Diagnostic Investigation Of Patients Research Articles

Hipertensão refratária em paciente jovem: Um relato de caso

Introduction: Pheochromocytoma, a rare tumor originating from the chromaffin tissue of the adrenal medulla, has a prevalence of about 0.1-0.6% in patients with hypertension. Usually benign, its surgical removal can be curative. However, delays in diagnosis and inadequate treatment can lead to high mortality and morbidity rates. Case Report: A 23-year-old man with a history of resistant hypertension since December 2022 presented with symptoms of headache, palpitation, sweating, and anxiety. Tests revealed elevated levels of metanephrines and catecholamines, leading to the suspicion of pheochromocytoma. An MRI of the abdomen identified an expansive lesion in the right adrenal gland. Treatment included clinical management with alpha- and beta-blockers, followed by successful adrenalectomy, resulting in improvement of symptoms and hypertension. Discussion: The case illustrates the complexity inherent in the diagnosis of pheochromocytoma, a condition that often manifests surreptitiously in hypertensive patients. Resistance to conventional antihypertensive therapy, combined with symptoms such as headache, palpitations, and sweating, should raise suspicions of secondary hypertension and, consequently, pheochromocytoma. This case underlines the importance of a meticulous diagnostic evaluation in patients with refractory hypertension. Conclusion: Pheochromocytoma, despite being a rare cause of hypertension, represents a crucial differential diagnosis in secondary hypertension. Early diagnosis and appropriate surgical intervention are essential to prevent associated morbidity and mortality. This case reinforces the need for clinical surveillance for suggestive symptoms and the importance of appropriate diagnostic investigations in patients with resistant hypertension, particularly in young people.

Enhanced differentiation between 3-hydroxyglutaric and 2-hydroxyglutaric acids facilitates diagnostic testing for glutaric aciduria type 1.

Glutaric aciduria type 1 (GA1) is an inherited neurometabolic disorder, in which deficiency of glutaryl-CoA dehydrogenase leads to accumulation of glutaric acid (GA) and 3-hydroxyglutaric acid (3-HG). Some low excretors may exhibit only slight elevation of urinary 3-HG, with normal urinary GA, yet are at significant risk of severe clinical disease. Accurate quantitation of urinary 3-HG is crucial in diagnostic workup for GA1, but in this context, current gas chromatography-mass spectrometry (GC-MS) methods have inherent analytical challenges. Co-elution and spectral similarities of the 3-HG and 2-HG structural isomers can cause difficulties in quantitation of slightly elevated 3-HG. Our laboratory recently acquired a gas chromatography system coupled to a triple quadrupole mass spectrometer (GC-MS/MS), and we took advantage of its increased sensitivity and specificity to improve our existing GC-MS method. A stable isotope dilution process is used, with sample treatment consisting of a double liquid-liquid extraction followed by a trimethylsilyl derivatization. The transitions m/z 349 → 333 for 3-HG and m/z 349 → 321 for 2-HG were selected to differentiate these two isobaric molecules based on their characteristic fragments, thus minimizing interferences despite co-elution. Method validation demonstrated satisfactory precision and accuracy. Using GC-MS/MS instead of GC-MS allowed us to decrease the required specimen volume, number of sample processing steps, chromatographic run time, and instrument maintenance. This enhanced assay facilitates clinical laboratory testing for GA1, both in confirmatory protocols following positive newborn screening and in diagnostic investigation of patients with suggestive signs or symptoms.

Genomic testing for suspected monogenic kidney disease in children and adults: A health economic evaluation

PurposeTo assess the relative cost-effectiveness of genomic testing compared with standard non-genomic diagnostic investigations in patients with suspected monogenic kidney disease from an Australian health care system perspective. MethodsDiagnostic and clinical information was used from a national cohort of 349 participants. Simulation modelling captured diagnostic, health, and economic outcomes during a time horizon from clinical presentation until 3 months post-test results based on the outcome of cost per additional diagnosis and lifetime horizon based on cost per quality-adjusted life-year (QALY) gained. ResultsGenomic testing was Australian dollars (AU$) 1600 more costly per patient and led to an additional 27 diagnoses out of a 100 individuals tested, resulting in an incremental cost-effectiveness ratio of AU$5991 per additional diagnosis. Using a lifetime horizon, genomic testing resulted in an additional cost of AU$438 and 0.04 QALYs gained per individual compared with standard diagnostic investigations, corresponding to an incremental cost-effectiveness ratio of AU$10,823 per QALY gained. Sub-group analyses identified that the results were largely driven by the cost-effectiveness in glomerular diseases. ConclusionBased on established or expected thresholds of cost-effectiveness, our evidence suggests that genomic testing is very likely to be cost saving for individuals with suspected glomerular diseases, whereas no evidence of cost-effectiveness was found for non-glomerular diseases.

WIDEFIELD FLUORESCEIN ANGIOGRAPHY IN THE DIAGNOSIS OF SUSAC SYNDROME.

To present the clinical manifestations and results of key diagnostic investigations in patients with Susac syndrome, with special emphasis on the principal role of fluorescein angiography (FA) of the peripheral retina. A retrospective analysis of medical records (collected 2000-2019) of 20 patients (15 women and five men), aged 20 to 51 years (mean age: 31.6 years) with complete or incomplete Susac syndrome diagnosed by an ophthalmic examination and widefield fluorescein angiography (WF-FA) by Spectralis and Optos Tx200. Fluorescein angiography abnormalities included vascular changes in the posterior pole in 64.7% and in the peripheral retina in 82.4%. Widefield FA abnormalities in the peripheral retina alone were seen in 35.3% and in the posterior pole, but without peripheral vascular involvement, in 17.6%. Secondary leakage from veins was noted in 58.8%. Widefield FA of the peripheral retina has a key role in cases of suspected Susac syndrome as it confirms the diagnosis and assesses disease activity. In addition to the characteristic findings, late-phase FA revealed leakage from veins which is not a typical sign. Patients experiencing migraine headaches may benefit from increasing awareness of neurologists and otologists who more promptly referred patients with suspected Susac syndrome for ophthalmologic evaluation and WF-FA of the peripheral retina.

An observational study on the association of anti-thyroid autoantibodies with clinical, EEG, MRI, FDG-PET, cerebrospinal fluid and anti-neuronal antibody findings in 530 patients with schizophreniform and affective disorders

IntroductionAlthough the link between autoimmune thyroiditis and mental illnesses is well established, the precise underlying pathophysiology and the influence of anti-thyroid antibodies on diagnostic findings require further research. Patients and MethodsA total of 530 patients with schizophreniform and affective syndromes were screened for anti-thyroid antibodies against thyroid peroxidase (TPO), thyroglobulin (TG), and thyroid-stimulating hormone receptor (TSH-R). The patient group analyzed here is a patient subgroup of a previously published cohort (Endres et al., 2020, Translational Psychiatry). The anti-thyroid antibody positive (N = 91) and negative (N = 439) patients were compared in terms of various clinical parameters, routine cerebrospinal fluid (CSF) findings, and the number of positive anti-neuronal antibodies in serum and/or CSF, as well as electroencephalography (EEG), magnetic resonance imaging (MRI), and [18 F]fluorodeoxyglucose positron emission tomography (FDG-PET) findings. ResultsAnti-TPO antibodies were increased in 17%, anti-TG antibodies in 15%, and anti-TSH-R antibodies in 2% of all patients. In CSF, higher protein concentrations (p = 0.018) and albumin quotients (p = 0.008) were found in the anti-thyroid antibody positive patient group. Also, there were more patients with elevated age-corrected albumin quotients in this group (p = 0.031). FDG-PET hypometabolism was significantly more frequent and the number of positive anti-neuronal intracellular antibodies was significantly higher in patients with anti-thyroid antibodies (p = 0.048, N = 29 and p = 0.032, N = 497 respectively). In addition, there was a trend for higher white blood cell (WBC) counts in all patients with anti-thyroid antibodies (p = 0.090). In the patient subgroup with anti-TPO antibodies this difference was statistically significant (p = 0.027). No relevant differences were found in the other CSF routine parameters, the number of anti-neuronal antibodies against cell surface antigens in serum and/or CSF, EEG and MRI findings. DiscussionThe present study provides evidence of impaired blood CSF barrier (BCSFB) function in patients with anti-TPO and anti-TG antibodies. An influence of anti-TG antibodies on BCSFB structures has been shown in previous laboratory studies, which reported that the antibodies bind to vascular smooth muscle cells. Due to BCSFB breakdown anti-thyroid antibodies might lead to increased autoimmune susceptibility. The alterations in the FDG-PET, WBC count, and anti-neuronal antibody findings against intracellular structures indicate that it could be useful to extend diagnostic investigations in patients with anti-thyroid antibodies. Further studies should investigate whether anti-thyroid antibodies can also act as “drivers of disease”.

Cost effectiveness of using Faecal Immunochemical Testing (FIT) as an initial diagnostic investigation for patients with lower gastrointestinal symptoms suggestive of malignancy

BackgroundThere has been an increase in the numbers of patients presenting to primary care with suspected colorectal malignancy and subsequently an increase in demand for endoscopy. This study aims to forecast the cost of faecal immunochemical testing (FIT) compared to conventional diagnostic tests as a primary investigation for patients with symptoms suggestive of colorectal malignancy.MethodsRetrospectively, 1950 patients with symptoms suggestive of colorectal malignancy who were referred through primary care and underwent investigations through standard endoscopic evaluation were included. These patients were used to forecast the cost of faecal immunochemical testing creating theoretical data for sensitivity and specificity. Outcome measures included: the number of investigations under current protocol; cost of current investigations; number of predicted false negatives and false positives and positive/negative predictive values using current sensitivity data for FIT; the cost forecast of using FIT as the primary investigation for colorectal malignancy.ResultsMedian age was 65 (IQR 47–82) with 43.7% male and 56.3% female. A total of 1950 investigations were carried out with a diagnostic yield of 26 cancers (18 colon, 8 rectal), 138 polyps and 29 high risk adenomas (HGD ± > 10 mm). In total, £713,948 was spent on the investigations. The commonest investigation was colonoscopy totalling £533,169. The total cost per cancer diagnosis was £27,459. Sensitivity (92.1% CI 86.9–95.3) and specificity (85.8% CI 78.3–90.1) for FIT in colorectal cancer was taken from NICE and was costed via the manufacturer(s). The projected total cost of FIT for the same population using a ≥ 4 μg haemoglobin cut off was £415,680 (£15,554 per cancer). The total cost of high-risk polyps using ≥ 4 μg cut off was £404,427 (sensitivity 71.2% CI 60.5–87.2, specificity 79.8%CI 76.1–83.7) or £13,945 per polyp.ConclusionsFIT is a cheaper and effective alternative test with the potential to replace current expensive methods. The forecast is based on the limited data available for sensitivity/specificity in the current literature. FIT has now been commenced for symptomatic patients in the UK and therefore sensitivity may change in the future.

RELEVANCE OF DIAGNOSTIC INVESTIGATIONS IN CHRONIC INFLAMMATORY DEMYELINATING POLIRADICULONEUROPATHY: DATA FROM THE ITALIAN CIDP DATABASE.

Background and aims to report the clinical features and the relevance of diagnostic investigations in patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). We retrospectively reviewed data from patients with a clinical diagnosis of CIDP included in a national database. Among the 500 included patients with a clinical diagnosis of CIDP, 437 patients (87%) fulfilled the EFNS/PNS criteria for CIDP (definite in 407, probable in 26, possible in four). In 352 patients (86%) motor nerve conduction abnormalities consistent with demyelination were sufficient for the diagnosis of definite CIDP. In 55 patients this diagnosis required the addition of one or two (from probable or from possible CIDP, respectively) supportive tests, while in 20 cases they improved the diagnosis from possible to probable CIDP, seven patients did not change diagnosis. Considering these 85 patients, CSF studies were performed in 79 cases (93%) upgrading the certainty of diagnosis in 59% of examined patients. Sensory nerve conduction studies were performed in 85% of patients with an improvement of diagnosis in 32% of cases. Nerve biopsy and US/MRI exams resulted positive in about 40% of examined patients, but they were performed in few patients (7 patients and 16 patients, respectively). A response to therapy was present in 84% of treated patients (n=77), contributing to support the diagnosis in 40 patients in whom the other supportive criteria were not sufficient. In most patients with CIDP the diagnosis is possible solely with motor nerve conduction studies while other investigations may help improving the diagnosis in a minority of patients. This article is protected by copyright. All rights reserved.

Role of Ultrasound Scan in Non-Traumatic Acute Abdomen Presenting in Surgery Department of a Tertiary Care Center

Introduction: An acute abdomen is defined as a clinical condition characterized by severe abdominal pain developing suddenly over several hours or less. Ultrasonography (USG) helps the managing surgeons arrive at early diagnosis and rule out alternative diseases, thus reducing negative laparotomy rate. This study analyzed the diagnostic yield of USG in patients with non-traumatic acute abdomen presenting to Surgery department via Emergency department/outpatient department of a tertiary hospital. Methods: This cross-sectional observational study included 110 patients with non-traumatic acute abdominal pain who were sent for USG examination. The percentage concordance of USG diagnosis with the final diagnosis at discharge was determined in terms of sensitivity, specificity, positive and negative predictive values for acute abdomen. Results: Of 110 patients, correct clinical diagnosis was made in 83 patients (75%) while USG made a correct diagnosis in 101 patients (91%). Hence, with the help of USG, accuracy of diagnosing cause of acute abdomen increased by 16 %. The sensitivity and specificity of USG in diagnosis of acute appendicitis were 87.7% and 98.3% respectively. Conclusion: USG is easily available and non-invasive modality without radiation exposure and requiring minimal patient preparation. USG should, therefore, be an important routine diagnostic investigation in patients presenting with acute abdomen.

Assessment of mitochondrial respiratory chain enzymes in cells and tissues.

Measurement of the individual enzymes involved in mitochondrial oxidative phosphorylation (OXPHOS) forms a key part of diagnostic investigations in patients with suspected mitochondrial disease, and can provide crucial information on mitochondrial OXPHOS function in a variety of cells and tissues that are applicable to many research investigations. In this chapter, we present methods for analysis of mitochondrial respiratory chain enzymes in cells and tissues based on assays performed in two geographically separate diagnostic referral centers, as part of clinical diagnostic investigations. Techniques for sample preparation from cells and tissues, and spectrophotometric assays for measurement of the activities of OXPHOS complexes I-V, the combined activity of complexes II+III, and the mitochondrial matrix enzyme citrate synthase, are provided. The activities of mitochondrial respiratory chain enzymes are often expressed relative to citrate synthase activity, since these ratios may be more robust in accounting for variability that may arise due to tissue quality, handling and storage, cell growth conditions, or any mitochondrial proliferation that may be present in tissues from patients with mitochondrial disease. Considerations for adaption of these techniques to other cells, tissues, and organisms are presented, as well as comparisons to alternate methods for analysis of respiratory chain function. In this context, a quantitative immunofluorescence protocol is also provided that is suitable for measurement of the amount of multiple respiratory chain complexes in small diagnostic tissue samples. The analysis and interpretation of OXPHOS enzyme activities are then placed in the context of mitochondrial disease tissue pathology and diagnosis.

Investigation of tumefactive demyelination is associated with higher economic burden and more adverse events compared with conventional multiple sclerosis

BackgroundTumefactive demyelinating lesions occur as part of the spectrum of multiple sclerosis (MS), but can be difficult to distinguish from other large cerebral lesions such as neoplasm or abscess. ObjectivesTo estimate the cost associated with diagnostic investigation of patients with tumefactive demyelination (TD), including associated morbidity, and compare this to more typical relapsing-remitting MS. MethodsRetrospective review of medical records of patients seen between 2013 and 2018 in clinics at the Brain and Mind Centre, Sydney, Australia; a center with tertiary referral expertise in MS. ResultsThirty-one patients with TD and 31 patients with MS were compared. The cost of investigating TD was more than 7.5 times higher per patient than MS ($18,300 vs $2418, p < 0.01). More patients in the TD group were admitted to hospital (22/31 versus 10/31) and ICU admissions only occurred in the TD group (10/22 versus 0/10). Brain biopsy was performed only in the TD group (7 patients), which contributed to cost differences and also accounted for differences in adverse outcomes. ConclusionThe cost and morbidity related to investigating TD is higher than in typical MS. Improvements in the diagnosis of TD have the potential to improve health and economic outcomes.

039 Estimating the health and economic burden of investigating tumefactive demyelination compared to conventional multiple sclerosis

IntroductionTumefactive demyelinating lesions, defined as demyelinating lesions &gt; 2cm in diameter, occur most commonly in association with multiple sclerosis (MS), and can pose a diagnostic challenge. The aim of this study was to estimate the cost and morbidity associated with the diagnostic investigation of patients with tumefactive demyelination (TD) compared to patients with conventional relapsing-remitting MS.MethodsRetrospective review of patients seen between 2013–2018 in clinics at the Brain and Mind Centre, Sydney; a centre with tertiary referral expertise in MS. Records were searched for the terms ‘tumefactive’ and ‘pseudotumour’. All patients diagnosed with TD were included and paired with a patient of similar age diagnosed in the same year with MS according to 2010 McDonald criteria.ResultsThere were 31 patients with TD and 31 patients with conventional relapsing remitting MS. The estimated cost of investigating TD was more than 7.5 times higher per patient than in MS ($18,300 AUD vs $2,418 AUD, p&lt;0.001). Brain biopsy was performed in 6/31 TD patients and 0/31 MS patients and was the cause of more adverse outcomes in the TD versus MS group. More patients in the TD group were admitted to hospital (22/31 vs 10/31) and ICU admissions only occurred in the TD group (10/22 vs 0/10).ConclusionThe cost and adverse outcomes associated with investigating TD are higher than in conventional MS. Improvements in the diagnosis of TD have the potential to improve health and economic outcomes.

Cost-effectiveness of second-line diagnostic investigations in patients included in the DANTE trial: a randomized controlled trial of lung cancer screening with low-dose computed tomography.

The aim of this study was to analyze the economic efficiency of second-line diagnostic investigations in patients with undetermined lung nodules. A retrospective review of all surgical cases included in the DANTE trial from 2001 to 2006 for lung cancer screening was performed. Overall, 217 patients and 261 lung nodules were analyzed. The cohort was divided into patients investigated with PET and/or computed tomography (CT)-guided biopsy (PET-CTB protocol; N=100), compared with those assessed with serial low-dose CT scans (standard protocol; N=161). Outpatient's and inpatient's costs were expressed in euros and derived from the Italian National Health Service. Ineffective costs were defined as the cost of procedures that lead to avoidable surgical intervention. The diagnostic accuracy of the two protocols was 91% for the standard (sensitivity 100%, specificity 91%, positive predictive value 26%, and negative predictive value 100%) and 90% for the PET-CTB protocol (sensitivity 98%, specificity 81%, positive predictive value 85%, and negative predictive value 97%). Average costs for outpatient's diagnostics were 694 and 1.462 euros, respectively, for the standard and PET-CTB protocol. Average inpatient's costs for both protocols were 12.121 euros. The two protocols showed comparable effectiveness in terms of outpatient's costs (94 and 90%, respectively; P=0.252). Inpatient's costs were effective in 36% of cases monitored according to the standard protocol compared with 85% of patients investigated with PET-CTB protocol. Ineffective costs corresponded to 64 and 15%, respectively (P<0.0001). Despite a higher average cost for outpatient's diagnostics, the implementation of PET imaging with or without CT-guided needle biopsy in the workup of suspicious lung nodules results in reduced unnecessary harm and costs related to inpatient's procedures.

Usefulness of multiple electrode aggregometry as a screening tool for bleeding disorders in a pediatric hospital

Platelet function testing is a cornerstone in the diagnostic investigation of patients with a bleeding history. Multiple electrode aggregometry (MEA) has been shown to detect von Willebrand disease (VWD), platelet function disorders, and drug-induced bleeding disorders. However, there are few studies supporting its successful use in children. We have implemented and used MEA over 3 years in our hemostasis laboratory in order to study its usefulness to supplement and expedite diagnosis. This is a retrospective, single-center, cohort study of 109 hospitalized children who underwent a laboratory investigation of hemostasis and either had a reported bleeding history or an abnormal bleeding episode. Plasmatic coagulation testing, blood counts, plasmatic von Willebrand testing, platelet function analyzer (PFA-100), and impedance aggregometry (MEA) were performed in all children. Light transmission aggregometry testing was performed as needed. In 41 cases (37.6%), a working diagnosis was made; a primary hemostatic disorder was detected in 35 children (VWD (n = 16), platelet disorder (n = 15), and valproic acid therapy-induced bleeding disorder (n = 3), acetylsalicylic acid-related bleeding (n = 1). In patients diagnosed with VWD, MEA ristocetin-induced platelet aggregation test (RISTO) high test revealed abnormally low aggregation in six patients (43.8%); whereas in patients diagnosed with a platelet function disorder, abnormally low values were found by MEA in only three children (20%). Three of the four children with laboratory evidence of drug-induced platelet dysfunction had abnormalities on MEA. There were no cases in which an abnormal MEA result was used to make a previously undetermined diagnosis. Retrospectively, MEA has demonstrated limited additional diagnostic value beyond standard laboratory testing for detecting defects of primary hemostasis in children.

Third Ventriculostomy in Late-onset Idiopathic Aqueductal Stenosis Treatment: A Focus on Clinical Presentation and Radiological Diagnosis.

Endoscopic third ventriculostomy (ETV) is considered the gold standard treatment for obstructive hydrocephalus due to partial or complete obstruction of cerebrospinal fluid (CSF) ventricular pathways caused by mass lesions. However long-term efficacy of this procedure remains controversial as treatment of chronic adult hydrocephalus due to stenosis of Sylvian acqueduct [late-onset idiopathic aqueductal stenosis (LIAS)]. The authors describe clinical presentation, diagnostic investigations in patients affected by LIAS, and define their clinical and radiological outcome after ETV. From January 2003 to December 2008, 13 consecutive LIAS patients treated by ETV were retrospectively reviewed. Pre- and post-operative clinical and radiological findings, including conventional and phase-contrast (PC) cine magnetic resonance imaging (MRI) were investigated. ETV was successfully performed in all patients. Patient's neurological condition improved. No one required a second ETV procedure or shunt implantation. Clinical and radiological results reveal a satisfactory outcome of LIAS patients treated by ETV. At follow-up a clinical improvement could be demonstrated in all cases. Selection criteria of LIAS patients seem to be crucial to obtain satisfactory and long-lasting results. Even in elderly patients with chronic hydrocephalus, ETV can be considered the treatment of choice.

Evaluation of Calcium Pyrophosphate Dihydrate Deposition Disease by Ultrasound

Objective: Our aim was to characterize the ultrasonographic features of patients with calcium pyrophosphate dihydrate (CPPD) deposition disease, and compare X-ray and ultrasound in evaluating CPPD deposition disease. Methods: In this retrospective study, all 71 patients between 2004 and 2007 with CPPD deposition disease proved by microscopic synovial fluid analysis were enrolled. We collected and analyzed 38 patients of those, on whom both conventional X-ray and high-resolution ultrasound had been carried out. Results: All patients were elderly (i.e.＞65y/o) and mostly coexisted with osteoarthritis. The involvement of knee joint was the most common site. Popliteal cyst was detected in 9 of 71 patients. Synovial fluid analysis of 38 patients with CPPD deposition disease revealed that the average total white cell count was 25592.1±16697.8/mm^3, with significant neutrophil predominance. There was significant evidence that ultrasound was more reliable than X-ray in the diagnosis of CPPD deposition disease (p=0.002). Besides, there were no patients with CPPD deposition disease in whom X-rays suggested CPPD deposition disease, but for whom ultrasound results were negative. Conclusion: We found that bright stippled foci in the synovial fluid or around the articular region, the thin hyperechoic band parallel to the surface of the hyaline cartilage, and the calcification of fibrocartilage seen on ultrasound could represent CPPD deposits. Our data showed that ultrasound is a useful and important tool in the diagnostic investigation of patients with CPPD deposition disease.

Teflon laryngeal granuloma presenting as laryngeal cancer on combined positron emission tomography and computed tomography scanning

Positron emission tomography with 18F-fluorodeoxyglucose (18FDG) has been increasingly used in the diagnostic investigation of patients with neoplasms of the head and neck. Positron emission tomography and computed tomography have also proven useful for surveillance of thyroid cancers that no longer concentrate radioiodine. However, certain benign or inflammatory lesions can also accumulate 18F-fluorodeoxyglucose and lead to misdiagnosis. We review and discuss the pitfalls of using positron emission tomography and computed tomography for surveillance of thyroid cancer. We present the case of a 48-year-old woman who was diagnosed with a laryngeal neoplasm on integrated positron emission tomography and computed tomography scanning, after a routine ultrasound demonstrated an enlarged thyroid nodule. On physical examination, she had a laryngeal mass overlying an immobile vocal fold. The mass was biopsied and found to harbour a Teflon granuloma. Positron emission tomography positive Teflon granulomas have previously been reported in the nasopharynx and vocal folds, and should be considered in the differential diagnosis of patients who have undergone prior surgery involving Teflon injection. It is important for otolaryngologists and radiologists to recognise potential causes of false positive positron emission tomography and computed tomography findings, including Teflon granulomas.

Preoperative staging of biliary carcinoma using 18F-fluorodeoxyglucose PET: prospective comparison with PET+CT, MDCT and histopathology

The aim of this study was to evaluate the value of positron emission tomography with (18)F-labeled fluorodeoxyglucose (FDG-PET) as a preoperative diagnostic investigation in patients with biliary carcinoma. Seventy-two patients with potentially resectable biliary carcinoma underwent preoperative multidetector-row computed tomography (MDCT) and FDG-PET. Both diagnoses were compared with subsequent histopathology and follow-up results. In 64 lesions with biliary carcinoma, 57 (89%) revealed an intense focal accumulation on FDG-PET and were interpreted as malignant. On the other hand, eight benign lesions did not show any specific accumulation. Detection rate of FDG-PET in the nodular type of the tumour (96% or 27/28) was superior to that of the infiltrating type (74% or 17/23) (p = 0.037). For the evaluation of lymph node metastasis, the overall accuracy was 69% (35/51) in both FDG-PET and MDCT: FDG-PET had a lower sensitivity (33% vs. 57%) and a higher specificity (97% vs. 79%) than MDCT, although the values were not significantly different. FDG-PET revealed all six lesions of distant metastases in six patients including two lesions missed by MDCT. FDG-PET has high detectability of biliary malignancies. Like MDCT, FDG-PET offers only modest accuracy for regional lymph node staging, but it may reveal distant metastases missed by MDCT.

Psychiatric Comorbidity Related to Alcohol Use Among Adolescents

Introduction: Alcohol use is apparently related to high prevalences of psychiatric comorbidity, although scientific studies focusing the problem among adolescents are still lacking. Objective: To evaluate the performance of adolescents with different patterns of alcohol use on screening instruments for psychiatric disorders. Method: Forty-one adolescents seeking assistance for alcohol-related problems were compared to a nonclinical sample of 43 adolescents. These 84 users were divided in three sub-groups according to pattern of recent alcohol intake. All subjects responded to validated versions of screening scales for mental disorders. Comparison of groups was held through Analysis of variance (ANOVA). Results: Self Report Questionnaire (SRQ) aims to evaluate the presence of mental disorders. Heavy users presented significant higher scores than the other groups (p < .05) and half of them presented a psychiatry diagnosis. The same was observed for the CES-D. Using the cut-off, 76.9% of daily-users adolescents were considered depressive. In the Beck Anxiety Inventory the same was observed and 50.0% of those adolescents who drank daily could be considered at risk of presenting anxiety disorders. Conclusion: We detected higher prevalences of mental disorders among heavy alcohol users. This reinforces the importance of detailed diagnostic investigation of patients.

Early surgery of ruptured anterior circulation aneurysm based on multislice helical computerised tomography angiography

The purpose of this study is to evaluate the utility of three-dimensional computed tomographic angiography (3D-CTA) as the primary diagnostic investigation in patients with spontaneous subarachnoid haemorrhage (SAH) from anterior circulation aneurysms, and to correlate the results with digital subtraction angiography (DSA) and intraoperative findings. From May 2005 to May 2007 a total of 38 consecutive patients admitted for SAH, suspicious for ruptured anterior circulation cerebral aneurysm, underwent 3D-CTA. Inclusion criteria were a SAH confirmed by a non-contrast head computed tomographic scan or by lumbar puncture. Exclusion criteria were: previous DSA, severe contrast medium allergy and severe renal failure. All patients underwent early surgical clipping of the aneurysm. The mean time between SAH onset and surgery was 43.6 h (range, 14-74 h). The 3D-CTA was performed in all cases; and in 13 out of 38 patients (34%) represented the only preoperative exam. In all patients that underwent surgery with the sole 3D-CTA, the images collected allowed a good visualisation of the morphology of aneurysms and of the anatomical relationship with the vascular structures. 3D-CTA allows accurate diagnosis with an excellent visualisation of ruptured aneurysms of the anterior circulation. Our results suggest that, in selected cases, ruptured anterior circulation aneurysms could be successfully treated on the basis of 3D-CTA alone.

Computed Tomographic Angiography as the Primary Diagnostic Study in Spontaneous Subarachnoid Hemorrhage

To evaluate the utility of computed tomographic angiography (CTA) as the primary diagnostic investigation in patients with spontaneous subarachnoid hemorrhage (SAH), and to correlate the results with intraoperative findings in those with ruptured aneurysms. A retrospective review of 243 patients with spontaneous SAH was performed. The patients selected were those with acute SAH confirmed by noncontrast head computed tomography or by cerebrospinal fluid findings from a lumbar puncture. Patients subsequently underwent preoperative three-dimensional CTA as the sole or primary diagnostic study. The results of the CTA were correlated with the intraoperative findings in those patients undergoing emergent surgical clipping of acutely ruptured intracranial aneurysms. CTA correctly detected the ruptured aneurysm in 170 of the 171 cases, which required surgical clipping. Our data demonstrates that CTA has a 99.4% detection rate in acutely ruptured aneurysms as compared to intraoperative findings [confidence interval 97.8-99.9%]. CTA can provide prompt and accurate diagnostic and anatomic information in the setting of SAH with an excellent detection rate in acute ruptured aneurysms. These findings suggest an increased role for CTA in the evaluation of cerebral aneurysms.