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1.
Cerebrovasc Dis ; : 1-9, 2019 Oct 29.
Artigo em Inglês | MEDLINE | ID: mdl-31661690

RESUMO

BACKGROUND: Carotid plaque neovascularization (vasa vasorum [VV]) may be useful for detecting high-risk atherosclerotic plaques. Contrast-enhanced ultrasound (CEUS) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) are 2 commonly used techniques for imaging VV of the carotid plaque, yet the relationship between their measurements remains unknown. OBJECTIVES: We aimed to blindly evaluate the correlation between CEUS and DCE-MRI in measuring carotid plaque VV. METHODS: We recruited subjects with asymptomatic carotid stenosis (≥50%). VV was graded by CEUS, based on richness of contrast signal, according to 3 different methods named CEUS_A, CEUS_B and CEUS_C on different point scales (the higher the values, the higher the estimated VV). A 3.0 T MRI scanner was used for VV quantification by DCE-MRI using gadolinium contrast kinetic modelling for computing the fractional plasma volume (vp) and transfer constant (Ktrans). RESULTS: The analysis included 30 patients. A significant correlation between CEUS and DCE-MRI findings was observed when CEUS_C was used for neovessel grading and DCE-MRI was used to determine adventitial (r = 0.460, p = 0.010) and plaque (r = 0.374, p = 0.042) Ktrans values. CEUS_B (r = 0.416, p = 0.022) and CEUS_C (r = 0.443, p = 0.014) grading showed a significant correlation with regard to the maximal Ktrans. CONCLUSIONS: We found a positive but weak correlation and a moderate diagnostic agreement between neovessels as visually graded by CEUS and adventitial neovessels assessed by DCE-MRI Ktrans in carotid atherosclerosis. These findings may help in understanding how VV density, flow, and permeability influence in vivo measurements by CEUS and DCE-MRI as well as in selecting the most appropriate variables and imaging method in future research and potentially in clinical settings. Further confirmative studies are necessary to confirm our results.

2.
Nutrients ; 11(9)2019 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-31487799

RESUMO

Gardening has been positively associated with fruit and vegetable (FV) consumption based on short-term studies among children, but long-term data among adolescents and young adults are lacking. This investigation sought to elucidate the association between gardening experience and FV intake among college students over a two-year period. Students (N = 593) from eight universities were assessed at the end of their freshman (Y1) and sophomore (Y2) years during the springs of 2016 and 2017, respectively. At each time point, participants completed the NCI FV Screener and questions related to gardening experience and FV-related attitudes and behaviors. Students were then categorized into four groups based on gardening experience: Gardened only during the first or second year (Y1 only and Y2 only gardeners), gardened both years (Y1+Y2 gardeners), and non-gardeners. While both Y1 only and Y1+Y2 gardeners reported significantly higher FV intake relative to non-gardeners at Y1 (2.3 ± 0.9 and 2.6 ± 0.7 versus 1.9 ± 0.6 cup equivalents (CE)/day, respectively; p < 0.01), only Y1+Y2 gardeners differed from non-gardeners at Y2 (2.4 ± 0.6 versus 1.8 ± 0.5 CE/day; p < 0.001). Additionally, Y1+Y2 gardeners reported more frequent engagement of several FV-related behaviors, including shopping at farmers' markets, eating locally grown foods, and cooking from basic ingredients; and were five times more likely to have gardened during childhood (OR: 5.2, 95%, CI: 3.5-8.8; p < 0.001). Findings suggest that while isolated gardening experiences during college are associated with FV intake, reoccurring experience may be essential for sustained benefit.

3.
Artigo em Inglês | MEDLINE | ID: mdl-31436837

RESUMO

OBJECTIVES: [18F]Fluorodeoxyglucose (FDG)-PET/CT and US are both well established for diagnosing GCA. The present study investigates their accuracy and whether they provide overlapping or complementary information in a cohort of patients presenting with suspicion of GCA. METHODS: We selected consecutive patients from our cohort of suspected GCA cases that underwent both extended vascular US and PET/CT for diagnostic work-up between December 2006 and August 2012. RESULTS: A total of 102 patients were included. Diagnosis of GCA was confirmed in 68 patients and excluded in 34 patients (controls). Vasculitic changes in US were most often found in the temporal artery with 32 positive findings on each side, followed by the popliteal artery (10 right, 9 left) and the subclavian/axillary artery (7 right, 8 left). By contrast, PET/CT showed vasculitis most frequently in the vertebral (23 right, 33 left) and common carotid arteries (32 right, 24 left), followed by the subclavian arteries (16 right, 18 left), and the thoracic (17) and abdominal aorta (23). In 37/68 GCA patients PET/CT and US both revealed vasculitic findings, 11/68 had positive findings in US only and 14/68 in PET/CT only. Specificity of US was higher (one false-positive vs five false-positive in PET/CT). On a single segment level, only 20 of 136 positive segments were positive in both imaging modalities. CONCLUSION: PET/CT measuring vessel wall metabolism and US vessel wall morphology showed a comparable diagnostic accuracy for GCA. However PET/CT and US were often discrepant within single vascular regions. Thus PET/CT and US should be considered as complementary methods, with a second imaging modality increasing the diagnostic yield by 16-20%.

4.
Eur J Clin Invest ; 49(9): e13154, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31246275

RESUMO

BACKGROUND: Combining high-sensitivity cardiac Troponin T (hs-cTnT), NT-pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (hs-CRP) may improve risk stratification of patients with pulmonary embolism (PE) beyond the PESI risk score. METHODS: In the prospective multicentre SWITCO65+ study, we analysed 214 patients ≥ 65 years with a new submassive PE. Biomarkers and clinical information for the PESI risk score were ascertained within 1 day after diagnosis. Associations of hs-TnT, NT-proBNP, hs-CRP and the PESI risk score with the primary endpoint defined as 6-month mortality were assessed. The discriminative power of the PESI risk score and its combination with hs-cTnT, NT-proBNP and hs-CRP for 6-month mortality was compared using integrated discrimination improvement (IDI) index and net reclassification improvement (NRI). RESULTS: Compared with the lowest quartile, patients in the highest quartile had a higher risk of death during the first 6 months for hs-cTnT (adjusted HR 10.22; 95% CI 1.79-58.34; P = 0.009) and a trend for NT-proBNP (adjusted HR 4.3; 95% CI 0.9-20.41; P = 0.067) unlike hs-CRP (adjusted HR 1.97; 95% CI 0.48-8.05; P = 0.344). The PESI risk score (c-statistic 0.77 (95% CI 0.69-0.84) had the highest prognostic accuracy for 6-month mortality, outperforming hs-cTnT, NT-proBNP and hs-CRP (c-statistics of 0.72, 0.72, and 0.54), respectively. Combining all three biomarkers had no clinically relevant impact on risk stratification when added to the PESI risk score (IDI = 0.067; 95% CI 0.012-0.123; P = 0.018; NRI = 0.101 95% CI -0.099-0.302; P = 0.321). CONCLUSIONS: In elderly patients with PE, 6-month mortality can adequately be predicted by the PESI risk score alone.

5.
Swiss Med Wkly ; 149: w20083, 2019 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-31154658

RESUMO

AIMS OF THE STUDY: The purpose of this study was to evaluate the safety and efficacy of endovenous laser ablation (EVLA) in patients 75 years and older in an outpatient setting. METHODS: In this multicentre retrospective study, we collected the demographic, procedural and outcome data of all consecutive patients with varicose veins class C2 to C6 undergoing EVLA of truncal and accessory saphenous veins. The primary efficacy endpoint was complete ablation of the treated veins diagnosed with duplex ultrasound at 4-week follow up. The primary safety endpoint was endothermal heat-induced thrombosis (EHIT) and deep vein thrombosis (DVT) at 4-week follow up as diagnosed by duplex ultrasound. A secondary endpoint was minor or major bleeding. RESULTS: Between February 2009 and December 2015, a total of 829 patients were treated with EVLA of the truncal and accessory saphenous veins. Among them, 747 were <75 years old (group 1) and 82 were ≥75 years old (group 2). The primary efficacy outcome was reached in 739 patients (98.9%) in group 1 and in 80 patients (97.6%) in group 2 (odd ratio [OR] 0.43, confidence interval [CI] 0.09–2.07; p = 0.295). The number of patients with EHIT type 2 and DVT were 4 (0.5%) and 2 (0.3%), respectively, in group 1, and 2 (2.4%) and 1 (1.2%), respectively, in group 2 (OR 4.64, CI 0.83–25.75; p = 0.079 and OR 4.59, CI 0.41–51.27; p = 0.215, respectively). Minor bleeding events occurred in 36 patients (4.8%) in group 1 and 7 patients (8.9%) in group 2 (OR 1.84, CI 0.79-4.29; p = 0.155). No major bleeding occurred in either group. Propensity score-matched analysis revealed no significant difference in efficacy and safety outcomes. CONCLUSION: EVLA performed as an outpatient procedure seems to be effective and safe in the elderly population as compared to the younger age group.

6.
Am J Emerg Med ; 2019 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-31088750

RESUMO

Rapid estimates of the central venous pressure (CVP) can be helpful to administer early fluid therapy or to manage cardiac preload in intensive care units, operating rooms or emergency rooms in order to start and monitor an adequate medical therapy. Invasive CVP measurements have inherent and non-negligible complication rates as well as great expenditures. Several noninvasive methods of CVP measurements, like ultrasound-guided techniques, are available, but require trained skills and special equipment which might not be at hand in all situations. Our purpose was to evaluate the feasibility and accuracy of CVP estimates assessed upon the height of hand veins collapse (HVC) using invasively measured CVP as the gold standard. The HVC was determined by slowly lifting the patient's hand while watching the dorsal hand veins to collapse. The vertical distance from the dorsal hand to a transducer air zero port was noted and converted to mmHg. The observer was blinded to the simultaneously measured CVP values, which were categorized as low (<7 mmHg), normal (7-12 mmHg) and high (>12 mmHg). Measurements were performed in 82 patients who had a median [IQR] age of 67 [60;74]. Median CVP was 12 [8;15] mmHg and the median absolute difference between the measured HVC and CVP was 4 [2;7] mmHg. The Spearman correlation coefficient between CVP and HVC was 0.55, 95%-CI [0.35;0.69]. Overall CVP categorization was correct in 45% of the cases. HVC had a sensitivity of 92% for a low CVP with a negative predictive value of 98%. A high HVC had a sensitivity of 29% but a high specificity of 94% for a high CVP. The overall performance of observing the hand vein collapse to estimate CVP was only moderate in the intensive care setting. However, the median difference to the CVP was low and HVC identifies a low CVP with a high sensitivity and excellent negative predictive value.

7.
J Thromb Haemost ; 17(2): 306-318, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30570809

RESUMO

Essentials Predictive ability of pro-hemostatic Gas6 for recurrent venous thromboembolism (VTE) is unknown. We measured Gas6 levels in 864 patients with VTE over 3 years. High Gas6 (> 157%) at diagnosis is associated with VTE recurrence, major bleeding and mortality. Gas6 plasma levels measured 12 months after the index VTE are discriminatory for VTE recurrence. SUMMARY: Background Growth arrest-specific gene 6 (Gas6) is a prohemostatic protein with an unknown predictive ability for recurrent venous thromboembolism (VTE). In the elderly, VTE results in higher mortality but does not have a higher rate of recurrence than in younger patients. Consequently, anticoagulation management in the elderly is challenging. Objective To prospectively investigate the performance of Gas6 in predicting VTE recurrence, major bleeding and mortality in the elderly. Methods Consecutive patients aged ≥ 65 years with acute VTE were followed for a period of 3 years. Primary outcomes were symptomatic VTE recurrence, major bleeding, and mortality. Plasma Gas6 was measured with ELISA. Results Gas6 levels were measured in 864 patients at the time of the index VTE (T1) and, in 70% of them, also 12 months later (T2). The Gas6 level at T1 was discriminatory for VTE recurrence (C-statistic, 0.56; 95% confidence interval [CI] 0.51-0.62), major bleeding (0.60, 95% CI 0.55-0.65) and mortality (0.69, 95% CI 0.65-0.73) up to 36 months. VTE recurrence up to 24 months after T2 was discriminated by the Gas6 level at T2 (0.62, 95% CI 0.54-0.71). High Gas6 levels (> 157%) and continuous Gas6 levels at T1 were associated with VTE recurrence up to 6 months and 12 months, respectively. Conclusions In elderly patients, a high Gas6 level is associated with higher risks of VTE recurrence, major bleeding, and death. These findings support further studies to assess the performance of Gas6 in adjusting the length of anticoagulation.

8.
Rheumatology (Oxford) ; 58(5): 792-797, 2019 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-30544199

RESUMO

OBJECTIVES: To assess changes of arterial vessel wall morphology in large vessel GCA patients (LV-GCA) by repeated US. METHODS: Patients with LV-GCA on US examination were followed up 6, 12 and 24 months after diagnosis by US of the temporal, vertebral, carotid (common, internal, external), subclavian, axillary, femoral (deep, superficial and common) and popliteal arteries. Clinical and laboratory data were assessed at each visit. Vessel wall thickening was classified as moderate, marked or arteriosclerotic. RESULTS: A total of 42 patients (26 female) with a median age of 75 years at diagnosis had in median 2 (range 1-3) US follow-up exams. Twenty-eight had both LV and temporal artery involvement and 14 had LV-GCA only. The common carotid, subclavian, axillary, popliteal and/or superficial femoral artery were most commonly involved. Reduction of LV wall thickening occurred in 45% of patients during follow-up, corresponding to 71 of the 284 (25%) initially 'vasculitic' LV segments. In contrast, a reduction of vessel wall thickening in the temporal artery was found in 85% of patients. Of the LVs, the vertebral, axillary, subclavian and deep femoral arteries were most likely to improve. There was no difference in relapses or the received cumulative steroid dose between patients with or without a reduction of vessel wall thickening (temporal artery or LV) during follow-up. CONCLUSION: Regression of wall thickening within the LV is significantly less common than in the temporal artery and irrespective of clinical remission. Morphological regression does not seem to be a useful predictor for relapses.

9.
Angiology ; 70(1): 20-34, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29783854

RESUMO

In the past decades, peripheral arteries have represented a model for the comprehension of atherosclerosis as well as for the development of new diagnostic imaging modalities and therapeutic strategies. Peripheral arteries may represent a window to study atherosclerosis. Pathology has prominently contributed to move the clinical and research attention from the arterial lumen stenosis and angiography to morphological and functional imaging techniques. Evidence from large and prospective cohort or randomized controlled studies is still modest. Nevertheless, several emerging imaging investigations represent a potential tool for a comprehensive "in vivo" evaluation of the entire natural history of peripheral atherosclerosis. This constitutes a demanding assignment, as it would be desirable to obtain both single-lesion focused and extensive arterial system views to achieve the most accurate prognostic information. Our narrative review rests upon the fundamental pathological evidence, summarizing the rapidly growing field of imaging of atherosclerosis in peripheral arteries and presenting a selection of both currently available and emerging imaging techniques.


Assuntos
Aterosclerose/diagnóstico por imagem , Doença Arterial Periférica/diagnóstico por imagem , Aterosclerose/patologia , Humanos , Doença Arterial Periférica/patologia
10.
Vasa ; : 1-8, 2018 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-30324866

RESUMO

Early detection of vascular damage in atherosclerosis and accurate assessment of cardiovascular risk factors are the basis for appropriate treatment strategies in cardiovascular medicine. The current review focuses on non-invasive ultrasound-based methods for imaging of atherosclerosis. Endothelial dysfunction is an accepted early manifestation of atherosclerosis. The most widely used technique to study endothelial function is non-invasive, flow-mediated dilation of the brachial artery under high-resolution ultrasound imaging. Although an increased intima-media thickness value is associated with future cardiovascular events in several large population studies, systematic use is not recommended in clinical practice for risk assessment of individual persons. Carotid plaque analysis with grey-scale median, 3-D ultrasound or contrast-enhanced ultrasound are promising techniques for further scientific work in prevention and therapy of generalized atherosclerosis.

11.
Vasa ; : 1-11, 2018 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-30324867

RESUMO

Ultrasound has been established as an important diagnostic tool in assessing vascular abnormalities. Standard B-mode and Doppler techniques have inherent limitations with regards to detection of slow flow and small vasculature. Contrast-enhanced ultrasound (CEUS) is a complementary tool and is useful in assessing both the macro- and microvascular anatomy of the aorta. CEUS can also provide valuable physiological information in real-time scanning sessions due to the physical and safety profiles of the administered microbubbles. From a macrovascular perspective, CEUS has been used to characterize aortic aneurysm rupture, dissection and endoleaks post-EVAR repair. With regard to microvasculature CEUS enables imaging of adventitial vasa vasorum thereby assessing aortic inflammation processes, such as monitoring treatment response in chronic periaortitis. CEUS may have additional clinical utility since adventitial vasa vasorum has important implications in the pathogenesis of aortic diseases. In recent years, there have been an increasing number of studies comparing CEUS to cross-sectional imaging for aortic applications. For endoleak surveillance CEUS has been shown to be equal or in certain cases superior in comparison to CT angiography. The recent advancement of CEUS software along with the ongoing development of drug-eluting contrast microbubbles has allowed improved targeted detection and real-time ultrasound guided therapy for aortic vasa vasorum inflammation and neovascularization in animal models. Therefore, CEUS is uniquely suited to comprehensively assess and potentially treat aortic vascular diseases in the future.

13.
Swiss Med Wkly ; 148: w14661, 2018 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-30141518

RESUMO

Historically, giant cell arteritis (GCA) was considered to be synonymous with temporal arteritis. However, the disease spectrum of GCA extends much further, and includes vasculitis of the aorta and its branches with or without involvement of the temporal arteries. Imaging is crucial for the diagnosis and follow-up of GCA patients. Large vessel GCA (LV-GCA) often presents as an inflammatory syndrome and is only detected by imaging modalities such as: colour duplex sonography (CDS), computed tomography (CT) / CT angiography (CTA), magnetic resonance imaging (MRI) or 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) / CT. Deciding which imaging modality to use in different clinical situations remains a matter of debate. CDS and MRI enable assessment of the temporal arteries with a presumably higher sensitivity than histology. In the context of a typical presentation, CDS can replace a biopsy. In about a third of patients, the temporal arteries are not involved, thus PET/CT, MRI, CT, or CDS of larger arteries is needed to diagnose GCA. The sensitivity of all modalities is affected by glucocorticoid therapy. Therefore, without delaying therapy, imaging should be performed within a few days of treatment initiation. The use of PET/CT for the work-up of inflammatory syndromes in the elderly reveals vasculitis in approximately 20% of examined patients and uncover relevant diagnoses in the majority of remaining patients. The aorta should be routinely assessed in all GCA patients at diagnosis and during follow-up. MRA or CTA are best suited to characterise structural damage of larger arteries. The role of imaging in monitoring GCA disease activity still needs to be further defined.

14.
Cardiovasc Diagn Ther ; 8(Suppl 1): S118-S130, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29850424

RESUMO

Ultrasound (US) represents the initial modality in the workup of abdominal aortic pathology based on the plethora of advantages including widespread availability, low cost, safety profile and repeatability. However, US has inherent limitations including limited spatial information of pathologic processes to neighboring structures, lower sensitivity to slow blood flow and aortic luminal irregularities. For evaluation of aortic pathology angiography has long been considered the gold standard. Non-invasive cross-sectional imaging techniques like computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have gradually replaced interventional angiography for the evaluation of aorta, currently being regarded as the diagnostic imaging modalities of choice for diagnosis of virtually every aortic disease. Interventional angiography is currently primarily performed for treatment purposes of aortic pathology. The introduction of microbubbles as ultrasonographic contrast agents has rendered contrast-enhanced ultrasound (CEUS) an evolving valuable complementary technique with markedly increased diagnostic accuracy for certain aortic applications. CEUS is characterized by the potential to be performed in patients with impaired renal function. Due to its superior spatial and temporal resolution, ability for prolonged scanning and dynamic and real-time imaging, it provides clinically significant additional information compared to the standard Duplex US. The purpose of this paper is to discuss the currently available literature regarding abdominal aortic applications of CEUS, briefly elaborate on CEUS technique and safety and present cases in order to illustrate the added value in aortic pathologies. Conditions discussed include abdominal aortic aneurysm (AAA), aneurysm rupture, aneurysm surveillance after endovascular repair, dissection and aortitis.

15.
Br J Radiol ; 91(1087): 20180013, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29658769

RESUMO

Endoleaks are a common complication of endovascular aortic repair (EVAR). As a result, patients require lifelong imaging surveillance following EVAR. In current clinical practice, evaluation for endoleaks is predominantly performed with CT angiography (CTA). Due to the significant cumulative radiation burden associated with repetitive CTA imaging, as well as the repeated administration of nephrotoxic contrast agent, contrast-enhanced ultrasound (CEUS) and magnetic resonance angiography (MRA) have evolved as potential modalities for lifelong surveillance post-EVAR. In this paper, multimodality imaging, including CTA, CEUS and MRA, for the surveillance of endoleaks is discussed. Further, new CTA techniques for radiation reduction are elaborated. Additionally, imagery for three cases of aortic endoleak detection using CTA and five cases using MRA are presented. Imaging for different types of endoleaks with CTA, MRA and CEUS are presented. For lifelong endoleak surveillance post-EVAR, CTA is still regarded as the imaging modality of choice. However, advancements in CEUS and MRA technique enable partial replacement of CTA in certain patients.


Assuntos
Doenças da Aorta/cirurgia , Endoleak/diagnóstico por imagem , Procedimentos Endovasculares , Imagem Multimodal , Complicações Pós-Operatórias/diagnóstico por imagem , Meios de Contraste , Humanos
16.
PLoS One ; 13(4): e0191172, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29649236

RESUMO

AIMS: Carotid intima media thickness (CIMT) predicts cardiovascular (CVD) events, but the predictive value of CIMT change is debated. We assessed the relation between CIMT change and events in individuals at high cardiovascular risk. METHODS AND RESULTS: From 31 cohorts with two CIMT scans (total n = 89070) on average 3.6 years apart and clinical follow-up, subcohorts were drawn: (A) individuals with at least 3 cardiovascular risk factors without previous CVD events, (B) individuals with carotid plaques without previous CVD events, and (C) individuals with previous CVD events. Cox regression models were fit to estimate the hazard ratio (HR) of the combined endpoint (myocardial infarction, stroke or vascular death) per standard deviation (SD) of CIMT change, adjusted for CVD risk factors. These HRs were pooled across studies. In groups A, B and C we observed 3483, 2845 and 1165 endpoint events, respectively. Average common CIMT was 0.79mm (SD 0.16mm), and annual common CIMT change was 0.01mm (SD 0.07mm), both in group A. The pooled HR per SD of annual common CIMT change (0.02 to 0.43mm) was 0.99 (95% confidence interval: 0.95-1.02) in group A, 0.98 (0.93-1.04) in group B, and 0.95 (0.89-1.04) in group C. The HR per SD of common CIMT (average of the first and the second CIMT scan, 0.09 to 0.75mm) was 1.15 (1.07-1.23) in group A, 1.13 (1.05-1.22) in group B, and 1.12 (1.05-1.20) in group C. CONCLUSIONS: We confirm that common CIMT is associated with future CVD events in individuals at high risk. CIMT change does not relate to future event risk in high-risk individuals.


Assuntos
Doenças Cardiovasculares/diagnóstico , Espessura Intima-Media Carotídea , Colaboração Intersetorial , Idoso , Doenças Cardiovasculares/diagnóstico por imagem , Doenças Cardiovasculares/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Fatores de Risco
17.
J Bone Joint Surg Am ; 100(3): 211-217, 2018 Feb 07.
Artigo em Inglês | MEDLINE | ID: mdl-29406342

RESUMO

BACKGROUND: The gastrocnemius muscle flap may be considered the first choice in many cases of soft-tissue reconstruction about the knee. Limited arc of rotation and reach of the flap as well as unsightly muscle bulk are major disadvantages and were the impetus to look for a local alternative. The aim of this study is to present a consecutive series of patients with a reconstruction about the knee involving the medial sural artery perforator flap (MSAPF). METHODS: A consecutive series of 17 cases of defect reconstructions about the knee using the MSAPF is described, with an emphasis on early postoperative complications. RESULTS: No major flap-related complications occurred except 1 case of tip necrosis that healed uneventfully after excision and secondary suture. Two patients with direct donor-site closure had a minor complication that required no revision, and 2 had partial skin-graft loss. CONCLUSIONS: In summary, use of this pedicled perforator flap represents a reliable technique for soft-tissue reconstruction about the knee with an acceptable complication rate and optimal contour reconstruction without the need for a skin graft and secondary debulking procedures. The range of motion associated with the MSAPF in comparison to the range associated with the gastrocnemius muscle flap is increased so that more proximal and lateral defects can be covered. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

18.
Am J Med ; 131(6): 703.e7-703.e16, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29307536

RESUMO

BACKGROUND: Little is known about predictors and outcomes of recurrent venous thromboembolism in elderly patients. METHODS: We prospectively followed up 991 patients aged ≥65 years with acute venous thromboembolism in a multicenter Swiss cohort study. The primary outcome was symptomatic recurrent venous thromboembolism. We explored the association between baseline characteristics and treatments and recurrent venous thromboembolism using competing risk regression, adjusting for periods of anticoagulation as a time-varying covariate. We also assessed the clinical consequences (case-fatality, localization) of recurrent venous thromboembolism. RESULTS: During a median follow-up period of 30 months, 122 patients developed recurrent venous thromboembolism, corresponding to a 3-year cumulative incidence of 14.8%. The case-fatality of recurrence was high (20.5%), particularly in patients with unprovoked (23%) and cancer-related venous thromboembolism (29%). After adjustment, only unprovoked venous thromboembolism (sub-hazard ratio, 1.67 compared with provoked venous thromboembolism; 95% confidence interval, 1.00-2.77) and proximal deep vein thrombosis (sub-hazard ratio, 2.41 compared with isolated distal deep vein thrombosis; 95% confidence interval, 1.07-5.38) were significantly associated with recurrence. Patients with initial pulmonary embolism were more likely to have another pulmonary embolism as a recurrent event than patients with deep vein thrombosis. CONCLUSIONS: Elderly patients with acute venous thromboembolism have a substantial long-term risk of recurrent venous thromboembolism, and recurrence carries a high case-fatality rate. Only 2 factors, unprovoked venous thromboembolism and proximal deep vein thrombosis, were independently associated with recurrent venous thromboembolism, indicating that traditional risk factors for venous thromboembolism recurrence (eg, cancer) may be less relevant in the elderly.

20.
Eur Heart J Cardiovasc Imaging ; 19(8): 933-940, 2018 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-29126277

RESUMO

Aims: The usefulness of [18F] fluorodeoxyglucose-positron emission tomography/computed tomography ([18F]FDG-PET/CT) for diagnosing giant cell arteritis (GCA) has been previously reported. Yet, the interpretation of PET scans is not clear-cut. The present study aimed at determining the best method to analyse PET/CT in a large, real-life cohort of patients presenting with suspicion of GCA. Methods and results: One hundred and three patients with clinical suspicion of GCA undergoing PET/CT between 2006 and 2012 were included. Clinical data were retrieved from patients' charts. PET/CT was categorized by visual scoring of the uptake and by the artery/liver standardized uptake values (SUV) ratios. Diagnosis of GCA was confirmed in 68 patients and excluded in 35 patients, which served as the controls. GCA patients were older (median age 75 vs. 68 years), and presented more often with ischaemic symptoms. The best discrimination between GCA patients and controls was achieved for PET/CT findings within the supra-aortic arteries (sensitivity 0.71, specificity 0.91 for a SUV/LE cut-off value of 1.0). Specificity of PET/CT for the aorta and the iliofemoral arteries was lower (<0.34). Visual scoring correlated poorly to SUV measurements (Kendall Tau-b 0.13-0.55) and had a lower diagnostic accuracy (sensitivity 0.77, specificity 0.75). Prednisone treatment for ≥10 days significantly reduced PET/CT sensitivity (P = 0.009). Conclusion: SUV based analysis of PET/CT enhances diagnostic accuracy with best discrimination in the supra-aortic region, particularly in steroid naïve patients. For discrimination based on the aorta and the iliofemoral region, higher cut-off values have to be applied, resulting in lower sensitivities for diagnosing GCA.

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