Role of US in evaluating breast implant integrity

Purpose

To assess the diagnostic accuracy and inter-observer variability of ultrasound (US) in recognizing signs of intra or extra-capsular rupture of silicone breast implants by using the magnetic resonance imaging (MRI) findings as the reference standard.

Methods

150 patients for a total of 300 implants underwent breast US and subsequently MR examination searching for signs of intra or extra-capsular rupture. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated for breast US having MRI findings as the reference standard. Cohen’s kappa statistics was used in order to assess inter-observer agreement for US.

Results

170/300 (57 %) implant ruptures were detected at US (intra-capsular n = 110, extra-capsular n = 60). By comparing US findings with MR results, overall sensitivity, specificity, accuracy, PPV, and NPV of 79, 63, 70, 65, and 77 %, respectively, were found for breast US. In case of intra-capsular rupture, sensitivity, specificity, accuracy, PPV, and NPV of 63, 63, 63, 45, and 77 %, respectively, were obtained; 100 % values were found for extra-capsular rupture US diagnosis.

Conclusion

US can be used as the first examination in patients with breast implants. US intra-capsular rupture detection requires further evaluation by MRI; in case of extra-capsular rupture US diagnosis, surgical implant removal could be proposed without further investigations.     

Joint effusion of the knee: potentialities and limitations of ultrasonography

Purpose

This study aimed at comparing the diagnostic accuracy of ultrasonography (US) and magnetic resonance imaging (MRI) for the detection of joint effusion of the knee.

Methods

For this retrospective study, approbation by the institutional review board was not required, and written informed consent from the patients was waived. One hundred and fifty-eight patients (83 men and 75 women; median age 41.2 years; age range 13–81 years) who underwent US and MRI of the knee were included in the study. The sensitivity and specificity of US with respect to MRI in the evaluation of the effusion of the knee and in each recess were compared.

Results

In evaluating joint effusion of the knee, compared with MRI, US correctly identified 78 of 96 patients with joint effusion, showing a sensitivity of 81.3 % and a specificity of 100 %, with a positive predictive value (PPV) of 100 % and a negative predictive value (NPV) of 77.5 % (p value = 0.001). Various results were obtained comparing ultrasound with MRI, regarding the various recesses.

Conclusion

US showed high specificity and sensitivity in diagnosing knee joint effusion and could be used in patients who cannot undergo MRI.

Electronic supplementary material

The online version of this article (doi:10.1007/s40477-015-0180-3) contains supplementary material, which is available to authorized users.     

Ultrasound examination using contrast agent and elastosonography in the evaluation of single thyroid nodules: Preliminary results

Aim

To evaluate the usefulness of ultrasound (US) using contrast agent and elastosonography in the characterization of thyroid nodules.

Materials and methods

From November 2006 to July 2007, 23 patients with single thyroid nodules underwent B-mode US and power Doppler, US examination using contrast agent, elastosonography and fine needle aspiration cytology (FNAC). Sixteen patients underwent thyroidectomy.

Results

The 23 nodules included 14 benign and 9 malignant lesions. Analysis of time/intensity curves showed that wash-in (8.8 ± 1.3 vs 12.1 ± 2.6 s; p = 0.002, t-test) and peak enhancement (15.3 ± 4.6 vs 22.2 ± 3.9 s; p = 0.001, t-test) occurred significantly earlier in the malignant nodules than in the benign nodules. Wash-out was monophasic in 70% of benign nodules, but in none of the malignant nodules; polyphasic in 30% of benign nodules and in 100% of malignant nodules. Polyphasic wash-out showed a statistically significant association with malignancy (p = 0.0007, χ²). Polyphasic wash-out yielded a sensitivity of 100%, specificity of 71%, positive predictive value (PPV) of 69%, negative predictive value (NPV) of 100% and diagnostic accuracy of 83%. In 78% of the benign nodules (11/14) elastosonographic patterns was 1–2 (elevated elasticity); in 88% of the malignant nodules (8/9) elastosonographic patterns was 3–4 (reduced elasticity). Elastosonography yielded a sensitivity of 88%, specificity of 78%, PPV of 72%, NPV of 91% and diagnostic accuracy of 82%. Elastosonographic patterns 3–4 is associated with malignancy (p = 0.001, χ²).

Conclusion

US using contrast agent and elastosonography can be a useful diagnostic tool in the evaluation of single thyroid nodules, particularly when FNAC result is non-diagnostic or suggests a follicular lesion, and in nodules <1 cm.     

Use of ultrasound–magnetic resonance image fusion to guide sacroiliac joint injections: a preliminary assessment

Background

The sacroiliac joint is one of the sources of chronic lower back pain. Intra-articular injections of anesthetic drugs and/or steroids are currently used in these cases for diagnostic and therapeutic purposes. However, given the anatomic and functional complexity of the joint, imaging guidance is mandatory during such procedures. In this context, the technique of fusing images obtained with two different modalities can often overcome the limitations and enhance the advantages of single-modality guidance.

Aim

The aim of this study was to evaluate the technique of ultrasound (US)–magnetic resonance (MR) image fusion to guide intra-articular injections of drugs into the sacroiliac joint.

Materials and methods

We evaluated seven sacroiliac joints in six patients with sacroiliac pain syndrome (four females, two males; mean age 59 years; range 46–76 years). Five were candidates for radiofrequency thermolysis, and a therapeutic nerve block was performed in the sixth. Using the volume navigation system, we fused three-dimensional MR images with simultaneously acquired real-time ultrasound images and used them to guide the intra-articular injections.

Results

In all patients, spatial accuracy was considered excellent, with definition of registration errors of less than 3 mm. The diagnostic blocks produced positive results in all patients with 80 % reductions in pain (measured with a Numerical Rating Scale, NRS) relative to baseline. The patient who underwent the therapeutic nerve block experienced complete resolution of symptoms that has been maintained over time. There were no complications.

Conclusions

US–MR imaging fusion guidance of sacroiliac joint injections is feasible and effective, in accordance with the data in the literature. The use of the MR for three-dimensional imaging eliminates the risk of radiation exposure.     

两种快速梅毒血清学试验的临床评价

目的：评价快速梅毒血清学试验检测梅毒的临床价值。方法对2868例皮肤科门诊患者的血清用甲苯胺红不加热血清试验（TRUST ）检测梅毒反应素,胶体金免疫层析试验（GICA ）检测梅毒螺体抗体。结果TRUST试验对梅毒的诊断灵敏度、诊断特异度、阳性预测值、阴性预测值、阳性似然比和阴性似然比分别为90．70％、96．33％、43．33％、99．70％、24．71和0．10,GICA试验对梅毒的诊断灵敏度、诊断特异度、阳性预测值、阴性预测值、阳性似然比和阴性似然比分别为93．02％、98．42％、64．52％、99．78％、58．87和0．07,TRUST 和GICA平行联合试验的诊断灵敏度、诊断特异度、阳性预测值、阴性预测值、阳性似然比和阴性似然比分别为98．84％、94．81％、37．12％、99．96％、19．04和0．01;TRUST 和GICA序列联合试验的诊断灵敏度、诊断特异度、阳性预测值、阴性预测值、阳性似然比和阴性似然比分别为84．88％、99．93％、97．33％、99．53％、1212．57和0．15。结论TRUS和GICA平行联合试验可提高诊断灵敏度,但会增加假阳性病例,应注意结合临床做好鉴别诊断。     

Distribution and reference interval establishment of neutral‐to‐lymphocyte ratio (NLR), lymphocyte‐to‐monocyte ratio (LMR), and platelet‐to‐lymphocyte ratio (PLR) in Chinese healthy adults

BackgroundNeutral‐to‐lymphocyte ratio (NLR), lymphocyte‐to‐monocyte ratio (LMR), and platelet‐to‐lymphocyte ratio (PLR) are associated with coronavirus disease 2019 (COVID‐19) and many diseases, but there are few data about the reference interval (RI) of NLR, LMR, and PLR.MethodsThe neutrophil count, lymphocyte count, monocyte count, and platelet count of 404,272 Chinese healthy adults (>18 years old) were measured by Sysmex XE‐2100 automatic hematology analyzer, and NLR, LMR, and PLR were calculated. According to CLSI C28‐A3, the nonparametric 95% percentile interval is defined as the reference interval.ResultsThe results of Mann‐Whitney U test showed that NLR (p < .001) in male was significantly higher than that in female; LMR (p < .001) and PLR (p < .001) in male were significantly lower than that in female. Kruskal‐Wallis H test showed that there were significant differences in NLR, LMR, and PLR among different genders and age groups (p < .001). The linear graph showed that the reference upper limit of NLR and PLR increased with age and the reference upper limit of LMR decreases with age in male population. In female population, the reference upper limit of NLR in 50–59 group, LMR in >80 group, and PLR in 70–79 group appeared a trough; the reference upper limit of NLR in >80 group, LMR in 50–59 group, and PLR in 40–49 group appeared peak.ConclusionThe establishment of RI for NLR, LMR, and PLR in Chinese healthy adults according to gender and age will promote the standardization of clinical application.     

Prospective evaluation of acoustic radiation force impulse technology in the differentiation of thyroid nodules: accuracy and interobserver variability assessment

Purpose

The aim of this study is to assess the diagnostic efficacy and interobserver agreement of acoustic radiation force impulse (ARFI) elasticity imaging in differentiating thyroid nodules.

Methods

In our study, 74 consecutive patients (52 females, 22 males; age range 27–77 years, mean: 41 years) with 82 thyroid nodules (60 benign nodules, and 22 malignant) were examined by two radiologists with different experience. Patients underwent either cytology using fine needle aspiration cytology or thyroid surgery. The diagnostic performance of the two operators at ARFI with sensitivity, specificity, positive predictive and negative predictive value, and ROC curves was estimated. Inter-reader variability between the two operators was defined using Cohen’s k.

Results

According to receiver operating characteristics ROC curves (AUROC = 0.86 for observer 1; 0.81 for observer 2) sensitivity, specificity, PPV and NPV of reader 1 and 2 were respectively: 90, 75, 90.91 and 96.55 %; (cut-off value of shear wave: 2.455 m/s); 90, 72, 90 and 96.90 % (cut-off value shear wave: 2.365 m/s). Concordance between the two operators was good (k = 0.755).

Conclusions

This work is a feasibility study evaluating ARFI imaging. Its results suggest that ARFI imaging is a reproducible method which can be utilized with good diagnostic performance in the thyroid for discriminating benign and malignant nodules using the cut-off value of 2.455 m/s. However, larger studies are needed to validate this method.     

A Cerebral Recovery Index (CRI) for early prognosis in patients after cardiac arrest

Introduction

Electroencephalogram (EEG) monitoring in patients treated with therapeutic hypothermia after cardiac arrest may assist in early outcome prediction. Quantitative EEG (qEEG) analysis can reduce the time needed to review long-term EEG and makes the analysis more objective. In this study, we evaluated the predictive value of qEEG analysis for neurologic outcome in postanoxic patients.

Methods

In total, 109 patients admitted to the ICU for therapeutic hypothermia after cardiac arrest were included, divided over a training and a test set. Continuous EEG was recorded during the first 5 days or until ICU discharge. Neurologic outcomes were based on the best achieved Cerebral Performance Category (CPC) score within 6 months. Of the training set, 27 of 56 patients (48%) and 26 of 53 patients (49%) of the test set achieved good outcome (CPC 1 to 2). In all patients, a 5 minute epoch was selected each hour, and five qEEG features were extracted. We introduced the Cerebral Recovery Index (CRI), which combines these features into a single number.

Results

At 24 hours after cardiac arrest, a CRI <0.29 was always associated with poor neurologic outcome, with a sensitivity of 0.55 (95% confidence interval (CI): 0.32 to 0.76) at a specificity of 1.00 (CI, 0.86 to 1.00) in the test set. This results in a positive predictive value (PPV) of 1.00 (CI, 0.73 to 1.00) and a negative predictive value (NPV) of 0.71 (CI, 0.53 to 0.85). At the same time, a CRI >0.69 predicted good outcome, with a sensitivity of 0.25 (CI, 0.10 to 0.14) at a specificity of 1.00 (CI, 0.85 to 1.00) in the test set, and a corresponding NPV of 1.00 (CI, 0.54 to 1.00) and a PPV of 0.55 (CI, 0.38 to 0.70).

Conclusions

We introduced a combination of qEEG measures expressed in a single number, the CRI, which can assist in prediction of both poor and good outcomes in postanoxic patients, within 24 hours after cardiac arrest.     

Sonographic evaluation of the temporomandibular joints in juvenile idiopathic arthritis

Introduction

Juvenile idiopathic arthritis (JIA) may cause damage to the temporomandibular joint (TMJ). In oligoarticular forms of JIA, TMJ involvement is often asymptomatic and consequently overlooked. The aim of this study was to evaluate the presence of TMJ joint effusion (JE) by ultrasonography (US) in patients with early arthritis.

Materials and methods

We examined 68 children (57 girls, 11 boys, age range 9.1–16.0 years, mean age 11.0 years) recently diagnosed with JIA. None had received any specific treatment for inflammation. Symptomatic TMJ involvement was diagnosed when one or more of the following were present: 1) recurrent pain (spontaneous or on movement of the jaw); 2) crepitation; 3) feeling of stiffness or fatigue of the jaw; 4) intermittent locking. US of the TMJ was performed in static and dynamic phases with a General Electric LOGIQ7 scanner and a linear transducer (8.5 MHz) positioned along the axis of the mandibular ramus. JE was diagnosed when the joint capsule was ≥1.5 mm thick.

Results

Forty-six out (68%) of 68 children had US evidence of TMJ effusions (bilateral in 16 [35%] cases), but only 2/46 were symptomatic.

Conclusions

These data suggest that children with early stage oligoarticular JIA children are likely to have inflammation of the TMJs even in the absence of symptoms. US is a simple-to-use, noninvasive, radiation-free tool that can provide useful information in the assessment and follow-up of TMJ involvement in children and young adults with JIA.     

Inferior vena cava collapsibility loses correlation with internal jugular vein collapsibility during increased thoracic or intra-abdominal pressure

Purpose

Point-of-care ultrasound evaluates inferior vena cava (IVC) and internal jugular vein (IJV) measurements to estimate intravascular volume status. The reliability of the IVC and IJV collapsibility index during increased thoracic or intra-abdominal pressure remains unclear.

Methods

Three phases of sonographic scanning were performed: spontaneous breathing phase, increased thoracic pressure phase via positive pressure ventilation (PPV) phase, and increased intra-abdominal pressure (IAP) phase via laparoscopic insufflation to 15 mmHg. IVC measurements were done at 1–2 cm below the diaphragm and IJV measurements were done at the level of the cricoid cartilage during a complete respiratory cycle. Collapsibility index was calculated by (max diameter − min diameter)/max diameter × 100 %. Chi square, t test, correlation procedure (CORR) and Fisher’s exact analyses were completed.

Results

A total of 144 scans of the IVC and IJV were completed in 16 patients who underwent laparoscopic surgery. Mean age was 46 ± 15 years, with 75 % female and 69 % African-American. IVC and IJV collapsibility correlated in the setting of spontaneous breathing (r² = 0.86, p < 0.01). IVC collapsibility had no correlation with the IJV in the setting of PPV (r² = 0.21, p = 0.52) or IAP (r² = 0.26, p = 0.42). Maximal IVC diameter was significantly smaller during increased IAP (16.5 mm ± 4.9) compared to spontaneous breathing (20.6 mm ± 4.8, p = 0.04) and PPV (21.8 mm ± 5.6, p = 0.01).

Conclusion

IJV and IVC collapsibility correlated during spontaneous breathing but there was no statistically significant correlation during increased thoracic or intra-abdominal pressure. Increased intra-abdominal pressure was associated with a significant smaller maximal IVC diameter and cautions the reliability of IVC diameter in clinical settings that are associated with intra-abdominal hypertension or abdominal compartment syndrome.     

Ultrasound assessment of elbow enthesitis in patients with seronegative arthropathies

Background

Enthesopathy is an evolving area for applied clinical research. MRI is the gold standard in the diagnosis of elbow joint pathology, but recent reports indicate that ultrasound imaging is more sensitive and accurate than MRI in detecting enthesopathy of the heels and knees. Too many patients are under-diagnosed and/or misdiagnosed because the early pathological changes of enthesitis in the different types of seronegative arthropathies are not detected.

Objectives

This study was undertaken to describe the ultrasound features of elbow enthesitis in patients with seronegative arthropathies.

Methods

We studied 38 diseased elbows in 38 patients with spondyloarthropathies (26 men and 12 women, mean age 32 years). All had elbow enthesopathy without typical conventional radiographic findings. Patients with histories of degenerative changes and/or local steroid injections were excluded. An HDI 3000 ATL ultrasound machine was used with a 5–12 MHz linear transducer to examine the affected elbow joints. The elbows of 10 normal healthy individuals were examined as normal controls. The patients were examined in the supine position with the elbow flexed 30°–50°. Longitudinal and transverse scans were obtained of the radiohumeral joint, the ulnahumeral joint, and the olecranon fossa. Two independent observers unaware of the clinical diagnosis read the ultrasound images and assessed the collateral ligaments, intratendinous echogenicity, tendon calcification, tendon thickness, presence of fluid, synovial proliferation, and bony changes. The reliability of the sonographic images was assessed by review of video recordings of the ultrasound examinations.

Results

Ultrasound revealed loss of the fibrillar echopattern (100 %), lack of a homogenous pattern with loss of the tightly packed echogenic dots (100 %), peritendinous edema with flaring of the tendon margins (84.2 %), irregular fusiform tendon thickening (100 %), and hyperechoic intratendinous lesions with ill-defined focal defects (18.4 %). Ultrasound also detected intratendinous calcifications of both the common extensor and common flexor tendons (52.6 %). Bony erosions were seen at the tendon insertions into the lateral epicondyles (13.15 %).

Conclusion

Ultrasonographic features of elbow enthesitis differed from those described in knee and heel enthesitis. Ultrasound clearly showed early signs of tendon calcification, tendon edema, peritendinitis, and bony entheseal erosions. However, in elbow enthesitis the early bone erosion was associated with bone marrow edema, and the common extensor tendon was diffusely thickened. Ultrasound is a reliable, reproducible bedside imaging procedure. It improves the documentation of disease activity, progression, and treatment responses in patients with spondyloarthropathies. We recommend its use for the diagnosis and post-treatment follow-up of patients with enthesitis and seronegative spondyloarthropathies.     

Diagnostic accuracy of emergency physician performed graded compression ultrasound study in acute appendicitis: a prospective study

Purpose

Accurate early diagnosis of appendicitis can decrease its complications and minimize the mortality, morbidity and costs. This prospective study evaluates the accuracy of bedside emergency physician performed ultrasound study diagnosis in acute appendicitis.

Methods

Patients who were suspicious to have appendicitis based on their clinical findings were included and underwent emergency physician performed ultrasound study. Then they were followed up until the recognition of final diagnosis based on pathology report or identification of an alternative diagnosis. Ultrasound studies were done by post-graduate year three emergency medicine residents or emergency medicine attending physicians who were attended in a 4 h didactic and practical course and with 7.5 MHz linear probe both in longitudinal and axial axes.

Results

Ninety-seven patients were included and analyzed. 27 (27.8 %) of patients had appendicitis according to the results of emergency physicians performed ultrasound studies. 19 (70.37 %) of them had appendicitis according to their pathologic reports too. Forty-three (44.3 %) of patients had appendicitis according to pathology reports. Only 19 (44.18 %) of them were diagnosed by emergency physicians. Emergency physician performed ultrasound study had a sensitivity of 44.18 %, specificity of 85.18 %, positive predictive value of 70.37 %, negative predictive value of 65.71 % and overall accuracy of 67.01 % in diagnosing appendicitis in patients clinically suspicious to have acute appendicitis.

Conclusion

Emergency physician performed bedside ultrasound has an acceptable overall accuracy but its sensitivity is low thus it can help emergency physicians to diagnose the acute appendicitis when used in conjunction with other clinical and para-clinical evaluations but not per se.     

Sonoelastography findings of biceps tendinitis and tendinosis

Objective

The purpose of this study was to evaluate sonoelastography (SE) in the assessment of the long head of biceps tendon (LHBT) in patients with symptoms of biceps tendinitis or tendinosis and in patients without biceps lesion. The findings were compared with those obtained at clinical examination, using ultrasonography (US).

Materials and methods

36 shoulders of 34 consecutively registered patients with clinical symptoms and US findings of biceps tendinitis or tendinosis, and 114 shoulders of 98 patients without biceps lesions were assessed with SE. Transverse and longitudinal images of LHBT were obtained using SE. SE images were evaluated by reviewers using an experimentally proven color grading system.

Results

The transverse images of SE showed a mean sensitivity of 69.4 %, a mean specificity of 95.6 % and a mean accuracy of 89.3 %. Good correlation of conventional ultrasound findings was found (p < 0.001, r = 0.763). The longitudinal images of SE showed a mean sensitivity of 94.4 %, a mean specificity of 92.1 % and a mean accuracy of 92.7 %. Good correlation of conventional ultrasound findings was found (p < 0.001, r = 0.585). Inter-observer reliability of SE was in “almost perfect agreement” with a weighted kappa coefficient of 0.84.

Conclusions

SE has potential to be clinically useful in the detection of the intratendinous and peritendinous alterations of LHBT and has excellent accuracy and excellent correlation with conventional ultrasound findings.     

Predictive significance of neutrophil‐to‐lymphocyte and platelet‐to‐lymphocyte for cytomegalovirus infection in infants less than 3 months: A retrospective study

BackgroundThe aim of this study was to evaluate the predictive value of the hematological parameters in the identification of human cytomegalovirus (CMV) infection in infants less than 3 months.MethodsA single‐center, observational study of infants with CMV infection was conducted retrospectively. Routine blood parameters were analyzed in CMV‐infected infants and controls with no differences of birthweight, sex, gestational age at birth, and date of admission. Furthermore, receiver‐operating curve was used to assess the predictive value of the hematological parameters for CMV infection.ResultsOne hundred ninety cases with CMV infection were studied retrospectively. Compared with the control group, there were significant differences in the white blood cell count, neutrophil count, lymphocyte count, platelet count, hemoglobin, neutrophil‐to‐lymphocyte (NLR), platelet‐to‐lymphocyte (PLR), and lymphocyte‐to‐monocyte (LMR) for the patients with CMV infection (all p < 0.001). The best predicted values for CMV infection based on the area under the curve (AUC) were NLR and PLR with the optimal cut‐off value of 0.28 and 65.36. NLR‐PLR score of 0, 1, or 2 based on an elevated NLR (>0.28), an elevated PLR (>65.36), or both. NLR‐PLR score for CMV infection prediction yielded higher AUC values than NLR or PLR alone (0.760 vs. 0.689, 0.689; p < 0.001).ConclusionsThe NLR combined with PLR is potentially useful as a predictor of CMV infection in infants less than 3 months.     

Computed tomography angiography vs 3?T black-blood cardiovascular magnetic resonance for identification of symptomatic carotid plaques

Background

The purpose of this prospective study was to perform a head-to-head comparison of the two methods most frequently used for evaluation of carotid plaque characteristics: Multi-detector Computed Tomography Angiography (MDCTA) and black-blood 3 T-cardiovascular magnetic resonance (bb-CMR) with respect to their ability to identify symptomatic carotid plaques.

Methods

22 stroke unit patients with unilateral symptomatic carotid disease and >50% stenosis by duplex ultrasound underwent MDCTA and bb-CMR (TOF, pre- and post-contrast fsT1w-, and fsT2w- sequences) within 15 days of symptom onset. Both symptomatic and contralateral asymptomatic sides were evaluated. By bb-CMR, plaque morphology, composition and prevalence of complicated AHA type VI lesions (AHA-LT6) were evaluated. By MDCTA, plaque type (non-calcified, mixed, calcified), plaque density in HU and presence of ulceration and/or thrombus were evaluated. Sensitivity (SE), specificity (SP), positive and negative predictive value (PPV, NPV) were calculated using a 2-by-2-table.

Results

To distinguish between symptomatic and asymptomatic plaques AHA-LT6 was the best CMR variable and presence / absence of plaque ulceration was the best CT variable, resulting in a SE, SP, PPV and NPV of 80%, 80%, 80% and 80% for AHA-LT6 as assessed by bb-CMR and 40%, 95%, 89% and 61% for plaque ulceration as assessed by MDCTA. The combined SE, SP, PPV and NPV of bb-CMR and MDCTA was 85%, 75%, 77% and 83%, respectively.

Conclusions

Bb-CMR is superior to MDCTA at identifying symptomatic carotid plaques, while MDCTA offers high specificity at the cost of low sensitivity. Results were only slightly improved over bb-CMR alone when combining both techniques.     

The Relationship between Coronary Collateral Circulation and Neutrophil/Lymphocyte Ratio in Patients with Coronary Chronic Total Occlusion

Objectives

To investigate the relationship between neutrophil/lymphocyte ratio (NLR) and coronary collateral circulation (CCC) in patients with coronary chronic total occlusion.

Subjects and Methods

Our study population consisted of 275 consecutive patients with chronic total occlusion. One hundred and thirty-eight patients with chronic total occlusion were included in the study. They were classified into 2 groups as follows: impaired CCC (group 1: Rentrop grades 0-1) and good CCC (group 2: Rentrop grades 2-3). The NLR was calculated from the complete blood count.

Results

The NLR values of the patients with impaired CCC (4.5 ± 0.7) were significantly higher than of those with good CCC (2.7 ± 0.6, p < 0.001). In the multivariate logistic regression test, NLR (OR 33.36, 95% CI 8.189-135.7, p < 0.001), high-sensitivity C-reactive protein (hs-CRP; OR 2.152, 95% CI 1.226-3.777, p = 0.008), estimated glomerular filtration rate (OR 1.167, 95% CI 1.049-1.298, p = 0.004) and systolic blood pressure (OR 1.068, 95% CI 1.009-1.1310, p = 0.025) were independent predictors of impaired CCC. The NLR value >3.55 yielded an area under the curve value of 0.957 (95% CI 0.921-0.992, p < 0.001) and demonstrated a sensitivity of 95% and a specificity of 90% for the prediction of CCC. A moderate correlation between NLR and hs-CRP was observed (r = 0.443; p < 0.001).

Conclusion

Our findings reveal that NLR correlates with the impaired development of coronary collaterals.Key Words: Neutrophil/lymphocyte ratio, Coronary collateral circulation, Chronic total occlusion     

Safe performance of magnetic resonance of the heart in patients with magnetic resonance conditional pacemaker systems: the safety issue of the ESTIMATE study

Background

No published data exist about the safety of diagnostic magnetic resonance (MR) of the heart performed in a larger series of patients implanted with MR conditional pacemakers (PM). The purpose of our study is to analyse safety and potential alterations of electrical lead parameters in patients implanted with the EnRhythm/Advisa MRI SureScan PM with 5086MRI leads (Medtronic Inc.) during and after MR of the heart at 1.5 Tesla.

Methods

Patients enrolled in this single center pilot study who underwent non-clinically indicated diagnostic MR of the heart were included in this analysis. Heart MR was performed for analyses of potential changes in right and left ventricular functional parameters under right ventricular pacing at 80 and 110 bpm. Atrial/ventricular sensing, atrial/ventricular pacing capture threshold [PCT], and pacing impedances were assessed immediately before, during, and immediately after MR, as well at 3 and 15 months post MR.

Results

Thirty-six patients (mean age 69 ± 13 years; high degree AV block 18 [50%]) underwent MR of the heart. No MR related adverse events occurred during MR or thereafter. Ventricular sensing differed significantly between the FU immediately after MR (10.3 ± 5.3 mV) and the baseline FU (9.8 ± 5.3 mV; p < 0.05). Despite PCT [V/0.4ms] was not significantly different between the FUs (baseline: 0.84 ± 0.27; in-between MR scans: 0.82 ± 0.27; immediately after MR: 0.84 ± 0.24; 3-month: 0.85 ± 0.23; 15-month: 0.90 ± 0.67; p = ns), 7 patients (19%) showed PCT increases by 100% (max. PCT measured: 1.0 V) at the 3-month FU compared to baseline. RV pacing impedance [Ω/5V] differed significantly at the FU in-between MR scans (516 ± 47), and at the 15-month FU (482 ± 58) compared to baseline (508 ± 75).

Conclusion

The results of our study suggest MR of the heart to be safe in patients with the MR conditional EnRhythm/Advisa system, albeit although noticeable but clinically irrelevant ventricular PCT changes were observed.     

CEUS in the study of bladder,method, administration and evaluation,a technical note

Purpose

Contrast-enhanced ultrasound (CEUS) is the application of ultrasound contrast agents (UCAs) to traditional medical sonography. The development of UCAs allowed to overcome some of the limitations of conventional B-mode and Doppler ultrasound techniques and enabled the display of the parenchymal microvasculature. Purpose of this paper is to delineate the elements of a solid and science-based technique in the execution of urinary bladder CEUS.

Methods

We describe the technical execution of urinary bladder CEUS and the use of perfusion softwares to perform contrast enhancement quantitative analysis with generation of time–intensity curves from regions of interest.

Results

During CEUS, normal bladder wall shows a wash-in time of 13 s, a time to peak (TTP) >40 s, a signal intensity (SI) <45 % and a wash-out time >80 s; Low-grade urothelial cell carcinoma (UCC) shows a wash-in time of 13 s, a time to peak TTP >28 s, a SI <45 % and a wash-out time of 40 s; High-grade UCC shows a wash-in time of 13 s, a TTP >28 s, a SI >50 % and a wash-out time of 58 s.

Conclusions

CEUS is a useful tool for an accurate characterization of bladder UCC although it has some drawbacks. To avoid misunderstandings, a widely accepted classification and a standardized terminology about the most significant parameters of this application should be adopted in the immediate future.     

Feasibility of common carotid artery point of care ultrasound in cardiac output measurements compared to invasive methods

Background

Cardiac output (CO) measurement in the intensive care unit (ICU) requires invasive devices such as the pulmonary artery (PA) catheter or arterial waveform pulse contour analysis (PCA). This study tests the accuracy and feasibility of point of care ultrasound (POCUS) of the common carotid artery to estimate the CO non-invasively and compare it to existing invasive CO measurement modalities.

Methods

Patients admitted to the surgical and cardiothoracic ICU in a tertiary university-affiliated academic center during a 4-month period, with invasive hemodynamic monitoring devices for management, were included in this cohort study. Common carotid artery POCUS was performed to measure the CO and the results were compared to an invasive device.

Results

Intensivists and ICU fellows, using ultrasound of the common carotid artery, obtained the CO measurements. Images of the Doppler flow and volume were obtained at the level of the thyroid gland. Concurrent CO measured via invasive devices was recorded. The patient cohort comprised 36 patients; 52 % were females. The average age was 59 ± 13 years, and 66 % were monitored via PCA device and 33 % via PA catheter. Intraclass correlation coefficient (ICC) analysis demonstrated almost perfect correlation (0.8152) between measurements of CO via ultrasound vs. invasive modalities. The ICC between POCUS and the invasive measurement via PCA was 0.84 and via PA catheter 0.74, showing substantial agreement between the ultrasound and both invasive modalities.

Conclusions

Common carotid artery POCUS offers a non-invasive method of measuring the CO in the critically ill population.     

Point of care ultrasound (POCUS) telemedicine project in rural Nicaragua and its impact on patient management

Background

Point of care ultrasound (POCUS) is a useful diagnostic tool in medicine. POCUS provides an easy and reproducible method of diagnosis where conventional radiologic studies are unavailable. Telemedicine is also a great means of communication between educators and students throughout the world.

Hypothesis

Implementing POCUS with didactics and hands-on training, using portable ultrasound devices followed by telecommunication training, will impact the differential diagnosis and patient management in a rural community outside the United States.

Materials and methods

This is an observational prospective study implementing POCUS in Las Salinas, a small village in rural western Nicaragua. Ultrasound was used to confirm a diagnosis based on clinical exam, or uncover a new, previously unknown diagnosis. The primary endpoint was a change in patient management. International sonographic instructors conducted didactic and practical training of local practitioners in POCUS, subsequently followed by remote guidance and telecommunication for 3 months.

Results

A total of 132 patients underwent ultrasound examination. The most common presentation was for a prenatal exam (23.5 %), followed by abdominal pain (17 %). Of the 132 patients, 69 (52 %) were found to have a new diagnosis. Excluding pregnancy, 67 patients of 101 (66 %) were found to have a new diagnosis. A change in management occurred in a total of 64 (48 %) patients, and 62 (61 %) after excluding pregnancy.

Conclusion

Implementing POCUS in rural Nicaragua led to a change in management in about half of the patients examined. With the appropriate training of clinicians, POCUS combined with telemedicine can positively impact patient care.