Large Regenerative Nodules and Focal Nodular Hyperplasia-Like Lesions: Definition, Pathogenesis, and Imaging Findings.

Focal nodular hyperplasia-like (FNH-like) nodules are hepatocellular lesions with similar radiologic and pathologic features as typical FNH but occur within an abnormal liver. They arise due to alteration of hepatic vasculature at both the microscopic and macroscopic levels. Although these nodules are not thought to have malignant potential, their imaging features overlap with premalignant and malignant lesions including hepatocellular carcinoma (HCC) and arise in patients who may be at risk for HCC, posing a diagnostic and management dilemma. It is important to consider these benign entities when reviewing liver imaging of patients at risk for HCC to reduce unnecessary interventions.

Atlantoaxial rotatory fixation in childhood: a staged management strategy incorporating manipulation under anaesthesia.

AIMS: The aims were to evaluate the safety of manipulation under anaesthesia (MUA) for atlantoaxial rotatory fixation (AARF) and the relative efficacy of rigid collar vs halo-body orthosis (HBO) in avoiding relapse and the need for open surgery. METHODS: Cases of CT-verified AARF treated by MUA were identified from a neurosurgical operative database. Demographic details, time to presentation and aetiology of AARF were ascertained through case note review. Cases were divided according to method of immobilisation after successful reduction, either rigid collar (group 1) or HBO (group 2). The primary outcome measure was relapse requiring open surgical arthrodesis. RESULTS: Thirty-three patients (2.2-12.7 years) satisfied inclusion criteria. Time to presentation varied from 1 day to 18 months. There were 19 patients in group 1 and 14 in group 2. There were no adverse events associated with MUA. 9/19 (47%) patients in group 1 resolved without need for further treatment compared with 10/14 (71%) in group 2 (p = 0.15). Of the 10 patients who failed group 1 treatment, four resolved after HBO. A total of ten patients (30%) failed treatment and required open surgery. CONCLUSIONS: MUA is a safe procedure for AARF where initial conservative measures have failed. MUA followed by immobilisation avoids the need for open surgery in over two thirds of cases. Immobilisation by cervical collar appears equally effective to HBO as an initial management, and so a step-wise approach may be reasonable. Delayed presentation may be a risk factor for relapse and need for open surgery.

Effect of Echo Times on Prostate Cancer Detection on T2-Weighted Images.

PURPOSE: To compare the effect of different echo times (TE) on the detection of prostate cancer (PCa) on T2-weighted MR images. MATERIALS AND METHODS: This study recruited patients (n = 38) with histologically confirmed PCa who underwent preoperative 3T MRI. Three radiologists independently marked region on interests (ROIs) on suspected PCa lesions on T2-weighted images at different TEs: 90, 150, and 180 ms obtained with Turbo Spin Echo imaging protocol with multiple echoes. The ROIs were assigned a value 1-5 indicating the reviewer's confidence in accurately detecting PCa. These ROIs were compared to histologically confirmed PCa (n = 95) on whole mount prostatectomy sections to calculate sensitivity, positive predictive value (PPV), and confidence score. RESULTS: Two radiologists (R1, R2) showed significantly increased sensitivity for PCa detection at 180 ms TE compared to 90 ms (R1: 43.2, 50.5, 50.5%, R2: 45.3, 44.2, 53.7% at TE of 90, 150, 180 ms, respectively) (p = 0.048, 0.033 for R1 and R2). Sensitivity was similar for radiologist 3 (45.3%-46.3%) at different TE values (p = 0.953). No significant difference in the PPV (R1: 64.1%-70.6%, R2: 46.7%-56.0%, R3: 70.5%-81.5%) and the confidence score assigned (R1: 4.6-4.8, R2: 4.6-4.8 R3: 4.3-4.4) was found for either of the radiologists. CONCLUSION: Our results suggest improved detection of PCa with similar PPV and confidence scores when higher TE values are utilized for T2-weighted image acquisition.

Depression symptoms are associated with key health outcomes in women with fibromyalgia: a cross-sectional study.

AIM: To analyze the association between depression severity and other fibromyalgia- (FM) related symptoms such as pain, fatigue, sleep problems, severity of the disease, activity pattern, functional capacity and quality of life. METHOD: The sample included 105 Spanish women with FM. Quality of life was assessed by means of the EQ-5D and symptom severity by the Fibromyalgia Impact Questionnaire. Pain, fatigue and unrestful sleep problems were assessed using 0-10 Visual Analog Scales. Activity patterns were determined by using the International Physical Activity Questionnaire while a battery of standardized field-based functional capacity tests was used to assess cardiorespiratory fitness, muscular strength, flexibility, agility and static and dynamic balance. Depression level was assessed and categorized according to the Beck Depression Inventory. RESULTS: Sixty-two percent of the participants were depressed. Depressed patients exhibited higher pain, fatigue level, sleep problems and severity of the symptoms, reduced levels of lower limb strength and physical activity time and worse quality of life when compared with non-depressed patients (P < 0.05). A negative relationship was found between total minutes of physical activity (P = 0.001) and caloric expenditure (P = 0.026), lower flexibility (P = 0.005), hand grip strength (P = 0.026) and lower limb strength (P < 0.001). A positive relationship was detected between depression and total sitting time (P = 0.018). These results were maintained when correlations were adjusted for body mass index. CONCLUSIONS: Depressed women with FM exhibited higher symptom severity and reported worse physical fitness and quality of life than their non-depressed peers.

Prostate Cancer: Utility of Whole-Lesion Apparent Diffusion Coefficient Metrics for Prediction of Biochemical Recurrence After Radical Prostatectomy.

OBJECTIVE: The purpose of this study was to investigate the additional value of whole-lesion histogram apparent diffusion coefficient (ADC) metrics, when combined with standard pathologic features, in prediction of biochemical recurrence (BCR) after radical prostatectomy for prostate cancer. MATERIALS AND METHODS: The study included 193 patients (mean age, 61 ± 7 years) who underwent 3-T MRI with DWI (b values, 50 and 1000 s/mm(2)) before prostatectomy. Histogram metrics were derived from 3D volumes of interest encompassing the entire lesion on ADC maps. Pathologic features from radical prostatectomy and subsequent BCR were recorded for each patient. The Fisher exact test and Mann-Whitney test were used to compare ADC-based metrics and pathologic features between patients with and patients without BCR. Stepwise logistic regression analysis was used to construct multivariable models for prediction of BCR, which were assessed by ROC analysis. RESULTS: BCR occurred in 16.6% (32/193) of patients. Variables significantly associated with BCR included primary Gleason grade, Gleason score, extraprostatic extension, seminal vesicle invasion, positive surgical margin, preoperative prostate-specific antigen level, MRI tumor volume, mean whole-lesion ADC, entropy ADC, and mean ADC of the bottom 10th, 10-25th, and 25-50th percentiles (p ≤ 0.019). Significant independent predictors of BCR at multivariable analysis were primary Gleason grade, extraprostatic extension, mean of the bottom 10th percentile ADC, and entropy ADC (p = 0.002-0.037). The AUC of this multivariable model was 0.94 for prediction of BCR; the AUC of pathologic features alone was 0.89 (p = 0.001). CONCLUSION: A model integrating whole-lesion ADC metrics had significantly higher performance for prediction of BCR than did standard pathologic features alone and may help guide postoperative prognostic assessments and decisions regarding adjuvant therapy.

SFTPC gene mutation p.R167Q in a premature infant.

We present an infant who was born premature at 23 weeks gestation with bronchopulmonary dysplasia and a SFTPC gene mutation, p.R167Q, who had a complicated neonatal course requiring 4 months of mechanical ventilation. Over time, his clinical course has improved, and he only requires oxygen by nasal cannula and low dose hydroxychloroquine, suggesting that p.R167Q mutation contributed to his clinical course and may manifest with a variable disease pattern making long-term prognostication difficult in the immediate newborn period.

Bleeding outcomes in patients given clopidogrel within 5 days of robotic coronary artery bypass graft procedure.

BACKGROUND: Current guidelines recommend that clopidogrel should be held for 5 days prior to coronary artery bypass graft (CABG) procedure. However, it is unknown if this recommendation should apply to robotic-assisted (rCABG), which is less invasive because it does not involve sternotomy and thus reduces the risk of bleeding. OBJECTIVE: To compare postoperative bleeding for rCABG patients who were taking clopidogrel within 5 days of the procedure with those who were not taking clopidogrel. METHODS: This was a retrospective cohort study conducted between January 1, 2012 and December 31, 2012 of consecutive patients undergoing rCABG. Patients were categorized into 2 groups based on whether or not clopidogrel was administered within 5 days prior to the date of surgery. The primary outcome measure was the occurrence of the Bleeding Academic Research Consortium (BARC) definition for CABG-related bleeding. The secondary outcome measure was a comparison of chest tube output during the first 24-hour postoperative period. RESULTS: A total of 136 rCABG patients were included in the final analyses. Of these, 39 (29%) received clopidogrel within 5 days of surgery. CABG-related bleeding using the BARC definition occurred in 26% of patients who received clopidogrel and 8% of patients who did not (P = .011). Median chest tube output during the first 24-hour postoperative period was also greater in patients who received clopidogrel (900 vs 735 mL, P = .002). CONCLUSIONS: The use of clopidogrel within 5 days of rCABG is associated with greater postoperative bleeding and chest tube output, as defined by the BARC criteria.

A rare cause of graft dysfunction after a heart transplant.

A 39-year-old man with a dilated cardiomyopathy was treated for recurrent life threatening ventricular arrhythmias with an automatic defibrillator and multiple antiarrhythmic agents. After transplant, the donor heart was asystolic probably secondary to these agents. A biventricular paracorporeal device supported the patient for four days and the heart recovered. He remains NYHA class I seven years later.

Migration of inferior vena cava stent into right ventricle: two- and three-dimensional echocardiographic imaging.

Right ventricular migration of a systemic venous stent is a rare complication. We present a case of stent migration in a 65-year-old male who underwent palliative intervention for inferior vena cava compression secondary to malignant mesothelioma. Two- and three-dimensional echocardiographic images revealed evidence of a free-stent trapped in the tricuspid valvular apparatus causing severe tricuspid regurgitation.

Superficial femoral artery thrombosis as a cause for distal embolism in primary antiphospholipid syndrome.

Antiphospholipid syndrome is a diagnosis with the clinical manifestations of thromboses in the presence of an antiphospholipid antibody. A 25-year-old man with a history of deep venous thrombosis, pulmonary emboli, and myocardial infarction, and receiving long-term anticoagulation with warfarin, all due to primary antiphospholipid syndrome, presented with blue toe syndrome from a primary superficial femoral artery thrombus. He was anticoagulated with fondaparinux in addition to dipyridamole and aspirin perioperatively. The area of thrombus was resected and reconstructed using a cephalic vein interposition graft. This report reviews antiphospholipid syndrome and identifies potential questions and problems relating to a rare clinical presentation.

Risk factor analysis for bridge to transplantation with the CardioWest total artificial heart.

BACKGROUND: Safety and efficacy studies of various mechanical circulatory support devices are important, but may not be strictly comparable. Lacking prospective randomized studies for different devices, we believe that comparison of risk factor analyses may give the surgeon a tool more powerful than current studies for matching a patient with an appropriate device. In this paper, we report risk factor profiles for bridge to transplantation with the CardioWest total artificial heart and summarize reports for other devices. METHODS: A multiinstitutional risk factor analysis of the CardioWest total artificial heart, as a bridge to transplantation in 81 patients, was conducted. Univariate analyses were performed on 43 preimplantation prognostic factors. From this group, eight factors were chosen for multivariate analysis. Our results were compared with all recent risk factor analyses for other devices. RESULTS: Independent predictors for death at three intervals by multivariate analysis were as follows: "implant to transplant": history of smoking (odds ratio, 34); "implant to 30 days after transplant": history of smoking (odds ratio, 10.00), prothrombin time greater than 16 seconds (odds ratio, 4.76); and "implant to 1 year after transplant": prothrombin time greater than 16 seconds (odds ratio, 3.85). The major difference between this experience and multiple reported experiences with left ventricular assist devices is that for left ventricular assist devices, but not for the temporary CardioWest total artificial heart, right heart failure, high central venous pressure, and being on a ventilator (with or without sepsis) were independent predictors of mortality. CONCLUSIONS: Risk factors for bridge to transplantation with the CardioWest total artificial heart are different from those reported for left ventricular assist devices. Recognition of these risk factor differences may facilitate appropriate device selection.

Amiodarone prophylaxis for atrial fibrillation after cardiac surgery: meta-analysis of dose response and timing of initiation.

STUDY OBJECTIVE: To investigate a possible dose-response relationship between amiodarone and reduction in incidence of postoperative atrial fibrillation, and to determine whether pre- or postoperative initiation of amiodarone is superior. DESIGN: Meta-analysis of randomized controlled trials. DATA SOURCE: MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Trials for English-language reports published between 1966 and December 2005. MEASUREMENTS AND MAIN RESULTS: Of 23 identified randomized controlled trials of amiodarone prophylaxis of postoperative atrial fibrillation, 14 were included in the final analysis. These studies enrolled a total of 2864 patients. For each study, the total administered amiodarone dose--categorized as low (< 3000 mg), medium (3000-5000 mg), or high (> 5000 mg)--and preoperative versus postoperative initiation were aggregated by using meta-analytic techniques. The incidence of postoperative atrial fibrillation was significantly reduced by amiodarone compared with placebo (p<0.001). Although the odds of developing atrial fibrillation appeared to be somewhat higher in the low-dose group, no significant differences were noted in the odds ratios (ORs) of developing atrial fibrillation among the low-, medium-, and high-dose groups: OR 0.58, 95% confidence interval (CI) 0.44-0.77; OR 0.45, 95% CI 0.30-0.69; and OR 0.44, 95% CI 0.33-0.58; respectively (p=0.238). In addition, the ORs for atrial fibrillation development associated with preoperative and postoperative initiation of amiodarone were not significantly different (OR 0.50, 95% CI 0.39-0.63; and OR 0.48, 95% CI 0.37-0.63; respectively, p=0.862). CONCLUSION: Total amiodarone doses of 3000 mg or higher may be more effective than lower doses in reducing the rate of postoperative atrial fibrillation after cardiac surgery. Preoperative initiation of amiodarone appears to be unnecessary. These findings require confirmation in prospective, randomized trials.

Update on the management of cardiogenic shock.

PURPOSE OF REVIEW: Cardiogenic shock is a life-threatening emergency that occurs frequently with acute coronary syndromes. If rapid myocardial reperfusion following acute myocardial infarction is not obtained, either with thrombolytics or by revascularization, cardiogenic shock frequently develops and the mortality rate is high. This review summarizes recent advances in the pathophysiology, incidence and treatment of cardiogenic shock. Particular attention is given to pharmacologic advances. RECENT FINDINGS: Cardiogenic shock continues to occur in 5-10% of patients who suffer a myocardial infarction and the mortality remains over 50% in most studies. Treatment preference is referral to a cardiac center capable of reperfusion using multiple therapies. While no delay in reperfusion is acceptable, emphasis on implementing supportive treatment such as vasopressors, inotropes, and fluids remains critical. There is a wide variance in treatment standards despite established guidelines. Overall mortality from cardiogenic shock has decreased but the incidence remains unchanged. SUMMARY: Emerging pharmacological interventions designed to counteract the underlying proinflammatory pathophysiologic mechanisms may, in combination with early revascularization, result in improved patient outcomes, but there is no magic bullet on the horizon. Attention to the timeliness of transport and treatment of patients with a focus on revascularization is required for cardiogenic shock patients.

Integrating traditional and emerging treatment options in heart failure.

PURPOSE: This paper reviews traditional approaches for the management of heart failure, as well as the emerging approach of using an aldosterone inhibitor. SUMMARY: In addition to prevention, the goals of heart failure therapy are to relieve symptoms, improve quality of life, slow progression of heart failure through both pharmacologic and nonpharmacologic therapies, minimize or prevent acute exacerbations, reduce hospitalizations, improve survival, favorably influence neurohormones, and reduce costs. Symptoms are alleviated with diuretics and digoxin; if digoxin is used, the target therapeutic range appears to be 0.4-0.8 ng/mL. Large, well-controlled clinical trials have documented the effectiveness of angiotensin-converting enzyme (ACE) inhibitors and beta-adrenergic blocking agents in reducing the mortality and morbidity in patients with heart failure ranging from post myocardial infarction left ventricular dysfunction to severe heart failure. Recent large studies have documented the effectiveness of aldosterone receptor antagonists in improving mortality and morbidity in patients with heart failure. There was a 30% reduction in mortality in patients with NYHA class III-IV heart failure when spironolactone compared with placebo was added to a regimen consisting of digoxin, furosemide, and an ACE inhibitor. A later study in which a gamma-blocker was also included in the regimen showed that patients with left ventricular systolic dysfunction with symptoms of mild heart failure following myocardial infarction taking eplerenone had a 15% relative reduction in all-cause mortality and a 21% reduction in sudden cardiac death compared with placebo. The incidence of gynecomastia was 9% and 0.5% for spironolactone and eplerenone, respectively. CONCLUSION: The data support adding aldosterone receptor antagonists alongside ACE inhibitors and beta-adrenergic blocking agents as ways to reduce mortality and morbidity in the treatment algorithm for heart failure. More research is needed to determine the usefulness of aldosterone receptor antagonists across the entire spectrum of heart failure.