Can conventional examinations contribute to the diagnostic power of unenhanced helical computed tomography in urolithiasis?

INTRODUCTION: To investigate whether ordinary tests used in urolithiasis can increase the diagnostic value of unenhanced helical computed tomography (HCT). MATERIALS AND METHODS: Of all patients admitted with acute flank pain, 137 without radiocontrast allergy, pregnancy and renal insufficiency were included in the study. After urinalysis (Ur) and ultrasonography (USG), HCT without a contrast agent was taken by 5-mm collimation, thereafter excretory urography (EU) was obtained. Confirmation of a stone was done by various tests and/or treatment methods. Statistically, the predictive values of HCT, USG, EU and Ur and their combinations were evaluated using the area under the receiver operating characteristic curve (AROC). RESULTS: The patients' mean age was 38 (range 4-72) years. Sensitivity values of HCT, USG, EU and Ur were 97, 69, 71 and 81%, respectively. Their specificity values were 96, 87, 91 and 65%, respectively. The widest AROC was found for HCT (97%). The best test combination was [HCT or USG] according to the AROC value (93%), but none of the AROC values of the test combinations was higher than that of HCT. However, 95% confidence intervals of the AROC values of these tests and their combinations overlapped. CONCLUSIONS: Because the HCT combinations with other tests improved the diagnostic value of HCT, they should be preferred in some individuals suspected of having urolithiasis. However, the most feasible single test meeting the all usage purposes was HCT in terms of the AROC value, and the combination was [HCT or USG] in which either HCT or USG was positive.     

Does the presence of ultrasound really affect computed tomographic scan use? A prospective randomized trial of ultrasound in trauma

BACKGROUND: The sliding hip screw has gained considerable acceptance in the treatment of unstable trochanteric fractures. However, the new type of 120 degrees fixed angle blade-plate with a buttress rod (RAB-plate) showed encouraging clinical results. The purpose of this study was to assess stability of fixation and analyze modes of failure in unstable trochanteric hip fractures treated with these devices. METHODS: A retrospective radiographic review of 218 unstable fractures was performed. Linear and angular displacements of the major fragments and implant migration into the femoral head during healing were assessed. Additionally, adequacy of the reduction and the location of the implant within the femoral head as predictors of fixation failure were evaluated. RESULTS: The postreduction neck-shaft angle was maintained in the majority of the fractures in both groups. However, there was a significantly higher incidence of varus angulation by 10 degrees or more by the completion of healing among fractures treated with the sliding hip screw (p = 0.04). There was no statistically significant difference in vertical migration of the device into the femoral head between the implants used (p = 0.3). There was a significant relationship between failure of the fixation and varus reduction (p = 0.04) as well as screw/neck angle deviation more than 20 degrees in the lateral projection (p = 0.005) or if the implant was in a superior or posterior position (p = 0.02). CONCLUSION: The RAB-plate provided a more stable fixation, especially with regard to maintained postoperative alignment. However, positive predictors for fixation failure were identical for both devices. Here, the screw/neck angle deviation has had the strongest significance for prediction of fixation failure.     

Does the method of cystometry affect the incidence of involuntary detrusor contractions? A prospective randomized urodynamic study

The International Continence Society (ICS) defines overactive detrusor as "one that is shown objectively to contract during the filling phase while the patient is attempting to inhibit micturition." The aim of the present study was to assess whether instructing the patient neither to try void nor to inhibit micturition during filling cystometry may improve the detection rate of involuntary detrusor contractions (IDCs). Forty-two consecutive patients (mean age 65 +/- 13.5 years), referred for urodynamic evaluation of persistent irritative lower urinary tract symptoms were prospectively enrolled. All patients were presumed, by history, to have IDCs. Cystometry was performed twice at the same session, each time by using randomly different instructions: Method 1, patients were instructed to try to inhibit micturition during bladder filling; and Method 2, patients were instructed to neither try to void nor try to inhibit micturition, but simply report his or her sensations to the examiner. The occurrence, as well as the urodynamic characteristics of IDCs, were analyzed separately and compared between the two filling methods. Method 1 identified only 20 cases of IDCs, while Method 2 identified 27 cases (48 versus 64 % of the study population, respectively; P = 0.02). Analysis of urodynamic characteristics revealed a clear trend of reduced bladder volume at which IDCs occurred when patients were instructed to neither try to void nor to inhibit micturition during bladder filling; however, statistical significance was not established (189 +/- 122 versus 240 +/- 149 mL, respectively; P = 0.13). All other urodynamic characteristics of IDCs were similar in both methods. In conclusion, better detection rates of IDCs were achieved by instructing the patient to neither try to void nor try to inhibit micturition, but simply report his or her sensations to the examiner, during filling cystometry. If the patient is instructed to inhibit micturition during bladder filling-about 26 % of the IDC cases are misdiagnosed.     

Can preoperative computed tomography of the chest predict completeness of the major pulmonary fissure at surgery?

Background

An incomplete major pulmonary fissure can make anatomic lung resection technically more difficult and may increase the risk of complications, such as prolonged postoperative air leak. The objective of this study was to determine if preoperative computed tomography (CT) of the chest could accurately predict the completeness of the major pulmonary fissure observed at the time of surgery.

Methods

From October 2008 to June 2009, patients at a single university institution were enrolled if they underwent surgery for a pulmonary nodule, mass or known cancer. At the time of surgery, completeness of the major pulmonary fissure was graded 1 if pulmonary lobes were entirely separate, 2 if the visceral cleft was complete with an exposed pulmonary artery at the base with some parenchyma fusion, 3 if the visceral cleft was only evident for part of the fissure without a visible pulmonary artery and 4 if the fissure was absent. The preoperative CT scan of each patient was graded by a single, blinded chest radiologist using the same scale. We used the Pearson χ² test with 2-tailed significance to test the independence of the operative and radiologic grading.

Results

In 48% (29 of 61) of patients, the radiologic and operative grading were the same. Of those graded differently, 94% (30 of 32) were within 1 grade. Despite this agreement, we observed no statistically significant correlation between the operative and radiologic grading (p = 0.24).

Conclusion

The major fissure can often be well-visualized on a preoperative CT scan, but preoperative CT cannot accurately predict the completeness of the major pulmonary fissure discovered at surgery.     

Can Phyllanthus niruri affect the efficacy of extracorporeal shock wave lithotripsy for renal stones? A randomized, prospective, long-term study

PURPOSE: Phyllanthus niruri is a plant used in Brazilian folk medicine for the treatment of urolithiasis. We assessed the efficacy of P. niruri after extracorporeal shock wave lithotripsy for renal stones. MATERIALS AND METHODS: We prospectively evaluated 150 patients with renal stones that were as large as 25 mm and composed of calcium oxalate. All patients received 1 to 3 extracorporeal shock wave lithotripsy sessions by Dornier Lithotriptor S. After treatment 78 of 150 patients (52%) underwent therapy with Uriston, a P. niruri extract (2 gm daily) for at least 3 months (group 1). Otherwise 72 of 150 patients (48%) were used as a control group (group 2). No significant difference in stone size between the 2 groups was found. Stone clearance was assessed after 30, 60, 90 and 180 days by abdominal x-ray and ultrasound scan. RESULTS: Stone-free rate (stone-free defined as the absence of any stone or residual fragments less than 3 mm) was 93.5% in group 1 and 83.3% in group 2 (p = 0.48) at the end point of the followup (180 days). For lower caliceal stones (56 patients) the stone-free rate was 93.7% in the treatment group and 70.8% in the control group (p = 0.01). Re-treatment need for group 1 was 39.7% and for group 2 it was 43.3% (p = 0.2). No side effects were recorded with extracorporeal shock wave lithotripsy or P. niruri therapy. CONCLUSIONS: Regular self-administration of P. niruri after extracorporeal shock wave lithotripsy for renal stones results in an increased stone-free rate that appears statistically significant for lower caliceal location. Its efficacy and the absolute lack of side effects make this therapy suitable to improve overall outcomes after extracorporeal shock wave lithotripsy for lower pole stones.     

‘In vivo’ size of knitted Dacron prostheses (Gelseal®) used in the thoracic aorta: a computed tomography study

When replacing the thoracic aorta, gelatin-sealed triaxial knitted Dacron prostheses are used as they have zero porosity and are easy to handle. It is known that knitted prostheses (not triaxially constructed), when implanted in the abdominal aorta or in the peripheral vessels, show a dilatation of 10–20%. The initial in vivo expansion of this prosthesis in the thoracic aorta was assessed using computed tomography scanning in 18 patients. The graft sizes used were 18 mm (n = 4), 20 mm (n = 5), 22 mm (n = 4), 26 mm (n = 1), 28 mm (n = 2) and 30 mm (n = 2). All patients were kept normotensive postoperatively. Computed tomography scan measurement was performed within 4 weeks of operation, using standard computed tomography equipment and no contrast. Two radiologists checked and agreed upon the slice levels and measurements compared with the manufacturer's stated size referring to internal diameter of the crimped prosthesis. The mean(s.d.) ‘in vivo’ size was 16.2(6)% larger. This ‘true size’ should be taken as the reference measurement when considering further dilatation over the period of follow-up.     

Can metal-on-metal bearings improve the longevity of total hip prostheses?

PURPOSE OF THE STUDY: In total hip arthroplasty (THA), inter-series comparative clinical results cannot be considered worthy before at least 10 years of average follow-up, as shown in the Swedish Arthroplasty Register experience (1978-1993). Last generation metal-on-metal bearings were introduced in France only nine years ago (1995). To date, using mid term information, data from the literature, and our experience, one could assume that this bearing material has the capacity to improve THA longevity. Three types of information were analyzed: 1) comparative radiographic and EBRA studies published on early migration (<2 years) of acetabular implants; 2) preliminary comparative data on wear and osteolysis at the 8-year maximum follow-up; 3) clinical data on dislocation frequency and in vitro and in vivo observations of bearing separation and sliding. Study no 1: primary stability of these metal-on-metal acetabular cups was better than for polyethylene (PE) cups or alumina liners; study no 2: no detectable wear and less osteolysis were observed to date with metal-on-metal bearings versus their alumina-on-PE counterparts. Study no 3: less dislocation and less head sliding were measured with the metal-on-metal versus alumina-on-PR bearings possibly due to the interfacial forces provided by lubricating fluid (suction fit). CONCLUSION: According to current knowledge, this metal-on-metal bearing still represent, with alumina-on-alumina and highly crosslinked PE, a competitive and comprehensive option to improve THA longevity. The real pending problem concerns the frequency and above all the intensity of metal delayed hypersensitivity reaction and their potential effect on implant loosening.     

An analysis of proctoscopy vs computed tomography scanning in the diagnosis of rectal injuries in children: which is better?

Background

Current dogma suggests that the diagnosis of rectal injury can be made after physical examination and proctoscopy (PR). However, anecdotal evidence suggests that these modalities lack specificity when applied to children and that computed tomography (CT) scanning may be superior. A direct comparison between CT scanning and PR has not been performed. We therefore sought to compare CT with PR in the diagnosis of rectal injury by analyzing our large institutional experience.

Methods

To assess institutional outcome, the charts of all children younger than 18 years admitted to our level I trauma center (1999-2004) were prospectively collected and retrospectively assessed. Demographics, diagnostic accuracy (PR vs CT), and outcome (length of stay, days in the intensive care unit [ICU], Injury Severity Score, and missed injury) were assessed.

Results

There were 24 injuries (63% boys, 71% blunt, 100% survival), and diagnostic modality included the following: PR, 37.5%; CT, 37.5%; laparotomy alone, 8%. Length of stay (PR 5.7 ± 6.2 vs CT 13.7 ± 22.2, NS) were similar between groups. Of the missed rectal injuries, 66% of patients undergoing PR had missed injuries that were ultimately detected by CT whereas 33% of the patients undergoing CT scan had a missed injury.

Conclusion

CT is at least as accurate as PR in diagnosing pediatric rectal injury. Consideration of early scanning as opposed to PR may improve diagnosis and outcome in these patients.     

Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care?

BACKGROUND: Although spiral computed tomographic scanning (SCT) is frequently used for spinal imaging in injured patients, many trauma centers continue to rely on plain film radiography (PFR). The purpose of this study was to determine the effects of a trauma center's transition from PFR to SCT for initial spine evaluation in trauma patients by comparing diagnostic sensitivity, time required for radiographic imaging, costs, charges, and radiation exposure. METHODS: Registry-based review of all trauma patients evaluated for spinal trauma during two three-month intervals, one before (1999, "X-ray Group"), and one after (2002, "CT Group") adopting SCT as the initial spinal imaging method. Demographic data, mechanism of injury, Injury Severity Score (ISS), the presence and location of spine fractures, and the results of all spine imaging were recorded. The dates and diagnostic sensitivity for spine fractures, time for initial imaging, costs, and charges were compared between groups. Radiation exposure associated with both SCT and PFR of the spine was measured. RESULTS: There were 254 patients in the X-ray Group and 319 in the CT Group, with similar demographic data, ISS, mechanism of injury, and incidence of spine fractures. Sensitivity in the detection of spine fractures was 70% (14 out of 20) in the X-ray Group compared with 100% (34 out of 34) for the CT Group (p < 0.001). Mean time in the radiology department during initial evaluation decreased significantly in the CT Group compared with the X-ray Group (1.0 hours vs. 1.9 hours; p < 0.001). SCT of the spine was associated with higher mean overall spinal imaging charges than PFR (4,386 dollars vs. 513 dollars, p < 0.001), but a similar mean overall spinal imaging cost per patient (172 dollars vs. 164 dollars). Radiation exposure was higher with SCT versus PFR for cervical spine imaging (26 mSv vs. 4 mSv) but SCT involved lower levels of exposure than PFR for thoracolumbar imaging (13 mSv vs. 26 mSv). CONCLUSIONS: SCT is a more rapid and sensitive modality for evaluating the spine compared with PFR and is obtained at a similar cost. The advantages of SCT suggest that this readily available diagnostic modality may replace PFR as the standard of care for the initial evaluation of the spine in trauma patients.     

Can computed tomography scan be performed effectively in the diagnosis of acute appendicitis without the added morbidity of rectal contrast?

The highest degrees of accuracy have been demonstrated for CT scans using rectal contrast in diagnosing appendicitis. However, the administration of rectal contrast is associated with patient discomfort and rarely, rectosigmoid perforation (0.04%). Additionally, the commonly accepted negative appendectomy rate is around 16 per cent. We performed a retrospective review of radiology, operative, and pathology reports of consecutive patients undergoing appendectomy or CT examination for appendicitis during 2006. CT scans were performed without rectal contrast. The accuracy of each type of inpatient CT examination and negative appendectomy rates were determined. Two hundred and thirty-eight patients underwent appendectomy. One hundred and thirty-four appendectomy patients (56%) received a preoperative CT scan. The negative appendectomy rates were 6.3 per cent overall, 8.7 per cent without CT examination and 4.5 per cent with CT (P = 0.3). Two hundred and forty-five inpatient CT scans were performed for suspected appendicitis with a sensitivity of 90 per cent, specificity of 98 per cent, accuracy of 94 per cent, positive predictive value of 98 per cent, and negative predictive value of 91 per cent. CT scanning without rectal contrast is effective for the diagnosis of acute appendicitis making rectal contrast, with its attendant morbidity, unnecessary. The previously acceptable published negative appendectomy rate is higher than that found in current surgical practice likely due to preoperative CT scanning.     

Does the use of doxazosin influence the success of SWL in the treatment of upper ureteral stones? A multicenter, prospective and randomized study

The objective of the study is to investigate the effect of doxazosin, administered to the subjects who underwent SWL due to upper ureteral stones, on therapeutic outcomes. The study enrolled the patients with a radio-opaque stone ≥5?mm in upper ureter. Patients were randomized into two groups: the first group underwent SWL following the diagnosis and they were recommended to receive oral hydration. The second group underwent SWL after initiating alpha blocker (doxazosin controlled-release tablet 4?mg/day) and drug therapy was continued until that the patient has been stone free. Parameters of SWL procedure, Steinstrasse, pain score at admission, time to stone passage, the complications developed, the additional procedures that were administered and number of hospital visits done due to pain during the treatment were recorded. A total of 79 patients were enrolled to the study. The subjects evaluated included 35 patients, who received an alpha blocker and 44 patients who did not receive an alpha blocker. For both groups, the level of energy applied per SWL session, the diameter of the stone, the number of hospital visits done due to pain, pain score and the need for analgesia were found to be similar (p?>?0.05). The group of doxazosin was more advantageous in terms of stone-free rate, the need for additional procedures and Steinstrasse (p?相似文献   

Do the anatomical defects associated with cystocoele affect the outcome of anterior repair? A clinical and radiological study

Introduction and hypothesis  

The purpose of this study was to investigate the defects associated with cystocoele and the outcome of anterior repair.     

Can a computed tomography scoring system predict the need for surgery in small-bowel obstruction?

BACKGROUND: Small-bowel obstruction (SBO) is a common dilemma faced by general surgeons. A timely and accurate diagnosis is crucial, based on history, physical examination, and radiographic studies. A computed tomography (CT) scan has become an increasingly common diagnostic modality. The aim of this study was to define a set of CT criteria that may help determine whether a patient would require operative intervention. METHODS: A retrospective chart review was performed over an 18-month period. Patients diagnosed with SBO or partial SBO (PSBO) who had a CT scan performed were included. CT scans were then reviewed independently by a staff radiologist blinded to the clinical outcome. A scoring system based on 7 radiographic criteria was then developed. Statistical analysis was performed on the data. RESULTS: From March 1, 2004, to August 30, 2005, 96 patients were found to have the diagnosis of SBO or PSBO and a documented CT scan. Seventy-four patients had undergone prior intra-abdominal procedures. Fifty-five percent were taken to the operating room (OR) over an average of 1.9 days (range 1-12 days). Seventy-nine percent of these patients went to the OR within the first 24 hours. Lysis of adhesions was performed in 38%, small bowel was resected in 47%, and incarcerated ventral hernias were found in 11%. Ischemic bowel was found in 11% of the cases. The CT scoring system was then correlated with the actual treatment. A score of 8 or higher predicted the need for surgery 75% of the time. When looking at the criteria individually, patients with a CT reading of complete obstruction, dilated small bowel, or free fluid were operated on 77%, 66%, and 65% of the time, respectively. CONCLUSION: A CT scoring system can successfully predict the need for surgery 75% of the time. Likewise, specific criteria, when present in combination, can predict the need for operative intervention in 79% of cases with SBO.     

Does routine serial computed tomography of the head influence management of traumatic brain injury? A prospective evaluation

BACKGROUND: Computed tomography (CT) of the head is the current standard for diagnosing intracranial pathology following blunt head trauma. It is common practice to repeat the head CT to evaluate any progression of injury. Recent retrospective reviews have challenged the need for serial head CT after traumatic brain injury (TBI). This study intends to prospectively examine the value of routine serial head CT after TBI. METHODS: Consecutive adult blunt trauma patients with an abnormal head CT admitted to an urban, Level I trauma center from January 2003 to September 2003 were prospectively studied. Variables collected included: initial head CT results, indication for repeat head CT (routine versus neurologic change), number and results of repeat head CT scans, and clinical interventions following repeat head CT. RESULTS: Over the 9-month period, there were 128 patients admitted with an abnormal head CT after sustaining blunt trauma. The 16 patients who died within 24 hours and the 12 patients who went directly to craniotomy were excluded. The remaining 100 patients make up the study population. Abnormal head CT findings were subarachnoid hemorrhage (47%), intraparenchymal hemorrhage (37%), subdural hematoma (28%), contusion (14%), epidural hematoma (11%), intraventricular hemorrhage (3%), and diffuse axonal injury (2%). Overall, 32 patients (32%) had only the admission head CT, while 68 patients (68%) underwent 90 repeat CT scans. Of the repeat head CT scans, 81 (90%) were performed on a routine basis without neurologic change. The remaining 9 (10%) were performed for a change in Glasgow Coma Scale (n = 5), change in intracranial pressure (n = 1), change in Glasgow Coma Scale and intracranial pressure (n = 1), change in pupil size (n = 1), or sudden appearance of a headache (n = 1). Three patients had their care altered after repeat head CT: two underwent craniotomy and one was started on barbiturate therapy. All three patients had their repeat head CT after neurologic change (decrease in Glasgow Coma Scale in 2 and increase in intracranial pressure in 1). CONCLUSIONS: Serial head CT is common after TBI. Most repeat head CT scans are performed on a routine basis without neurologic change. Few patients with TBI have their management altered after repeat head CT, and these patients have neurologic deterioration before the repeat head CT. The use of routine serial head CT in patients without neurologic deterioration is not supported by the findings of this study.     

Can a small endoscopic sphincterotomy plus a large-balloon dilation reduce the use of mechanical lithotripsy in patients with large bile duct stones?

Background  

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) is technically difficult in the patients with large extrahepaic bile duct stones. Small endoscopic sphincterotomy combined with large-balloon dilation (ESLBD) currently seems to be a promising alternative for patients with difficult bile duct stones that cannot be extracted by EST. This study compared the therapeutic benefits and complication rates of ESLBD with those of EST alone.     

Does the location of the entry point affect the reduction of proximal humeral fractures? A cadaveric study

The selection of the correct entry point for stabilisation of long bone fractures and particularly of the humérus with intramedullary nailing is of paramount importance. The insertion of a nail from the correct entry point ensures anatomical alignment of the head and the shaft fragment. However, particularly for the humérus, the literature addressing this issue is obscure. Twenty cadaveric humeri without soft tissue attachment were studied. Two groups were studied: Group A (straight nail) and Group B (angled nail). A fracture of the surgical neck of the humérus was simulated. Then intramedullary nail was inserted through the correct entry hole. Displacement at the fracture site and force to reduce the displacement were measured. The average horizontal displacement was 2.5 ± 2.2 mm in Group A and 1.9 ± 1.1 mm in Group B. The humeral shaft tended to displace medially. The force required to reduce the produced displacement was usually less than 15 N. Anatomical reduction could not be obtained in 3/20 humeri even after applying a force of over 35 N. Our results of an average displacement of 2 mm following nail insertion, supports the significance of the entry point as a cause of loss of reduction at the fracture site post nail insertion. In most cases, anatomical reduction can be corrected with relative small forces, whereas in the rest the correction of the displacement is not feasible even with the application of substantial forces.