Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial.

BACKGROUND: The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported. OBJECTIVE: To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia. DESIGN: Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505). SETTING: 46 U.S. and Canadian hospitals. PARTICIPANTS: Patients aged 50 years or older undergoing hip fracture surgery. INTERVENTION: Spinal or general anesthesia. MEASUREMENTS: Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care. RESULTS: A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups. LIMITATION: Missing outcome data and multiple outcomes assessed. CONCLUSION: Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

Focal confluent fibrosis in cirrhotic liver: natural history studied with serial CT.

OBJECTIVE: The objective of this study was to assess the long-term natural history of focal confluent fibrosis in cirrhotic liver with CT. MATERIALS AND METHODS: Two radiologists retrospectively reviewed in consensus 118 liver CT examinations in 26 patients (19 men, seven women; age range, 32-68 years; mean age, 50 years) performed over approximately 6 years. Helical CT scans were obtained before and 30-35 and 65-70 seconds after injection of 125-150 mL of contrast medium at a rate of 4-5 mL/s. Proof of cirrhosis was based on liver transplantation (n = 6), biopsy (n = 9), or imaging findings (n = 11). The number, location, and attenuation of fibrotic lesions and presence of trapped vessels were evaluated. Variation of hepatic retraction associated with the development of focal confluent fibrosis lesions was assessed using the ellipsoid volume formula and an arbitrary retraction index. RESULTS: Each radiologist identified 41 focal confluent fibrosis lesions. All lesions were identified by both radiologists. Twelve patients (46%) had a single lesion, 13 (50%) had two lesions, and one (4%) had three lesions. Thirty-four (83%) of 41 lesions were located in segment IV, VII, or VIII. Thirty-two lesions (78%) were hypoattenuating on unenhanced images, 25 lesions (61%) were hypoattenuating on hepatic arterial phase images, and 20 lesions (49%) were isoattenuating on portal venous phase images. Seven lesions (17%) were or became hyperattenuating at follow-up on portal venous phase images. Trapped vessels were found in six lesions (15%). The retraction index showed a significant increase over time (r = 0.423, p < or = 0.0001). CONCLUSION: The degree of capsule retraction associated with focal confluent fibrosis evolves with time and relates to the natural evolution of cirrhosis.

Perforated duodenal diverticulum: clinical and imaging findings in eight patients.

BACKGROUND: Duodenal diverticula are common and are usually asymptomatic. We have studied a substantial number of patients who had perforation of a duodenal diverticulum and found these challenging to diagnose with little guidance from prior publications. METHODS: Retrospective study for the most recent 10-year period of all patients who had a discharge diagnosis of perforated duodenal diverticulum or duodenal diverticulitis and also had relevant imaging studies. RESULTS: Eight patients had CT evaluation and six had upper GI fluoroscopic evaluation. All presented with acute abdominal pain. Duodenal diverticular perforation was spontaneous in 6 patients, and caused by endoscopy or feeding tube placement in one patient each. The diagnosis was made correctly by imaging in only 2 patients, while retrospective review showed clear evidence of a diverticulum and extraluminal gas in all cases. Clinical management included surgery in five patients and nonoperative management in three. Average duration of hospital stay was 32 days and two patients died. CONCLUSION: Perforation of a duodenal diverticulum may cause severe illness or death and is difficult to diagnose. Careful attention to CT findings and appropriate use of upper GI studies may allow more confident diagnosis and management.

Nonobstructing renal stones on unenhanced CT: a real cause for renal colic?

OBJECTIVE: The purpose of this study was to evaluate the incidence of nonobstructing renal stones on unenhanced CT in patients presenting to the emergency department with renal colic and to determine whether this finding might be the cause of patients' symptoms. CONCLUSION: Nonobstructing renal stones on unenhanced CT are a frequent finding in patients evaluated in the emergency department for suspected renal colic. These stones are usually not recognized as the cause of pain by physicians and may be responsible for multiple clinical and radiologic evaluations. In the absence of other clinical or CT evidence of a separate cause, these stones are likely to be the cause of a patient's acute pain.

Multiple hepatic adenomas associated with liver steatosis at CT and MRI: a case-control study.

OBJECTIVE: The objective of our study was to investigate the relationship between hepatic adenoma and liver steatosis. MATERIALS AND METHODS: Radiology and pathology records from January 1999 to March 2007 were reviewed to identify 24 patients (22 women and two men; mean age, 40 years) with a pathology-proven diagnosis of hepatic adenoma (mean size +/- SD, 7.2 +/- 3.7 cm) who underwent helical contrast-enhanced CT (n = 23) and/or gadolinium-enhanced MRI (n = 8). The control group was composed of 24 patients of similar age and sex (21 women and three men; mean age, 43 years) with hepatic hemangioma who underwent CT or MR evaluation during the same time period. Two radiologists independently interpreted the imaging studies to determine the number of lesions and whether steatosis was present. The difference in prevalence of steatosis between the adenoma group versus the control group and the difference between patients with a single hepatic adenoma versus those with multiple hepatic adenomas were assessed (chi-square test). RESULTS: Hepatic steatosis was present in 14 of 24 patients (58%) with hepatic adenoma versus seven of 24 patients (29%) with hemangioma (p = 0.042). Steatosis was more common in patients with multiple hepatic adenomas (9/11, 82%) than in those with a single hepatic adenoma (5/13, 38%) (p = 0.047). CONCLUSION: Hepatic adenomas occur more frequently and more often are multiple in patients with hepatic steatosis.

CT criteria for differentiating abdominal hemorrhage: anticoagulation or aortic aneurysm rupture?

OBJECTIVE: The purpose of our study was to test the hypothesis that CT criteria would allow accurate diagnosis of the specific cause of abdominal hemorrhage in patients with coagulopathy or abdominal aortic aneurysm. CONCLUSION: Attention to specific CT criteria allows accurate diagnosis of the specific cause of spontaneous abdominal hemorrhage even in patients who have both coagulopathy and an abdominal aortic aneurysm.

Direct comparison of computed tomography and magnetic resonance imaging for characterization of posterior left atrial morphology.

OBJECTIVE: Accumulating evidence points to the central importance of the posterior left atrium (PLA) for atrial fibrillation (AF). Catheter ablation intended to cure AF is increasingly practiced; performance and assessment of this procedure is enhanced by accurate imaging of PLA anatomy. Prior reports have suggested that both computed tomographic (CT) and magnetic resonance (MR) imaging techniques provide accurate PLA images. These techniques have never been compared directly. MATERIALS AND METHODS: Twenty patients referred for catheter ablation underwent preoperative imaging using both CT and MR. Each technique was used to create a multidimensional image of the PLA. RESULTS: Within patients, morphologic and dimensional PLA indices, including number of individual pulmonary venoatrial junctions, presence of ostial branches, circumference of each venoatrial junction, venoatrial junction "non-circularity", and distance between ipsilateral superior and inferior venoatrial junctions, were well correlated. CONCLUSIONS: CT and MR-based images of the PLA appear comparable. Technique selection should involve considerations of toxicity, tolerance, and local resources.

Multi-detector row CT of the left atrium and pulmonary veins before radio-frequency catheter ablation for atrial fibrillation.

Radio-frequency catheter ablation (RFCA) of the distal pulmonary veins and posterior left atrium is increasingly being used to treat recurrent or refractory atrial fibrillation that resists pharmacologic therapy or cardioversion. Successful RFCA of atrial fibrillation requires resolution of abnormal rhythms while minimizing complications and can be achieved with precise, preprocedural, three-dimensional (3D) anatomic delineation of the target, the atriopulmonary venous junction. Three-dimensional multi-detector row computed tomography (CT) of the pulmonary veins and left atrium provides the necessary anatomic information for successful RFCA, including (a) the number, location, and angulation of pulmonary veins and their ostial branches unobscured by adjacent cardiac and vascular anatomy, and (b) left atrial volume. The 3D multi-detector row CT scanning and postprocessing techniques used for pre-RFCA planning are straightforward. Radiologists must not only understand these techniques but must also be familiar with atrial fibrillation and the technical considerations and complications associated with RFCA of this condition. In addition, radiologists must be familiar with anatomic variants of the left atrium and distal pulmonary veins and understand the importance of these variants to the referring cardiac interventional electrophysiologist.

Radiographic manifestations of normal postoperative anatomy and gastrointestinal complications of bariatric surgery, with emphasis on CT imaging findings.

Recently, there has been a tremendous increase in the frequency of utilization of surgery to control morbid obesity that is very common and increasing in incidence in Western industrialized nations. Imaging plays an important role in the evaluation and management of patients before and after bariatric surgery. In this article, we discuss the imaging findings relating to bariatric procedures, focusing on the role of computed tomography (CT) in the evaluation of normal postoperative anatomy and gastrointestinal complications.

The aortic root: comparison of measurements from ECG-gated CT angiography with transthoracic echocardiography.

PURPOSE: The purpose of this study was to compare the measurements of the aortic root obtained from electrocardiographically (ECG)-gated computed tomography (CT) angiography (CTA) to the measurements obtained from transthoracic echocardiography (TTE). MATERIALS AND METHODS: This was a retrospective study in a patient population scanned at our institution between December 2005 and January 2007 with retrospectively ECG-gated CTA. ECG-gated CTA was performed with a 64-section helical CT scanner (Light speed, VCT, GE, Milwaukee, WI). Sixty-eight patients; 51 men and 17 women were included in this study. Aortic root diameters were measured by using double oblique reconstruction from axial source images. The TTE measurements of the aortic root were obtained from the reports that were performed within 2 months of CTA. RESULTS: The average aortic root diameter measured by TTE was 33+/-4.1 mm; on CTA it was 36.9+/-3.8 mm. The median difference between the 2 measurements was 3.9 mm which was significant (P<0.0001). In patients whose aortic root measurements with CTA were normal, the TTE measurements were also normal. However, in the group of patients with dilated aortic roots by CTA, TTE measurements were significantly lower and many were normal. In the group of patients with dilated aortic root by TTE, the CTA measurements of the aortic root were similarly increased. CONCLUSIONS: Retrospective comparison of TTE and CTA measurements of the aortic root reveal that TTE measurements are substantially lower or even normal in patients found to have dilated aortic root by CTA.

Ultrasound-guided biopsy of the thyroid: a comparison of technique with respect to diagnostic accuracy.

Ultrasound-guided sampling of the thyroid represents a standard diagnostic procedure in the evaluation of thyroid nodules. The two techniques typically used are fine-needle aspiration and fine-needle capillary biopsy. Each has been used with success in various body sites. Recently, a comparison of these two techniques showed no significant difference with regard to specimen adequacy. In this study, the type of technique was correlated with diagnostic accuracy. For each technique, the preoperative cytology diagnosis was compared with the surgical pathology diagnosis in 46 resected thyroid nodules. No false-positive diagnoses were identified. No significant difference in diagnostic accuracy was found on comparison of the two techniques. Therefore, either technique may be used according to the operator's preference.

Ultrasound-guided fine-needle aspiration versus fine-needle capillary sampling biopsy of thyroid nodules: does technique matter?

OBJECTIVE: Both fine-needle aspiration (FNA) and fine-needle capillary (FNC) sampling of palpable thyroid nodules have been advocated. The appropriate technique for biopsy of nonpalpable nodules now sampled under ultrasound guidance has not been assessed. The objective of this study was to determine cytologic adequacy rates of ultrasound-guided FNA and FNC sampling. METHODS: Ultrasound-guided fine-needle biopsy was performed on 180 thyroid nodules. Nodules were measured and characterized (mixed cystic-solid or solid) on diagnostic sonography. The technique used for biopsy (FNA versus FNC sampling) alternated sequentially per patient. Four 25-gauge fine-needle samples were obtained from each nodule. The sampling adequacy and cytopathologic diagnoses were recorded. The significance of differences in cytologic adequacy rates between techniques was then assessed with a repeated measures logistic regression model. RESULTS: Fine-needle aspiration and FNC sampling biopsies were performed in 88 and 92 nodules, respectively. Fine-needle aspiration was diagnostic (ie, satisfactory) in 78 (89%) of 88 nodules and nondiagnostic (less than optimal or unsatisfactory) in 10 (11%) of 88 nodules; FNC sampling was diagnostic in 80 (87%) of 92 nodules and nondiagnostic in 12 (13%) of 92 nodules. Fine-needle aspiration sampling was diagnostic in 38 (86%) of 44 solid nodules and 40 (91%) of 44 mixed cystic-solid nodules; FNC sampling was diagnostic in 48 (81%) of 59 solid nodules and 32 (97%) of 33 mixed cystic-solid nodules. These percentages were not significantly different. CONCLUSIONS: Ultrasound-guided FNA and FNC sampling result in comparable diagnostic cytologic adequacy rates. Equivalent diagnostic yields and the technical ease of capillary sampling may prompt adoption of FNC sampling at high-volume endocrine/radiology practices.

Gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery: clinical and imaging findings.

PURPOSE: To report the complications and imaging findings in a large group of patients who underwent Roux-en-Y gastric bypass (GBP) surgery. MATERIALS AND METHODS: Four hundred sixty-three patients were evaluated for upper gastrointestinal (GI) complications following Roux-en-Y GBP surgery. Major complications were those that required surgical or radiologic intervention and minor complications were those that resolved spontaneously. The time from surgery to complication and findings from upper GI series and computed tomography (CT) of the major complications and minor leaks were reviewed. RESULTS: Forty-four patients had 56 major complications: 23 small-bowel obstructions (14 internal hernias and nine adhesions), 16 major leaks, 15 anastomotic strictures, and two fistulas. There were 13 minor leaks and 18 other complications. Internal hernias were late complications and had a variety of findings at upper GI series and CT. Leaks were early complications and usually originated from the gastrojejunal anastomosis; findings from upper GI series and CT demonstrated extraluminal gas, contrast material, or both. Anastomotic strictures were late complications and were diagnosed at upper GI series with rounded dilation of the pouch and delayed emptying. CONCLUSION: Upper GI complications that required intervention occurred in 9.5% of patients. CT and upper GI series can depict most major complications.

Evaluation of responses to chemoembolization in patients with unresectable hepatocellular carcinoma.

BACKGROUND: The authors used computed tomography (CT) scans to correlate the changes in tumor vascularity, necrosis, and size with response and survival after transcatheter arterial chemoembolization (TACE) in patients with advanced, unresectable, hepatocellular carcinoma (HCC). METHODS: The authors studied 72 patients with biopsy-proven, unresectable HCC and focused on 186 individual tumor masses. A baseline, multiphase, helical CT was performed and at least three follow-up CT scans were performed after treatment by TACE. Tumors were classified as hypervascular or hypovascular and patients were classified as responders or nonresponders based on CT evidence of altered tumor size, tumor necrosis, and the appearance of new tumors. A new scoring system was used to monitor patient response to TACE. RESULTS: Thirty-eight patients were responders and 34 were nonresponders. Patient survival was significantly increased (P = 0.009) in patients who were hypervascular responders. Survival also was increased in hypervascular nonresponders compared with hypovascular nonresponders (P = 0.008) and in hypovascular responders compared with hypovascular nonresponders (P = 0.002). Response to chemoembolization was found to be significantly (P = 0.02) and inversely proportional to tumor size, but the number of tumor foci in an individual patient was not predictive. CONCLUSIONS: TACE appears to result in improved survival among HCC patients with hypervascular tumors who responded to therapy. However, even patients classified by CT as hypervascular nonresponders and hypovascular responders have improved survival.