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1.
Eur Radiol ; 2020 Jan 23.
Artigo em Inglês | MEDLINE | ID: mdl-31974691

RESUMO

OBJECTIVES: Initial trauma care could potentially be improved when conventional imaging and selective CT scanning is omitted and replaced by immediate total-body CT (iTBCT) scanning. Because of the potentially increased radiation exposure by this diagnostic approach, proper selection of the severely injured patients is mandatory. METHODS: In the REACT-2 trial, severe trauma patients were randomized to iTBCT or conventional imaging and selective CT based on predefined criteria regarding compromised vital parameters, clinical suspicion of severe injuries, or high-risk trauma mechanisms in five trauma centers. By logistic regression analysis with backward selection on the 15 study inclusion criteria, a revised set of criteria was derived and subsequently tested for prediction of severe injury and shifts in radiation exposure. RESULTS: In total, 1083 patients were enrolled with median ISS of 20 (IQR 9-29) and median GCS of 13 (IQR 3-15). Backward logistic regression resulted in a revised set consisting of nine original and one adjusted criteria. Positive predictive value improved from 76% (95% CI 74-79%) to 82% (95% CI 80-85%). Sensitivity decreased by 9% (95% CI 7-11%). The area under the receiver operating characteristics curve remained equal and was 0.80 (95% CI 0.77-0.83), original set 0.80 (95% CI 0.77-0.83). The revised set retains 8.78 mSv (95% CI 6.01-11.56) for 36% of the non-severely injured patients. CONCLUSIONS: Selection criteria for iTBCT can be reduced from 15 to 10 clinically criteria. This improves the positive predictive value for severe injury and reduces radiation exposure for less severely injured patients. KEY POINTS: • Selection criteria for iTBCT can be reduced to 10 clinically useful criteria. • This reduces radiation exposure in 36% of less severely injured patients. • Overall discriminative capacity for selection of severely injured patients remained equal.

2.
Eur Respir J ; 55(2)2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31727694

RESUMO

INTRODUCTION: In cancer patients, current guidance suggests similar treatment for incidental and symptomatic venous thromboembolism (VTE), mainly based on retrospective data. We aimed to evaluate anticoagulant therapy in cancer patients with incidental and symptomatic VTE. METHODS: The Hokusai VTE Cancer Study was a randomised controlled trial comparing edoxaban with dalteparin for cancer-associated VTE. The primary outcome was the composite of first recurrent VTE or major bleeding. Secondary outcomes included major bleeding, recurrent VTE and mortality. Outcomes in patients with incidental and symptomatic VTE were evaluated during the 12-month study period. RESULTS: 331 patients with incidental VTE and 679 patients with symptomatic VTE were enrolled, of whom the index event was confirmed by an independent radiologist. Median durations of anticoagulant treatment were 195 and 189 days, respectively. In patients with incidental VTE, the primary outcome occurred in 12.7% of patients, major bleeding in 6.6% of patients and recurrent VTE in 7.9% of patients. Out of the 26 VTE recurrences in patients with incidental VTE, five (31%) were incidental, seven (44%) were symptomatic and four (25%) were deaths for which pulmonary embolism could not be ruled out. In patients with symptomatic VTE, the primary outcome occurred in 13.8% of patients, major bleeding in 4.9% of patients and recurrent VTE in 10.9% of patients. All-cause mortality was similar in both groups. CONCLUSION: Clinical adverse outcomes are substantial in both cancer patients with incidental and symptomatic VTE, supporting current guideline recommendations that suggest treating incidental VTE in the same manner as symptomatic VTE.

3.
Cancers (Basel) ; 11(6)2019 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-31207904

RESUMO

First-line triplet chemotherapy including a taxane may prolong survival in patients with metastatic esophagogastric cancer. The added toxicity of the taxane might be minimized by using nab-paclitaxel. The aim of this phase I study was to determine the feasibility of combining nab-paclitaxel with the standard of care in the Netherlands, capecitabine and oxaliplatin (CapOx). Patients with metastatic esophagogastric adenocarcinoma received oxaliplatin 65 mg/m2 on days 1 and 8, and capecitabine 1000 mg/m2 bid on days 1-14 in a 21-day cycle, with nab-paclitaxel on days 1 and 8 at four dose levels (60, 80, 100, and 120 mg/m2, respectively), using a standard 3 + 3 dose escalation phase, followed by a safety expansion cohort. Baseline tissue and serum markers for activated tumor stroma were assessed as biomarkers for response and survival. Twenty-six patients were included. The first two dose-limiting toxicities (i.e., diarrhea and dehydration) occurred at dose level 3. The resulting maximum tolerable dose (MTD) of 80 mg/m2 was used in the expansion cohort, but was reduced to 60 mg/m2 after three out of eight patients experienced diarrhea grade 3. The objective response rate was 54%. The median progression-free (PFS) and overall survival were 8.0 and 12.8 months, respectively. High baseline serum ADAM12 was associated with a significantly shorter PFS (p = 0.011). In conclusion, albeit that the addition of nab-paclitaxel 60 mg/m2 to CapOx may be better tolerated than other taxane triplets, relevant toxicity was observed. There is a rationale for preserving taxanes for later-line treatment. ADAM12 is a potential biomarker to predict survival, and warrants further investigation.

4.
J Heart Lung Transplant ; 38(7): 731-738, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30962147

RESUMO

BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is often diagnosed after a long delay, even though signs may already be present on the computed tomography pulmonary angiogram (CTPA) used to diagnose a preceding acute pulmonary embolism (PE). In this setting of suspected acute PE, we evaluated the diagnostic accuracy of dedicated CTPA reading for the diagnosis of already existing CTEPH. METHODS: Three blinded expert radiologists scored radiologic signs of CTEPH on initial CTPA scans with confirmed acute PE in 50 patients who were subsequently diagnosed with CTEPH during follow-up (cases), and in 50 patients in whom sequential echocardiograms performed >2 years after the acute PE diagnosis did not show any signs of pulmonary hypertension (controls). All 50 control index CTPA scans had signs of right ventricular (RV) overload. Sensitivity and specificity of expert CTPA reading was calculated, and best-predicting radiologic parameters were identified. RESULTS: The overall expert reading yielded a sensitivity of 72% (95% confidence interval [CI] 58%-84%) and a specificity of 94% (95% CI 83%-99%) for CTEPH diagnosis. Multivariate analysis identified 6 radiologic parameters as independent predictors: intravascular webs; pulmonary artery retraction or dilatation; bronchial artery dilatation; right ventricular (RV) hypertrophy; and interventricular septum flattening. The presence of 3 or more these parameters was associated with a sensitivity of 70% (95% CI 55%-82%), a specificity of 96% (95% CI 86%-100%), and a c-statistic of 0.92. CONCLUSIONS: Standardized reading of CTPA scans performed for acute PE can be useful for the diagnosis of CTEPH when structured identification of 6 characteristics is employed during interpretation. The use of this strategy may help reduce diagnostic delay of CTEPH.

5.
JAMA Neurol ; 76(2): 194-202, 2019 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30615038

RESUMO

Importance: The positive treatment effect of endovascular therapy (EVT) is assumed to be caused by the preservation of brain tissue. It remains unclear to what extent the treatment-related reduction in follow-up infarct volume (FIV) explains the improved functional outcome after EVT in patients with acute ischemic stroke. Objective: To study whether FIV mediates the relationship between EVT and functional outcome in patients with acute ischemic stroke. Design, Setting, and Participants: Patient data from 7 randomized multicenter trials were pooled. These trials were conducted between December 2010 and April 2015 and included 1764 patients randomly assigned to receive either EVT or standard care (control). Follow-up infarct volume was assessed on computed tomography or magnetic resonance imaging after stroke onset. Mediation analysis was performed to examine the potential causal chain in which FIV may mediate the relationship between EVT and functional outcome. A total of 1690 patients met the inclusion criteria. Twenty-five additional patients were excluded, resulting in a total of 1665 patients, including 821 (49.3%) in the EVT group and 844 (50.7%) in the control group. Data were analyzed from January to June 2017. Main Outcome and Measure: The 90-day functional outcome via the modified Rankin Scale (mRS). Results: Among 1665 patients, the median (interquartile range [IQR]) age was 68 (57-76) years, and 781 (46.9%) were female. The median (IQR) time to FIV measurement was 30 (24-237) hours. The median (IQR) FIV was 41 (14-120) mL. Patients in the EVT group had significantly smaller FIVs compared with patients in the control group (median [IQR] FIV, 33 [11-99] vs 51 [18-134] mL; P = .007) and lower mRS scores at 90 days (median [IQR] score, 3 [1-4] vs 4 [2-5]). Follow-up infarct volume was a predictor of functional outcome (adjusted common odds ratio, 0.46; 95% CI, 0.39-0.54; P < .001). Follow-up infarct volume partially mediated the relationship between treatment type with mRS score, as EVT was still significantly associated with functional outcome after adjustment for FIV (adjusted common odds ratio, 2.22; 95% CI, 1.52-3.21; P < .001). Treatment-reduced FIV explained 12% (95% CI, 1-19) of the relationship between EVT and functional outcome. Conclusions and Relevance: In this analysis, follow-up infarct volume predicted functional outcome; however, a reduced infarct volume after treatment with EVT only explained 12% of the treatment benefit. Follow-up infarct volume as measured on computed tomography and magnetic resonance imaging is not a valid proxy for estimating treatment effect in phase II and III trials of acute ischemic stroke.


Assuntos
Isquemia Encefálica/patologia , Isquemia Encefálica/terapia , Procedimentos Endovasculares/estatística & dados numéricos , Acidente Vascular Cerebral/patologia , Acidente Vascular Cerebral/terapia , Idoso , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/fisiopatologia , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/patologia , Infarto Cerebral/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/fisiopatologia
6.
World J Surg ; 43(2): 490-496, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30327841

RESUMO

BACKGROUND: Immediate total-body CT (iTBCT) is often used for screening of potential severely injured patients. Patients requiring emergency bleeding control interventions benefit from fast and optimal trauma screening. The aim of this study was to assess whether an initial trauma assessment with iTBCT is associated with lower mortality in patients requiring emergency bleeding control interventions. METHODS: In the REACT-2 trial, patients who sustained major trauma were randomized for iTBCT or for conventional imaging and selective CT scanning (standard workup; STWU) in five trauma centers. Patients who underwent emergency bleeding control interventions following their initial trauma assessment with iTBCT were compared for mortality and clinically relevant time intervals to patients that underwent the initial trauma assessment with the STWU. RESULTS: In the REACT-2 trial, 1083 patients were enrolled of which 172 (15.9%) underwent emergency bleeding control interventions following their initial trauma assessment. Within these 172 patients, 85 (49.4%) underwent iTBCT as primary diagnostic modality during the initial trauma assessment. In trauma patients requiring emergency bleeding control interventions, in-hospital mortality was 12.9% (95% CI 7.2-21.9%) in the iTBCT group compared to 24.1% (95% CI 16.3-34.2%) in the STWU group (p = 0.059). Time to bleeding control intervention was not reduced; 82 min (IQR 5-121) versus 98 min (IQR 62-147), p = 0.108. CONCLUSIONS: Reduction in mortality in trauma patients requiring emergency bleeding control interventions by iTBCT could not be demonstrated in this study. However, a potentially clinically relevant absolute risk reduction of 11.2% (95% CI - 0.3 to 22.7%) in comparison with STWU was observed. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01523626.


Assuntos
Serviços Médicos de Emergência , Hemorragia/terapia , Tomografia Computadorizada por Raios X/métodos , Ferimentos e Lesões/diagnóstico por imagem , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ferimentos e Lesões/mortalidade
7.
Br J Haematol ; 183(4): 629-635, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30198551

RESUMO

The rate of identified isolated subsegmental pulmonary embolism (ssPE) has doubled with advances in computed tomography pulmonary angiography (CTPA) technology, but its clinical relevance is debated. The YEARS diagnostic algorithm was shown to safely reduce the number of required CTPAs in the diagnostic management of PE. We hypothesized that the higher threshold for performing CTPA in YEARS was associated with a lower prevalence of ssPE compared to the conventional diagnostic algorithm. We compared 2291 consecutive patients with suspected PE managed according to YEARS to 3306 consecutive control patients managed according to the Wells score for the prevalence of isolated ssPE. In the YEARS cohort, 52% were managed without CTPA, 12% had pulmonary embolism (PE) of which 10% were isolated ssPE, and the 3-month diagnostic failure rate was 0·35%. In the control cohort, 32% were managed without CTPA, 20% had PE of which 16% were isolated ssPE, and the 3-month failure rate was 0·73%. The isolated ssPE prevalence was significantly lower in YEARS (absolute difference 6·2% (95% confidence interval [CI] 1·4-10), Odds Ratio 0·58 (95% CI 0·37-0·90). In conclusion, YEARS is associated with a lower prevalence of isolated ssPE, due to reduction in CTPAs by the higher D-dimer threshold. This was however not associated with a higher risk of recurrent VTE during follow-up.


Assuntos
Algoritmos , Embolia Pulmonar , Tomografia Computadorizada por Raios X , Adulto , Idoso , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/mortalidade , Taxa de Sobrevida
8.
Eur Respir J ; 52(1)2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29773691

RESUMO

The value of various computed tomography parameters for prognosis and risk stratification in acute pulmonary embolism is controversial. Our objective was to evaluate the impact of specific cardiovascular computed tomography pulmonary angiography parameters on short- and long-term clinical outcomes.We analysed radiological and clinical data of 1950 patients with acute pulmonary embolism who participated in an international randomised clinical trial on anticoagulants. Parameters included right/left ventricular ratio, septal bowing, cardiothoracic ratio, diameters of pulmonary trunk and aorta, and intrahepatic/azygos vein contrast medium backflow. Associations with mortality, recurrent venous thromboembolism (VTE), hospitalisation, bleeding and adverse events were assessed over the short term (1 week and 1 month) and long term (12 months).Pulmonary trunk enlargement was the only parameter significantly associated with mortality over both the short and long term (OR 4.18 (95% CI 1.04-16.76) at 1 week to OR 2.33 (95% CI 1.36-3.97) after 1 year), as well as with recurrent VTE and hospitalisation.Most of the evaluated radiological parameters do not have strong effects on the short- or long-term outcome in patients with acute pulmonary embolism. Only an enlarged pulmonary trunk diameter carries an increased risk of mortality and recurrent VTE up to 12 months, and can be used for risk stratification.


Assuntos
Angiografia por Tomografia Computadorizada , Ventrículos do Coração/fisiopatologia , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/fisiopatologia , Tromboembolia Venosa/complicações , Adulto , Idoso , Anticoagulantes/uso terapêutico , Meios de Contraste , Feminino , Ventrículos do Coração/diagnóstico por imagem , Humanos , Internacionalidade , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Índice de Gravidade de Doença
9.
J Neurointerv Surg ; 10(12): 1137-1142, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29627794

RESUMO

BACKGROUND: Follow-up infarct volume (FIV) has been recommended as an early indicator of treatment efficacy in patients with acute ischemic stroke. Questions remain about the optimal imaging approach for FIV measurement. OBJECTIVE: To examine the association of FIV with 90-day modified Rankin Scale (mRS) score and investigate its dependency on acquisition time and modality. METHODS: Data of seven trials were pooled. FIV was assessed on follow-up (12 hours to 2 weeks) CT or MRI. Infarct location was defined as laterality and involvement of the Alberta Stroke Program Early CT Score regions. Relative quality and strength of multivariable regression models of the association between FIV and functional outcome were assessed. Dependency of imaging modality and acquisition time (≤48 hours vs >48 hours) was evaluated. RESULTS: Of 1665 included patients, 83% were imaged with CT. Median FIV was 41 mL (IQR 14-120). A large FIV was associated with worse functional outcome (OR=0.88(95% CI 0.87 to 0.89) per 10 mL) in adjusted analysis. A model including FIV, location, and hemorrhage type best predicted mRS score. FIV of ≥133 mL was highly specific for unfavorable outcome. FIV was equally strongly associated with mRS score for assessment on CT and MRI, even though large differences in volume were present (48 mL (IQR 15-131) vs 22 mL (IQR 8-71), respectively). Associations of both early and late FIV assessments with outcome were similar in strength (ρ=0.60(95% CI 0.56 to 0.64) and ρ=0.55(95% CI 0.50 to 0.60), respectively). CONCLUSIONS: In patients with an acute ischemic stroke due to a proximal intracranial occlusion of the anterior circulation, FIV is a strong independent predictor of functional outcome and can be assessed before 48 hours, oneither CT or MRI.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Recuperação de Função Fisiológica/fisiologia , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Isquemia Encefálica/terapia , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/terapia , Feminino , Seguimentos , Humanos , Imagem por Ressonância Magnética/métodos , Pessoa de Meia-Idade , Acidente Vascular Cerebral/terapia , Fatores de Tempo , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
10.
JAMA Neurol ; 75(4): 453-461, 2018 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-29365017

RESUMO

Importance: It is uncertain whether therapeutic reperfusion with endovascular treatment yields more or less brain edema. Objective: To elucidate the association between reperfusion and brain edema. The secondary objectives were to evaluate whether brain edema could partially be responsible for worse outcomes in patients with later reperfusion or lower Alberta Stroke Program Early Computed Tomography Score. Design, Setting, and Participants: This was a post hoc analysis of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), which was a prospective, randomized, multicenter clinical trial of endovascular treatment compared with conventional care of patients with acute anterior circulation ischemic stroke. Of 502 patients enrolled from December 2010 to June 2014, 2 patients declined to participate. Additionally, exclusion criteria were absence of follow-up imaging or presence of parenchymal hematoma, resulting in 462 patients included in this study. Brain edema was assessed retrospectively, from December 10, 2016, to July 24, 2017, by measuring midline shift (MLS) in all available follow-up scans. Observers were blinded to clinical data. Main Outcomes and Measures: Midline shift was assessed as present or absent and as a continuous variable. Reperfusion status was assessed by the modified thrombolysis in cerebral infarction score in the endovascular treatment arm. The modified arterial occlusive lesion score was used to evaluate the recanalization status in both arms. The modified Rankin scale score at 90 days was used for functional outcome. Results: Of 462 patients, the mean (SD) age was 65 (11) years, and 41.8% (n = 193) were women. Successful reperfusion and recanalization were associated with a reduced likelihood of having MLS (adjusted common odds ratio, 0.25; 95% CI, 0.12-0.53; P < .001 and adjusted common odds ratio, 0.34; 95% CI, 0.21-0.55; P < .001, respectively). Midline shift was partially responsible for worse modified Rankin scale scores in patients without reperfusion or recanalization (MLS changed the logistic regression coefficients by 30.3% and 12.6%, respectively). In patients with delayed reperfusion or lower Alberta Stroke Program Early Computed Tomography Score, MLS mediated part of the worse modified Rankin scale scores, corresponding to a change in the regression coefficient of 33.3% and 64.2%, respectively. Conclusions and Relevance: Successful reperfusion was associated with reduced MLS. This study identifies an additional benefit of reperfusion in relation to edema, as well as rescuing ischemic brain tissue at risk for infarction. Trial Registration: Netherlands Trial Registry number: NTR1804 and Current Controlled Trials number: ISRCTN10888758.


Assuntos
Edema Encefálico/etiologia , Procedimentos Endovasculares/métodos , Reperfusão/métodos , Acidente Vascular Cerebral/terapia , Resultado do Tratamento , Idoso , Isquemia Encefálica/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia
11.
Skeletal Radiol ; 47(6): 839-845, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28842739

RESUMO

OBJECTIVE: To quantify and optimize metal artifact reduction using virtual monochromatic dual-energy CT for different metal implants compared to non-metal reference scans. METHODS: Dual-energy CT scans of a pair of human cadaver limbs were acquired before and after implanting a titanium tibia plate, a stainless-steel tibia plate and a titanium intramedullary nail respectively. Virtual monochromatic images were analyzed from 70 to 190 keV. Region-of-interest (ROI), used to determine fluctuations and inaccuracies in CT numbers of soft tissues and bone, were placed in muscle, fat, cortical bone and intramedullary tibia canal. RESULTS: The stainless-steel implant resulted in more pronounced metal artifacts compared to both titanium implants. CT number inaccuracies in 70 keV reference images were minimized at 130, 180 and 190 keV for the titanium tibia plate, stainless-steel tibia plate and titanium intramedullary nail respectively. Noise, measured as the standard deviation of pixels within a ROI, was minimized at 130, 150 and 140 keV for the titanium tibia plate, stainless-steel tibia plate and titanium intramedullary nail respectively. CONCLUSION: Tailoring dual-energy CT protocols using implant specific virtual monochromatic images minimizes fluctuations and inaccuracies in CT numbers in bone and soft tissues compared to non-metal reference scans.


Assuntos
Artefatos , Próteses e Implantes , Interpretação de Imagem Radiográfica Assistida por Computador/métodos , Tíbia , Tomografia Computadorizada por Raios X/métodos , Cadáver , Humanos , Aço Inoxidável , Tíbia/diagnóstico por imagem , Tíbia/cirurgia , Titânio
12.
J Craniomaxillofac Surg ; 45(12): 1927-1933, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29046241

RESUMO

OBJECTIVE: The study aim was to investigate variations in the symmetry of the zygomaticomaxillary complex (ZMC) in normal individuals. METHOD: Computed tomography datasets of 200 individuals without facial fractures were analyzed using a validated three-dimensional analysis technique. The absolute average distance (AD) and 90th percentile distance (NPD) were calculated, representing respectively the overall and maximum symmetry between bilateral ZMCs. RESULTS: The mean AD and NPD of the total study group was 0.9 ± 0.3 mm (95% CI 0.3-2.3) and 1.7 ± 0.5 mm (95% CI 0.5-3.9), respectively. The mean AD and NPD in males were 1.0 ± 0.3 mm (95% CI 0.28-2.34) and 1.9 ± 0.5 mm (95% CI 0.5-3.9) versus 0.8 ± 0.3 mm (95% CI 0.4-1.7) and 1.6 ± 0.5 mm (95% CI 0.8-2.9), respectively, for females. A statistically significant difference between male and female was found for both AD and NPD (p < 0.01). The male population <40 years had a mean AD and NPD of 1.0 ± 0.3 mm and 1.8 ± 0.5 mm, which was not statistically significant when compared with males >40 years. CONCLUSION: The naturally occurring anatomic variation in ZMC symmetry described in this study is proposed as a benchmark for evaluating the amount of preoperative displacement and postoperative reduction of ZMC in trauma cases.


Assuntos
Variação Anatômica , Maxila/anatomia & histologia , Zigoma/anatomia & histologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valores de Referência , Adulto Jovem
13.
Lancet ; 390(10091): 289-297, 2017 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-28549662

RESUMO

BACKGROUND: Validated diagnostic algorithms in patients with suspected pulmonary embolism are often not used correctly or only benefit subgroups of patients, leading to overuse of computed tomography pulmonary angiography (CTPA). The YEARS clinical decision rule that incorporates differential D-dimer cutoff values at presentation, has been developed to be fast, to be compatible with clinical practice, and to reduce the number of CTPA investigations in all age groups. We aimed to prospectively evaluate this novel and simplified diagnostic algorithm for suspected acute pulmonary embolism. METHODS: We did a prospective, multicentre, cohort study in 12 hospitals in the Netherlands, including consecutive patients with suspected pulmonary embolism between Oct 5, 2013, to July 9, 2015. Patients were managed by simultaneous assessment of the YEARS clinical decision rule, consisting of three items (clinical signs of deep vein thrombosis, haemoptysis, and whether pulmonary embolism is the most likely diagnosis), and D-dimer concentrations. In patients without YEARS items and D-dimer less than 1000 ng/mL, or in patients with one or more YEARS items and D-dimer less than 500 ng/mL, pulmonary embolism was considered excluded. All other patients had CTPA. The primary outcome was the number of independently adjudicated events of venous thromboembolism during 3 months of follow-up after pulmonary embolism was excluded, and the secondary outcome was the number of required CTPA compared with the Wells' diagnostic algorithm. For the primary outcome regarding the safety of the diagnostic strategy, we used a per-protocol approach. For the secondary outcome regarding the efficiency of the diagnostic strategy, we used an intention-to-diagnose approach. This trial is registered with the Netherlands Trial Registry, number NTR4193. FINDINGS: 3616 consecutive patients with clinically suspected pulmonary embolism were screened, of whom 151 (4%) were excluded. The remaining 3465 patients were assessed of whom 456 (13%) were diagnosed with pulmonary embolism at baseline. Of the 2946 patients (85%) in whom pulmonary embolism was ruled out at baseline and remained untreated, 18 patients were diagnosed with symptomatic venous thromboembolism during 3-month follow-up (0·61%, 95% CI 0·36-0·96) of whom six had fatal pulmonary embolism (0·20%, 0·07-0·44). CTPA was not indicated in 1651 (48%) patients with the YEARS algorithm compared with 1174 (34%) patients, if Wells' rule and fixed D-dimer threshold of less than 500 ng/mL would have been applied, a difference of 14% (95% CI 12-16). INTERPRETATION: In our study pulmonary embolism was safely excluded by the YEARS diagnostic algorithm in patients with suspected pulmonary embolism. The main advantage of the YEARS algorithm in our patients is the absolute 14% decrease of CTPA examinations in all ages and across several relevant subgroups. FUNDING: This study was supported by unrestricted grants from the participating hospitals.


Assuntos
Embolia Pulmonar/diagnóstico , Idoso , Algoritmos , Biomarcadores/metabolismo , Angiografia por Tomografia Computadorizada/estatística & dados numéricos , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Embolia Pulmonar/terapia , Procedimentos Desnecessários/estatística & dados numéricos , Tromboembolia Venosa/etiologia
14.
Stroke ; 47(12): 2972-2978, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27827328

RESUMO

BACKGROUND AND PURPOSE: A high clot burden score (CBS) is associated with favorable outcome after intravenous treatment for acute ischemic stroke. The added benefit of intra-arterial treatment might be less in these patients. The aim of this exploratory post hoc analysis was to assess the relation of CBS with neurological improvement and endovascular treatment effect. METHODS: For 499 of 500 patients in the MR CLEAN study (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), the CBS was determined. Ordinal logistic regression models with and without main baseline prognostic variables were used to assess the association between CBS (continuous or dichotomized at CBS of 6) and a shift toward better outcome on the modified Rankin Scale. The model without main baseline prognostic variables only included treatment allocation and CBS. Models with and without a multiplicative interaction term of CBS and treatment were compared using the χ2 test to assess treatment effect modification by CBS. RESULTS: Higher CBS was associated with a shift toward better outcome on the modified Rankin Scale; adjusted common odds ratio per point CBS was 1.12 (95% confidence interval, 1.04-1.20]. Dichotomized CBS had an adjusted common odds ratio of 1.67 (95% confidence interval, 1.12-2.51). Both effect estimates were slightly attenuated by adding baseline prognostic variables. The addition of the interaction terms did not significantly improve the fit of the models. There was a small and insignificant increase of intra-arterial treatment efficacy in the high CBS group. CONCLUSIONS: A higher CBS is associated with improved outcome and may be used as a prognostic marker. We found no evidence that CBS modifies the effect of intra-arterial treatment. CLINICAL TRIAL REGISTRATION: URL: http://www.trialregister.nl. Unique identifier: NTR1804. URL: http://www.controlled-trials.com. Unique identifier: ISRCTN10888758.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Angiografia Cerebral/métodos , Angiografia por Tomografia Computadorizada/métodos , Acidente Vascular Cerebral/diagnóstico por imagem , Trombectomia/métodos , Trombose/diagnóstico por imagem , Idoso , Isquemia Encefálica/terapia , Feminino , Humanos , Infusões Intra-Arteriais , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/terapia , Terapia Trombolítica , Trombose/terapia
15.
Lancet ; 388(10045): 673-83, 2016 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-27371185

RESUMO

BACKGROUND: Published work suggests a survival benefit for patients with trauma who undergo total-body CT scanning during the initial trauma assessment; however, level 1 evidence is absent. We aimed to assess the effect of total-body CT scanning compared with the standard work-up on in-hospital mortality in patients with trauma. METHODS: We undertook an international, multicentre, randomised controlled trial at four hospitals in the Netherlands and one in Switzerland. Patients aged 18 years or older with trauma with compromised vital parameters, clinical suspicion of life-threatening injuries, or severe injury were randomly assigned (1:1) by ALEA randomisation to immediate total-body CT scanning or to a standard work-up with conventional imaging supplemented with selective CT scanning. Neither doctors nor patients were masked to treatment allocation. The primary endpoint was in-hospital mortality, analysed in the intention-to-treat population and in subgroups of patients with polytrauma and those with traumatic brain injury. The χ(2) test was used to assess differences in mortality. This trial is registered with ClinicalTrials.gov, number NCT01523626. FINDINGS: Between April 22, 2011, and Jan 1, 2014, 5475 patients were assessed for eligibility, 1403 of whom were randomly assigned: 702 to immediate total-body CT scanning and 701 to the standard work-up. 541 patients in the immediate total-body CT scanning group and 542 in the standard work-up group were included in the primary analysis. In-hospital mortality did not differ between groups (total-body CT 86 [16%] of 541 vs standard work-up 85 [16%] of 542; p=0.92). In-hospital mortality also did not differ between groups in subgroup analyses in patients with polytrauma (total-body CT 81 [22%] of 362 vs standard work-up 82 [25%] of 331; p=0.46) and traumatic brain injury (68 [38%] of 178 vs 66 [44%] of 151; p=0.31). Three serious adverse events were reported in patients in the total-body CT group (1%), one in the standard work-up group (<1%), and one in a patient who was excluded after random allocation. All five patients died. INTERPRETATION: Diagnosing patients with an immediate total-body CT scan does not reduce in-hospital mortality compared with the standard radiological work-up. Because of the increased radiation dose, future research should focus on the selection of patients who will benefit from immediate total-body CT. FUNDING: ZonMw, the Netherlands Organisation for Health Research and Development.


Assuntos
Mortalidade Hospitalar , Traumatismo Múltiplo/diagnóstico por imagem , Traumatismo Múltiplo/mortalidade , Tomografia Computadorizada por Raios X , Imagem Corporal Total/instrumentação , Adulto , Lesões Encefálicas/diagnóstico por imagem , Lesões Encefálicas/mortalidade , Feminino , Humanos , Escala de Gravidade do Ferimento , Cooperação Internacional , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Doses de Radiação , Suíça/epidemiologia , Fatores de Tempo
16.
Lancet Neurol ; 15(7): 685-694, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27302238

RESUMO

BACKGROUND: Whether infarct size modifies intra-arterial treatment effect is not certain, particularly in patients with large infarcts. We examined the effect of the baseline Alberta Stroke Program Early CT Score (ASPECTS) on the safety and efficacy of intra-arterial treatment in a subgroup analysis of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN). METHODS: MR CLEAN was a randomised, controlled, open-label, phase 3 trial of intra-arterial treatment in patients (aged ≥18 years from the Netherlands) with proximal arterial occlusion of the anterior circulation, given intra-arterial treatment within 6 h of stroke onset. The primary outcome was 90 day modified Rankin Scale (mRS) score. We estimated the intra-arterial treatment effect for all patients in MR CLEAN who had ASPECTS graded by using multivariable ordinal logistic regression analysis (a proportional odds model) to calculate the adjusted common odds ratio for a shift towards a better functional outcome according to the mRS for intra-arterial treatment and usual care than for usual care alone. We entered an interaction term into the model to test for interaction with prespecified ASPECTS subgroups: 0-4 (large infarct) versus 5-7 (moderate infarct) versus 8-10 (small infarct). MR CLEAN is registered with the Netherlands Trial Registry, number NTR1804, and the ISRCTN Registry, number ISRCTN10888758. FINDINGS: 496 patients-232 (47%) in the intra-arterial treatment and usual care group and 264 (53%) in the usual care alone group-were included in the analysis. We noted no significant difference in intra-arterial treatment effect between the ASPECTS subgroups according to 90 day ordinal mRS (adjusted common odds ratio interaction term relative to ASPECTS 8-10: ASPECTS 0-4: 0·79 [95% CI 0·20-3·19], p=0·740; and ASPECTS 5-7: 1·02 [0·44-2·35], p=0·966). Intra-arterial treatment did not cause a significant increase in the proportion of patients with at least one serious adverse event in any of the ASPECTS subgroups (ASPECTS 0-4: eight [73%] of 11 patients in treatment and usual care group vs 11 [58%] of 19 in usual care alone group, p=0·42; ASPECTS 5-7: 32 [59%] of 54 vs 19 [49%] of 39, p=0·31; ASPECTS 8-10: 70 [42%] of 167 vs 82 [40%] of 206; p=0·68). For death within 7 days or within 30 days and hemicraniectomy, the differences between the intra-arterial treatment and usual care versus usual care alone groups were not significant by ASPECTS subgroups. A significantly higher proportion of patients had recurrent ischaemic stroke in the intra-arterial treatment plus usual care group than in the usual care alone group in the ASPECTS 8-10 subgroup (eight [5%] vs one [<1%]; p=0·007). INTERPRETATION: Contrary to findings from previous studies suggesting that only patients with non-contrast CT ASPECTS of more than 7 benefit from intra-arterial treatment, data from this study suggest that patients with ASPECTS 5-7 should be treated. Further evidence is needed for patients with ASPECTS 0-4, for whom treatment might yield only marginal absolute benefit. FUNDING: Dutch Heart Foundation, AngioCare, Medtronic/Covidien/EV3, Medac/Lamepro, Penumbra, Stryker, and Top Medical.


Assuntos
Arteriopatias Oclusivas , Doenças das Artérias Carótidas , Fibrinolíticos/uso terapêutico , Infarto da Artéria Cerebral Média , Trombólise Mecânica/métodos , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X/métodos , Idoso , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/terapia , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/terapia , Terapia Combinada , Angiografia por Tomografia Computadorizada , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/terapia , Masculino , Pessoa de Meia-Idade , Países Baixos , Stents
17.
J Orthop Sci ; 21(5): 596-602, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27324664

RESUMO

INTRODUCTION: The Neer classification is the most commonly used fracture classification system for proximal humeral fractures. Inter- and intra-observer agreement is limited, especially for comminuted fractures. A possibly more straightforward and reliable classification system is the Hertel classification. The aim of this study was to compare the inter- and intra-observer variability of the Hertel with the Neer classification in comminuted proximal humeral fractures. MATERIALS AND METHODS: Four observers evaluated blinded radiographic images (X-rays, CT-scans, and CT-scans with 3D-reconstructions) of 60 patients. After at least two months classification was repeated. RESULTS: Inter-observer agreement on plain X-rays was fair for both Hertel (κ = 0.39; 95% CI 0.23-0.62) and Neer (κ = 0.29; 0.09-0.42). Inter-observer agreement on CT-scans was substantial (κ = 0.63; 0.56-0.72) for Hertel and moderate for Neer (κ = 0.51; 0.29-0.68). Inter-observer agreement on 3D-reconstructions was moderate for both Hertel (κ = 0.60; 0.53-0.72) and Neer (κ = 0.51; 0.39-0.58). Intra-observer agreement on plain X-rays was fair for both Hertel (κ = 0.38; 0.27-0.59) and Neer (κ = 0.40; 0.15-0.52). Intra-observer agreement on CT-scans was moderate for both Hertel (κ = 0.50; 0.38-0.66) and Neer (κ = 0.42; 0.35-0.52). Intra-observer agreement on 3D-reconstructions was moderate for Hertel (κ = 0.55; 0.45-0.64) and substantial for Neer (κ = 0.63; 0.48-0.79). CONCLUSIONS: The Hertel and Neer classifications showed a fair to substantial inter- and intra-observer agreement on the three diagnostic modalities used. Although inter-observer agreement was highest for Hertel classification on CT-scans, Neer classification had the highest intra-observer agreement on 3D-reconstructions. Data of this study do not confirm superiority of either classification system for the classification of comminuted proximal humeral fractures.


Assuntos
Fraturas Cominutivas/classificação , Imagem Tridimensional , Fraturas do Ombro/classificação , Tomografia Computadorizada por Raios X/métodos , Estudos de Coortes , Feminino , Fraturas Cominutivas/diagnóstico por imagem , Humanos , Escala de Gravidade do Ferimento , Masculino , Variações Dependentes do Observador , Ortopedia/classificação , Radiografia/métodos , Reprodutibilidade dos Testes , Fraturas do Ombro/diagnóstico por imagem
18.
Stroke ; 47(3): 768-76, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26903582

RESUMO

BACKGROUND AND PURPOSE: Recent randomized trials have proven the benefit of intra-arterial treatment (IAT) with retrievable stents in acute ischemic stroke. Patients with poor or absent collaterals (preexistent anastomoses to maintain blood flow in case of a primary vessel occlusion) may gain less clinical benefit from IAT. In this post hoc analysis, we aimed to assess whether the effect of IAT was modified by collateral status on baseline computed tomographic angiography in the Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN). METHODS: MR CLEAN was a multicenter, randomized trial of IAT versus no IAT. Primary outcome was the modified Rankin Scale at 90 days. The primary effect parameter was the adjusted common odds ratio for a shift in direction of a better outcome on the modified Rankin Scale. Collaterals were graded from 0 (absent) to 3 (good). We used multivariable ordinal logistic regression analysis with interaction terms to estimate treatment effect modification by collateral status. RESULTS: We found a significant modification of treatment effect by collaterals (P=0.038). The strongest benefit (adjusted common odds ratio 3.2 [95% confidence intervals 1.7-6.2]) was found in patients with good collaterals (grade 3). The adjusted common odds ratio was 1.6 [95% confidence intervals 1.0-2.7] for moderate collaterals (grade 2), 1.2 [95% confidence intervals 0.7-2.3] for poor collaterals (grade 1), and 1.0 [95% confidence intervals 0.1-8.7] for patients with absent collaterals (grade 0). CONCLUSIONS: In MR CLEAN, baseline computed tomographic angiography collateral status modified the treatment effect. The benefit of IAT was greatest in patients with good collaterals on baseline computed tomographic angiography. Treatment benefit appeared less and may be absent in patients with absent or poor collaterals. CLINICAL TRIAL REGISTRATION: URL: http://www.trialregister.nl and http://www.controlled-trials.com. Unique identifier: (NTR)1804 and ISRCTN10888758, respectively.


Assuntos
Angiografia Cerebral/métodos , Circulação Colateral/fisiologia , Procedimentos Endovasculares/métodos , Infusões Intra-Arteriais/métodos , Acidente Vascular Cerebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Idoso , Circulação Cerebrovascular/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/terapia
19.
Eur J Radiol ; 85(1): 55-60, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26724649

RESUMO

INTRODUCTION: International guidelines define if and what type of radiography is advised in children to clear the cervical spine (C-spine). However, adherence to these guidelines has never been evaluated in a paediatric population. Therefore, we wanted to assess the adherence to the guidelines for C-spine clearance in a level-one trauma centre. METHODS: We retrospectively included all children, presented at the ED between January 2006 and December 2013, in whom radiographic imaging of the C-spine was obtained following blunt trauma. Primary outcome was the adherence to the international guidelines with regard to (1) if the indication for radiographic imaging was correct and (2) if the type of radiographic imaging was correct. RESULTS: Included were 573 patients; 336 boys (58.7%). Median age was 11 years (IQR 5.25-15). The indication for radiographic imaging was correct in all cases. The type of primary imaging modality was concordant with the guidelines in 99,7%. In 41% of the cases supplementary radiographs were made. The most common supplementary view was the odontoid. In 15% an incomplete set of radiographs was obtained. CONCLUSION: The adherence to the international guidelines when to obtain radiographic imaging was 100%. However, in a large proportion of patients (56%), not the recommended number of radiographs was obtained.


Assuntos
Vértebras Cervicais/diagnóstico por imagem , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Centros de Traumatologia , Ferimentos não Penetrantes/diagnóstico por imagem , Adolescente , Fatores Etários , Vértebras Cervicais/lesões , Criança , Pré-Escolar , Diagnóstico por Imagem , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Guias de Prática Clínica como Assunto , Doses de Radiação , Estudos Retrospectivos , Traumatismos da Coluna Vertebral/epidemiologia , Índices de Gravidade do Trauma , Ferimentos não Penetrantes/epidemiologia
20.
JAMA Neurol ; 73(2): 190-6, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26716735

RESUMO

IMPORTANCE: Intra-arterial treatment (IAT) for acute ischemic stroke caused by intracranial arterial occlusion leads to improved functional outcome in patients treated within 6 hours after onset. The influence of treatment delay on treatment effect is not yet known. OBJECTIVE: To evaluate the influence of time from stroke onset to the start of treatment and from stroke onset to reperfusion on the effect of IAT. DESIGN, SETTING, AND PARTICIPANTS: The Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN) was a multicenter, randomized clinical open-label trial of IAT vs no IAT in 500 patients. The time to the start of treatment was defined as the time from onset of symptoms to groin puncture (TOG). The time from onset of treatment to reperfusion (TOR) was defined as the time to reopening the vessel occlusion or the end of the procedure in cases for which reperfusion was not achieved. Data were collected from December 3, 2010, to June 3, 2014, and analyzed (intention to treat) from July 1, 2014, to September 19, 2015. MAIN OUTCOMES AND MEASURES: Main outcome was the modified Rankin Scale (mRS) score for functional outcome (range, 0 [no symptoms] to 6 [death]). Multiple ordinal logistic regression analysis estimated the effect of treatment and tested for the interaction of time to randomization, TOG, and TOR with treatment. The effect of treatment as a risk difference on reaching independence (mRS score, 0-2) was computed as a function of TOG and TOR. Calculations were adjusted for age, National Institutes of Health Stroke Scale score, previous stroke, atrial fibrillation, diabetes mellitus, and intracranial arterial terminus occlusion. RESULTS: Among 500 patients (58% male; median age, 67 years), the median TOG was 260 (interquartile range [IQR], 210-311) minutes; median TOR, 340 (IQR, 274-395) minutes. An interaction between TOR and treatment (P = .04) existed, but not between TOG and treatment (P = .26). The adjusted risk difference (95% CI) was 25.9% (8.3%-44.4%) when reperfusion was reached at 3 hours, 18.8% (6.6%-32.6%) at 4 hours, and 6.7% (0.4%-14.5%) at 6 hours. CONCLUSION AND RELEVANCE: For every hour of reperfusion delay, the initially large benefit of IAT decreases; the absolute risk difference for a good outcome is reduced by 6% per hour of delay. Patients with acute ischemic stroke require immediate diagnostic workup and IAT in case of intracranial arterial vessel occlusion. TRIAL REGISTRATION: trialregister.nl Identifier: NTR1804.


Assuntos
Isquemia Encefálica/cirurgia , Fibrinolíticos/uso terapêutico , Reperfusão , Acidente Vascular Cerebral/cirurgia , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/tratamento farmacológico , Procedimentos Endovasculares/métodos , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/tratamento farmacológico , Fatores de Tempo , Ativador de Plasminogênio Tecidual/administração & dosagem , Resultado do Tratamento
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