Faizatul Izza Rozalli

Imaging features of primary extranodal lymphomas

Lymphomas are generally considered tumours of lymph nodes, but up to 40% arise extranodally. This group shows distinctive pathological, radiological, and clinical features. Different subtypes of extranodal lymphoma may show sufficiently specific radiological features to be of significant value in both establishing a diagnosis of lymphoma and ascertaining the exact subtype. Rapidly evolving lymphoma classifications and emergence of new entities have, however, hampered the accurate description of these features in the literature. In this review, we discuss the radiological appearances, using a variety of imaging methods, of the full spectrum of primary extranodal lymphomas, categorized according to the current World Health Organisation classification.

Differentiation between benign and malignant breast lesions using quantitative diffusion-weighted sequence on 3 T MRI

AIM To investigate the capability and diagnostic accuracy of diffusion-weighted imaging (DWI) in differentiating benign from malignant breast lesions using 3 T magnetic resonance imaging (MRI). MATERIALS AND METHODS Women with suspicious or indeterminate breast lesions detected at MRI, mammogram and/or ultrasound were recruited for dynamic contrast-enhanced (DCE)-MRI and DWI prior to their biopsy. Image fusion of DCE-MRI with apparent diffusion coefficient (ADC) map was utilized to select the region of interest (ROI) for ADC calculation in the area that showed the most avid enhancement. DWI was performed using two sets of b-values at 500 and 1000 s/mm(2), respectively. RESULTS Fifty women were recruited and the final analysis comprised 44 breast lesions, 31 of which were malignant and 13 were benign. Significant results were obtained between ADC values of benign and malignant lesions (p < 0.001). The cut-off ADC values for benign and malignant lesions were 1.21 × 10(-3) mm(2)/s for b = 500 s/mm(2) and 1.22 × 10(-3) mm(2)/s for b = 1000 s/mm(2), respectively. The sensitivity of DCE-MRI alone was 100% with a specificity of 66.7%. When DCE-MRI was combined with b = 1000 s/mm(2), the specificity rose to 100%, while only mildly affecting sensitivity (90.6%). No significant correlation was found between ADC values and prognostic factors, such as lymph node metastasis, tumour size, oestrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status, and tumour grades. CONCLUSION The present study provides consistent evidence to support DWI as a diagnostic tool for breast lesion characterization. A combination of DCE-MRI with DWI is suggested to improve the sensitivity and specificity of lesion characterization.

Shearwave Elastography Increases Diagnostic Accuracy in Characterization of Breast Lesions.

AbstractThe purpose of this study was to investigate the diagnostic efficacy of shearwave elastography (SWE) in differentiating between benign and malignant breast lesions.One hundred and fifty-nine lesions were assessed using B-mode ultrasound (US) and SWE parameters were recorded (Emax, Emean, Emin, Eratio, SD). SWE measurements were then correlated with histopathological diagnosis.The final sample contained 85 benign and 74 malignant lesions. The maximum stiffness (Emax) with a cutoff point of ≥ 56.0 kPa (based on ROC curves) provided sensitivity of 100.0%, specificity of 97.6%, positive predictive value (PPV) of 97.4%, and negative predictive value (NPV) of 100% in detecting malignant lesions. A cutoff of ≥80 kPa managed to downgrade 95.5% of the Breast Imaging-Reporting and Data System (BI-RADS) 4a lesions to BI-RADS 3, negating the need for biopsy. Using a combination of BI-RADS and SWE, the authors managed to improve the PPV from 2.3% to 50% in BI-RADS 4a lesions.SWE of the breast provides highly specific and sensitive quantitative values that are beneficial in the characterization of breast lesions. Our results showed that Emax is the most accurate value for differentiating benign from malignant lesions.

Relationship between ultrasonographic nerve morphology and severity of diabetic sensorimotor polyneuropathy.

In the current study, the aim was to characterize the nerve ultrasound cross‐sectional areas (CSAs) of type 2 diabetic patients with diabetic sensorimotor polyneuropathy (DSP) of different severities.

Serial peripheral nerve ultrasound in Guillain–Barré syndrome

OBJECTIVE To assess the longitudinal changes of nerve ultrasound in Guillain-Barré syndrome (GBS) patients. METHODS We prospectively recruited 17 GBS patients and 17 age and gender-matched controls. Serial studies of their nerve conduction parameters and nerve ultrasound, documenting the cross-sectional areas (CSA), were performed at admission and repeated at several time points throughout disease course. RESULTS Serial nerve ultrasound revealed significantly enlarged CSA in median, ulnar and sural nerves within the first 3 weeks of disease onset. Longitudinal evaluation revealed an improvement in the nerve CSA with time, reaching significance in the ulnar and sural nerves after 12 weeks. There was no significant difference between the demyelinating and axonal subtypes. There was also no significant correlation found between nerve CSA and neurophysiological parameters or changes in nerve CSA and muscle strength. CONCLUSION In GBS, serial studies of peripheral nerve ultrasound CSA are helpful to detect a gradual improvement in the nerve size. SIGNIFICANCE Serial nerve ultrasound studies could serve as a useful tool in demonstrating nerve recovery in GBS.

Mild Joint Symptoms are Associated with Lower Risk of Falls than Asymptomatic Individuals with Radiological Evidence of Osteoarthritis

Osteoarthritis (OA) exacerbates skeletal muscle functioning, leading to postural instability and increased falls risk. However, the link between impaired physical function, OA and falls have not been elucidated. We investigated the role of impaired physical function as a potential mediator in the association between OA and falls. This study included 389 participants [229 fallers (≥2 falls or one injurious fall in the past 12 months), 160 non-fallers (no history of falls)], age (≥65 years) from a randomized controlled trial, the Malaysian Falls Assessment and Intervention Trial (MyFAIT). Physical function was assessed using Timed Up and Go (TUG) and Functional Reach (FR) tests. Knee and hip OA were diagnosed using three methods: Clinical, Radiological and Self-report. OA symptom severity was assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC). The total WOMAC score was categorized to asymptomatic, mild, moderate and severe symptoms. Individuals with radiological OA and ‘mild’ overall symptoms on the WOMAC score had reduced risk of falls compared to asymptomatic OA [OR: 0.402(0.172–0.940), p = 0.042]. Individuals with clinical OA and ‘severe’ overall symptoms had increased risk of falls compared to those with ‘mild’ OA [OR: 4.487(1.883–10.693), p = 0.005]. In individuals with radiological OA, mild symptoms appear protective of falls while those with clinical OA and severe symptoms have increased falls risk compared to those with mild symptoms. Both relationships between OA and falls were not mediated by physical limitations. Larger prospective studies are needed for further evaluation.

Effect of Modified Otago Exercises on Postural Balance, Fear of Falling, and Fall Risk in Older Fallers With Knee Osteoarthritis and Impaired Gait and Balance: A Secondary Analysis

Osteoarthritis (OA) is considered an established risk factor for falls. Published studies evaluating secondary falls prevention strategies among individuals with OA are limited.

Mild encephalitis/encephalopathy with reversible splenial lesion (MERS) due to dengue virus

A 14-year-old girl presented with encephalopathy, delirium and ophthalmoplegia following a 3day history of high-grade fever. Brain MRI on day 6 of illness showed diffusion restricted ovoid lesion in the splenium of corpus callosum. Dengue virus encephalitis was diagnosed with positive PCR for dengue virus type-2 in both serum and cerebrospinal fluid. She made a complete recovery from day 10 of illness. Repeat brain MRI on day 12 of illness showed resolution of the splenial lesion. Serial diffusion tensor imaging (DTI) showed normal fractional anisotropy values on resolution of splenial lesion indicating that MERS was likely due to transient interstitial oedema with preservation of white matter tracts. This is the first reported case of MERS following dengue virus infection. It highlights the usefulness of performing serial DTI in understanding the underlying pathogenesis of MERS. Our case report widens the neurological manifestations associated with dengue infection and reiterates that patients with MERS should be managed supportively as the splenial white matter tracts are reversibly involved in MERS.

The mediating role of psychological symptoms on falls risk among older adults with osteoarthritis

The purpose of this study was to investigate the role of fear of falling (FoF) and psychological symptoms in explaining the relationship between osteoarthritis (OA) symptom severity and falls. Individuals aged ≥65 years with ≥2 falls or ≥1 injurious fall over the past 12 months were included in the falls group, while volunteers aged ≥65 years with no history of falls over 12 months were recruited as controls. The presence of lower extremity OA was determined radiologically and clinically. Severity of symptoms was assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. FoF and psychological status were measured with the shortened version of the Falls Efficacy Scale-International and the 21-item Depression, Anxiety and Stress Scale (DASS-21), respectively. Of 389 (229 fallers, 160 non-fallers) potential participants, mean (SD) age: 73.74 (6.60) years, 141 had clinical OA and 171 had radiological OA. Fallers with both radiological OA and clinical OA had significantly higher FoF and DASS-21 scores than non-fallers. FoF was significantly positively correlated with symptom severity in fallers and non-fallers with radiological and clinical OA. Depression, anxiety, and stress scores were only significantly correlated with symptom severity among fallers but not non-fallers in both clinical and radiological OA. The relationship between mild symptoms and reduced risk of falls compared to no symptoms in those with radiological OA was attenuated by increased anxiety. The increased falls risk associated with severe symptoms compared to mild symptoms in clinical OA was attenuated by FoF. FoF may, therefore, be a potentially modifiable risk factor for OA-associated falls which could be considered in future intervention studies.

Midgut volvulus: a rare cause of intestinal obstruction in adults

Volvulus of small intestine secondary to malrotation accounts for about 0.2% of intestinal obstruction in adults. Manifestations of malrotation in adults are protean and include recurrent vomiting, colicky postprandial abdominal pain, weight loss and malabsorption. Colour Doppler and multi-detector computerised tomography (CT) scans currently pick up more cases of malrotation in asymptomatic adults. Adult surgeons need periodic reminder to avoid errors in diagnosis and management when encountering the altered anatomy at laparotomy. A 26-year-old man presented with intermittent abdominal pain, bilious vomiting and weight loss over few weeks. The upper abdomen was full with a few palpable bowel loops. Acute small intestinal obstruction, caused by internal herniation or intraabdominal neoplasm was considered and a CT scan with intravenous and oral contrast was done. CT showed twisting of the small bowel mesentery and the superior mesenteric vessels in the upper abdomen with whirlpool appearance (Fig. 1; vide infra). There was dilatation of stomach and proximal of duodenum. The small bowel and ascending colon were collapsed. At emergency laparotomy, there was nearly 360° volvulus of midgut. The midgut was untwisted in an anticlockwise direction. After partial untwisting, a flimsy peritoneal band from right upper abdomen was seen across the proximal transverse colon and the proximal duodenum (Fig. 2). The band was released and the volvulus completely undone. The duodeno-jejunal junction was on the right side of the midline. Ladd’s procedure was done. Postoperative recovery was uneventful and the patient has been well on follow-up for the past 1 year. In classical malrotation, the shorter and more vertical small bowel mesentery predisposes to axial rotation of nearly the whole of midgut, most often in a clockwise direction. In addition, abnormal peritoneal bands result in compression of adjacent structures such as the duodenum and transverse colon, as in our patient. Upper gastrointestinal (UGI) series is the investigation of choice in children with suspected malrotation but in adults, CT (with oral and intravenous contrast) is preferred since the UGI findings of volvulus in adults are subtle. In malrotation, inversion of the normal relationship between superior mesenteric artery (SMA) and superior mesenteric vein (SMV) is characteristic with the SMV lying anterior to and left of SMA to a varying extent. This altered relationship is demonstrable in colour Doppler, contrast CT and magnetic resonance imaging. However, such altered relation may be rarely seen in patients without malrotation and may be absent in nearly one-third of patients with malrotation. The ‘whirlpool sign’, seen on abdominal CT scans and colour Doppler refers to whirling or spiral shape of the SMV around SMA and is higly sensitive in the diagnosis of malrotation. When accompanied by spiralling of the intestinal loops and their feeding vessels around the SMA, whirlpool sign is highly specific for the diagnosis of malrotation with volvulus.