Diagnostic Approach In Patients Research Articles

Degradation of Troponin I in Serum or Plasma: Mechanisms, and Analytical and Clinical Implications

A prolonged myocardial ischemia, which results from a total deprivation of blood supply to an area of cardiac muscle for an appreciable period of time, is the leading mechanism responsible for acute myocardial infarction (AMI). The irreversible injury of myocardiocytes and the subsequent release of a variety of intracellular components into blood is the cornerstone of the diagnosis of AMI. Cardiac troponins are advocated as the biochemical gold standards among the various biomarkers of plaque instability, plaque rupture, ischemia, reversible cellular injury, and early and late necrosis (i.e., irreversible injury). The assessment of cardiac troponins in the diagnostic approach of patients with chest pain presents, however, some specific challenges due to the complex mechanisms of release from the injured myocardium, as well as to the enzymatic degradation by cardiac and extracardiac proteases (i.e., calpains, caspases, cathepsin L, and gelatinase A) that might alter the immunoreactivity (and thus laboratory detection) of the molecules. These two aspects will be discussed in this article, with specific focus on cardiac troponin I, as a variety of immunoassays based on antibodies which recognize different epitopes on the molecule is available for the measurement of this important cardiac biomarker.

Diagnostic approach of patients with longitudinally extensive transverse myelitis

The aim of this study is to present a diagnostic and therapeutic approach in patients with LETM. In a period between June 2008 and June 2010, all patients who fulfilled criteria for LETM were included in the study. All patients underwent a standardized protocol of investigations presented in this paper. Ten patients were included (5 male, 5 female, with the age distribution from 24 to 70 years). Four patients were diagnosed with NMO/spatially limited NMO spectrum disorder, three patients were diagnosed with spinal cord ADEM, two multiple sclerosis (MS) and one patient with copper deficiency myelopathy. Laboratory support for the diagnosis of NMO was positive NMO-IgG antibody; for the diagnosis of ADEM signs of peripheral nervous system involvement on electromyoneurography; and for the diagnosis of MS brain MRI lesions typical for MS, as well as positive oligoclonal bands (OCB) in the cerebrospinal fluid (CSF). All cases with inflammatory myelopathy were treated either with steroids or plasma exchange and copper replacement was started in the case of copper deficiency. The mean time from the first symptom until the final diagnosis was 16.3 months (range 1 month to 7 years). As each of idiopathic inflammatory demyelinating diseases that can present with LETM have specific therapy, the postponement in making the correct diagnosis can lead to a poor recovery. In patients with LETM, a standardized diagnostic approach can result in a correct diagnosis and appropriate treatment.

Comparison of conventional and highly-sensitive troponin I measurement in ultra-marathon runners

Cardiac troponins are a mainstay in the diagnostic approach of patients with suspected acute coronary syndrome. Along with other causes of cardiac injury, strenuous aerobic exercise is an important source of troponin leakage from myocardium. Due to recent immunoassays development, there is no information on variation of highly-sensitive (HS) troponin I (TnI) in ultra-marathon runners. We studied 15 healthy trained Caucasian athletes before and immediately after completion of a 60km, ultra-marathon. TnI was measured with both the conventional AccuTnI and the novel HS-AccuTnI immunoassays. At the end of the ultra-marathon the concentration of HS-AccuTnI significantly increased from the baseline value (19.2±4.2 vs. 5.2±0.8ng/l; P=0.001). The number of athletes displaying HS-AccuTnI values exceeding the 99th percentile of the reference limit was 2 (13%) pre-exercise, increasing significantly to 12 (80%; P<0.001) post-exercise. Measurable value of AccuTnI were found in 1 (7%) and 12 (80%; P<0.001) athletes pre- and post exercise, respectively. All AccuTnI values were below the 99th percentile reference limit pre-exercise, whereas this cut-off was overcome in 20% of athletes, post-exercise. These results suggest that the myocardium release of TnI during strenuous aerobic exercise mirrors that of troponin T. Moreover, the improved sensitivity of the HS-AccuTnI over the conventional assay makes it more suited for detecting even minor elevations of TnI in blood.

Medical and Surgical Evaluation and Treatment of Adrenal Incidentalomas

Adrenal incidentalomas are detected in approximately 4% of patients undergoing high-resolution abdominal imaging studies. The majority of adrenal incidentalomas are benign, but careful evaluation of all patients is warranted to be certain that primary adrenocortical carcinoma and functional adenomas are not missed. The diagnostic approach in patients with adrenal incidentalomas should focus on two main questions: whether the lesion is malignant, and whether it is hormonally active. Radiological evaluation including noncontrast and contrast computed tomography attenuation values expressed in Hounsfield units is the best tool to differentiate between benign and malignant adrenal masses. All adrenal tumors with suspicious radiological findings, most functional tumors, and all tumors more than 4 cm in size that lack characteristic benign imaging features should be surgically excised. All patients should undergo hormonal evaluation for subclinical Cushing's syndrome and pheochromocytoma, and those with hypertension should also be evaluated for hyperaldosteronism. Combined 1-mg dexamethasone suppression test, plasma metanephrines, and aldosterone/plasma renin activity measurements (if hypertensive) are reasonable initial hormonal evaluations. Annual biochemical follow-up of most patients with adrenal incidentalomas, especially if the tumor is more than 3 cm in size, for up to 5 yr may be reasonable. Patients with adrenal masses less than 4 cm in size and a noncontrast attenuation value of more than 10 Hounsfield units should have a repeat computed tomography study in 3-6 months and then yearly for 2 yr. Adrenal tumors with indeterminate radiological features that grow to at least 0.8 cm over 3-12 months may be considered for surgical resection.

Do negative CCT and CSF findings exclude a subarachnoid haemorrhage? A retrospective analysis of 220 patients with subarachnoid haemorrhage

Subarachnoid haemorrhage (SAH) constitutes a neurological emergency. In most cases, the diagnosis is easy to establish; however, in rare cases, verification of the diagnosis is difficult. In this retrospective analysis, we report the clinical characteristics of patients with SAH who were admitted to our neurological intensive care unit. We focus on the additional diagnostic approaches in patients with a high suspicion of SAH but failure of the 'classic' diagnostic tools. A retrospective chart review was performed for all patients in whom SAH was diagnosed between 1996 and 2008. Two hundred and twenty patients were analysed for presenting symptoms, radiological and laboratory findings, hospital course and outcome. A total of 220 patients were identified (mean age 50.5 years, 127 women). In 217 patients, the diagnosis was based upon cerebral computed tomography (CCT) or lumbar puncture. In three patients, the diagnostic work-up was continued because of distinct clinical signs even though CCT and cerebrospinal fluid (CSF) were negative for SAH. In these patients, vasospasm was detected by transcranial doppler sonography (TCD) and/or diagnosis of aneurysm was confirmed by conventional angiography. Subarachnoid haemorrhage with negative CCT and CSF is a rare presentation of a severe acute neurological emergency. Further diagnostic as TCD/computed tomography (CT)-A or MR-A should be considered in all patients with typical clinical presentation for SAH but unremarkable CCT and CSF as an additional diagnostic tool. Ultimately, a conventional angiography should be performed if distinct clinical signs of SAH are presented.

POLG1-Related and other “Mitochondrial Parkinsonisms”: an Overview

Mitochondrial dysfunction has been implicated in the pathogenesis of sporadic, idiopathic Parkinson disease. In some cases, mitochondrial DNA primary genetic abnormalities, or more commonly, secondary rearrangements due to polymerase gamma (POLG1) gene mutation, can directly cause parkinsonism. The case of a Parkinson disease patient with some signs or symptoms suggestive of mitochondrial disease (i.e., ptosis, myopathy, neuropathy) is a relatively common event in the neurological practice. Mitochondrial parkinsonisms do not have distinctive features allowing an immediate diagnosis, and a negative family history does not rule out a possible diagnosis of mitochondrial disorder. In this article, we do not revise the mitochondrial hypothesis of sporadic, idiopathic Parkinson disease, extensively discussed elsewhere, but we review POLG1-related parkinsonism and other well-defined forms of "mitochondrial parkinsonisms", with mtDNA mutations or rearrangements. Lastly, we try to introduce a possible diagnostic approach for patients with parkinsonism and suspected mitochondrial disorder.

The measurement of cardiac troponins in patients undergoing major orthopaedic surgery

We read with interest the article of Talsnes et al. who concluded that laboratory analyses on cardiospecific troponins, namely, troponin T, provide useful information on the risk of fatal outcome in elderly patients undergoing hip fracture surgery [1]. The development and introduction into routine laboratory practice of assays for measuring cardiospecific troponins has revolutionised the diagnostic approach of patients with chest pain and suspected acute coronary syndrome (ACS). The recent advent of high-sensitivity assays has further increased the diagnostic efficiency of these markers, allowing identification of cardiac and extra-cardiac conditions where troponin value is measurable in the absence of a clear ischemic myocardial injury (e.g., severe arrhythmias, heart failure, chemotherapy toxicity, amiloidosis and sarcoidosis, pulmonary embolism, chronic renal failure, sepsis, strenuous physical exercise) [2]. Following the findings of Talsnes and colleagues, it is interesting to express some considerations on the troponin T increases that seem to predict a fatal outcome after hip fracture surgery in the elderly. First, although the main cause of death is not clearly reported, it is conceivable that this might be mainly attributable to either venous thromboembolism or myocardial infarction. In both these clinical conditions, cardiac troponin T values are significantly increased and predict short- and long-term mortality [2, 3]. It is also interesting to analyse the kinetics of the marker, whose increase is modest overall ( 1 μg/mL). As such, these detectable values in blood seem to mirror increased membrane permeability and early troponin release (i.e., “leakage”) from the unbound cytosolic pool rather than an irreversible myocardial injury [4]. This information is highly significant from a pathophysiological standpoint, because it is conceivable that even a minor cardiac lesion occurring immediately after major orthopaedic surgery (which is only detectable by laboratory testing and not by ECG) should guide clinicians to establish early preventive or therapeutic interventions to limit irreversible myocardial damage. This hypothesis is consistent with our previous findings, that NT- brain natriuretic peptide (NT-proBNP) and ischemia modified albumin (IMA) values are significantly increased 72 hours after major orthopaedic surgery, thus reflecting myocardial stress and ischemia, respectively [5]. Whether routine troponin testing after major surgery should be recommended or not, can only be answered by further prospective investigations and cost-effectiveness analyses. At this point in time, however, it seems reasonable to include major orthopaedic surgery among the sources of troponin increase and eventually recommend troubleshooting the cause/s underlying this increase in the individual patient to rule out the presence of myocardial injury or other co-morbidities associated with increased values of troponins in blood.

Chylothorax: diagnostic approach

This review evaluates recent research findings and proposes an up-to-date diagnostic approach for patients with suspected chylothorax. Typically, chylothorax is a milky exudate with high triglyceride content (>110 mg/dl). However, milky appearance is not always the case and triglyceride levels can be less than 110 mg/dl, especially in fasting or malnourished patients. Transudative chylothoraces have been reported when cirrhosis, nephrosis or heart failure co-exist. In addition, although the vast majority of the white blood cells in chyle are lymphocytes, chylothoraces can be neutrophilic, especially the postsurgical ones. Chylothorax is the accumulation of chyle into the pleural cavity usually due to thoracic duct leak and should be suspected not only in patients with milky effusions but also in the presence of certain co-morbidities or history of chest/neck trauma. Fluid triglycerides more than 110 mg/dl or less than 50 mg/dl virtually establish or exclude the diagnosis, respectively; ambiguous cases with values 50-110 mg/dl require lipoprotein analysis for the demonstration of chylomicrons. In fasting or malnourished patients lipoprotein analysis is suggested even with triglycerides less than 50 mg/dl. Typical pleural fluid in chylothorax is a lymphocytic exudate with low lactate dehydrogenase; atypical fluid characteristics (i.e. transudative nature, neutrophil-predominance or high lactate dehydrogenase) may be a sign of additional causes of pleural fluid accumulation.

Transient loss of consciousness: an ongoing challenge

This editorial refers to ‘Epidemiological characteristics and diagnostic approach in patients admitted to the emergency room for transient loss of consciousness: Group for Syncope Study in the Emergency Room (GESINUR) study’ G. Baron-Esquivias et al. , on page 869. Transient loss of consciousness (T-LOC) is a common clinical entity that affects patients and engrosses physicians and national healthcare systems. As a symptom, whether syncopal or non-syncopal, T-LOC may lead to physical injury, while reducing patient's self-confidence because of its sporadic and sometimes unpredictable nature. The elucidation of the mechanism and prognostic significance of T-LOC is a challenge for physicians as opposed to the investigation of other symptoms of cardiovascular origin, like chest pain or dyspnoea. From the financial point of view, increased hospitalization rates and the cost of diagnostic tests that are sometimes overused in search for the real cause often make the management of syncope an expensive procedure. Recently, the European Society of Cardiology (ESC) guidelines1 have made a significant contribution not only to correctly diagnosing T-LOC, but also to defining the risk stratification procedure …

Echocardiographic Evaluation of Cardiac Function in Female Patients with Thyroid Disorders

The aim of this study was to assess echocardiographic changes in female patients with untreated dysfunctional thyroid states and whether the therapy aimed to normalize the thyroid dysfunction could lead to improvement in cardiac systolic and diastolic function. The study included 90 female subjects who performed control of thyroid hormonal status at the Institute of Nuclear Medicine at the University of Sarajevo Clinics Centre and who previously were untreated for the thyroid functional disorders. The study sample was divided in three groups based on the thyroid hormones levels: a) hyperthyroid group (n= 30) b) hypothyroid group (n=30) and c) euthyroid (control). Echocardiography measurements were performed on commercially available Toshiba, SSH 140. Before the therapy no statistically significant differences in the peak early and late mitral inflow velocities (E/A) values between the study groups was observed, but the mean left ventricular ejection fraction (LVEF) in hypothyroid group was significantly lower (58.30+/-1.05) compared to control (64.96+/-0.71) and hyperthyroid group (64.69+/-1.31) (p<0.001). In hypothyroid group we found significant increase in mean LVEF (58.30+/-1.05 vs. 64.95+/-0.86, p<0.01) and E/A (1.06+/-0.07 vs. 1.17+/-0.08; p=0.01) values after the normalization of thyroid hormone status.Thyroid dysfunctional states were not associated with impaired diastolic function, probably due to the short duration of thyroid dysfunction and timely and successful conversion therapy. Systolic function however was significantly reduced in hypothyroid patients but subsequently improved after the adequate therapy. Early diagnostic approach in patients with thyroid dysfunctional states is important for avoidance of cardiac complications that accompany these disorders.

The Present and Future of Cardiac CT in Research and Clinical Practice: Moderated Discussion and Scientific Debate with Representatives from the Four Main Vendors

Noninvasive imaging of the heart using computed tomography (CT) is an increasingly important diagnostic approach for patients with known or suspected coronary artery disease. Coronary CT angiography has recently received great attention because it provides imaging of the coronary arteries and quantification of the coronary plaque burden with a spatial and temporal resolution not available with any other noninvasive imaging test. In this moderated scientific debate we discuss the advantages and disadvantages of different technical solutions to CT imaging of the fast moving heart including its small and tortuous coronary arteries. Our discussion goes into the details of developments regarding larger Z-axis coverage (320-row volume CT, high pitch spiral acquisition), improved temporal resolution (dual-source CT, adaptive multi-segment reconstruction, and shorter gantry rotation times with air-bearing gantries), improved spatial resolution (high-definition detectors), and improved reconstruction algorithms (iterative reconstruction, cone beam reconstruction). The discussion also touches on the future technological developments that will be necessary to further improve the acceptance and widespread clinical use of cardiac CT, focusing on radiation exposure reduction and independence from heart rate. Finally, the representatives of the four main vendors explain the most important research projects regarding cardiac CT that they plan to pursue in the near future.

Epidemiological characteristics and diagnostic approach in patients admitted to the emergency room for transient loss of consciousness: Group for Syncope Study in the Emergency Room (GESINUR) study

To assess the clinical presentation and acute management of patients with transient loss of consciousness (T-LOC) in the emergency department (ED). A multi-centre prospective observational study was carried out in 19 Spanish hospitals over 1 month. The patients included were > or =14 years old and were admitted to the ED because of an episode of T-LOC. Questionnaires and corresponding electrocardiograms (ECGs) were reviewed by a Steering Committee (SC) to unify diagnostic criteria, evaluate adherence to guidelines, and diagnose correctly the ECGs. We included 1419 patients (prevalence, 1.14%). ECG was performed in 1335 patients (94%) in the ED: 498 (37.3%) ECGs were classified as abnormal. The positive diagnostic yield ranged from 0% for the chest X-ray to 12% for the orthostatic test. In the ED, 1217 (86%) patients received a final diagnosis of syncope, whereas the remaining 202 (14%) were diagnosed of non-syncopal transient loss of consciousness (NST-LOC). After final review by the SC, 1080 patients (76%) were diagnosed of syncope, whereas 339 (24%) were diagnosed of NST-LOC (P < 0.001). Syncope was diagnosed correctly in 84% of patients. Only 25% of patients with T-LOC were admitted to hospitals. Adherence to clinical guidelines for syncope management was low; many diagnostic tests were performed with low diagnostic yield. Important differences were observed between syncope diagnoses at the ED and by SC decision.

The significance of catheter diameter in diagnostic peritoneal lavage: a prospective, randomized, controlled clinical trial

BACKGROUND: Diagnostic peritoneal lavage (DPL) is a preferred diagnostic approach for patients with abdominal trauma. The aim of this article is to determine the effect of catheter diameter on procedure time and on the incidence of liquid transfer complications in patients with abdominal trauma. METHODS (Study Design): Sixty-eight patients (49 males, 19 females; age range, 16–82 years; mean age, 32.4 years) with abdominal trauma were prospectively randomized to undergo standard catheter (3 mm) open, wide catheter (5 mm) open, standard semi-open, or wide catheter semi-open DPL. Mean DPL, surgical procedure and liquid transfer time and complication ratio were compared. RESULTS: Total DPL duration was significantly shorter for the wide catheter open technique than for the standard open technique (19 vs. 28.5 min, p < 0.01). Total surgical procedure duration for the wide catheter semi-open technique was also significantly shorter than for the standard semi-open technique (10.25 vs. 18 min, p < 0.01). There were two liquid transfer complications with the wide catheter open method, compared with five for the standard open technique, and one and six, respectively, for the wide catheter semi-open and standard semi-open techniques (p < 0.01). CONCLUSIONS: Increasing the catheter diameter from 3 mm to 5 mm for open and semi-open DPL procedures decreased the total surgical procedure duration and reduced the incidence of liquid transfer-induced complications.

Clinical Features and Diagnostic Approach in Patients with Undervirilised External Male Genitalia

Background. Sex development in humans is a complex and multiple step process. SRY gene on Y chromosome has met the criteria for a testis determining factor, however subsequent stages of differentiation require the expression of several other genes. Male pseudohermaphroditism refers to genetically XY male with differentiated testes and varying degree of undermasculinization of the external genitalia. Aim. Our study aimed at exploring the clinical characteristics, cytogenetic and SRY gene analyses in a group of 14 pediatric patients with male pseudohermaphroditism. Material and Methods. Clinical presentations were: micropenis and/or penoscrotal/perineal hypospadia in 86%, altered appearance of the scrotum in 79% and Mullerian duct remnants in 50% of the patients. Results. Cytogenetic analyses revealed a normal male karyotype in all patients. SRY gene was found positive in all 14 patients. Conclusion. We concluded that SRY gene analysis in patients with male pseudohermaphroditism confirms the clinical diagnosis and directs further investigations. SRY gene analysis is a quick and relatively simple diagnostic method that can be included at the early stage diagnostic of sex differentiation disorders.

Improvable quality of diagnostic assessment of colorectal cancer in southern Netherlands

To determine the extent of guideline implementation of the diagnostic approach in patients with colorectal cancer (CRC) in southern Netherlands in 2005, with special focus on colonoscopy. Data were extracted from the medical records for a random sample of 257 colon and 251 rectal cancer patients newly diagnosed in 2005 and recorded from the Eindhoven Cancer Registry. Adherence to guidelines was determined for diagnostic assessment. Multivariable logistic regression analysis was conducted to assess determinants of complete colonoscopy. Diagnostic assessment was carried out mainly by internists (50%) and gastroenterologists (36%). Colonoscopy was performed in 83% of patients with proximal/transverse colon cancer, 55% of those with distal colon cancer, and 65% of those with rectal cancer. A tumour biopsy was taken for 84% of colon and 93% of rectal tumours. Colonoscopy completeness was lower for patients with comorbidity, obstructing tumours, and patients with poor bowel preparation. Abdominal ultrasound was performed for 72% of colon and 52% of rectal cancer patients and a thoracic radiography of over 80% of CRC patients. Computed tomography (CT) of the abdomen was performed in over half of the colon cancer patients and a pelvic CT scan or magnetic resonance imaging in 36% of rectal cancer patients. Improvements in adherence to diagnostic guidelines for CRC appear possible, especially in the performance of imaging procedures. Among patients where complete visualization of the colon was not feasible with colonoscopy, imaging techniques such as virtual CT might be of added value in the near future.

Diagnostic Accuracy of a New Shortened Peroral Cholangioscope in Indeterminate Biliary Stricures and Filling Defects

Background: Suspicious biliary strictures and filling defects are a diagnostic challenge in endoscopic practice. A new 95 cm shortened peroral cholangioscopy (sPOCS) introduced through the lateral port of the duodenoscope was developed to improve diagnostic approaches in patients with indeterminate biliary strictures or filling defects. Patients and Methods: In the study period from January 2007 to November 2008, 58 consecutive patients (25 men, 33 women; mean age 63 years) were included in this prospective trial. Endoluminal appearance and biopsies were obtained in 40 patients with indeterminate strictures, 18 patients had filling defects. The diagnostic accuracy of sPOCS in visualisation of strictures and tissue sampling was evaluated, therapeutic success was monitored. Results: 40 patients had indeterminate strictures. Using the criteria “circular stenosis” and “irregular surface or margins”, sPOCS correctly described all 16 out of 17 malignant biliary strictures, and correctly described 21 out of 23 benign lesions (sensitivity, 94.1%; specificity, 91.3%). Visually targeted forceps biopsies were performed in 42 patients, i.e. 40 strictures and 2 patients with filling defects. Tissue sampling during sPOCS revealed malignant tissue in 11 of 17 cases (Sensitivity: 64.7%, respectively). In 18 patients with filling defects, 7 patients with bile duct stones were successfully with conventional stone removal. 9 patients with difficult stones (4 giant stones and 5 intrahepatic stones) were treated with visually guided laserlithotrypsy and stone removal. 2 patients had biliary polyps and were surgically resected or received liver transplantation. Conclusion: The new shortened 95 cm sPOCS allows accurate detection of malignant tumors in the biliary tree, and shows improved sensitivity of endoscopically guided forceps biopsies in up to 65%. Filling defects are accurately distinguished. Intrahepatic stones could be reached and successfully treated in all patients investigated.

The upper airway in sleep‐disordered breathing: A clinical prediction model

An examination of the upper airway in patients with suspected sleep disordered breathing (SDB) is recommended prior to nighttime polysomnography (PSG) despite a reported low predictive value of those examinations. The aim of this study was to evaluate the data of the clinical examination and to create a clinical prediction model. Retrospective cohort study. A recently introduced method of dynamic examination of the upper airway during simulated snoring (SS) in awake patients is conducted in patients with suspected SDB. Clinical parameters, body mass index (BMI), and the Epworth sleepiness scale (ESS) scores of 622 patients were included in a clinical prediction model and correlated to the apnea-hypopnea index (AHI). A correlation was detected between the AHI and alterations of the upper airway during SS, BMI, and ESS score. A clinical prediction model including clinical data, BMI, and ESS score revealed a high sensitivity but low specificity predicting the nocturnal AHI: calculated AHI = tonsil size x 2.648 + uvula size x 3.776 + dorsal movement during SS x 2.842 + collapse at tongue base level during SS x 4.769 + BMI x 0.609 + ESS score x 1.177 - 27.685. The dynamic examination of the upper airway during SS in awake patients in combination with clinical data, the BMI, and ESS score is an easy-to-perform screening procedure prior to nighttime PSG and might support the otorhinolaryngologic diagnostic approach in patients with suspected SDB.

Single vessel abdominal arterial disease

The long-standing discussion concerning the mere existence of single vessel abdominal artery disease can be closed: chronic gastrointestinal ischaemia (CGI) due to single vessel abdominal artery stenosis exists, can be treated successfully and in a safe manner. The most common causes of single vessel CGI are the coeliac artery compression syndrome (CACS) in younger patients, and atherosclerotic disease in elderly patients. The clinical symptoms of single vessel CGI patients are postprandial and exercise-related pain, weight loss, and an abdominal bruit. The current diagnostic approach in patients suspected of single vessel CGI is gastrointestinal tonometry combined with radiological visualisation of the abdominal arteries to define possible arterial stenosis. Especially in single vessel abdominal artery stenosis, gastrointestinal tonometry plays a pivotal role in establishing the diagnosis CGI. First-choice treatment of single vessel CGI remains surgical revascularisation, especially in CACS. In elderly or selected patients endovascular stent placement therapy is an acceptable option.

A new diagnostic approach in patients with type 2 macular telangiectasia: confocal reflectance imaging

A new diagnostic approach in patients with type 2 macular telangiectasia: confocal reflectance imaging

Usefulness of 64-slice multidetector computed tomography as an initial diagnostic approach in patients with acute chest pain

Recently, multidetector computed tomography (MDCT) has been proposed as an accurate diagnostic tool to evaluate for coronary artery disease. However, the role of MDCT as part of the initial diagnostic for evaluating acute chest pain is less well established. We prospectively enrolled patients presenting with acute chest pain to the emergency department (ED) and risk stratified them based on the pretest probability for an acute coronary syndrome (ACS): (1) very low, (2) low, (3) intermediate, (4) high, and (5) very high or definite. After exclusion of very low and very high risk patients, 268 patients were randomized to either immediate 64-slice cardiac MDCT or a conventional diagnostic strategy. Number of admissions, ED and hospital length of stay (LOS), and major adverse cardiac events over 30 days of follow-up were compared between the strategies based on the pretest probability for ACS. The number of patients ultimately diagnosed with an ACS did not differ between the 2 strategies. Emergency department LOS and total admissions were not different between strategies. Patients in the MDCT-based strategy had a decreased hospital LOS (P = .049) and fewer admissions deemed unnecessary (P = .007). Reductions in unnecessary admissions were more prominent in intermediate-risk patients (P = .015). None of the patients discharged from the ED in the MDCT-based strategy experienced major adverse cardiac events at follow-up. Use of an MDCT-based strategy in the ED as part of the initial diagnostic approach for patients presenting with acute chest pain is safe and efficiently reduces avoidable admissions in patients with an intermediate pretest probability for ACS.