Nondiagnostic Studies Research Articles

128-Detector-Row Computed Tomography Coronary Angiography Evaluating Coronary Artery Disease: Who Avoids Cardiac Catheterization?

To evaluate the prevalence of significant coronary artery disease (CAD) and nondiagnostic studies in patients referred for clinically indicated coronary angiography performed by 128 multidetector computed tomography (MDCT). We examined patients referred for coronary computed tomography (CT) angiography for the presence of CAD. The analysis included 438 studies classified as normal, with nonsignificant CAD, with significant CAD, or nondiagnostic. Of the 438 cases evaluated, 121 (27.6%) cases were reported as normal, 184 (42%) were classified as nonsignificant CAD, 92 (21%) as significant CAD, and 41 (9.3%) were inconclusive. Therefore, 69.7% of the study population most probably did not require conventional coronary angiography. Among patients referred for computed tomography angiography (CTA) for appropriate indications, 69.6% had either normal coronary arteries or nonobstructive disease. Given the high negative predictive value of coronary CTA, these patients most likely would not require invasive coronary angiography. Selective cardiac CTA may substantially decrease unnecessary diagnostic cardiac catheterizations.

How good is capsule endoscopy for detection of periampullary lesions? Results of a tertiary-referral center

Ampullary adenomas are increasingly being recognized, particularly in patients with familial adenomatous polyposis. A capsule endoscopy (CE) is routinely recommended for surveillance of small-intestinal polyposis. Performance characteristics of CE for the detection of periampullary lesions are unclear. To evaluate the ability of CE to detect the major duodenal papilla. A total of 146 consecutive CE studies were reviewed by 2 CE gastroenterologists at 5 frames per second. Primary outcome was visualization of the major duodenal papilla. Discrepancies were reviewed by 5 CE gastroenterologists. A tertiary-referral center. The ability of CE to detect the duodenal papilla. Among 146 consecutive CE studies, 21 were excluded: capsule retention (3), patient age <18 years (6), duplicate study (8), and prior surgery disrupting duodenal anatomy (4). Of the remaining 125 studies, indications were the following: obscure GI bleeding (45.6%), iron deficiency anemia (19.2%), abdominal pain (17.6%), diarrhea (10.4%), and Crohn's disease (4.8%). In total, 13 major duodenal papillae were visualized. The median time of detection was 31 seconds after the first duodenal image. This translates to a CE sensitivity of 10.4% for detection of the major papilla. Papilla position was not verified by an EGD. CE has limited sensitivity to visualize the major papilla and lesions in the periampullary small intestine. Nondiagnostic CE studies must not be relied upon as proof that small-bowel lesions do not exist. Consideration should be given for an enteroscopy or side-viewing duodenoscopy in cases where significant clinical concern exists for unrecognized periampullary lesions. The current recommendations about surveillance for small-bowel polyposis should be revised.

Spontaneous septic diskitis: a common complaint with a serious pathologic cause that should not been overlooked

Many people who have low back pain are likely to be out of work and taking medication and probably make demands on both primary and secondary health care as well as the private sector. Septic diskitis is a rare cause of back pain, accounting for less than 0.01% of cases in the primary care setting (Carragee EJ. Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am. 1997;79:874-80). It has been associated with a high morbidity and mortality in the past. Although it is an unusual complication in a postoperative patient, it is even more rare in a nonoperative patient. It accounts for 2% of all osteomyelitis (Maiuri F, Iaconetta G, Gallicchio B, Manto A, Briganti F. Spondylodiscitis. Clinical and magnetic resonance diagnosis. Spine. 1997;22:1741-6) and may occur spontaneously, after surgery (especially after epidural anesthesia), in the immunosuppressed, and systemic infections. It has the potential to be an orthopedic pitfall in the emergency department because it can be presented with nonspecific symptoms, nonspecific laboratory abnormalities, and nondiagnostic radiographic studies. We present a case of low back pain in a previously healthy individual as a result of spontaneous septic diskitis, which had been initially misdiagnosed in the private sector as herniation of an intervertebral disk.

Fulminant Guillain–Barré syndrome after closed head injury: a potentially reversible cause of an ominous examination

Fulminant Guillain-Barré syndrome (GBS) is a rapidly progressive form of polyneuropathy in which patients demonstrate eventual flaccid quadriplegia and an absence of brainstem function. Most patients present after a mild upper respiratory or gastrointestinal illness and have nondiagnostic cerebral imaging studies. The authors present a case of fulminant GBS that developed in a 55-year-old alcoholic man 1 week after admission for a closed head injury. The details of this case and a discussion of GBS will be presented. This case provides evidence for combined central and peripheral nervous system involvement in severe cases of GBS. Recognition of fulminant GBS is important to prevent inappropriate declaration of brain death or withdrawal of support in the face of a potentially reversible process.

Waiting to exhale: salvaging the nondiagnostic CT pulmonary angiogram by using expiratory imaging to improve contrast dynamics

We attempted to investigate whether computed tomography pulmonary angiography (CTPA) in the expiratory phase can improve contrast enhancement of the pulmonary arteries and mitigate the effect of inspiratory transient attenuation artifact, potentially salvaging nondiagnostic studies. Eighteen patients with indeterminate inspiratory CTPA, despite proper contrast bolus were studied. Patients were rescanned in expiration using the same contrast bolus and scanning parameters. The attenuation of each pulmonary arterial segment, superior and inferior vena cava, and atria and ventricles during the two phases of respiration was measured independently by three radiologists. All pulmonary segments were evaluated for filling defects during the two phases. In addition, the studies were graded for diagnostic quality of enhancement and probable impact on management. A statistically significant increase in pulmonary arterial enhancement was seen during expiration from the pulmonary trunk to the segmental pulmonary arteries (P < 0.001) and for the inferior vena cava, the right atrium, and the ventricle. The incidence of nondiagnostic inspiratory studies ranged from 89 to 100%, depending on the observer. All studies were upgraded to fully acceptable diagnostic quality with follow-up expiratory imaging (P < 0.0001). Expiratory phase imaging was observed to have diagnostic impact in 78 to 88% of cases, with overall good to moderate interobserver agreement. In one case, pulmonary embolism was detected on the expiratory scan, which was not seen on the inspiratory scan. Expiratory imaging for nondiagnostic CTPA improves pulmonary arterial enhancement and improves diagnostic quality of CTPA by eliminating transient attenuation artifact, thus facilitating more accurate diagnosis and providing earlier treatment of pulmonary embolism.

Prevalence of obstructive coronary artery disease in an outpatient cardiac CT angiography environment

Purpose To determine the prevalence of significant obstructive disease and non-diagnostic studies using coronary computed tomographic angiography (CTA) in an outpatient environment, to establish if CTA could help avoid unnecessary diagnostic cardiac catheterizations. Methods We evaluated all cases consecutively performed in our outpatient CTA laboratory seen over one year with an indication that could warrant a cardiac catheterization to establish the presence or absence of coronary artery disease (CAD). Excluded were patients without established indications for cardiac catheterization and those with known CAD (i.e.— prior myocardial infarction, revascularization). Four hundred and ninety-three (493) CTA case studies were included for the analysis. Patients were classified as normal (no luminal irregularities seen), non-obstructive coronary disease (< 50% stenosis), significant obstructive coronary disease (> 50% stenosis), or a non-diagnostic study. We assumed that all patients assigned to the obstructive CAD group and the non-diagnostic study group would require a cardiac catheterization. In the remaining two groups, a cardiac catheterization would not be necessary for diagnosis or treatment. Results Of the 493 index cases evaluated, 157 (32%) cases were reported to be normal, 204 patients were classified as having non-obstructive disease (41%), 93 patients were defined to have obstructive CAD (19%), and 39 cases were inconclusive (8%). Thus, in 27% of the study population, a conventional coronary angiography would be indicated to clarify the diagnosis or provide definitive disease severity for subsequent revascularization. Conclusion Among ambulatory patients referred for CT angiography with symptoms or positive (or equivocal) cardiac stress tests, 73% of patients were found to have either normal coronary arteries or non-obstructive disease. Given the high negative predictive power of cardiac CTA (93–99%), these patients most likely would not require subsequent invasive coronary angiography. A strategy of selective cardiac catheterization may substantially decrease unnecessary diagnostic cardiac catheterizations and reduce health care expenses.

CLINICOPATHOLOGIC CORRELATES OF RENAL BIOPSY SPECIMENS IN CENTRAL VALLEY, CALIFORNIA.

Purpose Although several registries collecting data of patients with kidney diseases exist, there are only a few registries that specifically collect data relating to renal biopsy. We set out to gather regional data regarding indications, results, and outcomes of renal biopsies. Methods We retrospectively gathered data of 412 renal biopsy specimen results consecutively performed between 1998 and 2005 in our setting. Results The most common clinical syndrome was renal failure (46%), urinary abnormality (28%). Nephrotic syndrome early in diabetes was an important cause of biopsy. Hispanic was the predominant race. Focal segmental glomerulosclerosis (FSGS) was the most common overall picture; IgA nephropathy (IgAN) was the commonest cause of nephritic/hematuria picture. IgAN was dominant in nonwhite males; FSGS showed equal sex distribution. Nondiagnostic studies were seen in young acute renal failure specimens. Conclusion These data with regional flavor will give answers to several questions in both prevention and treatment of renal diseases. It would throw more light on the etiologies and prevalence of kidney diseases.

Culture-Positive and Culture-Negative Endocarditis in Patients With Cancer

Endocarditis is uncommon in patients with cancer. The characteristics of culture-positive (CPE) and culture-negative endocarditis (CNE) in high-risk cancer patients are not known; therefore we sought to evaluate the disease characteristics in patients with endocarditis at a comprehensive cancer center. We retrospectively reviewed the transthoracic (TTE) and transesophageal (TEE) echocardiograms obtained from 654 consecutive cancer patients in whom endocarditis was suspected between 1994 and 2004. Endocarditis was confirmed in 45 (7%) of 654 patients using modified Duke University criteria based on information obtained from hospital records and computerized data systems. In 21 (95%) of 22 cases, TEE examinations were diagnostic, and 16 (42%) of 38 patients with initially nondiagnostic TTE studies had the diagnosis confirmed by TEE study; this difference between diagnostic TEE and initial nondiagnostic TTE was significant (p < 0.0001). Among the 26 (58%) patients with CPE, Staphylococcus aureus (35%) was the most common organism isolated, followed by coagulase-negative Staphylococcus species (23%). Eighteen (78%) of 23 patients with a central venous catheter had CPE, whereas only 8 (36%) of 22 patients without a central venous catheter had CPE (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.69-23.53; p < 0.006). Vegetations were larger in patients with CPE than in patients with CNE (median +/- standard deviation, 10 +/- 8.8 vs. 8.7 +/- 3.9 mm). Fifteen patients (58%) with CPE and 10 (53%) with CNE had embolic complications. We note that cutaneous and septic pulmonary emboli were more common in patients with CPE than in patients with CNE (31% vs. 11% and 15% vs. 0%, respectively), whereas embolic cerebrovascular and fatal embolic coronary events were more common in patients with CNE than in those with CPE (37% vs. 12% and 21% vs. 0%, respectively; p = 0.026). The 4-week endocarditis-attributable death rate did not differ significantly between the groups (CPE, 15% vs. CNE, 32%; p = 0.28). On stepwise multivariate regression analysis, patients with neutropenia (OR, 22.52; 95% CI, 2.25-225.48; p < 0.008) and those with embolic cerebrovascular events (OR, 17.07; 95% CI, 1.63-178.45; p < 0.01) had an increased probability of death due to endocarditis. The clinical spectrums of CPE and CNE differed in these patients with cancer. In patients with CNE, embolic cerebrovascular and fatal myocardial infarction were relatively common.

Contrast Echocardiography Can Save Nondiagnostic Exams in Mechanically Ventilated Patients

Patients in an intensive care unit (ICU) under mechanical ventilation (MV) are very difficult to image by transthoracic echocardiography, diminishing the beneficial information that could be obtained by this noninvasive approach. The objective of this study is to assess whether the addition of a contrast agent to fundamental imaging (FI) can improve or change the initial diagnosis in cardiac postoperative patients under mechanical ventilation by enhancing endocardial border delineation and Doppler flow signal. Thirty mechanically ventilated post-cardiac surgery patients (20 men, mean age 61 +/- 13 years) were evaluated with FI before and after intravenous injection of contrast. Left ventricular endocardial border delineation score index (EBDSI), estimated left ventricular ejection fraction (LVEF), and color and spectral Doppler were analyzed. The use of contrast resulted in a significant increase in the number of well-delineated segments, with a salvage rate of 77% of nondiagnostic studies. EBDSI was 1.62 +/- 0.61, before contrast, increasing to 2.05 +/- 0.53 after it (P < 0.001). There was a change in the LVEF estimation in 5 exams, and a new wall motion abnormality was detected in other 4 exams, after the use of contrast. Moreover, a significant change was observed in the quantification of mitral regurgitation in 5 patients, in the aortic transvalvular peak gradient in 1 patient, and measurement of tricuspid regurgitation peak flow velocity in 8 patients. It is concluded that in cardiac postoperative patients under mechanical ventilation, intravenous injection of a contrast agent using FI resulted in a high salvage rate of studies and changed the initial diagnosis in a significant number of patients.

Eliminating the “Non-Diagnostic” EUS-FNA Specimen: Effect of a Quality Improvement Program on Cytologic Interpretation

Eliminating the ‘‘Non-Diagnostic’’ EUS-FNA Specimen: Effect of a Quality Improvement Program on Cytologic Interpretation Kyung W. Noh, Massimo Raimondo, Timothy A. Woodward, Alan D. Savoy, Joy N. Hardee, Michael B. Wallace Background: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is increasingly becoming a first line method for diagnosing and staging gastrointestinal and mediastinal malignancies, but interpretation of EUS-FNA cytological material is difficult and new to many pathologists. We hypothesized that a EUS-FNA specific educational program between endosonographers and pathologists would decrease our rate of ‘‘inadequate’’ specimens. Methods: We evaluated the prevalence of ‘‘inadequate’’ specimens before and after an educational intervention. The intervention was performed among 3 endosonographers and the pathology faculty of the Mayo Clinic Jacksonville. The intervention consisted of a) precise definition of ‘‘adequate’’ specimens (for lymph nodes, presence of abundant lymphocytes and tingible body macrophages, for pancreas masses, at least 2-3 clusters of benign or malignant pancreatic glandular cells), and b) review of an EUS-FNA cytology interpretation seminar. The use of on-site cytotechnology interpretation, needle type, number of passes, and lesion distribution was not changed during the study period. All cytological specimens were categorized into inadequate, benign, suspicious and malignant. Cases during the 1-month training period were not included. Results: A total of 3138 consecutive EUS cases performed at a single center by 3 experienced endoscopists from January 1996 to September 2004 were reviewed. EUS-FNA was performed in 793 cases. Prior to EUS-FNA cytopathology training, 137 of 500 cases (27%) were deemed to be inadequate by the pathologist. However, after completion of training, only 19 of 293 cases (6%) were judged to be inadequate (p ! 0.001). (Figure 1) The rates of inadequacy decreased in all of the most common indications of EUS-FNA, particularly pancreas cytology. (Table 1) The improvement was also seen across all three endosonographers. Conclusions: The percentage of inadequate specimens decreased significantly after training of cytopathologists and endosonographers on EUS-FNA cytology. This has the potential to reduce the number of non-diagnostic studies.

Accuracy of Magnetic Resonance Cholangiopancreatography (MRCP) in the Diagnosis of Pancreas Divisum (PD)

Background: Patients with PD may develop recurrent acute or chronic pancreatitis. ERCP is the gold standard for diagnosing PD. MRCP is a non invasive test reported to be highly accurate in diagnosing PD (Matos et al. GI Endosc 2001;53:728-33, Bret et al. Radiol 1996; 199:99-103). Aim: To evaluate the diagnostic accuracy of MRCP in detecting PD at our institution. Methods: During a 22-month period (10/02-07/04), 205 patients underwent ERCP and MRCP for various indications. 146 patients had diagnostic endoscopic pancreatograms (ERP) after MRCP and comprise our study population. MRCP was performed with the 1.5 T Signa Horizon LX scanner (GE Imaging Systems, Milwaukee, WI). Secretin 16 mg (SecreFlo™, ChiRhoClin, Burtonsville, MD) was given in 113/146 patients (S-MRCP). The remaining 33/146 had MRCP without secretin. Since 7/33 MRCP without secretin (21.2%) were non-diagnostic, further study focused on S-MRCP only. The S-MRCP was interpreted prior to ERP by 4 gastrointestinal radiologists as part of the routine daily workload and compared to subsequent ERP results. Results: 113 patients with S-MRCP and ERP (54 male, mean age 47.1 years) were evaluated. ERP identified PD in 19/113 (16.8%). S-MRCP identified 14/19 PD and was false positive in 3 cases (sensitivity 73.3%, specificity 96.8%, positive predictive value 82.4%, negative predictive value 94.8%). Five of 8 patients (63%) with inaccurate S-MRCP had changes of chronic pancreatitis by ERP. This differs from the frequency of chronic pancreatitis by ERP in 24/105 patients (25%) with accurate MRCP findings (p = 0.03). Summary: S-MRCP had a satisfactory specificity for detecting PD. However, the sensitivity of S-MRCP for diagnosis of PD was modest at 73.3%. This is low compared to previous smaller studies, which reported a sensitivity of MRCP up to 100%. Conclusions: 1) Our experience at a large referral center does not reflect the high diagnostic accuracy of MRCP for PD in previous studies. 2) MRCP without secretin results in a high percentage of non-diagnostic studies and should be obsolete if pancreatic assessment is desired. 3) It is more difficult to diagnose PD by MRCP in the setting of chronic pancreatitis. Background: Patients with PD may develop recurrent acute or chronic pancreatitis. ERCP is the gold standard for diagnosing PD. MRCP is a non invasive test reported to be highly accurate in diagnosing PD (Matos et al. GI Endosc 2001;53:728-33, Bret et al. Radiol 1996; 199:99-103). Aim: To evaluate the diagnostic accuracy of MRCP in detecting PD at our institution. Methods: During a 22-month period (10/02-07/04), 205 patients underwent ERCP and MRCP for various indications. 146 patients had diagnostic endoscopic pancreatograms (ERP) after MRCP and comprise our study population. MRCP was performed with the 1.5 T Signa Horizon LX scanner (GE Imaging Systems, Milwaukee, WI). Secretin 16 mg (SecreFlo™, ChiRhoClin, Burtonsville, MD) was given in 113/146 patients (S-MRCP). The remaining 33/146 had MRCP without secretin. Since 7/33 MRCP without secretin (21.2%) were non-diagnostic, further study focused on S-MRCP only. The S-MRCP was interpreted prior to ERP by 4 gastrointestinal radiologists as part of the routine daily workload and compared to subsequent ERP results. Results: 113 patients with S-MRCP and ERP (54 male, mean age 47.1 years) were evaluated. ERP identified PD in 19/113 (16.8%). S-MRCP identified 14/19 PD and was false positive in 3 cases (sensitivity 73.3%, specificity 96.8%, positive predictive value 82.4%, negative predictive value 94.8%). Five of 8 patients (63%) with inaccurate S-MRCP had changes of chronic pancreatitis by ERP. This differs from the frequency of chronic pancreatitis by ERP in 24/105 patients (25%) with accurate MRCP findings (p = 0.03). Summary: S-MRCP had a satisfactory specificity for detecting PD. However, the sensitivity of S-MRCP for diagnosis of PD was modest at 73.3%. This is low compared to previous smaller studies, which reported a sensitivity of MRCP up to 100%. Conclusions: 1) Our experience at a large referral center does not reflect the high diagnostic accuracy of MRCP for PD in previous studies. 2) MRCP without secretin results in a high percentage of non-diagnostic studies and should be obsolete if pancreatic assessment is desired. 3) It is more difficult to diagnose PD by MRCP in the setting of chronic pancreatitis. ErratumGastrointestinal EndoscopyVol. 62Issue 2PreviewIn the DDW 2005 Abstract issue (Volume 61, Number 5), two abstracts contained a typographical error in one author's name. For the abstracts “Accuracy of Magnetic Resonance Cholangiopancreatography (MRCP) in the Diagnosis of Pancreas Divisum (PD)” (Gastrointest Endosc 2005:61:AB100) and “ERCP Findings in Idiopathic Pancreatitis (IP): Cystic Fibrosis (CF) Gene Positive and Negative Patients” (Gastrointest Endosc 2005;61:AB186), the correct spelling of the author's name is Waleed Alazmi. Full-Text PDF

Exercise treadmill testing using a modified exercise protocol in women with suspected myocardial ischemia: Findings from the National Heart, Lung and Blood Institute–sponsored Women's Ischemia Syndrome Evaluation (WISE)

Exercise testing, a major diagnostic modality in individuals with suspected coronary artery disease (CAD), has in general demonstrated less overall diagnostic accuracy in women compared to men. As part of the WISE, a modified protocol was examined with the intention of improving reliability of exercise testing. Criteria for entry in the WISE study include clinically indicated coronary angiography. Exercise testing was performed using a protocol modified to be more appropriate for women. The study population consisted of 96 women, mean age of 55.8 y (range 34-77), who completed exercise treadmill test (ETT). Most (78%) were postmenopausal; 96% had >or =2 risk factors for CAD. By core laboratory angiography, 29/96 women had stenosis > or =50% in at least one coronary artery. Of these 29 women, 9 had abnormal ETT, yielding overall sensitivity of 31%. The remaining 20 women had normal (12/29, 41%) or nondiagnostic (8/29, 28%) studies. Among the 67 women with minimal or no coronary stenosis, 35 had no ischemic ST-segment changes during ETT, yielding overall specificity of 52%. Analysis with exclusion of women with nondiagnostic studies yielded sensitivity and specificity of 43% and 66%, respectively. The presence of coronary artery stenosis and inability to perform ETT, but not results of testing, predicted the outcomes of myocardial infarction, heart failure, and death. Exercise treadmill test appears to be of limited diagnostic value in women with suspected myocardial ischemia referred for coronary angiography. Sensitivity and specificity remain poor even with modified exercise protocol and core laboratory angiographic analysis. These findings merit consideration in view of current guidelines that recommend exercise testing in women with suspected CAD.

Effect of the introduction of helical CT on radiation dose in the investigation of pulmonary embolism

The aim of this study was to assess the change in patient radiation dose in the radiological investigation of pulmonary embolism since the introduction of helical CT pulmonary angiography (CTPA) in a large teaching hospital. All radiological investigations performed as an integral part of the imaging protocol in the investigation of clinically suspected pulmonary embolism (PE) were retrospectively reviewed. The protocol for the investigation of PE changed in our institution after the introduction of CTPA. Protocols 1 and 2 were the protocols in place before and after the introduction of CTPA, respectively. An in-depth evaluation was made of the imaging records and radiation dose for 30 consecutive patients investigated for clinically suspected PE in 1995 (protocol 1) and 2002 (protocol 2). Radiation doses were then extrapolated for the total number of patients investigated in each year. The number of radiological investigations performed per patient decreased from a mean of 1.17 in protocol 1 to 1.06 in protocol 2. There was a 44% increase in the total number of patients investigated. The effective dose per patient increased from 1.30 mSv to 1.35 mSv with the introduction of CTPA into the imaging protocol, an increase of only 4%. First line investigations showed a significant decrease in indeterminate examinations from 25.7% to 8.5%. Two different imaging protocols are reviewed with respect to type and number of procedures required for the investigation of PE and the resulting patient effective dose incurred. Results demonstrate an increase in the number of patients being investigated for suspected PE and a small increase in effective dose per patient since the introduction of helical CTPA. Although CTPA in itself incurs a higher effective dose, this is offset by the significant decrease in the number of non-diagnostic and total number of investigations per patient. In addition the ventilation component of lung scintigraphy was not required in protocol 2, thus reducing the dose further. We believe this small increase in effective dose is justified by the decrease in non-diagnostic studies and the reduction in total number of investigations per patient. We hope this paper will serve as a stimulus for the radiology community to examine current protocols in all areas of diagnostic imaging. We stress the importance of assessing new and established imaging investigative protocols to maximize the benefit and reduce any risk to patients.

Diagnosing Pulmonary Embolism with Four–Detector Row Helical CT: Prospective Evaluation of 216 Outpatients and Inpatients

To prospectively evaluate multi-detector row helical computed tomography (CT) for the diagnosis of pulmonary embolism (PE), with focus on the proportion of diagnostic studies and frequency of subsegmental and chronic PE. Institutional review board approval and patient consent were not required. A total of 220 consecutive CT angiography studies, 124 (56%) of which involved inpatients, were assessed. Thoracic CT angiography was performed in 216 patients; there were 101 male (age range, 25-93 years; median, 66 years) and 115 female (age range, 15-98 years; median, 67 years) patients. Contiguous 1.25-mm sections were acquired through the entire thorax after injection of 140 mL of contrast material at a rate of 4 mL/sec. CT venography was combined with thoracic CT angiography in 178 patients over 40 years of age. CT studies were interpreted first in the emergency setting and subsequently by two experienced chest radiologists. Untreated patients with normal results were contacted by telephone after 3 months. Proportions were compared with the chi(2) test, and agreement was assessed by calculating the kappa statistic (for thoracic CT angiography). Concordance between the two reading sessions was good (kappa = 0.88; 95% confidence interval: 0.77, 0.98). The proportion of nondiagnostic thoracic CT angiography studies was 9% (20 of 220). PE was found in 54 (24.5%) of 220 cases; eight (15%) of 54 patients had only subsegmental PE, which was associated with a calf vein thrombosis in two patients, and six patients (11%) had chronic PE. CT venography demonstrated venous thrombosis in 15% (26 of 178) of the patients thus studied, as well as in 45% (21 of 47) of patients with positive results at thoracic CT angiography and 4% (five of 131) of patients with negative results at thoracic CT angiography. The 3-month rate of thromboembolic events after negative results was 1.8% (two of 111) (95% confidence interval: 0.2%, 6.4%). Multi-detector row CT enables diagnosis in 91% of cases and identification of isolated subsegmental or chronic PE in a relatively high proportion of patients.

Salvage of nondiagnostic transthoracic echocardiograms on patients in intensive care units with intravenous ultrasound contrast

Transthoracic echocardiography (TTE) is often technically difficult on patients in intensive care units. Contrast echocardiography can improve left ventricular wall visualization and the assessment of regional and global left ventricular wall motion. Our study undertook to determine what proportion of nondiagnostic TTE studies on patients in intensive care units could be salvaged (i.e., converted to diagnostic studies) with contrast. Ninety-two patients with nondiagnostic TTEs had a repeat study after contrast. Using predefined criteria, 51% of studies were salvaged with contrast. Female gender emerged as the only factor associated with less likelihood of salvaging a study.

Dimer Testing for Suspected PE with Nondiagnostic Imaging Studies

Pulmonary embolism (PE) can be life threatening as well as very difficult to diagnose. PE has a myriad of presentations, and imaging studies often are

Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography

Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography

Ectopic intracavernous sinus adrenocorticotropic hormone—secreting microadenoma: could this be a common cause of failed transsphenoidal surgery in Cushing disease?

Despite diagnostic advances, it remains difficult to identify intrasellar and ectopic parasellar adrenocorticotropic hormone (ACTH)-secreting microadenomas. The authors present the case of a 61-year-old woman with Cushing disease in whom a significant central-to-peripheral and lateralized right-sided ACTH gradient was demonstrated on inferior petrosal sinus sampling; no discernible abnormality was seen on magnetic resonance imaging. She underwent transnasal transsphenoidal surgery. No tumor was found on sellar exploration and a total hypophysectomy was performed, yet her hypercortisolemia persisted. The patient died of cardiac events 17 days postsurgery. Autopsy revealed an isolated, right-sided, intracavernous ACTH-secreting adenoma with no intrasellar communication. This case represents the first failed transsphenoidal surgery for Cushing disease in which there is postmortem confirmation of a suspected intracavernous sinus lesion. It supports the hypothesis that Cushing disease associated with nondiagnostic imaging studies, a strong ACTH gradient on venography, and negative findings on sellar exploration may be caused by an ectopic intracavernous ACTH-secreting adenoma. There are no premortem means of confirming the presence of such lesions, but these tumors could underlie similar cases of failed surgery. Radiation therapy targeting the sella turcica and both cavernous sinuses, possibly supplemented with medical treatment, is suggested for similar patients in whom transsphenoidal hypophysectomy has failed. Adrenalectomy may also be appropriate if a rapid reduction in ACTH is necessary.

Muscle biopsy in the evaluation of patients with modestly elevated creatine kinase levels.

The utility of muscle biopsy in patients with modest elevations of serum creatine kinase (CK) level but normal neurological examinations and nondiagnostic electrodiagnostic studies is uncertain. We performed systematic, extensive studies on muscle biopsies of 20 such patients. A definitive diagnosis was arrived at in only 1 by histochemical studies, although 4 others demonstrated minor myopathic changes. Biochemical evaluation led to a diagnosis in an additional 5. Muscle biopsy is useful for evaluating such patients, but extensive studies of the muscle are necessary.

Quantitative diagnosis of apical cardiomyopathy using contrast echocardiography

Background: The echocardiographic diagnosis of apical hypertrophic cardiomyopathy (ACM) has been limited by the frequent inability to visualize the apical endocardium. We hypothesized that the use of contrast agents in patients with suspected ACM, but nondiagnostic echocardiographic studies, would allow quantitative diagnosis. Methods: Contrast enhancement was performed in 26 patients with nondiagnostic transthoracic echocardiograms (TTEs) for the diagnosis of ACM; 6 patients with suspected ACM based on unexplained symmetric precordial T-wave inversions and increased apical tracer uptake on single-photon emission computed tomography (SPECT) scans, 10 patients with normal electrocardiogram (ECG) readings and no history of hypertension (healthy group), and 10 patients with hypertension and ECG criteria for left ventricular hypertrophy (LVH group). Images were obtained with Optison (Mallinckrodt Medical; IV, 1.0 mL) using harmonic imaging and low mechanical index. Posterior (PW) and septal wall (SW) thicknesses were measured at end-diastole in the parasternal long-axis view. Apical wall thickness (A) was measured from the contrast-enhanced apical endocardium to the visceral epicardial surface in the apical 4-chamber view. A/PW and A/SW ratios were calculated for each group. Asymmetric apical hypertrophy was defined as an A/PW ratio greater than 1.5. Results: Contrast-enhanced apical thickness was greater than 2.0 cm in all patients in the suspected ACM group but less than 1.2 cm in all patients in the LVH and healthy groups. In all 6 patients in the suspected ACM group, A/PW and A/SW ratios were greater than 1.5. No patient in the healthy or LVH groups had thickness ratios greater than 0.85. Conclusion: Contrast echocardiography allows quantitative diagnosis of ACM in patients with suggestive ECG and SPECT but nondiagnostic TTEs. This study suggests that contrast echocardiography should be performed before using more expensive or invasive diagnostic testing for this condition. (J Am Soc Echocardiogr 2002;15:316-22.)