Method For High-risk Patients Research Articles

Outcomes of Primary Peritoneal Drainage and Taylor’s Conservative Method in High-Risk Cases of Perforated Peritonitis

Aim: To evaluate the outcomes of primary peritoneal drainage and Taylor’s conservative method in high-risk patients of perforated peritonitis. Methods: The study was carried out within 6 months after the approval of synopsis i.e. from 21st August, 2020 till 20th February, 2021, in the East Surgical department, Mayo hospital Lahore. A total of 66 patients who fulfilled the inclusion criteria were enrolled. Percutaneous peritoneal drainage was performed under local anesthesia and two wide bored intra-abdominal tube drains were placed in both flanks through these incisions. Pus/fluid/bile was evacuated. Outcomes were monitored in terms of mortality, morbidity (SSI, wound dehiscence) and need for definitive surgery after PPD within 14 days (as per operational definition). Post stratification Chi square test was applied and a p-value of ≤0.05 was considered as significant. Results: The mean age of the patients was 49±9.9. Mortality occurred in 65.2% patients, morbidity was seen in 25.8% patients, out of which 13.6% patients had superficial SSI. 62.1% patients had to undergo laparotomy. However, only 31.8% of the patients died postoperatively after definitive laparotomy, which is less than the high mortality rate in high-risk patients of perforation peritonitis. Conclusion: We have concluded from our study that PPD with Taylor’s conservative method served as an effective method of initial resuscitation and stablilization in high-risk patients of perforation peritonitis. Once the general condition of the patients improved, they were subjected to definitive laparotomy under general anesthesia. Post-laparotomy outcomes were improved in such patients. Keywords: peritonitis, drainage, laparotomy

Acute Cholecystitis Management During the COVID-19 Pandemic - A Systematic Review and Meta-analysis.

<br><b>Aim:</b> The aim of this study is to evaluate the prevalence of acute cholecystitis (AC) and review its possible management options during the COVID-19 pandemic.</br> <br><b>Methods:</b> The present systematic review and meta-analysis was done in accordance with the PRISMA guideline. In August 2021, two independent reviewers reviewed a number of articles with the aim of finding studies on the management of acute cholecystitis during the COVID-19 pandemic. Articles were searched in the Cochrane, Embassies, and Medline libraries. Using the Stata statistical software 14, the estimated pooled rates were calculated. Funnel plot and I2 indices were applied for evaluating the heterogeneity between the studies.</br> <br><b>Results:</b> An overall of 8 studies consisting of 654 patients suspected for AC were included. The prevalence of COVID-19 among our included patients was 82% (95% CI: 79-84%, I2: 99.2%). Regarding the type of management, 35% (95% CI: 26-45%, I2: 46.9%) of patients undergone cholecystectomy, 47% (95% CI: 43-51%, I2: 54.4%) were managed by non-surgical methods, and 19% (95% CI: 14-23%, I2: 68.1%) of patients were treated by percutaneous cholecystostomy. The prevalence of grade 2 and 3 among our patients was 44 and 15%, respectively.</br> <br><b>Conclusions:</b> Considering the fact that due to the current pandemic, the number of patients referring with higher grades is assumed to be increased, early cholecystectomy remains the best management option for AC patients. However, LC seems not to be the most favorable option since it is associated with a relatively higher risk of contamination with COVID-19. PC can also be considered as a temporary and safe method in high-risk patients which might enable us to protect both patients and healthcare providers.</br&gt.

Correlation of Dermatoglyphics with Clinical Characteristics of Cervix Carcinoma Patients at a Tertiary Care Centre in Kanpur, Uttar Pradesh, India

Introduction: Cervix cancer is most prevalent cancer in females. Early detection and regular screening methods are helpful for the prevention of cervix cancer related morbidity and mortality. Early stages of development, dermatoglyphic features are generated under genetic influences, but they can be influenced by environmental variables during the first three months of pregnancy. These trends may reflect an individual’s genetic make-up and, as a result, his or her proclivity for particular diseases. Therefore, the dermatoglyphic prints may serves as a non invasive anatomic marker of cervix cancer risk, allowing for early detection and treatment. Aim: To characterise dermatoglyphics in cervix cancer patient and correlate them to principal clinical features. Materials and Methods: This cross-sectional study included 300 cervix cancer patients, analysed the clinical presentations and dermatoglyphics prospectively after obtaining ethics approval from a tertiary care hospital, Kanpur, Uttar Pradesh, India, during December 2016-January 2020. The palmar dermatoglyphics (loops, arches, whorls and palmar angle) were obtained and evaluated for correlation with principal clinical features like vaginal discharge, postmenopausal bleeding, and intermenstrual bleeding using Spearman’s correlation test. Results: In this study, the frequencies of arches, loops and whorls were 81, 2051, 868 respectively. A strong positive correlation (r>0.92) existed between whorls of palmar digits and clinical features of cervix cancer. Conclusion: Dermatoglyphic patterns could be used to investigate the genetic cause of cervix cancer and could potentially be used as a non invasive anatomical screening method in high-risk patients.

Sternal closure methods in high-risk patients: Should they be specific to the patient?

Background: To analyze and investigate the most effective sternum closure method in high-risk patients undergoing median sternotomy, we compared a steel wire-titanium hooks combination with a steel wire-titanium plates and screws combination. Patients and Methods: We examined 67 patients who underwent median sternotomy between October 2018 and January 2020. Patients who needed postoperative chemotherapy or radiotherapy due to malignancy were excluded from the study. The patients were randomly divided into two groups with similar risk factors. In the first group, a steel wire – titanium hooks combination was used to close the sternum. A steel wire – titanium plates and screws combination was used in the second group of patients. Results: No dehiscence or mediastinitis were observed in either patient group. Superficial wound infection was seen in four patients from each group and was successfully treated with antibiotic therapy. There was no significant difference between the two groups regarding the intensive care stay, the duration of hospitalization, the amount of bleeding or the need for re-exploration (p > 0.05). Conclusion: The choice between sternal closure techniques in high-risk patients should be mainly based on the characteristics of the patient. Beyond this, the most cost-effective method in which the surgeon is most experienced should be preferred. Keywords: Titanium hooks; titanium plates and screws; tersonalized sternal closure methods

Factors for Blood Transfusions Following Hemi Hip Arthroplasty for Patients With Femoral Neck Fracture.

Background:Hemi hip arthroplasty is one treatment option for femoral neck fractures; however, there has been limited evidence on factors associated with blood transfusions following hemi hip arthroplasty. Hence, the aim of this study was to identify the predictors of blood transfusion after hemi hip arthroplasty, which could lead to the establishment of proper guidelines for management protocols.Materials and Methods:This study was a retrospective cohort study, conducted in a single center of 323 femoral neck fracture patients having undergone hemi hip arthroplasty. Peri-operative factors and demographic data were extracted from the electronic medical records, from 2007 to 2019. A predictive model was developed by logistic regression (LR), and adjusted by multivariate logistic regression.Result:One hundred and twenty-six (39%) patients received blood transfusions. On multivariate analysis, those of a female gender (odds ratio (OR) 2.00, p = 0.037), having a body mass index lower than 18.5 kg/m2 (OR 2.40, p = 0.028), lower preoperative hemoglobin levels (OR 0.52, p < 0.001) and given general anesthesia (OR 2.07, p = 0.028) were shown to be significantly associated with a higher risk of requiring a blood transfusion.Conclusion:The authors recommend that preparation of blood components coupled with the utilization of blood conserving methods for high risk patients, as studies have stated, in addition to the consideration of spinal anesthesia; if patients have no contraindication, should be implemented.

Initial Slovenian experience with MitraClip therapy : Careful selection of patients is crucial for optimal outcome.

MitraClip is a percutaneous mitral repair technology increasingly used for high surgical risk patients with primary or secondary mitral regurgitation. We describe initialSlovenian experiencewith MitraClip and discuss the importance of identifying the suitable candidates for this procedure. We retrospectively analyzed the first 10 patients (mean age 75.6± 6.9 years, logistic Euroscore 28.4± 10.9%) with severe and moderate to severe mitral regurgitation (8secondary, 1primary and 1mixed etiology) who underwent a MitraClip procedure between January 2015 and February 2017. Acute reduction of mitral regurgitation was achieved in all but one patient (90%). There were no periprocedural mortalities and at short to mid-term follow-up (median 12months, interquartile range3-15 months). In eight patients improvement of functional class was observed at discharge. No functional improvement was achieved in apatient with advanced ischemic cardiomyopathy, and in apatient with degenerative mitral disease in whom the MitraClip procedure had failed necessitating mitral valve surgery. One patient experienced late leaflet detachment and was effectively managed with a second MitraClip procedure. There were two vascular complications at the access site and one percutaneous closure of an iatrogenic atrial septal defect. Our initial experiences with asmall number of patients indicate that percutaneous mitral repair with MitraClip is afeasible and safe method in high-risk patients. Special attention should be paid to careful patient selection including detailed echocardiographic evaluation of mitral valve anatomy, technical performance and final result, particularly at the beginning of the learning curve in order to reduce the rate of serious complications.

Efficacy of endovascular treatment for high-risk patients with chronic carotid artery occlusion

Objective To investigate the safety and short-term effect of endovascular treatment for high-risk patients of chronic carotid artery occlusion. Methods We retrospectively analyzed the data of 12 patients with high-risk chronic carotid artery occlusion who were admitted to First Affiliated Hospital of Xinjiang Medical University from October 2014 to February 2016 and underwent endovascular treatment. National Institute of Health stroke scale(NIHSS)was used to evaluate patients'neuronal functions.Follow-up studies were conducted 1 week, 30 days and 6 months post operations to observe the adverse events. The follow-up time ranged from 4 to 17 months(mean, 13.6 months). Results 11 patients(11/12) achieved recanalization successfully.The degrees of preoperative and postoperative carotid stenosis in 12 patients was 100% and (22.5±8.9)%, respectively (P<0.05). At 1 week post operation, the adverse event of persistent hypotension occurred in 1 case. Among the 11 patients with successful endovascular treatment, the 6-month postoperative score (3.36±1.56) based on the NIHSS was significantly improved from preoperative level (2.59±1.37) (P<0.05). Conclusion Endovascular treatment suggests to be a safe and effective method for high-risk patients of chronic carotid artery occlusion in terms of short- and medium-term effects. Key words: Carotid arteries; Arterial occlusive diseases; Endovascular treatment; Treatment outcome

Conventional vs. Transapical vs. Transfemoral Aortic Valve Replacement - Real World Comparison of 3,751 Patients

Background and Hypothesis: Transcatheter aortic valve replacement (TAVR) is an established method in high-risk patients. Two aspects of this procedure are currently under discussion: 1.) Do the data acquired from randomized studies and registers justify expansion of the procedure to include younger and healthier patients? 2.) Is the transfemoral approach superior to the transapical approach with regard to mortality and periprocedural complications? Against this background we examined the mortality and morbidity of all patients who received an isolated conventional, transapical or transfemoral aortic valve replacement in accordance with the criteria of the Valve Academic Research Consortium (VARC)-2.

Abstract 17539: Conventional vs. Transcatheter Aortic Valve Replacement - Propensity Score Adjusted Comparison of 3,751 Unselected Patients

Background and Hypothesis: Transcatheter aortic valve replacement (TAVR) is an established method in high-risk patients. Two aspects of this procedure are currently under discussion: 1.) Do the data acquired from randomized studies and registers justify expansion of the procedure to include younger and healthier patients? 2.) Is the transfemoral approach superior to the transapical approach with regard to mortality and periprocedural complications? Against this background we examined the mortality and morbidity of all patients who received an isolated conventional, transapical or transfemoral aortic valve replacement in accordance with the criteria of the Valve Academic Research Consortium (VARC)-2. Methods: A prospective register was taken from a single center recording all conventional (CONV, n=2,881), transapical (TAVR-TA, n=363) and transfemoral (TAVR-TF, n=570) aortic valve implantations during the period from 07/2009 to 10/2014. Using propensity score (PS) matching, first CONV and TAVRall (TA+TF) and then TAVR-TA and TAVR-TF were paired on the basis of 21 risk variables, creating comparable groups. Results: 393 pairs CONV vs. TAVRall within a moderate risk could be created (EuroSCORE 18.7 vs. 18.5; STS 5.0 vs. 5.4). Comparison revealed no difference for 30d mortality (4.6% CONV vs. 5.1% TAVRall, p=0.74), stroke (2.8% vs. 2.0%, p=0.48) or myocardial infarction (0.0 vs. 0.3%, p=0.50). Bleeding complications were significantly more frequent in the CONV, SM implantations and vascular complications in the TAVRall group. In the PS-adjusted comparison TAVR-TA vs. TAVR-TF (289 pairs; EuroSCORE 25.1 vs. 22.1; STS 6.8 vs. 6.7) there was also no difference in the hard endpoints (30d mortality 4.9% TA vs. 4.2% TF, p=0.70; stroke 3.1% vs. 2.8%, p=0.81; myocardial infarction 0.4% vs. 0.4%, p=1.00). Here bleeding complications were significantly more frequent in the TA group, SM implantations and vascular complications in the TF group. Subgroup analyses show an advantage of the TAVR procedure in patients with high STS or low LVEF. Conclusions: These data show that 1.) conventional aortic valve replacement and TAVR are comparable in the moderate risk group, and 2.) the two approaches, transapical and transfemoral, produce comparable results.

Comparison of One- and 12-Month Outcomes of Transcatheter Aortic Valve Replacement in Patients With Severely Stenotic Bicuspid Versus Tricuspid Aortic Valves (Results from a Multicenter Registry)

The aim of the study was to evaluate the transcatheter aortic valve replacement (TAVR) in high-risk patients with severe bicuspid aortic valve (BAV) stenosis and to compare the outcomes with a matched group of patients with tricuspid aortic valve. TAVR became an alternative treatment method in high-risk patients with symptomatic aortic stenosis; however, BAV stenosis is regarded as a relative contraindication to TAVR. The study population comprised 28 patients with BAV who underwent TAVR. BAV was diagnosed based on a transesophageal echocardiography. CoreValve and Edwards SAPIEN prostheses were implanted. The control group consisted of 84 patients (3:1 matching) with significant tricuspid aortic valve stenosis treated with TAVR. There were no significant differences between patients with and without BAV in device success (93% vs 93%, p= 1.0), risk of annulus rupture (0% in both groups), or conversion to cardiosurgery (4% vs 0%, respectively, p= 0.25). The postprocedural mean pressure gradient (11.5 ± 6.4 vs 10.4 ± 4.5mm Hg, p=0.33), aortic regurgitation grade ≥2 of 4 (32% vs 23%, p= 0.45), 30-day mortality (4% vs 7%, p= 0.68), and 1-year all-cause mortality (19% vs 18%, p= 1.00) did not differ between the groups. Echocardiography showed well-functioning valve prosthesis with a mean prosthetic valve area of 1.6 ± 0.4cm(2) versus 1.7 ± 0.3cm(2) (p= 0.73), a mean pressure gradient of 10.3 ± 5.4 versus 9.8 ± 2.8mm Hg (p= 0.64), and aortic regurgitation grade ≥2 of 4 (22% vs 22%, p= 1.00) for the 2 groups. In conclusion, selected high-risk patients with BAV can be successfully treated with TAVR, and their outcomes are similar to those reported in patients without BAV.

Thromboprophylaxis and bleeding diathesis in minimally invasive stone surgery

With populations ageing and active treatment of urinary stones increasingly in demand, more patients with stones are presenting with an underlying bleeding disorder or need for regular thromboprophylaxis, by means of antiplatelet and other medication. A practical guide to thromboprophylaxis in the treatment of urinary tract lithiasis has not yet been established. Patients can be stratified according to levels of risk of arterial and venous thromboembolism, which influence the requirements for antiplatelet and anticoagulant medications, respectively. Patients should also be stratified according to their risk of bleeding. Consideration of the combined risks of bleeding and thromboembolism should determine the perioperative thromboprophylactic strategy. The choice of shockwave lithotripsy, percutaneous nephrolithotomy or ureteroscopy with laser lithotripsy for treatment of lithiasis should be determined with regard to these risks. Although ureteroscopy is the preferred method in high-risk patients, shockwave lithotripsy and percutaneous nephrolithotomy can be chosen when indicated, if appropriate guidelines are strictly followed.

Lumbar facet joint injection: feasibility as an alternative method in high-risk patients

To evaluate the effectiveness of therapeutic facet joint steroid injections for symptoms caused by lumbar spinal stenosis in patients who are at risk of bleeding. We analysed 134 patients who had previously undergone one-level bilateral facet joint steroid injections for lumbar radiculopathy caused by spinal stenosis from January 2011 to December 2012. All patients had a bleeding tendency due to several medical conditions. A retrospective chart review was conducted by one radiologist. Response was measured by using a five-point patient satisfaction scale. Evaluations of the relationship between possible outcome predictors were made using the chi-squared or Fisher's exact test, as appropriate. Among the 42 enrolled patients (male/female = 14/28; mean age, 58 years; range, 41-88 years), 25 patients (59.5 %) were classified to have received effective treatment; in 17 patients treatment was classified as ineffective. Eighteen (72 %) of the 25 patients with mild-to-moderate central canal stenosis had symptom relief, and 7 of the 17 (41.2 %) patients with severe central canal stenosis had symptom relief (P < 0.05). Other outcome predictors were not statistically significant. Therapeutic facet joint steroid injection is potentially effective for lumbar radiculopathy caused by spinal stenosis. This could be helpful in patients at risk of bleeding. • Epidural injection of steroids is a conventional treatment for lumbar radiculopathy. • Facet joint steroid injections showed similar therapeutic effects in lumbar spinal stenosis. • No serious complications, including bleeding, occurred with facet joint injections. • Facet joint steroid injection offers an alternative therapy in patients with bleeding risk.

Abstract LB-509: Early detection of pancreatic cancer in transgenic mice with ultrasonic molecular imaging and VEGFR2-targeted microbubbles

Abstract Pancreatic cancer is a lethal disease largely due to presence of advanced and inoperable disease at the time of diagnosis. Evidence from current screening programs for high-risk individuals suggests that aggressive detection at operable stages could dramatically improve prognosis; however, current radiological imaging screen methods are not standardized and rely on solid mass recognition from anatomical/morphological imaging strategies. Incorporation of a molecular imaging strategy can provide a highly reliable and cancer-specific diagnosis, as well as, improved delineation of tumor boundaries for therapeutic and surgical guidance. Molecular ultrasound imaging is accomplished by conjugating targeting molecules (peptides/antibodies) to the surface of gas-filled microbubble contrast agents (1-4 μm diameter), and these contrast agents bind to markers overexpressed on disease-associated endothelium. In this study, we investigated the ability to detect small pancreatic cancers with contrast microbubbles targeted to vascular endothelial growth factor receptor type 2 (VEGFR2) and small animal transabdominal ultrasound (US) imaging in a transgenic mouse model of pancreatic cancer (Pdx1-Cre; KRasV12G; Ink4a-/-; PC mice). Small tumors ranging from 0.8 mm to 3.0 mm in diameter (mean: 1.7 ± 0.6 mm) could be detected with high-resolution B-mode US imaging, and showed 7.8-fold higher (P &amp;lt; 0.001) VEGFR2-targeted molecular US signal (mean signal intensity: 6.5 ± 8.4 arbitrary units; n=32 tumors) in PC mice compared with normal pancreas in wildtype mice (mean signal intensity: 0.8 ± 0.6 arbitrary units; n=14 mice). Small pancreatic tumors showed 3-fold higher VEGFR2-targeted US signal (mean signal intensity: 10.5 ± 9.4 arbitrary units) compared with US signal measured with non-targeted microbubbles (mean signal intensity: 3.6 ± 1.8 arbitrary units), indicating high specificity for VEGFR2. Ex vivo histological (H&amp;E) analysis and immunostaining of VEGFR2 confirmed millimeter-sized tumors in the pancreas and VEGFR2 expression in PC mice (VEGFR2-positive tumors); in contrast, pancreas tissue from normal, wildtype mice was VEGFR2-negative. Taken together, these studies indicate that VEGFR2-targeted US imaging can detect small pancreatic cancers that are not normally recognized with conventional anatomical imaging, and may be highly useful for establishing a standardized pancreatic cancer screening/monitoring method for high-risk patients. Supported by the Canary Foundation, and NIH/NCI grants R21 CA139279 and Fellowship R25 CA11868. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr LB-509. doi:1538-7445.AM2012-LB-509

Kontrastmittel-MRT der Brust bei Staging und Früherkennung: Wo benötigen wir sie?

PURPOSE: When imaging is used for screening or preoperative staging, a considerable number of diagnoses show normal breasts or breast tissue. Thus, in contrast to other indications, a high specificity of the methods employed is required in addition to a good sensitivity. Ample data is available for both indications and is analyzed here. MATERIAL AND METHODS: A search of the Pubmed und Cochrane libraries was performed. Original work, systematic reviews, meta-analyses, national and international recommendations and guidelines were considered. RESULTS: Contrast-enhanced breast MRI proved to be the most sensitive method for high risk patients. However, false positive findings leading to “short-term” (4-6 months) follow-up recommendations or to histopathological assessment may occur in 15-20 % of cases, and MR-guided histopathological assessment and, in particular, MR-guided percutaneous biopsy, constitute a bottleneck. The most important advantage of intensified screening programs using MRI is the earlier detection of malignancy, even though evidence from randomized studies is lacking. For preoperative staging no evidence exists to date for an improved outcome, as measured by a decreased number of re-excisions, a decreased rate of recurrences, or improved survival. However, more aggressive treatment has been documented after preoperative MRI. Therefore updated guidelines have not recommended using MRI for preoperative staging in general, but only recommend it for certain subgroups. CONCLUSION: MRI can be recommended as an additional imaging method for the screening of high risk women. However, good quality control and appropriate patient information is necessary. Preoperative MRI is only recommended for selected subgroups. More research is needed before further recommendations can be given.

Microvolt T-wave alternans during exercise and pacing are not comparable

The absence of microvolt T-wave alternans (MTWA) identifies a group of patients who are at low risk for ventricular arrhythmia or sudden cardiac death. However, in exercised assessed MTWA, 20-40% of all test results are indeterminate. We hypothesised that MTWA during pacing would yield less indeterminate results. Thirty patients with ischaemic cardiomyopathy and prior dual chamber implantable cardioverter defibrillator implantation were enrolled. All patients underwent sequential MTWA testing using an exercise (E), atrial-paced (A), and atrioventricular-paced (AV) protocol. The number of indeterminate tests was lower during pacing (A: 17%; AV: 3%) compared with exercise (37%) (E vs. A: P = 0.015, E vs. AV: P = <0.001). When positive and indeterminate test results were grouped as non-negative, the concordance rates between E and A, E and AV, and A and AV were 60% (kappa = 0.17), 57% (kappa = 0.058), and 70% (kappa = 0.348), respectively. If indeterminate results were excluded, agreements were 60% (kappa = 0.19), 50% (kappa = 0.129) and 67% (kappa = 0.33), respectively. Indeterminate test results are less common during pacing. However, there is a low concordance rate between test results using different protocols. This necessitates further study to determine the predictive value of each method in high risk patients with ischaemic cardiomyopathy.

A prospective study of real-time panfungal PCR for the early diagnosis of invasive fungal infection in haemato-oncology patients

A blinded prospective study was performed to determine whether screening of whole blood using a real-time, panfungal polymerase chain reaction (PCR) technique could predict the development of invasive fungal infection (IFI) in immunocompromised haemato-oncology patients. In all, 78 patients (125 treatment episodes) were screened twice weekly by real-time panfungal PCR using LightCyclertrade mark technology. IFI was documented in 19 treatment episodes (five proven, three probable and 11 possible), and in 12, PCR was sequentially positive. PCR positivity occurred in: 4/5 proven; 2/3 probable; 6/11 possible; and 29/106 with no IFI. In 8/12 with IFI and sequentially positive PCR results, PCR positivity occurred before (median 19.5 days) and in 4/12 (median 10.5 days) after the initiation of empirical antifungal therapy. Based on sequential positive results for proven/probable IFI sensitivity, specificity, positive predictive value and negative predictive value were 75, 70, 15 and 98%, respectively. Real-time panfungal PCR is a sensitive tool for the early diagnosis of IFI in immunocompromised haemato-oncology patients. It may be most useful as a screening method in high-risk patients, either to direct early pre-emptive antifungal therapy or to determine when empirical antifungal therapy can be withheld in patients with antibiotic--resistant neutropenic fever. However, these strategies require further assessment in comparative clinical trials.

Barium Enema and Endoscopy for the Detection of Colorectal Neoplasia: Sensitivity, Specificity, Complications and its Determinants

AIM: To analyse sensitivity, specificity and complication rate of endoscopy, and barium enema for the detection of colorectal neoplasia. MATERIALS AND METHODS: A MEDLINE search was performed (1980–2000) directed at the endoscopic and radiologic literature on barium enema. Articles were selected based on the type of study, availability of sensitivity and specificity values in sizeable patient groups, and reports on complications. Sixty articles were included in the analysis. RESULTS: Endoscopy proved to have superior sensitivity for polyps in patients at high-risk for colorectal neoplasia. The role of endoscopy and radiology in average-risk screening populations is not known. Sensitivity and specificity rates ranged widely, probably due to bias. For the detection of small polyps endoscopy has superior performance, whereas sensitivity is similar for endoscopy and barium enema for the detection of larger (>1cm) polyps and tumours. Overall, endoscopy is associated with a higher complication rate. CONCLUSION: Endoscopy is the preferred detection method in high-risk patients. The role of endoscopy and radiology in a screening setting requires evaluation. This review provides the test characteristics of endoscopy and radiology which are relevant for a cost-effectiveness analysis. Double-contrast barium enema may play an important role for screening purposes, owing to its good sensitivity for detecting larger (>1cm) polyps and its lack of major complications. de Zwart, I. M.et al. (2001). Clinical Radiology56, 401–409.

Carbon dioxide angiography for endovascular grafting in high-risk patients with infrarenal abdominal aortic aneurysms

Allergic reactions to contrast media, preexisting renal dysfunction, and hyperthyroidism are relative contraindications for angiography with conventional contrast medium. Carbon dioxide (CO2) angiography is an alternative method in high-risk patients because CO2 is nontoxic, without allergic potential, and not iodic. CO2-related complications are extremely rare. Because renal insufficiency often occurs in vascular patients, this method will become increasingly important for endovascular surgery. We report on three consecutive patients with asymptomatic infrarenal aortic aneurysm and concomitant renal dysfunction or allergic reactions to standard contrast media. Aortic stent grafts were deployed under CO2 angiographic control without complications or worsening of renal function. (J Vasc Surg 2001;33:646-9.)

Diagnostic and prognostic value of exercise testing.

Measuring blood pressure during exercise under a standard protocol could be a useful diagnostic method in high-risk patients and in borderline hypertensive subjects. It may also serve as an adapted test for hypertensive subjects undergoing physical activity at work or at leisure time with a particular cardiovascular work load. It can be used as a method of assessment to confirm the efficacy of an antihypertensive drug, and for prognostic evaluation of cardiovascular risk in terms of morbidity and mortality. An exercise blood pressure profile does not provide information about blood pressure during activities of daily living. For this purpose, ambulatory blood pressure measurement appears to be more relevant.

A comparison of nuclear magnetic resonance and intravenous xeroangiography with conventional arteriography in popliteal artery imaging

Twenty-nine patients with peripheral vascular disease had the popliteal artery segment assessed by xeroangiography and nuclear magnetic resonance (NMR) scanning. The result of each test was compared with conventional contrast arteriography. Nuclear magnetic resonance and xeroangiography correctly predicted popliteal artery patency in 97% and 100% of limbs, respectively, and occlusion was correctly predicted in 44% and 63% of limbs. The ability of xeroangiography to define the state of the popliteal artery accurately makes this a useful method in high-risk patients. The potential for NMR imaging appears very promising but more work is required to define its future clinical application.