Use Of Clinical Criteria Research Articles

Fat Embolism Syndrome: Case Report

Fat embolism syndrome (FES) is a systemic inflammatory cascade affecting multiple organ systems occurring after trauma, orthopedic procedures and rarely in non-traumatic patients causing high morbidity and mortality. Fat emboli develop in many patients with bone fractures (incidence of this problem can be up to 90% in patients who have sustained major injuries), but are usually asymptomatic. A minority of patients develop signs and symptoms of organ system dysfunction due to mechanical obstruction of capillaries by fat emboli or due to fat hydrolyzing to fatty acids. A triad of lung, brain and skin involvement develops after 24 - 72 hours of asymptomatic period. This symptom complex is known as FES. Fat embolism is diagnosed clinically with non-specific and insensitive diagnostic tests. Treatment of FES is supportive and in most cases can be prevented by early fixation of large bone fractures. Here we report a case of traumatic fat embolism, treated successfully with supportive management. Diagnosis of FES needs high index of suspicion and use of clinical criteria along with imaging. J Neurol Res. 2016;6(5-6):114-117 doi: https://doi.org/10.14740/jnr405w

Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 7: Aortic Diseases, Including Marfan Syndrome: A Scientific Statement From the American Heart Association and American College of Cardiology.

Acute aortic dissection or rupture in Marfan syndrome or other aortopathies is an important cause of sudden death in athletes.1 Increased blood pressure and aortic stress during intense physical exertion place the patient with Marfan syndrome, Loeys-Dietz syndrome, familial thoracic aortic aneurysm (TAA) and dissection syndrome, bicuspid aortic valve (BAV) aortopathy, aortic aneurysm, or other genetically triggered aortic diseases at risk for aortic catastrophe from aortic dissection or rupture or may accelerate aneurysm formation. Therefore, for people with aortic disease or a condition associated with aortic disease, discussion about safe levels of low-intensity, noncompetitive exercise should be emphasized beginning at a young age. This is important for a healthy lifestyle and to prevent social stigmatization, which may occur when physical activity is restricted excessively in young people. Marfan syndrome, an autosomal dominant disorder of connective tissue with an estimated prevalence of 1 in 5000 to 10 000, is caused by abnormal fibrillin-1 attributable to mutations in the FBN1 gene.2 Manifestations involve multiple organ systems, including the aorta, heart and valves, skeleton, eye, lungs, and dura. FBN1 mutations can be identified in the vast majority of patients satisfying the revised Ghent criteria for Marfan syndrome.2 The diagnosis of Marfan syndrome is made by use of clinical criteria, imaging, family history, and genetic testing as outlined in the revised Ghent criteria (Tables 1 and 2).2 Cardiovascular features of Marfan syndrome include mitral valve prolapse, mitral regurgitation, aortic root dilatation (most pronounced at the sinuses of Valsalva), and aortic dissection.2 The descending aorta, although less commonly involved in young patients, is also at risk for aneurysm formation and dissection. View this table: Table 1. Revised Ghent Criteria for the Diagnosis of Marfan Syndrome Other genetically triggered aortic aneurysm syndromes and conditions associated with aortopathy may increase the risk of aortic dissection in competitive athletes. …

NGTS-03CHARACTERIZATION OF PRIMARY GLIOMAS IN INDIVIDUALS WITH LI-FRAUMENI SYNDROME: A CASE SERIES

Li-Fraumeni Syndrome (LFS) is a rare hereditary cancer syndrome that has classically been associated with familial sarcomas, but now includes brain tumors, premenopausal breast cancer, and adrenocortical carcinomas in its recognized core tumor pathologies. Germline mutations in the TP53 gene are the only known cause of LFS. Affected individuals are typically diagnosed at younger ages than individuals with sporadic tumors and are at risk for multiple malignancies over their lifetime. Characterization of the evolving phenotype of LFS is ongoing, including the use of clinical criteria to identify index patients. Few studies, however, have described the phenotype of primary gliomas in LFS. In this case series, we describe the presentation of four individuals, two male and two female, with primary gliomas and molecularly confirmed LFS at our institution. All individuals presented with high-grade gliomas: two with anaplastic astrocytoma, one with anaplastic oligodendroglioma, and one with glioblastoma multiforme. The age of diagnosis ranged from 25 to 50 years. Glioma was the first presentation of disease in three individuals. The fourth individual had a previous diagnosis of osteosarcoma. Family history was remarkable, positive with regards to Chompret criteria, in two individuals and negative or unknown in two individuals. Molecular tumor testing was available for three individuals: one individual had two somatic TP53 mutations and two individuals had one TP53 mutation with loss of heterozygosity at the opposite allele. These cases demonstrate that individuals with LFS may first present in a neuro-oncology clinic for initial diagnosis. Screening for LFS should be prompted in individuals with a personal and/or family history that includes LFS core tumor pathologies. Further characterization of these individuals is necessary to improve the early identification of LFS, specifically in individuals who present first with glioma, and provide appropriate management recommendations for patients and their families.

Comparison of bacillary index on slit skin smear with bacillary index of granuloma in leprosy and its relevance to present therapeutic regimens.

Background:As the world moves toward elimination of leprosy, persistence of infective cases in endemic pockets remains a significant problem. The use of clinical criteria to decide the paucibacillary (PB) versus multibacillary (MB) regimens has greatly simplified therapy at the field setting. However, a small but significant risk of under-treatment of so-called “PB” cases which actually have significant bacillary load exists. This study was undertaken to assess this risk and compare two methods of assessment of bacillary load, namely bacillary index on slit skin smear (BIS) versus bacillary index of granuloma (BIG).Aims:To compare BIS with BIG on skin biopsy in consecutive untreated cases of leprosy.Materials and Methods:This prospective study was conducted over a period of 12 months, wherein new untreated patients with leprosy were consecutively recruited. After a thorough clinical examination, each patient underwent slit skin smear (SSS) where the BIS was calculated. The same patient also underwent a skin biopsy from a clinical lesion where, the BIG was calculated. SSS and skin biopsy for BIS and BIG respectively were repeated for all patients at the end of therapy for comparison. All patients received therapy according to World Health Organization-Multidrug Therapy Guidelines.Results:The BIG was positive in all cases where the BIS was positive. Significantly, BIG was positive in three cases of borderline tuberculoid leprosy with <5 lesions who received PB regimen, whereas the BIS was negative in all three cases.Conclusion:This study suggests that BIG may be a better indicator of the true bacillary load in leprosy as compared to BIS. Its role in management is significant, at least in tertiary care centers to prevent “under-treatment” of so called PB cases, which may actually warrant MB regimens.

Response to comments on Value of past clinical history in differentiating bronchial asthma from chronic obstructive pulmonary disorder in male smokers presenting with shortness of breath and fixed airway obstruction.

Sir, We thank Ahmed et al.[1] for their keen interest in our article “Value of past clinical history in differentiating bronchial asthma from chronic obstructive pulmonary disorder (COPD) in male smokers presenting with shortness of breath (SOB) and fixed airway obstruction”.[2] In their comments on this article, Ahmed et al.[1] have discussed the current concepts on pathogenesis and molecular biology of asthma, COPD and a newly recognized subgroup “the overlap syndrome”.[3456789] These are now established facts but the learned readers of this journal are also aware that in routine practice, clinicians have to differentiate asthma from COPD on the basis of their clinical judgement and spirometry and where such differentiation is not possible, a diagnosis of COPD or overlap syndrome is made. Facilities for estimation of biological markers including IL-4, IL-5 and IL-13 or the sputum eosinophilia are limited to a few tertiary medical centers and it is neither feasible nor practical use these markers in differentiating these disorders. Its use, at best, is limited to experimental studies/clinical trials. Further, our intention while planning this study was to explore simple clinical criteria that can be used in routine clinical practice to differentiate asthma from COPD in patients presenting with fixed airflow obstruction with the use of the past clinical history, more so in male smokers.[1] Obviously such clinical criteria can not be foolproof and a few patients with possible overlap syndrome might escape such differentiation. This limitation apart, it was possible to separate out majority of asthma patients from COPD with the use of clinical criteria devised by us to diagnose asthma in such a difficult clinical scenario. It was neither the aim nor the intention of the authors of this study to explore the background for future trials including those for the upcoming therapies like anti-interleukin 5 monoclonal antibodies.

Diagnostic yield of endoscopic ultrasonography in patients with intermediate or high likelihood of choledocholithiasis: a retrospective study from one university-based endoscopy center.

BackgroundDiagnosis of choledocholithiasis requires clinical manifestations and imaging examination findings suggesting a stone in the common bile duct (CBD), but these factors are not highly sensitive or specific. The choledocholithiasis management algorithm proposed by the American Society for Gastrointestinal Endoscopy (ASGE) may not be appropriate for patients who fulfill the clinical criteria for a high likelihood of choledocholithiasis. Endoscopic ultrasonography (EUS) may replace endoscopic retrograde cholangiopancreatography (ERCP) for the detection of CBD stones in all patients. The aims of this study were to determine the diagnostic yield and optimal timing of EUS in patients with an intermediate or high likelihood of choledocholithiasis requiring therapeutic ERCP.MethodsPatients with suspected choledocholithiasis who underwent EUS between June 2009 and January 2012 were retrospectively reviewed. The patients were divided into two groups based on the likelihood of choledocholithiasis according to the clinical predictors described by the ASGE guidelines: an intermediate likelihood group and a high likelihood group. The demographic data, clinical manifestations at presentation, blood test results, EUS and ERCP findings, and clinical manifestations during the follow-up period were recorded and analyzed.ResultsNinety-three patients were enrolled in the study (52.7% in the intermediate likelihood group and 47.3% in the high likelihood group). CBD stones were detected in 22.44% of patients in the intermediate likelihood group and 38.63% of patients in the high likelihood group. EUS had a sensitivity of 100% and specificity of 80% for detection of CBD stones. An alkaline phosphatase level of >133 mg/dL (area under the curve, 0.576) was the only factor that was significantly associated with detection of CBD stones in patients who underwent EUS >7 days after the initial clinical presentation (odds ratio 4.87, p = 0.01).ConclusionsEUS is an accurate diagnostic tool for the detection of CBD stones, and can prevent the unnecessary use of ERCP. This study found that use of clinical criteria alone might not provide a good prediction of the presence of CBD stones, even in patients who fulfill the criteria for a high likelihood of choledocholithiasis.

The clinical utility of pain classification in non-specific arm pain

Mechanisms-based pain classification has received considerable attention recently for its potential use in clinical decision making. A number of algorithms for pain classification have been proposed. Non-specific arm pain (NSAP) is a poorly defined condition, which could benefit from classification according to pain mechanisms to improve treatment selection. This study used three published classification algorithms (hereafter called NeuPSIG, Smart, Schafer) to investigate the frequency of different pain classifications in NSAP and the clinical utility of these systems in assessing NSAP.Forty people with NSAP underwent a clinical examination and quantitative sensory testing. Findings were used to classify participants according to three classification algorithms. Frequency of pain classification including number unclassified was analysed using descriptive statistics. Inter-rater agreement was analysed using kappa coefficients.NSAP was primarily classified as ‘unlikely neuropathic pain’ using NeuPSIG criteria, ‘peripheral neuropathic pain’ using the Smart classification and ‘peripheral nerve sensitisation’ using the Schafer algorithm. Two of the three algorithms allowed classification of all but one participant; up to 45% of participants (n = 18) were categorised as mixed by the Smart classification. Inter-rater agreement was good for the Schafer algorithm (к = 0.78) and moderate for the Smart classification (к = 0.40). A kappa value was unattainable for the NeuPSIG algorithm but agreement was high.Pain classification was achievable with high inter-rater agreement for two of the three algorithms assessed. The Smart classification may be useful but requires further direction regarding the use of clinical criteria included. The impact of adding a pain classification to clinical assessment on patient outcomes needs to be evaluated.

Synthesizing Lessons Learned From Get With The Guidelines

The American Heart Association/American Stroke Association (AHA/ASA) is a trusted source of scientific information in cardiovascular medicine. The AHA/ASA has a longstanding commitment to support state-of-the-art scientific research in cardiovascular disease and stroke. The AHA/ASA has also developed a leadership role in translating cardiovascular science into internationally respected guidelines. In 2000, however, the AHA/ASA concluded that, to provide maximal benefit for patients with cardiovascular disease and those at risk, it needed to develop a rigorous approach to translating its guidelines into clinical practice. The result was a comprehensive suite of programs collectively called Get With The Guidelines (GWTG). Modeled in part on the University of California, Los Angeles Cardiovascular Hospitalization Atherosclerosis Management Program (CHAMP),1,2 GWTG was successfully piloted by the AHA in Massachusetts.3 Based on the success of the Massachusetts pilot, the AHA committed significant human and financial resources to extend the program across the United States. This commitment included the development of a national steering committee composed of AHA/ASA volunteers, and the addition of multiple modules including hospital-based management of coronary artery disease, heart failure, stroke, and resuscitation after in-hospital cardiac arrest. The scientific foundation of the program is the best evidence from the latest American College of Cardiology/AHA/ASA guidelines. GWTG staff work with participating hospitals to implement these guidelines by using AHA/ASA quality improvement professional consultation, workshops, and Webinars. In addition, the AHA developed sophisticated clinical databases (registries) through which hospitals and physicians collect information in real time for the assessment of quality, regional, and national benchmarking, national recognition, and the generation of new science. The AHA underwrites a portion of the costs associated with the technology platform and data collection tools to reduce the financial burden on participating sites. From the 4 GWTG disease-specific registries, >200 articles have been published in peer-reviewed journals. …

A metabolic remodeling in right ventricular hypertrophy is associated with decreased angiogenesis and a transition from a compensated to a decompensated state in pulmonary hypertension

Right ventricular (RV) failure is an important clinical problem with no available therapies, largely because its molecular mechanisms are unknown. Mitochondrial remodeling resulting to a metabolic shift toward glycolysis has been described in RV hypertrophy (RVH), but it is unknown whether this is beneficial or detrimental. While clinically RV failure follows a period of compensation, the transition from a compensated (cRVH) to a decompensated hypertrophied RV (dRVH) is not studied in animal models. We modeled the natural history of RVH and failure in the monocrotaline rat model of pulmonary hypertension by serially assessing clinically relevant parameters in the same animal. We defined dRVH as the stage in which RV systolic pressure started decreasing, along with the cardiac output, while the RV continued to remodel. dRVH was characterized by ascites, weight loss, and high mortality, compared to cRVH. A cRVH myocardium had hyperpolarized mitochondria and low production of mitochondria-derived reactive oxygen species (mROS), activated hypoxia-inducible factor 1α (HIF1α), and increased levels of glucose transporter 1, vascular endothelial growth factor, and stromal-derived factor 1, promoting increased glucose uptake (measured by positron emission tomography-computed tomography) and angiogenesis measured by lectin imaging in vivo. The transition to dRVH was marked by a sharp rise in mROS, inhibition of HIF1α, and activation of p53, both of which contributed to down-regulation of pyruvate dehydrogenase kinase and decreased glucose uptake. This transition was also associated with a sharp decrease in angiogenic factors and angiogenesis. We show that the previously described metabolic shift, promoting HIF1α activation and angiogenesis, is not sustained during the progression of RV failure. The loss of this beneficial remodeling may be triggered by a rise in mROS resulting in HIF1α inhibition and suppressed angiogenesis. The resultant ischemia may contribute to the rapid deterioration of RV function upon entrance to a decompensation phase. The use of clinical criteria and techniques to define and study dRVH facilitates clinical translation of our findings with direct implications for RV therapeutic and biomarker discovery programs. Decreased RV angiogenesis marks the transition from a cRVH to a dRVH. The RVs in cRVH animals are associated with decreased mROS and increased HIF1α activity compared to dRVH. The RVs in cRVH animals have increased GLUT1 levels and increased glucose uptake compared to the dRVH.

Enfermedad de Kawasaki: serie de casos en la Clfnica Universitaria Colombia, 2007-2009

BackgroundKawasaki disease is a vasculitis of unknown etiology, first described by Tomisaku Kawasaki in January 1961. During the decade of the 1960s it was called "ocular mucocutane-ous syndrome" or "mucocutaneous lymph-node syndrome". In 1974 Kawasaki published the first report of 50 patients, from which the disease was renamed with the eponymous currently in use. Kawasaki's disease had an initial presentation as a national epidemic, but currently occurs as regional outbreaks. It is a clinical entity poorly diagnosed in our setting, which can be attributed in part to limited knowledge about the diagnostic criteria by health professionals. Summary of casesWe conducted a review of clinical records for the years 2007 to 2009 of children less than five years of age who had a feverish syndrome or exanthemáta's viral features, identifying four who were diagnosed as Kawasaki disease. The most common clinical manifestations were fever and changes in the oropharynx (100% of the cases), alterations in palms and soles polymorphic erythema (75%), and conjunctival injection and cervical adenop-athy (50%). Two of the patients presented echo-cardiograms coronary alterations. ConclusionsThe appropriate use of clinical criteria is the most important tool for the health professional to diagnose of Kawasaki disease and prevent associated complications.

A Comparison of Clinical and Pathologic Assessments for the Prediction of Occult Nipple Involvement in Nipple-Sparing Mastectomies

Nipple-sparing mastectomy (NSM) for both risk reduction and cancer is increasing. In the cancer setting, most studies suggest the use of both clinical and intraoperative biopsy criteria in patient selection. This study examines the use of both biopsy and clinical criteria in women undergoing total nipple-removing mastectomy. The study consisted of 58 patients undergoing total mastectomy without nipple sparing. Biopsies of the subareola tissue (SA), proximal nipple (NC) contents and radial sections of the residual nipple (NR) were examined microscopically. Tumor size and distance from the nipple were also noted. Using clinical criteria alone, the false negative rate was 53.8% and a false positive rate of 44.4%. When adding subareola and nipple core biopsies to clinical criteria the false negative rate fell to 7.7% but the false positive rate remained at 44.4%. When using only SA and NC biopsies to predict occult nipple involvement, the false negative rate was 11.8%. In 4 cases the NC was positive while the SA was negative for cancer and in 6 cases the SA was positive and NC negative. In 2 cases both the NC and SA biopsies were negative while the NR was positive. This study supports a more limited role in the use of clinical criteria for evaluating patients for NSM. This maximizes the number of patients who are candidates for NSM with minimal risk of nipple involvement. It was also noted that intraoperative biopsies are not totally reliable in predicting occult nipple involvement.

Clinical Assessment of Low-Back-Pain Treatment Outcomes in Athletes

PATIENT SCENARIO: A 21-year-old male rodeo athlete complains of acute low back pain (LBP) after a bareback event. The athlete wishes to compete in a rodeo event in 4 d. CLINICAL OUTCOMES ASSESSMENT: Given the questionable validity and reliability of traditional clinical examination techniques for LBP, a treatment subgroup classification system combined with clinical outcomes assessment provides greater insight into suitable clinical interventions and patient response to treatment. Four LBP treatment subgroups based on the patient's clinical presentation and symptoms have been established: manipulation, stabilization, specific exercise, and traction. Manipulation subgroup research has produced a valid clinical prediction rule (CPR). The Visual Analog Scale, Numeric Rating Scale (NRS), Oswestry Low Back Pain Disability Index (ODI), Roland Morris Disability Questionnaire, Short Form 36 (SF-36), and Global Rating of Change Scale are valid, reliable, and responsive outcomes instruments with established values for minimum clinically important difference (MCID). These instruments document important changes in disablement and health-related quality of life in patients with low back injury, as well as demonstrate treatment outcomes. CLINICAL DECISION MAKING: On examination the athlete presents with moderate pain and disability as measured by the NRS, ODI, and SF-36 and meets all 5 criteria for the manipulation subgroup, indicating a high likelihood of success with manipulative therapy when following the guidelines presented in the CPR. Expected outcomes values, based on MCID values, were met after 1 treatment. Preferred outcomes, based on physical activity requirements for sport, were met on day 4. LBP generators are difficult to establish using traditional clinical examination techniques. The combined use of clinical criteria, using an LBP subgroup system, and baseline outcomes measures should guide treatment. Benchmarks should be guided by established MCID values for each instrument.

The Capacity to Vote of Persons With Serious Mental Illness

Despite legal protections, persons with mental illness continue to experience discrimination that limits their access to voting in elections. In response, a number of states have adopted individualized functional determinations of mental capacity to vote. A 2001 federal court decision offered clear criteria for determining voting capacity that are based on understanding the nature and effect of voting ("the Doe standard"). This study explored the performance on these criteria by a sample of individuals with serious mental illness. The Doe standard has been operationalized with the Competency Assessment Tool for Voting (CAT-V) along with measures of reasoning and appreciation. Performance was assessed with the CAT-V in a sample of 52 community-dwelling persons with serious mental illness and then compared on measures of cognition, verbal IQ, and symptom severity. The interview questions were scored with good interrater reliability and took an average of less than five minutes to administer. Performance was high, with 92% scoring a 5 or 6 out of 6 possible points on the Doe-standard criteria. Performance did not correlate with cognition, verbal IQ, or symptom severity. The CAT-V is an easy and efficient method of determining voting capacity according to the Doe standard. Assuming that the high scores in this sample are confirmed in other groups, in general it may be appropriate to assume that even persons with serious mental illness are capable of voting. When a person's capacity to vote is called into question, screening instruments such as the CAT-V may be useful to guide an assessment.

The Capacity to Vote of Persons With Serious Mental Illness

The Capacity to Vote of Persons With Serious Mental Illness

Diagnostic accuracy of clinical criteria for identifying systolic and diastolic heart failure: cross‐sectional study

To determine the validity and clinical usefulness of clinical criteria in the diagnosis of systolic and diastolic heart failure. Cross-sectional diagnostic study. 216 patients admitted consecutively to the cardiology section of an academic hospital with a suspected diagnosis of heart failure in a period of 12 months. A definite diagnosis of heart failure (echocardiographic diagnostic criteria of left ventricular dysfunction) was cross-matched with the results obtained using the test under investigation (Framingham clinical diagnostic criteria for heart failure). Sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio for positive test result (LR+) and likelihood ratio for negative test result (LR-) were calculated and used to construct clinical decision-making diagrams. The Framingham clinical criteria are very sensitive (92%) and moderately specific (79%). The diagnosis of heart failure was ruled out with a good LR- (0.1) but the diagnosis was confirmed with only a low level of evidence as the LR+ was 4.3. The main difference found between systolic and diastolic heart failure is that in the case of systolic failure the disease is ruled out conclusively (0.04), whereas in the case of diastolic failure the change in probability generated is at the borderline between conclusive and moderate (0.1). The absence of the Framingham clinical criteria rules out the diagnosis of heart failure, particularly in the case of systolic heart failure. However, the presence of these criteria do not necessarily confirm the diagnosis, which may be based in echocardiography.

Rate of Healing in Skin-Grafted Burn Wounds

Sir: We thank Lloyd et al. for their interest in our study. In general, we acknowledge that many aspects of clinical care are not precise, hence the use of clinical criteria in our report. The setting for our study was a public hospital, where time and resources are limited for the use of laboratory studies that do not contribute to clinical decision making with regard to patient treatment. Precise, histologically guided care, debridement, and skin grafting are not part of clinical care in our center, nor throughout most of the world. Our report deals with these “real-world” activities. It would be very interesting to study a homogenous population with burn wounds that are uniform in depth, size, and location, but such burn wounds do not occur outside of a laboratory. If Drs. Lloyd et al. choose to do a research study using either their patients or an animal model to study these questions, we will be glad to read the outcomes. As regards specific comments in their letter, they are correct that we did not verify the depth of burn in our patients via the histologic techniques they advocate. As they know, clinically, burn wound depth is classified as follows: superficial burns appear dry and red, blanch with pressure, and are painful; superficial partial-thickness burns blister, are moist and red, blanch with pressure, and are painful; deep partial-thickness burns blister, are moist, may have variable color, do not blanch, and are sensitive to pressure; full-thickness burns range from white to black, are dry and inelastic, do not blanch, and are insensate. We are confident that these criteria allowed us to compare “like with like.” Also, they are correct that the level of tangential excision differs according to the depth of injury, but again, this is a clinical judgment based on visualization of the tissues during surgery, not histologic examination. Excision is continued until healthy bleeding tissue is encountered, whether it is dermis, fat, or muscle. Skin graft adherence and epithelial outgrowth from graft edges should be essentially the same if placed on a well-vascularized wound bed. The purpose of our study was to give practitioners clinically useful information regarding wound healing after a skin graft, specifically with regard to how long their patients can reasonably expect to require dressing changes, and associated conditions that may prolong this process. We are confident that our report accomplished this goal with accurate clinical diagnosis of burn wound depth, premorbid conditions, and close, postsurgical observation. Warren L. Garner, F.A.C.S. Lisa Jewell, M.D. Department of Plastic Surgery University of Southern California Los Angeles, Calif.

Retrievable versus Permanent Caval Filter Procedures: When Are They Cost-effective for Interventional Radiology?

Because many retrievable inferior vena cava (IVC) filters are placed without ever being removed, placement of a retrievable device that is not removed incurs greater technical cost for the institution than a cheaper permanent filter (PF), with no clinical benefit for the patient and no additional professional or technical revenue for the interventional radiologist and institution. The purposes of this study are to identify patient characteristics associated with lack of removal of a retrievable filter (RF) and to develop a cost-effective strategy for placement of a retrievable IVC filter. A retrospective evaluation of 160 consecutive patients who underwent IVC filter placement with or without removal in our interventional radiology (IR) unit over a period of 31 months was performed. Patient characteristics were identified that were associated with lack of removal of retrievable IVC filters, and the cost savings were calculated in the event that a PF had been substituted for an RF in these patients. A total of 160 consecutive IVC filters were placed during the study period. Of these, 42 (26%) were PFs and 118 (74%) were RFs. During the study period, only 27 of the 118 RFs (23%) were subsequently removed. Factors associated with lack of removal of an RF included patient age (P = .003), presence of ongoing malignancy (P = .04), and indication for filter placement (P = .01). Retrospectively, the use of retrievable devices only in the presence of two of the three selection criteria (ie, age <65 years, no ongoing malignancy, prophylactic indication) would have resulted in a net incremental benefit of $59,562 for the IR service. The preferential use of retrievable versus permanent devices for filter placement is financially advantageous for an IR unit only if at least 41% of them are eventually removed. The use of clinical criteria to select device type allows significant cost savings.

Roles of Clinical Criteria, Computed Tomography Scan, and Adrenal Vein Sampling in Differential Diagnosis of Primary Aldosteronism Subtypes

In patients with primary aldosteronism (PA), it is fundamental to distinguish between subtypes that benefit from different therapies. Computed tomography (CT) scans lack sensitivity and specificity and must be followed by adrenal venous sampling (AVS). Because AVS is not widely available, a list of clinical criteria that indicate the presence of an aldosterone-producing adenoma (APA) has been suggested. The objective of the study was to test the sensitivity and specificity of the last generation CT scans, test prospectively the usefulness of clinical criteria in the diagnosis of APA, and develop a flow chart to be used when AVS is not easily available. Hypertensive patients referred to our hypertension unit were included in our study. Seventy-one patients with confirmed PA participated in our study. All patients had a CT scan and underwent AVS. Final diagnosis of APA was the main measure. A total of 44 and 56% of patients were diagnosed as having an APA and a bilateral adrenal hyperplasia (BAH), respectively. Twenty percent of patients with PA displayed hypokalemia. CT scans displayed a sensitivity of 0.87 and a specificity of 0.71. The posture test displayed a lower sensitivity and specificity (0.64 and 0.70, respectively). The distribution grades of hypertension were not significantly different between APA and BAH. Biochemical criteria of high probability of APA displayed a sensitivity of 0.32 and a specificity of 0.95. This study underlines the central role of AVS in the subtype diagnosis of PA. The use of the clinical criteria to distinguish between APA and BAH did not display a satisfactory diagnostic power.

Diagnosis of Familial Hypercholesterolemia in General Practice Using Clinical Diagnostic Criteria or Genetic Testing as Part of Cascade Genetic Screening

Background: Too few familial hypercholesterolemia (FH) patients are diagnosed. The most cost-effective strategy to diagnose FH is to examine first-degree relatives of already diagnosed patients. This is referred to as cascade genetic screening. Methods and Results: One thousand eight hundred and five first-degree relatives of index patients with molecularly defined FH consented to cascade genetic screening by the use of molecular genetic testing. Of these, 44.8% were mutation carriers and 55.2% were noncarriers. Only 44.2% of the mutation carriers were on lipid-lowering drugs at the time of genetic testing. Of these, only 9.4% had a value for total serum cholesterol below 5 mM. Among adult mutation carriers who were not on lipid-lowering treatment at the time of genetic testing, reductions in total serum cholesterol and low-density lipoprotein cholesterol of 18.4% (p < 0.0001) and 25.3% (p < 0.0001), respectively, were observed 6 months after genetic testing. It is assumed that this improvement in the lipid profile is due to a definite diagnosis obtained by molecular genetic testing. By using the results of genetic testing as the gold standard for diagnosis of FH, data from a questionnaire filled out by the relatives showed that the use of clinical criteria to diagnose FH in general practice had a sensitivity of 46.2% and a specificity of 88.0%. Conclusions: The use of clinical diagnostic criteria to diagnose FH in general practice identifies only approximately 50% of FH patients. Molecular genetic testing as part of cascade genetic screening is an efficient tool to diagnose patients, leading to significant improvement in the lipid profile. It should therefore be implemented in clinical medicine.

Fat embolism syndrome: Clinical and imaging considerations: Case report and review of literature

Fat embolism syndrome (FES) is a serious clinical disorder occurring after trauma, orthopedic procedures and rarely in non-traumatic patients. Fat emboli develop in nearly all patients with bone fractures, but they are usually asymptomatic. Small number of patients develop signs and symptoms of various organ system dysfunction due to either mechanical obstruction of capillaries by fat emboli or due to hydrolysis of fat to fatty acids. A triad of lung, brain and skin involvement develop after an asymptomatic period of 24 to 72 hours. This symptom complex is called FES. The incidence reported is up to 30%, but many mild cases may recover unnoticed. Diagnosis of fat embolism is clinical with nonspecific, insensitive diagnostic test results. Treatment of fat embolism syndrome remains supportive and in most cases can be prevented by early fixation of large bone factures. Here we report two cases of traumatic fat embolism, which were diagnosed initially by Gurd's criteria and subsequently confirmed by typical appearance on magnetic resonance imaging (MRI) of the brain in these patients. These patients were successfully treated with supportive management. In conclusion, diagnosis of FES needs high index of suspicion, exclusion of other conditions and use of clinical criteria in combination with imaging. Magnetic resonance imaging of the brain is of great importance in diagnosis and management of these patients.