Diagnostic Impact of Transesophageal Echocardiography in Patients with Acute Cerebral Ischemia.

OBJECTIVES: Transesophageal echocardiography (TEE) is the diagnostic gold standard for the detection of structural heart diseases as potential sources of cardiac emboli in patients with acute cerebral ischemia. We sought to determine the diagnostic yield of TEE in patients with acute ischemic stroke or transient ischemic attack (TIA). METHODS: We retrospectively analyzed consecutive patients with acute cerebral ischemia who were admitted to our hospital between October 2008 and December 2011. TEE reports were screened for detection of cardiac source of embolism judged by the recommendation to change medical management. We performed univariate and multivariate analyses to identify predictors of clinically relevant TEE findings among baseline characteristics. RESULTS: Of 3314 patients with ischemic stroke or TIA, TEE was performed in 791 (24%) patients (mean age 64 ± 13 years, 589 [74%] ischemic stroke, 202 [26%] TIA). A potential cardioembolic source was found in 71 (9%) patients with patent foramen ovale with atrial septal aneurysm being the most common finding (24/71 patients, 34%). In multivariate analysis, peripheral vascular disease (OR 2.57; 95%CI 1.00-6.61), imaging evidence of infarction in multiple locations (OR 4.13; 95%CI 1.36-12.58), and infarction in the posterior circulation (OR 2.11; 95%CI 1.01-4.42) were associated with the identification of a potential cardioembolic source with TEE. CONCLUSION: TEE identified a potential structural cardioembolic source in nearly 10% of our selected patient population with acute ischemic stroke or TIA, thus underlining its diagnostic value. Our data suggest that patients with hitherto unknown stroke etiology should be considered for additional TEE.

Modified constraint-induced movement therapy versus intensive bimanual training for children with hemiplegia - a randomized controlled trial.

OBJECTIVE: To clarify whether modified constraint-induced movement therapy provides greater improvement than intensive bimanual training both for motor functions and spontaneous use of the paretic arm and hand in everyday life activities. DESIGN: Randomized controlled, single-blind trial. SETTING: Inpatient paediatric rehabilitation clinic. SUBJECTS: Forty-seven children with unilateral cerebral palsy or other non-progressive hemiplegia (aged 3.3-11.4 years) were randomly assigned to either a modified constraint-induced movement programme (kid-CIMT) or intensive bimanual training. INTERVENTIONS: Patients in the kid-CIMT group received 60 hours of unilateral constraint-induced and 20 hours of bimanual training over four weeks. Patients in the bimanual treatment group received 80 hours of bimanual training over four weeks. MAIN OUTCOME MEASURES: Melbourne Assessment of Unilateral Upper Limb Function and Assisting Hand Assessment. RESULTS: Modified constraint-induced therapy provided a significantly better outcome for isolated motor functions of the paretic arm than bimanual training (gain in Melbourne Assessment, percent score: 6.6 vs. 2.3, P= 0.033). Regarding spontaneous use both methods led to similar improvement (gain in Assisting Hand Assessment, percent score: 6.2 vs. 4.6, P= 0.579). More-disabled children showed greater improvement than less-disabled ones (correlation with Assisting Hand Assessment pretreatment score r = -0.40). Age did not affect treatment outcome. CONCLUSIONS: Modified constraint-induced movement therapy can improve isolated functions of the hemiplegic arm better than intensive bimanual training, but regarding spontaneous hand use in everyday life both methods lead to similar improvement. Improvements are generally greater in more impaired children. Age does not affect outcome.

Prognostic value of tumor response to neoadjuvant therapy in rectal carcinoma.

BACKGROUND: Neoadjuvant treatment in the multimodal therapy concept of rectal carcinoma has considerable effects on prognosis appraisal. OBJECTIVE: This study aimed to evaluate the tumor response specified as an improvement by at least one stage defined in terms of the International Union Against Cancer stages as a prognostic factor. DESIGN: This investigation was designed as a prospective cohort study. SETTING: This study was performed at a community-based hospital with a specialized colorectal unit. PATIENTS: One hundred seventy-four patients with locally advanced rectal carcinoma, treated in the Dresden-Friedrichstadt hospital from 1997 to 2009, who received long-term preoperative chemoradiotherapy and underwent curative resection, were included in this study. MAIN OUTCOME MEASURES: The main outcome measures were cause-specific and disease-free survival with respect to T and N category, International Union Against Cancer stage, venous and lymphatic invasions, grading, CEA level, complete pathologic response, tumor regression grading, International Union Against Cancer stage shift, T, N, and CEA shift, types of neoadjuvant therapy, adjuvant therapy, interval between completion of neoadjuvant chemoradiotherapy and surgery, and number of extracted lymph nodes in resected specimens. Univariate and multivariate analyses were performed. RESULTS: Median follow-up was 45 months. One hundred twenty-one patients (69.5%) showed a response to the treatment, whereas 53 (30.5%) did not. Five-year cause-specific and disease-free survival for responders (n = 121) vs nonresponders (n = 53) were 92.6% and 73.7% vs 84.9% and 47.9%. In the univariate analysis, ypN category, venous and lymphatic invasion, tumor regression grading, International Union Against Cancer stage shift, and T and N shift were significantly predictive for cause-specific and disease-free survival. Furthermore, ypUICC stage, ypT category, grading, and complete pathologic response had an impact on disease-free survival. In the multivariate analysis, only the International Union Against Cancer stage shift kept its independent explanatory power for cause-specific P = .012, HR 3.10 (95% CI 1.28-7.51) and disease-free survival P < .001, HR 3.85 (95% CI 1.98-7.51). LIMITATIONS: The determination of International Union Against Cancer stage shift depends on the pretreatment staging modalities. CONCLUSION: Our investigation demonstrates that the response of tumor to neoadjuvant therapy is an independent prognostic factor in patients with rectal carcinoma.

Focal colorectal uptake in (18)FDG-PET/CT: maximum standard uptake value as a trigger in a semi-automated screening setting.

BACKGROUND: Focal colorectal uptake in (18)FDG-PET/CT may be associated with a malignancy and can be quantified. This provides the basis for an automatic trigger threshold above which cases are flagged for colonoscopic evaluation and below which for individual assessment. PURPOSE: To determine the lowest maximum standard uptake (SUVmax) in colorectal cancer that could be used as a threshold to trigger endoscopic evaluation and to evaluate whether the SUVmax needs to be further normalised to a priori known extrinsic factors. METHODS: The SUVmax was measured in 54 colorectal carcinomas and correlated with gender, age, blood glucose level, injected activity, body mass index and time to scan using t test or correlation coefficients (Pearson or Spearman, according to distribution). RESULTS: There was no correlation between SUVmax and any of the extrinsic factors mentioned above. The lowest SUVmax value was 5 [mean ± SD (range): 11.1 ± 4.8 (5.0-24.6)]. CONCLUSION: In contrast to most other screening techniques, semi-automation in colorectal screening seems possible with PET/CT. This opens the door for further study into the feasibility of automated screening. Independent from extrinsic factors, an SUVmax ≥5.0 in a focal colorectal uptake in (18)FDG-PET/CT should automatically trigger for endoscopic evaluation, if not contraindicated. Cases with SUVmax <5 should be assessed individually before referral for endoscopy. Thus, more interpretation time could be spent on those cases with a lower uptake and more ambiguous diagnosis.

Diagnostic and Prognostic Impact of pc-ASPECTS Applied to Perfusion CT in the Basilar Artery International Cooperation Study.

BACKGROUND AND PURPOSE: The posterior circulation Acute Stroke Prognosis Early CT Score (pc-APECTS) applied to CT angiography source images (CTA-SI) predicts the functional outcome of patients in the Basilar Artery International Cooperation Study (BASICS). We assessed the diagnostic and prognostic impact of pc-ASPECTS applied to perfusion CT (CTP) in the BASICS registry population. METHODS: We applied pc-ASPECTS to CTA-SI and cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) parameter maps of BASICS patients with CTA and CTP studies performed. Hypoattenuation on CTA-SI, relative reduction in CBV or CBF, or relative increase in MTT were rated as abnormal. RESULTS: CTA and CTP were available in 27/592 BASICS patients (4.6%). The proportion of patients with any perfusion abnormality was highest for MTT (93%; 95% confidence interval [CI], 76%-99%), compared with 78% (58%-91%) for CTA-SI and CBF, and 46% (27%-67%) for CBV (P < .001). All 3 patients with a CBV pc-ASPECTS < 8 compared to 6/23 patients with a CBV pc-ASPECTS ≥ 8 had died at 1 month (RR 3.8; 95% CI, 1.9-7.6). CONCLUSION: CTP was performed in a minority of the BASICS registry population. Perfusion disturbances in the posterior circulation were most pronounced on MTT parameter maps. CBV pc-ASPECTS < 8 may indicate patients with high case fatality.

Sinonasal inhalation of tobramycin vibrating aerosol in cystic fibrosis patients with upper airway Pseudomonas aeruginosa colonization: results of a randomized, double-blind, placebo-controlled pilot study.

RATIONALE: In cystic fibrosis (CF), the paranasal sinuses are sites of first and persistent colonization by pathogens such as Pseudomonas aeruginosa. Pathogens subsequently descend to the lower airways, with P. aeruginosa remaining the primary cause of premature death in patients with the inherited disease. Unlike conventional aerosols, vibrating aerosols applied with the PARI Sinus™ nebulizer deposit drugs into the paranasal sinuses. This trial assessed the effects of vibrating sinonasal inhalation of the antibiotic tobramycin in CF patients positive for P. aeruginosa in nasal lavage. OBJECTIVES: To evaluate the effects of sinonasal inhalation of tobramycin on P. aeruginosa quantification in nasal lavage; and on patient quality of life, measured with the Sino-Nasal Outcome Test (SNOT-20), and otologic and renal safety and tolerability. METHODS: Patients were randomized to inhalation of tobramycin (80 mg/2 mL) or placebo (2 mL isotonic saline) once daily (4 minutes/nostril) with the PARI Sinus™ nebulizer over 28 days, with all patients eligible for a subsequent course of open-label inhalation of tobramycin for 28 days. Nasal lavage was obtained before starting and 2 days after the end of each treatment period by rinsing each nostril with 10 mL of isotonic saline. RESULTS: Nine patients participated, six initially receiving tobramycin and three placebo. Sinonasal inhalation was well tolerated, with serum tobramycin <0.5 mg/L and stable creatinine. P. aeruginosa quantity decreased in four of six (67%) patients given tobramycin, compared with zero of three given placebo (non-significant). SNOT-20 scores were significantly lower in the tobramycin than in the placebo group (P=0.033). CONCLUSION: Sinonasal inhalation of vibrating antibiotic aerosols appears promising for reducing pathogen colonization of paranasal sinuses and for control of symptoms in patients with CF.

Sinonasal inhalation of dornase alfa in CF: A double-blind placebo-controlled cross-over pilot trial.

OBJECTIVE: The paranasal sinuses are almost always involved in cystic fibrosis, and chronic rhinosinusitis and nasal polyps are very frequent in the disease. Hereby, the patients' quality of life and their overall health are relevantly impaired. Although dornase alfa, a mucolytic agent, may also be effective in the upper airways, deposition of inhaled drugs into paranasal sinuses is substantially limited. The novel PARI SINUS™ nebuliser has been shown in deposition studies to deliver aerosol into paranasal sinuses but has not yet been clinically tested. This DBPC pilot-trial applying dornase alfa aims to evaluate outcome parameters and sample sizes for a subsequent efficacy trial. METHODS: Primary outcome parameters assessed were the Sino-Nasal Outcome Test (SNOT-20, a disease-specific quality of life assessment tool) and ventilated volume as measured by magnetic resonance imaging. Five CF patients were randomised to inhale either dornase alfa or 0.9% NaCl for 28 days and, after a wash-out period of 28 days, crossed over to the alternative treatment. RESULTS: Whereas normal saline was not associated with relevant changes in SNOT-20 scores, dornase alfa improved quality of life (p=0.043). MRI results showed no definite trend. CONCLUSION: This first clinical study with the novel device gives promising results for the new therapeutic concept of sinonasal inhalation with vibrating aerosols in regard to further analysis involving larger collectives.