Imaging of non-specific complaints of the arm, neck, and/or shoulder (CANS): role of the scalene muscles and piercing variants in neurogenic thoracic outlet syndrome

Complaints of the arm, neck and/or shoulder (CANS) are common in the general population (40%) and workers (30%) and have significant economic impact. Twenty-three conditions have been designated as specific CANS. Cases where no cause is identified are reported as non-specific CANS; these cases make up the majority of CANS. Non-specific CANS presentations overlap with clinical entities including cervicobrachial and scalene myofascial syndromes that are associated with neurogenic thoracic outlet syndrome (NTOS). The scalene muscles have been identified as the commonest site of NTOS, although this has been reported to be functional and in conjunction with cervicothoracic junction variants that compromise the brachial plexus lower trunk. Anatomical variants in relation to both the scalene muscles and brachial plexus are not widely recognised in the clinical and imaging literature; however, pass-through and pass-over (or "piercing") variants of the brachial plexus upper trunk and scalene muscles have been well described in the anatomical and anaesthetic literature. In this review, we demonstrate the presence and describe the imaging of scalene muscle pathology and variant muscle-brachial plexus anatomy affecting the upper trunk that are underdiagnosed causes of non-specific CANS presentations and NTOS.

Regional cardiac dysfunction determined by radiation dose in patients with breast cancer

Background

Subclinical left ventricular (LV) dysfunction by 2D global longitudinal strain (GLS) immediately following radiotherapy (RT) and persisting at 12 months has been described in breast cancer (BC) patients. We hypothesised that persistent LV dysfunction may be regional and correlate with segmental RT.

Methods

Transthoracic echocardiograms were performed at baseline, 6 weeks and 12 months post-RT on 61 chemotherapy-naïve women with left sided BC.

Results

Anterior and anteroseptal regions received the highest radiation dose, and posterior and inferior segments the lowest radiation dose (Figure 1). Within each region, there was a progressive increase in the radiation dose received from base to apex. At 6 weeks, the greatest reduction in strain was observed in the anterior and anteroseptal regions, with the most significant reduction in strain in the apical segments. At 12 months, despite improvement in strain, the percentage reduction in strain was similar. There was a significant interaction between both region and segment, on the percentage change in strain at 6 weeks (p<0.001) and at 12 months (p=0.007). Pairwise comparisons of apical to basal percentage change in strain demonstrated the most significant reductions in the anterior region at 6 weeks and 12 months (Table 1).

Conclusions

RT causes segmental myocardial dysfunction, with areas receiving the highest RT demonstrating the largest impairment in strain, with these changes persisting at 12 months. Long term correlation with adverse events is required.

Figure 1. Radiation dose by region and segment

Funding Acknowledgement

Type of funding source: None

Pubic apophysitis in elite Australian Rules football players: MRI findings and the utility of VIBE sequences in evaluating athletes with groin pain

AIM

To confirm that pubic apophysitis is common in Australian Rules footballers with groin pain.

MATERIALS AND METHODS

Thirteen male Australian Football League (AFL) players with groin pain were assessed with volumetric interpolated breath-hold examination (VIBE) MRI over the 2017, 2018, and 2019 AFL seasons. Images were reviewed for pubic maturation, the presence of pubic apophysitis, and associated bone pathology and correlated with side of groin pain.

RESULTS

Pubic apophysitis was seen in 92% of AFL players with groin pain. Delayed maturation of the pubic apophyses was observed in 85%. Pubic bone erosions and cyst-like changes were common (100% and 46%, respectively), but due to delayed maturation of the apophyses and apophysiolysis. Apophysitis associated with adductor brevis-gracilis was more common than adductor longus-associated apophysitis.

CONCLUSION

Pubic apophysitis associated with delayed maturation of the pubic apophyses is common in AFL players and is potentially a significant cause of groin pain in these athletes. Imaging findings in this group are the same as those conventionally describing osteitis pubis. Pubic apophysitis is best visualised with VIBE magnetic resonance imaging (MRI) and may be a more pathologically correct description of early, adductor load-related pubic bone pathology.

Flow Interruption of the Distal Radial Artery: Treatment for Finger Ischemia in a Matured Radiocephalic AVF

Purpose

To establish an effective approach for diagnosis and treatment of hand ischemia in matured radiocephalic arteriovenous fistulae (AVF).

Methods

One hundred and fifty end-stage renal disease patients (4% of our practice) presented to our outpatient vascular access facility complaining of a range of symptoms including coldness, numbness and pain in the fingers indicative of ischemia due to steal syndrome. In 15 patients the symptoms of steal syndrome were limited to the fingers, sparing the hand. Physical examination was indicative of steal syndrome caused by shunting of blood from the ulnar artery via the palmar arch, away from the fingers and into the fistula. To confirm the diagnosis, angiography was performed which demonstrated retrograde flow in the distal radial artery (DRA), a hypertrophied palmar arch, and a patent hypertrophied ulnar artery. Ischemia was treated with DRA flow interruption. Transcatheter coil embolization of the DRA (10 patients) was preferred because it proved to be a quick, safe and effective technique. Whenever embolization was not possible ligation of the DRA was performed in accordance with accepted surgical literature (five patients).

Results

DRA flow interruption was effectively accomplished by either ligation or coil embolization in all cases. All patients had symptomatic improvement. Complete symptom resolution was experienced by 100% (10/10) of patients who received DRA embolization and by 3/5 patients who required ligation. The average follow-up period was 9 months. There were no complications during the procedure or during the follow-up period.

Conclusion

Diagnosis using physical examination, angiography and treatment with embolization or ligation of the DRA can be performed with great success in an outpatient setting.

Probabilistic dietary exposure to ethyl carbamate from fermented foods and alcoholic beverages in the Korean population

The occurrence of ethyl carbamate was investigated in fermented foods and alcoholic beverages of the Korean total diet study. The concentrations of ethyl carbamate ranged from not detected to 166.5 μg kg^-1. Dietary exposure to ethyl carbamate was estimated by the probabilistic method. Estimated intakes of ethyl carbamate from foods and alcoholic beverages were 4.12 ng kg^-1 body weight (bw) per day for average consumers and 12.37 ng kg^-1 bw/day for 95th percentile high consumers. The major foods contributing to ethyl carbamate exposure were soy sauce (63%), followed by maesilju (plum liqueur, 30%), whisky (5%), and bokbunjaju (black raspberry wine, 2%). On the basis of the benchmark dose lower confidence limit 10% (BMDL₁₀) of 0.3 mg kg^-1 bw/day, margins of exposure were 128,000 for mean exposure and 40,000 for 95th percentile exposure. This indicates that the exposure of the Korean general population for ethyl carbamate is of low concern. However, careful vigilance should be continued for high consumers of fermented foods and alcoholic beverages.

Effects of testosterone replacement therapy on metabolic syndrome among Japanese hypogonadal men: A subanalysis of a prospective randomised controlled trial (EARTH study)

We investigated the effects of testosterone replacement therapy (TRT) on metabolic factors among hypogonadal men with a metabolic syndrome. From the study population of the EARTH study, which was a randomised controlled study in Japan, 65 hypogonadal patients with a metabolic syndrome, comprising the TRT group (n = 32) and controls (n = 33), were included in this study analysis. The TRT group was administered 250 mg of testosterone enanthate as an intramuscular injection every 4 weeks for 12 months. Waist circumference, body mass index, body fat volume and blood pressure were measured in all patients at baseline and at 12 months. In addition, blood biochemical data, including total cholesterol, triglyceride (TG), HDL cholesterol, fasting plasma glucose (FPG) and haemoglobin A1c (HbA1c) levels, were also evaluated. Changes in these categories from baseline to 12 months were compared between the TRT and control groups, with significant differences observed in waist circumference, body fat percentage, FPG, TG and HbA1c levels. No significant differences were observed in other parameters. TRT for 1 year was associated with improvements in some metabolic factors among Japanese men with hypogonadism and metabolic syndrome.

A PLK4 mutation causing azoospermia in a man with Sertoli cell-only syndrome

About 15% of couples wishing to have children are infertile; approximately half these cases involve a male factor. Polo-like kinase 4 (PLK-4) is a member of the polo protein family and a key regulator of centriole duplication. Male mice with a point mutation in the Plk4 gene show azoospermia associated with germ cell loss. Mutational analysis of 81 patients with azoospermia and Sertoli cell-only syndrome (SCOS) identified one man with a heterozygous 13-bp deletion in the Ser/Thr kinase domain of PLK4. Division of centrioles occurred in wild-type PLK4-transfected cells, but was hampered in PLK-4-mutant transfectants, which also showed abnormal nuclei. Thus, this PLK4 mutation might be a cause of human SCOS and nonobstructive azoospermia.

Exaggerated natri-calci-uresis and increased circulating levels of parathyroid hormone and 1,25-dihydroxyvitamin D in patients with senile hypertension

Renal handling of Na and Ca in response to physiological saline infusion (20 ml/kg i.v. for 2 h) was compared between 27 hypertensive (mean +/- SD age 79.8 +/- 9.2 years) and 44 normotensive (79.1 +/- 4.1 years) senile females. Compared to the normotensive group, the hypertensive group showed statistically significant decreases in the basal values of serum Ca and PRA, and significant increases in basal circulating levels of parathyroid hormone and 1,25(OH)2D and in urinary excretions of Na, Ca and Pi in the 2-hour urine specimens during the saline infusion. These results suggest that the excessive excretions of Ca and Pi associated with exaggerated natriuresis may participate in aberration of Ca metabolism in low-renin hypertensive seniles.

Y chromosome haplogroup D2a1 is significantly associated with high levels of luteinizing hormone in Japanese men

The association between the Y chromosome haplogroup D2 and risk of azoospermia and low sperm motility has been previously studied, and it was indicated that haplogroups DE (YAP lineage) are associated with prostate cancer risk in Japanese males. Our assumption had been that Y chromosome haplogroups may be associated with sex hormone levels, because sex hormones have been deemed responsible for spermatogenesis and carcinogenesis. In this study, we assessed the association between Y chromosome haplogroups and sex hormone levels, including those of testosterone, sex hormone-binding globulin (SHBG), follicle-stimulating hormone (FSH), luteinizing hormone (LH), inhibin-B, and calculated free testosterone (cFT), in 901 young men from the general Japanese population (cohort 1) and 786 Japanese men of proven fertility (cohort 2). We found that the haplogroup D2a1 was significantly associated with high LH levels in a combined analysis involving two cohorts (β = 0.068, SE = 0.025, p = 0.0075), following correction for multiple testing. To date, this result is the first evidence that implicates Y chromosome haplogroups in an association with sex hormone levels.

Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery-VMI): lessons from exploration of cultural variations in visual-motor integration performance of preschoolers

BACKGROUND

Visual-motor integration (VMI) is important in children's development because it is associated with the performance of many functional skills. Deficits in VMI have been linked to difficulties in academic performance and functional tasks. Clinical assessment experience of occupational therapists in Singapore suggested that there is a potential difference between the VMI performance of Singaporean and American children. Cross-cultural studies also implied that culture has an influence on a child's VMI performance, as it shapes the activities that a child participates in. The purpose of this study was to (1) explore if there was a difference between the VMI performance of Singaporean and American preschoolers, and (2) determine if there were ethnic differences in the VMI performance of Singaporean preschoolers.

METHODS

The Beery-VMI, which was standardized in America, is commonly used by occupational therapists in Singapore to assess the VMI ability of children. We administered the Beery-VMI (fifth edition) full form test (excluding the supplemental tests) to 385 preschoolers (mean age = 63.3 months) from randomly selected schools in Singapore. We compared the scores of Singaporean preschoolers with those of the American standardization norms using the one-sample t-test. Scores of different ethnic groups among the Singapore population were also compared using a one-way anova, followed by the Bonferroni post-hoc test.

RESULTS

Singaporean preschoolers and the standardization sample of American children performed significantly differently in all age groups (P < 0.05). Among the Singapore population, the scores were also significantly different (P < 0.05) between the (i) Chinese and Malay and (ii) Chinese and Indians ethnic groups.

CONCLUSION

Preschoolers from different cultural and ethnic groups had different VMI performance. Certain cultural beliefs and practices may affect VMI performance. Clinicians should exercise caution when using an assessment in communities and cultures outside the ones on which it was standardized.

SIN3A mutations are rare in men with azoospermia

A loss of function of the murine Sin3A gene resulted in male infertility with Sertoli cell-only syndrome (SCOS) phenotype in mice. Here, we investigated the relevance of this gene to human male infertility with azoospermia caused by SCOS. Mutation analysis of SIN3A in the coding region was performed on 80 Japanese patients. However, no variants could be detected. This study suggests a lack of association of SIN3A gene sequence variants with azoospermia caused by SCOS in humans.

[Thoracic surgery for patients with deep vein thrombosis]

Deep vein thrombosis (DVT) is a main cause of pulmonary thromboembolism (PTE), and therefore both diseases are categorized as a serial pathophysiology of venous thromboembolism (VTE). Treatment goals for DVT include stopping clot propagation and preventing the recurrence of thrombus, the occurrence of PTE, and the development of pulmonary hypertension, which can be a complication of multiple recurrent pulmonary emboli. Clinical guidelines stratify the risk of VTE to 4 levels and recommend the treatment options. In high or extremely high risk patients for VTE, the use of low-dose heparin is recommended. The prevention against VTE, such as elastic compression stockings and intermittent sequential pneumatic leg compression( ISPC), is the most important prophylactic treatment against perioperative PTE by reducing thrombotic risk in low or moderate high risk patients for VET. Since there is no clear evidence that screening all or even selected patients for thrombophilias improves long-term outcomes, the physician's clinical judgment, and consultation with appropriate subspecialists should guide management perioperatively. Once PTE is suspected, immediate and accurate diagnosis and appropriate treatment are mandatory.

[Ruptured bronchial artery aneurysm with left hemothorax: report of a case]

A 74-year-old man was admitted to hospital because of sudden onset of chest pain and dyspnea. The chest X-ray film revealed left hemothorax. Chest computed tomographic (CT) scan confirmed left hemothorax and excluded the possibility of aortic dissection and aneurysm of the aorta. But the presence of some vascular mass, about 20 mm in diameter, was suspected at subcarina. Three-dimensional (3D) -CT confirmed a definitive diagnosis of ruptured bronchial artery aneurysm. Bronchial artery embolization (BAE) was performed. We report a case of ruptured bronchial artery aneurysm complicated by life-threatening massive bleeding and resembling a clinical picture of aortic dissection.

Serum calcium concentration affects signal changes on diffusion-weighted imaging in hypoglycemic encephalopathy

BACKGROUND AND PURPOSE

Abnormal signals in brain DWI may appear in patients with HE. The aim of this study was to compare the clinical condition and various physiologic factors between patients with HE with and without abnormal signal intensity changes on DWI.

MATERIALS AND METHODS

We retrospectively enrolled patients with HE who underwent brain DWI studies from January 2002 to November 2010. A diagnosis of HE was defined as low serum glucose levels (<50 mg/dL) with alteration of consciousness. Several clinical conditions and physiologic parameters were compared between patients with and without abnormal signals on DWI, including consciousness levels; outcome; body temperature; blood pressure; and serum levels of glucose, calcium, sodium, blood urea nitrogen, and creatinine.

RESULTS

Nine patients with HE were included, and 3 of them (33%) had abnormal signals on brain DWI. There was a trend toward serum calcium concentrations being lower in patients with normal findings on DWI studies compared with patients with abnormal DWI signals (7.6 ± 1.7 versus 9.4 ± 0.7 mg/dL, P = .07). Serum glucose concentration, duration of hypoglycemia, consciousness levels, other physiologic parameters, and clinical outcome did not reveal any differences between the 2 groups.

CONCLUSIONS

One-third of patients with HE had abnormal signals on brain DWI, and patients with low serum calcium levels may be less likely to present with abnormal DWI signals.