Meta-analysis of 143 reported cases of aortic intramural hematoma.

Aortic intramural hematoma (IMH) is a clinical condition that has still not been completely defined. We conducted a meta-analysis of reported cases and analyzed the demographic profiles, imaging modalities, pathologic sites, and treatment strategies in relation to outcome in 143 patients with IMH. We performed an English language search of Medline for manuscripts with the keywords "aortic diseases," "aorta AND hematoma," and "intramural hematoma." Data from 143 reported cases were extracted. IMH of the aorta has a reported incidence of 5% to 20% among patients with acute aortic syndromes and a mortality rate of 21%. Most patients were men (61%) and median age was 68 years (range 15 to 88). Hypertension was a predisposing factor in 53% of the patients. Most patients had chest and/or back pain (80%). Transesophageal echocardiography, computer tomographic scan, or magnetic resonance imaging may be effectively used to diagnose this condition. There is no difference in the overall mortality rates in Stanford type A versus type B patients. Patients with Stanford type A IMH who underwent surgery, compared with those who underwent medical management, had a significantly better prognosis (14% vs 36% mortality, respectively, p < 0.02). Patients in Stanford group A who received medical treatment had a higher mortality rate than those in group B who received medical treatment (36% vs 14% mortality respectively, p < 0.02). In type B patients, medical and surgical outcomes were similar.

Evaluation of hemolysis in patients with prosthetic heart valves.

The primary mechanism and most common cause of hemolytic disease in patients with prosthetic heart valves are mechanical trauma to red blood cells and paraprosthetic valvular regurgitation, respectively. Presenting features in patients with this condition include anemia, congestive heart failure, fatigue, jaundice, dark urine, and a regurgitant murmur. Various laboratory studies can be utilized to diagnose hemolytic anemia and to assess the severity of hemolysis. Transthoracic echocardiography, transesophageal echocardiography, and Doppler studies including color Doppler are useful imaging methods to assess valve function. Treatment is usually medical (oral iron); however, in patients with paravalvular regurgitation, surgery is often required to correct the anemia.

Coronary dissection and thrombosis associated with exercise testing three months after successful coronary stenting.

Exercise testing is commonly performed to assess the functional result of coronary revascularization procedures and is usually not associated with any complications. However, this report documents a rare case of coronary dissection and thrombosis, which resulted in an acute myocardial infarction, in a patient who underwent stress testing 3 months following successful coronary stent implantation.

Hypoxia due to patent foramen ovale in the absence of pulmonary hypertension.

In most patients with a patent foramen ovale, blood flows from the left atrium to the right atrium in the absence of pulmonary hypertension. Our report describes a patient with a patent foramen ovale in whom flow occurred from the right atrium to the left atrium in the absence of pulmonary hypertension. We discuss hemodynamic findings and present a brief review of the pertinent medical literature regarding this phenomenon. We also discuss the role of transesophageal echocardiography in the diagnosis of this condition and in the elucidation of the underlying mechanisms, and we suggest several mechanisms that may explain the occurrence of this phenomenon in our patient.

Procalcitonin and C-reactive protein levels in HIV-positive subjects with tuberculosis and pneumonia.

Pulmonary tuberculosis (PTB) and pneumococcal community-acquired pneumonia (PCAP) are common causes of lower respiratory tract infections in HIV-seropositive patients and may have similar clinical and radiological features. This study aimed to assess the value of serum procalcitonin (PCT) and C-reactive protein (CRP) levels in HIV-seropositive patients with pneumonia, and to investigate their potential role in differentiating pneumococcal from mycobacterial infections. HIV-seropositive patients admitted with pneumonia were evaluated prospectively, 34 with PTB and 33 with PCAP. All 33 patients in the PCAP group and 20 of 34 patients in the PTB group had elevated PCT levels (>0.1 ng x mL(-1)). All patients in both groups had elevated CRP levels (>10 mg x L(-1)). The PTB group had significantly lower CD4 T-lymphocyte counts, lower CRP levels, lower white cell counts, and lower PCT levels than the PCAP group. Receiver operating characteristic analysis showed that optimal discrimination between PTB and PCAP could be performed at a cut-off point of 3 ng x mL(-1) for PCT (sensitivity 81.8%; specificity 82.35%) and 246 mg x L(-1) for CRP (sensitivity 78.8%; specificity 82.3%). In conclusion, HIV-seropositive patients with pneumococcal community-acquired pneumonia had significantly higher procalcitonin and C-reactive protein levels than those with pulmonary tuberculosis. A procalcitonin level >3 ng x mL(-1) and a C-reactive protein level >246 mg x L(-1) were both highly predictive of pneumococcal infection.

Resectability rate of hepatocellular carcinoma in rural southern Africans.

The purpose of this analysis was to ascertain the resectability rate of symptomatic hepatocellular carcinoma in rural southern African black males. All 224 such patients proven to have hepatocellular carcinoma in a single hospital were included in the study. Of 205 patients undergoing a complete diagnostic work-up, 134 [65.3 per cent) were judged on clinical criteria to be inoperable, 23 (11.2 per cent) had pulmonary or osseous metastases, and 38 (18.5 per cent) proved on hepatic imaging and 5 (2.4 per cent) on hepatic arteriography to have an irresectable tumour. Thus, only five (2.4 per cent) of these patients proceeded to laparotomy. Another 7 patients who did not have an arteriogram, 9 with surgical emergencies, and 2 mistakenly believed to have an amoebic hepatic abscess also underwent laparotomy. Only 2 patients (0.9 per cent of 223) proved to have a resectable tumour. The extremely low resectability rate reinforces the urgent need for a surveillance programme to detect early tumours in high-risk members of this population.