Review article: Management of the child with refractory constipation.

BACKGROUND: Caring for children with constipation refractory to conventional treatment can be challenging and management practices vary widely. AIMS: To review recent advances in the evaluation and treatment of children with refractory constipation and to propose an algorithm that incorporates the latest evidence and our institutional experience. METHODS: We performed a literature review on diagnostic tests and treatment options for children with refractory constipation. RESULTS: Evaluation of a child with refractory constipation seeks to better understand factors contributing to an individual child's presentation. Anorectal manometry evaluating for a rectal evacuation disorder and colonic manometry evaluating for colonic dysmotility can guide subsequent treatment. For the child who has not responded to conventional treatment, a trial of newer medications like linaclotide can be helpful. Transanal irrigation offers a safe and effective alternative for families able to administer daily rectal treatment. Despite mixed evidence in children, pelvic floor biofeedback therapy can help some children with pelvic floor dyssynergia. For younger children unable to cooperate with pelvic floor therapy, or older children with refractory symptoms, internal anal sphincter botulinum toxin injection can be beneficial. Antegrade continence enema treatment can be effective for children with either normal colonic motility or segmental dysmotility. Sacral nerve stimulation is generally reserved for symptoms that persist despite antegrade continence enemas, particularly if faecal incontinence is prominent. In more severe cases, temporary or permanent colonic diversion and segmental colonic resection may be needed. CONCLUSIONS: Recent advances offer hope for children with refractory constipation.

Correlation of maximal nasal septal deviation with deviation at the maxillary insertion.

PURPOSE: It is unclear if septal deviation at the insertion points to the nasal cavity is associated with the overall septal deviation. This study aimed to assess septal deviation at the cribriform plate (CP) and maxillary crest (MC) using CT scans and to see if there was any correlation with overall septal deviation. METHODS: All consecutive CT sinus scans between January 2020 and December 2021 were retrospectively reviewed. Patients were excluded if they had a history of head, nasal or facial trauma, or any previous nasal surgical procedure. Angles between the septum and MC and the septum and CP as well as maximal angle of septal deviation (MSD) were measured. RESULTS: A total of 70 scans were included in the final analysis. The mean MSD was 8.14°. The mean septal deviation was 0.89° at the CP and 2.02° at the MC. The correlation coefficient between the deviation at the CP and MSD was 0.025 and between the deviation at the MC and MSD was 0.321. CONCLUSION: Our data reveal a positive correlation between septal deviation at the floor of the nose and overall septal deviation; this was not observed at the septal deviation at the roof. This could be explained due to the inherent tilt in the cribriform plate or by earlier ossification and fixation of the septum during its development at its insertion to the roof, thereby allowing further growth and potential for deviation of the lower part of the septum and its insertion to the floor.

Beware of the Acute Respiratory Distress Syndrome in a Pulmonary Blastomycosis!

Blastomyces dermatitidis is a dimorphic fungus that can range from mild to severe disease presentation, including the acute respiratory distress syndrome (ARDS) based on the individual's immunity. Acute respiratory distress syndrome is an uncommon presentation having an incidence of about 10% to 15% but has a high mortality exceeding 90%. This is a case of a 50-year-old female with past medical history of asthma and type 2 diabetes mellitus who presented to the pulmonology clinic with worsening dyspnea for the last 2 months. She also had a lesion in the left lower back, which was draining purulent fluid. Chest radiographs showed bilateral infiltrates and was started empirically on vancomycin and piperacillin-tazobactam. Bronchoalveolar lavage was done and the cultures grew B dermatitidis. The patient was moved to a higher level of care and given amphotericin B. Unfortunately, the patient experienced septic shock, which later deteriorated into cardiac arrest, ultimately leading to their passing. The importance of early diagnosis of blastomycosis and timely treatment has been emphasized in this case report.

Radiation reduction for interventional radiology imaging: a video frame interpolation solution.

PURPOSE: The aim of this study was to diminish radiation exposure in interventional radiology (IR) imaging while maintaining image quality. This was achieved by decreasing the acquisition frame rate and employing a deep neural network to interpolate the reduced frames. METHODS: This retrospective study involved the analysis of 1634 IR sequences from 167 pediatric patients (March 2014 to January 2022). The dataset underwent a random split into training and validation subsets (at a 9:1 ratio) for model training and evaluation. Our approach proficiently synthesized absent frames in simulated low-frame-rate sequences by excluding intermediate frames from the validation subset. Accuracy assessments encompassed both objective experiments and subjective evaluations conducted by nine radiologists. RESULTS: The deep learning model adeptly interpolated the eliminated frames within IR sequences, demonstrating encouraging peak signal-to-noise ratio (PSNR) and structural similarity index (SSIM) results. The average PSNR values for angiographic, subtraction, and fluoroscopic modes were 44.94 dB, 34.84 dB, and 33.82 dB, respectively, while the corresponding SSIM values were 0.9840, 0.9194, and 0.7752. Subjective experiments conducted with experienced interventional radiologists revealed minimal discernible differences between interpolated and authentic sequences. CONCLUSION: Our method, which interpolates low-frame-rate IR sequences, has shown the capability to produce high-quality IR images. Additionally, the model exhibits potential for reducing the frame rate during IR image acquisition, consequently mitigating radiation exposure. CRITICAL RELEVANCE STATEMENT: This study presents a critical advancement in clinical radiology by demonstrating the effectiveness of a deep neural network in reducing radiation exposure during pediatric interventional radiology while maintaining image quality, offering a potential solution to enhance patient safety. KEY POINTS: • Reducing radiation: cutting IR image to reduce radiation. • Accurate frame interpolation: our model effectively interpolates missing frames. • High visual quality in terms of PSNR and SSIM, making IR procedures safer without sacrificing quality.

Recurrent Aortic Thromboembolism Associated With TET2 Mutation in Chronic Myelomonocytic Leukemia.

Ten-eleven translocation 2 (TET2) plays a pivotal role in epigenetic regulation, cell differentiation, and the inflammatory response. It also mediates the transcriptional regulation for inflammatory cytokines, particularly interleukin-6. While loss-of-function mutation in TET2 has been associated with hematological malignancies, it has been increasingly recognized to cause atherosclerotic disease. The increased atherogenicity is thought to be the result of increased production of pro-inflammatory interleukin-1ß cytokines following activation of NLRP3 inflammasomes. We present a unique case of recurrent atherothrombosis in an elderly man who was diagnosed with chronic myelomonocytic leukemia in the setting of TET2 mutation.

Transformed Testicular Teratoma to Embryonic-Type Neuroectodermal Tumor With Metastasis to Mediastinum.

Testicular teratomas may present in both prepubertal and adult men; however, the prognosis differs greatly between these 2 populations. In children, teratomas (prepubertal type) most often occur before the age of 4, are generally seen in their pure form, and behave in a benign fashion. In adults (postpubertal type), teratomas are usually part of a mixed germ cell tumor, and they have the potential to be found at metastatic sites, especially following chemotherapy for non-teratomatous germ cell tumor. Analyses of metastases from germ cell tumors and teratomas from the same patient have demonstrated a high degree of concordance in the observed genetic abnormalities. In rare cases, testicular teratoma can transform into a malignant germ cell tumor. One such type of transformation is into a primitive neuroectodermal tumor. These tumors are malignant and often metastasize to the retroperitoneum but may also metastasize to other sites. A multimodal treatment approach is needed, including surgery and adjuvant chemotherapy. We describe a rare case of malignant transformation of a testicular teratoma into a primitive neuroectodermal tumor with metastasis to the mediastinum. The patient was treated with radical orchiectomy, retroperitoneal lymph node dissection, and adjuvant vincristine, adriamycin, and cyclofosfamide alternating with ifosfamide and etoposide (VAC/IE therapy).

Recurrent Idiopathic Neuroretinitis: Anti-MOG Positive?

Neuroretinitis, originally described by Leber at the turn of the 20th century, has long perplexed ophthalmologists due to its multiple recognized causes and often atypical presentation. Optic disk edema and macular star in the affected eye are well-agreed upon findings and are due to increased permeability of blood vessels near the optic disk and in the retina at large. It also is universally painless and presents with a relative afferent pupillary defect (RAPD) in the affected eye or eyes. However, depending on the infectious agent, an underlying autoimmune condition, or undefined idiopathic cause, there can be various degrees of vision loss, visual field loss, progression or recurrence, as well as involvement of the other eye. We present this case of presumed sequential idiopathic neuroretinitis with severe vision and visual field loss with a low-positive anti-MOG test in the border county of El Paso.

Predicting gene mutation status via artificial intelligence technologies based on multimodal integration (MMI) to advance precision oncology.

Personalized treatment strategies for cancer frequently rely on the detection of genetic alterations which are determined by molecular biology assays. Historically, these processes typically required single-gene sequencing, next-generation sequencing, or visual inspection of histopathology slides by experienced pathologists in a clinical context. In the past decade, advances in artificial intelligence (AI) technologies have demonstrated remarkable potential in assisting physicians with accurate diagnosis of oncology image-recognition tasks. Meanwhile, AI techniques make it possible to integrate multimodal data such as radiology, histology, and genomics, providing critical guidance for the stratification of patients in the context of precision therapy. Given that the mutation detection is unaffordable and time-consuming for a considerable number of patients, predicting gene mutations based on routine clinical radiological scans or whole-slide images of tissue with AI-based methods has become a hot issue in actual clinical practice. In this review, we synthesized the general framework of multimodal integration (MMI) for molecular intelligent diagnostics beyond standard techniques. Then we summarized the emerging applications of AI in the prediction of mutational and molecular profiles of common cancers (lung, brain, breast, and other tumor types) pertaining to radiology and histology imaging. Furthermore, we concluded that there truly exist multiple challenges of AI techniques in the way of its real-world application in the medical field, including data curation, feature fusion, model interpretability, and practice regulations. Despite these challenges, we still prospect the clinical implementation of AI as a highly potential decision-support tool to aid oncologists in future cancer treatment management.

Presentation of Colorectal Carcinoma as Abdominal Wall Phlegmon.

Colorectal cancer (CRC) is the third most common malignancy and the second most common deadly cancer worldwide as of 2020. Unusual presentation of this cancer with locally advanced disease is rare and seen in only 5% to 22% of cases. We present the case of a 53-year-old male who had invasive cecal adenocarcinoma with phlegmon of the abdominal wall musculature at presentation and an aggressive course that did not respond to the standard lines of therapy. In the current era of ongoing tremendous developments in colorectal cancer diagnosis and treatment, this uncommon case reminds us that locally advanced CRC is still a challenge to manage. Precision medicine with treatment strategies tailored to an individual's genetic, environmental and lifestyle factors is the current need.

Advances in the diagnosis of primary solid small bowel tumors by contrast-enhanced multislice spiral CT / 中国辐射卫生

@#Primary small bowel tumors have low incidence and contain predominantly solid components, and the lesions are similar and difficult to be detected and distinguished with multislice spiral CT (MSCT) plain scans. In this article we describe contrast-enhanced MSCT technique and imaging characteristics for solid small bowel tumors or small bowel tumors containing predominantly solid components, including the type and use of contrast agents. In contrast-enhanced MSCT, small bowel imaging with CT has the advantages of determining the true extent of intestinal wall lesions, the possible extent of wall penetration, the degree of mesenteric involvement, and distant metastases, as well as easiness to detect and identify the blood supply vessels of small bowel tumors and assessment of the corresponding complications. Contrast-enhanced MSCT has become the best noninvasive imaging technique for the diagnosis, evaluation, and staging of solid small bowel tumors or small bowel tumors containing predominantly solid components. CT texture analysis (CTTA) is a new research hotspot and can be useful for the correct diagnosis of primary small bowel tumors containing predominantly solid components.

The Prevalence of Bronchodilator Responsiveness "Asthma" Among Adult Indigenous Australians Referred for Lung Function Testing in the Top End Northern Territory of Australia.

Background: Among Indigenous Australians, studies examining the clinical significance of airway bronchodilator responsiveness (BDR) are limited. In this retrospective study, we examined the nature of underlying lung disease in adult Indigenous patients with BDR referred for lung function testing (LFT) in the Top End Health Service region of the Northern Territory of Australia. Methods: Presence or absence of BDR as per usual (FVC or FEV1 change pre to post ≥12% and ≥0.2L) and updated (2021 ">10% predicted) ATS/ERS criteria among Indigenous and non-Indigenous Australians was determined. The radiological findings in the Indigenous study participants with and without BDR were next assessed for the presence of underlying chronic airway/lung disease. Results: We found that 123/742 (17%) Indigenous and 578/4579 (13%) non-Indigenous patients had a significant BDR. Indigenous patients with BDR were younger (mean difference 7 years), with a greater proportion of females (52 vs 32%), underweight (15 vs 4%) and current smokers (52 vs 25%). Indigenous patients with BDR displayed lower LFT values, and a higher proportion exhibited FVC BDR compared to non-Indigenous (34 vs 20%). Almost half (46%) of Indigenous patients with BDR had evidence of COPD and/or bronchiectasis on radiology. Adjusting for the presence of radiologic or spirometric evidence of COPD, the presence of BDR was similar between Indigenous and non-Indigenous patients (5-8 vs 7-11%), irrespective of which BDR criteria was used. Conclusion: BDR was higher overall among Indigenous in comparison to non-Indigenous patients; however, a significant proportion of Indigenous patients demonstrating BDR had evidence of underlying COPD/bronchiectasis. This study highlights that although presence of BDR among Indigenous people may indicate asthma, it may also be observed among patients with COPD/bronchiectasis or could represent asthma/COPD/bronchiectasis overlap. Hence, a combination of clinical history, LFT and radiology should be considered for precise diagnosis of lung disease in this population.

Magnetic resonance imaging has a limited role in investigating odynophagia if examination is normal: A binary logistic regression analysis of 484 patients presenting to a tertiary head and neck clinic.

INTRODUCTION: Investigation of head and neck cancers places a significant burden on the National Health Service and effective resource allocation is of perpetual importance. Existing risk calculators are designed to stratify the likelihood of underlying malignancy according to symptoms, but are less relevant in secondary care as they do not integrate clinical examination findings (e.g. naso-endoscopy). We looked to evaluate the utility of magnetic resonance imaging (MRI) in investigating patients with unilateral odynophagia and a normal clinical examination. METHODS: A retrospective analysis was conducted over a 54-month period; 484 consecutively-recruited adult patients who underwent MRI of the neck for suspected malignancy were included. Imaging reports, case notes, and histopathology results were reviewed. Patients with previously diagnosed/treated malignancy, undergoing surveillance, or those with pathology of the salivary glands, oral cavity or thyroid gland, were excluded. A multivariate binary logistical regression model was performed to calculate the odds ratios and probabilities of malignancy for each presenting symptom, with and without negative nasoendoscopy findings. RESULTS: The overall incidence of malignancy within the cohort was 173/484 patients (35.7%; 95% CI 31.5%-40.2%) with no cases of malignancy in patients presenting with odynophagia and a normal nasoendoscopy (0/39). The presence of a neck lump was significantly associated with malignancy, (odds ratio [OR] 2.03, p = .001; 95% CI 1.59-2.58), as was dysphagia (OR 1.52, p = .009; 95% CI 1.11-2.11). Conversely, globus was found to have an inverse association (OR 0.41, p < .001; 95% CI 0.24-0.70). SUMMARY: New patients presenting with odynophagia alone and normal endoscopy or globus have a low likelihood of underlying malignancy, justifying reassurance and follow-up in the event of persistent symptoms. Contrariwise, patients with a neck lump, dysphagia, odynophagia and multiple concurrent aerodigestive tract symptoms, or an abnormal endoscopy have a high likelihood of underlying malignancy and should be investigated accordingly.

Cystic Lung Disease as a Sequela of Severe COVID-19: Case Series.

Coronavirus disease 2019 (COVID-19) presented in December 2019 and has persisted since. The global pandemic has given rise to a novel acute disease process with a continually rapidly increasing prevalence of chronic disease and associated complications. There is minimal information on the long-term pulmonary complications of this disease. We present a series of 9 patient case reports and their respective imaging admitted with COVID-19 acute respiratory distress syndrome (ARDS) to highlight the cystic lung disease complications which may arise due to severity and disease progression. Our aim is to raise awareness of the sequela of COVID-19 ARDS, including its potentially catastrophic long-term consequences to the respiratory tract involving cystic lung disease.

Pulmonary Giant Cavitary Coccidioides With Fungal Ball and Hemoptysis.

Coccidioidomycosis (CM) is a fungal disease that results from inhalation of spores of Coccidioides immitis and C posadasii. If symptomatic, disease primarily manifests as community-acquired pneumonia; however, additional pulmonary manifestations such as pleural effusion, empyema, and cavitation may occur. Diabetic patients have an increased risk of severe and cavitary CM. Cavitary disease may erode vasculature and pulmonary parenchyma leading to further complications. Furthermore, chronic cavities can become colonized as well and develop superimposed infections. This is a case of cavitary CM in uncontrolled diabetic nonadherent to treatment presenting with hemoptysis and mycetoma.

Vertebral and carotid artery aneurysms and polyarthritis in a patient with Takayasu arteritis: A case report.

Takayasu arteritis (TA) is a common autoimmune disease in the clinical setting. However, vertebral artery aneurysms caused by TA are rarely reported. We herein describe a 28-year-old man with multiple vertebral artery aneurysms and carotid artery aneurysms caused by TA, which showed typical wall thickening and lumen dilation with a "string of beads" appearance by Doppler ultrasound and radiology. Previous studies have shown that most TA-associated vertebral artery lesions are stenosis, occlusion, and dissection of the intracranial part of the artery. In this case, TA mainly affected the cervical segment of the vertebral artery (the intracranial segment was not obviously involved), and the main manifestations were aneurysms and occlusion. This case provides more information for further understanding of TA-associated vertebral artery lesions.

Massive Chylous Ascites After Living Donor Nephrectomy Successfully Treated With Lymphatic Embolization.

Chylous ascites may result from a variety of pathological conditions, most of them from nontraumatic causes, such as congenital defects of the lymphatic system, infections, liver cirrhosis, and malignancy. Rarely, chylous ascites occurs as an iatrogenic complication after left-sided laparoscopic donor nephrectomy (LDN). Injury to the cisterna chyli and its main lymphatic tributaries around the para-aortic region intraoperatively can cause the lymphatic fluid to accumulate. There is currently no standardized treatment for chylous ascites as there have only been 54 cases documented to date. Most patients can be managed with conservative therapy. Recommended guidelines include high-protein and low-fat diet with medium-chain triglycerides. Paracentesis is often used as a diagnostic and therapeutic first-line measure with total parenteral nutrition (TPN), bowel rest, and somatostatin analogue as adjunct therapies. We present a case of massive chylous ascites refractory to conservative therapy. The patient had progressive abdominal distention and unintentional weight gain 2 weeks postoperatively warranting multiple paracenteses of >7 L of chylous fluid. Ultimately, the patient was successfully treated with lymphatic embolization using N-butyl cyanoacrylate glue.

Chronic Eosinophilic Pneumonia Masquerading as a Lung Mass.

Lung masses are becoming more common, and although most are tumors, benign or malignant, some are not solid masses. Many pathologies can present as lung nodules, including lung cancers, hamartomas, lung abscesses, granulomas, and eosinophilic pneumonia, to name a few. A 40-year-old woman with a long history of smoking presented with cough and left-sided chest pain. After multiple imaging studies, she was thought to have a lung malignancy; however, multiple biopsies proved this was not the case. The histology reports of 3 to 4 biopsies at separate times indicated chronic inflammation ongoing in the lungs without any cancer cells present. She was treated for chronic eosinophilic pneumonia with a resolution of symptoms. The purpose of this case report is to discuss a case that was initially thought to be a lung mass but found to be chronic eosinophilic pneumonia manifesting as a lung mass.

Case Series: Hypercalcemia From Granulomatous Silicosis Developing After COVID-19 Infection.

Hypercalcemia is one of the most commonly encountered laboratory abnormalities in clinical medicine. Various causes have been well established. However, it is likely that the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), may be a newly found cause of this frequent finding, especially amongst those with a history of cosmetic surgery, specifically by means of silicone injection. In this case series, we describe 2 patients presenting with symptomatic hypercalcemia likely from their prior silicone injections. Interestingly, each patient only developed symptoms of hypercalcemia following infection with SARS-CoV-2.

Micro-CT Imaging of Pediatric Thyroglossal Duct Cysts: A Prospective Case Series.

Objectives: To determine the feasibility of micro-CT as a high-resolution 3D imaging tool for thyroglossal duct cysts and to evaluate its role augmenting traditional histopathological examination of resected specimens. Methods: A single centre, prospective case series of consecutive children undergoing excision of a thyroglossal duct cyst was performed at a quaternary paediatric referral hospital in the United Kingdom. Consecutive children listed for excision of a thyroglossal duct cyst whose parents agreed to participate were included and there were no exclusion criteria. Results: Surgically excised thyroglossal duct cyst or remnant specimens from five patients (two males, three females) were examined using micro-CT alongside traditional histopathological examination. In all cases, micro-CT imaging was able to demonstrate 3D imaging datasets of the specimens successfully and direct radio-pathological comparisons were made (Figures 1-5, Supplementary Video 1). Conclusions: The study has shown the feasibility and utility of post-operative micro-CT imaging of thyroglossal duct cysts specimens as a visual aid to traditional histopathological examination. It better informs the pathological specimen sectioning using multi-planar reconstruction and volume rendering tools without tissue destruction. In the complex, often arborised relationship between a thyroglossal duct cyst and the hyoid, micro-CT provides valuable image plane orientation and indicates proximity of the duct to the surgical margins. This is the first case series to explore the use of micro-CT imaging for pediatric thyroglossal duct specimens and it informs future work investigating the generalizability of micro-CT imaging methods for other lesions, particularly those from the head and neck region where precisely defining margins of excision may be challenging.

Perpetually Positive: Post-COVID Interstitial Lung Disease in an Immunocompromised Patient With Diffuse Large B-cell Lymphoma.

As more patients recover from COVID-19 infection, long-term complications are beginning to arise. Our case report will explore a debilitating long-term complication, Post-COVID Interstitial Lung Disease (PC-ILD). We will introduce a patient who developed PC-ILD in the setting of diffuse large B-cell lymphoma, outlining a difficult hospital course, including a positive COVID-19 polymerase chain reaction (PCR) for more than 3 months. We will then discuss the human body's physiological response to the virus and how our patient was not able to adequately mount an immune response. Finally, the pathophysiology of PC-ILD will be explored and correlated with the patient's subsequent computed tomographic images obtained over a 3-month period. The difficult hospital course and complex medical decision-making outlined in this case report serve as a reminder for health care providers to maintain vigilance in protecting our most vulnerable patient population from such a devastating disease process.