A clinical approach to the management of a patient with suspected renovascular disease who presents with leg ischemia.

Atherosclerotic renal artery stenosis (ARAS) may cause hypertension, progressive renal failure, and recurrent pulmonary edema. It typically occurs in high risk patients with coexistent vascular disease elsewhere. Most patients with ARAS are likely to die from coronary heart disease or stroke before end-stage renal failure occurs. Recent controlled trials have shown that most patients undergoing angioplasty to treat renovascular hypertension still need antihypertensive agents 6 or 12 months after the procedure. Nevertheless, the number of antihypertensive agents required to control blood pressure adequately is lower following angioplasty than for medication alone. Trials assessing the value of revascularization for preserving renal function or preventing clinical events are only in the early recruitment phase. Revascularization should be undertaken in patients with ARAS and resistant hypertension or heart failure, and probably in those with rapidly deteriorating renal function or with an increase in plasma creatinine levels during angiotensin-converting enzyme inhibition. With or without revascularization, medical therapy using antihypertensive, hypolipidemic and antiplatelet agents is necessary in almost all cases.     

Sonographic features of benign thyroid nodules: interobserver reliability and overlap with malignancy.

OBJECTIVE: To prospectively determine the sonographic findings of nodular hyperplasia of the thyroid, to compare these with reported findings associated with malignancy, and to assess interobserver reliability. METHODS: Seventy thyroid nodules were scanned, and then biopsies of the nodules were performed under sonographic guidance with fine-needle cytologic analysis; in all cases images were reviewed by 2 experienced radiologists without knowledge of clinical outcome. Findings reported associated with malignancy were specifically assessed. Interobserver agreement between the expert and secondary readers for each finding was calculated by the kappa or weighted kappa statistic and the Fisher exact test of independence. RESULTS: There were 68 benign and 2 malignant nodules in a population of 63 female and 7 male patients. The mean benign nodule size was 2.9 cm; 60% were solid; 54% were hypoechoic; 59% were microlobulated or macrolobulated; 47% had central vascularity; 24% contained calcifications; and 82% were elliptical in shape. There was very good interobserver reliability for the presence of calcium (kappa = 0.91) and good agreement for the presence and location of vascularity (kappa = 0.75) and the amount of cystic components (kappa = 0.62; all P < .01). CONCLUSIONS: Sixty-nine percent of benign nodules had at least 1 finding reported previously as associated with malignancy. The interobserver reliability of the sonographic findings was good to very good for 3 of the 5 findings assessed.     

Malignant peripheral nerve sheath tumour of the cervical vagus nerve in a neurofibromatosis type 1 patient.

One serious complication of neurofibromatosis type 1 (NF1) is the development of malignant peripheral nerve sheath tumours (MPNSTs). These malignancies often develop within pre-existing plexiform neurofibromas and their development is now thought to be associated with both tumour suppressor gene mutations and dysregulated growth factor signalling. Recent work demonstrates that the lifetime risk of malignant transformation is significantly greater than previously thought. Ionising radiation, a long-standing disease, particularly the presence of a large number of plexiform neurofibromas from an early age, are suggested risk factors. We present an NF1 patient who developed an MPNST of the cervical vagus nerve which was successfully treated with surgery. Close monitoring of patients with NF and a high level of suspicion towards rapidly enlarging and painful swellings is merited as these features may signify malignant transformation. Whether a positive history of MPNST in other affected family members predisposes the individual to a higher risk of malignant transformation is unclear.