Smriti Hari

Magnetic resonance imaging findings among women with tubercular tubo-ovarian masses

To assess the usefulness of magnetic resonance imaging (MRI) in women with tubercular tubo‐ovarian masses.

Multidetector CT evaluation of central airways stenoses: Comparison of virtual bronchoscopy, minimal-intensity projection, and multiplanar reformatted images

Aims: To evaluate the diagnostic utility of virtual bronchoscopy, multiplanar reformatted images, and minimal-intensity projection in assessing airway stenoses. Settings and Design: It was a prospective study involving 150 patients with symptoms of major airway disease. Materials and Methods: Fifty-six patients were selected for analysis based on the detection of major airway lesions on fiber-optic bronchoscopy (FB) or routine axial images. Comparisons were made between axial images, virtual bronchoscopy (VB), minimal-intensity projection (minIP), and multiplanar reformatted (MPR) images using FB as the gold standard. Lesions were evaluated in terms of degree of airway narrowing, distance from carina, length of the narrowed segment and visualization of airway distal to the lesion. Results: MPR images had the highest degree of agreement with FB (Κ = 0.76) in the depiction of degree of narrowing. minIP had the least degree of agreement with FB (Κ = 0.51) in this regard. The distal visualization was best on MPR images (84.2%), followed by axial images (80.7%), whereas FB could visualize the lesions only in 45.4% of the cases. VB had the best agreement with FB in assessing the segment length (Κ = 0.62). Overall there were no statistically significant differences in the measurement of the distance from the carina in the axial, minIP, and MPR images. MPR images had the highest overall degree of confidence, namely, 70.17% (n = 40). Conclusion: Three-dimensional reconstruction techniques were found to improve lesion evaluation compared with axial images alone. The technique of MPR images was the most useful for lesion evaluation and provided additional information useful for surgical and airway interventions in tracheobronchial stenosis. minIP was useful in the overall depiction of airway anatomy.

Potential of Diffusion-Weighted Imaging in the Characterization of Malignant, Benign, and Healthy Breast Tissues and Molecular Subtypes of Breast Cancer

The role of apparent diffusion coefficient (ADC) in the diagnosis of breast cancer and its association with molecular biomarkers was investigated in 259 patients with breast cancer, 67 with benign pathology, and 54 healthy volunteers using diffusion-weighted imaging (DWI) at 1.5 T. In 59 breast cancer patients, dynamic contrast-enhanced MRI (DCEMRI) was also acquired. Mean ADC of malignant lesions was significantly lower (1.02 ± 0.17 × 10−3 mm2/s) compared to benign (1.57 ± 0.26 × 10−3 mm2/s) and healthy (1.78 ± 0.13 × 10−3 mm2/s) breast tissues. A cutoff ADC value of 1.23 × 10−3 mm2/s (sensitivity 92.5%; specificity 91.1%; area under the curve 0.96) to differentiate malignant from benign diseases was arrived by receiver operating curve analysis. In 10/59 breast cancer patients, indeterminate DCE curve was seen, while their ADC value was indicative of malignancy, implying the potential of the addition of DWI in increasing the specificity of DCEMRI data. Further, the association of ADC with tumor volume, stage, hormonal receptors [estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor (HER2)], and menopausal status was investigated. A significant difference was seen in tumor volume between breast cancer patients of stages IIA and IIIA, IIB and IIIA, and IIB and III (B + C), respectively (P < 0.05). Patients with early breast cancer (n = 52) had significantly lower ADC and tumor volume than those with locally advanced breast cancer (n = 207). No association was found in ADC and tumor volume with the menopausal status. Breast cancers with ER−, PR−, and triple-negative (TN) status showed a significantly larger tumor volume compared to ER+, PR+, and non-triple-negative (nTN) cancers, respectively. Also, TN tumors showed a significantly higher ADC compared to ER+, PR+, and nTN cancers. Patients with ER− and TN cancers were younger than those with ER+ and nTN cancers. The present study demonstrated that ADC may increase the diagnostic specificity of DCEMRI and be useful for treatment management in clinical setting. Additionally, it provides an insight into characterization of molecular types of breast cancer and may serve as an indicator of metabolic reprograming underlying tumor proliferation.

Noninvasive screening for preclinical atherosclerosis in children on phenytoin or carbamazepine monotherapy: A cross sectional study

PURPOSE This study was carried out to compare the carotid Intimal Media Thickness (IMT), and endothelial function using brachial flow mediated dilatation (FMD), in Epileptic children (6-12 years) on phenytoin (PHT) or carbamazepine (CBZ) monotherapy for ≥18 months with a control group of children. METHODS In this cross-sectional study 30 children (aged 6-12 years) on PHT monotherapy and 28 children on CBZ monotherapy were compared with an equal number of apparently healthy age and sex matched children unexposed to antiepileptics. Fasting lipids, sugar, Hs-CRP levels and ultrasonographic assessment of carotid IMT and endothelial function using brachial FMD were conducted. RESULTS The age (years) of the children in the CBZ group (9.1±2), PHT group (9.4±2) and the controls (9.3±2) was comparable. The duration of CBZ therapy was 30.8±13.2 months and that of PHT therapy was 29.5±13.6 months. The mean dose of CBZ was 18.18±8.5mg/kg and that of PHT was 5.5±2.3mg/kg body weight. The time since last seizure was 15.6±8.4 months in the CBZ group and 17.3±10.4 months in the PHT group. The fasting blood sugar was below 110mg/dl in all children. The height, weight, waist and hip measurements, waist hip ratio and blood pressures were similar in the groups. The total cholesterol levels (161.7±24.8 vs 140.2±20.8mg/dl, p=0.001), HDL (53.8±10.5 vs 47.1±8.8mg/dl, p=0.017) and LDL (85±21.1 vs 70.9±19.4mg/dl, p=0.01) were significantly higher in the CBZ group compared to the control group. The HDL levels (54.6±9.4 vs 45.8±7.7mg/dl, p<0.0001) were significantly higher in the PHT group compared to the control group. The right carotid (0.374±0.04 vs 0.339±0.05mm, p=0.012), left carotid (0.382±0.05 vs 0.351±0.05mm, p=0.044) and the overall average carotid intima media thickness (0.378±.048 vs 0.345±.052mm, p=0.018) of the children on CBZ was significantly higher than the carotid IMT in control group children. The right carotid (0.370±0.04 vs 0.342±0.05mm, p=0.032) and the overall average carotid IMT (0.374±0.04 vs 0.348±0.05mm, p=0.035) of the children on PHT was significantly higher than the carotid IMT in controls. The FMD were comparable in the children on CBZ or PHT and the control group. CONCLUSIONS The results are preliminary but could signal the increased vulnerability of epileptic children on long term antiepileptics to have subclinical atherosclerosis.

Biliary cryptococcosis in a child: MR imaging findings

Cryptococcosis is a systemic mycosis with a worldwide distribution. It frequently occurs in patients who are immunologically compromised or chronically ill. Clinical manifestations are usually confined to the central nervous system, lungs and skin. Involvement of the hepatobiliary system is very rare. We describe the MR imaging appearance of a rare case of disseminated cryptococcosis in an immunocompetent child in whom the clinical presentation was dominated by biliary and lymph nodal involvement.

Six months versus nine months anti-tuberculous therapy for female genital tuberculosis: a randomized controlled trial

OBJECTIVE To compare six months versus nine months anti-tuberculous therapy in patients of female genital tuberculosis. STUDY DESIGN It was a randomized controlled trial in a tertiary referral center teaching institute on 175 women presenting with infertility and found to have female genital tuberculosis on clinical examination and investigations. Group I women (86 women) were given 9 months of intermitted anti-tuberculous therapy under directly observed treatment short course (DOTS) strategy while Group II (89 women) were given 6 months of anti-tuberculous therapy under DOTS. Patients were evaluated for primary end points (complete cure, partial response, no response) and secondary end points (recurrence rate, pregnancy rate) during treatment. All patients were followed up further for one year after completion of therapy to assess recurrence of disease and further pregnancies. RESULTS Baseline characteristics were similar between two randomized groups. There was no difference in the complete clinical response rate (95.3% vs 97.7%, p=0.441) between 9-months and 6-months groups. Four patients in 9-months group and two patients in 6-months group had recurrence of disease and required category II anti tuberculous therapy (p=0.441). Pregnancy rate during treatment and up to one year follow up was also similar in the two groups (23.2% vs 21.3%, p=0.762). Side effects occurred in 27(31.4%) and 29(32.6%) in 9-months and 6-months of therapy and were similar (p=0.866). CONCLUSIONS There was no difference in complete cure rate, recurrent rate and pregnancy rate for either 6-months or 9-months of intermittent directly observed treatment short course anti-tuberculous therapy in female genital tuberculosis. CLINICAL TRIAL REGISTRATION The trial was registered in clinicaltrials.gov with registration no: CTRI/2009/091/001088.

Evaluation of breast parenchymal density with QUANTRA software

Purpose: To evaluate breast parenchymal density using QUANTRA software and to correlate numerical breast density values obtained from QUANTRA with ACR BI-RADS breast density categories. Materials and Methods: Two-view digital mammograms of 545 consecutive women (mean age - 47.7 years) were categorized visually by three independent radiologists into one of the four ACR BI-RADS categories (D1-D4). Numerical breast density values as obtained by QUANTRA software were then used to establish the cutoff values for each category using receiver operator characteristic (ROC) analysis. Results: Numerical breast density values obtained by QUANTRA (range - 7-42%) were systematically lower than visual estimates. QUANTRA breast density value of less than 14.5% could accurately differentiate category D1 from the categories D2, D3, and D4 [area under curve (AUC) on ROC analysis - 94.09%, sensitivity - 85.71%, specificity - 84.21%]. QUANTRA density values of <19.5% accurately differentiated categories D1 and D2 from D3 and D4 (AUC - 94.4%, sensitivity - 87.50%, specificity - 84.60%); QUANTRA density values of <26.5% accurately differentiated categories D1, D2, and D3 from category D4 (AUC - 90.75%, sensitivity - 88.89%, specificity - 88.621%). Conclusions: Breast density values obtained by QUANTRA software can be used to obtain objective cutoff values for each ACR BI-RADS breast density category. Although the numerical density values obtained by QUANTRA are lower than visual estimates, they correlate well with the BI-RADS breast density categories assigned visually to the mammograms.

Traumatic diaphragmatic rupture complicated by intercostal tube insertion into the stomach

Fig 1. Axial CECT scan mediastinal window at the midthoracic level shows the stomach to be lying in close contact with the posterior chest wall, without any intervening lung parenchyma (dependent viscera sign), causing collapse of left lung lower lobe and mediastinal shift. The chest tube is seen within the stomach. A 30-YEAR-OLD MAN came to the casualty unit with a history of a fall from a height 14 days previously, following which he developed left chest pain and a pleural effusion. An intercostal tube was introduced after which he noticed passage of orally ingested food material through the tube. At the time of presentation to our institute, he was moderately dyspneic, with a chest tube in the left hemithorax. A frontal chest radiograph revealed a homogeneous opacity in the left hemithorax (mid and lower zone) having a convex upper margin and an air-fluid level, with a chest tube inside. A contrast-enhanced computed tomography (CECT) scan was performed with oral as well as intravenous iodinated contrast. The axial (Fig 1) and sagittal reformatted images (Fig 2) revealed a posterolateral diaphragmatic tear with intrathoracic herniation of stomach and the chest tube within the stomach lumen. At surgical exploration, the stomach was reduced below the diaphragm, the chest tube removed and the diaphragmatic tear repaired primarily. The postoperative course was uneventful and he was discharged on the seventh postoperative day.

Pyelonephritis Presenting with Severe Acute Renal Failure

We describe an unusual case of an 8-yr-old child presenting with low grade fever and acute renal failure. Investigations showed blood urea 246 mg/dl, serum creatinine 6.4 mg/dl, microscopic hematuria and 2+ proteinuria. Renal biopsy was done in view of rapidly worsening kidney function and showed dense lymphoplasmacytic infiltrate and neutrophils with focal areas of interstitial necrosis, confirming acute pyelonephritis. Ultrasonography and MRI demonstrated multiple renal abscesses. He was managed with antimicrobial therapy and hemodialysis.

Steroid-responsive nephrotic syndrome in a patient with nail-patella syndrome

Nail-patella syndrome (NPS) is a rare disorder with autosomal dominant mode of inheritance. We report a child with NPS and steroid-responsive, frequently relapsing nephrotic syndrome. The child had dystrophic nails, flexion contractures of both elbows and normal renal functions. X-rays of the knees and pelvis showed hypoplastic patellae and iliac horns. Renal histology was unremarkable with mild focal increase in mesangial cellularity compatible with minimal change disease. Ultrastructural features of NPS including thickening of the glomerular basement membrane with electron-lucent areas were not found.