Pulmonary Embolism in Pregnancy: A Review for Clinical Practitioners.

Diagnostic and therapeutic decision-making in pregnancy with suspected pulmonary embolism (PE) is challenging. European and other international professional societies have proposed various recommendations that are ambiguous, probably due to the unavailability of randomized controlled trials. In the following sections, we discuss the supporting diagnostic steps and treatments. We suggest a standardized diagnostic work-up in pregnant patients presenting with symptoms of PE to make evidence-based diagnostic and therapeutic decisions. We strongly recommend that clinical decisions on treatment in pregnant patients with intermediate- or high-risk pulmonary embolism should include a multidisciplinary team approach involving emergency physicians, pulmonologists, angiologist, cardiologists, thoracic and/or cardiovascular surgeons, radiologists, and obstetricians to choose a tailored management option including an interventional treatment. It is important to be aware of the differences among guidelines and to assess each case individually, considering the specific views of the different specialties. This review summarizes key concepts of the diagnostics and acute management of pregnant women with suspected PE that are supportive for the clinician on duty.

[Role of computed tomography in the preoperative diagnosis of otosclerosis]. / Stellenwert der Computertomographie in der präoperativen Diagnostik der Otosklerose.

BACKGROUND: Otosclerosis is an osteodystrophy of the otic capsule and presents with progressive conductive hearing loss. Imaging studies, especially computed tomography (CT) and cone-beam CT, have gained increased relevance in the diagnosis of otosclerosis. OBJECTIVE: This study investigated whether there is a correlation between the extent of otosclerosis in high-resolution or cone-beam CT and hearing loss in pure-tone audiometry. MATERIALS AND METHODS: Based on an existing classification of otosclerotic foci, a classification was established. Preoperative CT scans of patients undergoing stapedotomy between 2015 and 2019 were evaluated and classified by two independent otorhinolaryngologists. The preoperative pure-tone audiograms were analysed and compared to the results of CT. RESULTS: A total of 168 CT studies (i.e., 168 ears) in 156 patients with intraoperatively confirmed otosclerosis were included in our study. A correlation between the extent of the otosclerotic focus or the calculated scores and hearing loss in pure-tone audiometry (air conduction, bone conduction and air-bone-gap) could not be proven. CONCLUSION: Preoperative CT is not obligatory. However, preoperative imaging using CT or cone-beam CT can be helpful to confirm the diagnosis and exclude other middle or inner ear pathologies as well as in planning of the surgical procedure in the overall context of otoscopy and audiometry. A correlation with the degree of hearing impairment could not be demonstrated and remains unclear.

COVID-19 and the role of imaging: early experiences in Central Switzerland.

The SARS-CoV-2 virus (COVID-19) was initially observed in a group of Chinese patients with unclear pneumonia in Wuhan, Hubei [1] in late December 2019. The first positive case in Switzerland was confirmed on 25 February 2020 in a patient from canton Tessin, who most likely caught the virus during a visit to Milan, Italy [2]. The country has since been preparing for an imminent public health emergency caused by the pandemic. As of 14 May 2020, the Swiss healthcare system is facing a total of 30,463 corona virus-positive people [3]. With numbers of new infections decreasing after the first pandemic wave, the continuing endemic situation will continue to be a major challenge for the Swiss healthcare system. It remains crucial to separate the clinically low-symptomatic from the severely affected patients in order to offer a specific therapeutic strategy to every SARS-CoV-2 patient. Reports from Chinese cohorts describe an increasing role of imaging strategies in the detection and surveillance of COVID-19 patients because of insufficient testing sensitivity of real-time reverse transcription polymerase chain reaction (RT-PCR) tests [4]. Chest computed tomography (CT), with a reported sensitivity of up to 97% [5, 6], gained importance particularly in patients with false negative RT-PCR results. In this short communication, we describe our first clinical experiences with 55 COVID-19 patients in Central Switzerland, who were either imaged with a standard chest x-ray, chest CT, or both. We provide an illustrative and schematic description of typical COVID-19 imaging features and suggest that imaging plays an important role in the clinical work-up of suspected or confirmed COVID-19 patients. This study was approved by the national ethics review committee (EKNZ, Switzerland) and patients’ informed consent was waived.

A blind passenger: a rare case of documented seroconversion in an Angiostrongylus cantonensis induced eosinophilic meningitis in a traveler visiting friends and relatives.

BACKGROUND: Eosinophilic meningitis (EOM) is a rare condition that is caused by various communicable and non-communicable factors. The rat-lungworm Angiostrongylus cantonensis, which is associated with consumption of raw or undercooked paratenic or intermediate hosts, is the most common cause of parasitic eosinophilic meningitis worldwide. While the majority of A. cantonensis cases are reported from endemic regions, cases in travelers pose a challenge to clinicians in non-endemic countries. Here we report a rare case of eosinophilic meningitis caused by A. cantonensis in a Swiss traveler who was diagnosed after returning from Thailand. CASE PRESENTATION: A 33-year old woman with a travel history to rural north-eastern Thailand presented to an emergency department in Switzerland with severe headache and vomiting. Eosinophilic meningitis was confirmed as the cause of the symptoms; however, serologic investigations failed to confirm an A. cantonensis infection on the first evaluation. Nevertheless, empirical treatment with an anthelminthic and steroid regimen led to a rapid alleviation of symptoms. Repeated serology confirmed seroconversion 2 weeks after treatment initiation. DISCUSSION: Parasitic etiology must be considered in returning travelers who present with symptoms compatible with a central nervous system infection. A thorough medical history, including types of food consumed, is paramount and can often suggest differential diagnosis. Neuroangiostrongyliasis is rare and might be missed if serology does not cover possible seroconversion.

Gout tophus detection-a comparison of dual-energy CT (DECT) and histology.

OBJECTIVES: To compare dual-energy CT images (DECT) directly with gold standard histology. METHODS: A 85-year-old woman with chronic recurrent gouty arthritis and macroscopically visible tophi was assessed with DECT-scans of her feet. When she died 7 days later, three tophi in different regions and in different tissues of her left foot were processed for histological examination. RESULTS: Of the selected tophi, two were almost completely missed by the color-coding DECT sequences. The tophi remained in most of their volume below the detection threshold value of 150HU (default value). CONCLUSIONS: It could be demonstrated that DECT only highlights the dense tophi (corresponding of approximately 15-20vol% urate in the tophus). Less dense tophi, despite considerable size, will be missed in the color-coded images.

[Imaging studies in the diagnosis of functional abdominal disorders]. / Bildgebung bei unspezifischen Abdominalbeschwerden.

Functional abdominal disorders are predominantly diagnosed on the basis of a thorough history and clinical examination. It is a challenge to clinicians to define the adequate place of imaging studies in order to rule out relevant organic disease. In functional dyspepsia, oesphago-gastroduodensoscopy and abdominal ultrasound are widely used as first line studies. Although irritable bowel syndrome is mainly diagnosed on clinical grounds, in patients over 50 years of age colonoscopy is almost mandatory, taking into account the importance of screening for colorectal cancer. In constipation-dominant irritable bowel syndrome, a marker study to determine colonic transit time will be helpful to differentiate this disorder from true slow transit constipation. Chronic or recurrent abdominal pain often warrants abdominal CT scan. Select cases are referred for laparoscopy.

Chronic recurrent multifocal osteomyelitis (CRMO) with symmetric involvement of both femora: X-ray, bone scintigram, and MR imaging findings in one case.

The case of a 17-month-old boy with symmetric involvement of both femora in chronic recurrent multifocal osteomyelitis (CRMO) is presented. Imaging showed an extraordinary involvement of both femoral diaphyses and distal metaphyses with extensive lamellar-like periosteal reactions. Diagnosis was based upon laboratory tests, bone scintigraphy, and MRI findings and was proved by open bone biopsy.

Bone metabolism during the perimenopausal transition: a prospective study.

OBJECTIVE: Changes in biochemical markers of bone formation and resorption were followed over the course of 1 year in premenopausal, perimenopausal and early postmenopausal women. METHODS: Sixty-four subjects were analyzed, grouped according to their menstrual pattern, menopausal complaints and endocrinological parameters to be premenopausal (n=20), perimenopausal (n=24) or early postmenopausal (n=20). The parameters studied at four visits during the 12-month study period were the urinary pyridinium cross-links pyridinoline (PYD) and deoxypyridinoline (DPD), and N-terminal telopeptide (NTX) as bone resorption markers, as well as osteocalcin (OC) and bone-specific alkaline phosphatase (BAP) in serum, representing bone formation. The longitudinal changes over time as well as intergroup differences were analyzed using generalized estimating equations (GEE) in connection with Wald statistics. RESULTS: Over the course of 1 year BAP levels decreased in the late premenopausal group (P<0.05). The perimenopausal group exhibited significant changes of PYD, DPD and OC (P<0.01), NTX levels were higher than in premenopause. Postmenopausal subjects had elevated NTX values, while PYD and DPD levels remained close to the perimenopausal range. Only for OC a time effect was seen during postmenopause. CONCLUSIONS: Changes in bone turnover already begin in late premenopause, when decreased bone formation may precede increased bone resorption. The rise of NTX from late premenopause through early postmenopause indicates diagnostic sensitivity of this parameter to changes in bone metabolism induced by estrogen withdrawal. PYD and DPD do not follow this pattern, but change significantly with time during perimenopause to then remain largely unchanged in early postmenopause.