Initial Test Of Choice Research Articles

Update on the Role of Imaging in the Diagnosis, Staging, and Prognostication of Gallbladder Cancer

AbstractGallbladder cancer (GBC) is a highly aggressive malignancy with dismal prognosis. GBC is characterized by marked geographic predilection. GBC has distinct morphological types that pose unique challenges in diagnosis and differentiation from benign lesions. There are no specific clinical or serological markers of GBC. Imaging plays a key role not only in diagnosis and staging but also in prognostication. Ultrasound (US) is the initial test of choice that allows risk stratification in wall thickening and polypoidal type of gallbladder lesions. US findings guide further investigations and management. Computed tomography (CT) is the test of choice for staging GBC as it allows comprehensive evaluation of the gallbladder lesion, liver involvement, lymph nodes, peritoneum, and other distant sites for potential metastases. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography allow better delineation of the biliary system involvement. Contrast-enhanced US and advanced MRI techniques including diffusion-weighted imaging and dynamic contrast-enhanced MRI are used as problem-solving tools in cases where distinction from benign lesion is challenging at US and CT. Positron emission tomography is also used in selected cases for accurate staging of the disease. In this review, we provide an up-to-date insight into the role of imaging in diagnosis, staging, and prognostication of GBC.

Discordant Care and Decision Quality: Patients' Reasons for Not Receiving Their Initial Test of Choice in Colorectal Cancer Screening.

Concordance between a person's values and the test or treatment they ultimately receive is widely considered to be an essential outcome for good decision quality. There is little research, however, on why patients receive "discordant" care. A large, randomized trial of decision aids for colorectal cancer (CRC) screening provided an opportunity to assess why some patients received a different test than the one they preferred at an earlier time point. Of 688 patients who participated in the trial, 43 received a different CRC screening test than the one they selected after viewing a decision aid 6 mo prior. These patients answered 2 brief, open-ended questions about the reasons for this discordance. The research team analyzed their answers using qualitative description. Patient responses reflected 6 major categories: barriers or risks of initially favored test, benefits of alternative test, costs or health insurance coverage, discussion with family or friends, provider factors or recommendation, and health issues. Some of the patients' explanations fit well with the informed concordance approach, which infers poor decision quality from the existence of discordant care, since in these cases it appears that the patient's values and preferences were not adequately respected. Other statements suggest that the patient had an informed rationale for changing their mind about which test to undergo. These cases may reflect high-quality decision making, despite the existence of discordance as measured in the trial. This analysis highlights a major challenge to a popular approach for assessing decision quality, the difficulty of normatively assessing the quality of decision making when apparent discordant care has been provided, and the need to assess patient values and preference over time. Value-choice concordance is an accepted measure for assessing decision quality in decision aid trials, but greater exploration of apparently discordant care challenges key assumptions of this method; this study provides evidence that discordance as typically measured may not always reflect low-quality patient decision making.Researchers evaluating decision aids and assessing decision quality should consider the use of qualitative methods to supplement measures of decision quality and consider assessing patient preferences at multiple time points.

Protocolo diagnóstico ante la sospecha de feocromocitoma

Pheochromocytomas are rare neuroendocrine tumors that arise from the adrenal medulla cells. When a pheochromocytoma is suspected, the first step is to demonstrate that there is excessive catecholamine production. Among the different available tests for the diagnosis of pheochromocytoma, those with the greatest diagnostic accuaracy are fractionated metanephrines in urine or plasma. If false positives that justify the elevation of metanephrines have been ruled out, the next step is the localization diagnosis, with a CT scan considered the initial test of choice. Nuclear medicine tests are useful for initial tumor staging as well as for detecting lesions not localized by conventional imaging techniques. Once the diagnosis has been confirmed and taking into account that 15% – 40% of pheochromocytomas are hereditary, it is recommended to request a genetic study for all patients, ideally through massive parallel sequencing techniques.

DIAGNOSTIC ACCURACY OF CT CORONARY ANGIOGRAPHY.

Coronary Artery Disease (CAD) is an emerging and commonest type of heart disease resulting in morbidity and mortality globally. Coronary angiography is a diagnostic modality used to diagnose the coronary artery disease or the extent of blockage of coronary arteries. The multi-slice computed tomography (MSCT) technology such as 64-slice, 128-slice, 256-slice, and now 320-slice MSCT has produced a high diagnostic accuracy of CT coronary angiography. This prospective-cross sectional study was done in Department of Cardiology in Medanta, the Medicity, from November 2017 to December 2018 with the aim to evaluate the diagnostic accuracy of 256 slice CT coronary angiogram in measuring the percentage diameter stenosis compared to invasive angiography and to determine the sensitivity and specicity of CT coronary angiography in detection of coronary artery stenosis among symptomatic patients. A total of 60 patients presented with acute or chronic chest pain with risk for CAD were included. The mean age of the participants was 57.35±10.16 years and 88.3% participants were male and 11.7% participants were females. 56.6% participants had BMI >25, 11.7% were alcoholic, 40% were smoker, 16.7% had diabetes and 38.3% had hypertension. The study concluded that CCTA should be considered initial test of choice in patients presenting with chest pain with low to intermediate probability of CAD because the time required for diagnosis is signicantly shorter, high sensitivity, specicity, PPV and NPV on per vessel and per segment basis, determination of LVEF and has the ability to rule out causes of atypical chest pain including pulmonary embolism and aortic dissection.

Venous popliteal entrapment syndrome

Popliteal entrapment syndrome (PES) describes a set of symptoms related to compression of the neurovascular bundle in the popliteal fossa, with popliteal artery involvement the most widely recognized variation. Popliteal vein entrapment is a rare variation which can easily go undiagnosed. This is most commonly due to an anomaly of the medial head of the gastrocnemius muscle, but other etiologies include excess adipose tissue or cysts within the popliteal fossa, popliteal artery aneurysm, fibrous bands, thickened perivenous fascia, compression by the popliteus muscle or muscular hypertrophy independent of anomalous anatomy, or variant origin of the short saphenous vein. However, with improving awareness, it is a condition which should be increasingly considered in patients presenting with unexplained lower extremity swelling or other symptoms of lower extremity thrombosis. The initial test of choice is typically ultrasound with flexion and extension maneuvers. Venography is the gold standard for diagnosis, but MRI offers a noninvasive option for both diagnosis and evaluation of etiology and should be considered in the work-up of popliteal venous entrapment. Management is based on severity and type of symptoms, ranging from conservative management with compression stockings to surgical management if there is popliteal artery involvement or more severe symptoms. Endovascular therapy such as angioplasty or stenting has also been reported with good results.

Spontaneous Internal Pancreatic Fistulae Complicating Acute Pancreatitis.

Spontaneous pancreatic fistula (PF) is a rare but challenging complication of acute pancreatitis (AP). The fistulae could be internal (draining into another viscera or cavity, e.g., pancreaticocolonic, gastric, duodenal, jejunal, ileal, pleural, or bronchial) or external (draining to skin, i.e., pancreaticocutaneous). Internal fistulae constitute the majority of PF and will be discussed in this review. Male sex, alcohol abuse, severe AP, and infected necrosis are the major risk factors for development of internal PF. A high index of suspicion is required to diagnose PF. Broad availability of computed tomography makes it the initial test of choice. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography have higher sensitivity compared with computed tomography scan and also allow for assessment of pancreatic duct for leak or disconnection, which affects treatment approaches. Certain complications of PF including hemorrhage and sepsis could be life-threatening and require urgent intervention. In nonurgent/chronic cases, management of internal PF involves control of sepsis, which requires effective drainage of any residual pancreatic collection/necrosis, sometimes by enlarging the fistula. Decreasing fistula output with somatostatin analogs (in pancreaticopleural fistula) and decreasing intraductal pressure with endoscopic retrograde cholangiopancreatography or endoscopic ultrasound/interventional radiology-guided interventions or surgery are commonly used strategies for management of PF. More than 60% of the internal PF close with medical and nonsurgical interventions. Colonic fistula, medical refractory-PF, or PF associated with disconnected pancreatic duct can require surgical intervention including bowel resection or distal pancreatectomy. In conclusion, AP-induced spontaneous internal PF is a complex complication requiring multidisciplinary care for successful management.

Sinus pericranii: an update illustrated with a large case with long-term follow-up

Sinus pericranii (SP) is a rare venous anomaly consisting of an aberrant communication between the intra- and extra-cranial venous systems forming a venous malformation in the scalp. It is usually defined as midline frontal or parietal fluctuating bluish tumour that increases in size with Valsalva manoeuvre. The gold standard for its diagnosis is digital subtraction angiography, but initial test of choice is magnetic angio-resonance imaging. Although being a benign condition it usually poses aesthetic concerns and fear of complications. This is the reason why, although conservative management is accepted, treatment is usually considered, either endovascular or surgical. We herein review the current management of these rare vascular lesions and illustrate it with a case of a large frontal SP in which surgical excision was decided and performed with an excellent long-term result. We underline the importance of careful haemostasis and multidisciplinary work for the safe management of complex vascular anomalies. Level of evidence: Level V, therapeutic study.

2633 A Challenging Case of Ileo-cecal Intussusception in Pregnancy

INTRODUCTION: Intussusception is an extremely rare cause of intestinal obstruction in adults; being reported in up to 1% of cases of obstruction and in contrast to children almost always is secondary to an identifiable lesion forming a lead point. Its incidence is even lower in pregnancy with studies reporting incidence rates ranging from 0.067% to 0.0015%. Rarity of the condition combined with non-specific clinical presentation make diagnosis difficult in adults. This is particularly challenging in pregnant patients due to the overlap of symptoms with pregnancy and limited findings on abdominal examination. High morbidity and mortality for both mother and child warrant prompt investigation and surgery. CASE DESCRIPTION/METHODS: We describe the case of a 39-year-old female who presented in the third trimester with abdominal pain and an episode of hematochezia. Ultrasound findings were suggestive of ileo-colic intussusception that was confirmed with subsequent magnetic resonance imaging. The lead point was formed by an adenocarcinoma of the colon measuring 4 cm. Our patient underwent a right-sided colectomy with primary ileocolostomy. The postoperative course was uneventful for both mother and fetus, and the patient was discharged a week after the surgery. DISCUSSION: Intussusception very rarely presents during pregnancy. Ultrasonography of the abdomen is the initial test of choice in most cases and the findings of single or double anechoic rings surrounding a central echogenic focus is the classic hallmark. CT scanning is considered to be superior in adults with a reported diagnostic yield of over 50%. MRI, however, is the preferred imaging modality in pregnancy as it helps avoid the risk of radiation to the fetus and has comparable sensitivity to CT. Most cases are diagnosed by exploratory laparotomy which itself is associated with a high risk of miscarriage and pre-term birth, with some studies reporting miscarriage rates as high as 8%. Adults almost always require surgery as untreated bowel obstruction carries a maternal mortality of up to 6% and fetal mortality as high as 26%. Surgical reduction of intussusception can be tried but most patients require bowel resection, which is also the procedure of choice if a mass is identified at the leading point. Nearly 50% of these masses will be malignant. This report highlights the importance of abdominal imaging and urgent intervention in suspected cases of intussusception in pregnancy.

Outcomes and Predictors of Readmissions with GI Bleeding in Patients with Left Ventricular Assist Devices.

Gastrointestinal (GI) bleeding is a major comorbidity in patients with left ventricular assist devices (LVADs). The study aim was to estimate the rate of hospital readmissions for GI bleeding in patients with LVADs using a nationally representative database. Additionally, we evaluated the etiologies, costs, endoscopy utilization, mortality, and predictors of GI bleeding readmissions in these patients. We analyzed data from the National Readmissions Database (NRD) from 2010 through 2014. We compared hospitalized adult patients with congestive heart failure (CHF) who underwent LVAD implantation (cases) with CHF patients without LVAD or heart transplant (controls). Three age- and sex-matched controls were randomly selected per single case. A multivariate Cox regression model was used to compare the hazards of 60-day all-cause and GI bleeding readmission between the groups, controlling for significant confounders. A total of 3293 hospitalized patients with CHF who had LVAD placement (cases) and 9879 who did not have LVADs (controls) were included in the study. At 60 days, patients with LVAD had a significantly higher readmission rate with GI bleeding (8.7% vs 2.3%, adjusted hazard ratio [aHR] 4.45, 95% confidence interval 3.71-5.33, P < 0.0001). The all-cause readmission rate also was higher (43.3% vs 35.7%, aHR 1.23, 95% confidence interval 1.12-1.34, P < 0.0001). The most common etiologies of bleeding in patients with LVADs were gastroduodenal and small intestinal arteriovenous malformations (28.6%). During bleeding readmissions, patients with LVAD were more likely to undergo endoscopy (72.1% vs 33.5%, P < 0.0001) and receive packed red blood cell transfusions (62% vs 36.6%, P< 0.0001) compared with controls. GI bleeding readmissions were more costly ($40,936 vs $35,313, P< 0.0001), and longer (12 vs 10.9 days, P< 0.0001) in patients with LVADs compared with controls. Independent risk factors for 60-day GI bleeding readmission were increasing age (aHR 1.04, P< 0.0001) and GI bleeding during index admission (aHR 2.68, P< 0.0001). In those without bleeding during index admission, increasing age and chronic anemia were associated with 60-day GI bleeding readmission. Mortality during bleeding readmission was similarly low in patients with LVADs compared with CHF controls (0.2% vs 0.3%, P = 0.14). After LVAD implantation, there is a fivefold increased risk of readmission with GI bleeding within 60 days. Gastroduodenal and small intestinal arteriovenous malformations are the most common culprit lesions. These findings suggest that small bowel enteroscopy should be considered as the initial test of choice in patients with suspected upper gastroduodenal bleeding. Readmissions with bleeding in patients with LVADs increase morbidity and cost of care but not mortality. Older patients and those with a history of bleeding during LVAD implantation are at higher risk of bleeding readmission and may benefit from close monitoring and cautious anticoagulation to prevent rebleeding.

False-Positive Monospot in a Returning Traveler with Dengue Fever

The heterophile antibody (Monospot), initial test of choice for Epstein-Barr virus (EBV)-associated infectious mononucleosis, is both sensitive (70-92%) and specific (96-100%). False positives have been demonstrated in cases of viral hepatitis, human immunodeficiency virus, leukemia, lymphoma, pancreatic cancer, systemic lupus erythematosus, and rubella. We present a case of a 46-yr-old male who developed fever, chills, headaches, myalgia, fatigue, and photophobia 1 d after returning from the Philippines. He demonstrated a mild transaminitis and significant thrombocytopenia (12,000 cells/μL). His initial evaluation revealed a positive heterophile antibody test. Without a classic EBV presentation, a fever in returning traveler evaluation was instituted resulting in a positive dengue test by direct fluorescence IgM (8.82 IU) and IgG (7.13 IU), respectively. Both his EBV DNA polymerase chain reaction and IgM by viral capsid antigen were negative. Dengue, an RNA flavivirus, and the dengue antibody have demonstrated cross-reactivity with other flaviviruses including Japanese encephalitis virus, yellow fever virus, West Nile virus, and St. Louis encephalitis. However, EBV is a double-helix DNA herpesvirus and structurally very different. To our knowledge, this is the first reported case of cross-reactivity between dengue and EBV that describes a potential false positive for the heterophile antibody test.

ECG Diagnosis: Apical Hypertrophic Cardiomyopathy

Joel T Levis, MD, PhD, FACEP, FAAEM Perm J 2013 Spring; 17(2):84 http://dx.doi.org/10.7812/TPP/12-089 Apical hypertrophic cardiomyopathy (HCM) is an atypical phenotype of nonobstructive HCM with an indistinguishable histology.1 In Japan this apical varia

The End of X‐rays for Suspected Small Bowel Obstruction? Using Evidence‐based Diagnostics to Inform Best Practices in Emergency Medicine

The End of X‐rays for Suspected Small Bowel Obstruction? Using Evidence‐based Diagnostics to Inform Best Practices in Emergency Medicine

The role of Endoscopic Ultrasound (EUS) in the management of patients with pancreatic cancer: now bigger than ever.

In this issue of the Journal of Gastrointestinal Oncology De Angelis et al. provide a comprehensive review of the role of endoscopic ultrasound (EUS) in the management of pancreatic cancer. At present the two main established roles of EUS are imaging and tissue acquisition. In addition some EUS-guided therapieshave gained limited but expanding role in pancreatic cancer patients. As correctly pointed by the authors, the role of standard EUS imaging for diagnosis and staging has decreased with the advent of dynamic contrast enhanced multi-detector row computed tomography (MDCT). Nevertheless, contrary to the prevailing perceptions both EUS and MDCT are operator dependent and significant variability of image quality and interpretations exist with MDCT. Furthermore, EUS remains superior imaging modality to detect small pancreatic lesions, mural nodules within a cyst, small lymph nodes and coexisting biliary pathology. We concur with the authors that inmost patients EUS and MDCT should be considered complimentary rather than competing imaging modalities for the evaluation of patients with suspected pancreatic lesions with MDCT been the initial test in most patients. Anotable exception is the screening of populations at high risk for pancreatic cancer where the recent International Cancer of the Pancreas Screening (CAPS) Consortium summit endorsed EUS as the initial test of choice (1,2). EUS is also preferably used for serial surveillance of premalignant pancreatic lesions [e.g., Intraductal papillary mucinous neoplasm (IPMN)] without the radiation exposure associated with MDCT (3). The addition of contrast-enhanced EUS and elastography may expand the utility of EUS imaging for solid pancreatic masses but their role is yet to be determined (4,5). Furthermore, early data on EUS-guided needle based confocal laser endomicroscopy (nCLE) have shown promising results in the evaluation of pancreatic cysts (6,7). On the contrary, EUS with fine needle aspiration (EUS-FNA) has refused to share the scene with other sampling modalities and has become the preferred method for tissue acquisition in patients with pancreatic lesions. EUS may not be necessary in all pancreatic cancer cases but pretreatment pathological diagnosis is essential in most patients with both resectable and advanced disease. Recently the role of EUS sampling has expanded further with the introduction of a new needle with core trap that can provide histologic samples also refereed as fine needle biopsy (EUS-FNB) (8). This is an exciting development because EUS-FNB can facilitate accurate tissue diagnosis in situations where FNA cytology has been known to be inadequate (e.g., autoimmune pancreatitis, lymphoma) but also can provide assessment for tumor vascular and lymphatic invasion. Furthermore, in the forceable future treatment decisions and patient prognosis most likely will be based on molecular markers and EUS appears to be the ideal tool to gather adequate tissue for analysis (9). EUS has also has expanded its role in selected patients with pancreatic cancer as a valuable therapeutic tool. At present, EUS-guided fiducial placement is now routinely done to facilitate image guided radiation therapy (10), EUS-guided celiac plexus neurolysis can greatly facilitate the management of pancreatic cancer pain (11), and EUS-guided biliary drainage is a viable alternative to percutaneous drainage in patient that had failed endoscopic retrograde cholangiopancreatography (ERCP) or in patients with altered gastric anatomy (12). Importantly, in the future EUS most likely will play an important role in delivering novel local antitumor therapy. Ethanol ablation for selected small mucinous cyst has shown promising results and EUS fine needle injection (EUS-FNI) of various viral and biologic therapies has undergone preliminary evaluation (13). In conclusion, despitestiff competition from other imaging modalities standard EUS imaging remains a valuable tool. Contrast-enhanced EUS, EUS elastography and needle based confocal endomicroscopy may further expand the utility of EUS imaging but their exact role is yet to be determined. EUS-FNA is currently the preferred modality for tissue acquisition in patients with pancreatic lesions and the advent of FNB may further solidify this essential role. The therapeutic role of EUS has expanded and ranges from primary in the case of fiducial deployment to fall back strategy in the case of EUS-guided biliary drainage. In the forceable future, EUS-FNI most likely will play a central role for delivery of novel targeted antitumor medications but for now its role is limited to palliative celiac plexus neurolysis.

Assessing the implications of implementing the NICE guideline 95 for evaluation of stable chest pain of recent onset: a single centre experience

Prompt and accurate assessment of patients with chest pain likely of cardiac origin (of recent onset) is important and requires excellent coordination between the specialist cardiology services with general/emergency medicine and primary care physicians. The presence of clear guidelines helps streamline this process for all stakeholders, to meet the requirements set out in with the National Service Framework for managing coronary artery disease (CAD). However, the new guidance offered by NICE guideline 95 (March 2010)(1) for evaluation of patients in England and Wales with chest pain of recent onset, represent several major changes to its former guideline (NICE TA 73), and the Scottish Intercollegiate Guidelines Network (SIGN) guideline 96 (2007, which is based on recommendations from European Society of Cardiology(2)) currently guiding the management of such patient in Scotland. This is likely to cause confusion and lack of uniformity in assessing patients across the United Kingdom. We evaluated what change of practices and services that may be necessary, if the recommendations of this NICE guideline 95 were accommodated or adopted by SIGN, in a Rapid Access Chest Pain Clinic (RACPC) setting in a medium sized teaching hospital in Scotland, United Kingdom. All patients (n = 96) evaluated with chest pain of recent onset in the RACPC at Ninewells Hospital for two consecutive calendar months (January, February 2010, i.e. immediately prior to issue of the NICE guideline 95) were included in this analysis. The study design was retrospective review of case notes. The investigations currently offered and their outcomes were recorded and contrasted with outcomes if the new NICE guidelines were adopted, based on the NICE guidance to calculate Pre-test likelihood of presence of significant coronary artery disease. If the NICE guidance on chest pain of recent onset had been implemented in our study population, a significant change in the offer of specialist cardiac investigations may have been required at the initial clinical assessment. This includes a 42.7% increase in offer of invasive coronary angiography, 24.0% increase in functional imaging, 8.3% increase in CT calcium scoring as the initial test of choice, in lieu of a 74.1% reduction of offer of exercise tolerance tests. If the NICE guidance on chest pain of recent onset had been implemented in our study population, the need for change of the offer of specific first line tests (as discussed above) means that, a major re-organisation in both the services in RACPCs and the current process of referral to these specialists cardiac services from the primary care physicians will be required. Whilst acknowledging that regional variations may exist in the proportions of tests needed (depending on the incidence and prevalence of CAD and risk factors), these figures from our study represent a much higher level of need of these specialist tests for patients attending RACPCs than initially suggested by contemporary reviews. We therefore conclude that data from larger studies in many regions may be useful for understanding the degree of regional and national changes required for organising the structure and referrals to specialist cardiac services in Scotland, if an equitable service based on NICE guidance 95 is rolled out throughout United Kingdom in future.

Pitfalls in the Diagnosis of Vitamin B12 Deficiency

Vitamin B12 deficiency is a well-described disorder with a spectrum of manifestations ranging from macrocytic anemia to neuropsychiatric disorders including depression, dementia, and subacute combined degeneration of the spinal cord. Lack of vitamin B12 arises from insufficient intake or malabsorption. In clinical practice, serum total cobalamin (Cbl) levels are the initial test of choice for detecting B12 deficiency as they are widely available and cost-effective. However, this test is limited in specificity and sensitivity, missing many patients within the laboratory “gray zone” of deficiency. Measurements of serum methylmalonic acid (MMA) and homocysteine (Hcy) levels, which accumulate in B12 deficiency, become useful when Cbl levels are equivocal but clinical suspicion remains high. Early vitamin B12 replacement is important in preventing potentially irreversible neurologic damage. We report a case of a 75 year-old man presenting with symptomatic anemia, neuropsychiatric findings, and repeatedly normal serum cobalamin levels, eventually diagnosed with vitamin B12 deficiency due to pernicious anemia. This case highlights the potential difficulty in establishing this common diagnosis due to false-negative Cbl assay results. Given its high prevalence, vitamin B12 deficiency must be included in the differential diagnosis of patients with progressive neuropsychiatric findings and/or hematologic derangements as rapid diagnosis and supplementation may prevent permanent complications.

Diagnosis of Subarachnoid Hemorrhage

See related articles, p 2115 . Although the most concerning diagnosis in patients presenting with thunderclap headache (abrupt onset of a severe unusual headache) is nontraumatic subarachnoid hemorrhage (SAH), only 8% to 12% of neurologically intact patients with thunderclap headache will have SAH; most have benign causes.1 Of those with aneurysmal SAH, 40% to 50% of patients will present neurologically intact. Therefore, diagnostic testing beyond history and physical examination is necessary. The initial test of choice is a noncontrast CT scan of the brain. Although CT is an excellent test for SAH, its sensitivity is both a function of timing from the onset of the headache as well as severity of the hemorrhage.1 CT sensitivity is extremely high early but rapidly diminishes with time. Clinicians frequently encounter neurologically normal patients with a thunderclap headache and a negative CT scan. Even using third-generation scanners, CT by itself is insufficient to exclude SAH.2 Therefore, guidelines recommend that a lumbar puncture (LP) be performed in these patients whose CT scans are negative or nondiagnostic.3,4 Although LP is a relatively benign test, it adds time, patient discomfort, and, sometimes, diagnostic ambiguity from a traumatic tap. Prior studies of CT sensitivity do not adequately account for the issue of timing in the earliest hours after the hemorrhage. In this issue of Stroke , Backes et al5 present data suggesting that CT scan is 100% sensitive for SAH if performed within 6 hours of the headache onset and apart from 2 caveats, the authors recommend …

Detection of fetomaternal hemorrhage

The prevention of Rhesus D alloimmunization through Rh immune globulin (RhIg) administration is the major indication for the accurate detection and quantification of fetomaternal hemorrhage (FMH). In the setting of D incompatibility, D-positive fetal cells can sensitize the D-negative mother, resulting in maternal anti-D alloantibody production. These anti-D alloantibodies may lead to undesirable sequelae such as hemolytic disease of the newborn (HDN). Since the widespread adoption of FMH screening and RhIg immunoprophylaxis, the overall risk of Rh alloimmunization and infant mortality from HDN has substantially decreased. The rosette screen, the initial test of choice, is highly sensitive in qualitatively detecting 10 mL of fetal whole blood in the maternal circulation. As the screen is reliant on the presence of the D antigen to distinguish fetal from maternal cells, it cannot be used to detect FMH in D-positive mothers or in D-negative mothers carrying a D-negative fetus. The Kleihauer-Betke acid-elution test, the most widely used confirmatory test for quantifying FMH, relies on the principle that fetal RBCs contain mostly fetal hemoglobin (HbF), which is resistant to acid-elution whereas adult hemoglobin is acid-sensitive. Although the Kleihauer-Betke test is inexpensive and requires no special equipment, it lacks standardization and precision, and may not be accurate in conditions with elevated F-cells. Anti-HbF flow cytometry is a promising alternative, although its use is limited by equipment and staffing costs. Hematology analyzers with flow cytometry capabilities may be adapted for fetal cell detection, thus giving clinical laboratories a potentially attractive automated alternative for quantifying FMH.

An Interesting Case of Chronic Idiopathic Non-cirrhotic Portal Vein Thrombosis

Purpose: Introduction: Portal vein thrombosis was first reported in 1868 by Balfour and Stewart. It is a rare condition that typically presents in non-cirrhotic patients. Inherited (Factor V Leiden and Prothrombin gene mutation G201210A, Protein C, S, Anti thrombin III deficiency) and acquired thrombophilias (Lupus Anticoagulant, myeloproliferative diseases, malignancy, surgery and trauma) account for majority of the cases of portal vein thrombosis. Doppler ultrasound studies are usually the initial test of choice. Case Report: 63 year old Hispanic Female with history of hypertension, Diabetes Mellitus, coronary artery disease presented with complaints of epigastric pain & bloody vomiting. She initially had epigastric discomfort & 2 episodes of hematemesis. She denied alcohol use. Abdominal examination was unremarkable except for mild epigastric tenderness. Laboratory analysis revealed hemoglobin of 10.5 mg/dl with normal liver function tests and aminotransferases. An upper gastrointestinal endoscopic examination was done which revealed grade 4 esophageal varices with fresh blood in the distal esophagus which were subsequently ligated. She was started on octreotide and propranolol. She had another episode of GI bleed requiring emergent endoscopic intervention. She underwent a liver biopsy. Pathology revealed focal mild portal fibrosis with mild micro & macro vesicular steatosis but no cirrhosis. A Doppler Ultrasound revealed portal vein thrombosis and concomitant portal hypertension. An extensive hypercoaguable work up was done which included protein C & S levels, anti thrombin III, Prothrombin gene mutation G20210A, Factor V Leiden, Lupus anticoagulant, Anticardiolipin antibodies, Homocysteine level & they were all negative. We also tested her blood for flow-cytometry for CD 55 and CD 59 but the test was normal and in the process effectively ruled out paroxysmal nocturnal hemoglobinuria. She also was also tested for the JAK 2 mutation. It was negative. We gave her the clinical diagnosis of chronic idiopathic non-cirrhotic portal vein thrombosis. She subsequently had a meso-caval shunt done to relieve the portal hypertension. She was started on warfarin anticoagulation 3 days later with close monitoring for bleeding. She clinically got better and was then discharged home. Discussion: Non-cirrhotic portal vein thrombosis can be acute or chronic. Acute cases need at least 3 months of anticoagulation. Chronic cases needs porto-systemic shunting. The use of anticoagulation in chronic cases should be decided upon on a case by case basis weighing the risk of bleeding versus thrombosis. We opted to give longterm anticoagulation to our patient to prevent re-thrombosis of the mesocaval shunt/graft.

Stone-In-Neck phenomenon: a new sign of cholecystitis

Abstract Introduction Physical examination and laboratory testing lack sufficient accuracy to distinguish cholecystitis from cholelithiasis. As a result, imaging studies are often required to safely disposition patients presenting with right upper quadrant or epigastric pain. Ultrasound is the initial test of choice in the majority of these cases, and generally relies a combination of findings (anterior gallbladder wall thickening, pericholecystic fluid/wall edema, hydrops, or a sonographic Murphy’s sign) to establish a definitive diagnosis. We suggest that the Stone-In-Neck (SIN) phenomenon, defined as an immobile stone lodged in the neck of the gallbladder, is specific for cholecystitis in the absence of other findings. Methods We prospectively compared the surgical pathologies of 57 patients diagnosed with either SIN or simple lithiasis to determine the incidence of cholecystitis in each group. Results SIN had a specificity of 97% and a positive predictive value of 93% in diagnosing cholecystitis. Conclusion Physicians performing right upper quadrant ultrasound should have a high index of suspicion for cholecystitis when the SIN phenomenon is present, and should be aware that this group of patients are at much higher risk for cholecystitis than those with simple lithiasis.

ACR Appropriateness Criteria® on Recurrent Symptoms Following Lower-Extremity Angioplasty

Lower-extremity arteriopathy patients can be managed nonsurgically, but there is no standard algorithm for follow-up. The authors present a consensus on appropriate postangioplasty studies in the setting of claudication or a threatened limb. Physical examination with measurements of the ankle-brachial index should be the first step in patients with recurrent symptoms. When there is high clinical suspicion for a threatened limb, the patient should proceed directly to catheter angiography for possible reintervention. However, in the setting of claudication alone, segmental Doppler pressures and pulse volume recordings are the initial test of choice. Magnetic resonance angiography or ultrasound can be used in conjunction to further characterize lesions with more detail. Computed tomographic angiography may also be used to image lower-extremity vasculature but is limited by the presence of large amounts of vascular calcifications. Novel techniques, including dual-energy computed tomographic angiography and noncontrast magnetic resonance angiography, may provide clinicians with alternative approaches in patients with large amounts of vascular calcifications and renal insufficiency, respectively.