Correlation of transesophageal ultrasound of the pericardium with computed tomography.

OBJECTIVE: In this study, we assess the sensitivity and specificity of ultrasound and computed tomography (CT) for pericardial effusion and constrictive pericarditis. MATERIALS AND METHODS: This was a retrospective, institutional review board-approved, and health insurance privacy accountability act compliant study performed at a single tertiary center over a 10-year period (2001-2011) for patients who had clinical symptoms of pericarditis and had undergone both cardiac CT imaging and transesophageal echocardiogram (TEE) in a span of 2 weeks. INCLUSION CRITERIA: Inclusion criteria included patients with clinical symptoms of pericarditis, pericardial thickness measuring more than 2 mm on CT, and patients who had both cardiac CT imaging and TEE performed within 2 weeks. EXCLUSION CRITERIA: Exclusion criteria included patients with pericardial thickness measuring 2 mm or less on CT, no TEE, TEE not done within 2 weeks of the thoracic CT, and calcified pericardium on CT.Computed tomographic images were retrospectively reviewed by 2 radiologists who were unaware of the TEE findings. Pericardial effusion on CT was deemed present if there was obliteration of the fat plane in the left pulmonic recess. STATISTICAL ANALYSIS: Statistical analysis was performed using the R statistical environment (Rstat). Intraobserver and interobserver variability was estimated using Cohen κ- statistic (Cohen). RESULTS: Forty-three cases constituted the study population (28 men and 15 women; mean age, 55 years; age range, 22-82 years). Twenty-one patients had pathologic confirmation of pericarditis.The findings for CT and TEE were discrepant in 10 cases. Intraobserver variability Cohen κ statistic was 0.855. Interobserver variability Cohen κ statistics were 0.54 and 0.49. CONCLUSIONS: Computed tomography is sensitive to pericardial effusion and pericardial thickening, whereas TEE seems insensitive to isolated pericardial thickening.

Effect of intracranial bleeds on the health and quality of life of boys with hemophilia.

OBJECTIVES: To compare the health, physical function, and quality of life (QoL) of boys with hemophilia with and without a history of intracranial hemorrhage (ICH). STUDY DESIGN: Of 172 patients with hemophilia A or B, 18 (10%) had at least one episode of ICH. For outcome assessments, 16 of 18 (89%) boys with ICH and 32 controls, matched (1:2) for age and severity of hemophilia, were available. The outcome measures were neurologic function, physical function, and QoL. RESULTS: The median age of the boys at the first ICH was 5.9 months (range, 1 day to 2.7 years). Boys with ICH had a higher incidence of inhibitors and lower mean household income. Neurologic examination was abnormal in seven of 16 (44%) boys with ICH and nine of 32 (28%) controls (P=.3). The mean physical function in boys with ICH was lower (82%+/-25%) compared with controls (93.5%+/-12%, P=.045). The QoL was decreased in boys with ICH compared with controls (6.8+/-3.2 vs 8.5+/-1.4, P=.02), whereas health-related QoL was not significantly different between groups. CONCLUSION: The poorer long-term outcomes of boys with hemophilia appropriately treated for ICH, especially in the domain of QoL, suggest that new strategies to prevent ICH and to manage ICH effectively in this population are needed.

The use of ordering protocols and other maneuvers: the Canadian experience.

Canada's socialized, single-provider, fee-for-service environment has provided an opportunity for widespread implementation and evaluation of a number of utilization control measures. Enforced consolidation of services certainly eliminates redundancy but the implementation cost and disruption of such a measure is high. Whether noncompetition will eventually eliminate any cost savings achieved is difficult to predict. Risk sharing in which ordering doctors and laboratories are paid from the same source of funds and both groups stand financially responsible for excess utilization seems to be an effective approach. From a fiscal standpoint it is, but such measures can create ill will. Establishing utilization caps has an absolute fiscal effect but, unless very carefully designed and monitored, may create more problems than they solve. Utilization control can be achieved using a minimal list requisition form. Form control is also essential to ensure the success of protocol and CPG implementation. The development of protocols and CPGs has proved to be very effective in reducing laboratory testing while also standardizing aspects of medical practice. Such guidelines work well when (1) dealing with testing areas of high volume (or high cost); and (2) amenable to simple rules on which there generally can be agreement. A collaborative implementation environment is necessary. After about 15 such protocols, however, it becomes increasingly difficult to define new areas to target. Physician chart audits are a useful adjunct to help deal with problem areas and to keep all physicians highly aware of good ordering practices. Utilization problems have not been solved in the Canadian system. Certain ventures, however, have proved to have a positive effect. It is likely that when electronic knowledge support tools become a standard feature of medical practice the protocol-CPG approach will be maximized.

The use of expert systems for improving test use and enhancing the accuracy of diagnosis.

The experience with BloodLink and LAS provides strong evidence that electronic knowledge support has a significant and lasting effect on laboratory test ordering by physicians. Compliance with CPG is also improved despite the ability of the guideline process to keep up to date. As discussed previously, the limitations to the application of protocols and CPG can be eliminated by electronic knowledge support. Indeed, this technology may be considered the future salvation of evidence-based medicine. It is also apparent that using the expert system to provide interpretations of the results ensures optimal use of the tests. The ability to reduce costs by 20% using stringent use control measures is meaningless if by misunderstanding, all of the potential information is not understood. In the future, as computer connectivity becomes pervasive within the practice of medicine, systems, such as BloodLink and LAS, will be used routinely for many aspects of care. Molecular genetic testing and proteomics will become a major component of routine medical practice. The complexity of what to order, the implications of performing the tests, on whom to do them, and what the vast array of data mean, will demand the use of CARTKS. It is becoming increasingly popular for patients to obtain their own results and to manage their own medical record. In some jurisdictions patients may order their own tests. We will undoubtedly see the development of knowledge support tools that are designed for patient use. The CARTKS provided by computer systems is the most powerful approach to use control and it has the additional benefit of doing so while enhancing medical care.

Incorrect biochemistry complicates prostate cancer management.

A man with a prostate specific antigen (PSA) of 6.1 ng/mL, a clinical stage T2b prostate nodule and biopsies that showed Gleason sum 6 adenocarcinoma of the prostate underwent a radical prostatectomy. The final pathology showed organ-confined disease. His postoperative PSA remained elevated at 4.0 ng/mL. The PSA was repeated several times and was in the same range. It was re-evaluated at another lab facility and was unmeasurable (<0.02 ng/mL). He has an antibody that cross-reacts with an assay reagent causing this false reading. The most likely antibody is one against mouse immunoglobulin G (IgG).

Gains in sensitivity with a device that mixes microarray hybridization solution in a 25-microm-thick chamber.

A microarray hybridization system that allows mixing in volumes comparable to those used by glass coverslips is presented. This system is composed of a disposable flexible lid that binds to 1 in. x 3 in. glass slides via an adhesive gasket, forming a uniform 25-microm-thick hybridization chamber. This chamber rests on a base unit for temperature control. The lid contains two air-driven bladders that continuously mix the hybridization fluid. Mixing enhances sensitivity from a typical microarray experiment 2-3-fold. Mixing is particularly effective at high spotted probe and low labeled target concentrations and overcoming local target depletion that occurs when homologous probes are spotted in close proximity. Mixing appears to be compatible with most hybridization conditions; however, mix versus no-mix control experiments should be performed. Also covered are a number of microfluidic issues related to manufacturing, filling, mixing, and packaging.