Objective
Cerebral aneurysms can cause substantial morbidity and mortality, specifically if they rupture, leading to nontraumatic subarachnoid hemorrhage (SAH). This meta‐analysis summarizes evidence ...about the accuracy of noninvasive computed tomographic (CT) angiography for diagnosing intracranial aneurysms in symptomatic patients.
Methods
Four databases including PubMed were searched without language restrictions from January 1995 to February 2010. Two independent reviewers selected and extracted 45 studies that compared CT angiography with digital subtraction angiography (DSA) and/or intraoperative findings in patients suspected of having cerebral aneurysms. Data from eligible studies were used to reconstruct 2 × 2 contingency tables on a per‐patient basis in at least 5 diseased and 5 nondiseased patients, with additional data on a per‐aneurysm basis when available.
Results
The 45 included studies generally were of high methodological quality. Among the 3,643 patients included, about 86% had nontraumatic SAH, and 77% had cerebral aneurysms. Overall, CT angiography had a pooled sensitivity of 97.2% (95% confidence interval, 95.8–98.2%) for detecting and specificity of 97.9% (95.7–99.0%) for ruling out cerebral aneurysms on a per‐patient basis. On a per‐aneurysm basis, the pooled sensitivity was 95.0% (93.2–96.4%), and the specificity 96.2% (92.9–98.0%). The diagnostic accuracy of CT angiography with 16‐ or 64‐row multidetector CT was significantly higher than that of single‐detector CT, especially in detecting small aneurysms of ≤4mm in diameter.
Interpretation
CT angiography has a high accuracy in diagnosing cerebral aneurysms, specifically when using modern multidetector CT. In the future, CT angiography may increasingly supplement or selectively replace DSA in patients suspected of having a cerebral aneurysm. ANN NEUROL 2011
Rheumatoid arthritis (RA) is a type of inflammatory arthritis that affects ~1% of the general population. Although arthritis is the cardinal symptom, many extra-articular manifestations can occur. ...Lung involvement and particularly interstitial lung disease (ILD) is among the most common. Although ILD can occur as part of the natural history of RA (RA-ILD), pulmonary fibrosis has been also linked with methotrexate (MTX); a condition also known as MTX-pneumonitis (M-pneu). This review aims to discuss epidemiological, diagnostic, imaging and histopathological features, risk factors, and treatment options in RA-ILD and M-pneu. M-pneu, usually has an acute/subacute course characterized by cough, dyspnea and fever. Several risk factors, including genetic and environmental factors have been suggested, but none have been validated. The diagnosis is based on clinical and radiologic findings which are mostly consistent with non-specific interstitial pneumonia (NSIP), more so than bronchiolitis obliterans organizing pneumonia (BOOP). Histological findings include interstitial infiltrates by lymphocytes, histiocytes, and eosinophils with or without non-caseating granulomas. Treatment requires immediate cessation of MTX and commencement of glucocorticoids. RA-ILD shares the same symptomatology with M-pneu. However, it usually has a more chronic course. RA-ILD occurs in about 3–5% of RA patients, although this percentage is significantly increased when radiologic criteria are used. Usual interstitial pneumonia (UIP) and NSIP are the most common radiologic patterns. Several risk factors have been identified for RA-ILD including smoking, male gender, and positivity for anti-citrullinated peptide antibodies and rheumatoid factor. Diagnosis is based on clinical and radiologic findings while pulmonary function tests may demonstrate a restrictive pattern. Although no clear guidelines exist for RA-ILD treatment, glucocorticoids and conventional disease modifying antirheumatic drugs (DMARDs) like MTX or leflunomide, as well as treatment with biologic DMARDs can be effective. There is limited evidence that rituximab, abatacept, and tocilizumab are better options compared to TNF-inhibitors.
Thromboembolism in Atrial Fibrillation Menke, Jan, MD; Lüthje, Lars, MD; Kastrup, Andreas, MD ...
The American journal of cardiology,
02/2010, Letnik:
105, Številka:
4
Journal Article
Recenzirano
Thromboembolism is a severe complication in atrial fibrillation. This overview presents thromboembolic disease as a single entity, ranging from stroke through mesenteric ischemia to acute limb ...ischemia. The PubMed, Embase, and Cochrane databases were systematically searched for the terms “atrial fibrillation” and “thromboembolism” in reports published from January 1986 to September 2009. The information of 10 evidence-based practice guideline documents and 61 further sources was systematically extracted. In atrial fibrillation, the average annual stroke risk is increased by 2.3% (lethality 30%). The annual incidence of acute mesenteric ischemia is 0.14% (lethality 70%), and that of acute limb ischemia is 0.4% (lethality 16%). In total, approximately 80% of embolism-related deaths are from stroke and 20% from other systemic thromboembolism. The ischemic symptoms generally have an acute onset but may mimic other diseases, particularly in mesenteric ischemia. Early diagnosis and treatment can limit or even prevent tissue infarction. Guideline-recommended therapy with aspirin or warfarin reduces the thromboembolic risk. Suitable patients may optimize their warfarin therapy by self-monitoring of the international normalized ratio (INR). New oral and parenteral anticoagulants with more stable pharmacokinetics are being developed. In conclusion, atrial fibrillation predisposes to thromboembolism. If ischemic stroke or systemic thromboembolism occurs, early diagnosis and treatment can improve outcomes. The thromboembolic risks are reduced by guideline-adherent antithrombotic therapy with warfarin or aspirin. Future directions may include self-monitoring of the international normalized ratio and novel anticoagulants.
Microbiological culture of the liver sample, urine, and catheter tips and arterial and venous blood cultures did not yield any pathogens. A range of microorganisms have been shown to produce gas when ...colonising bone, including Pseudomonas spp, Streptococcus spp, Enterococcus spp, E coli, Salmonella spp, Staphylococcus aureus, and fungi.
Antisynthetase syndrome (ASyS) is a rare autoimmune disease characterized by inflammatory myopathy, arthritis, fever, and interstitial lung disease (ILD). Pulmonary involvement in ASyS significantly ...increases morbidity and mortality and, therefore, requires prompt and effective immunosuppressive treatment. Owing to the rarity of ASyS, limited data exists on progression and prognosis of ILD under immunosuppression.
The objective of the study was to evaluate the radiological progression and outcome measures of ILD with immunosuppressive therapy in patients with ASyS.
Twelve patients with ASyS-associated ILD (ASyS-ILD) were included. Demographic and clinical data, including organ involvement, pulmonary function tests (PFT), laboratory parameters, imaging studies, and treatment regimens were retrospectively analyzed from routinely collected data. The extent of ground glass opacities, fibrotic changes and honeycombing was analyzed and scored using high-resolution chest computed tomography (HRCT) scans. HRCT findings were compared between baseline and follow-up examinations. In addition, patients were stratified depending on whether they had received rituximab (RTX) or not.
Pulmonary function tests revealed stable lung function and follow-up HRCT scans showed an improvement of radiological alterations in the majority of ASyS patients under immunosuppressive therapy. We did not detect significant differences between the RTX- and non-RTX-treated groups, but the RTX-treated patients more frequently had myositis and relapsing disease.
Radiographic alterations in ASyS-associated ILD respond to immunosuppressive treatment. RTX is a feasible treatment option with similar clinical and radiographic outcomes in patients with relapsing disease and clinically apparent myositis.
Key Clinical Message
Hypophyseal dysfunction may be overlooked by the currently generally accepted laboratory routine for the differential diagnosis in patients suffering from symptoms of depression ...or dementia.
Hypothyroidism is an important cause of depression and potentially reversible cognitive impairment. Whereas the determination of the plasma concentration of thyrotropin (TSH) is generally considered part of the laboratory screening tests for dementia, the measurement of total or free triiodothyronine (T3, FT3), thyroxine (T4, FT4) and cortisol in plasma does not belong to the routine diagnostic workup in patients with depression or suspected dementia. In an 87‐year‐old lady suffering from increasingly poor general health, decreased fluid and food intake, mood depression and lack of energy, three measurements of plasma TSH produced normal values. A cranial computed tomography (cCT) 2 days prior to hospital admission had been assessed as apparently normal. A second cCT performed following a loss of consciousness complicated by tongue bite showed a hypophyseal tumor. Then, low plasma levels of FT3, FT4 and cortisol were found. Following hormone replacement and transsphenoidal tumor resection, the patient recovered rapidly. The present case report illustrates the pitfalls of measuring merely the TSH level in the detection of thyroid and hypophyseal dysfunction.
Hypothyroidism despite repeatedly normal plasma thyrotropin levels in a patient with hypophyseal tumor.
Patients' wishes should guide therapeutic considerations in the face of options and necessities, particularly when an intervention carries the risk of death. Therefore, in the medical management of ...the young and the old, everything should be attempted as long as the patient has a strong will to live.
Patients' wishes should guide therapeutic considerations in the face of options and necessities, particularly when an intervention carries the risk of death. Therefore, in the medical management of the young and the old, everything should be attempted as long as the patient has a strong will to live.
BOLD fMRI is becoming the preferred modality to study cerebrovascular reactivity. Amongst the vasoactive stimuli to induce it, breath holding is considered equal to other methods but both ...cerebrovascular reserve measures and breath holding designs lack standardization. We have systematically considered whether breath holding paradigms at short time periods are both a practical as well as equally effective and robust alternative to the elaborate CO2-inhalation in estimating cerebrovascular reactivity.
Using BOLD fMRI, eleven healthy subjects were examined with dynamic T2*-weighted echo planar imaging at 3 T. Cerebrovascular reactivity was measured during episodes of breath holding for 10 s and 20 s, both after deep inspiration and after extended expiration, and compared to the reactivity following inhalation of an air mixture with 5% CO2-content.
20 s breath holding challenges yielded higher reactivities represented by corresponding higher BOLD-signal changes when compared to 10 s ones, as did expiratory paradigms when compared to inspiratory ones. Mean signal changes ranged from 2% (10 s breath holding after inspiration) to 3% (20 s breath holding after expiration). The CO2-challenge yielded an about threefold higher reactivity (6%).
The breath holding tasks evoked BOLD-signal increases which compare favorably to published data. A 20 s breath holding period appears to be ideal and is tolerated well. This experimental design is thus practical, effective and robust. To further standardize the breath holding design and the measurement of cerebrovascular reserve, controlled breathing during resting periods as well as modelling of the fMRI-signal to end-tidal CO2-levels should be employed in future studies.
Experimental and intraoperative evaluation of the efficiency of a novel technique.
To determine the accuracy of pedicle screw hole placements before screw implantation in the lumbar spine.
Deviations ...from planned trajectories occur in a significant number of screw placements in posterior lumbar fixation. Several techniques have been proposed to minimize this complication, although none has gained general acceptance. This may be due to costs associated with their implementation or considerably extended operating times required by some techniques.
Pedicle screw holes were placed in 24 pedicles of 2 postmortem human lumbar spine specimens. Sixteen optimal trajectories were placed and 8 intentional cortical breaches. Each pedicular drill hole was examined using a 360 degrees ultrasound transducer and CT scanning. The ultrasonographic images were reviewed by 3 independent investigators who were blinded to the CT findings. In addition, 20 screw holes were placed intraoperatively in 3 patients, and equally assessed by intraoperative intraosseous ultrasonography and postoperative CT scanning.
Ultrasonographic images of pedicle screw holes in postmortem human spine specimen were correctly interpreted in 99% of cases. No cortical breech was missed, i.e., no false-negatives occurred. Intraoperative findings closely matched the experimental data. None of the intraoperative ultrasound scans demonstrated a cortical breach, a finding confirmed by postoperative CT. The intraoperative time required for the ultrasonographic analysis of each pedicle was about 1 minute and the interpretation of the resulting images was judged intuitive by the evaluating neurosurgeons.
Intraosseous ultrasound is a highly reliable technique for the intraoperative assessment of pedicle screw holes before pedicle screw placement. Additional expenses with respect to procedure time and manpower are minimal.
Contrast-enhanced magnetic resonance angiography (MRA) is a noninvasive, radiation-free imaging method for studying peripheral arterial disease (PAD) of the lower extremities.
To summarize evidence ...of prospective studies about how well MRA identifies or excludes arterial steno-occlusions (50% to 100% lumen reduction) in adults with PAD symptoms.
PubMed and 3 other databases were searched from 1998 to 2009 without language restrictions.
Two independent reviewers selected 32 studies that compared MRA with intra-arterial digital subtraction angiography in PAD. Eligible studies were prospective and provided data to reconstruct 2 x 2 or 3 x 3 contingency tables (<50% stenosis vs. > or =50% stenosis or occlusion of arterial segments) in at least 10 patients with PAD symptoms.
Two reviewers independently assessed the study quality and extracted the study data, with disagreements resolved by consensus.
The 32 included studies generally had high methodological quality. About 26% of the 1022 included patients had critical limb ischemia with pain at rest or tissue loss. Overall, the pooled sensitivity of MRA was 94.7% (95% CI, 92.1% to 96.4%) and the specificity was 95.6% (CI, 94.0% to 96.8%) for diagnosing segmental steno-occlusions. The pooled positive and negative likelihood ratios were 21.56 (CI, 15.70 to 29.69) and 0.056 (CI, 0.037 to 0.083), respectively. Magnetic resonance angiography correctly classified 95.3%, overstaged 3.1%, and understaged 1.6% of arterial segments.
Similar to most studies of computed tomographic angiography in PAD, the primary studies reported the diagnostic accuracy of MRA on a per-segment basis, not a per-patient basis.
This meta-analysis of 32 prospective studies further increases the evidence that contrast-enhanced MRA has high accuracy for identifying or excluding clinically relevant arterial steno-occlusions in adults with PAD symptoms.
None.
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