Visualization of the renal artery in kidney transplant patients using time-resolved computed tomography angiography.

BACKGROUND: Transplant renal artery stenosis (TRAS) is a post-operative complication which most often occurs between 3 months and 2 years after transplantation. TRAS is associated with kidney failure and hypertension and, thereby, with an increased risk of cardiovascular events. PURPOSE: The purpose of this retrospective study was to report our experience of perfusion computed tomography angiography (P-CTA) to identify a 50% lumen reduction (as compared to digital subtraction angiography, DSA), assess its subjective image quality and evaluate if contrast-induced acute kidney injury (CI-AKI) occurred. MATERIAL AND METHODS: All 13 patients who had undergone P-CTA for suspected TRAS at our institution were retrospectively evaluated. At P-CTA, eight or 12 g of iodine were administered intravenously, and five to seven scan sequences were merged into time-resolved images after motion correction. Eight patients underwent subsequent DSA. RESULTS: The average patient weight was 76 kg (range 55-97 kg). Image quality was rated as good or excellent for all patients, and pathological changes were shown in 10 of 13 patients undergoing P-CTA. Two patients had a serum creatinine increase of >26 µmol/L during the first 3 days, but serum creatinine was significantly lower in all patients 1 month after P-CTA (165+/-69 µmol/L versus 232+/-66 µmol/L, P < .01). The diagnosis at P-CTA was verified in all eight patients who underwent DSA. However, in two cases with suspected stenosis, renal function was restored without angioplasty. CONCLUSION: Anatomy and blood flow of the transplant renal artery can be visualized using less than a third of the standard contrast media dose by using P-CTA technique.

Evaluation of arteriovenous fistula-bilateral computed tomography venography combining diluted and undiluted contrast media injection: A case study.

A 45-year-old female dialysis patient with sudden onset of severe pain in the left shoulder and chest was referred for computed tomography of her left arm and thoracic veins. The computed tomography venography revealed 2 completely occluded venous grafts and 2 pronounced stenoses of the subclavian vein. By using a dual injection of diluted and undiluted contrast medium, artifact-free visualization of arteriovenous fistula, arm veins and adequate enhancement of thoracic veins were obtained.

Early gain in pain reduction and hip function, but more complications following the direct anterior minimally invasive approach for total hip arthroplasty: a randomized trial of 100 patients with 5 years of follow up.

Background and purpose - The minimally invasive direct anterior (DA) approach for total hip arthroplasty (THA) is supposed to reduce surgical tissue trauma. We hypothesized that patients operated with the DA technique would have less postoperative pain and better hip function compared with a group operated with a conventional direct lateral (DL) approach. Patients and methods - 100 patients with hip osteoarthritis scheduled for THA were equally randomized to surgery through either DA or DL. Pain was assessed on a VAS scale, hip function with TUG, 10mWT, HHS, and quality of life with EQ-5D. Patients were followed up after the first 3 days, 8 weeks, and at 1 and 5 years postoperatively. Results - The DA group registered less pain with activity on the second day (VAS 42 vs. 55), performed TUG 6 seconds faster on the third day and had 8 points higher HHS and higher EQ-5D index (0.86 vs 0.78) at 8 weeks; all differences were statistically significant. No clinically relevant differences between groups in pain, hip function, or quality of life were seen at 1 or 5 years. 7 surgical approach related complications appeared in the DA group, none in the DL. Interpretation - The results indicate that the presumably less traumatic approach results in reduced immediate postoperative pain and better hip function and higher quality of life in the early postoperative period. However, this positive effect is not seen at later time points. Instead, complications appear to be over-represented, thus questioning the use of the method.

Hepatic contrast medium enhancement at computed tomography and its correlation with various body size measures.

BACKGROUND: When the same dose of iodine is given to all patients when performing abdominal computed tomography (CT) there may be a wide inter-individual variation in contrast medium (CM) enhancement of the liver. PURPOSE: To evaluate if any of the measures body height (BH), body mass index (BMI), lean body mass (LBM), ideal body weight (IBW), and body surface area (BSA) correlated better than body weight (BW) with hepatic enhancement, and to compare the enhancement when using iodixanol and iomeprol. MATERIAL AND METHODS: One hundred patients referred for standard three-phase CT examination of abdomen were enrolled. Body weight and height were measured at the time of the CT examination. Forty grams of iodine (iodixanol 320 mg I/mL or iomeprol 400 mg I/mL) was injected at a rate of 1.6 g-I/s, followed by a 50 mL saline flush. The late arterial phase was determined by using a semi-automatic smart prep technique with a scan delay of 20 s. The hepatic parenchymal phase started automatically 25 s after the late arterial phase. CM concentration was estimated by placement of regions of interest in aorta (native and late arterial phase) and in liver (native and parenchymal phase). RESULTS: BW (r = -0.51 and -0.64), LBM (r = -0.54 and -0.59), and BSA (r = -0.54 and -0.65) showed the best correlation coefficients with aortic and hepatic parenchymal enhancement, respectively, without any significant differences between the measures. Comparing iodixanol and iomeprol there was no significant difference in aortic enhancement. The liver enhancement was significantly higher (P < 0.05) using iodixanol than iomeprol. CONCLUSION: To achieve a consistent hepatic enhancement, CM dose may simply be adjusted to body weight instead of using more complicated calculated parameters based on both weight and height.

Adverse reaction to metal release from a modular metal-on-polyethylene hip prosthesis.

A 70-year-old man with an uncemented metal-on-polyethylene total hip prosthesis underwent revision arthroplasty 33 months later because of pain, swelling and recurrent dislocation. There appeared to be corrosion and metal release from the prosthetic head, resulting in pseudotumour formation and severe local soft-tissue destruction. The corrosion occurred at the junction between the titanium-molybdenum-zirconium-iron taper and the cobalt-chrome-molybdenum head, but the mechanism was unproven.

Heart rate variability and heat sensation during CT coronary angiography: Low-osmolar versus iso-osmolar contrast media.

BACKGROUND: During computed tomography coronary angiography (CTCA) unexpected changes in heart rate while scanning may affect image quality. PURPOSE: To evaluate whether an iso-osmolar contrast medium (IOCM, iodixanol) and a low-osmolar contrast medium (LOCM, iomeprol) affect heart rate and experienced heat sensation differently. MATERIAL AND METHODS: One hundred patients scheduled for CTCA were randomized to receive either iodixanol 320 mgI/ml or iomeprol 400 mgI/ml. Depending on their heart rate, the patients were assigned to one of five scanning protocols, each optimized for different heart rate ranges. During scanning the time between each heart beat (hb) was recorded, and the corresponding heart rate was calculated. For each contrast medium (CM) the average heart rate, the variation in heart rate from individual mean heart rate, and the mean deviation from the predefined scanning protocol were calculated. Experience of heat was obtained immediately after scanning by using a visual analog scale (VAS). Examination quality was rated by two radiologists on a three-point scale. RESULTS: The mean variation in heart rate after IOCM was 1.4 hb/min and after LOCM it was 4.4 hb/min (NS). The mean deviations in heart rate from that in the predefined scanning protocol were 2.0 hb/min and 4.7 hb/min, respectively (NS). A greater number of arrhythmic hb were observed after LOCM compared with IOCM (P<0.001). There was no statistically significant difference in image quality. The LOCM group reported a stronger heat sensation after CM injection than the IOCM group (VAS =36 mm and 18 mm, P<0.05). CONCLUSION: At clinically used concentrations the IOCM, iodixanol 320 mgI/ml, does not increase the heart rate during CTCA and causes less heart arrhythmia and less heat sensation than the LOCM, iomeprol 400 mgI/ml.

Observer reliability in the arthroscopic classification of osteoarthritis of the knee.

We studied 19 videotaped knee arthroscopies in 19 patients with mild to moderate osteoarthritis (OA) of the knee in order to compare the intraobserver and interobserver reliability and the patterns of disagreement between four orthopaedic surgeons. The classifications of OA of Collins, Outerbridge and the French Society of Arthroscopy were used. Intraobserver and interobserver agreements using kappa measures were 0.42 to 0.66 and 0.43 to 0.49, respectively. Only 6% to 8% of paired intraobserver classifications differed by more than one category. Observer-specific disagreement was evident both within and between observers. A small, but significant, occasional variation was also seen. Although reliability may improve by an analysis of disagreement, it appears that the arthroscopic grading of early osteoarthritic lesions is inexact.

[Telemedicine in diagnosis and treatment of occupational skin diseases]. / Ispol'zovanie telemeditsiny dlia diagnosstiki i lecheniia professional'nykh zabolevanii zabolevanii kozhi.

Advances of new data transfer technologies in medicine enable distant consultations for far places residents. Scandinavian countries, especially Sweden, have accumulated significant experience with using television medicine in dermatology. Applying television medicine technologies in occupational dermatology is the most topical item for Nizhny Novgorod region. In these cases transfer could cover not only images of diseased skin sites, but also text (history description and other medical information). International cooperation with foreign colleagues including Swedish doctors is considered prospective.

Effect of load on articular cartilage matrix and the development of guinea-pig osteoarthritis.

OBJECTIVE: To study the biochemical changes in the early development of primary guinea-pig knee osteoarthritis (OA) and its dependence on load. METHODS: Load distribution was modified with below-knee amputation or femur valgus osteotomy in 9-month-old guinea-pigs. Soft tissue sham operated animals served as controls. The composition of uncalcified and calcified articular cartilage at the medial and lateral tibial condyle was studied by analysing small and large proteoglycans (PG) by gel electrophoresis and sulfation pattern with high-performance liquid chromatography. Collagen concentration was also determined. RESULTS: The articular surfaces with a presumed higher load after surgery had a slight, but consistent, higher water content. Decreased load-on the ipsilateral medial condyle after femur osteotomy, and on the ipsilateral medial and lateral condyles following tibia amputation-was associated with an increased concentration of PGs, while this concentration decreased in condyles with increased load. Collagen concentration followed a similar pattern in the osteotomy group. In the amputated animals collagen concentration went down in all condyles, regardless of change of load. The aggregability and proportion of large and small PGs, the concentration of hyaluronan and the sulfation pattern of chondroitin sulfate was not affected by load. No consistent changes in PG, collagen or HA concentration, HA aggregability or sulfation pattern were seen in the calcified cartilage. CONCLUSIONS: Primary guinea-pig knee OA is a reproducible model similar to human OA. It develops slowly and biochemical changes seem to appear before the morphological lesions become evident. The biochemical events are affected by load redistribution and correlate closely to morphological changes. These changes eventually result in a cartilage devoid in aggrecan, as also has been demonstrated in advanced human OA. All of this makes primary guinea-pig OA a suitable model for studying early OA changes.

Acute hemodynamic effects of induced hypothermia in hemorrhagic shock: an experimental study in the pig.

Hypothermia (HT) is used in certain surgical procedures to reduce metabolism and protect the brain, but in trauma victims accidental HT is considered harmful. Recent animal studies indicate that HT has protective effects in hemorrhagic shock. The aim of the present study was to examine how induced HT modifies the hemodynamic pattern in hemorrhagic shock. Twenty pigs with a body weight of between 17 and 24 kg (mean 20.8) were anesthetized, 50% of their blood volume was withdrawn, and hypothermia (30 degrees C) was induced in half of them (HT group) while the others served as controls. Central hemodynamics was monitored during 4 h via an arterial line and a pulmonary artery catheter. Blood samples were obtained for measurement of leukocyte and platelet counts. Three of the control pigs died while all the animals in the HT group survived the experiment. The hemorrhage resulted in a marked increase in heart rate and a drop in cardiac output and mean arterial pressure. HT slowed the heart rate and induced a further reduction of cardiac output, which parallelled the depression of the core temperature, while the stroke volume did not change in any of the groups. A significant decrease in mean arterial pressure and the leukocyte count became apparent 2 h after the induction of HT. HT aggravated the hypokinetic situation resulting from hemorrhagic shock but without increasing the mortality.

Laser-induced shock wave endothelial cell injury.

BACKGROUND AND OBJECTIVE: Several laser procedures, extracorporeal lithotripsies (ESWL), and high-velocity missile trauma generate pressure transients that are transmitted through the tissues. Despite several publications demonstrating shock wave-induced tissue injury, little is known about its pathophysiology. This study introduces an in vitro model for studying shock wave effects on endothelial cell (EC) monolayers. STUDY DESIGN/MATERIALS AND METHODS: A Nd:YAG laser-driven flyer-plate technique was used to generate shock waves. Physical characteristics were determined with a pressure transducer, a high-speed video camera, and sequential photography. Biological effects were studied with phase contrast and lightfield microscopy, computerized morphometry, immunocytochemistry, spectrophotometry, and enzyme-linked immunosorbent assay (ELISA). RESULTS: The shock waves generated were highly reproducible. Cavitation was verified and quantified, and its extent could be varied in the vials. Exposed cultures exhibited areas with cell membrane damage and cell detachment. Release of LD was elevated (P < 0.01) in exposed vials. The EC lesions were larger (>P < 0.01) in cultures submitted to high vs. low extent of cavitation. CONCLUSION: The flyer-plate model can be used to subject cell monolayers to defined and reproducible shock waves causing immediate cell injury similar to the previously reported vascular lesions associated with ESWL, pulsed lasers, and blast trauma. With the flyer-plate model, such lesions may be further studied on the cellular and subcellular levels.

Patients with recurrent injuries--psychosocial characteristics and injury panorama.

Accidents are often considered to be a direct function of exposure to risk, but this study implies that there are subgroups of patients that expose themselves to more risks than others. Based on a consecutive series of moderately injured patients this study aimed to compare patients with repeated trauma episodes with patients with single trauma. The study showed that the former had experienced more violence during their lives, had a less favourable psychosocial situation and more often reported psychiatric problems and alcohol abuse compared with the latter, confirming the clinical knowledge that injury recurrence is associated with risk factors such as alcohol abuse, pre-existing psychopathology and a propensity towards violence.

Monobactams and carbapenems for treatment of intraabdominal infections.

During the last decade improved clinical and microbiological methods have resulted in the realization that most intraabdominal infections involve both aerobic and anaerobic bacteria. Papers on the use of different antimicrobial agents directed against the polymicrobial flora of the infected site have been published. In this paper the use of monobactams and carbapenems for treatment of intraabdominal infections is reviewed. The review is based on data published since 1990. Three hundred forty-four patients participated in three trials where aztreonam combined with clindamycin was compared with other antimicrobial agents for treatment of intraabdominal infections. Eighty-six percent of the patients receiving aztreonam plus clindamycin were cured/improved, while 83% of the patients receiving the comparative drugs had favorable outcomes. Eleven trials compared imipenem/cilastatin versus other antimicrobial combinations for therapy of intraabdominal infections. One thousand three hundred seventy-five patients were evaluated in the trials. Eighty percent of patients treated with imipenem/cilastatin had favorable outcomes, while 81% of the patients receiving the comparative drugs were cured/improved. Nine studies including 1,205 patients for evaluation of meropenem versus other antimicrobial agents in the treatment of intraabdominal infections have been published. Cure/improvement was seen in 96% of the patients treated with meropenem and in 91% receiving the comparative drugs. One trial has been published comparing biapenem with imipenem/cilastatin for treatment of intraabdominal infections. Eighty-three patients participated, 65% of the patients in the biapenem group were cured/improved and 68% in the imipenem/cilastatin group.

Psychotic disorders among inpatients with abuse of cannabis, amphetamine and opiates. Do dopaminergic stimulants facilitate psychiatric illness?

We have studied the occurrence of dual diagnoses (psychoses as well as abuse of either amphetamine, cannabis or opiates) during a 15-year period, among patients treated at Huddinge Hospital, Stockholm, Sweden. The purpose of the study is to evaluate if the different drugs were coupled to different rates of psychiatric co-morbidity. During the period in question, 461, 425 and 371 different patients respectively had been admitted at least once due to dependency on amphetamine, cannabis and opiates. Approximately 30% of the patients with a pure abuse of amphetamine or cannabis and less than 6% of the opiate abusers had been diagnosed at least once with any of the psychoses studied. Comparing the frequency of psychoses among mixed and pure abusers of illegal drugs, with and without a concomitant abuse of alcohol, we found that the co-morbidity rate for mixed opiate abusers increased significantly from 7.2 to 20.2% when alcohol abuse was also present. For abusers of amphetamine and cannabis (both pure and mixed), no differences in co-morbidity rates were seen when an abuse of alcohol was added to that of the drugs. It is difficult to find an explanation for the significant difference between the co-morbidity of pure abuse of amphetamine or cannabis on the one hand and opiates on the other. In conclusion, our findings show that the distribution of psychotic illness is high among abusers of amphetamine and cannabis, in contrast to the generally lower co-morbidity among abusers of opiates. Although these findings are consistent with earlier studies that have shown a propensity for developing psychoses among abusers of amphetamine and cannabis, one should bear in mind that this study is based on inpatients, and is not necessarily representative for all abusers of the drugs in question.

The significance of alcohol for violence and accidents.

For almost all types of accidents and violence, there is a causal relationship with alcohol intoxication or alcohol abuse. Alcohol may have significance as a risk factor for the perpetrator (culprit, car driver, etc.), as well as for the victim. This is especially clear in cases of violence and assault. Younger males are overrepresented in much of the data that shows causal relationships. A clear dose-response association can be seen in many accident cases concerning both accident risk and severity. The correlation is not as clear in cases of violence. However, the causal relationships between alcohol and accidents or violence may be difficult to evaluate. Factors such as the abuse of other drugs, unemployment, and other sociodemographic factors must be taken into account. The populations studied are often selected, e.g., from emergency departments, pathology units (postmortem data), or related to those epidemiological studies based on interviews. There is often a lack of relevant control data.

Acute metabolic and endocrine effects of induced hypothermia in hemorrhagic shock: an experimental study in the pig.

BACKGROUND: Hypothermia is considered harmful in trauma patients. In surgery, hypothermia is occasionally used to reduce metabolism and protect the brain. Recent studies in animals have also shown protective effects of hypothermia in hemorrhagic shock. The aim of this study was to evaluate the metabolic and endocrine effects of induced hypothermia in hemorrhagic shock. METHODS: Half of the individually calculated blood volume was removed from 17 anesthetized piglets. They were then randomized to normothermia or hypothermia and followed for 4 hours after hemorrhage. RESULTS: In the hypothermic pigs, arterial PO2 increased from 10.3 +/- 0.7 to 16.4 +/- 0.9 kPa, but it remained unchanged in the normothermic group. The serum levels of potassium increased from 3.9 +/- 0.2 to 5.0 +/- 0.2 mmol/L in the normothermic group. In the hypothermic pigs, the potassium levels temporarily decreased from 3.8 +/- 0.1 to 3.0 +/- 0.1 mmol/L but then returned to baseline levels. The levels of serum catecholamines surged in both groups during hemorrhage. They remained elevated in normothermic pigs but declined in the hypothermic group. CONCLUSION: In porcine hemorrhagic shock, induced hypothermia increases arterial oxygen tension and stabilizes serum levels of potassium and catecholamines.

Somatic morbidity among patients diagnosed with affective psychoses and paranoid disorders. A case-control study.

Several studies have shown an increased mortality rate among psychiatric patients. Morbidity, however, has been studied less often. In this study, the authors examined the number of hospitalizations with somatic diagnoses in 722 patients with affective psychoses and 472 with a paranoid disorder. Every patient had an age- and sex-matched control subject who did not have a psychiatric illness. Both groups of patients exhibited an increased number of somatic diagnoses compared with their control subjects, and this was true for the majority of the 14 different groups classified according to the International Classification of Diseases the authors studied. The pattern of somatic diagnoses was similar to that presented in one of the authors' prior studies of schizophrenic patients.

Somatic morbidity in schizophrenia--a case control study.

Several studies have stated that rates of premature mortality of schizophrenic patients are increased. Morbidity, however, is less often examined. In the present study we have compared the number of hospitalizations due to different somatic diseases in 775 schizophrenic patients with their sex- and age-matched controls. The total number of patients hospitalized due to somatic diseases was significantly greater among the schizophrenics than among the controls. In the former group, 523 out of 775 and in the latter 373 out of 775 had been admitted at least once during a 15 y period. If the schizophrenic patients who also had been diagnosed as substance abusers at least once were excluded from the analysis there was still a significant difference between the remaining patients and their controls. The patients exhibited an over-morbidity in almost all diagnostic groups, the most prominent excess morbidity appeared in the groups of injuries and symptoms, signs and ill-defined conditions, when compared with the controls. Even if there are confounding factors which should be taken into consideration when interpreting morbidity data, the pattern of excess morbidity among schizophrenic patients found in this study is so definite that it cannot be considered merely coincidental.

Sensory and sympathetic block during interpleural analgesia.

BACKGROUND AND OBJECTIVES: Interpleural analgesia is an effective method for pain relief after upper abdominal surgery. To examine whether the analgesic effect is obtained by block of the intercostal nerves, we assessed the analgesic efficacy of the block, the skin sensitivity, and indices of sympathetic outflow over the trunk. METHODS: Interpleural analgesia was instituted at the end of open cholecystectomy in 20 patients 24-81 years of age (mean, 42 years). After a washout period of 8 hours, the analgesic effect was tested 5-12 times during the postoperative follow-up period by using a visual analogue scale before and 20 minutes after injection of 20 mL of bupivacaine 0.25%. Temperature and pain sensations were tested on the day after surgery, and in nine of the patients, the cutaneous blood flow over the trunk was studied by an electronic thermometer, laser Doppler flowmetry, and fluorescein flowmetry. In addition, the conduction velocity in the phrenic nerve was studied in four of the patients. RESULTS: Interpleural analgesia significantly reduced the median visual analogue score from of 5.7 (range 2-10) to 1.1 (range, 0-4). Although the analgesic effect was very good in all patients, half of them still showed skin sensitivity to pain and temperature. Cutaneous blood flow did not change, which showed than block of the intercostal nerves was incomplete. The phrenic nerve was not affected. CONCLUSION: The incomplete cutaneous sensory and sympathetic block indicates that the analgesic effect of interpleural analgesia cannot be explained by retrograde diffusion of the local anesthetic solution into the intercostal nerves alone.