Significance of Cardiac Computed Tomography Incidental Findings in Acute Chest Pain

Background

Coronary computed tomography angiography might improve the management of patients presenting to the emergency department with acute chest pain; however, noncoronary incidental findings are frequently detected. The prevalence and clinical significance of these findings have not been well described.

Methods

Consecutive patients presenting to the emergency department with acute chest pain and inconclusive initial evaluation between May 2005 and May 2007 underwent 64-slice coronary computed tomography angiography before hospital admission with noncoronary incidental findings immediately reported. An expert panel adjudicated which incidental findings changed in-hospital patient management, and projections for additional testing were based on standard medical practice.

Results

Among 395 patients (37.0% were female, mean age 53 ± 12 years), incidental findings were detected in 44.8% (n = 177): noncalcified pulmonary nodules (n = 94, 23.8%), simple liver cysts (n = 26, 6.6%), calcified pulmonary nodules (n = 16, 4.1%), and contrast-enhancing liver lesions (n = 9, 2.3%). In-hospital management was changed because of incidental finding reporting in 5 patients (1.3%), and a potential alternative diagnosis was offered in another 16 patients (4.1%). Subsequent diagnostic imaging tests were recommended in 81 patients (20.5%), including 74 chest computed tomography scans. After 6 months, biopsy was performed in 3 patients, revealing cancer in 2 (0.5%) who underwent successful tumor resection.

Conclusion

Clinically important findings are detected in up to 5% of patients with a lead symptom of acute chest pain and low to intermediate likelihood of acute coronary syndrome, but only few directly change patient management; 21% are recommended for further imaging tests, resulting in invasive procedures and detection of cancer in few patients.     

Suppression of HIV-1 plasma viral load below detection preserves IL-17 producing T cells in HIV-1 infection

IL-17 is proinflammatory cytokine secreted by a unique CD4+ T (Th17) cell subset and proposed to play a role in host defense. We hypothesized that Th17 cells are lost in HIV-1 infection. HIV-1-infected children with plasma viremia below 50 copies/ml had IL-17 production, whereas those with detectable viremia had minimal secretion. These results imply viral-mediated destruction or impairment of Th17 cells and argue for complete suppression of viremia for reconstitution of Th17 cells.     

Line it up—Inadvertent placement of nasogastric tube in pleural space resulting in iatrogenic empyema

Dobhoff tubes, used for post‐pyloric feedings, have a weighted metal end with a small diameter that enhances their flexibility to traverse the gastrointestinal tract. Unfortunately, the metal stylet can iatrogenically perforate surrounding structures in patients with diminished cough and gag (1), and extreme caution should be considered before its utilization.     

To posture or not to posture after macular hole surgery

OBJECTIVE: To evaluate the anatomic and functional success of phacovitrectomy and intraocular gas tamponade for macular hole surgery with only first night face down posturing. METHODS: This was a nonrandomized observational prospective trial over 9 months, with data collection on 28 eyes of 26 consecutive patients who underwent phacovitrectomy, internal limiting membrane peel, and intraocular gas tamponade (C2F6) for stage 2, 3, and 4 macular holes. Data included sex, age, hole latency and Gass stage, preoperative and postoperative visual acuity and ocular coherence tomography, refractive outcome, ocular comorbidity, first postoperative day gas fill, and intraocular pressure. Postoperatively, all patients were postured face down overnight. Thereafter, patients with more than 70% gas fill (beyond the inferior retinal vascular arcade) were asked to stop posturing, although they were advised not to lie flat on their backs at night for 10 days. RESULTS: The sample was divided into patients who did and did not need to posture postoperatively, depending on first day gas fill. Twenty patients did not need posturing and 8 patients needed postoperative posturing for 10 days. The mean macular hole duration was 10.5 months. A total of 87.5% compared to 100% achieved hole closure in the posture and nonposture group, respectively. The mean postoperative visual acuity was 0.5 +/- 0.25 LogMAR. Statistical analysis revealed no significant difference in age, hole duration, preoperative and postoperative visual acuities, intraocular pressure measured 24 hours postoperatively, or refractive error between the two samples. CONCLUSION: Phacovitrectomy for macular hole surgery without postoperative face down posture is a reasonable approach, as long as the eye has more than 70% gas fill (beyond the inferior retinal vascular arcade) on the first postoperative day. This study showed no statistically significant difference between patients who postured and those who did not posture. The combination of phacoemulsification, pars plana vitrectomy, internal limiting membrane, and gas tamponade in macular hole surgery reduces the difficulty of posturing in elderly patients. This technique saves the patient from exposure to a second intraocular intervention to remove a cataract which will commonly develop after vitrectomy and gas tamponade alone.     

Combination 20 and 23-gauge transconjunctival vitrectomy: A new approach

The advent of smaller gauge instrumentation allows for minimally invasive vitreoretinal surgery (MIVS) as compared to conventional pars plana vitrectomy. Sutureless posterior segment surgery has the advantages of faster wound healing, minimal surgical trauma, decreased convalescence period besides reduced postoperative astigmatism; however, slower gel removal and limited peripheral vitreous dissection are disadvantages with smaller gauge systems. We herein describe a new technique combining 23-gauge and 20-gauge vitrectomy to improve the effectiveness and outcomes of vitreoretinal surgery.     

Mitochondrial μ-calpain is not involved in the processing of apoptosis-inducing factor

Caspase-independent cell death, an important death pathway in many cells including neurons, is executed via apoptosis-inducing factor (AIF), an oxidoreductase, localized to the mitochondrial intermembrane space. AIF is processed and released from mitochondria following mitochondrial permeability transition pore (mPTP) formation, and translocates to the nucleus to induce DNA fragmentation and cell death. The release of AIF requires cleavage of its N-terminus anchored in the inner mitochondrial membrane. The protease responsible for this AIF truncation has not been established, although there is considerable evidence suggesting a role for μ-calpain. We previously found that a pool of μ-calpain is localized to the mitochondrial intermembrane space, the submitochondrial compartment in which AIF truncation occurs. The close submitochondrial proximity of mitochondrial μ-calpain and AIF gives support to the hypothesis that mitochondrial μ-calpain may be the protease responsible for processing AIF prior to its release. In the present study, AIF was released from rat liver mitochondria following mPTP induction by atractyloside. This release was inhibited by the cysteine protease inhibitor MDL28170, but not by more specific calpain inhibitors PD150606 and calpastatin. Atractyloside caused swelling in rat brain mitochondria, but did not induce AIF release. In a mitochondrial fraction from SH-SY5Y neuroblastoma cells, incubation with 5 mM Ca²⁺ resulted in the activation of μ-calpain but not in AIF truncation. In summary, the localization of μ-calpain to the mitochondrial intermembrane space is suggestive of its possible involvement in AIF processing, but direct experimental evidence supporting such a role has been elusive.     

Functional outcome following quadriceps tendon lengthening in congenital dislocation of the knee, with special reference to extensor weakness

This study reports the incidence and proposes a probable cause of flexion deformity and extensor weakness following lengthening of quadriceps tendon for the congenital dislocation of the knee and also proposes a modification of the functional grading given in the literature to this effect. Seventeen knees in ten patients were treated with a follow-up from 3 to 8 years. Fifteen knees were grade III and were operated with quadriceps lengthening and anterior capsulotomy. Two knees were Grade II and were initially closed reduced, but operated later due to recurrence. The results were graded on a modification of functional grading system given in the literature [1]. There were excellent results in four, good in five and fair in eight knees. There was an extensor weakness in ten knees (average 12.2°) and flexion deformity (15°) in one. Eight patients could squat and all started walking independently by 10–20 months of age, except one. V-lengthening of the quadriceps tendon produced a satisfactory improvement in the knee function. The theoretical role of the gastrocnemius and hamstring muscles in abetting flexion deformity and extensor weakness is suggested.