An infant with trisomy 18 and a ventricular septal defect

Decisions for critically ill infants with trisomy 18 raise thorny issues about values, futility, the burdens of treatment, cost-effectiveness, and justice. We presented the case of an infant with trisomy 18 to 2 neonatologists with experience in clinical ethics, Annie Janvier and Felix Okah, and to a parent, Barbara Farlow. They do not agree about the right thing to do.     

Quantification of atherosclerotic coronary plaque components by submillimeter computed tomography

Background: Although several investigations have shown that multi-detecor row computed tomography (MDCT) of the coronary arteries can detect noncalcified atherosclerotic plaque, it has remained unresolved if the method also determines features of a rupture-prone plaque. We set out to correlate the size of atherosclerotic plaque components with cardiac MDCT with histology. Methods and results: In 30 autopsy cases, hearts were isolated, coronary arteries filled with contrast agent, and depicted with a clinical 16-row detector CT with a slice thickness of 0.63 mm. Transections of the three main coronary arteries were reconstructed and compared with histopathologic sections using light microscopy. MDCT measurements of total plaque area (r = 0.73, P < 0.0001) and calcified plaque area (r = 0.83, P < 0.0001) correlated well with histopathology, while measurements of non-calcified plaque area (r = 0.53, P < 0.0001) and lipid core size (r = 0.43; P < 0.0001) correlated less well. MDCT overestimated all plaque areas except lipid core size, which was underestimated. Conclusions: Coronary CT provides an accurate and reproducible method for the quantitative assessment of total plaque and calcified plaque areas. However, the method is less accurate for the quantification of non-calcified plaque area and lipid core size, which is ascribed to limited spatial and contrast resolution. With the present technique, the detection of vulnerable plaques by MDCT remains uncertain.     

Distinguishing specific sexual and general emotional effects in fMRI-subcortical and cortical arousal during erotic picture viewing

Sexual activity involves excitement with high arousal and pleasure as typical features of emotions. Brain activations specifically related to erotic feelings and those related to general emotional processing are therefore hard to disentangle. Using fMRI in 21 healthy subjects (11 males and 10 females), we investigated regions that show activations specifically related to the viewing of sexually intense pictures while controlling for general emotional arousal (GEA) or pleasure. Activations in the ventral striatum and hypothalamus were found to be modulated by the stimulus' specific sexual intensity (SSI) while activations in the anterior cingulate cortex were associated with an interaction between sexual intensity and emotional valence. In contrast, activation in other regions like the dorsomedial prefrontal cortex, the mediodorsal thalamus and the amygdala was associated only with a general emotional component during sexual arousal. No differences were found in these effects when comparing females and males. Our findings demonstrate for the first time neural differentiation between emotional and sexual components in the neural network underlying sexual arousal.     

Prehospital ultrasound detects pericardial tamponade in a pregnant victim of stabbing assault

The development of handheld, portable ultrasound devices has enabled the use of this diagnostic tool also in the out-of-hospital environment. We report on a pregnant teenager who was found haemodynamically unstable after a stab assault. When she suffered cardiac arrest shortly thereafter, diagnosis of cardiac tamponade was made by portable ultrasound, and immediate pericardiocentesis was performed by the emergency physician. While her baby died after emergency Caesarean section, the teenager survived after thoracotomy and prolonged resuscitation without neurological sequelae.     

Intraoperative ultrasound to define focal cortical dysplasia in epilepsy surgery

Focal cortical dyplasia (FCD) is a frequent cause of medication-resistant focal epilepsy. Patients with FCD may benefit from epilepsy surgery. However, it is difficult to intraoperatively define lesion boundaries. In this case report we present a novel tool to identify FCD intraoperatively. A patient with frontal lobe epilepsy underwent resection of a left frontomesial FCD. Image guidance was achieved by intraoperative ultrasound, which depicted the lesion with a higher resolution than preoperative MRI. Postoperatively the patient remained seizure free. Intraoperative ultrasound may be helpful in identifying and targeting subtle epileptogenic lesions, which are difficult to visualize.     

Evaluation of prostate cancer detection with ultrasound real-time elastography: a comparison with step section pathological analysis after radical prostatectomy

BACKGROUND: Conventional gray scale ultrasound has a low sensitivity and specificity for prostate cancer detection. Better imaging modalities are needed. OBJECTIVE: To determine sensitivity and specificity for prostate cancer detection with ultrasound-based real-time elastography (elastography) in patients scheduled for radical prostatectomy (RP). DESIGN, SETTING, AND PARTICIPANTS: Between July and October 2007, 109 patients with biopsy-proven localized prostate cancer (PCa) underwent elastography before RP. The investigator was blinded to clinical data. MEASUREMENTS: A EUB-6500HV ultrasound system with a V53W 7.5MHz end-fire transrectal probe was used preoperatively. Areas found to be suspicious for PCa were recorded for left and right side of the apex, mid-gland, and base. These findings were correlated with the obtained whole-mount sections after RP. RESULTS AND LIMITATIONS: Sensitivity and specificity for detecting PCa were 75.4% and 76.6%, respectively. A total of 439 suspicious areas in elastography were recorded, and 451 cancerous areas were found in the RP specimens. Positive predictive value, negative predictive value, and accuracy for elastography were 87.8%, 59%, and 76%, respectively. Nevertheless, there are limitations to our studies because we investigated specific patients scheduled for RP with apparent PCa. Whether elastography is practical as a diagnostic tool or can be used to target a biopsy and be at least as sensitive in tumor detection as extended biopsy schemes has yet to be determined. CONCLUSION: Elastography can detect prostate cancer foci within the prostate with good accuracy and has potential to increase ultrasound-based PCa detection. Further studies need to be done to approve these data and to evaluate whether tumor detection can be increased by elastography-guided biopsies.