We present 3 cases of small bowel diverticulitis ultimately presenting to our Emergency Department over a span of 2 years. Though the final diagnosis was the same, each patient's symptomatology was ...different, mimicking more common pathologies. Thus, it is important to consider this entity when confronted with signs and symptoms of acute abdomen, especially in the elderly. A missed or delayed diagnosis can lead to costly erroneous studies, incorrect treatments and delay in proper management, resulting in significant morbidity and even mortality. The variety of presentations can often be misleading; therefore, a high index of suspicion is needed on the part of the Emergency Department physician and Radiologist.
Vitamin D deficiency rickets is a childhood osteomalacia, with impaired skeletal development and potentially skeletal deformities. The radiographic findings of rickets are many but include widening, ...fraying, and cupping of the metaphysis. Developmental delay and related complications of seizure and tetany have also been reported. This medical entity is often thought of as a classic medical disease of the past. However, it persists, and the recognition of rickets is on the rise. The reemergence of rickets correlates with the increase in the number of children exclusively breastfed and with the frequent use of sun block in the pediatric population. We present two cases of rickets, diagnosed through a visit to the Emergency Department made for unrelated symptoms. These two cases illustrate the importance of diagnosing rickets as an “incidental” finding. With early detection, dietary supplementation can be initiated potentially sparing the patient symptomatic disease.
To assess the impact of flip angle with gradient sequences on the "magic angle effect". We characterized the magic angle effect in various gradient echo sequences and compared the signal-to-noise ...ratios present on these sequences with the signal-to-noise ratios of spin echo sequences.
Ten normal healthy volunteers were positioned such that the flexor hallucis longus tendon remained at approximately at 55 degrees to the main magnetic field (the magic angle). The tendon was imaged by a conventional spin echo T1- and T2-weighted techniques and by a series of gradient techniques. Gradient sequences were altered by both TE and flip angle. Signal-to-noise measurements were obtained at segments of the flexor hallucis longus tendon demonstrating the magic angle effect to quantify the artifact. Signal-to-noise measurements were compared and statistical analysis performed. Similar measurements were taken of the anterior tibialis tendon as an internal control.
We demonstrated the magic angle effect on all the gradient sequences. The intensity of the artifact was affected by both the TE and flip angle. Low TE values and a high flip angle demonstrated the greatest magic angle effect. At TE values less than 30 ms, a high flip angle will markedly increase the magic angle effect.
To develop a new method of magnetic resonance arthrography (MRA) of the knee using an anterior approach analogous to the portals used for knee arthroscopy.
An anterior approach to the knee joint was ...devised mimicking anterior portals used for knee arthroscopy. Seven patients scheduled for routine knee MRA were placed in a decubitus position and under fluoroscopic guidance a needle was advanced from a position adjacent to the patellar tendon into the knee joint. After confirmation of the needle tip location, a dilute gadolinium solution was injected.
All the arthrograms were technically successful. The anterior approach to knee MRA has greater technical ease than the traditional approach with little patient discomfort.
This study uses magnetic resonance (MR) imaging to delineate the types and frequencies of injuries seen in the knee after ipsilateral femoral shaft fracture. We also compare the results of the ...orthopedic knee examination with the MR findings.
MR imaging of the ipsilateral knee was performed on 34 patients with closed femoral shaft fractures. Indications for knee MR imaging included knee pain at the time of fracture, soft tissue swelling or an effusion of the knee, or a positive knee examination under anesthesia. The patients had a mean age of 27 years and all were stabilized with intramedullary nails. Imaging was performed a mean time of 2.5 days after surgery. All patients had knee examinations done under anesthesia, and the MR results were compiled and compared with the clinical examinations.
Ninety-seven percent of patients demonstrated knee effusions. Twenty-seven percent of patients demonstrated meniscal tears, with the posterior horn of the medial meniscus most frequently torn. The medial collateral ligament was the most frequent site of ligamentous injury (38%) followed by the posterior cruciate ligament (21%). Fifty percent of patients had injuries of the extensor mechanism. Bone bruises were noted in 32% of patients. Articular cartilage injuries were confined to the patella in four cases. One occult tibial plateau fracture and one meniscocapsular separation were seen.
There is a common incidence of both ligamentous and meniscal injury to the knee after ipsilateral femoral shaft fracture. MR imaging can be useful in assessing the extent of injury, and may reveal findings unsuspected after clinical examination of the knee.
Infective endocarditis (IE) is a rare but potentially fatal complication following heart transplantation (HTx). There is a lack of literature regarding the patterns and clinical course of IE ...development following HTx. We sought to pool the existing data in regards to defining characteristics, management options, and outcomes of IE following HTx.
An electronic search of Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Ovid Medline, and the Scopus databases were performed to identify all articles in the English literature that report IE following HTx in adult patients. Patient-level data were extracted and analyzed.
Systematic search yielded 57 patients from 32 articles. Median patient age was 52 IQR 43, 59 and 75% of patients (43/57) were male. Median time to IE presentation post-HTx was 8.4 IQR 3.0, 35.8 months. IE of the mitral valve was observed in 36.8% (21/57) of patients, followed by mural IE in 24.6% (14/57), and tricuspid valve IE in 21.1% (12/57). The most common organisms were Staphylococcus aureus in 26.3% (15/57), Aspergillus fumigatus in 19.3% (11/57), Enterococcus faecalis in 12.3% (7/57), and an undetermined or unspecified organism in 14.0% (8/57) patients. Overall case fatality was 44.6% (25/56). Fungal IE was associated with a significantly higher case fatality 75.0% (9/12) than that of bacterial IE 36.1% (13/36) (p = 0.02). Surgical management of post-HTx IE was observed in 35.1% (20/57) of patients. This included valve surgery for 70.0% (14/20), including the mitral valve in 50.0% (7/14), aortic valve in 35.7% (5/14), and the tricuspid valve in 14.3% (2/14) of patients.
In addition to bacterial organisms, fungi also represent a frequent cause of IE in post-HTx patients. Overall HTx patient survival in the setting of IE is poor and may be worse if caused by A. fumigatus.
•Overall case fatality of infective endocarditis after heart transplantation is 44.6%.•Median time to presentation after transplantation is 8.4 months.•Fungal endocarditis after heart transplantation may be more severe than bacterial.
Anterior dislocation of the hip is a rare phenomenon, seen in only 5-10% of all hip dislocations. These dislocations can be divided into two types: superior or subspinous and inferior or obturator ...dislocations. Osteochondral impaction fractures of the femoral head are a known complication of anterior dislocation, but little has been reported on the types of acetabular and pelvic fractures associated with this dislocation. Five anterior dislocations were studied with radiographs and computed tomographic (CT) imaging, and the CT findings are described. Fractures were seen in the femoral head, acetabular roof, and medial wall, as well as in the anterior inferior iliac spine. The most severe injuries occurred after a superior dislocation, but the obturator dislocations demonstrated impaction fractures of the femoral head as well as an intra-articular bone fragment. CT of the acetabuli is recommended after reduction of these dislocations to identify these complications.PUBLICATION ABSTRACT
The purpose of this study was to examine the role of abdominal computed tomography (CT) in the evaluation and management of stab wounds to the back and flank. We retrospectively studied 62 patients ...with nonsuperficial stab wounds to the back and flank who presented without signs of peritonitis or hemodynamic instability. Twenty-seven patients had conventional CT with oral and intravenous contrast medium administration. Twenty-seven patients had CT with oral, intravenous, and rectal contrast medium, which is called "triple contrast CT" (TCCT). Eight patients had CT with oral and intravenous contrast medium with the addition of air insufflated rectally. Patients with no CT evidence of intra-abdominal injury or with evidence of visceral injury that was considered minor were initially treated with observation. Patients with CT evidence of surgically significant injury received immediate celiotomy. The results of laparotomy and/or patient follow-up were used to determine the sensitivity and specificity of CT for classification of patients into operative or nonoperative categories. For proper classification of patients into operative or nonoperative categories, conventional CT and CT with rectal contrast demonstrated nearly identical sensitivities of 100%, specificities of 96%, and accuracies of 96%. The results were similar for the group that received rectal air. Combining all patients, CT demonstrated a sensitivity of 100%, a specificity of 96%, and an accuracy of 97%. The negative predictive value was 100%, and only 2 of the 62 patients (3.2%) received nontherapeutic laparotomies. CT is useful in the routine management of hemodynamically stable patients with nonsuperficial stab wounds to the back and flank.PUBLICATION ABSTRACT
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