Role of Echo Doppler in Diagnosing the Testicular Torsion-Retrospective Study

Introduction: Acute scrotum is a wide term that is used for cases that presenting with scrotal swelling and pain. Etiology can be infectious or strangulation from torsion of the testis, depending on its clinical diagnosis, requires surgical intervention or medical treatment.Aim of study: Aim of this study was to determine the rate of accuracy of the Echo Doppler scanning in the diagnosis of the testicular torsion. Considering that there are different protocols in diagnosis, some suggest surgical exploration, while some Hospitals report 100% accuracy in diagnosis of testicular torsion with Doppler ultrasound.Materials and methods: We retrospectively evaluated 4 year period, from 2011-2014, during this time all the patients that were admitted as acute scrotum where evaluated excluding the cases that were incarcerated hernias. In all admitted patients, physical examination, lab analysis and Echo Doppler study were performed.Results: In total, there were 83 patients, based on physical examination, lab and Echo Doppler scan, 50 cases were diagnosed as epididymo-orchititis, 21 cases were patients with testicular torsion and 12 cases were torqued hydatid of Morgagni. In 3 patients false positive blood circulation in affected testis was detected with Echo Doppler scan. In following days they were operated and gangrene of testis was found.Discussion: Complete absence of intratesticular blood flow and normal extratesticular blood flow on color Doppler images is diagnostic, if the flow is normal in the contra lateral testis. Color Doppler has a very high accuracy in detecting the obstacles in blood flow, but as with other diagnostic techniques, this should be not taken as granted.Conclusion: Testicular torsion is real urological emergency. Delay in diagnosis and management can lead to the loss of the testis. If there any doubts are present, urgent surgical exploration is indicated. Keywords: Testicular torsion, acute scrotum, echo Doppler, diagnostic techniques, managemen

Treatment Approach of Cryptorchidism in Developing Country

The history of testicular descent is closely connected with the expression of masculinity and as such can be traced back to ancient Egypt. Research into testicular descent was initiated by Haller and Hunter. It was Hunter who discovered that the testes descend during embryonal life from dorsal abdominal wall into the scrotum.  In the study conducted by “John Radcliffe Hospital” the incidence of cryptorchidism is 1.58%, spontaneous descent occurred postnatal in the first three months, and beyond that time, it was rare[1, 2]. As with other pathologies treatment and timing had changed during the years.Very important part of modern medical infrastructure is a functioning informative system, where the data about patients are registered.  In the postwar developing country (Kosovo), rebuilding medical care and information system required a lot of effort and time. When the whole medical system needs to be rebuild and equipped, informative system is not in top priorities. What in normal circumstances can be one click away like history of patients, medical chart, lab exams, imagery studies, becomes lot of paper work that can easily be lost. Mainly difficulties were with patients in rural areas where awareness and access to specialist is not well covered. Providing medical care in these conditions can be quite challenging. The study was started after noticing that the patients that were diagnosed with cryptorchidism lost precious time until they were treated. In our series the mean age of patients was higher than recommended age for treating cryptorchidism.  Ideal age for treating cryptorchidism is from 6 month to 2 years of life. First signs of damage to testes are identified at about 6 month of age. We decided to study this pathology in 3 years period, after starting awareness program and systematic controls in schools and kindergartens.Conclusion: After starting systematic controls and awareness program, mean age of the patients diagnosed and treated for cryptorchidism is in decline. Keywords: Cryptorchidism, Testes, Orchiopexy, Hormones, Medical risks, Modern treatment

Carotid artery disease : plaque features and vulnerability

Background: Atherosclerosis is an important cause of stroke. Ultrasound offers the convenience of real-time and detailed assessment of carotid plaque features as well as arterial wall thickening and composition. Evaluation of these features is important for determining patients’ risk of suffering vascular events and also contributes to selecting the best treatment strategy. Methods: Using ultrasound data analysis we have determined plaque features in the bifurcation and internal carotid artery (ICA), including: surface plaque irregularities, calcification, echogenicity (grey scale median-GSM) and other textural plaque features (Juxtaluminal black area, entropy, coarseness). In addition, intima media thickens (IMT) and its grey scale median (IM-GSM) was measured in common carotid artery (CCA). Using Cone Beam CT (CBCT) we have quantified calcification volume of the carotid plaques extracted after carotid endarterectomy procedure. For the meta-analysis we have used comprehensive meta-analysis software version 3. Study I: We have included 39 patients and we compared carotid plaque features of the contralateral arteries with those located ipsilateral to symptomatic side and arteries of asymptomatic patients. Study II: The accuracy of US to detect atherosclerosis calcification was assessed against CBCT in 88 patients. Study III: Based on the previous vascular events in coronary, carotid and lower extremity arterial system, 87 patients were divided into three groups: asymptomatic, symptoms in one vascular system and symptoms in more that one vascular system. IMT, IM-GSM and plaque features were compared between groups. Study IV: We have meta-analyzed ten cohort prospective studies evaluating carotid plaque echogenicity for cerebrovascular symptoms prediction. Results: Study I. Plaques of the contralateral to symptomatic arteries had similar features to those in symptomatic and more vulnerable than asymptomatic arteries. Study II. Carotid ultrasound was accurate in detecting calcification volumes of ≥8mm3 with very high sensitivity but it was less accurate in detecting lower calcification volumes (<8mm3). Carotid calcification was not different between symptomatic and asymptomatic patients. Study III. Echogenicity of the intima-media complex (IM-GSM), but not its thickness (IMT), was significantly decreased with increasing number of arterial systems affected by atherosclerosis. IM-GSM was lower in patients with prior myocardial infarction and stroke. Study IV. Carotid plaque echogenicity evaluated by US could predict future cerebrovascular events in patients with asymptomatic, relative risk RR 2.72 (95% CI, 1.86 to 3.96), and recurrent symptoms in symptomatic patients, RR 2.97 (95% CI, 1.85-4.78). Conclusion: Plaques located in the contralateral to symptomatic arteries have similar features as symptomatic side and more vulnerable than asymptomatic arteries. Carotid ultrasound could accurately detect larger but not smaller carotid plaque calcification volumes (<8 mm3). Low IM- GSM could identify patients with multi-system atherosclerosis disease, suggesting a better marker for determining systemic atherosclerosis disease burden compared to conventional IMT. Finally, carotid plaque echogenicity predicts future cerebrovascular events in patients with symptomatic and asymptomatic carotid stenosis.

Carotid artery disease : plaque features and vulnerability

Background: Atherosclerosis is an important cause of stroke. Ultrasound offers the convenience of real-time and detailed assessment of carotid plaque features as well as arterial wall thickening and composition. Evaluation of these features is important for determining patients’ risk of suffering vascular events and also contributes to selecting the best treatment strategy. Methods: Using ultrasound data analysis we have determined plaque features in the bifurcation and internal carotid artery (ICA), including: surface plaque irregularities, calcification, echogenicity (grey scale median-GSM) and other textural plaque features (Juxtaluminal black area, entropy, coarseness). In addition, intima media thickens (IMT) and its grey scale median (IM-GSM) was measured in common carotid artery (CCA). Using Cone Beam CT (CBCT) we have quantified calcification volume of the carotid plaques extracted after carotid endarterectomy procedure. For the meta-analysis we have used comprehensive meta-analysis software version 3. Study I: We have included 39 patients and we compared carotid plaque features of the contralateral arteries with those located ipsilateral to symptomatic side and arteries of asymptomatic patients. Study II: The accuracy of US to detect atherosclerosis calcification was assessed against CBCT in 88 patients. Study III: Based on the previous vascular events in coronary, carotid and lower extremity arterial system, 87 patients were divided into three groups: asymptomatic, symptoms in one vascular system and symptoms in more that one vascular system. IMT, IM-GSM and plaque features were compared between groups. Study IV: We have meta-analyzed ten cohort prospective studies evaluating carotid plaque echogenicity for cerebrovascular symptoms prediction. Results: Study I. Plaques of the contralateral to symptomatic arteries had similar features to those in symptomatic and more vulnerable than asymptomatic arteries. Study II. Carotid ultrasound was accurate in detecting calcification volumes of ≥8mm3 with very high sensitivity but it was less accurate in detecting lower calcification volumes (<8mm3). Carotid calcification was not different between symptomatic and asymptomatic patients. Study III. Echogenicity of the intima-media complex (IM-GSM), but not its thickness (IMT), was significantly decreased with increasing number of arterial systems affected by atherosclerosis. IM-GSM was lower in patients with prior myocardial infarction and stroke. Study IV. Carotid plaque echogenicity evaluated by US could predict future cerebrovascular events in patients with asymptomatic, relative risk RR 2.72 (95% CI, 1.86 to 3.96), and recurrent symptoms in symptomatic patients, RR 2.97 (95% CI, 1.85-4.78). Conclusion: Plaques located in the contralateral to symptomatic arteries have similar features as symptomatic side and more vulnerable than asymptomatic arteries. Carotid ultrasound could accurately detect larger but not smaller carotid plaque calcification volumes (<8 mm3). Low IM- GSM could identify patients with multi-system atherosclerosis disease, suggesting a better marker for determining systemic atherosclerosis disease burden compared to conventional IMT. Finally, carotid plaque echogenicity predicts future cerebrovascular events in patients with symptomatic and asymptomatic carotid stenosis.

Atherosclerotic Calcification Detection: A Comparative Study of Carotid Ultrasound and Cone Beam CT

Background and Aim: Arterial calcification is often detected on ultrasound examination but its diagnostic accuracy is not well validated. The aim of this study was to determine the accuracy of carotid ultrasound B mode findings in detecting atherosclerotic calcification quantified by cone beam computed tomography (CBCT). Methods: We analyzed 94 carotid arteries, from 88 patients (mean age 70 ± 7 years, 33% females), who underwent pre-endarterectomy ultrasound examination. Plaques with high echogenic nodules and posterior shadowing were considered calcified. After surgery, the excised plaques were examined using CBCT, from which the calcification volume (mm3) was calculated. In cases with multiple calcifications the largest calcification nodule volume was used to represent the plaque. Carotid artery calcification by the two imaging techniques was compared using conventional correlations. Results: Carotid ultrasound was highly accurate in detecting the presence of calcification; with a sensitivity of 88.2%. Based on the quartile ranges of calcification volumes measured by CBCT we have divided plaque calcification into four groups: <8; 8–35; 36–70 and >70 mm3. Calcification volumes ≥8 were accurately detectable by ultrasound with a sensitivity of 96%. Of the 21 plaques with <8 mm3 calcification volume; only 13 were detected by ultrasound; resulting in a sensitivity of 62%. There was no difference in the volume of calcification between symptomatic and asymptomatic patients. Conclusion: Carotid ultrasound is highly accurate in detecting the presence of calcified atherosclerotic lesions of volume ≥8 mm3; but less accurate in detecting smaller volume calcified plaques. Further development of ultrasound techniques should allow better detection of early arterial calcification

A 14-Year-Old Male Patient with Kawasaki Disease Presented with Stroke after COVID-19

According to several studies, children represent only about 2% of the patients affected by the current SARS-CoV-2, and most often, they are asymptomatic. However, there is a concern about a vascular inflammatory disease which is similar to Kawasaki disease observed in children and adolescents weeks after infection. We report a case of Kawasaki disease presented with ischemic stroke in a 14-year-old male patient following SARS-Cov-2 infection. Case report A 14-year-old male with classical signs of Kawasaki Disease (KD) and no chronic medical condition presented with ischemic stroke. The diagnosis was challenging because the prior COVID-19 was silent and the skin rashes were very prominent on admission. Therefore, the patient was admitted and empirically treated in the clinic of dermatology at first days, and only after complicated with neurological symptoms, he was transferred to the Neurology Clinic. Prior infection with SARS-CoV-2 was confirmed based on serological testing and prior contact with the infected family member. Brain ischemia was confirmed with MRI. Even though there was not any large artery or venous occlusion apparent on CTA, increased pulsatility index was found on the left MCA suggesting distal small diameter arterial segments occlusion. After treatment with IVIG, corticosteroids, and low-dose aspirin, the neurological deficit was resolved. The exact pathomechanism of the Multisystem Inflammatory Syndrome in Children (MIS-C) is not clear. Given the lag between SARS-CoV-2 infection and MIS-C and the finding that many patients are positive for antibodies and negative for the viral antigen, it has been suggested that abnormal immune response might be the key factor. A potential role of the antibodies in the pathogenesis of KD has been accepted, and the prevalence of such antibodies to target different tissues in the body could explain the multisystem presentation in MIS-C [10]. Conclusion There is a myriad of COVID-19 symptoms and sequelae making the diagnosis challenging. Early diagnosis and prompt treatment of the secondary inflammatory syndromes, including Kawasaki disease, is very important for preventing end-organ damage and long-term complications

Individualizing Treatment Approaches for Epileptic Patients with Glucose Transporter Type1 (GLUT-1) Deficiency

Monogenic and polygenic mutations are important contributors in patients suffering from epilepsy, including metabolic epilepsies which are inborn errors of metabolism with a good respond to specific dietetic treatments. Heterozygous variation in solute carrier family 2, facilitated glucose transporter member 1 (SLC2A1) and mutations of the GLUT1/SLC2A2 gene results in the failure of glucose transport, which is related with a glucose type-1 transporter (GLUT1) deficiency syndrome (GLUT1DS). GLUT1 deficiency syndrome is a treatable disorder of glucose transport into the brain caused by a variety of mutations in the SLC2A1 gene which are the cause of different neurological disorders also with different types of epilepsy and related clinical phenotypes. Since patients continue to experience seizures due to a pharmacoresistance, an early clinical diagnosis associated with specific genetic testing in SLC2A1 pathogenic variants in clinical phenotypes could predict pure drug response and might improve safety and efficacy of treatment with the initiation of an alternative energy source including ketogenic or analog diets in such patients providing individualized strategy approaches

Hypoglycemia-Induced Hemiparesis in a Diabetic Woman after Childbirth

A 24-year-old female with type 1 diabetes mellitus presented with hemiparesis induced by hypoglycemia. She was hospitalized because she has noticed a weakness of her right hand and leg three days after childbirth. On physical examination she had an expressive dysphasia and right side hemiparesis with facial drop. Hypoglycemia is rarely associated with hemiparesis and it is often overlooked, especially when it happens in patients at higher risk of other diseases frequently associated with hemiparesis. Although sporadical cases of hypoglycemia-induced hemiparesis were reported, the clear pathophysiology behind this is not well determined. However, any individual case is important in order to increase the awareness of hypoglycemia as an important etiology of this condition

Normal ranges of left ventricular strain in children : a meta-analysis

Aims: The definition of normal values of two-dimensional speckle-tracking echocardiography derived left ventricular (LV) deformation parameters, is of critical importance for the routine application of this modality in children. The objectives of this study were to perform a meta-analysis of normal ranges for longitudinal, circumferential and radial strain/strain rate values and to identify confounders that may contribute to differences in reported measures. Methods and Results: A systematic search was conducted. Studies describing normal healthy subjects and observational studies that used control groups as a comparison were included. Data were combined using a random-effect model. Effects of demographic, clinical and equipment variables were assessed through meta-regression. The search identified 1,192 subjects form 28 articles. Longitudinal strain (LS) normal mean values varied from -12.9 to -26.5 (mean, -20.5; 95 % CI, -20.0 to -21.0). Normal mean values of circumferential strain (CS) varied from -10.5 to -27.0 (mean, -22.06; 95 % CI, -21.5 to -22.5). Radial strain (RS) normal mean values varied from 24.9 to 62.1 (mean, 45.4; 95 % CI, 43.0 to 47.8). Meta-regression showed LV end diastolic diameter as a significant determinant of variation for LS. Longitudinal systolic strain rate (LSRs) was significantly determined by the age and RS by the type of vendor used. Conclusion: Variations among different normal ranges were dependent on the vendor used, LV end-diastolic diameter and age. Vendor-independent software for analyzing myocardial deformation in children, using images from different vendors would be the ideal solution for strain measurements or else using the same system for patient's follow up

Superior Sagittal Sinus Thrombosis Presenting with Hallucinations in the Puerperium: A Case Report

Cerebral venous sinus thrombosis is an uncommon cause of stroke presenting with varied presentation patterns. We report a case of a 21-year-old woman with superior sagittal sinus (SSS) thrombosis (SSST) developing after childbirth, presenting with visual hallucinations, severe headache, and tonic-clonic seizures. Time-of-flight magnetic resonance angiography (TOF-MRA) demonstrated the presence of thrombus in SSS. She was treated with low molecular weight heparin (LMWH) followed by warfarin. She had excellent recovery a few weeks after admission and was regularly followed up. Although this condition can be presented with different neurological symptoms, it does not typically present with hallucinations. We suggest that CSVT should be suspected even when a patient presents with an atypical picture in a category of patients at higher risk