Is There a Benefit of Frequent CT Follow-up After EVAR?

ObjectiveImaging follow-up (FU) after endovascular aneurysm repair (EVAR) is usually performed by periodic contrast-enhanced computed tomography (CT) scans. This study aims to evaluate the effectiveness of CT-FU after EVAR.MethodsIn this study, 279 of 304 consecutive patients (261 male, aged 74 years (interquartile range (IQR): 70–79 years) with a median abdominal aortic aneurysm (AAA) diameter of 58 mm (IQR: 53–67 mm)) underwent at least one of the yearly CT scans and plain abdominal films after EVAR. All patients received Zenith stent-grafts for non-ruptured AAAs at a single institution. Patients were considered asymptomatic when a re-intervention was done solely due to an imaging FU finding. The data were prospectively entered in a computer database and retrospectively analysed.ResultsAs a follow-up, 1167 CT scans were performed at a median of 54 months (IQR: 34–74 months) after EVAR. Twenty-seven patients exhibited postoperative AAA expansion (a 5-year expansion-free rate of 88 ± 2%), and 57 patients underwent 78 postoperative re-interventions with a 5-year secondary success rate of 91 ± 2%. Of the 279 patients, 26 (9.3%) undergoing imaging FU benefitted from the yearly CT scans, since they had re-interventions based on asymptomatic imaging findings: AAA diameter expansion with or without endoleaks (n = 18), kink in the stent-graft limbs (n = 4), endoleak type III due to stent-graft limb separation without simultaneous AAA expansion (n = 2), isolated common iliac artery expansion (n = 1) and superior mesenteric artery malperfusion due to partial coverage by the stent-graft fabric (n = 1).ConclusionsLess than 10% of the patients benefit from the yearly CT-FU after EVAR. Only one re-intervention due to partial coverage of a branch by the stent-graft would have been delayed if routine FU had been based on simple diameter measurements and plain abdominal radiograph. This suggests that less-frequent CT is sufficient in the majority of patients, which may simplify the FU protocol, reduce radiation exposure and the total costs of EVAR. Contrast-enhanced CT scans continue, nevertheless, to be critical when re-interventions are planned.     

Bronchiectases at early chest computed tomography in children with cystic fibrosis are associated with increased risk of subsequent pulmonary exacerbations and chronic pseudomonas infection

BackgroundChildren with cystic fibrosis (CF) are often Pseudomonas aeruginosa (PsA) free and exhibit normal spirometry between the ages of 5 and 7. It is reported that computed tomography (CT) is more sensitive than FEV1 as an instrument in the identification of pulmonary disease. It is not known whether CF-CT scores in childhood may be used to highlight children at risk of developing severe disease.Aims1 — To assess the number of respiratory exacerbations (RTEs) during a follow-up period of 6 years and their correlation with the CF-CT scores in young CF children. 2 — To assess whether PsA-negative CF children with high chest CF-CT scores are more likely to develop chronic PsA lung infection.Methods68 chest CT performed in patients without chronic PsA infection were scored. All patients (median age 7.8 years) had at least 4 clinical, functional and microbiologic assessments/year in the subsequent 6 years. RTE was defined as hospitalization and IV antibiotic treatment for respiratory symptoms.Results86.8% patients had < 3 RTEs in the 6 year follow-up period. The number of RTEs in the 6 years subsequent to the CT scan was correlated to the bronchiectasis CT score (BCTS) (r = 0.612; p < 0.001) and to FEV1 at baseline (r = − 0.495, p < 0.001). A BCTS ≥ 17.5 identified patients with > 3 RTEs during follow-up (sensitivity: 100%, specificity: 85%), while FEV1 did not. Only BCTS was significant in a logistic multivariate model (RR 1.15). BCTS was significantly lower and FEV1 higher in patients who did not develop chronic PsA infection by the end of the study.ConclusionIn CF children free from chronic PsA, both CT scores and FEV1 values demonstrate significant correlation with disease severity in the subsequent 6 years but CT score has higher predictive value in the identification of patients at risk.     

Unenhanced CT for clinical triage of elderly patients presenting to the emergency department with acute abdominal pain

PurposeThe purpose of this study was to compare the diagnostic accuracy and inter-reader agreement of unenhanced computed tomography (CT) to those of contrast-enhanced CT for triage of patients older than 75 years admitted to emergency department (ED) with acute abdominal pain (AAP).Patients and methodsTwo hundred and eight consecutive patients presenting with AAP to the ED who underwent CT with unenhanced and contrast-enhanced images were retrospectively included. There were 90 men and 118 women with a mean age of 85.4 ± 4.9 (SD) (range: 75–101.4 years). Three readers reviewed unenhanced CT images first, and then unenhanced and contrast-enhanced CT images as a single set. Diagnostic accuracy was compared to the standard of reference defined as the final diagnosis obtained after complete clinico-biological and radiological evaluation. Correctness of the working diagnosis proposed by the ED physician was evaluated. Intra- and inter-reader agreements were calculated using the kappa test and interclass correlation. Subgroup analyses were performed for patients requiring only conservative management and for those requiring intervention.ResultsDiagnostic accuracy ranged from 64% (95% CI: 62–66%) to 68% (95% CI: 66–70%) for unenhanced CT, and from 68% (95% CI: 66–70%) to 71% (95% CI: 69–73%) for both unenhanced and contrast-enhanced CT. Contrast-enhanced CT did not significantly improve the diagnostic accuracy (P = 0.973–0.979). CT corrected the working diagnosis proposed by the ED physician in 59.1% (range: 58.1–60.0%) and 61.2% (range: 57.6–65.5%) of patients before and after contrast injection (P > 0.05). Intra-observer agreement was moderate to substantial (k = 0.513–0.711). Inter-reader agreement was substantial for unenhanced (kappa = 0.745–0.789) and combined unenhanced and contrast-enhanced CT (kappa = 0.745–0.799). Results were similar in subgroup analyses.ConclusionUnenhanced CT alone is accurate and associated with high degrees of inter-reader agreement for clinical triage of patients older than 75 years with AAP in the emergency setting.     

Computed tomography follow-up of acute portal vein thrombosis

PurposeTo assess the evolution of acute portal vein thrombosis by computed tomography (CT).Patients and methodsRetrospective single-centre study (2005–2011) including 23 patients who had an initial CT scan and a CT scan during the first year. The analysis compared the last CT scan available with that of the initial CT scan. Neoplastic thrombosis, extrinsic compressions and cavernomas were excluded. All patients received anticoagulant treatment.ResultsThe causes included: cirrhoses (n = 6), blood disorders (n = 4), locoregional inflammations and infections (n = 8), abdominal surgery (n = 1). The thrombosis was idiopathic in 4 cases. After a mean follow-up of 7.7 months, 7 patients (30%) benefited from a restitutio ad integrum of the portal system, a stable or partially regressive thrombosis was noted in 12 patients (52%) and an aggravation of the thrombosis was noted in 4 patients (18%). In the sub-group of portal vein thrombosis, repermeabilisation was noted in 37.5% of the patients (6/16) and 6 cavernomas developed.ConclusionCT monitoring helps follow the evolution of an acute portal vein thrombosis and demonstrates complete repermeabilisation of the portal vein in 30% of the patients.     

CT scan and Diagnostic Peritoneal Lavage: towards a better diagnosis in the area of nonoperative management of blunt abdominal trauma

BackgroundThe diagnosis of small bowel and mesenteric injuries (BBMI) after blunt abdominal trauma remains difficult, which results in delayed treatment and increased mortality and morbidity. Diagnostic peritoneal lavage (DPL) in patients with 1 or 2 abnormal CT findings that are suggestive of BBMI was proposed, but the rate of unnecessary surgical exploration remains high.Patients and methodsBlunt abdominal trauma patients with 1 or 2 CT findings predictive of BBMI from 2001 to 2014 underwent a DPL with calculation of a cell count ratio (CCR) dividing the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid by the WBC/RBC ratio in peripheral blood. Surgical exploration of the abdomen was performed immediately in cases with a CCR ≥ 1. CT findings, DPL and surgery results, and global outcome were analyzed.ResultsThirty-seven were included in the study (27 males, median age of 30 years (range, 17–69 years)). Exploratory laparotomy was performed in 24 patients (65%). Sixteen patients (67%) had BBMI: 7 hollow organ perforations or tears (29%), including 4 bowel resection with primary anastomosis and 3 single sutures, and 9 patients had mesenteric injuries. CT findings associated with BBMI and hollow organ perforation were large peritoneal effusion (p = 0.02) and small bowel wall abnormalities (p = 0.002). No postoperative complications were observed. Sensitivity and specificity of DPL for the diagnosis of bowel injuries were respectively 100% (CI 95% [59–100]) and 43% (CI 95% [25–63]). The sensitivity remained 100% (CI 95% [59–100]) when the ratio was ≥4 (n = 10 patients), and the specificity reached 90% (CI 95% [73–98]).ConclusionDPL is sensitive for the diagnosis of BBMI in stable trauma patients with 1 or 2 unexplained CT abnormalities, but specificity is low with a high rate of nontherapeutic laparotomy in case of CCR ≥ 1. Indications for exploratory laparotomy could be restricted to patients with a CCR ≥ 4 to improve the specificity of diagnosis management.     

Factores pronósticos en pielonefritis enfisematosa

ObjectivesThe purpose of this study is to analyze our experience with 18 cases of Emphysematous pyelonephritis (EPN) in a tertiary care center and describe our treatment strategy.Material and methodsOf 262 patients admitted with acute pyelonephritis, 18 had CT findings of EPN. The Wan and Huang classifications were used. We assessed the clinical, radiological, and therapeutic characteristics of these patients and investigated potential prognostic factors of mortality.ResultsBetween 2005 and 2010, 17 women and 1 man with EPN were treated. Mean age was 52.4 years. Diabetes was found in 66% and hypertension in 72%. The most common clinical findings were tachycardia (11), fever (11) and flank pain (9); 66% (12) presented with severe sepsis and 2 had septic shock. Acute renal injury developed in 61%. Nine patients were treated exclusively with conservative management; 5 had double J stenting, 3 had CT-guided PCD and 1 required nephrectomy after unsuccessful medical management. Mortality was 11%. Altered consciousness (P = .0001), multiple organ failure (P = .0004), hyperglycemia (P = .003) and elevated leukocyte count (> 20 000 K) (P = .01) were more frequent among patients dying from EPN. No difference in mortality was found between patients managed conservatively and those undergoing invasive therapy.ConclusionsAlthough rare, EPN should be suspected in patients with multiple comorbidities presenting with severe sepsis. Altered consciousness, multiple organ failure, hyperglycemia and elevated leukocyte count are poor prognosis indicators. Invasive management should be used judiciously and medical treatment can be a safe strategy in selected cases.     

Role of Computed tomography in predicting prognosis of Hepatic portal venous gas

BackgroundThe aim of this study was to report through 13 cases the particularities of abdominal computed tomography (CT) aspects of hepatic portal venous gas (HPVG) and its correlation with patient prognosis.MethodsWe analyzed abundance of HPVG and its association with pneumatosis intestinalis (PI) in correlation with fatal outcome using chi-square tests.ResultsEtiologies were mesenteric infarction (n = 5), sigmoid diverticulitis (n =  1), septic shock (n = 1), postoperative peritonitis (n = 1), acute pancreatitis (n = 1), iatrogenic cause (n = 3) and idiopathic after a laparotomy (n = 1). The outcome was fatal in for 6 patients. Abundance of HPV was expressed in total number of hepatic segments involved. The involvement of 3 or more segments was a sensitive sign for lethal outcome with high sensitivity (100%) but it was not specific (50%). Negative predictive value of this sign was 100% (p ≤ 0.005). Positive predictive value of PI for death was 100% (p ≤ 0.001).DiscussionAbundance of HPVG is correlated with prognosis. The presence of PI announces poor outcome Negative predictive value of presence of HPVG in 3 or more segments is interesting. Predicting prognosis with CT can help surgeons to assess the most adequate treatment. Iatrogenic causes are increasingly described after interventional radiology procedures with favorable course.ConclusionThe first etiology radiologists should look for in front of HPVG involving more than 3 hepatic segments and associated with PI is intestinal necrosis which announces a poor prognosis. This study shows that outside of shock situations, HPVG involving 2 or less hepatic segments without PI predicts a good outcome.     

A snapshot of circulation failure following acute traumatic injury: The expansion of computed tomography beyond injury diagnosis

ObjectiveCT scans with a flat Inferior Vena Cava (IVC) suggest hypovolemia, and the presence of shock bowel implies hypoperfusion. The purpose of this study is to correlate injury severity, resuscitation needs, and clinical outcomes with CT indices of hypovolemia and hypoperfusion.DesignRetrospective cohort study.SettingLevel II trauma centre in Central California.PatientsAdult patients imaged with abdominal and pelvic CT scans, from January 2010–January 2011.InterventionsNone.Measurements and main resultsCirculatory derangements on CT scans were defined as an IVC (AP) diameter measurement of <9 mm, flat IVC (FIVC), hypovolemia. The presence of small intestine hypoperfusion was shock bowel (SB). The absence of these findings was a normal CT scan (NCT). Comparisons of acid-base status, fluids, morbidity and mortality were made based on CT findings. Subgroups were: FIVC (n = 20), FIVC + SB (n = 19), SB (n = 4) only versus normal CT scans, NCT (n = 47).ResultsOverall ISS was 19 (SD) 14. The lowest ISS was in NCT 14 (SD) 10 and there was an incremental increase in ISS based on circulatory derangements, p = 0.001. ICU admission was lowest in NCT and highest in the presence of hyovolemia and hypoperfusion, p = 0.03.Similarly ED crystalloid requirements and the activation of a massive transfusion protocol (MTP), was lowest in NCT group and gradually increased significantly as hypovolemia and hypoperfusion was demonstrated on CT scans. Additional parameters such as metabolic acidosis, nosocomial infections and mortality were associated with acute CT findings of circulatory failure.ConclusionsHypovolemia and hypoperfusion, markers of abnormal circulation, were demonstrated on CT scans for trauma evaluation. The presence of these findings alone or in combination showed strong correlation with high injury severity, and the need for aggressive resuscitation.     

Endovascular Repair of the Thoracic Aorta: Predictors of 30-Day Mortality in Patients on the New Zealand Thoracic Aortic Stent Database (NZ TAS)

ObjectivesTo evaluate data in the New Zealand Thoracic Aortic Stent database to try and identify a scoring system that could predict 30-day mortality in patients undergoing stenting of the descending thoracic aorta (TEVAR).DesignRetrospective analysis of the New Zealand thoracic aortic stent database between December 2001 and August 2007.Materials and methodsThe 30-day mortality of the 122 patients is 7.38% (n = 9). Risk factors were recorded based on the Society of Thoracic Surgeons (STS) risk score. Glasgow aneurysm score was calculated and the pathology being treated analysed. Univariate analyisis was carried out.ResultsThe mortality of three pathology groups was compared. 30-day mortality was 2.04% (n = 1) in the elective aneurysm group, 17.95% (n = 7) in the complicated Stanford type B dissection group, and 0% (n = 0) in the trauma group. Thirty-day mortality is significantly higher in the dissection group compared with the elective aneurysm (p = 0.02) and trauma (p = 0.03) groups. The most frequent risk factors in the dissection group of patients were peripheral vascular disease, smoking and hypertension. Although percentage mortality is higher with increasing GAS, the results are not statistically significant (p = 0.34). No independent risk factors were identified from the STS risk score data.ConclusionNo specific risk score system seems to be able to predict mortality in TEVAR patients.     

Multidisciplinary management of posterior fossa dural arteriovenous fistula: A single-center experience

PurposeThe management of posterior fossa dural arteriovenous fistulas (pfDAVFs) is challenging. Here, we show how multidisciplinarity leads to their successful management, even in complex cases.MethodsAll pfDAVFs managed from 2010 to 2019 at our center were reviewed. The preoperative clinical and radiological characteristics, their management and the occlusion rate were retrieved. The radiological and functional outcomes were retrieved at discharge and last follow-up (FU).Resultsn = 27 patients were included (6 females, mean age: 61-years-old, mean FU: 22.5 months). n = 8 patients presented with cerebral hemorrhage. Among patients with ruptured pfDAVFs, n = 7 had headache, n = 4 had ataxia, and n = 2 had impaired level of consciousness. In the unruptured group N (n = 19), n = 7 patients had headache, n = 6 patients had focal neurological deficit, n = 4 patients had tinnitus, n = 3 (had ataxia, and one presented with seizure. n = 24 patients were treated by endovascular therapy (EVT), n = 2 patients were treated by microsurgery (MS) and n = 1 patient was managed with a combined approach. Re-treatment was necessary in n = 6 patients. n = 24 patients showed total exclusion at last FU. n = 2 patients died during the first 30 days; n = 1 patient died during FU.ConclusionsWhile EVT should be advocated as the first line therapy whenever possible, MS should not be banned from the treatment armamentarium. Neurosurgeons must be able to achieve direct surgical occlusion when the angioarchitecture speaks against EVT.     

Perioperative axial loading computed tomography findings in varus ankle osteoarthritis: Effect of supramalleolar osteotomy on abnormal internal rotation of the talus

BackgroundWe used axial loading computed tomography (AL CT) to evaluate preoperative and postoperative talocrural joints of patients who underwent supramalleolar osteotomy (SMO) to treat varus ankle osteoarthritis.MethodsWe performed retrospective analyses of 16 patients (18 feet) who underwent SMO including fibular osteotomy. Radiographic assessment was performed with weightbearing radiographs and AL CT. Clinical outcomes were assessed based on American Orthopedic Foot & Ankle Society (AOFAS) scale, visual analog scale (VAS) for pain, and Foot and Ankle Ability Measure (FAAM).ResultsThe mean 2-year follow-up tibial-ankle surface angle, talar tilt angle, Takakura stage, and tibial-lateral surface angle were all significantly different relative to preoperative parameters (P < .05). The mean 6-month follow-up talus rotation ratio was significantly corrected compared to the preoperative value (P = .001). The mean 2-year follow-up AOFAS, VAS at gait, and FAAM scores were all significantly improved relative to preoperative measurements (P = .001).ConclusionsAbnormal internal rotation of the talus in mild to moderate varus ankle osteoarthritis found on AL CT was significantly corrected after SMO.Level of evidenceTherapeutic Level IV     

L’hémodiafiltration online en mode prédilutionnel : quelle dose d’anticoagulation ?

IntroductionPatients in end stage renal disease on hemodialysis are in higher risk of bleeding related to the anticoagulation used during a session, so only the lowest effective dose of anticoagulation must be used. The aim of this study was to evaluate the efficacy of predilution in hemodiafiltration with reduced dose of anticoagulation compared to hemodialysis in preventing coagulation of circuits.Patients and methodsThis study was conducted in stable hemodialysis patients without high bleeding risk. All patients were treated by two different treatments: (A) conventional hemodialysis, (B) predilution hemodiafiltration with the half dose of anticoagulation used during treatment (A). Other confounding parameters were kept constant during the study. The primary endpoint was the incidence of major thrombotic events judged on a subjective visual score.ResultsTwenty-one patients were included (105 sessions for each treatment). Major incidents are occurring more frequently in predilution hemodiafiltration with reduced dose of anticoagulation (P = 0.03). The premature discontinuation of sessions was more frequent in predilution hemodiafiltration, this difference was not significant (P = 0.07). Duration of sessions was significantly shorter in predilution hemodiafiltration (P = 0.03). The higher frequency of thrombotic events in predilution hemodiafiltration has no effect on net ultrafiltration volume achieved in both treatments.ConclusionPredilution hemodiafiltration with a lower dose of anticoagulation did not prevent major clotting of extracorporeal circuit manner at least equivalent to a reference method.     

Safety of rituximab in rheumatoid arthritis patients with a history of severe or recurrent bacterial infection: Observational study of 30 cases in everyday practice

ObjectivesTo report our experience with rituximab therapy in patients with rheumatoid arthritis (RA) and a history of severe or recurrent bacterial infections.Patients and methodsRetrospective observational study in five rheumatology departments experienced in the use of biotherapies. Patients were included if they had RA and a history of severe or recurrent bacterial infection (requiring admission and/or intravenous antimicrobial therapy) that contraindicated the introduction or continuation of TNFα antagonist therapy.ResultsOf 161 RA patients given rituximab in the five study centers, 30 met the inclusion criteria, 23 females and seven males with a mean age of 58.4 ± 11.8 years and a mean disease duration of 11.4 ± 13.9 years. Among them, 22 had rheumatoid factors and 21 had received TNFα antagonist therapy (one agent in 15 patients, two in five patients and three in one patient). Prior infections were as follows: septicemia, n = 2; lower respiratory tract infection or lung abscess, n = 12; prosthesis infection, n = 3; septic arthritis, n = 3; endocarditis, n = 1; pyelonephritis, n = 2; osteitis, n = 4; and various skin infections (erysipelas, cellulitis or skin abscess), n = 6. Of these 33 infections, 21 occurred during TNFα antagonist therapy. During rituximab therapy, all patients received concomitant glucocorticoid therapy (mean dosage, 12 ± 7.9 mg/day). The number of rituximab cycles was one in 13 patients, two in seven patients and three or more in 10 patients. Mean time from the single or last serious infection and the first rituximab infusion was 20.1 ± 18.7 months. Mean follow-up since the first rituximab infusion was 19.3 ± 7.4 months. During follow-up, six (20%) patients experienced one infection each. Immunoglobulin levels after rituximab therapy were within the normal range.ConclusionRituximab therapy was well tolerated in 24 (80%) of 30 patients with RA and a history of severe or recurrent bacterial infection. In everyday practice, rituximab therapy seems safe with regard to the recurrence of infectious episodes. However, longer follow-ups are needed.     

Treatment of shoulder calcifications of the cuff: A controlled study

ObjectivesAbout 1 in 10 patients with shoulder calcifications complains of chronic pain. Removal techniques have been developed. We carried out the first randomized study to validate bursoscopy (BS) and (needling fragmentation irrigation) (NFI) versus a control group (CT).Methods102 shoulders (96 patients) with calcifications >5 mm whose medical treatment had failed (>4 months) were first injected using a corticosteroid; 49 shoulders improved by more than 70%. The other 53 shoulders were randomized in 3 groups: NFI (n = 16), BS (n = 20), and CT (n = 17). All patients were reviewed at T 1–4–12–24 months.ResultsAfter 4 months, we observed respectively in groups NFI – BS – CT: 62%, 65% and 29% patients showing global improvements >70% (NFI vs CT: p = 0.03; BS vs CT: p = 0.02); ?37%, ?29% and ?11% pain VAS variation (ns), +16%, +12% and ?15% Constant score variation (NFI vs CT: p = 0.03; BS vs CT: p = 0.02), and ?58%, ?77% and +4% area calcification variation (NFI vs CT: p = 0.005; BS vs CT: p = 0.0002; BS vs NFI: p = 0.01). After 24 months, results were maintained in NFI and BS groups, and in the CT group only 6/17 patients were still improved. There were no significant differences between NFI and BS groups. Three partial tears of the cuff were found using MRI in failures, (1 in each group).ConclusionNFI and BS are now validated removal techniques of shoulder calcifications when there is chronic pain and other medical treatments have failed. Results were maintained after 24 months, and were similar between NFI and BS. However NFI could be preferred because of its simplicity and low cost.     

Oncological outcomes of laparoscopic nephroureterectomy with pluck method for distal ureter resection

ObjectiveTo report the oncologic outcomes of upper tract urothelial carcinoma treated with laparoscopic nephroureterectomy and pluck method for distal ureter resection.Materials and methodsBetween May 2004 and November 2015, 118 patients with upper urinary tract urothelial carcinoma received laparoscopic radical nephroureterectomy with endoscopic bladder cuff excision at our institution. The medical records were reviewed retrospectively for clinical and pathological results. Cox regression analyses were performed on factors related to oncological outcomes.ResultsThe median follow-up was 26 months. Bladder recurrence was found in 27 patients (22.9%), extravesical retroperitoneal recurrence in four patients (3.4%), and metastases in 17 patients (14.4%). Multivariate analyses showed that male sex was associated with higher bladder recurrence [odds ratio (OR) = 2.2; 95% confidence interval (CI), 1.02–4.78; p = 0.045)], tumor size had significant correlation with locoregional recurrence (OR = 1.29; 95% CI, 1.07–3.43; p = 0.029), tumor stage was significantly correlated with subsequent metastasis (OR = 2.08; 95% CI, 1.21–3.56; p = 0.008) and overall survival (OR = 1.84; 95% CI, 1.06–3.22 ; p = 0.031), and tumor size correlated significantly with cancer-specific survival (OR = 2.57; 95% CI, 1.16–5.72; p = 0.021).ConclusionsTumor size and tumor stage were significantly associated with survival (cancer-specific and overall survival) in patients receiving nephroureterectomy with pluck method.     

Avoiding delayed diagnosis of significant blunt bowel and mesenteric injuries: Can a scoring tool make the difference? A 7-year retrospective cohort study

IntroductionSignificant blunt bowel and mesenteric injuries (sBBMI) are frequently missed despite the widespread use of computed tomography (CT). Early treatment improves the outcome related to these injuries. The aim of this study was to assess the prevalence of sBBMI, the incidence of delayed diagnosis and to test the performance of the Bowel Injury Prediction Score (BIPS), determined by the white blood cell (WBC) count, presence or absence of abdominal tenderness and CT grade of mesenteric injury.Patients and methodsSingle-centre, registry-based retrospective cohort study, screening all consecutive trauma patients admitted to Lausanne University Hospital Trauma Centre from 2008 to 2015 after a road traffic accident. All patients with reliable information about the presence or absence of sBBMI who underwent abdominal CT and for whom calculation of the BIPS was possible were included for analysis. The incidence of delayed (>24 h after admission) diagnosis in the patient group with sBBMI was determined and the diagnostic performance of the BIPS for sBBMI was assessed.ResultsFor analysis, 766 patients with reliable information about the presence or absence of sBBMI were included. The prevalence of sBBMI was 3.1% (24/766). In 24% (5/21) of stable trauma patients undergoing CT, a diagnostic delay of more than 24 h occurred. Abdominal tenderness (p < 0.0001) and CT grade ≥4 (p < 0.0001) were associated with sBBMI, whereas CT grade 4 alone (p = 0.93) and WBC count ≥17 G/l (p = 0.30) were not. A BIPS ≥2 had a sensitivity of 89% (95% CI, 67–99), specificity of 89% (95% CI, 86–91), positive likelihood ratio of 8 (95% CI, 6.1–10), negative likelihood ratio of 0.12 (95% CI, 0.03–0.44), positive predictive value (PPV) of 19% (95% CI, 15–24) and negative predictive value (NPV) of 99.7% (95% CI, 98.7–99.9). CT alone identified 79% (15/19) and the BIPS 89% (17/19) of patients with sBBMI (p = 0.66).ConclusionsDiagnostic delays in patients with sBBMI are common (24%), despite the routine use of abdominal CT. Application of the BIPS on the present cohort would have led to a high number of non-therapeutic abdominal explorations without identifying significantly more sBBMI early than CT alone.     

Whipple's disease diagnosed during biological treatment for joint disease

ObjectivesIncreased susceptibility to infections is among the main safety concerns raised by biological agents. We describe five cases of Whipple's disease diagnosed during treatment with biological agents.MethodsWe retrospectively identified five cases of Whipple's disease diagnosed between 2003 and 2009 in patients treated with TNFα antagonists in five French hospitals.ResultsFive patients (four male; mean age: 50.4 years; range: 38–67) underwent biological therapy according to prior diagnoses of rheumatoid arthritis (n = 2), ankylosing spondylitis (n = 2), or spondyloarthropathy (n = 1). Biological therapy failed to control the disease, which responded to appropriate antibiotics for Whipple's disease. Retrospectively, clinical symptoms before biological therapy were consistent with Whipple's disease. All five patients had favorable outcomes (mean follow-up, 29 months [13–71]).ConclusionsBiological therapy probably worsened preexisting Whipple's disease, triggering the visceral disorders. Whipple's disease must be ruled out in patients with joint disease, as patients with this spontaneously fatal condition should not receive immunosuppressive agents.     

Predictors of osteoarthritis following operative treatment of medial tibial plateau fractures

PurposeTo determine factors influencing the development of posttraumatic osteoarthritis (OA) following medial tibial plateau fractures and to evaluate concomitant injuries associated with these fractures.Materials and methodsA chart review of patients with operatively treated medial tibial plateau fractures admitted to our Level I trauma centre from 2002 to 2008 was performed. Of 63 patients, 41 participated in a clinical and radiographic examination. The mean age was 47 years (range 16–78) and the mean follow-up time was 7.6 (range 4.7–11.7) years. All patients had preoperative computed tomography (CT) scans and postoperative radiographs. At the end of follow-up, standing radiographs, mechanical axis, and CT scans were evaluated.ResultsOf the 41 patients, 24 had no or mild (Kellgren-Lawrence grade 0–2) OA and 17 had severe (grade 3–4) OA. Initial articular depression measured from preoperative CT scans was a significant predictor of OA (median 1.8 mm vs 4.5 mm, p = 0.009). Fracture line extension to the lateral plateau (p = 0.68) or fracture comminution (p = 0.21) had no effect on the development of posttraumatic OA, nor did articular depression at the end of follow-up (p = 0.68) measured from CT scans. Mechanical axis >4° of varus and ≥2 mm articular depression or step-off were associated with worse WOMAC pain scores, but did not affect other functional outcome scores. Six patients (10%) had permanent peroneal nerve dysfunction. Ten patients (16%) required LCL reconstruction and nine (14%) ACL avulsions were treated at the time of fracture stabilisation.ConclusionsThe amount of articular depression measured from preoperative CT scans seems to predict the development of posttraumatic OA, probably reflecting the severity of chondral injury at the time of fracture. Restoration of mechanical axis and articular congruence are important in achieving a good clinical outcome.     

Efficacy of second intra-tendinous platelet-rich-plasma injection in case of incomplete response of the first injection: Three-year follow up experience

PurposeTendinopathy is a frequent and ubiquitous disease developing early disorganized collagen fibers with neo-angiogenesis on histology. Peritendinous injection of corticosteroid is the commonly accepted strategy despite the absence of inflammation in tendinopathy. Platelet-rich plasma (PRP) might be a useful strategy to rapidly accelerate healing of the tendinopathy but there is a lack ok knowledge about the amount of PRP to be injected and the opportunity of a second injection in case of partial pain relief. The aim of our study was to assess the potential therapeutic effect of early second PRP intra-tendinous to treat persistent painful tendon tear and tendinosis in a long-term follow-up by ultrasonography (US) and clinical data in case of incomplete efficiency of first PRP treatment injection.Materials and methodsTwenty-four consecutive patients referred for US treatment of tendon tear or tendinosis (T+) were included retrospectively. All had previously received a single intra-tendinous injection of PRP under US guidance (PRPT+) and benefited of a second PRP injection (PRPT2+) under US guidance in order to treat persistent painful. US and clinical data were collected for each anatomic compartment for upper and lower limbs before treatment (D0), 6 weeks (W6) after first treatment, 6 weeks (W12) after second treatment and until 32-month follow-up. We used Mac Nemar test and regression model to compare US and clinical data.ResultsThe residual US size of lesions was not significantly lower at W12 after PRPT2+ as compared to W6 (P = 0.86 in upper and P = NS in lower member) independently of age (P = 0.22), gender (P = 0.97) and kind of tendinopathy (P = NS). Quick dash test values and WOMAC values were not significantly lower in PRPT+ at W12 (average: 21.5 months) as compared to W6 (P > 0.66) and long-term follow-up (P > 0.75) independently of age (P = 0.39), gender (P = 0.63) and kind of tendinopathy (P = NS). Nevertheless, comparison between D0 and long-term follow-up (LTF) functionnal score was statistically significant (p<0.001 in upper and lower member).ConclusionOur study suggests that second early intra-tendinous PRP injection under US guidance does not permit rapid decrease of tendinopathy area in US, nor does it quickly improve clinical pain and functional data in case of incomplete efficiency of first PRP injection. However, in long-term follow-up, patients improved their ability to mobilize pathologic tendons.     

Is intraoperative pedography helpful in clinical use—Preliminary results of 100 cases from a consecutive,prospective, randomized,controlled clinical study

BackgroundThe purpose of this study was to assess the clinical use, and to analyze the potential clinical benefit of intraoperative pedography (IP) in a sufficient number of cases in comparison with cases treated without IP.MethodsPatients (age 18 years and older) which sustained an arthrodesis and/or correction of the foot and ankle were included.ResultsOne hundred cases were included (ankle correction arthrodesis, n = 12; subtalar joint correction arthrodesis, n = 14; arthrodesis without correction midfoot, n = 15; correction arthrodesis midfoot, n = 26; correction forefoot, n = 33). Fifty-two patients were randomized for the use of IP. In 24 of the 52 patients (46%), the correction was modified after IP during the same operation.ConclusionsIn 46% of the cases a modification of the surgical correction was made after IP in the same surgical procedure. Whether IP improve the plantar force distribution of the foot and the mid- or long-term clinical outcome has to be critically analyzed when longer follow-up is completed.