[Agranulocytosis after use of metamizole - an underestimated risk?] / Agranulozytose nach Metamizol-Einnahme ­ ein unterschätztes Risiko?

OBJECTIVE: Metamizole was the second most common drug prescribed in Germany in 2018 despite the known risk of agranulocytosis and the strict indication. According to Stammschulte et al. up to 25 % of all prescriptions are off-label use. Although mandatory according to the prescribing information of metamizole, regular blood cell counts are not performed in up to 50 % of the patients with long-term use of this drug. MATERIAL AND METHODS: Retrospective analysis of eight cases metamizole-induced agranulocytosis over a period of five years (2016-2020) in the university ENT department in Erlangen. Five patients were men and three women. Mean age of diagnosis was 52,4 years (±â€Š25,6). RESULTS: Agranulocytosis after use of metamizole is a serious adverse drug reaction that may affect patients of all ages. Frequently, only distinct clinical symptoms such as temperature of unknown origin, dysphagia and tonsillitis in combination with abscesses in the head and neck area result in the detection of a metamizole-induced agranulocytosis. An agranulocytosis provokes partially radical surgery and/ or intensive-care measures and could lead to sepsis with organ failure or even to death. CONCLUSIONS: These patient cases show that agranulocytosis is a dangerous or even deadly adverse drug reaction after use of metamizole. Although the risk of agranulocytosis appears to increase with duration of use, we would recommend patient education as well as documentation of even a single administration of metamizole. This may facilitate early diagnosis of metamizole-induced agranulocytosis and thus prevent the onset of severe complications with possible lethal outcome.

Efficacy and Safety of Angioplasty Balloon Interposition in CT-Guided Percutaneous Thermal Ablation of Hepatic Malignancies to Protect Adjacent Organs.

PURPOSE: To evaluate the feasibility and safety of placing angioplasty balloons between the liver surface and adjacent organs in CT-guided thermal ablation of subcapsular liver malignancies in case of inadequate success of conventional dissection techniques. MATERIALS AND METHODS: A retrospective, single-centre database query identified 327 hepatic malignancies in 153 patients treated in 215 sessions from 2016 to 2018 by thermal ablation. Demographic data, tumour size, distance to adjacent structures, complications and long-term outcomes were assessed when ancillary procedures were performed to protect adjacent organs. RESULTS: In 21 of 327 (6.4%) ablations, thermal protection was necessary. Balloon interposition was successfully performed in 9 cases in 8 patients after hydrodissection or gas insufflation failed to separate adherent organs. Median pre- and post-balloon insertion distance was 0 mm [0-2 mm] and 17 mm [8-20 mm]. No balloons were damaged, ruptured or slid away from their initial position. Technical success of MWA and protection of adherent structures were achieved in all procedures. In a median follow-up of 11.5 months [0-49 months], the local control rate was 88.9% as 1 patient was treated twice with an interval of 3 months for local recurrence. Three non-process-related major complications and 1 minor complication occurred. CONCLUSION: Balloon interposition is a safe and feasible method to enable thermal ablation to a greater number of patients, even after established thermo-protective techniques fail to separate the colon or stomach from the liver surface.

Prognostic Value of CTA-Derived Left Ventricular Mass in Neonates with Congenital Heart Disease.

For therapeutic decisions regarding uni- or biventricular surgical repair in congenital heart disease (CHD), left ventricular mass (LVM) is an important factor. The aim of this retrospective study was to determine the LVM of infants with CHD in thoracic computed tomography angiographies (CTAs) and to evaluate its usefulness as a prognostic parameter, with special attention paid to hypoplastic left heart (HLH) patients. Manual segmentation of the left ventricular endo- and epicardial volumes was performed in CTAs of 132 infants. LVMs were determined from these volumes and normalized to body surface area. LVMs of patients with different types of CHD were compared to each other using analyses of variances (ANOVA). An LVM cutoff for discrimination between uni- and biventricular repair was determined using receiver operating characteristics. Survival rates were calculated using Kaplan-Meier statistics. Patients with a clinical diagnosis of an HLH had significantly lower mean LVM (21.88 g/m2) compared to patients without applicable disease (50.22 g/m2; p < 0.0001) and compared to other CHDs, including persistent truncus arteriosus, left ventricular outflow tract obstruction, transposition of the great arteries, pulmonary artery stenosis or atresia, and double-outlet right ventricle (all, p < 0.05). The LVM cutoff for uni- vs. biventricular surgery was 33.9 g/m2 (sensitivity: 82.3%; specificity: 73.7%; PPV: 94.9%). In a subanalysis of HLH patients, a sensitivity of 50.0%, specificity of 100%, PPV of 100%, and NPV of 83.3% was determined. Patient survival was not significantly different between the surgical approaches or between patients with LVM above or below the cutoff. LVM can be measured in chest CTA of newborns with CHD and can be used as a prognostic factor.

Pilot study using intraoperative fluorescence angiography during arteriovenous hemodialysis access surgery.

INTRODUCTION:: In this pilot study, we used indocyanine green fluorescence angiography during hemodialysis access surgery. The aim was to evaluate its relevance as a diagnostic tool to visualize changes in hand microperfusion. PATIENTS AND METHODS:: In this prospective single-center study, 47 adult patients (33 male, 14 female) with renal disease (24 preemptive, 23 endstage) were enrolled. Surgical creation of an arteriovenous fistula was performed (22 forearm, 25 upper arm). Microperfusion of the ipsilateral hand and fingers was evaluated intraoperatively using indocyanine green fluorescence angiography. We compared the cumulated microperfusion parameters ingress (In) and ingress rate (InR) before and after opening of the anastomosis. To compare the dimension of microcirculatory decline, we calculated the ratios of the parameters (RatioIn and RatioInR) after to those before anastomosis opening. RESULTS:: The cumulated microperfusion parameters In and InR showed a significant decrease after completion of anastomosis and declamping. This effect has been seen in all patients for the hand and for each finger consecutively. During follow-up (mean 4.6, range 3-11 months), 5 patients (10.6%) complained about hemodialysis access-induced distal ischemia. The ratio of intraoperative microperfusion in those five hemodialysis access-induced ischemia patients was significantly lower compared to asymptomatic patients (RatioIn 0.23 vs 0.58, p = 0.001, and RatioInR 0.25 vs 0.62, p = 0.003). CONCLUSION:: Intraoperative fluorescence angiography could visualize the deterioration of ipsilateral hand microperfusion after surgical creation of an arteriovenous fistula. It seems to be a promising tool to detect patients at risk for hemodialysis access-induced distal ischemia early in the peri- or even intraoperative stage.

Correlation between pain and MRI findings in TMD patients.

INTRODUCTION: Magnetic resonance imaging has been established as the gold standard for assessment of the temporomandibular joint. Apart from an excellent assessment of the soft tissues it has the advantage not to expose the patient to ionizing radiation. There is a lack of literature concerning the correlation between pain intensity and radiological findings of the temporomandibular joint. Moreover there is the question of whether a progressive degeneration of the cartilaginous components is accompanied by an increasing degeneration of the osseous parts of the mandibular joint and vice versa. Therefore, this study aims at analyzing correlations between pain and radiological findings. Furthermore, the link between osseous and cartilaginous degeneration is studied. MATERIALS AND METHODS: 91 patients who attend our outpatient clinic for temporomandibular disorders are included in this prospective study. Apart from a detailed anamnesis and clinical examination - adapted to the Research Diagnostic Criteria for Temporomandibular Disorders -magnetic resonance imaging of both mandibular joints is performed. Pain intensity is measured using the visual analog scale. To assess and grade the radiological findings a classification system is established. The evaluation of the osseous components is based on the classification of osteoarthritis by Kellgren and Lawrence whereas the rating of the cartilaginous components is adapted to the Research Diagnostic Criteria for Temporomandibular Disorders. Correlations are verified by Spearman-Rho. RESULTS: 83,5% of all patients are female. Most of the time, both sides are affected (47.25%). Women state an average pain of 5.7 (±2.4), men 3.5 (±2.5). 182 discs are examined and assessed with our classification system. Most discs (n = 71) show no pathological changes. The majority of patients show no dislocation (n = 104). The most common forms of dislocation are anterior dislocations (n = 51). The majority of patients show no changes in the osseous component (n = 115). Weak to moderate correlations are found between disc and bone degeneration. Moderate to strong correlations are found between left and right TMJ. CONCLUSIONS: The classification system which is designed and applied during the study proves to be a reliable and practical Instrument. A standardized evaluation of pathologies concerning the temporomandibular joint is possible by using this system. Numerous patients attending our outpatient clinic do not show any signs of degenerative dysfunctions in the mandibular joints. Degenerations of the osseous components tend to be connected with degenerations of the cartilaginous components and vice versa. The question remains if in the future new procedures in imaging will be able to record pathologies not yet detected.

Dose reduction in abdominal computed tomography: intraindividual comparison of image quality of full-dose standard and half-dose iterative reconstructions with dual-source computed tomography.

OBJECTIVES: We sought to evaluate the image quality of iterative reconstruction in image space (IRIS) in half-dose (HD) datasets compared with full-dose (FD) and HD filtered back projection (FBP) reconstruction in abdominal computed tomography (CT). MATERIALS AND METHODS: To acquire data with FD and HD simultaneously, contrast-enhanced abdominal CT was performed with a dual-source CT system, both tubes operating at 120 kV, 100 ref.mAs, and pitch 0.8. Three different image datasets were reconstructed from the raw data: Standard FD images applying FBP which served as reference, HD images applying FBP and HD images applying IRIS. For the HD data sets, only data from 1 tube detector-system was used. Quantitative image quality analysis was performed by measuring image noise in tissue and air. Qualitative image quality was evaluated according to the European Guidelines on Quality criteria for CT. Additional assessment of artifacts, lesion conspicuity, and edge sharpness was performed. RESULTS: : Image noise in soft tissue was substantially decreased in HD-IRIS (-3.4 HU, -22%) and increased in HD-FBP (+6.2 HU, +39%) images when compared with the reference (mean noise, 15.9 HU). No significant differences between the FD-FBP and HD-IRIS images were found for the visually sharp anatomic reproduction, overall diagnostic acceptability (P = 0.923), lesion conspicuity (P = 0.592), and edge sharpness (P = 0.589), while HD-FBP was rated inferior. Streak artifacts and beam hardening was significantly more prominent in HD-FBP while HD-IRIS images exhibited a slightly different noise pattern. CONCLUSIONS: Direct intrapatient comparison of standard FD body protocols and HD-IRIS reconstruction suggest that the latest iterative reconstruction algorithms allow for approximately 50% dose reduction without deterioration of the high image quality necessary for confident diagnosis.