Chulalongkorn Medical Journal

Analysis of breast MRI performed on patients with axillary nodal metastasis and negative mammogram and ultrasound

Pakpawee Pichayakul, Palita Hansakul — Thu, 25 Jan 2024 00:00:00 +0700

Background: Occult breast cancer is a rare type of breast cancer which magnetic resonance imaging (MRI) has an immense role to confirm diagnosis and disclose non-demonstrable finding on initial modality.

Objectives: To analyge breast MRI findings in patients with axillary nodal metastasis and negative mammo gram and ultrasound and retrospectively review the initial mammography and second-look ultrasound.

Methods: From January 2010 to January 2023, women who diagnosed occult breast cancer by presenting metastatic axillary lymph node on pathological report with negative mammography and ultrasonography, underwent breast MRI to identify occult breast carcinoma. Their breast MRI were retrospectively reviewed. The imaging findings on breast MRI were collected and confirmed associated findings on second-look ultrasound and initial mammograms.

Results: There were 12 patients diagnosed with occult breast cancer. Breast MRI detected primary cancer in 4 of 12 (33.0%) patients. In two out of four patients, the MR-correlated second-look ultrasound localized lesions that were not detected on the initial exam. One case demonstrated MR-correlated finding on retrospective mammography and the other case was detected as suspicious lesions on both second-look ultrasound and retrospective mammography.

Conclusion: Breast MRI is an important modality for investigation of occult breast cancer. MR-correlated second-look ultrasound and retrospective mammography localized lesions from the prior negative reports are valuable learning points to improve detection and interpretation skills.

Pediatric appendicitis or not: A retrospective cohort study from a single institution-our management and factors determining the disease

Thu, 25 Jan 2024 00:00:00 +0700

Background: Appendicitis in children is a common health problem, but its management still has some controversial aspects.

Objectives: This study aimed to assess our treatment guidelines and determine factors in differentiating children with acute appendicitis from other diseases.

Methods: Pediatric surgery consultations for suspected appendicitis from October 2019 to October 2021 was retrospectively studied. The treatment guidelines of children with suspected appendicitis were elucidated. Moreover, factors identifying the diagnosis of appendicitis were analyzed using multi-variate logistic regression.

Results: Ninety-one children were consulted for suspected appendicitis. Forty-one children (45.1%) were promptly successfully treated without observation or ultrasonography, except one negative appendectomy (2.4%). The other 50 children (54.9%), showed equivocal clinical symptoms and signs, requiring further management either overnight observation (11 cases) or ultrasonography (39 cases). Following observation, 7 patients (63.6%) were successfully treated without further imaging studies. On the contrary, after abdominal ultrasound (39 cases), appendices or other intra-abdominal pathologies could be demonstrated, leading to definitive diagnosis and treatment in 17 patients (43.6%), except one false-positive case (5.9%). Only 6 patients had computed tomography (CT) scintigraphy following equivocal ultrasound findings. Accordingly, the treatment guidelines achieved an overall 93.4% accuracy. Clinical complaints were statistically different as majority of cases with appendicitis having migratory pain (46.3%, P < 0.001). With logistic regression analysis, it was revealed that migratory pain, right lower quadrant (RLQ) tenderness, elevated white blood cell (WBC) count and high proportion of neutrophils were significantly associated with appendicitis.

Conclusion: Pediatric appendicitis is occasionally arduous to diagnose. By minimizing the utilization of CT scan, our treatment guidelines accomplish high accuracy. Careful history taking, thorough physical examination, and basic laboratories were crucial for accurate diagnosis.

Electrical conductivity of 24-hour urine is decreased in patients with calcium oxalate urolithiasis

Thu, 25 Jan 2024 00:00:00 +0700

Background: Electrical conductivity (EC) of urine depends on the ionic substance-to-water ratio. Calcium oxalate (CaOx) is the most common type of urinary stone, and its formation is driven by decreased urine volume, increased lithogenic substances, and decreased stone inhibitory compounds (specifically citrate). Low urinary citrate excretion (hypocitraturia) is a prominent risk factor in Thai urolithiasis patients.

Objective: To measure the urinary EC, urinary calcium, and urine specific gravity in CaOx stone patients compared with non-stone forming (NSF) subjects.

Methods: The urinary EC was measured in 24-hour urine samples obtained from 42 CaOx stone patients and 121 NSF subjects. Urinary calcium and urine specific gravity were measured to evaluate whether they were associated with the urinary EC.

Results: The urinary EC of CaOx stone patients was significantly lower than the NSF subjects. The urinary EC level was positively correlated with urine specific gravity, but not urinary calcium. At the selected cutoff of 14.3 mS/cm, the sensitivity, specificity, and accuracy of the urinary EC for diagnosing CaOx urolithiasis were 74.0%, 50.0%, and 56.0%, respectively. In CaOx stone group, patients who had low urinary citrate had lower urinary EC than patients who had high urinary citrate. Experimentally, we demonstrated in artificial urine that citrate concentrations actively influenced the EC values. Decreased citrate level directly caused decreased EC value.

Conclusion: The EC of 24-hour urine in CaOx stone patients was decreased relative to the NSF individuals. The urinary EC was linearly correlated with urine specific gravity. Low urinary EC observed in CaOx stone patients possibly resulted from a low urinary citrate excretion that was highly prevalent in the stone patients. In addition, gradual decrease in citrate level caused a gradual decrease in EC level.

Does asymptomatic generalized joint hypermobility influence musculotendinous extensibility and knee joint proprioception?

Pawan Chaiparinya, Sujitra Boonyong, Chitanongk Gaogasigam — Thu, 25 Jan 2024 00:00:00 +0700

Background: It is unclear whether generalized joint hypermobility (GJH) influences the musculotendinous unit (MTU) extensibility or proprioception of the knee joint in individuals with asymptomatic GJH.

Objectives: This study aimed to compare the quadriceps and hamstring MTU length as well as knee joint force sense (FS) and joint position sense (JPS) between individuals with asymptomatic GJH and non-GJH controls.

Methods: Thirty-two female subjects were recruited, with 16 subjects in the GJH and non-GJH groups. The angles measured from modified prone knee bend (mPKB) and straight leg raising (SLR) tests were used to identify the quadriceps and hamstrings MTU extensibility using photographic-based angle measurements. The FS of the quadriceps and hamstrings and the JPS of the knee joint were assessed via ipsilateral angle and force-matching tasks, respectively. The results from the GJH and non-GJH groups were compared using unpaired t - tests or chi-square tests based on the distribution of the data.

Results: The results indicated that the angles measured by the mPKB and SLR tests were not significantly different between the two groups. Furthermore, neither FS nor JPS differed between the GJH group and their peers.

Conclusion: The asymptomatic GJH individuals did not show signs of hyperextensibility of the quadriceps or hamstring muscles. Moreover, the ability to perceive muscle force and the joint position of the knee joint were well preserved.

Effect of fluid replacement during 60 minutes of moderate-intensity running on splanchnic blood flow

Thu, 25 Jan 2024 00:00:00 +0700

Background: Exercise-induced splanchnic hypoperfusion has been linked to impaired gastrointestinal function and associated symptoms. The effectiveness of fluid replacement in protecting against splanchnic hypoperfusion is less clear.

Objective: To evaluate the effects of fluid replacement during 60 minutes of moderate-intensity running on the splanchnic blood flow (SBF) using non-invasive Doppler ultrasound.

Methods: Seven healthy men aged 35.4 ± 7.0 years participated in two 60 minute running trials at moderateintensity: the first trial with no water replacement (NW) followed by the second trial with ambient temperature water (28 - 29^oC) replacement (AW). A minimum interval of 48 hours was introduced for the washout period between the trials. SBF was determined by Doppler ultrasound of the superior mesenteric artery (SMA) and portal vein (PV) before and immediately after the run. The core body temperature (Tcore) was also measured rectally.

Results: Running for 60 minutes significantly decreased the SMA flow by 31.2% (425.5 ± 98.0 mL/min to 291.7 ± 79.1 mL/min; P = 0.002) in NW and a non-significant decrease of 9.8% (497.2 ± 144.7 mL/min to 438.4 ± 103.1 mL/min; P = 0.076) in AW. The PV flow decreased by 50.6% (688.7 ± 81.9 mL/min to 333.6 ± 65.6 mL/min; P < 0.001) in NW and a non-significant decrease of 18.6% (718.9 ± 131.3 mL/min to 574.2 ± 145.9 mL/ min; P = 0.069) in AW. At 60 minutes, Tcore showed a significant increase from baseline by 2.19^oC (P < 0.001) in NW and 1.86oC (P < 0.001) in AW, but there was no significant difference in Tcore at 60 minutes between NW and AW.

Conclusion: Fluid replacement during 60 minutes of moderate-intensity running reduces splanchnic hypoperfusion, but not Tcore. This indicates that running-associated gut hypoperfusion may be prevented by fluid replacement during exercise.

Comparison of endoscopic-guided vs. electromyographyguided Botulinum toxin injection treatments in adductor spasmodic dysphonia

Manintorn Praditthum, Premsuda Sombuntham — Thu, 25 Jan 2024 00:00:00 +0700

Background: Electromyography (EMG)-guided botulinum injection is recommended in clinical practice guideline for spasmodic dysphonia. However, other alternative techniques have been practiced in absence of EMG machine. Comparison of the techniques is limited in the literatures.

Objectives: This study aimed to compare the effectiveness of treatment between the EMG-guided technique and the endoscopic-guided technique in adductor spasmodic dysphonia.

Methods: Five patients who were diagnosed with adductor spasmodic dysphonia (AdSD) were enrolled and then randomized into two groups. Patient data (before and after treatment) were collected. The outcome measurement included voice analysis, voice handicap index (VHI), duration aspiration, duration of breathiness, mean effective duration, and satisfaction score (visual analog scale). The difference between the pretreatment data and the posttreatment data at 1 and 3 months was compared.

Results: The mean effective duration between of the EMG group and the endoscopic group was not significantly different. There were no significant differences in voice analysis differences in the EMG group and the endoscopic group after botulinum toxin injection 1 month and 3 months after treatment. There were no significant differences in adverse effects between the two groups in both durations of breathiness and duration of aspiration. No significant difference in satistactions score among two groups was observed.

Conclusion: Botulinum toxin injection under endoscopic guidance is a feasible technique for the treatment of adductor spasmodic dysphonia in the context of lack of EMG equipment. Additionally, endoscopic guidance is a simple and inexpensive device, composed of materials at hand in every otolaryngology unit. However, we suggest that the optimal injection technique would be determined by surgeon training, equipment availability, and preferences.

Primary lung and pleural malignancies in children: Imaging of a case series

Teerasak Phewplung, Tanitha Phruksahirun — Thu, 25 Jan 2024 00:00:00 +0700

Early diagnosis of primary lung and pleural malignancies is a challenge because it is extremely rare in children. The patient often presents with metastatic disease and non-neoplastic lesions. Clinical detection and imaging studies are nonspecific findings and may be indistinguishable from other lung malformations, resulting in a delay in diagnosis and treatment and an increase in tumor morbidity and mortality. We present four cases of children whose clinical presentation and initial imaging had suspicious abnormalities and were eventually revealed to be primary lung and pleural malignancies. The literature on primary lung and pleural malignancies is also briefly reviewed.

Rosai-Dorfman disease of the breast: A case report

Amornthip Ongchaiwattana, Tikamporn Jitpasutham, Jenjeera Prueksadee — Thu, 25 Jan 2024 00:00:00 +0700

A case report of Rosai-Dorfman disease (sinus histiocytosis with massive lymphadenopathy) of the breast is one of the rare diseases, characterized by benign proliferative disorder of histiocyte. Most of them occur within lymph nodes whereas the rest involve extranodal sites. Breast involvement is considered extremely rare but considerable because of radiological findings simulating breast cancer. We hereby report a case of a 59-year-old Thai woman who underwent screening mammography. Her biopsy resulted in abnormal histiocytes with S-100 protein expression, some of them with emperipolesis (lymphophagocytosis). Recognition of Rosai-Dorfman disease leads to correct diagnosis and further appropriate proper treatment strategy.