Ovarian and tubal torsion: imaging findings on US, CT, and MRI.

Accurate diagnosis of adnexal torsion is often challenging, as clinical presentation is nonspecific and the differential for pelvic pain is broad. However, prompt diagnosis and treatment is critical to good clinical outcomes and preservation of the ovary and/or fallopian tube. Ultrasound (US) imaging is most frequently used to assess torsion. However, as computed tomography (CT) utilization in the emergency setting has increased, there are times when CT is the initial imaging test. Additionally, the nonspecific clinical presentation may initially be interpreted as gastrointestinal in etiology, where CT is the preferred exam. For these reasons, it is imperative to know the findings of adnexal torsion on CT as well as US. Magnetic resonance imaging (MRI) is helpful in cases where the diagnosis remains unclear and is particularly helpful in the young or pregnant patient with equivocal sonographic findings, as it provides excellent soft tissue contrast without ionizing radiation. This article will illustrate the findings of surgically confirmed ovarian and fallopian tube torsion on US, CT, and MRI, including those in the pregnant patient. Ovarian enlargement, adnexal mass, twisting of the vascular pedicle, edematous and heterogeneous appearance of the ovary, peripheral ovarian follicles, free fluid, uterine deviation towards the side of torsion, adnexal fat stranding, tubal dilatation, and decreased adnexal enhancement will be reviewed. Familiarity with the range of imaging findings across multiple modalities is key to improving the likelihood of timely diagnosis and therefore improved clinical outcomes.

Comparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulation.

INTRODUCTION: High-fidelity medical simulation of sudden cardiac arrest (SCA) presents an opportunity for systematic probing of in-hospital resuscitation systems. Investigators developed and implemented the SimCode program to evaluate simulation's ability to generate meaningful data for system safety analysis and determine concordance of observed results with institutional quality data. METHODS: Resuscitation response performance data were collected during in situ SCA simulations on hospital medical floors. SimCode dataset was compared with chart review-based dataset of actual (live) in-hospital resuscitation system performance for SCA events of similar acuity and complexity. RESULTS: 135 hospital personnel participated in nine SimCode resuscitations between 2006 and 2008. Resuscitation teams arrived at 2.5+/-1.3 min (mean+/-SD) after resuscitation initiation, started bag-valve-mask ventilation by 2.8+/-0.5 min, and completed endotracheal intubations at 11.3+/-4.0 min. CPR was performed within 3.1+/-2.3 min; arrhythmia recognition occurred by 4.9+/-2.1 min, defibrillation at 6.8+/-2.4 min. Chart review data for 168 live in-hospital SCA events during a contemporaneous period were extracted from institutional database. CPR and defibrillation occurred later during SimCodes than reported by chart review, i.e., live: 0.9+/-2.3 min (p<0.01) and 2.1+/-4.1 min (p<0.01), respectively. Chart review noted fewer problems with CPR performance (simulated: 43% proper CPR vs. live: 98%, p<0.01). Potential causes of discrepancies between resuscitation response datasets included sample size and data limitations, simulation fidelity, unmatched SCA scenario pools, and dissimilar determination of SCA response performance by complementary reviewing methodologies. CONCLUSION: On-site simulations successfully generated SCA response measurements for comparison with live resuscitation chart review data. Continued research may refine simulation's role in quality initiatives, clarify methodologic discrepancies and improve SCA response.

High-fidelity medical simulation as an assessment tool for radiology residents' acute contrast reaction management skills.

PURPOSE: The aims of this study were to use medical simulation as an assessment tool for the evaluation of radiology residents' compliance with contrast reaction treatment protocols and to gauge their perceptions of the simulation experience. METHODS: A prospective, observational study of postgraduate year 2 and 3 radiology residents' management of simulated life-threatening contrast reactions was designed. After standard didactic teaching on departmental contrast reaction protocols, residents participated individually in high-fidelity medical simulations of acute contrast reactions. Residents' performance of predetermined critical actions was recorded. Presimulation and postsimulation multiple-choice testing evaluated residents' knowledge of departmental protocols. Each resident completed 5-point, Likert-type surveys assessing comfort level while managing contrast reactions and perceptions of the simulation experience. RESULTS: Residents performed a mean of 13 of 20 critical actions (range, 10-16). The average presimulation multiple-choice testing score was 56%, whereas the average postsimulation score was 92% (P = .0003). Subjects' average ratings of comfort level in managing in-hospital contrast reactions before and after study intervention were 3.47 and 4.07, respectively (P = .03). Average ratings for comfort level in the outpatient setting were 3.08 before and 3.69 after the study (P = .69). All residents strongly agreed that the simulation was a valuable educational experience, while 85% strongly agreed that it improved their skills in managing acute contrast reactions. CONCLUSION: Standard didactic instruction may provide insufficient training and reinforcement of acute contrast reaction management skills. Medical simulation may provide a valuable means of assessing residents' skills and comfort levels in managing severe contrast reactions.

Does 16-detector computed tomography improve detection of non-traumatic subarachnoid hemorrhage in the Emergency Department?

The diagnosis of subarachnoid hemorrhage remains difficult to establish, yet the sensitivity of increasingly available 16-detector computed tomography (CT) has not been evaluated. The objective of this study was to estimate the sensitivity of 16-detector CT for the diagnosis of non-traumatic subarachnoid hemorrhage in the Emergency Department (ED). A retrospective review was performed in an academic tertiary care hospital. Patients presenting to the ED from September 2003 through December 2004 with symptoms suggestive of subarachnoid hemorrhage and having a final diagnosis of non-traumatic subarachnoid hemorrhage were eligible for study. Diagnosis was established by positive 16-detector CT examination of the brain, or spinal fluid analysis. Patient demographics and results of CT, angiogram, and spinal fluid analysis were reviewed. Sensitivity of 16-detector CT was calculated by comparing CT results and cerebral angiogram results. Refined Wilson Simple Asymptotic 95% confidence intervals were calculated. Sixty-one consecutive patients met the study criteria and had a final diagnosis of non-traumatic subarachnoid hemorrhage. One of these patients did not have subarachnoid hemorrhage identified by 16-detector CT, but had a positive lumbar puncture and an aneurysm confirmed on cerebral angiography. Sensitivity of 16-detector CT for subarachnoid hemorrhage was 97% (95% confidence interval 84-100%). Sixteen-detector CT did not improve detection of non-traumatic subarachnoid hemorrhage when compared with studies using single-detector CT. If there is high clinical suspicion for non-traumatic subarachnoid hemorrhage and non-contrast 16-detector CT scan is negative, further evaluation is suggested.

Myocardial preconditioning factors evoke mesenteric ischemic tolerance via opioid receptors and K(ATP) channels.

We have shown that a reverse-phase concentrate generated from the effluent of preconditioned (PC) rabbit hearts evokes a cardioprotective effect in virgin acceptor hearts. With the use of a model of sustained (1 h) simulated ischemia in isolated, spontaneously contracting rabbit jejunum, our current aims were to 1) determine whether protective factor(s) released from PC hearts can improve ischemic tolerance in noncardiac tissue; and 2) obtain preliminary insight into the mediator(s) involved in triggering and eliciting this remote protection. Recovery of contractile force following reoxygenation (our index of ischemic tolerance) was enhanced in jejunal segments pretreated with concentrate generated from PC hearts (33 +/- 3% of baseline, P < 0.01) versus segments that received no concentrate (21 +/- 2%) and segments treated with concentrate from normoxic hearts (16 +/- 3%; P < 0.01). Protection achieved with PC concentrate was attenuated by coadministration of naloxone or glibenclamide, thereby implicating the involvement of opioids and ATP-sensitive potassium channels. Moreover, evaluation of purified subfractions of the crude PC concentrate identified a specific bioactive fraction that may participate in triggering the improved jejunal ischemic tolerance.

Delta opiates increase ischemic tolerance in isolated rabbit jejunum.

UNLABELLED: Mammalian hibernation is mediated by humoral agonists of the delta opioid receptor (DOR). Moreover, transfer of either humoral or synthetic DOR agonists to non-hibernators reportedly induces a state of improved myocardial ischemic tolerance. OBJECTIVE: To determine whether the DOR agonist D-Ala 2, D-Leu 5, enkephalin (DADLE) similarly elicits protection in noncardiac-i.e., mesenteric-tissue. METHODS: In Protocols 1 and 2, the authors developed and characterized an in vitro model of mesenteric ischemia/reperfusion in isolated rabbit jejunum by documenting the effect of increasing ischemic duration (0 to 120 minutes) and the relative importance of glucose and/or oxygen deprivation on the evolution of jejunal injury. In Protocol 3, jejunal segments were randomized to receive either no treatment (controls) or 15 minutes of pretreatment with 1 microM DADLE, followed by 60 minutes of simulated ischemia and 30 minutes of reperfusion. Jejunal injury was quantified by repeated, time-matched assessment of peak contractile force evoked by 1 microM acetylcholine (all protocols) and delineation of tissue necrosis (Protocol 1). RESULTS: Development of significant jejunal injury required combined oxygen/glucose deprivation. Moreover, there was a direct relationship between ischemic duration and tissue injury, and a significant inverse correlation between reperfusion contractile force (% of baseline) and the extent of smooth muscle necrosis (r(2) = 0.87; p < 0.01). Most notably, mesenteric ischemia/reperfusion injury was attenuated by DADLE: reperfusion contractile force was 47 +/- 5% versus 36 +/- 5% in DADLE-treated versus control segments (p < 0.01). CONCLUSIONS: Treatment with the delta opioid agonist DADLE increases ischemic tolerance of isolated rabbit jejunum.