Peripheral vascular changes in the lower limbs following cocaine abuse.

Background: Worldwide, substance use disorder is on the rise, especially amongst the young generation. Although cocaine-induced cardiovascular and cerebrovascular events are well documented, knowledge about the relationship of cocaine use and its effect on arterial perfusion in the lower limbs is scarce.Objective: This study sought to investigate the relationship between cocaine use and peripheral arterial disease.Methods: The study population comprised 30 subjects' dependent on cocaine, smoking and alcohol [Group A] and another 30 subjects dependent on smoking and alcohol only [Group B]. A comprehensive lower limb vascular assessment was conducted utilizing pulse palpation, Doppler spectral waveform analysis, Ankle brachial pressure index (ABPI) and Toe brachial pressure index (TBPI) to determine the arterial perfusion status in the lower limbs.Results: Group A had lower ABPIs and TBPIs than Group B suggesting poorer vascular perfusion in lower limbs. Furthermore, a larger percentage of Group A had monophasic/continuous waveforms of all three pedal pulses compared to Group B. Conversely there was a higher percentage in Group B with biphasic/triphasic waveforms compared to Group A implying better vascular perfusion.Conclusion: In this study, cocaine use was associated with diminished arterial perfusion of the lower limbs suggesting that cocaine use has the potential to increase the risk of peripheral arterial disease. Regular vascular foot screening is warranted if foot complications are to be avoided.

The progression rate of peripheral arterial disease in patients with intermittent claudication: a systematic review.

BACKGROUND: Intermittent claudication (IC) is the most common symptom of peripheral arterial disease and is generally treated conservatively due to limited prognostic evidence to support early revascularisation in the individual patient. This approach may lead to the possible loss of opportunity of early revascularisation in patients who are more likely to deteriorate to critical limb ischaemia. The aim of this review is to evaluate the available literature related to the progression rate of symptomatic peripheral arterial disease. METHODS: We conducted a systematic review of the literature in PubMed and MEDLINE, Cochrane library, Elsevier, Web of Science, CINAHL and Opengrey using relevant search terms to identify the progression rate of peripheral arterial disease in patients with claudication. Outcomes of interest were progression rate in terms of haemodynamic measurement and time to development of adverse outcomes. Two independent reviewers determined study eligibility and extracted descriptive, methodologic, and outcome data. Quality of evidence was evaluated using the Cochrane recommendations for assessing risk of bias and was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Seven prospective cohort studies and one retrospective cohort study were identified and included in this review with the number of participants in each study ranging from 38 to 1244. Progression rate reports varied from a yearly decrease of 0.01 in ankle-brachial pressure index (ABPI) to a yearly decrease ABPI of 0.014 in 21% of participants. Quality of evidence ranged from low to moderate mostly due to limited allocation concealment at recruitment and survival selection bias. CONCLUSIONS: Progression of PAD in IC patients is probably underestimated in the literature due to study design issues. Predicting which patients with claudication are likely to deteriorate to critical limb ischaemia is difficult since there is a lack of evidence related to lower limb prognosis. Further research is required to enable early identification of patients at high risk of progressing to critical ischaemia and appropriate early revascularisation to reduce lower limb morbidity.

Development of an inventory of biomedical imaging physics learning outcomes for MRI radiographers.

INTRODUCTION: MRI is highly physics based yet no research-based inventory of physics learning outcomes specific to MRI radiographers was found in the literature. The purpose of this study was the development of such an inventory using a multi-stakeholder, multi-disciplinary approach (as advised by the WHO) and which would support a previously published competence profile. METHODS: The inventory was developed in two phases: Phase 1: Development of an initial version of the learning outcomes inventory required to be able to deliver the competences via an analysis of textbooks and literature and validated by a small (n = 3) expert advisory group Phase 2: Final validation carried out via a bigger (n = 15) international group of subject matter experts (SMEs). Consensus was achieved via a dichotomous web-based questionnaire. RESULTS: At 70% level of consensus the expert group validated an inventory of biomedical physics learning outcomes consisting of 281 knowledge and skill statements. It is subdivided into two sections: 'fundamental' physics learning outcomes which are generic to all competences and 'additional' physics learning outcomes specific to each individual competence. CONCLUSION: The process used is sufficiently generic to be easily adapted to the development of physics learning outcome inventories in other specialties of radiography and for other healthcare professions whose work involves highly technological medical devices. As a result of this study, the current MRI curriculum would need to be revised as it was not based on a formal systematic research process and many learning outcomes are in fact missing.

A Novel Method to Determine Dynamic Temperature Trends Applied to In-Shoe Temperature Data During Walking.

Body temperature is one of the fundamental measures considered in the assessment of health and well-being, with various medical conditions known to give rise to abnormal changes in temperature. In particular, abnormal variations in dynamic temperature patterns during walking or exercise may be linked to a range of foot problems, which are of particular concern in diabetic patients.A number of studies have investigated normative temperature patterns of a population by considering data from multiple participants and averaging results after an acclimatisation interval. In this work we demonstrate that the temperature patterns obtained using such an approach may not be truly representative of temperature changes in a population, and the averaging process adopted may yield skewed results.An alternative approach to determine generic reference temperature patterns based on a minimization of root mean square differences between time-shifted versions of temperature data collected from multiple participants is proposed. The results obtained indicate that this approach can yield a general trend that is more representative of actual temperature changes across a population than conventional averaging methods. The method we propose is also shown to better capture and link the effects of factors that influence dynamic temperature trends, which could in turn lead to a better understanding of underlying physiological phenomena.

The development of patient information leaflets incorporating patient diversity considerations: Varicocele embolisation and fluoroscopy guided joint injection examinations.

PURPOSE: The production of patient information leaflets (PILs) for diverse patient cohorts is challenging. This study developed varicocele and fluoroscopy guided joint injection (FLGJI) procedural PILs. METHODOLOGY: Evidence-based PILs were developed, providing radiological procedural information - preparation, explanation of interventional procedures and aftercare. PIL readability was tested via validated readability programs: Flesch Kincaid and Flesch ease reading score methods. Radiology approval of PIL(s) content was confirmed. PILs were distributed with appointment information. Patient interviews were conducted just prior to examination and by telephone, 7 days post procedure. RESULTS: Participants were purposely sampled (6 months): varicocele embolisation (n = 17) and FLGJI (n = 47). Overall 78.1% of all participants preferred Maltese leaflets. Varicocele embolisation patients were generally younger and a greater percentage educated to tertiary level compared to FLGJI patients. Education and age were found to be recurrent significant variables in the patient demographics and responses for both patient cohorts. Age versus education for the FLGJI cohort proved to be significant for several responses. Readability statistics identified the FLGJI leaflet as a plain English rating, the varicocele embolisation leaflet was more difficult. Patient feedback identified 'what is a varicocele?' as important to varicocele embolisation patients whereas FLGJI patients chose, 'advice about aftercare' and 'advice about pain management', highlighting differences in patients' priorities between procedures. CONCLUSION: PILs provided tangible, accurate information pre and post examination. Patient involvement in achieving appropriate information informed the PILs development, which were adopted clinically. The development of tailored PILs to meet the diversity of other interventional radiology procedures is recommended.

An international survey of MRI qualification and certification frameworks with an emphasis on identifying elements of good practice.

The purpose of the study was to survey MRI qualification and certification frameworks in the major English-speaking countries (Australia, New Zealand, US, Canada, UK, Ireland) with the aim of identifying elements of good practice. The intention is to incorporate these elements in a national framework that could be used in supporting an MRI specialist register. The study was conducted using document analysis of MRI qualification and certification documents from these states with data triangulated through a web-based questionnaire amongst an expert group of MRI radiographers (n = 59) from the same states. Based on the results of the study, recommendations have been put forward for those countries that are in the process of developing such frameworks. The main recommendations include that a professional or regulatory body externally accredits MRI programmes and that learning outcomes be based on an MRI competence profile that addresses current and forecasted needs of the particular country. The MRI competence profile should encompass a novice-to expert continuum and be referenced directly to a national qualification framework. Ideally each level of expertise should be assessed and evidenced by a portfolio of CPD activities, including clinical and management case studies appropriate to that level.

Cardiac manifestations of subarachnoid hemorrhage.

INTRODUCTION: Cardiac manifestations of intracranial subarachnoid hemorrhage patients include mild electrocardiogram variability, reversible left ventricular dysfunction (Takotsubo), non-ST elevation myocardial infarction, ST-elevation myocardial infarction and cardiac arrest, but their clinical relevance is unclear. The aim of the present study was to categorize the relative frequency of different cardiac abnormalities in patients with subarachnoid hemorrhage and determine the influence of each abnormality on outcome.  METHODS: A retrospective review of 617 consecutive patients who presented with non-traumatic aneurysmal subarachnoid hemorrhage at our institution was performed. A cohort of 87 (14.1%) patients who required concomitantly cardiological evaluation was selected for subgroup univariate and multi-variable analysis of radiographic, clinical and cardiac data.  RESULTS: Cardiac complications included myocardial infarction arrhythmia and congestive heart failure in 47%, 63% and 31% of the patients respectively. The overall mortality of our cohort (23%) was similar to that of national inpatient databases. In our cohort a high World Federation of Neurosurgical Surgeons grading scale and a troponin level >1.0 mcg/L were associated with a 33 times and 10 times higher risk of death respectively. CONCLUSIONS: Among patients suffering from cardiac events at the time of aneurysmal subarachnoid hemorrhage, those with myocardial infarction and in particular those with a troponin level greater than 1.0 mcg/L had a 10 times increased risk of death. 

Compression of the superior vena cava by an interatrial septal lipoma: a case report.

Primary cardiac tumours are rare; their prevalence ranges from 0.0017% to 0.28% in various autopsy series. Cardiac lipomas are well-encapsulated benign tumours typically composed of mature fat cells, and their reported size ranges from 1 to 15 cm. They are usually seen in the left ventricle and the right atrium. Lipomas are true neoplasms, as opposed to lipomatous hypertrophy of the interatrial septum, which is a nonencapsulated hyperplastic accumulation of mature and foetal adipose tissue. Cardiac lipomas occur in patients of all ages, and the frequency of occurrence has been found to be equal in both sexes. Patients are usually asymptomatic, although the manifestation of symptoms depends upon both size and location of the tumour. We present the case of a patient with an interatrial septal lipoma, causing obstruction of the superior vena cava.

Sevoflurane vs. propofol in patients with coronary disease undergoing mitral surgery: a randomised study.

BACKGROUND: Myocardial ischemic damage is reduced by volatile anaesthetics in patients undergoing low-risk coronary artery bypass graft surgery; few and discordant results exist in other settings. We therefore performed a randomised controlled trial (sevoflurane vs. propofol) to compare cardiac troponin release in patients with coronary disease undergoing mitral surgery. METHODS: Patients with coronary artery disease undergoing mitral surgery were randomly allocated to receive either sevoflurane (50 patients) or propofol (50 patients) as main hypnotic. The primary endpoint of the study was peak post-operative cardiac troponin release defined as the maximum value among the post-operative values measured at intensive care unit arrival, 4 h later, on the first and second post-operative day. RESULTS: There was no significant difference in post-operative peak troponin release, the median (25th-75th percentiles) values being 14.9 (10.1-22.1) ng/ml and 14.5 (8.8-17.6) ng/ml in the sevoflurane and propofol groups, respectively (P = 0.4). Fentanyl administration was different between the two groups: 1347 ± 447 µg in patients receiving sevoflurane and 1670 ± 469 µg in those receiving propofol, P = 0.002. The 1-year follow-up identified two patients who died in the propofol group (one myocardial infarction and one low cardiac output syndrome) and one in the sevoflurane group (myocardial infarction). CONCLUSION: In this study, patients with coronary artery disease undergoing mitral surgery did not benefit from the cardioprotective properties of halogenated anaesthetics. Sevoflurane anaesthesia was not associated to lower cardiac troponin release when compared with propofol anaesthesia.

Intracranial calcifications. A pictorial review.

Brain calcifications are a common radiographic finding. The pathogenesis is diverse and ranges from benign physiological calcifications to a variety of pathological disorders. Whereas certain calcifications are considered an incidental finding, their presence can sometimes be crucial in making a specific diagnosis. Several pathological conditions affecting the brain parenchyma are associated with calcifications and their recognition and location might help in narrowing the differential. Knowledge of physiological calcifications is essential to avoid misinterpretation. This review illustrates a broad spectrum of CNS disorders associated with calcifications, and tries to highlight the salient radiological findings.

Imaging Paget's disease of bone--from head to toe.

Paget's disease of the bone is a common, non-inflammatory, metabolic, skeletal disorder of unknown aetiology characterized by an increase in osteoclast-mediated bone resorption and compensatory excessive osteoblast activation. Prevalence increases with age, and a pronounced geographical variation is well documented. The disease is often an incidental finding on a radiological examination requested for an unrelated indication. The osteolytic, mixed osteolytic/osteoblastic, and osteosclerotic phases may occur in the same patient and same bone in a synchronous or metachronous fashion. Radiological features in each phase mirror the histopathological appearances, and are distinctive enough to establish a diagnosis with confidence. Using multi-technique imaging, this review illustrates the most common and the not so common radiological patterns of involvement in Paget's disease of bone observed at our centre during the past 20 years.

Levosimendan reduces mortality in critically ill patients. A meta-analysis of randomized controlled studies.

AIM: Critically ill patients often need catecholamines, but these agents could be associated with an increased risk of death and other adverse cardiac events. Levosimendan is a calcium sensitizer that is able to enhance myocardial contractility without increasing myocardial oxygen use. We conducted a meta-analysis to determine the impact of levosimendan on mortality in critically ill patients. METHODS: Four investigators independently searched BioMedCentral and PubMed to identify all randomized trials that compared levosimendan vs. control with no restriction in dose or time of administration. Exclusion criteria were duplicate publications, non-human experimental studies, and no information on the primary outcome (mortality). RESULTS: Data from a total of 3,350 patients from 27 randomized controlled studies were included in the analysis. Levosimendan was associated with a significant reduction in mortality (333/1893 [17.6%] in the levosimendan group vs. 326/1457 [22.4%] in the control arm, OR=0.74 [0.62-0.89], P for effect=0.001) and in the rate of myocardial infarction (3/493 [0.6%] in the levosimendan group vs. 14/356 [3.9%] in the control arm P=0.007), with a significant increase in the rate of hypotension (164/1484 [11.1%] in the levosimendan group vs. 106/1093 [9.7%] in the control arm P=0.02). CONCLUSION: Levosimendan has cardioprotective effects that could result in a reduced mortality in critically ill patients. A large randomized controlled study is warranted in this setting.

Fenoldopam to prevent renal replacement therapy after cardiac surgery. Design of the FENO-HSR study.

INTRODUCTION: Acute kidney injury requiring renal replacement therapy is a serious complication following cardiac surgery associated with poor clinical outcomes. Until now no drug showed nephroprotective effects. Fenoldopam is a dopamine-1 receptor agonist which seems to be effective in improving postoperative renal function. The aim of this paper is to describe the design of the FENO-HSR study, planned to assess the effect of a continuous infusion of fenoldopam in reducing the need for renal replacement therapy in patients with acute kidney injury after cardiac surgery. METHODS: We're performing a double blind, placebo-controlled multicentre randomized trial in over 20 Italian hospitals. Patients who develop acute renal failure defined as R of RIFLE score following cardiac surgery are randomized to receive a 96-hours continuous infusion of either fenoldopam (0.025-0.3 µg/kg/min) or placebo. RESULTS: The primary endpoint will be the rate of renal replacement therapy. Secondary endpoints will be: mortality, time on mechanical ventilation, length of intensive care unit and hospital stay, peak serum creatinine and the rate of acute renal failure (following the RIFLE score). CONCLUSIONS: This trial is planned to assess if fenoldopam could improve relevant outcomes in patients undergoing cardiac surgery who develop acute renal dysfunction. Results of this double-blind randomized trial could provide important insights to improve the management strategy of patients at high risk for postoperative acute kidney injury.

Cardiac protection by volatile anesthetics in non-cardiac surgery? A meta-analysis of randomized controlled studies on clinically relevant endpoints.

INTRODUCTION: Volatile anesthetics improve post-ischemic recovery. A meta-analysis suggested that the cardioprotective properties of desflurane and sevoflurane could reduce mortality and cardiac morbidity in cardiac surgery. Recent American College of Cardiology / American Heart Association Guidelines recommended volatile anesthetic agents during non-cardiac surgery for the maintenance of general anesthesia in patients at risk for myocardial infarction but whether these cardioprotective properties exist in non-cardiac surgery settings is controversial. We therefore performed a meta-analysis of randomized studies to investigate this issue. METHODS: Two investigators independently searched PubMed. Inclusion criteria were random allocation to treatment, comparison of a total intravenous anesthesia regimen vs an anesthesia plan including desflurane or sevoflurane, performed on adult patients undergoing non-cardiac surgery. The primary endpoints were the incidence of perioperative myocardial infarction and death. RESULTS: A total of 6219 patients from 79 randomized trials were identified. No myocardial infarctions or deaths were reported in any of the studies we examined. CONCLUSIONS: This meta-analysis highlights a weakness in the literature and the results can be used to design future studies: the cardioprotective properties of desflurane and sevoflurane have never been studied in noncardiac surgery. No randomized study, among those which compared desflurane or sevoflurane to intravenous anesthetics, has addressed major outcomes such as myocardial infarction or mortality. Large, multicentre, randomized clinical trials including patients undergoing high-risk non-cardiac surgery and reporting clinically relevant outcomes such as myocardial infarction and mortality are needed.

Periferic intravenous infusion of fenoldopam through an elastomeric pump.

INTRODUCTION: Fenoldopam has been used to protect renal function in critically ill patients and in those undergoing major surgery, where a possible damage of kidney is expected. Numerous randomized studies and meta-analysis demonstrated the efficacy of fenoldopam in this setting. We performed this study to demonstrate the feasibility of administering fenoldopam, trough an elastomeric pump connected to a peripheral vein, to patients undergoing nephron sparing surgery. MATERIALS AND METHODS: Twenty consecutive patients, ASA physical status class I-III, undergoing laparoscopic or laparotomic renal tumorectomy were enrolled. Fenoldopam was infused trough an elastomeric pump at a fixed dosage of 0.1 mcg/kg/min, obtained after diluting the drug with saline solution according to the weight of the patient. We injected the drug trough a peripheral vein from the induction of anaesthesia for 48 hours after the end of surgery. RESULTS: The infusion of fenoldopam did not modify the haemodynamic parameters. We did not find episodes of hypotension and only in three patients we registered episodes of tachycardia, not requiring the suspension of the infusion. No other side-effect was noted. CONCLUSIONS: The administration of fenoldopam, trough an elastomeric pump, in patients undergoing renal tumorectomy is feasible through a peripheral vein access.

Rate of computed tomography pulmonary angiographies (CTPA) positive for pulmonary embolism and predictive scores.

PURPOSE: In March 2005, the Simplified Wells Scoring System was introduced as a predictive tool for pulmonary embolism at Hairmyres Hospital in Scotland. This study was conducted to evaluate the efficacy of the Wells score in predicting the presence of pulmonary embolism in terms of rate of positive computed tomography pulmonary angiographies (CTPAs). MATERIALS AND METHODS: Two hundred patients with suspected pulmonary embolism were retrospectively reviewed using a sequential method: 100 patients before implementation of the Wells score and a further 100 after its introduction. RESULTS: The rate of positive CTPAs for pulmonary embolism changed from 23% before to 27% after the introduction of the Wells Scoring System. CONCLUSIONS: The rate of positive CTPAs did not change significantly after the introduction of the Wells score.

Technical inadequacies of peripheral contrast-enhanced magnetic resonance angiography: incidence, causes and management strategies.

AIM: To assess the incidence, causes and effects of technical inadequacies in peripheral contrast-enhanced magnetic resonance angiography (CE-MRA) and to discuss relevant management strategies. MATERIALS AND METHODS: A retrospective analysis of 249 peripheral CE-MRA examinations was performed using the radiology department's RIS/PACS (radiology information system/picture archiving and communication system) database. All failed or technically inadequate MRAs were reviewed. In cases that underwent further imaging by conventional angiography (CA), we assessed if relevant arterial disease had been masked on the MRA. RESULTS: Of the 249 examinations, 215 (86.3%) were technically satisfactory while 34 (13.7%) were a combination of technical inadequacies [29 cases (11.6%)] and examination failures [five cases (2%)]. The causes of technical inadequacies were: (1) venous contamination (13 cases; 5.2%), (2) motion-induced subtraction artefact (eight cases; 3.2%), (3) stent-induced artefact (four cases; 1.6%), (4) inadequate scan coverage (two cases; 0.8%), and (5) contrast timing error (two cases; 0.8%). The causes of failed examinations were: (1) inability to tolerate lying in the scanner (three cases; 1.2%) and (2) inability to fit into the scanner (two cases; 0.8%). Fifteen (44.1%) of the 34 cases underwent further imaging by CA, and in eight of these there was significant arterial disease that was missed on the MRA. CONCLUSION: Technical inadequacies occur in a small but significant proportion of peripheral CE-MRAs and can mask significant arterial disease. Knowledge of the potential causes of technical problems and the relevant management options is important for quality assurance and for limiting the need for an alternative investigation.

Magnetic resonance angiography in potential live renal donors: a joint radiological and surgical evaluation.

AIM: To assess the impact of a joint surgical and radiological audit on the accuracy of contrast-enhanced magnetic resonance angiography (MRA) reports in the evaluation of potential renal donors. MATERIALS AND METHODS: We analysed the records of live renal donors who underwent gadolinium-enhanced MRA as part of the pre-operative evaluation to assess renal vasculature between August 1999 and July 2002 when feedback from surgical findings to radiology had been available. In cases of discrepancy between MRA reports and surgical findings, studies were retrieved from the magnetic resonance imaging (MRI) workstation and subjected to detailed joint clinical and radiological review. Scan quality was assessed and sources of discrepancy were identified. RESULTS: There were 45 donors, 23 men and 22 women with a mean age of 41 years. Reported MRA findings were fully confirmed at surgery in 38 of 45 cases. These images were not analysed further. In seven donors the findings at surgery were discrepant with the radiological reports: there were four cases of "missed" early branches and three cases of "missed" accessory arteries. In the first year of the audit there were four discrepant cases out of 18 (22%), all of which were radiological reporting errors. The number of discrepant cases in the second year was two out of 19 cases (11%). Neither of these was a radiological reporting error. There was one "missed" early renal artery branch in the third year of audit, which was identified on MRA review. CONCLUSION: The study highlights the importance of detecting and clearly reporting not only accessory renal arteries, but also early renal arterial branches in the pre-operative evaluation of renal donors. The accuracy of pre-operative MRA in potential renal donors is high, but radiological reporting of MRA examinations is improved through careful clinical feedback, audit and interdisciplinary co-operation.

The role of follow-up imaging in paediatric blunt abdominal trauma.

AIM: To assess the role of follow-up imaging in paediatric blunt abdominal trauma. METHOD: All children who underwent CT scanning of their abdomen at our institution following acute blunt injury between January 1997 and December 2000 were included in the study. Case notes where researched for details regarding mechanism of injury, initial clinical presentation, acute management, complications and follow-up until discharge. Reports of imaging investigations were retrieved from the RIS database. RESULTS: In the study period 75 children underwent CT scanning of their abdomen as a primary investigation for acute blunt abdominal trauma. Of these, 12 were normal, 52 showed evidence of intra-abdominal organ injury and 11 showed findings other than abdominal organ injury. Of the 52 children that sustained intra-abdominal organ injury, 48 (92 percent) were treated conservatively. 4 (8 percent) underwent emergency surgery, 3 for bowel injury and 1 for renal trauma. Of the 48 that were treated conservatively, 9 had a complicated clinical course with 7 showing complications on follow-up imaging. The remaining 39 children had an uneventful clinical course with follow-up imaging by CT or US in 34. None showed complications that required a change in management. CONCLUSION: In our series, follow-up imaging did not contribute to further management in children with an uncomplicated clinical course following blunt abdominal trauma.