosphate receptor-1 (S1PR1), which is known to regulate inflammatory processes. Our meta-analysis supports the involvement of SMAD genes in the pathophysiology of schizophrenia through their role in inflammatory processes, as well as demonstrates the importance of gene expression meta-analysis for improving our understanding of psychiatric diseases.

A Mobile Thrombus of the Thoracic Aorta.

A mobile thrombus of the thoracic aorta is a rare entity, which might have serious clinical manifestations, including arterial emboli. Due to its low incidence, there is no consensus regarding the most adequate management of mobile thoracic aorta thrombus. The current case describes a patient with Polycythemia Vera and myeloproliferative neoplasm, who presented with mobile thrombus of the thoracic aorta, manifested by blue toe syndrome and asymptomatic splenic infarct. She was treated conservatively with anti-coagulation and Iloprost alongside the patient's permanent treatment of Aspirin, Hydrea and Atorvastatin. Under this treatment, the thrombus resolved completely, and the blue toes improved, except for one.

The Granulated Sweetener Packet Sign.

The last two decades have seen a continuing shift from visual and tactile diagnoses in dermatology towards novel, state-of-the-art, and noninvasive instrumental technologies. Against the current tide toward replacing classical physical examinations with sophisticated high-tech ones, the present article will describe an easy-to-use and practical clinical sign to differentiate between metastases of malignant lesions and apparently benign inflamed/infected dermoid cysts. Epidermoid cysts (sometimes erroneously called "sebaceous cysts") are subcutaneous nodules containing keratin and encapsulated by an epidermoid wall. They are mobile nodules, smooth to the touch, variable in size, and most commonly located on the face, neck, and trunk. They may rupture or become infected and inflamed, red, painful, or purulent. Diagnosis is usually clear-cut, and uncomplicated cysts may not require treatment. Patients usually seek advice and request excision for esthetic or medical reasons (inflammation/infection). A 48-year-old otherwise healthy woman presented for a consultation because of a small cyst on her forehead (Figure 1). Two-finger palpation of the cyst revealed that it did not have the gelatinous fluctuant consistency of an ordinary cyst, but rather felt like a packet of granulated sweetener. The histological diagnosis of the cyst was small-to-medium-sized T-cell lymphoma. The diagnostic challenge of this case was to distinguish between metastases and an ordinary innocent-appearing cyst. The impression of a packet containing granular material upon palpitation of a cyst can be the definitive clue to detecting metastases of malignant lesions among what appear to be uncomplicated dermoid cysts. We have seen several such cases of subcutaneous nodules that turned out to be metastases of sarcomas and carcinomas, all of them with the same impression of a packet of granulated material upon palpation. We propose the term "granulated sweetener packet sign" for this diagnostic sign.

Aortic Intramural Hematoma due to Intercostal Artery Aneurysms.

BackgroundIntercostal artery aneurysms (ICA) are rare vascular disease. A rupture of ICA is a possible mechanism of intramural aortic hematoma (IH). We report a case with IH and ICAs without clear etiology. Case presentation: A 64-year-old man was admitted to our emergency room with a sudden onset of acute diffused abdominal and chest pain, radiating to the back. Without previous traumatic insult, a computed tomographic angiography scan (CTA) revealed an IH beginning inferior to the left subclavian artery extending to the level of the celiac trunk. Follow-up CTA demonstrated a stable maximal IH thickness diameter of 11 mm, maximal aortic diameter of 40 mm, a new left hemorrhagic pleural effusion, and a focal contrast enhancement at T9 level. Due to these findings, thoracic endovascular aortic repair (TEVAR) was performed. During follow up, T9 focal enhancement continues to grow and an additional one developed. Selective angiography was performed demonstrating a connection to the costal artery and the aortic lumen, confirming ICA. Successful embolization with micro coils was performed. During follow up, additional 2 ICAs developed and treated with embolization. CTA three months later showed a complete resolution of the IH and obliteration of all treated ICAs. Infectious, inflammatory and connective tissue disease investigations were undertaken without a clear etiology. Conclusions: This is a case of IH and ICAs, in the absence of a clear etiology which were successfully treated by endovascular procedures TEVAR and coil embolization. It is not clear whether the hematoma was the source of the ICA or the other way round. Lack of ICAs in the initial CTA might be due to the pressure exerted by the hematoma or that they were too small to be detected but continued to grow on follow up. Rupture of these micro-aneurysms is a possible mechanism of intramural aortic hematoma.