Coronary CTA assessment of coronary anomalies

Coronary anomalies occur in <1% of the general population and can range from a benign incidental finding to the cause of sudden cardiac death. The coronary anomalies are classified here according to the traditional grouping into those of origin and course, intrinsic arterial anatomy, and termination. Classic coronary anomalies of origin and course include those in which a coronary artery originates from the contralateral aortic sinus or the pulmonary artery with anomalous course. Single coronary artery anomalies, in which single coronary artery branches to supply the entire coronary tree, are also included in this category. Anomalies of intrinsic arterial anatomy are a broad class that includes myocardial bridges, coronary ectasia and aneurysms, subendocardial coursing arteries, and coronary artery duplication. Coronary anomalies of termination are those in which a coronary artery terminates in a fistulous connection to a great vessel or cardiac chamber. In the case of those anomalies associated with a risk of sudden cardiac death, the relevant imaging features on CT angiography (CTA) associated with poorer prognosis are reviewed. Recent guidelines and appropriateness criteria favor the use of coronary CTA for the evaluation of coronary anomalies. Although invasive angiography has historically been used to diagnose coronary anomalies, multidetector CT imaging techniques have now become an accurate noninvasive alternative. Cardiac CTA provides excellent spatial and temporal resolution, allowing accurate anatomical assessment of these anomalies.     

Pleiotropic Effects of Inhibitors of the RAAS in the Diabetic Population: Above and Beyond Blood Pressure Lowering

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are indispensable therapeutic agents for treating hypertension and proteinuria in patients with diabetes mellitus. Studies have shown that the renin-angiotensin-aldosterone system (RAAS) has effects on various organ systems, including the central nervous system, heart, and kidneys. Angiotensin II has major deleterious effects on vascular compliance, vascular relaxation, and plasma markers of inflammation, which are surrogate markers of cardiovascular disease. Evidence is established from major trials that ACE inhibitors and ARB therapy improve these surrogate markers and reduce cardiovascular disease, renal disease, and stroke. Accumulating evidence also supports the newer class of medication, the direct renin inhibitor aliskiren, as beneficial in hypertensive persons with diabetes mellitus. In this article, we review the mechanisms through which inhibitors of the RAAS benefit persons with hypertension and decrease the development of cardiovascular and renal disease above and beyond blood pressure lowering.     

Right lower quadrant pain in young patients with leukemia. A surgical perspective.

A retrospective review of cecal and appendiceal complications occurring in young patients with acute leukemia since 1969 was performed. The objective of this study was to determine the relative incidence of appendicitis and typhlitis among patients with acute leukemia who had operation or autopsy in this institution as well as to determine the risks of operative intervention. Fifteen patients with these complications were identified among the 400 patients with acute leukemia seen during this time period. Signs and symptoms of an acute abdomen were present despite immunosuppression. The incidence of sepsis at the time of presentation was 53%. Preoperative risk factors identified most frequently were coagulopathy and organ failure resulting from sepsis. Postoperative morbidity (25%) and mortality rates (8%) were related to the development of infectious complications. Appendicitis occurred in eight of the 15 patients studied, whereas typhlitis or its complications was found in seven patients. No preoperative factors could be found to differentiate typhlitis from appendicitis on clinical examination. It is suggested that operation can be safely performed in neutropenic patients who have acute right lower quadrant pain and signs of peritoneal irritation and may be the only effective way of differentiating appendicitis from typhlitis.     

Harnwegsinfekt nach Nierenallotransplantation: Abgrenzung von Bakterien-Kolonisation und bakteriellem Infekt

Summary Among 124 recipients of a renal allotransplant (22 men, 52 women), 60 patients (27 men, 33 women) showed more than 10⁶ colony-forming units/ml midstream urine on one or several occasions. 26 patients (10 men, 16 women) did not present with leucocyturia whereas 23 (10 men, 13 women) did so. Urine samples were examined 1/2 to 5 1/2 years after transplantation.The comparison of the 2 groups of patients with and without leucocyturia revealed the following: there was no age difference; during the first year after grafting, bacteriuria with leucocyturia was more common; recurrent and de novo infections, dysuria, pyelonephritis and demonstration of E. coli were more frequent. Therapy was more effective in cases of bacteriuria without leucocyturia; the serum creatinine was more seldom elevated above the normal range and complications with ureters, bladder emptying or stenoses of the urethra were more seldomly observed.

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Abkürzungen MSU Mittelstrahlurin - HPF Gesichtsfeld, 400-fache Vergrößerung - HWK Harnwegskolonisation - HWI Harnwegsinfekt - Cr-s Serumkreatininkonzentration     

Contrast echocardiography improves the diagnostic yield of transthoracic studies performed in the intensive care setting by novice sonographers.

BACKGROUND: Bedside portable echocardiography in the intensive care department (ICU) is technically difficult, but crucial for directing patient care. Prior studies have shown contrast echocardiography (CE) in the ICU clarifies left ventricular wall motion when performed by experienced sonographers (ESO). However, in most hospitals, ESO are unavailable around the clock, and less experienced cardiovascular fellows or trainees may be asked to perform these examinations. METHODS: Transthoracic echocardiograms were retrospectively evaluated by level III trained echocardiographers for 213 patients in the ICU. Most were performed to assess left ventricular function (65% or 139 of 213) and were scanned by cardiology fellows (70% or 149 of 213) with less than 3 months echocardiography experience. Contrast agent was used in 29% (62 of 213) of all patients. RESULTS: The conversion of suboptimal or diagnostically inadequate apical 4- and 2-chamber views to diagnostically adequate with contrast was statistically significant when performed by both cardiology fellows and ESO (Fischer exact test, P < .0002). CONCLUSIONS: CE is effective in improving the diagnostic yield of transthoracic echocardiographic ICU studies performed by both novice sonographers and ESO. Using cardiology fellows to perform CE in this setting can be appropriate, particularly in after-hour situations, when ESO are not always available and the clinical question is left ventricular function. Results also suggest cardiology fellows can easily learn CE.     

Topical retinoic acid treatment of drug-induced pseudopemphigoid

A case of drug-induced ocular cicatricial pemphigoid with pronounced keratinizing squamous epithelium metaplasia was treated for 5 months with all-trans retinoic acid ointment. Keratinization reversed completely and the cicatricial process was stabilized in one eye and slowed down in the other eye. The treatment was well tolerated.     

Meta-Analysis of Trials on Prophylactic Use of Levosimendan in Patients Undergoing Cardiac Surgery

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Changes in brain functional connectivity patterns are driven by an individual lesion in MS: a resting-state fMRI study

Diffuse inflammation in multiple sclerosis (MS) extends beyond focal lesion sites, affecting interconnected regions; however, little is known about the impact of an individual lesion affecting major white matter (WM) pathways on brain functional connectivity (FC). Here, we longitudinally assessed the effects of acute and chronic lesions on FC in relapsing-remitting MS (RRMS) patients using resting-state fMRI. 45 MRI data sets from 9 RRMS patients were recorded using 3T MR scanner over 5 time points at 8 week intervals. Patients were divided into two groups based on the presence (n?=?5; MS+) and absence (n?=?4; MS-) of a lesion at a predilection site for MS. While FC levels were found not to fluctuate significantly in the overall patient group, the MS+ patient group showed increased FC in the contralateral cuneus and precuneus and in the ipsilateral precuneus (p?<?0.01, corrected). This can be interpreted as the recruitment of intact cortical regions to compensate for tissue damage. During the study, one patient developed an acute WM lesion in the left posterior periventricular space. A marked increase in FC in the right pre-, post-central gyrus, right superior frontal gyrus, the left cuneus, the vermis and the posterior and anterior lobes of the cerebellum was noted following the clinical relapse, which gradually decreased in subsequent follow-ups, suggesting short-term functional reorganization during the acute phase. This strongly suggests that the lesion-related network changes observed in patients with chronic lesions occur as a result of reorganization processes following the initial appearance of an acute lesion.