A Case of Complex Pulmonary Hypertension: the Importance of Diagnostic Investigation

Pulmonary hypertension (PH) encompasses several heterogeneous groups of multiple diseases characterized by abnormal pulmonary arterial blood pressure elevation. Unrepaired atrial septal defect (ASD) may be associated with pulmonary arterial hypertension (PAH), indicating pulmonary vascular remodeling. Furthermore, unrepaired ASD could also be associated with other conditions, such as left heart disease or thromboembolism, contributing to the disease progression. We present a case of a 61-years-old woman with complex PH comprising several etiologies, which are PAH due to unrepaired Secundum ASD, mitral regurgitation caused by mitral valve prolapse as a group 2 PH, pulmonary embolism (PE) which progress to chronic thromboembolism PH (CTEPH) and post-acute sequelae of SARS Cov-2. We highlighted the importance of diagnostic investigation in PH, which is crucial to avoid misdiagnosis and inappropriate treatment that could be detrimental for the patient.

Occult insulinoma after oesophagectomy for oesophageal cancer-diagnostic challenges

Hypoglycaemia in the post-operative period is mainly iatrogenic (related to anti-hyperglycaemic drugs), but can be explained by an endogenous hyperinsulinemic state. In the context of previous gastrointestinal surgery, a form of dumping syndrome can mask hypoglycaemia from an underlying cause, such as an insulinoma. The authors present a clinical case of a male patient who underwent oesophageal surgery for an oesophago-gastric junction adenocarcinoma and developed hypoglycaemic symptoms in the post-operative period, caused by an undiagnosed insulinoma. This case report portraits the diagnostic investigation of a hypoglycaemia state in the post-operative period, narrowing to the workup of an endogenous hyperinsulinemic hypoglycaemia and provides a summary of insulinoma’s treatment. An insulinoma should always be considered in a patient with endogenous hyperinsulinemic hypoglycaemia, even with a history of oesophago-gastric surgery.

Chronic subdural hematoma recurrence due to contralateral neovascularization following middle meningeal artery embolization

Introduction Chronic subdural hematoma (CSDH) is one of the most commonly encountered neurosurgical diseases. Middle meningeal artery embolization (MMAE) is a technique for the management of CSDH that has elicited promising results. Despite the encouraging results of MMAE, recurrence does occur. One uncommon mechanism for recurrence of CSDH is by means of neovascularization of the contralateral middle meningeal artery (MMA). We describe two cases of CSDH recurrence by means of contralateral middle meningeal artery neovascularization treated with contralateral MMAE. Methods We identified two cases of recurrent subdural hematoma secondary to neovascularization following treatment with contralateral MMAE. Results Two patients initially treated with MMAE were identified with CSDH recurrence secondary to contralateral MMA neovascularization. There was no traumatic or coagulopathic contribution to CSDH recurrence. In both cases, patients underwent contralateral MMAE. Both patients were neurologically intact with radiographic improvement of CSDH at follow up. Conclusions Re-accumulation of SDH following MMAE by means of contralateral MMA neovascularization is a rare subtype of subdural hematoma (SDH) recurrence following MMAE. Within the context of re-accumulation of SDH following MMAE, catheter angiography is an important diagnostic investigation to elucidate the etiology of the recurrence. Furthermore, when angiography reveals neovascularization of the contralateral MMA, embolization of the contralateral MMA achieves good clinical and radiographic result.

Hampton’s Hump: A Notable Radiographic Finding in a Patient with Infectious Endocarditis

Infectious endocarditis is a relatively uncommon entity that may present with a variety of clinical scenarios, ranging from a stable patient with nonspecific symptoms to a critically ill patient suffering from embolic disease. We report a case of an otherwise healthy 35-year-old female who presented to the Emergency Department with gradually progressive dyspnea, weight loss, and lower extremity edema. As part of her initial evaluation, a chest radiograph was performed and demonstrated Hampton’s Hump, a peripheral wedge-shaped opacity consistent with a possible pulmonary infarct. Further diagnostic investigation in the Emergency Department led to an unanticipated diagnosis of infectious endocarditis. This case serves as an important reminder that nonspecific diagnostic findings need to be appropriately considered in context and is a rare demonstration of Hampton’s Hump associated with infectious endocarditis.

Moiré topography as a screening and diagnostic tool—A systematic review

Diagnostic investigation can be carried out using non-radiological and non-contact methods. Moiré topography (MT) seems to be a viable alternative to radiographic research in evaluating the spine and/or trunk deviations. The aim of this systematic review was to analyze the current knowledge regarding the reliability and validity of Moiré topography as a screening and diagnostic tool. The systematic review was performed from 2010 until March 2021 in the PubMed, EBSCO, Web of Science, and Scopus databases, according to the eligibility criteria. This review fulfilled the following criteria according to the PICO system: population (children and adolescents), intervention (MT measurement), comparison (repeated MT measurements, MT compared to Cobb angle or scoliometer), outcome (reliability and validity of MT). Eight studies fulfilled the inclusion criteria for further analysis. All the studies were assessed to be of high quality. Included studies found that MT had high repeatability and high intraobserver and interobserver correlation, and correlation between MT parameters and radiographic Cobb angle ranged from moderate to high. The authors reported difficulty in defining the cut-off values for MT parameter (Surface Trunk Rotation—STR), and unsatisfactory sensitivity and specificity of MT examination. The studies did not reveal the advantage of MT as a screening method in the detection of idiopathic scoliosis in comparison to radiograph. Based on the evidence from eight studies, the results indicated moderate evidence for reliability and validity of Moiré topography as a screening and diagnostic tool. There is still no strong evidence for the accuracy of MT.

EP.TU.170Audit to assess the management of patients presenting with lower gastrointestinal (LGI) bleeds in the Trust

Aims To identify presentations of LGI bleeds, assimilate learning and make appropriate recommendations to improve management in hospital. Methods 336 patients with ‘PR bleed’ on their coding summary in 2019 were identified. Data obtained through eCare and EDM was analysed as outlined: Results 69% were emergency presentations of LGI bleed and the remaining 31% were elective admissions. 5% of emergency LGI bleed patients were discharged on the same day as compared to 97.4% of elective patients. The remaining 80% of emergency patients went on to have outpatient investigations. Positive cases included haemorrhoids, inflammatory bowel disease and diverticulitis. Conclusions All emergency presentations occurred during inpatient stay creating disparities in manner of presentation and duration of admission between cohorts. However, outcomes between the cohorts were broadly similar, suggesting absence of significant disparities in management. Colonoscopy is the gold standard diagnostic investigation in LGI bleeds however, flexible-sigmoidoscopy can be considered in under 50’s. 80% of patients had a colonoscopy during admission as per guidelines. No reasoning was documented for patients who underwent other methods of investigation as first-line, thus creating a need for improved documentation when deviating from guidelines. Recommendation to re-audit in 1 year to assess changes.

The role of PMCT for the assessment of the cause of death in natural disaster (landslide and flood): a Sicilian experience

In this report, the authors provide a contribution of PMCT in assessing the cause of death due to natural disasters. Here, the PMCT findings of 43 subjects who died during both landslide and flood were described. The post-mortem imaging revealed, clearly, traumatic injuries and/or the presence of foreign material in airways allowing to assess the cause of death of each subject, together with external inspection and the collected circumstantial data. Particularly, the PMCT has been helpful for characterization and localization of the clogging substance in airways providing findings on bronchial branches involvement. Moreover, the investigation offered detailed data on skeletal injuries in all anatomic districts and put in evidence both the precise fracturing site and the characteristics of fracture stubs for each bone fracture. This report supports the recommendation of the virtual autopsy in a case with several victims, as in natural disasters, and its role as an alternative diagnostic investigation when the standard autopsy is not feasible.