Usefulness of mean platelet volume as a marker for clinical outcomes after out-of-hospital cardiac arrest: a retrospective cohort study.

Essentials It is unknown whether mean platelet volume (MPV) estimates outcomes after cardiac arrest (CA). We investigated whether MPV was associated with 30-day neurologic outcome and mortality after CA. Elevated MPV at admission was associated with poor neurological outcomes and mortality at 30 days. Identifying levels of MPV is helpful for estimating disease severity among resuscitated patients. SUMMARY: Background Whole-body ischemia followed by reperfusion during cardiac arrest and after return of spontaneous circulation (ROSC) triggers systemic sterile inflammatory responses, inducing a sepsis-like state during post-cardiac arrest syndrome. Activated platelets are enlarged, and contain vasoactive and prothrombic factors that aggravate systemic inflammation and endothelial dysfunction. Objectives To investigate whether mean platelet volume (MPV) is useful as a marker for early mortality and neurologic outcomes in patients who achieve ROSC after out-of-hospital cardiac arrest (OHCA). Methods OHCA records from the Emergency Department Cardiac Arrest Registry were retrospectively analyzed. Patients who survived for > 24 h after ROSC were included. We evaluated mortality and cerebral performance category scores after 30 days. Results We analyzed records from 184 patients with OHCA. Increased 30-day mortality among patients who achieved ROSC after OHCA was associated with MPV at admission (hazard ratio [HR] 1.36; 95% confidence interval [CI] 1.06-1.75). An elevated MPV at admission was also associated with poor neurologic outcomes (HR 1.28; 95% CI 1.06-1.55). Conclusions An elevated MPV was independently associated with increased 30-day mortality, with the highest discriminative value being obtained upon admission after OHCA. An elevated MPV on admission was associated with poor neurologic outcomes. High MPVs are helpful for estimating 30-day mortality and neurologic outcomes among patients who achieve ROSC after OHCA.

CT findings of laryngeal tuberculosis: comparison to laryngeal carcinoma.

PURPOSE: Our goal was to describe the appearance of laryngeal tuberculosis using CT, with the intent of identifying features distinguishing laryngeal tuberculosis and carcinoma. METHOD: CT scans of 12 patients with laryngeal tuberculosis were analyzed retrospectively. Clinical symptoms, laryngoscopic exams, and presence of pulmonary tuberculosis on chest radiographs were also reviewed. RESULTS: In laryngeal tuberculosis, bilateral involvement was noted in nine patients (75%), while unilateral involvement was seen in three (25%). Diffuse thickening of the free margin of the epiglottis was a characteristic and frequent finding in tuberculosis (n = 6, 50%). No deep submucosal infiltration of the preepiglottic and paralaryngeal fat spaces was seen even when there was extensive involvement of the laryngeal mucosa. Cartilage destruction was not found in any case. CONCLUSION: Characteristic CT findings of laryngeal tuberculosis include bilateral involvement, thickening of the free margin of the epiglottis, and good preservation of the preepiglottic and paralaryngeal fat spaces even in the presence of extensive mucosal involvement. By comparison, laryngeal carcinoma presented unilateral involvement, infiltration of the preepiglottic and paralaryngeal fat spaces by a submucosal mass, cartilage destruction, and extralaryngeal invasion.

Scintigraphic evaluation of renovascular hypertension.

ACE inhibitor challenged renal scintigraphic studies offer noninvasive means of evaluating patients for renovascular hypertension, and provide help in selecting patients who will benefit most from interventional procedures designed for alleviation of renal artery stenosis. These studies provide functional assessment of each kidney which also helps the vascular surgeons to plan which renal artery to repair first, when bilateral renal arteries are stenotic, prior to an abdominal aortic aneurysm repair. Vasotec challenged Tc99mMAG3 renal scintigraphy is one of such tests with several advantages over other similar methods, and appears to have a great potential of being a preferred scintigraphic study for evaluation of renovascular hypertension.

Two-dimensional-three-dimensional reconstruction computed tomography techniques.

A brief but comprehensive review of the technologic basis of computed tomography leading to the generation of more specialized and sophisticated reformatted and reconstructed two- and three-dimensional images is presented. Elements that influence the quality of such images are emphasized. Examples of clinical applications in maxillofacial and dental practice are illustrated.

Medical imaging in cochlear implant candidates.

A retrospective study of preoperative radiographic surveys obtained in 85 cochlear implant patients was performed. A total of 90 cochlear implant patients were seen at our institution during the last 10 years. In three, the implant was placed at another institution. In two otosclerosis patients, no preimplant radiographic examination was obtained. Meningitis was the cause of deafness in 45 of 90 patients (50 percent); 28 of 40 pediatric age group patients (70 percent), and in 17 of 50 adult patients (34 percent). Thirty-three of 45 postmeningitis patients (73 percent) showed characteristic radiographic signs of sclerosing labyrinthitis or labyrinthitis ossificans. These signs were present in only one other patient who was deaf with unknown cause. Deformity of the inner ear sufficient to explain congenital deafness was noted in three cases; one Mondini deformity and two obliterated base of the cochlea (modiolus). Three otosclerosis patients who had preimplant radiographs, and one congenital syphilis patient showed classic radiographic signs of their respective diseases. Obliteration or stenosis of the round and/or the oval windows were observed in 26 cases drawn from all major etiologic groups. State-of-the-art high resolution, thin-section CT can demonstrate subtle changes that may be the only clue to the cause of deafness. MRI promises to be a useful technique to follow meningitis patients with membraneous labyrinth changes progressing to sclerosing labyrinthitis.

Interventional radiology for restoration of vascular patency in the postoperative patient--case reports.

The postoperative patient may present with one or more of a variety of problems amenable to management by interventional radiologic techniques, which may be curative by themselves or may, in addition, require or allow successful surgical intervention. To optimize patient care, a good working relationship between the vascular surgeon and the interventional radiologist is essential. Consideration should be given to the patient's presenting signs and symptoms, the surgical history with its alteration of anatomy, the results of available noninvasive studies, and knowledge of various therapeutic alternatives. Vascular radiologic interventions include angioplasty, thrombolytic therapy, a combination of both angioplasty and thrombolysis, and newer techniques such as percutaneous valvectomy. In this report, examples of some of the experience at Indiana University are presented. Emphasis is placed on the appropriate approach to the patient.

Fibrinolytic therapy.

The state of the art of fibrinolytic therapy is constantly changing; perhaps no other area of medicine is developing as rapidly. This paper presents the status of fibrinolytic therapy from the authors' viewpoint. Many statements are controversial. It is possible to find divergent opinions expressed by experts on almost any aspect of fibrinolysis. Objective data are rapidly accumulating, but because new substances continue to be developed, the present and future statuses of fibrinolysis remain unclear. The current results of fibrinolytic therapy are excellent but will be dwarfed by the effects of new compounds and techniques in the near future. Continued developments in this field will have a major impact on improved health care delivery.

Percutaneous transluminal angioplasty in complicated renal vascular hypertension.

Fourteen patients with renovascular hypertension complicated by renal impairment and/or a nonfunctioning kidney underwent percutaneous transluminal angioplasty of the remaining kidney(s) for the purpose of improving blood pressure control and/or renal function. The outcome of percutaneous transluminal angioplasty in these individuals was evaluated over periods ranging from 1 to 72 months. All patients had atherosclerotic renovascular hypertension as judged by the X-ray appearance of the stenotic lesions of the renal artery as well as evidence of aortic atherosclerosis. Four of the 14 subjects demonstrated a decrease in serum creatinine greater than or equal to 20% following the procedure, and an equal number showed a similar increase in serum creatinine. In the 1st month following the procedure, 5 patients required dialysis because of deterioration of renal function, 4 of whom subsequently died. Over the entire population, only 4 subjects showed improvement in blood pressure and renal function which persisted for 18 to 72 months. One of these subjects had a recurrence of renovascular hypertension and underwent successful repeat dilatation for bilateral disease after 2 years following the initial angioplasty. This patient remains improved. These observations confirm that when renovascular hypertension occurs in an older population with cardiac and renal disease or occurs in a solitary functioning kidney, the remote prognosis is not good. The improvement rate of 29% with dilatation alone in this population appears to be less than that observed following surgical intervention in a similar population. Thus, transluminal angioplasty should be reserved for those subjects who are not surgical candidates or who refuse surgical intervention.

Renal vascular hypertension. Surgery vs. dilation.

The blood pressure response to surgery or percutaneous transluminal angioplasty (PTA) was determined an average of 3 years after treatment. In atherosclerotic disease, 85% of patients benefited. Furthermore, the extremely low overall cure rate of 6% (4/67) suggests that renal artery stenosis due to atherosclerosis is rarely a sole cause of hypertension, but more likely is an atherosclerotic complication of essential hypertension that develops in patients who are cigarette smokers. In fibrodysplastic disease both treatments were likely to improve the blood pressure. However, surgery resulted in a 41% rate of loss of the operated kidney. The response to PTA or surgery is strongly influenced by the etiology of the lesion being treated.

Ethanol thrombotherapy of esophageal varices: further experience.

Fifty patients with liver cirrhosis (13 Child class B, 37 class C) were treated for variceal hemorrhage during a 3-year period using the transhepatic selective catheterization and injection of absolute ethanol. Technical failure of the procedure was encountered in 13 instances. The causes were the presence of massive ascites and rigidly contracted liver, cavernous transformation of the main portal vein, and severe coagulopathy. Of the 13 failures, 12 were in Child class C and one in class B. Of 37 initially successfully treated patients, 13 rebled subsequently. Nine of these were Child class C and four were class B. Rebleeding was fatal in five of nine class C patients. Rebleeding was due to recanalization of previously thrombosed access channel in two of 13 patients. Nine patients died, despite successful thrombosis of varices, due to underlying medical conditions. Fifteen patients survived 6 months or more after initial thrombosis without rebleeding. Child class B patients are better candidates for this treatment technique because more favorable treatment results are expected in them. Child class C patients with massive ascites and severely contracted and rigid liver pose a significant technical challenge, but in about one-third, successful control of variceal bleeding can be achieved. Most of those who survived more than 6 months showed varying degrees of improvement in clinical signs and symptoms.

Influence of cardiac function on the quality of intravenous digital subtraction arteriograms.

In a retrospective comparison between 22 pairs of matched intravenous digital subtraction angiogram (DSA) images, five angiographers made independent determinations as to which one of each pair was superior in image quality (110 image comparisons). Matched pairs were identical for anatomic region filmed, catheter position during injection, amount of contrast material injected, injection rate, and iodine concentration of the contrast material. Each pair consisted of images from one patient with a normal (less than 1 S.D. above the mean) sodium dehydrocholate circulation time and images from one patient with a prolonged (greater than 1 S.D. above the mean) circulation time. In 85 of the 110 instances (77.3%) an image judged superior in quality to its matched counterpart derived from a DSA exam in a patient with normal circulation time; images from the exam with prolonged circulation time were judged equal in quality to the ones with the normal circulation time in 14 comparisons (12.3%); in 11 comparisons (10%) the images from the DSA with the prolonged circulation time were judged superior to the ones from the DSA with the normal circulation time. These results show that with statistically significant frequency (P less than 0.001) observers judge intravenous DSA images deriving from patients with normal circulation times superior in quality to those deriving from patients with prolonged circulation times.

Angiographic assessment of renal artery pathology: how reliable?

The accuracy of the angiographic interpretation of the histologic type of renal artery stenosis was assessed using a renal pathologist's diagnosis as the "gold standard." The angiograms of 42 renal artery stenoses were interpreted without other information, except age and gender, independently by six angiographers. This assessment indicated that angiography is not an accurate means by which to distinguish between the individual types of fibromuscular disease of the renal artery. However, it is a fairly accurate means by which to distinguish fibromuscular disease in general from atherosclerosis of the renal artery, 207 (82%) correct interpretations of 252. In addition, in the presence of renal artery stenosis, the absence of abdominal aortic atherosclerosis on angiography is an excellent predictor of fibromuscular renal artery disease, 17 (94%) of 18 specimens. Likewise, in the presence of a renal artery stenosis, angiographically demonstrable abdominal aortic atherosclerosis is a fair predictor of atherosclerotic renal artery disease, 16 (76%) of 21 specimens.

Catheter-related thrombosis and fibrinolytic therapy.

Fifty-seven local transcatheter infusions of low doses of fibrinolytic agents for the treatment of occlusive vascular disease were performed in 49 patients. Thrombosis developed around the infusing catheter in 15 (26%) of these cases. Patients with occlusive vascular disease are at increased risk for the development of thrombosis around indwelling catheters because of the low flow state that exists proximal to the occlusion.

Klippel-Feil syndrome and associated ear deformities.

The Klippel-Feil syndrome is characterized by a short, thick neck with restricted head mobility and a low occipital hairline. The head appears to rest directly on the thorax and the trapezius muscles flare out on either side of the neck, producing a pterygium-like effect. Cervical roentgenograms demonstrate fusion of some or even all of the vertebral bodies into bony blocks. Ear deformities occur in approximately one-third of the Klippel-Feil patient population. We report five cases of Klippel-Feil syndrome and describe their otologic and roentgenographic features. Although no single characteristic otologic or audiologic problem is identified, a proclivity for major malformations of involved ears is demonstrated. Early audiometric and otologic evaluation is indicated when the diagnosis of Klippel-Feil syndrome is made.

Low-dose fibrinolytic therapy. Results and new concepts.

The authors report their experience with the first 57 infusions (50 patients) in an ongoing study of local low-dose fibrinolysis for treatment of thromboembolic disease. Complete lysis occurred in nearly half of cases, while some therapeutic effect was demonstrable in more than two thirds. Success seems to be most directly related to the type of vessel infused, with the greatest success seen in vessels with no alternate pathways for egress of the fibrinolytic agent. Chronic fibrin deposits could also be treated with this technique. Since new thrombus formation occurs in a significant percentage of patients during local fibrinolytic therapy, the authors recommend cautious use of concomitant continuous intravenous heparin at a dosage sufficient to maintain the partial thromboplastin time at 1.5 times normal. While fibrinolytic therapy is usually not curative, it frequently facilitates detection of the underlying lesion, permitting definitive therapy.

Limitations of digital subtraction angiography in evaluating potential renal donors.

Six potential renal donors were evaluated by both conventional and digital subtraction angiography to determine the number of renal arteries to each kidney. The digital examination missed an accessory renal artery in one of six patients for an error rate of 17%.