Kock continent ileal urinary reservoir. Anatomy and potential pitfalls of radionuclide imaging

The Kock continent ileal urinary reservoir (Kock pouch) is a new form of urinary diversion that, due to its advantages over previous techniques of urinary bypass, will probably become widespread in urologic practice. When bone imaging is performed in the presence of the Kock pouch, the unusual configuration of the pouch may obscure or simulate osseous lesions. An understanding of the surgical anatomy as well as the planar and SPECT scintigraphic appearances of the Kock pouch is necessary to avoid errors during interpretation. This series of 51 bone images reports on the variable scintigraphic appearance of the Kock pouch. In addition, the incidence and type of potentially avoidable pitfalls in the interpretation of bone imaging when this form of urinary diversion is used are evaluated.     

Hepatobiliary imaging in choledocholithiasis. A comparison with ultrasound

A retrospective analysis of preoperative biliary imaging and ultrasound in 22 patients with surgically proven choledocholithiasis was performed. Ultrasound detected dilated ducts greater than 7 mm in 11 of 14 jaundiced patients (79%). Hepatobiliary imaging was able to detect either absent or delayed bowel visualization or prominent bile ducts in 13 of 14 jaundiced patients (93%). Of eight nonjaundiced patients, ultrasound showed dilated ducts in three (38%). Hepatobiliary imaging showed either absent bowel activity or prominent ducts in six of eight nonjaundiced patients (75%). Twenty of 22 patients had stones in the gallbladder that were detected by ultrasound, although only one patient had actual visualization of the common duct stone. Hepatobiliary imaging may show abnormalities in choledocholithiasis with normal ultrasound studies.     

Enterogastric reflux in suspected acute cholecystitis

Ninety patients undergoing Tc-99m disofenin hepatobiliary scintigraphy for suspected acute cholecystitis were assessed for enterogastric reflux. Seventy-seven cases showed bowel activity by one hour and were included in the study. Twenty-six percent (20/77) showed definite enterogastric reflux. The gastric activity tended to clear rapidly, even though patients remained supine during examination. Six of 20 patients (30%) with enterogastric reflux had gallbladder visualization. Of these six, one had acute cholecystitis and one had resolving acute cholecystitis with gallstone pancreatitis. There was one case each of pancreatitis, amebic abscess, sepsis, and one normal. Thus, of 20 patients with enterogastric reflux, 16 had acute cholecystitis (80%). Twenty-three of seventy-seven patients (30%) had surgically proven acute cholecystitis: of these, 16 of 23 (70% sensitivity) had gastric reflux, and 50 of 54 without acute cholecystitis did not have reflux (93% specificity). The overall accuracy of enterogastric reflux for acute cholecystitis is 86%. Gastric reflux seen on cholescintigraphy is a secondary sign of acute cholecystitis. Reflux may be related to duodenal irritation from the adjacent inflamed gallbladder.     

Carcinoma of the cystic duct

Two patients with carcinoma of the cystic duct presented with obstructive jaundice due to extrinsic compression of the common hepatic duct by the tumor. Sonography and computed tomography showed dilatation of the intrahepatic bile ducts and gallbladder. In one patient, a calculus seen in the gallbladder neck suggested Mirizzi syndrome. In the other, a small soft tissue mass was indistinguishable from a common duct tumor or an enlarged lymph node. In both cases, direct cholangiography demonstrated extrinsic compression and displacement of the common duct with proximal biliary dilatation and nonvisualization of the gallbladder. Carcinoma of the cystic duct should be considered whenever there is evidence of cystic duct obstruction and/or when cholangiography shows extrinsic mass effect on the common duct.     

Double Up Food Bucks Participation is Associated with Increased Fruit and Vegetable Consumption and Food Security Among Low-Income Adults

Objective

To evaluate the effect of the Utah Double Up Food Bucks (DUFB) program on fruit and vegetable (F&V) intake and food security status among Supplemental Nutrition Assistance Program (SNAP) recipients.

The sixth vital sign: prehospital end-tidal carbon dioxide predicts in-hospital mortality and metabolic disturbances

Objective

To determine the ability of prehospital end-tidal carbon dioxide (ETCO₂) to predict in-hospital mortality compared to conventional vital signs.

Methods

We conducted a retrospective cohort study among patients transported by emergency medical services during a 29-month period. Included patients had ETCO₂ recorded in addition to initial vital signs. The main outcome was death at any point during hospitalization. Secondary outcomes included laboratory results and admitting diagnosis.

Results

Of 1328 records reviewed, hospital discharge data, ETCO₂, and all 6 prehospital vital signs were available in 1088 patients. Low ETCO₂ levels were the strongest predictor of mortality in the overall group (area under the receiver operating characteristic curve (AUC of 0.76, 95% confidence interval [CI] 0.66-0.85), as well as subgroup analysis excluding prehospital cardiac arrest (AUC of 0.77, 95% CI 0.67-0.87). The sensitivity of abnormal ETCO₂ for predicting mortality was 93% (95% CI 79%-98%), the specificity was 44% (95% CI 41%-48%), and the negative predictive value was 99% (95% CI 92%-100%). There were significant associations between ETCO₂ and serum bicarbonate levels (r = 0.429, P < .001), anion gap (r = − 0.216, P < .001), and lactate (r = –0.376, P < .001).

Conclusion

Of all prehospital vital signs, ETCO₂ was the most predictive and consistent for mortality, which may be related to an association with metabolic acidosis.     

Sonography of diffuse liver disease.

Sonography is often the first imaging procedure performed in the evaluation of individuals with suspected liver disease. Evaluation for biliary dilatation is always performed, because bile duct obstruction can cause abnormal liver test results, raising the suspicion of liver disease. Ultrasound is a useful but imperfect tool in evaluating diffuse liver disease. We discuss the uses and limitations of sonography in evaluating parenchymal liver disease. Sonography can show hepatomegaly, fatty infiltration of the liver, and cirrhosis, all with good but imperfect sensitivity and specificity. Sonography is of limited usefulness in acute hepatitis. Increased parenchymal echogenicity is a reliable criterion for diagnosing fatty liver. Cirrhosis can be diagnosed in the correct clinical setting when the following are present: a nodular liver surface, decreased right lobe-caudate lobe ratio, and indirect evidence of portal hypertension (collateral vessels and splenomegaly). Ultrasound plays an important role in the imaging of conditions and procedures common in patients with diffuse liver disease.     

Prehospital End-tidal Carbon Dioxide Predicts Mortality in Trauma Patients

Background: End-tidal carbon dioxide (EtCO₂) measurement has been shown to have prognostic value in acute trauma. Objective: Evaluate the association of prehospital EtCO₂ and in-hospital mortality in trauma patients and to assess its prognostic value when compared to traditional vital signs. Methods: Retrospective, cross-sectional study of patients transported by a single EMS agency to a level one trauma center. We evaluated initial out-of-hospital vital signs documented by EMS personnel including EtCO₂, respiratory rate (RR), systolic BP (SBP), diastolic BP (DBP), pulse (P), and oxygen saturation (O₂) and hospital data. The main outcome measure was mortality. Results: 135 trauma patients were included; 9 (7%) did not survive. The mean age of patients was 40 (SD17) [Range 16–89], 97 (72%) were male, 76 (56%) were admitted to the hospital and 15 (11%) went to the ICU. The mean EtCO2 level was 18 mmHg (95%CI 9–28) [Range 5–41] in non-survivors compared to 34 mmHg (95%CI 32–35) [Range 11–51] in survivors. The area under the ROC curve (AUC) for EtCO₂ in predicting mortality was 0.84 (0.67–1.00) (p = 0.001), RR was 0.82 (0.63–1.00), SBP was 0.72 (0.49–0.96), DBP was 0.72 (0.47–0.97), pulse was 0.51 (0.26–0.76), and O₂ was 0.64 (0.37–0.91). Cut-off values at 30 mmHg yielded sensitivity = 89% (51–99), specificity = 68% (59–76), PPV = 13% (6–24) and NPV = 99% (93–100) for predicting mortality. There was no correlation between RR and EtCO₂ (correlation 0.16; p = 0.06). Conclusion: We found an inverse association between prehospital EtCO₂ and mortality. This has implications for improving triage and assisting EMS in directing patients to an appropriate trauma center.