Acute pulmonary embolism: diagnosis with MR angiography

PURPOSE: To prospectively evaluate pulmonary magnetic (MR) angiography as a diagnostic examination for acute pulmonary embolism (PE). MATERIALS AND METHODS: Thirty-six consecutive patients (19 women, 17 men; age range, 28-84 years) underwent pulmonary digital subtraction angiography (DSA) and pulmonary MR angiography. MR angiograms were obtained during suspended respiration and the pulmonary arterial phase of gadolinium-based contrast medium injection. A steady-state gradient-recalled-echo sequence with free induction decay sampling was used. DSA studies were interpreted for the presence of acute PE by two independent radiologists; an adjudicator made the final decision on discordant interpretations. RESULTS: By using DSA, a total of 19 acute pulmonary emboli were depicted in 13 patients. Prospectively, 13 of these emboli were depicted by using MR angiography. MR angiography missed six emboli: Four required the DSA adjudicator to make the decision, and one was in a patient whose MR angiogram was acquired during breathing. Four of these six emboli were small subsegmental emboli, and two were segmental. CONCLUSION: Performed without pulmonary arterial catheterization, iodinated contrast media, or ionizing radiation, pulmonary MR angiography had a high accuracy for depicting lobar and segmental emboli, but was unable to depict four of five subsegmental emboli.     

Increased incidence of gastrointestinal surgical complications in renal transplant recipients with polycystic kidney disease

BACKGROUND: We had the impression that, although our renal transplant recipients with polycystic kidney disease (PKD) had excellent long-term renal graft function, they had an increased incidence of postoperative gastrointestinal (GI) complications. METHODS: Over a 10-year period (1987 through 1996), 1467 renal transplants were performed in 1417 patients; 145 of these transplants involved PKD recipients. In the PKD group, 18 patients (12.4%) developed a posttransplant complication necessitating GI surgery (PKD-GI), an incidence twice that in the non-PKD recipients (73 patients or 6.2%, non-PKD-GI). RESULTS: PKD and non-PKD recipients displayed no significant difference in mortality. The PKD patients had better long-term renal graft survival than the non-PKD patients (P=0.08). There was no difference in mortality (P>0.6) or renal graft survival (P>0.6) between the PKD-GI and PKD-non-GI groups. The PKD-GI group had no increased mortality over the non-PKD-GI patients (P>0.6), despite a higher incidence of GI surgical complications in the PKD group versus the non-PKD group (overall: 12.4 vs. 6.2%, P<0.01; within 90 days of transplant: 7.6 vs. 3.3%, P<0.02) and a greater propensity for small and large bowel complications (overall: 9.0 vs. 2.6%; P< 0.001; less than 90 days: 6.9 vs. 2.0%, P<0.002). The PKD-GI recipients tended toward less long-term graft loss than their non-PKD-GI counterparts (11.1 vs. 27.4%; P=.22). The PKD-GI recipients suffered no acute rejection episodes within 90 days after their GI operation versus 11 of 73 non-PKD-GI recipients (O vs. 15.1%; P=0.075). CONCLUSIONS: PKD recipients of renal grafts should be watched closely early after transplant because of their increased risk of GI complications. These complications resulted in no increase in mortality or graft loss compared to non-PKD recipients with GI complications despite the PKD group's higher incidence of bowel perforation and increased age at time of transplant.     

Platelet glycoprotein IIb/IIIa receptor antagonists: current concepts and future directions

Platelets play a key role in the development of thrombosis. Glycoprotein (GP) IIb/IIIa antagonists are a new class of potent drugs that profoundly inhibit platelet function by blocking the key receptor involved in platelet aggregation. Several antiplatelet agents with varying characteristics have emerged in the past few years and have been evaluated in a variety of potential clinical settings. Clinical trials have established the effectiveness of these drugs in conditions where thrombosis plays a major contributing role such as unstable angina pectoris, myocardial infarction, and high-risk coronary intervention. Despite their potent antiplatelet effects, GP IIb/IIIa antagonists appear to be remarkably well tolerated, provided that the concomitant use of other anticoagulants such as heparin is managed carefully. Ongoing and future studies will further refine the role of GP IIb/IIIa antagonists, explore new applications, and further test their safety and cost effectiveness in the short and long term.     

The radiology of intracranial tuberculosis in children.

Radiology provides valuable clues to the correct diagnosis of intracranial tuberculosis. Twenty-three children with this problem were reviewed. Fifteen had meningitis, 12 of whom had abnormal chest radiographs, nine of them suggestive of tuberculosis. Common neuroradiologic findings were minor suture separation, abnormal activity in the region of the sylvian fissure on brain scans, mild ventricular dilatation, and vasculitis. Among the eight patients with tuberculomas, abnormal chest radiographs were less common. Neuroradiologic abnormalities included evidence of increased intracranial pressure on skull radiographs, focal deep lesions on brain scans, and hydrocephalus and mass lesions on air studies. Most tuberculomas were calcified one year later.     

Cytomegalovirus as a risk factor in renal transplantation

A prospective study of 276 patients that were greater than 12 years old and received transplants between October 1, 1977 and September 30, 1979 has been undertaken. Any patient with clinical findings compatible with overt cytomegalovirus (CMV) disease was placed on a "CMV disease diagnostic protocol." All diagnosed cases of CMV occurring before November 15, 1979 have been analyzed. Eighty patients (29%) had overt CMV disease. Seventy-two (90%) of them contracted CMV within the first 3 months post-transplant. The incidence of overt CMV varied with donor type. Eight percent (4 of 49), 17% (8 of 48), 20% (5 of 25), 40% (46 of 115) and 43% (15 of 35) of HLA-identical (ID) siblings, non-ID siblings, child donor, cadaveric donor, and parental donor, respectively, contracted CMV disease. Overt clinical CMV disease influenced the graft function and patient survival rates significantly (P < 0.01). Several risk factors have been considered as possible indicators of CMV disease. These include age, sex, diabetic status, time of onset of CMV, donor and recipient CMV complement-fixing (CF) and indirect fluorescence (IF) titers. The same variables were analyzed to determine whether they might also predict the severity of the disease. Donor CF is the single most important risk factor. Recipient serology alone was not found to be a significant risk factor but 15 of 27 (56%) persons who had a negative titer and received a kidney from a donor with a positive CF titer contracted overt CMV. Nine of those 15 (60%) had moderate, severe, or lethal illness.     

Some epidemiological observations on medicinal and non-medicinal poisoning in preschool children.

STUDY OBJECTIVE--The aim was to identify and compare rates of admission to hospital of preschool children for medicinal and non-medicinal poisoning in a defined population. DESIGN--The study was an analysis of computerised abstracts of hospital inpatient records for poisoning. SETTING--Six districts in southern England covered by the Oxford record linkage study. SUBJECTS--The subjects were children under six years of age residing in the six districts from 1975 to 1986. MEASUREMENTS AND MAIN RESULTS--6152 children, drawn from an average annual resident population of 164,000 children in 1975-1986, experienced 6562 hospital admissions for poisoning before six years; 3702 (56.4%) were attributed to medicinal and 2860 (43.6%) to non-medicinal agents. Of the latter, 646 (9.8% of the total) were recorded under the International classification of diseases code, described as "noxious food" (almost exclusively plant material). Average annual admission rates in children under six were 1.88 per 1000 for medicinal agents and 1.45 for non-medicinal substances. Analgesics accounted for 28.1% of the admissions for medicinal poisoning; berries and mushrooms for 97.4% of the plant materials; and corrosive aromatics, acids and alkalis for 22.0% of the other non-medicinals. Admission rates were higher in males than females in each category of poisoning. In children aged 1-4 years there was a significant decrease in admission rates between 1975 and 1986, averaging per annum 5.8% for medicinal poisoning, 6.9% for non-medicinal poisoning (excluding plant material), and 12.8% for plant material poisoning. Significant seasonal variation was found for each class of poisoning. CONCLUSIONS--Admission rates for medicinal and non-medicinal poisoning in preschool children declined between 1975 and 1986. The decline could reflect a change in thresholds for admission although, if so, this would be against the general trend in paediatric medical admissions, which is upward. An alternative explanation is a decline in the incidence of poisoning.     

A foot in the door: art therapy in the nursing home

Inclusion of art therapy in the residential nursing home and a day-care facility had positive effects on the elderly. Socialization, self-esteem, and memory retrieval were enhanced by the art experience. In addition, the staff and administrators of both the nursing home and day-care facility found art therapy to be valuable and arranged to continue the program. The funding agent for the pilot project was particularly interested in supporting a program that included an educational component, and the university recognized this program as an excellent training opportunity. The five art therapy interns gained experience in working with a population that will need increased professional services in the future, and the successful addition of part-time art therapists at the two pilot agencies will assure a continuation of intern training sites for art therapy students interested in gerontology. By developing sites for art therapy interns, we have opened the door to a method which will not only train professionals to work with older adults but will also offer job sharing between nursing homes. It has been suggested by the administrator of the nursing home in the program that we investigate the possibility of one art therapist serving two or three nursing homes on a part-time/full-time employment basis. Programs would then be affordable at most sites, and thus more people would be able to benefit from art therapy.     

Appointment-keeping behavior and patient satisfaction: implications for health professionals

This study examines patient satisfaction with care received in a subspecialty clinic, appointment-keeping behavior in that clinic, and the interrelationships between satisfaction and appointment-keeping compliance. The implications for health education and patient counselling are also discussed. The setting is an outpatient clinic of a large university hospital that serves both an urban and rural population. A mailed questionnaire was returned by 150/270 (56%) patients. While satisfaction and compliance were not significantly related, satisfaction was significantly related to the patient's perception of benefit received as a result of care provided by the clinic.