CT of gastro-duodenal obstruction.

Gastro-duodenal obstruction encompasses a spectrum of benign and malignant disease. Historically, chronic peptic ulcer disease was the main cause of gastro-duodenal obstruction, whereas now malignant cause with gastric carcinomas for gastric obstruction and pancreatic tumors for duodenal obstruction predominate. This paper reviews the role of CT in diagnosing gastro-duodenal obstruction, its level, its cause by identifying intraluminal, parietal, or extrinsic process, and the presence of complication.

Compassion fatigue and anxiety in critical care emergency nurses: In between efficiency and humanity.

OBJECTIVES: To determine the emotional impact of permanent proximity to trauma and death in the Emergency and ICU's nurses establishing prevalence of Compassionate Fatigue (burnout and Secondary Traumatic Stress) and anxiety. Analyze its relationship with sociodemographic, training, workplace and psychological variables. METHODS: Descriptive, cross-sectional and multicentre study. The validated ProQOL v. IV and STAI scales and an ad-hoc questionnaire with the variables of the second objective were used in 710 nurses from nine highly complex hospitals in Catalonia (Spain). RESULTS: In both units, the prevalence of professionals affected with high scores of burnout was higher than 20%, on Secondary Traumatic Stress was 30% and, 12% on anxiety. Each subscale was significantly associated with the intention to leave units and the career. 97% of participants stated that they needed to be trained in emotional management. CONCLUSION: The prevalence of burnout and Secondary Traumatic Stress were higher in our study than those offered in the reference literature in emergency and ICU nurses. The prevalence of each construct was individually related to the desire to leave work units and career. This fact, together with the participants' desire to be better trained in emotional management exposes the need to establish educational plans, as well as institutional measures to prevent and support nurses for Compassion Fatigue.

Exposure to medicines among patients admitted for hip fracture and the case-fatality rate at 1 year: a longitudinal study.

PURPOSE: To describe the demographic and clinical characteristics and the pre-fracture exposure to medicines of patients admitted for a hip fracture, and to explore their association with fatal outcome 1 year after the fracture. METHODS: All patients ≥ 65 years old admitted for a hip fracture in a tertiary hospital in Barcelona between January 1 and December 31 2007 were included. Data on the patients' clinical characteristics before and during hospital admission and on pre-fracture exposures to medicines were collected from the clinical records. One-year mortality was checked by approaching the patients and their families and was cross-checked with the national mortality statistics database. A Cox proportional hazards analysis was carried out. RESULTS: Four hundred and fifty-six patients [mean age (SD) 82.9 (7.2) years, 73.5 % female], were admitted with hip fracture during the study period. Almost 80 % of the patients (363, 79.6 %) had three or more associated conditions, and 41.7 % received pre-fracture treatment with five or more drugs. The case-fatality rate during hospital admission was 4.6 % (21 patients). One hundred and seven patients died within 1 year (23.5 %). Advanced age, male gender, two or more associated chronic conditions, cancer, severe cognitive impairment, and treatment with opiates before fracture were significantly associated with the risk of dying. An inverse association was recorded between mortality and pre-hospital exposure to medicines for osteoporosis. CONCLUSIONS: One-quarter of patients admitted for hip fracture died within 1 year after the fracture. Exposure to opiates before hip fracture was associated with an increased 1-year death rate, whereas treatment with drugs for osteoporosis was associated with a decrease in death rate. These results should be confirmed in studies with detailed prospective collection of information on exposure to medicines.

Trichilemmal carcinoma of the scalp.

This report describes the case of an 86-year-old male who presented with a large scalp tumour. Imaging revealed a large vertex mass, without intracranial extension, and multiple nodular subcapsular hepatic lesions suspected to be secondary in nature. Surgical resection was performed. Pathological examination revealed an adnexal carcinoma of follicular origin, thus a trichilemmal carcinoma. Controlled wound healing (budding of the diploë) was completely successful within 12 months. The patient refused the assessment and treatment of his metastases.

[MR Imaging of primary ovarian tumors with pathologic correlation]. / Corrélations anatomopathologiques: IRM des tumeurs ovariennes primitives.

Ovarian tumors are classified based on the cell of origin into epithelial tumors, germ cell tumors and sex cord-stromal tumors. This pictorial essay illustrates the MR imaging features of the main ovarian tumors with pathologic correlation. These key features are helpful to suggest a specific diagnosis or narrow the differential diagnosis, in order to optimize the surgical approach.

Breast tomosynthesis: What do we know and where do we stand?

Digital breast tomosynthesis (DBT) is a new imaging technology that addresses the limitation caused by overlapping structures in conventional two-dimensional digital mammography owing to the acquisition of a series of low-dose projection images. This unique technique provides a dual benefit to patients screened for breast cancer. First, DBT increases the cancer detection rate mostly by highlighting architectural distortions and allowing better assessment of masses shape and margins. Second, DBT helps reduce recall rate by discarding asymmetries related to overlapping tissue. However, DBT is not included in the majority of cancer screening programs worldwide. Several issues still need to be addressed such as over-diagnosis and over-treatment, lack of reduction of interval breast cancer, quality control and storage, and radiation dose. In the diagnostic setting, DBT increases the diagnostic accuracy and reduces the number of indeterminate lesions in symptomatic women. Its aforementioned performances regarding asymmetries, masses and architectural distortions allow reducing the number of additional views while working-up a screening-detected lesion. Tumor size is also better assessed at DBT as well as multicentricity, two significant benefits in the staging of breast cancer. Finally, DBT allows a better analysis of scars and helps reduce the rate of indeterminate findings after surgery. Although somewhat limited by high breast density, DBT globally outperforms digital mammography in both screening and diagnostic breast imaging. Additional research is however needed, particularly on relevant screening outcomes. This review describes the main performances of breast DBT in breast cancer screening and diagnosis and the resulting consequences in both settings.

Magnetic resonance imaging in breast cancer management in the context of neo-adjuvant chemotherapy.

This review discusses the clinical applications of magnetic resonance imaging (MRI) for the assessment of neo-adjuvant chemotherapy (NAC) indication, axillary lymph node status, preNAC cancer prognosis, early and intermediate response to NAC, and post-NAC residual disease in patients with breast cancer. Contrast-enhanced MRI with analysis of the tumor morphological features and qualitative enhancement kinetics must be considered as the standard method for pre-NAC breast cancer staging and post-NAC residual disease assessment. Diffusion-weighted imaging (DWI) is easy to perform and may increase the specificity of breast MRI for tumor staging, and also for the assessment of tumor multifocality and multicentricity and lymph node status. It also provides an ancillary added value in the early and post-NAC response evaluation. Changes in the functional tumor volume are the main criterion for the early response analysis. Other MRI methods, such as quantitative perfusion analysis, MR spectroscopy and texture analysis, are still under study.

The phosphodiesterase inhibitory selectivity and the in vitro and in vivo potency of the new PDE5 inhibitor vardenafil.

We investigated the potency and the selectivity profile of vardenafil on phosphodiesterase (PDEs) enzymes, its ability to modify cGMP metabolism and cause relaxation of penile smooth muscle and its effect on erections in vivo under conditions of exogenous nitric oxide (NO) stimulation. PDE isozymes were extracted and purified from human platelets (PDE5) or bovine sources (PDEs 1, 2, 3, 4 and 6). The inhibition of these PDEs and of human recombinant PDEs by vardenafil was determined. The ability to potentiate NO-mediated relaxation and influence cGMP levels in human corpus cavernosum strips was measured in vitro, and erection-inducing activity was demonstrated in conscious rabbits after oral administration together with intravenous doses of sodium nitroprusside (SNP). The effects of vardenafil were compared with those of the well-recognized PDE5 inhibitor, sildenafil (values for sildenafil in brackets). Vardenafil specifically inhibited the hydrolysis of cGMP by PDE5 with an IC50 of 0.7 nM (6.6 nM). In contrast, the IC50 of vardenafil for PDE1 was 180 nM; for PDE6, 11 nM; for PDE2, PDE3 and PDE4, more than 1000 nM. Relative to PDE5, the ratios of the IC50 for PDE1 were 257 (60), for PDE6 16 (7.4). Vardenafil significantly enhanced the SNP-induced relaxation of human trabecular smooth muscle at 3 nM (10 nM). Vardenafil also significantly potentiated both ACh-induced and transmural electrical stimulation-induced relaxation of trabecular smooth muscle. The minimum concentration of vardenafil that significantly potentiated SNP-induced cGMP accumulation was 3 nM (30 nM). In vivo studies in rabbits showed that orally administered vardenafil dose-dependently potentiated erectile responses to intravenously administered SNP. The minimal effective dose that significantly potentiated erection was 0.1 mg/kg (1 mg/kg). The selectivity for PDE5, the potentiation of NO-induced relaxation and cGMP accumulation in human trabecular smooth muscle and the ability to enhance NO-induced erection in vivo indicate that vardenafil has the appropriate properties to be a potential compound for the treatment of erectile dysfunction. Vardenafil was more potent and selective than sildenafil on its inhibitory activity on PDE5.

[Factors associated with mortality and gait impairment in elderly patients with hip fractures]. / Fracturas de cadera en el anciano determinantes de mortalidad y capacidad de marcha.

BACKGROUND: Hip fractures are a major source of mortality and morbidity among the elderly. The aim of the present study is to try to identify predictors of death and of non-deambulation during the period of acute treatment. PATIENTS AND METHODS: Consecutive prospective study of 459 patients older than 65 years admitted to our hospital with acute proximal femoral fractures with 12 months follow-up. RESULTS: The mean length of hospital stay was 26.6 days, it exists a highly percentage of non-ambulatory patients at discharge from hospital (44.3%), a low percentage of mortality in the immediate postoperative period (6.1%) and a larger percentage of mortality at 6 months (26.15%). Factors associated with risk of death at hospital are male sex (OR = 2.38; 95% CI = 1.04-5.47), deteriorated mental status (OR = 2.62; 95% CI = 1.01-6.76) and no previous personal independence (OR = 3.16; 95% CI = 1.19-8.38). Age over 80 years (OR = 2.27; 95% CI = 1.43-3.60), deteriorated mental status (OR = 7.90; 95% CI = 3.83-16.3), no walking ability before fracture (OR = 3.72; 95% CI = 2.33-5.91) and type of fracture (OR = 1.84; 95% CI = 1.15-2.95) are shown as the determinants of gait capacity. CONCLUSIONS: Mortality in the immediate postoperative period is associated with sex, dementia and previous personal independence. The hospital stay is extended and functional recovery at discharge is low, therefore, new programs for these patients should be considered.

Correlation between MR imaging - prognosis factors and molecular classification of breast cancers.

The molecular classification of breast cancers defines subgroups of cancer with different prognoses and treatments. Each molecular type representing the intrinsic signature of the cancer corresponds to a histological profile incorporating hormone receptors, HER2 status and the proliferation index. This article describes the correlations between this molecular classification obtained in routine clinical practice using histological parameters and MRI. It shows that there is a specific MRI profile for triple-negative cancers: distinct demarcation, regular edges, hyperintensity on T2 weighted signals and, particularly, a crown enhancement. It is important for the radiologist to understand this molecular classification, firstly because of the relatively suggestive appearance of triple-negative basal-like cancers in the molecular classification, secondly, and particularly, as cancers in patients with the BRCA1 mutation are often triple-negative meaning that the criteria for reading the MRI needs to be tailored to this feature of the cancers, and finally because the efficacy of MRI in assessing response to neoadjuvant chemotherapy depends on the molecular class of cancer treated.

Mechanical occlusions: diagnostic traps and key points of the report.

Management of mechanical occlusion, particularly of the small intestine, has altered considerably over recent years, with a change of paradigm and the indication for surgery depending on the cause of the occlusion and any signs of entrapment or strangulation. It is therefore important today to make a positive diagnosis of mechanical occlusion, to assess its degree, its location and its cause, and to look for signs of entrapment and strangulation. Only computer tomography can provide the answers to these different questions. The aim of this paper is to provide a reminder of the CT signs that enable us to confirm diagnosis of the various aspects of mechanical occlusion of the stomach and duodenum, small intestine or colon, to emphasize and illustrate the diagnostic traps in CT and to set out the key points of a CT report of mechanical occlusion.

Infection of the right iliac fossa.

Febrile pain in the right iliac fossa is one of the most common reasons for consulting at an emergency service. Within this framework, the main diagnosis that is considered is appendicitis, the main complication of which is perforation. However, a certain number of other conditions can be responsible for this clinical picture, primarily including digestive tract and mesentery disorders including mesenteric lymphadenitis, Crohn's disease, infectious enterocolitis, small intestine or colonic diverticulitis, ischaemic colitis or cancer of the caecum. This article illustrates the imaging semiology of the various right colonic, iliac, mesenteric and appendicular conditions that could potentially cause an infection of the right iliac fossa. It specifies the indications of ultrasound and CT scans, respectively, which depend on the age of the patient and the clinical signs and symptoms. Though the CT scan is commonly used in abdominal emergencies in general, and particularly in clinical pictures of infection of the right iliac fossa, ultrasound remains recommended as first line imaging when confronted with suspected appendicitis or lymphadenitis in a young subject or in the monitoring of Crohn's disease.

Pearls and pitfalls in breast MRI.

At our academic institution, we have noticed repeated examples of both false-positive and false-negative MR diagnoses in breast cancer. The most common diagnostic errors in interpreting MRI of the breast are discussed in this review and experience-based advice is provided to avoid similar mistakes. The most common reasons for false-positive diagnoses are misinterpretation of artefacts, confusion between normal enhancing structures and tumours and, above all, insufficient use of the American College of Radiology breast imaging reporting and data system lexicon, whereas false-negative diagnoses are made as a result of missed tiny enhancement, a background-enhancing breast, or enhancement interpreted as benign rather than malignant.

Epidemiological factors associated with the exposure of cattle to Coxiella burnetii in the Madrid region of Spain.

Domestic ruminants are considered to be the major source of Coxiella burnetii, the causative agent of Q fever. Even though Q fever is considered to be present worldwide, its distribution in many areas and countries remains unknown. Here, a serological assay was used to estimate the seroprevalence of C. burnetii in cattle in the Madrid region of Spain, to assess its spatial distribution, and to identify risk factors associated with positive results. Ten animals from each of 110 herds (n=1100) were randomly selected and analyzed using an ELISA test. In addition, epidemiological information, at both the herd and individual level, was collected. Variables for which an association with test results was detected in a bivariate analysis were included as predictors (main effects) in a multivariable logistic regression model. Herd and individual seroprevalences were 30% (95% CI=22.2-39.1) and 6.76% (95% CI=5.42-8.41), respectively, and a strong spatial dependence was identified at the first neighbour level using the Cuzick-Edwards test. Production type (dairy >beef >bullfighting) and age of animals (old vs. young) were the only variables significantly associated (P<0.05) with positive serological results at the herd and individual levels, respectively. These results indicate that cattle are exposed to C. burnetii in the Madrid region The high herd seroprevalence found in dairy herds (75%) indicates a higher risk of infection (probably for management reasons) whereas no C. burnetii positive bullfighting herds were identified.

Up to 21-day banked red blood cells collected by apheresis and stored for 14 days after automated wash at different times of storage.

BACKGROUND AND OBJECTIVES: A closed-system technology (ACP-215, Haemonetics, Braintree, MA) enables automated washing and extended storage of frozen red blood cells (RBC). This technology was applied to wash banked RBC for removal of undesirable protein and metabolites before transfusion. We studied protein and metabolite depletion as well as RBC metabolism and viability up to 14 days postwash with regard to various pre-storage times. MATERIALS AND METHODS: Thirty RBC units were collected by means of apheresis and subdivided into three arms based on prewash storage time period (6 days/group 1, 14 days/group 2, 21 days/group 3). Wash efficacy (protein depletion, IgA), RBC metabolism (pH, lactate, potassium, haemolysis) and cell viability (ATP) were analysed immediately and 14 days after washing. RESULTS: Total protein and IgA postwash were lowered by automated wash in all groups and uniformly met EC guidelines. Potassium (mmol/l) was below 1.2 mmol/l postwash and significantly below prewash values in all groups, even after 14 days of storage (prewash vs. postwash; P < 0.05). RBCs washed after 14 and 21 days, respectively, showed significantly lower pH values and lower ATP content than RBCs washed after only 6 days of storage. Haemolysis rate remained significantly below 0.8%, the maximum level recommended by the EC guidelines, immediately and 14 days after washing in all units. CONCLUSION: Our data confirm that RBC units banked up to 21 days can be effectively protein- and potassium-depleted with the ACP-215 independent from prewash storage time. With respect to high ATP levels and pH, postwash storage of 2 weeks should be limited to units not older than 7 days before wash. This new washing technology ensures better standardization in washed RBC and provides blood centres with a logistical alternative to 24-h washed RBC products.

Neurological abnormalities, major orthopaedic deformities and ambulation analysis in a myelomeningocele population in Catalonia (Spain).

UNLABELLED: The aim of the study was to analyze the present status of neurologic abnormalities, major orthopaedic deformities and ambulatory status in a large myelomeningocele population. PATIENTS AND METHODS: Cross-sectional study based on the clinical and radiographic records of 322 patients treated and followed-up from 1967-1995. The setting was a multidisciplinary spina bifida unit within a third-level university hospital, which serves as the referral centre for these patients in Catalonia (Spain). We collected information on diagnosis, central nervous system, musculoskeletal system (spinal and hip deformities) and functional level in each patient. To study relationships among the variables, the Mann-Whitney U and the Chi-squared tests were applied. Results were considered to be statistically significant at P levels of < or = 0.05. RESULTS: Mean age was 15.9 years. 78.1% of patients had mid-lumbar, low-lumbar or sacral neurological levels; 97.5% had hydrocephalus and 68.8% were shunted. Prevalence of spine deformities was 45.3%; 38.8% had dislocation of one or both hips. Median age of walking onset was 37.1 months and 74.8% of patients were ambulatory. Median age at which ambulation ceased was 128 months (10 years and 8 months). The bivariate analysis showed statistically significant relationships between neurological level and all the variables studied (P<0.001, P<0.02) except body mass indexes and intelligence quotient. CONCLUSIONS: Neurological level was the main factor that determined neurological abnormalities, major orthopaedic deformities and ambulatory status.

Physeal injuries in myelomeningocele patients.

Epiphysiolysis from a series of 253 patients under regular control in the Spina Bifida Unit at our hospital has been analysed from 1967 to the present time. From that total there have been 18 physeal fractures in 9 of the myelomeningocele patients. The clinical characteristics, diagnostic difficulties and therapeutic criteria for this type of lesion are considered, and we suggest the need to use suitable orthoses whenever the patient is able to walk, and to temporarily increase the level of orthotisation in patients if the physis of the knee is affected.

Thoracic disc herniation, cord compression, and paraplegia caused by electrical injury: case report and review of the literature.

The case of a patient with thoracic intervertebral disc prolapse, cord compression, and delayed paraplegia with recovery secondary to high-tension electrical current is presented. The unusual entry wound in the neck, makes this a rare event that to our knowledge has not been previously described in the literature. Magnetic resonance imaging allowed noninvasive and early diagnosis, and in the future probably will reveal the true incidence of cord compression in electrical injury victims.