Prognostic Value of CTA-Derived Left Ventricular Mass in Neonates with Congenital Heart Disease

For therapeutic decisions regarding uni- or biventricular surgical repair in congenital heart disease (CHD), left ventricular mass (LVM) is an important factor. The aim of this retrospective study was to determine the LVM of infants with CHD in thoracic computed tomography angiographies (CTAs) and to evaluate its usefulness as a prognostic parameter, with special attention paid to hypoplastic left heart (HLH) patients. Manual segmentation of the left ventricular endo- and epicardial volumes was performed in CTAs of 132 infants. LVMs were determined from these volumes and normalized to body surface area. LVMs of patients with different types of CHD were compared to each other using analyses of variances (ANOVA). An LVM cutoff for discrimination between uni- and biventricular repair was determined using receiver operating characteristics. Survival rates were calculated using Kaplan–Meier statistics. Patients with a clinical diagnosis of an HLH had significantly lower mean LVM (21.88 g/m²) compared to patients without applicable disease (50.22 g/m²; p < 0.0001) and compared to other CHDs, including persistent truncus arteriosus, left ventricular outflow tract obstruction, transposition of the great arteries, pulmonary artery stenosis or atresia, and double-outlet right ventricle (all, p < 0.05). The LVM cutoff for uni- vs. biventricular surgery was 33.9 g/m² (sensitivity: 82.3%; specificity: 73.7%; PPV: 94.9%). In a subanalysis of HLH patients, a sensitivity of 50.0%, specificity of 100%, PPV of 100%, and NPV of 83.3% was determined. Patient survival was not significantly different between the surgical approaches or between patients with LVM above or below the cutoff. LVM can be measured in chest CTA of newborns with CHD and can be used as a prognostic factor.

[Agranulocytosis after use of metamizole - an underestimated risk?]

OBJECTIVE

Metamizole was the second most common drug prescribed in Germany in 2018 despite the known risk of agranulocytosis and the strict indication. According to Stammschulte et al. up to 25 % of all prescriptions are off-label use. Although mandatory according to the prescribing information of metamizole, regular blood cell counts are not performed in up to 50 % of the patients with long-term use of this drug.

MATERIAL AND METHODS

Retrospective analysis of eight cases metamizole-induced agranulocytosis over a period of five years (2016-2020) in the university ENT department in Erlangen. Five patients were men and three women. Mean age of diagnosis was 52,4 years (± 25,6).

RESULTS

Agranulocytosis after use of metamizole is a serious adverse drug reaction that may affect patients of all ages. Frequently, only distinct clinical symptoms such as temperature of unknown origin, dysphagia and tonsillitis in combination with abscesses in the head and neck area result in the detection of a metamizole-induced agranulocytosis. An agranulocytosis provokes partially radical surgery and/ or intensive-care measures and could lead to sepsis with organ failure or even to death.

CONCLUSIONS

These patient cases show that agranulocytosis is a dangerous or even deadly adverse drug reaction after use of metamizole. Although the risk of agranulocytosis appears to increase with duration of use, we would recommend patient education as well as documentation of even a single administration of metamizole. This may facilitate early diagnosis of metamizole-induced agranulocytosis and thus prevent the onset of severe complications with possible lethal outcome.

Carotid CTA at the Lowest Tube Voltage (70 kV) in Comparison with Automated Tube Voltage Adaption

BACKGROUND AND PURPOSE

CTA is the imaging modality of choice in many institutions for the evaluation of the supraaortic vessels, but radiation exposure remains a matter of concern. Our aim was to evaluate a 70-kV protocol for CT angiography of the carotid arteries with respect to image quality and radiation exposure compared with automated tube voltage adaption.

MATERIALS AND METHODS

A total of 90 consecutive patients were included in this prospective study and randomized to the study group (n = 45, 70 kV) or control group (n = 45, automated tube voltage adaptation). Volume CT dose indices and dose-length products were recorded in the examination protocol. Image quality was assessed as arterial vessel contrast, signal-to-noise ratio, contrast-to-noise ratio, and contrast-to-noise ratio in reference to the radiation dose. Subjective overall image-quality analysis, image-artifact analysis, and diagnostic evaluation were performed by 2 observers by using a 4-point Likert scale.

RESULTS

Radiation exposure was significantly lower in the study group (volume CT dose index reduced by 22%, dose-length product reduction by 20%; each P < .001). Contrast (P = .15), SNR (P = .4), and contrast-to-noise ratio (P = .5) did not show significant differences between the groups. The contrast-to-noise ratio in reference to the radiation dose was not significantly increased using the study protocol (P = .2). Subjective image quality and visualization of pathologic findings did not differ significantly between the groups.

CONCLUSIONS

Carotid CTA using the lowest available voltage (70 kV) is feasible at very-low-dose levels, while overall image quality is comparable with protocols using automated tube voltage selection.

Pilot study using intraoperative fluorescence angiography during arteriovenous hemodialysis access surgery

INTRODUCTION:

In this pilot study, we used indocyanine green fluorescence angiography during hemodialysis access surgery. The aim was to evaluate its relevance as a diagnostic tool to visualize changes in hand microperfusion.

PATIENTS AND METHODS:

In this prospective single-center study, 47 adult patients (33 male, 14 female) with renal disease (24 preemptive, 23 endstage) were enrolled. Surgical creation of an arteriovenous fistula was performed (22 forearm, 25 upper arm). Microperfusion of the ipsilateral hand and fingers was evaluated intraoperatively using indocyanine green fluorescence angiography. We compared the cumulated microperfusion parameters ingress (In) and ingress rate (InR) before and after opening of the anastomosis. To compare the dimension of microcirculatory decline, we calculated the ratios of the parameters (RatioIn and RatioInR) after to those before anastomosis opening.

RESULTS:

The cumulated microperfusion parameters In and InR showed a significant decrease after completion of anastomosis and declamping. This effect has been seen in all patients for the hand and for each finger consecutively. During follow-up (mean 4.6, range 3-11 months), 5 patients (10.6%) complained about hemodialysis access-induced distal ischemia. The ratio of intraoperative microperfusion in those five hemodialysis access-induced ischemia patients was significantly lower compared to asymptomatic patients (RatioIn 0.23 vs 0.58, p = 0.001, and RatioInR 0.25 vs 0.62, p = 0.003).

CONCLUSION:

Intraoperative fluorescence angiography could visualize the deterioration of ipsilateral hand microperfusion after surgical creation of an arteriovenous fistula. It seems to be a promising tool to detect patients at risk for hemodialysis access-induced distal ischemia early in the peri- or even intraoperative stage.

Ultrasound elastography of pulmonary lesions - a feasibility study

INTRODUCTION

The potential of sonography in the examination of lung tissue is extremely limited by the air-filled alveoles of the lung. Only in special circumstances like pleural adhesion lesions, atelectasis or pneumonia can lung tissue be visualized by B-mode sonography. Real-time elastography was primarily applied to detect and visualize pulmonary lesions.

METHODS AND PATIENTS

8 patients with a total of 18 histologically proven metastases of the lung were included. All pulmonary lesions were detected by computed tomography. Sonographic examination was performed with a 7.5 MHz linear transducer (Acuson Antares premium edition, Siemens, Erlangen, Germany), including B-mode and real-time elastography (RTE). The mean distance between pleura and the lesions ranged from 0 to 2.5 cm. Two lesions were located in the upper right lobe, eleven lesions in the lower right and five in the lower left lobe.

RESULTS

RTE was able to detect and visualize all 18 pulmonary lesions in contrast to B-mode. The size and distance of the lesions from the pleura correlated with the CT findings.

CONCLUSION

In contrast to B-mode sonography, RTE is able to detect and visualize peripheral, non-pleural adherent pulmonary lesions.

[Geriatric day clinic. What is the status of an acute geriatric day clinical in the service chain?]

Geriatric care covers a variety of differentiated services and structures, and the well-established system of in- and outpatient treatment has now been expanded to include the day hospital. The 30-bed geriatric day hospital at the "Zentrum für Akutgeriatrie und Frührehabilitation", ZAGF (Center for Acute Geriatric Medicine and Early Rehabilitation) at the Municipal Hospital Munich Neuperlach provides diagnostic and therapeutic services for acute and chronic illnesses with the aim of obviating or shortening hospitalization, helping patients to practise self-help, and preserving social competence. A multi-dimensional interdisciplinary geriatric assessment is used to clarify indications and contraindications, and to plan holistic individual therapeutic strategies.

[Effectiveness of short-term triple therapy for healing Helicobacter pylori infection in ulcer disease]

There is evidence that triple therapy with two antibiotics and a proton pump inhibitor is more cost-effective than various dual therapies for the eradication of Helicobacter pylori. We have analyzed the effectiveness and acceptability of the so-called "Italian protocol" (clarithromycin 250 mg b.i.d., metronidazole 500 mg b.i.d. and omeprazole 20 mg daily for one week, followed by 20 mg omeprazole daily for further 3 weeks) in a prospective study of 36 patients with Helicobacter pylori-associated ulcers (10 gastric ulcers, 26 duodenal ulcers). Primary eradication was achieved in 35 out of 36 patients (96%). Side effects such as dysgeusia and diarrhea were rare and rapidly reversible. We conclude that this triple therapy was cost-effective and well tolerated in our study population.

[Cystic lymphangioma of the mesenterial root as a rare cause of acute abdomen]

Mesenteric lymphangioma is a rare, benign cystic tumor of the lymphatic system, which is commonly found in younger children and may in certain cases lead to an acute abdominal manifestation. The treatment of choice is surgical resection without damage to the blood supply of the bowel. The prognosis is generally favourable, but with increasing tumor size radical resection becomes more difficult and local recurrence more probable.

[Ulcer symptoms without demonstration of ulcer: causative therapy with demonstration of Helicobacter pylori]

Helicobacter pylori-associated gastritis was found by endoscopy in 15 (= 28%) out of 53 patients presenting gastric pain of ulcer type without macroscopically detectable lesion of the gastric mucosa. Following a treatment of four weeks with bismuth subcitrate tablets (2 x 2 tablets daily), in 73% improvement of histological findings and in 87% elimination of bacteria could be attained. Thus, this causal therapy had a favourable effect on patient complaints.

The lung after trauma and shock--fine structure of the alveolar-capillary barrier in 23 autopsies

We have examined the ultrastructure of the alveolar septa in the lungs of 23 victims of severe trauma and shock. In ten patients, who died within a week after trauma, protein-poor interstitial edema and fat emboli were the most constant ultrastructural change. The alveolar epithelium and the capillary endothelium were surprisingly devoid of morphologic evidence of injury. A high incidence of pneumonia and/or sepsis complicated the hospital course of patients surviving for longer periods of time. Ultrastructurally, the lungs of these patients showed variable degrees of injury to the alveolar epithelium and capillary endothelium and accumulation of protein-rich edema fluid in the extravascular spaces. The study suggests that most of the pulmonary pathologic lesions attributed to tissue trauma and shock are the consequence of systemic or local infections to which trauma patients are particularly susceptible.

[Salmonella colitis]

Salmonella colitis is defined on the basis of 3 case reports and 75 well-documented cases from the literature. Salmonella colitis is an acute ulcerative colitis occurring in enteric salmonellosis. There is complete clinical and endoscopic remission within 4--8 weeks and no relapse. The disease is to be distinguished from idiopathic ulcerative colitis in a salmonella carrier state. The difficulties of this differential diagnosis are demonstrated in a further case report.

[Bronchiolo-alveolar cell carcinoma]

15 cases of bronchiolo-alveolar cell carcinoma were observed at the Dept. of Surgery of the University Hospital of Zurich from 1961 to 1976. The mean age of these patients was 56 years. The sex distribution was 13 males and 2 females. Five cases were discovered accidentally; the symptoms of the remaining 10 were uncharacteristic. Cytology, bronchoscopy and mediastinoscopy were negative at early stages. Diagnosis was made by histologic examination of the specimens only. Needle biopsy, performed routinely over recent years, proved helpful in 4 cases. In 12 out of 14 patients, lobectomy was considered 'radical'; nevertheless, only 2 survived more than 5 years. The disseminated form of the bronchiolo-alveolar cell carcinoma is characterized by a particularly poor prognosis. According to our experience and to the literature, only the solitary, nodular type shows a more favourable outlook.

[Silicosis, chronic bronchitis and smoking habits]

In 333 patients suffereing from silicosis the incidence of chronic bronchitis and/or obstruction of the respiratory tract has been correlated with cigarette smoking. The incidence of chronic bronchitis and/or airway obstruction in patients who had acquired either slight or severe silicosis in Switzerland was over 50%. A positive correlation between cigarette smoking and chronic bronchitis and/or airway obstruction could be found only in younger patients with slight silicosis. Chronic bronchitis and/or airway obstruction was not more frequent in foundry-workers suffering from silicosis where they had been exposed to fumes which irritated the respiratory tract. Deformation of the respiratory tract due to silicosis has a greater bearing on the development of chronic bronchitis and airway obstruction than immoderate cigarette smoking.