Efficacy of serum procalcitonin in evaluating severity of community-acquired pneumonia in childhood.

Microbe-specific diagnosis of community-acquired pneumonia (CAP) in childhood is difficult in clinical practice. Chest radiographs and non-specific inflammatory markers have been used to separate presumably bacterial from viral infection but the results have been inconsistent. The aim of the present study was to evaluate the usefulness of procalcitonin (PCT) in assessing the severity as well as the bacterial or viral aetiology of CAP. Serum PCT was measured by an immunoluminometric assay in 100 patients with CAP; 26 were treated as inpatients and 74 as outpatients. The pulmonary infiltrate was considered to be alveolar in 62 and interstitial in 38 cases, according to the radiological diagnosis. The bacterial and viral aetiology of pneumonia was studied by an extensive serological test panel. No differences were found in PCT concentrations between the 4 aetiological (pneumococcal, atypical bacterial, viral, unknown) and the 3 age (< 2, 2-4 and > or = 5 y) groups. Serum PCT was >0.5 ng/ml in 69%, >1.0 ng/ml in 54% and >2.0 ng/ml in 47% of all patients. PCT was higher in patients that were admitted than as outpatients (medians 17.81 vs 0.72 ng/ml, respectively, p<0.01) and higher in alveolar than in interstitial pneumonia (medians 9.43 vs 0.53 ng/ml, respectively, p<0.01). In conclusion, serum PCT values were found to be related to the severity of CAP in children even though they were not capable, at any level of serum concentration, to differentiate between bacterial and viral aetiology.

Color-Doppler sonography vs CT-angiography in discriminating carotid atherosclerotic plaques for surgical treatment. A prospective study.

PURPOSE: To compare the diagnostic accuracy of colour-Doppler sonography and CT-angiography in the selection of extracranial stenosis of the internal carotid artery to be treated with either endarterectomy or percutaneous transluminal angioplasty. MATERIALS AND METHODS: A total of 35 atherosclerotic plaques in 20 patients were studied with colour-Doppler sonography and CT-angiography (technical parameters: 2 mm raw thickness; 3.5 helical pitch; 2 mm image thickness; 1 mm reconstruction interval; non ionic contrast medium; Iodine concentration: 400 mg/ml, injection rate 5 ml/sec; Sure Start). On colour-Doppler sonography, we evaluated: the level of geometric stenosis (NASCET classification), maximum systolic peak velocity at the point of maximal stenosis and post-stenotic flow features. On CT-angiography we evaluated the level of geometric stenosis (NASCET classification) and the presence of calcium. We compared the degrees of geometric stenosis obtained with both techniques and considered the role each technique had in selecting candidates for surgery. CT-angiography was considered the gold standard. RESULTS: Three out of 35 plaques on CT-angiography were determining total carotid occlusion; all three of them were also shown on colour-Doppler sonography; 12 of 35 plaques were responsible for a degree of stenosis over 60% on CT-angiography and 11 of them (91.6%) were correctly shown on colour-Doppler sonography. 19 out of 35 plaques were determining a degree of stenosis less than 60% on CT-angiography and 11 of them (89.5%) were correctly shown on colour-Doppler sonography. The positive and negative predictive values were 92.3% and 95%, respectively, in detecting the plaques responsible for a degree of stenosis greater than 60%. DISCUSSION AND CONCLUSIONS: Colour-Doppler sonography is considered the first step in the diagnostic work-up of carotid atherosclerosis and evaluation of plaque conspicuity to select which plaques need to be treated with endarterectomy or percutaneous transluminal angioplasty. It has not been clearly demonstrated whether colour-Doppler sonography should be regarded as the sole preoperative imaging test or whether more expensive and invasive procedures such as CT-angiography, MRI and angiography are required. This study suggests that the accuracy of colour-Doppler sonography is comparable to that of CT-angiography in evaluating the degree of geometric stenosis caused by the plaque; in addition, it provides functional information on the plaque's haemodynamics effects. CT-angiography, rightly regarded as the gold standard, should be used for evaluating plaque composition (in particular predicting calcium presence and conspicuity) and in those cases in which the sonographic evaluation is not conclusive.

Doppler evaluation of arterial complications of adult orthotopic liver transplantation.

PURPOSE: The aim of this study was to analyze the role of the resistance index (RI), systolic acceleration time (SAT), and spectral waveform's morphologic characteristics in the sonographic evaluation of the hepatic artery for early detection of stenosis or thrombosis after orthotopic liver transplantation. METHODS: Arterial Doppler sonograms of 174 transplanted livers in 150 patients were analyzed for presence or absence of blood flow, RI, SAT, and peak systolic velocity. A qualitative evaluation of the spectral waveform morphologic characteristics was also made. In patients who had had abnormal findings on sonography, we compared those results with results obtained on multislice helical CT or angiography. RESULTS: At least 1 of the Doppler criteria for hepatic artery stenosis or thrombosis was identified in 25 of the transplants. The findings on multislice helical CT, angiography, or both confirmed the diagnosis of stenosis or thrombosis in 20 of the 25 cases: in 9 of 10 cases of absent hepatic arterial blood flow, 5 of 9 with an RI lower than 0.5, 6 of 7 cases with an SAT longer than 0.08 second, 10 of 11 cases of changes to a tardus-parvus-like spectral waveform, and in the 1 case of a peak systolic velocity greater than 2 m/second. CONCLUSIONS: The most accurate indicator of hepatic arterial stenosis or thrombosis was a change in the spectral waveform to a tardus-parvus pattern, with 91% sensitivity and 99.1% specificity. Among the other parameters, an increase of the SAT value (> 0.08 second), when associated with the morphologic modification of the systolic peak, is a more reliable parameter than the RI for early detection of artery stenosis, especially when the type of anastomosis is unknown.

Real-time compound sonography of the rotator-cuff: evaluation of artefact reduction and image definition.

PURPOSE: The aim of this study was to compare real time compound sonography with conventional sonography in the evaluation of rotator cuff tears. MATERIALS AND METHODS: A prospective study was performed on 50 supraspinatus tendons in 101 patients treated by surgical acromioplasty. The surgeon described 33 (66%) full-thickness tears and 17 (34%) partial-thickness tears. All tendons were examined by conventional sonography and real time compound sonography on the day before surgery. The techniques were compared by evaluating the images for freedom from artefacts, contrast resolution and overall image definition. RESULTS: Real time compound sonography proved to be superior to conventional sonography as regards freedom from artefacts in 50 cases out of 50 (100%). It was superior to conventional sonography in evaluating the image contrast resolution in 45 cases out of 50 (90%), and superior to conventional sonography in overall image definition in 45 out of 50 cases (90%). CONCLUSIONS: Real-time compound sonography reduces the intrinsic artefacts of conventional sonography and allows better overall image definition. In particular, the digital technique allowed us to study the rotator cuff with better contrast resolution and sharper and more detailed images than did conventional sonography.

Efficacy of selective B cell blockade in the treatment of rheumatoid arthritis: evidence for a pathogenetic role of B cells.

OBJECTIVE: The pathogenetic role of B cells in rheumatoid arthritis (RA) is under debate, but it is currently believed to be marginal. The availability of selective anti-B cell treatment provides a unique opportunity to clarify this issue. This study was undertaken to investigate the effects of B cell blockade in the treatment of refractory RA, and to evaluate the implications with regard to the role of B cells in the disease. METHODS: Five female patients with active, evolving erosive RA were treated with rituximab, an anti-CD20 chimeric monoclonal antibody. All 5 patients had been nonresponders to combination therapy with methotrexate plus cyclosporin A. Two of the 5 had also failed to respond to anti-tumor necrosis factor alpha therapy. All of these treatments were discontinued 1 month before institution of anti-CD20 therapy. RESULTS: Marked clinical improvement was observed in 2 patients (American College of Rheumatology 70% response [ACR70] and ACR50, respectively), starting at the end of the second month after institution of anti-CD20 therapy (month 2) and lasting until month 10 in 1 patient (articular relapse) and month 12 in the other (last followup). ACR20 response was observed in 2 additional patients, lasting until month 5 and month 7, respectively (articular relapse in both). Decrease or normalization of serum C-reactive protein and rheumatoid factor levels were observed in these patients. In contrast, patient 3 had no response to the treatment. RA synovitis and evolving erosive damage were decreased in patients exhibiting a major response, as demonstrated by imaging studies. CONCLUSION: Our finding of the clinical efficacy of selective B cell blockade indicates that B cells play a critical role in rheumatoid synovitis, at least in a subset of patients. Qualitative or quantitative differences in B cell commitment in RA pathobiology might have a function in the different responses observed.

Sonographic findings in glomus tympanicum tumor.

A glomus tympanicum tumor that is associated with a visible retrotympanic mass is the most frequent cause of pulsatile tinnitus. The preoperative diagnostic approach to this lesion includes a meticulous physical examination as well as high-resolution CT, magnetic resonance angiography, and digital angiography, which can also be used for preoperative embolization. We report the use of color transcranial Doppler sonography in the evaluation of glomus tympanicum tumor in a 67-year-old woman with a 3-year history of left tinnitus. An otoscopic examination revealed a reddish pulsatile mass behind an intact tympanic membrane. No lesions were visualized on gray-scale sonography. Contrast-enhanced color transcranial Doppler sonography showed a vascular ovoid mass that measured 2 x 1 x 1 cm; spectral analysis of the lesion revealed arterial flow with a low resistance index. Color transcranial Doppler sonography helped define the dimensions and vascular characteristics of the lesion.

Color Doppler sonography of hepatic artery reconstruction in liver transplantation.

PURPOSE: The purpose of this study was to evaluate the Doppler spectral waveforms in the hepatic artery after liver transplantation and hepatic artery reconstruction by end-to-end anastomosis or aortohepatic bypass. The peak systolic velocities (PSVs), end-diastolic velocities (EDVs), and resistance indices (RIs) between the 2 reconstruction groups were compared to establish normal post-transplantation values. METHODS: We retrospectively reviewed the Doppler sonograms and the sonographic reports from 48 patients who had undergone liver transplantation, 30 with end-to-end arterial anastomoses and 18 with aortohepatic bypasses. All aortohepatic bypasses had been performed using the infrarenal technique. All sonographic examinations had been performed 3-6 months after transplantation in patients with no clinical sign of transplant failure and whose liver function test results more normal. We compared the mean hepatic artery PSVs, EDVs, and RIs of the 2 groups. RESULTS: Doppler spectral analysis allowed the detection of 2 types of arterial flow, a low-resistance pattern in the end-to-end anastomosis group and a high-resistance pattern with low diastolic flow in the infrarenal bypass group. The mean PSV +/- standard deviation (SD) was 57 +/- 16 seconds in the end-to-end anastomosis group and 62 +/- 16 cm/second in the infrarenal bypass group. The mean EDV +/- SD was 25 +/- 14 cm/second in the end-to-end anastomosis group and 12 +/- 4 cm/second in the infrarenal bypass group. The RIs ranged from 0.33 to 0.71 (mean +/- SD, 0.58 +/- 0.13) in the patients with end-to-end anastomoses and from 0.70 to 0.87 (mean +/- SD, 0.77 +/- 0.06) in those with infrarenal bypasses. The difference in the mean RIs between the 2 groups was statistically significant (p < 0.05). CONCLUSIONS: Spectral waveform and RI are associated with the length and caliber of the type of hepatic artery anastomosis used. End-to-end anastomoses are short and have a uniform small caliber; aortohepatic bypasses are longer and have a progressively by smaller caliber. We must be cognizant of the method of anastomosis used when examining patients for complications after liver transplantation because the method used affects the resulting spectral waveform and RI.