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FNH-like Nodules: Possible Precursor Lesions in Patients With Focal Nodular Hyperplasia (FNH). Sébastien Lepreux, Christophe Laurent, Charles Balabaud, et al. Comp Hepatol 2003; 2:7. (C.B., Service de Hépato-gastroentérologie, Hôpital St André, CHU Bordeaux, France; e-mail: charles.balabaud@chu-bordeaux.fr)
Background: The typical lesion of focal nodular hyperplasia (FNH) is a benign tumor-like mass characterized by hepatocytic nodules separated by fibrous bands. The solitary central artery with high flow and the absent portal vein give the lesions their characteristic radiological appearance. The great majority of cases seen in daily practice conform to the above description. Additional small nodules (from 1–2 up to 15–20 mm in diameter) detected by imaging techniques or on macroscopic examination may be difficult to identify as representing FNH if they lack the key features of FNH as defined in larger lesions. The aim of this study was to characterize these small nodules, and to compare their characteristics with those of typical lesions of FNH present in the same specimens. Results: Eight patients underwent hepatic resections for the removal of a mass lesion ("nodule") diagnosed as: FNH (1 patient); nodules of unknown nature (5 patients); or nodules thought to be adenoma or hepatocellular carcinoma (2 patients). Six nodules out of 9 discovered by imaging techniques met histopathological criteria for the diagnosis of typical FNH, at least in parts of the nodule; 2 nodules corresponded to a minor form of FNH ("subtle FNH") and one nodule to a steatotic area. Although FNH was thought to be found in a normal or nearly normal liver, this study revealed that, in addition, there were various types of small FNH-like nodules and vascular abnormalities in the liver with typical FNH nodule. The various types of small FNH-like nodules (n = 8, diameter 2 to 20 mm) consisted of the association to various degrees of numerous and/or enlarged arteries in portal tracts or in septa, with hyperplastic foci, slight ductular reaction, and regions of sinusoidal dilatation, accompanied by thin fibrous bands. Vascular abnormalities consisted of unpaired arteries, portal tracts with arteries larger than the associated bile duct, and regions of sinusoidal dilatation. Conclusions: Although these small nodules can be considered as insufficient type or abortive forms of FNH, or adenoma, they can be precursors of the large mass lesions in which FNH was recognized and defined.
Authors’ Abstract
Reason for selecting abstract:
• Implications for imaging
Selected by Giuseppe Brancatelli, MD
Radiology Department, University of Palermo, Italy
Background and Clinical Impact of Tissue Congestion in Right-lobe Living-donor Liver Grafts: A Magnetic Resonance Imaging Study. Hidekazu Yamamoto, Yoji Maetani, Tetsuya Kiuchi, et al. Transplantation 2003; 76:164–169. (Koichi Tanaka, Department of Transplant Surgery, Kyoto University Hospital, 54 Kawara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan)
Background: Although right-lobe liver grafts from living donors have been widely accepted as an option for adult patients, impact of middle hepatic vein (MHV) deprivation is a recent controversy. Methods: Fifty recipients of right-lobe living-donor liver grafts without MHV or drainage reconstruction in anterior segment were evaluated for posttransplant tissue congestion with T2-weighted magnetic resonance imagings. Age of recipients and donors ranged from 19 to 69 (median 50) and 19 to 64 (46) years, respectively. Graft-to-recipient weight ratio ranged from 0.74% to 1.66% (1.06%). Cavoplasty was provided during right hepatic vein reconstruction to avoid anastomotic stricture. Results: Congestion was observed in 88% of segments V and 85% of segments VIII in the first month. Congestion positively correlated with anatomic dependency on MHV. Also, donors were significantly older in age in grafts with more congestion. However, congestion improved within several months in most grafts. Graft congestion was associated neither with morbidities nor with graft loss except for temporary correlation with ascites production in the third and fourth posttransplant weeks. Conclusion: A significant proportion of right-lobe liver grafts without MHV experience morphologic congestion of the anterior segment in the early phase after transplantation, which is dependent on venous anatomy and donor age. However, the congestion spontaneously resolves in most cases. These results suggest that reconstruction of drainage vein(s) from the anterior segment is not necessary for all grafts provided good outflow through compensatory routes is secured. Additional reconstruction may be indicated in grafts with marginal size, anatomy, and quality.
Authors’ Abstract
Reason for selecting abstract:
• Use of MR imaging
Selected by Giuseppe Brancatelli, MD
Radiology Department, University of Palermo, Italy
Preoperative Liver Donor Evaluation: Imaging and Pitfalls. Koenraad J. Mortelé, Vito Cantisani, Roberto Troisi, et al. Liver Transpl 2003; 9:S6–S14. (K.J.M., Department of Radiology, Division of Abdominal Imaging and Intervention, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; e-mail: kmortele@partners.org)
This article discusses the rationale behind living (related) donor liver transplantation, the role of imaging in the preoperative evaluation of the potential donor, and the currently available imaging modalities for fulfilling this task. Furthermore, the normal hepatic vascular and biliary anatomy, as seen on imaging, is reviewed and the most common anomalies are highlighted. Finally, critical concepts in the diagnostic evaluation of a donor are discussed with special emphasis on how to accurately measure liver volumes.
Authors’ Abstract
Reasons for selecting abstract:
• Use of imaging
• Review
Selected by Giuseppe Brancatelli, MD
Radiology Department, University of Palermo, Italy
MRI Angiography Is Superior to Helical CT for Detection of HCC Prior to Liver Transplantation: An Explant Correlation. Marta Burrel, Josep M. Llovet, Carmen Ayuso, et al. Hepatology 2003; 38:1034–1042. (Jordi Bruix, BCLC Group, Liver Unit IMD. Hospital Clinic i Provincial Villarroel 170, 08036-Barcelona, Catalonia, Spain; e-mail: bruix@medicina.ub.es)
Helical computerized tomography (CT) and magnetic resonance imaging (MRI) are used for staging of hepatocellular carcinoma (HCC) prior to curative treatments but underestimate tumor extension in 30% to 50% of cases when compared with pathologic explants. This study compares a new technology, MRI angiography (MRA), with triphasic helical CT in detection of HCC. Fifty cirrhotic patients, 29 with HCC, undergoing liver transplantation were analyzed. MRA was performed with a 3-D breath-hold fast spoiled gradient-echo sequence by using an effective section thickness of 2 to 2.5 mm. The gold standard was the pathologic examination (liver cut into 5-mm slices). One hundred twenty-seven lesions were identified at the explant: 76 HCC, 13 high-grade dysplastic nodules, 31 macroregenerative nodules, 7 hemangiomas. Diameter of the main HCC nodules was 29 ± 14 mm and 11 ± 7 mm for the 47 additional nodules. On a per nodule basis, sensitivity of MRA was superior to CT (58/76 [76%] vs. 43/70 [61%], respectively, P =.001). Sensitivity of MRA for detection of additional nodules decreased with size (>20 mm: 6/6 [100%]; 10–20 mm: 16/19 [84%]; <10 mm: 7/22 [32%]) and was superior to CT for nodules 10 to 20 mm (84% vs. 47%, P =.016). Nonspecific hypervascular nodules >5 mm at MRA were HCC in two thirds of the cases. In conclusion, MRA has a high diagnostic accuracy for HCC 
10 mm and is more sensitive than triphasic helical CT in nodules sized 10 to 20 mm. MRA is the optimal technique for HCC staging prior to curative therapies.
Authors’ Abstract
Reasons for selecting abstract:
• Use of imaging
• Topic of current interest
Selected by Giuseppe Brancatelli, MD
Radiology Department, University of Palermo, Italy
Thorax
Legionnaires Disease and HIV Infection. Maria Luisa Pedro-Botet, Miquel Sabrià, Nieves Sopena, et al. Chest 2003; 124:543–547. (M.L.P.B., Infectious Disease Unit, Hospital Universitario Germans Trias i Pujol, Crtra/del Canyet s/n, Badalona 08916, Spain; e-mail: mlpbotet@ns.hugtip.scs.es)
Study objectives: To compare the outcome of Legionnaires disease (LD) in patients with and without HIV infection. Design: Retrospective review of clinical charts. Setting: Six hundred-bed university hospital. Patients: We studied the clinical findings of 64 patients without HIV and 15 patients with HIV. Patients with a serologic diagnosis only were not included. Patients with previous immunosuppressive therapy or transplant recipients were excluded from the former group. In the HIV group, the mean CD4 cell count was 347.5/µL, plasma viral load was undetectable in 50% of the patients, and only one patient (7%) was receiving cotrimoxazole as prophylaxis against Pneumocystis carinii at the time of pneumonia. No differences were observed in the two groups with respect to community or nosocomial acquisition, delay in the initiation of appropriate treatment, the use of macrolides or fluoroquinolones, and Fine score in cases of community-acquired LD. Results: Univariate analysis showed that time to apyrexia was longer, and respiratory symptoms, bilateral infiltrates in chest radiograph, hyponatremia, increase in aspartate aminotransferase and creatine phosphokinase (CK), and respiratory failure were more frequent in the HIV group. Mortality was greater in patients with HIV, achieving a statistically significant value of 20%; however, multivariate analysis only confirmed these differences with respect to the increase in CK. Conclusions: LD has a more severe clinical presentation and worse evolution in patients with HIV.
Authors’ Abstract
Reason for selecting abstract:
• Severe opportunistic infection
Selected by Robert M. Steiner, MD
University of Pennsylvania Health System and Pennsylvania Hospital, Philadelphia
Value of F-18 Fluorodeoxyglucose Positron Emission Tomography for Predicting the Clinical Outcome of Patients With Aggressive Lymphoma Prior to and After Autologous Stem-Cell Transplantation. Jean-Emmanuel Filmont, Johannes Czernin, Cecelia Yap, et al. Chest 2003; 124:608–613. (J.C., School of Medicine, Nuclear Medicine, AR277A CHS, 10833 Le Conte Ave, Los Angeles, CA 90095-6942; e-mail: jczernin@mednet.ucle.edu)
Study objectives: To determine and compare the values of positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG) and CT for predicting clinical outcome of patients with aggressive lymphoma undergoing salvage cytoreductive chemotherapy followed by high-dose chemotherapy and autologous stem-cell transplantation (ASCT). Patients and methods: Forty-three patients with lymphoma who underwent ASCT with FDG-PET evaluation were studied. Group 1 (n = 20) patients (6 patients with Hodgkin disease [HD], and 14 patients with non-Hodgkin lymphoma [NHL]) underwent PET 2 to 5 weeks after initiation of salvage chemotherapy, prior to ASCT. Group 2 (n = 23) patients (6 patients with HD, and 17 patients with NHL) underwent PET within a median interval of 2.4 months (range, 2 to 6 months) after ASCT. Measurements and results: Study end points were complete remission, relapse, or death. In group 1, 8 of 20 patients (40%) were disease free after a median follow-up of 13.3 months; 12 patients relapsed or died. PET findings were true-negative in 7 of 8 patients and true-positive in 11 of 12 patients who relapsed after ASCT. In group 2, 9 of 23 patients (39%) were disease free after a median follow-up of 16.5-months; 14 patients relapsed. PET findings were true-negative in 8 of 9 patients and true-positive in 13 of 14 patients who relapsed. Positive and negative predictive values of PET were 92% and 88% (group 1) and 93% and 89% (group 2), respectively. Predictive accuracy values of PET were 90% and 91% for group 1 and group 2, respectively, vs 58% and 67% for CT (p < 0.05). Conclusions: PET findings but not CT results were strongly correlated with disease-free survival (p < 0.01). Our results show that FDG-PET can be used to predict the post-ASCT outcome of lymphoma patients with high accuracy.
Authors’ Abstract
Reason for selecting abstract:
• PET and correlation with CT
Selected by Robert M. Steiner, MD
University of Pennsylvania Health System and Pennsylvania Hospital, Philadelphia
The Cost-Effectiveness of Low-Dose CT Screening for Lung Cancer: Preliminary Results of Baseline Screening. Juan P. Wisnivesky, Alvin I. Mushlin, Nachum Sicherman, et al. Chest 2003; 124:614–621. (Claudia Henschke, Department of Radiology, Weill Medical College of Cornell University, 525 East Sixty-Eigth St, New York, NY 10021; e-mail: chensch@mail.med.cornell.edu)
Background: Low-dose CT scan screening greatly improves the likelihood of detecting small nodules and, thus, of detecting lung cancer at a potentially more curable stage. Methods: To evaluate the cost-effectiveness of a single baseline low-dose CT scan for lung cancer screening in high-risk individuals, data from the Early Lung Cancer Action Project (ELCAP) was incorporated into a decision analysis model comparing low-dose CT scan screening of high-risk individuals (ie, those 60 years with at least 10 pack-years of cigarette smoking and no other malignancies) to observation without screening. Cost-effectiveness was expressed as the incremental cost per year of life saved. The analysis adopted the perspectives of the health-care system. The probability of the different outcomes following the decision either to screen or not to screen an individual at risk was based on data from ELCAP and the Surveillance, Epidemiology, and End Results Registry or published data, respectively. The cost of the screening and treatment of patients with lung cancer was established based on data from the New York Presbyterian Hospital’s financial system. The base-case analysis was conducted under the assumption of similar aggressiveness of screen-detected and incidentally discovered lung cancers and then was followed by multiple sensitivity analyses to relax these assumptions. Results: The incremental cost-effectiveness ratio of a single baseline low-dose CT scan was $2,500 per year of life saved. The base-case analysis showed that screening would be expected to increase survival by 0.1 year at an incremental cost of approximately $230. Only when the likelihood of overdiagnosis was > 50% did the cost effectiveness ratio exceed $50,000 per year of life saved. The cost-effectiveness ratios were also relatively insensitive to estimates of the potential lead-time bias. Conclusions: A baseline low-dose CT scan for lung cancer screening is potentially highly cost-effective and compares favorably to the cost-effectiveness ratios of other screening programs.
Authors’ Abstract
Reason for selecting abstract:
• Collateral information from screening trial
Selected by Robert M. Steiner, MD
University of Pennsylvania Health System and Pennsylvania Hospital, Philadelphia
Endovascular Stent Grafting of Descending Thoracic Aortic Aneurysms. Ramesh M. Gowda, Deepika Misra, Robert F. Tranbaugh, et al. Chest 2003; 124:714–719. (Ijaz A. Kahn, Creighton University Cardiac Center, 3006 Webster St, Omaha, NE 68131; e-mail: ikahn@cardiac.creighton.edu)
The treatment of descending thoracic aortic aneurysms using endovascular stents is one of the more recent advances in treatment and is receiving increasing attention as it is a less invasive alternative to open surgical repair. Although the technology is still primitive, significant improvements have lately been made in the design and deployment of the endovascular stent-grafts. Aortic stent-grafts were used initially to exclude abdominal, and later thoracic, aortic true and false aneurysms. These prostheses have been increasingly used to treat aneurysms, dissections, and traumatic ruptures of the descending thoracic aorta with good early and mid-term outcomes. Although the long-term outcome of patients with aneurysms of the descending thoracic aorta after stent graft implantation has not been investigated, continued refinement of the endovascular approaches has decreased the need for conventional open thoracic aortic aneurysm repair, especially in patients who are at a high risk for standard surgery because of advanced age or the presence of comorbid diseases. The placement of endoluminal stent-grafts to exclude the dissected or ruptured site of thoracic aortic aneurysms is a technically feasible and relatively safe procedure. With the rapid development of endovascular approaches, the treatment of the descending thoracic aortic aneurysms might alter even more, but an extended follow-up is necessary to determine the longer term outcome. Historical perspectives, advantages, device considerations, complications, and current perspectives of the endovascular stent grafting of the descending thoracic aortic aneurysms are elaborated on.
Authors’ Abstract
Reason for selecting abstract:
• Treatment approach
Selected by Robert M. Steiner, MD
University of Pennsylvania Health System and Pennsylvania Hospital, Philadelphia
Assessment of Spontaneous Pneumomediastinum: Experience With 12 Patients. Jacques B. Jougon, Michel Ballester, Frédéric Delcambre, et al. Ann Thorac Surg 2003; 75:1711–1714. (J.B.J., Service de Chirurgie Thoracique, CHU de Bordeaux, Hôpital de Haut-Lévêque, 33604 Pessac, France; e-mail: jacques.jougon@chu -bordeaux.fr)
Background: The aim of this study is to report a series of spontaneous pneumomediastinum in a population of young, tall, and thin patients with a history of thoracic hyper pressure, and to analyze the assessment required in such patients. Methods: A retrospective study of an unicentric series and a review of the literature from 1980 to 2002 were performed. Results: Between December 1996 and January 2002, 12 patients (mean age, 25 years old; mean height, 172 cm; and mean weight, 63 kg) were admitted with spontaneous pneumomediastinum. In all patients, high intrathoracic pressure by cough or acute effort was the precipitating factor. Most frequent complaints were acute chest pain, asthenia, and subcutaneous emphysema. The following assessment was performed: chest roentgenogram in 12 of 12 patients (12/12); computer tomography (CT) scan in 8/12; bronchoscopy in 7/12; esophagoscopy in 6/12; esophagography in 2/12. Outcome was always uneventful without any recurrence. Hospital stay ranged from 0 to 6 days. The Medline research revealed that articles consist mainly of case reports. Two articles only report a multicentric series of 25 and 36 cases, respectively. No organ perforation was found either in our series or in our review of the literature. Conclusions: Spontaneous pneumomediastinum follows alveolar rupture in the pulmonary interstitium. The dissection of gas towards the hilum and mediastinum is produced by an episode of acute high intrathoracic pressure. It affects mostly young people, and this is the case in our series. Endoscopic thoracic assessment may be risky and is not always necessary. Chest CT or esophageal contrast study should be performed in case of diagnostic doubt of esophageal perforation.
Authors’ Abstract
Reason for selecting abstract:
• Review of entity
Selected by Sheila D. Davis, MD
New York Presbyterian Hospital, New York, NY
The Value of Chest Computer Tomography and Cervical Mediastinoscopy in the Preoperative Assessment of Patients With Malignant Pleural Mesothelioma. J. Hugo Schouwink, Leo Schultze Kool, Emiel J. Rutgers, et al. Ann Thorac Surg 2003; 75:1715–1710. (J.H.S., Medisch Spectrum Twente, Department of Pulmonary Diseases, Postbus 50000, Enschede 7500 KA, The Netherlands; e-mail: j.schouwink@ziekenhuis-mst.nl)
Background: Patients with localized malignant pleural mesothelioma (MPM) can be considered for surgical resection with or without additional treatment. For this approach it is imperative to select patients without mediastinal lymph node involvement. In this study cervical mediastinoscopy (CM) is compared with computer tomography (CT) scanning for its diagnostic accuracy in assessing mediastinal lymph nodes during preoperative workup. Methods: Computer tomography scans of the chest and CM were performed in 43 patients with proven unilateral MPM. The CT scans were reviewed by one radiologist and two chest physicians. At CM the lymph node samples were taken from stations Naruke 2, 3, 4, and 7. Computer tomography and CM results were compared with final histopathologic findings obtained at thoracotomy or, if this was not performed, at CM. Results: Computer tomography scanning revealed pathologic enlarged lymph nodes with a shortest diameter of at least 10 mm in 17 of 43 patients (39%). There was histopathologic evidence of lymph node metastases at CM in 11 of these patients (26%). This resulted in a sensitivity of 60% and 80%, a specificity of 71% and 100%, and a diagnostic accuracy of 67% and 93% for CT and CM, respectively. Conclusions: Cervical mediastinoscopy is a valuable diagnostic procedure for patients with MPM who are considered candidates for surgical-based therapy. Results of CM are more reliable than those obtained by CT scanning. Our data confirm results of previous studies reporting that mediastinal lymph node involvement is a frequent event in MPM.
Authors’ Abstract
Reason for selecting abstract:
• Comparison of results
Selected by Sheila D. Davis, MD
New York Presbyterian Hospital, New York, NY
Factors Predictive of Complete Resection of Operable Esophageal Cancer: A Prospective Study. Christophe Mariette, Laetitia Finzi, Sylvain Fabre, et al. Ann Thorac Surg 2003; 75:1720–1726. (Jean-Pierre J. Triboulet, Service de Chirurgie Digestive et Générale Hôpital, Claude Huriez-CHRU, Palace de Verdun, Lille Cedex, 59037 France; e-mail: jp-triboulet@chru -lille.fr)
Background: Esophagectomy remains a standard treatment for patients with resectable esophageal cancer, but the 5-year survival is only 20% to 25%. After complete resection survival is significantly longer than after incomplete resection with microscopic or macroscopic penetration. The purpose of this study was to prospectively identify the factors predictive of complete resection of operable esophageal cancers. Methods: Betwen January 1995 and January 2002, 372 patients with esophageal cancer underwent surgery with curative intent. Complete resection was performed in 304 patients (81.7%), incomplete resection with microscopic penetration in 28 (7.5%), and incomplete resection with macroscopic penetration in 40 (10.8%). Univariate and multivariate analysis included 16 preoperative and operative factors. Results: Factors predictive of complete resection were absence of any modification of the esophageal axis on the barium swallow (p = 0.019) and a partial or complete response to preoperative radiochemotherapy (p = 0.042). Three groups of patients were identified: group 1 had no deviation of the axis on the barium swallow (n = 253); group 2 had deviation of the axis on the barium swallow and partial or complete response to radiochemotherapy (n = 66); and group 3 had deviation of the axis on the barium swallow and no response to radiochemotherapy or no preoperative treatment (n = 53). Rates of complete resection were 90.1%, 74.2%, and 50.9%, and 5-year actuarial survivals were 46%, 37%, and 0%, respectively (p < 0.001). Conclusions: Complete resection of esophageal cancer is predictable. Deviation axis on the barium swallow and morphologic response to neoadjuvant radiochemotherapy are variables available for all patients at onset of therapeutic management.
Authors’ Abstract
Reason for selecting abstract:
• Use of imaging
Selected by Sheila D. Davis, MD
New York Presbyterian Hospital, New York, NY
Breast
Effect of Breast Augmentation on the Accuracy of Mammography and Cancer Characteristics. Diana L. Miglioretti, Carolyn M. Rutter, Berta M. Geller, et al. JAMA 2004; 291:442–450. (D.L.M., Center for Health Studies, Group Health Cooperative, 1730 Minor Ave, Suite 1600, Seattle, WA 98101; e-mail: miglioretti.d@ghc.org)
Context: Breast augmentation is not associated with an increased risk of breast cancer; however, implants may interfere with the detection of breast cancer thereby delaying cancer diagnosis in women with augmentation. Objective: To determine whether mammography accuracy and tumor characteristics are different for women with and without augmentation. Design, Setting, and Participants: A prospective cohort of 137 women with augmentation and 685 women without augmentation diagnosed with breast cancer between January 1, 1995, and October 15, 2002, matched (1:5) by age, race/ethnicity, previous mammography screening, and mammography registry, and 10 533 women with augmentation and 974 915 women without augmentation and without breast cancer among 7 mammography registries in Denver, Colo; Lebanon, NH; Albuquerque, NM; Chapel Hill, NC; San Francisco, Calif; Seattle, Wash; and Burlington, Vt. Main Outcome Measures: Comparison between women with and without augmentation of mammography performance measures and cancer characteristics, including invasive carcinoma or ductal carcinoma in situ, tumor stage, nodal status, size, grade, and estrogen-receptor status. Results: Among asymptomatic women, the sensitivity of screening mammography based on the final assessment was lower in women with breast augmentation vs women without (45.0% [95% confidence interval {CI}, 29.3%–61.5%] vs 66.8% [95% CI, 60.4%–72.8%]; P =.008), and specificity was slightly higher in women with augmentation (97.7% [95% CI, 97.4%–98.0%] vs 96.7% [95% CI, 96.6%–96.7%]; P<.001). Among symptomatic women, both sensitivity and specificity were lower for women with augmentation compared with women without but these differences were not significant. Tumors were of similar stage, size, estrogen-receptor status, and nodal status but tended to be lower grade (P =.052) for women with breast augmentation vs without. Conclusions: Breast augmentation decreases the sensitivity of screening mammography among asymptomatic women but does not increase the false-positive rate. Despite the lower accuracy of mammography in women with augmentation, the prognostic characteristics of tumors are not influenced by augmentation.
Authors’ Abstract
Reason for selecting abstract:
• Accuracy and prognostic characteristics
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Cardiovascular System
Premature Coronary-Artery Atherosclerosis in Systemic Lupus Erythematosus. Yu Asanuma, Annette Oeser, Ayumi K. Shintani, et al. N Engl J Med 2003; 349:2407–2415. (From the Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee)
Background: Premature coronary artery disease is a major cause of illness and death in patients with systemic lupus erythematosus, but little is known about the prevalence, extent, and causes of coronary-artery atherosclerosis. Methods: We used electron-beam computed tomography to screen for the presence of coronary-artery calcification in 65 patients with systemic lupus erythematosus (mean [±SD] age, 40.3±11.6 years) and 69 control subjects (mean age, 42.7±12.6 years) with no history of coronary artery disease. When calcification was detected, the extent was measured by means of the Agatston score. The frequency of risk factors for coronary artery disease was compared in patients and controls, and the relation between the patients’ clinical characteristics and the presence or absence of coronary-artery calcification was examined. Results: The two groups were similar with respect to age, race, and sex. Coronary-artery calcification was more frequent in patients with lupus (20 of 65 patients) than in control subjects (6 of 69 subjects) (P=0.002). The mean calcification score was 68.9±244.2 in the patients and 8.8±41.8 (P<0.001) in controls. Levels of total, high-density lipoprotein, and low-density lipoprotein cholesterol were not elevated in patients with lupus, but levels of triglycerides (P=0.02) and homocysteine (P<0.001) were. Among patients with lupus, measures of disease activity were similar in those with and those without coronary-artery calcification, but those with calcification were more likely to be older (P<0.001) and male (P=0.008). Conclusions: In patients with systemic lupus erythematosus, the prevalence of coronary-artery atherosclerosis is elevated and the age at onset is reduced. Early detection of atherosclerosis may provide an opportunity for therapeutic intervention.
Authors’ Abstract
Reason for selecting abstract:
• Prevalence information
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
The Subvalvular Apparatus in Rheumatic Mitral Stenosis: Methods of Assessment and Therapeutic Implications. Yoav Turgeman, Shaul Atar, Tiberio Rosenfeld. Chest 2003; 124:1929–1936. (Y.T., Department of Cardiology, Ha’Emek Medical Center, Afula, 18104 Israel; e-mail: yoav_t@clalit.org.il)
The assessment of the structure and function of the subvalvular apparatus (SVA) in patients with rheumatic mitral stenosis (MS) is complex, yet is of major importance prior to therapeutic decision making. Currently available methods of assessment are neither sufficiently accurate nor feasible. We review anatomic and functional aspects of the SVA and define SVA involvement in rheumatic MS. The role of various noninvasive and invasive methods for evaluating the integrity and function of SVA in rheumatic MS, as well as clinical implications and pitfalls in assessment of SVA are also discussed.
Authors’ Abstract
Reason for selecting abstract:
• Pathophysiology information
Selected by Robert M. Steiner, MD
University of Pennsylvania Health System and Pennsylvania Hospital, Philadelphia
Musculoskeletal System
The Accuracy of the Ottawa Knee Rule To Rule Out Knee Fractures: A Systematic Review. Lucas M. Bachmann, Sophie Haberzeth, Johann Steurer, et al. Ann Intern Med 2004; 140:121–124. (L.M.B., Horten Centre, Zurich University, Postfach Nord, CH-8091 Zurich, Switzerland; e-mail: lucas.bachmann @evimed.ch)
Background: The Ottawa knee rule is a clinical decision aid that helps rule out fractures and avoid unnecessary radiography. Purpose: To summarize evidence about the accuracy of the Ottawa knee rule. Data Sources: Relevant English- and non-English-language articles were identified from PreMEDLINE and MEDLINE (1966–2003), EMBASE (1980–2003), CINAHL (1982–2003), BIOSIS (1990–2003), the Cochrane Library (2002, Issue 3), the Science Citation Index database, reference lists of included studies, and experts. Study Selection: Articles were included if they reported enough information to determine the sensitivity and specificity of the Ottawa knee rule for detecting fractures confirmed either radiologically or in combination with follow-up. Data Extraction: Two reviewers independently extracted data on study samples, the ways that the Ottawa knee rule was used, and methodologic characteristics of studies. Data Synthesis: Of 11 identified studies, 6 involving 4249 adult patients were considered appropriate for pooled analysis. The pooled negative likelihood ratio was 0.05 (95% CI, 0.02 to 0.23), the pooled sensitivity was 98.5% (CI, 93.2% to 100%), and the pooled specificity was 48.6% (CI, 43.4% to 51.0%). Conclusion: A negative result on an Ottawa knee rule test accurately excluded knee fractures after acute knee injury. However, because the rule is calibrated toward 100% sensitivity and actual fracture prevalences are usually low, large-scale, multicentered studies are still needed to establish the cost-effectiveness of routinely implementing the rule.
Authors’ Abstract
Reason for selecting abstract:
• Systematic review
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Pediatrics
Pigtail Catheter Drain in the Treatment of Empyema Thoracis. M. J. Pierrepoint, A. Evans, S. J. Morris, et al. Arch Dis Child 2002; 87:331–332. (From the Cystic Fibrosis/Respiratory Unit, Department of Child Health, University Hospital of Wales, Cardiff, UK)
We compared the outcome of children with empyema managed either through thoracotomy with pleural debridment, conventional stiff chest drain, or pigtail chest drain. Compared to conventional drain, children who received either thoracotomy or pigtail catheters had a significantly decreased period of drain in situ, were afebrile earlier, were clinically improved earlier, and were discharged earlier.
Authors’ Abstract
Reason for selecting abstract:
• Improved outcome
Selected by Paula W. Brill, MD
New York Presbyterian Hospital, New York, NY
Ultrasound of the Thyroid Gland in the Newborn: Normative Data. R. J. Perry, A. S. Hollman, A. M. Wood, et al. Arch Dis Child Fetal Neonatal Ed 2002; 87:F209–211. (R.J.P., Department of Child Health, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ, Scotland, UK; e-mail: rebjperry@hotmail.com)
Objective: To establish reference ranges for thyroid length, breadth, depth, and volume in healthy term Scottish infants. Design: Prospective observational study of 100 (49 male) neonates. Length, breadth, and depth were measured, and the volume of each lobe was calculated using the formula for a prolate ellipsoid (volume = length x breadth x depth x 
/6). Results: All measurements showed gaussian distribution, with no significant differences between the right and the left lobes. Values (mean (SD) range) were: length (cm), 1.94 (0.24) 0.9–2.5; breadth (cm), 0.88 (0.16) 0.5–1.4; depth (cm), 0.96 (0.17) 0.6–2.0; volume (ml), 0.81 (0.24) 0.3–1.7; combined volume (ml), 1.62 (0.41) 0.7–3.3. Although there was no difference in mean volume between right and left lobes, there was considerable variation (–0.8 to + 0.7 ml) between the two lobes in individual babies. Conclusions: Both lobes should be measured to give a combined volume. Our findings provide a reference against which thyroid hypoplasia or goitre can be evaluated.
Authors’ Abstract
Reason for selecting abstract:
• New normative data
Selected by Paula W. Brill, MD
New York Presbyterian Hospital, New York, NY
Paranasal Sinus Findings in Children During Respiratory Infection Evaluated With Magnetic Resonance Imaging. Aila Kristo, Matti Uhari, Jukka Luotonen, et al. Pediatrics 2003; 111:e586–e589. (A.K., Department of Otorhinolaryngology, University of Oulu, Oulu, Finland; e-mail: aila.kristo@oulu.fi)
Objective: The spreading of acute respiratory infection into the paranasal sinuses in children is poorly defined. The main objective of this study was to evaluate the frequency and spontaneous resolution of paranasal sinus abnormalities in children with acute respiratory infection using magnetic resonance imaging (MRI). Methods: We examined 60 children with MRI (mean age: 5.7 years) with symptoms of acute respiratory infection. Twenty-six children with major abnormalities in the first MRI scan had a follow-up MRI taken 2 weeks later. Results: The children had had symptoms of uncomplicated acute respiratory infection for an average of 6 days before the first examination (mean duration: 6.5; standard deviation: 3.0). Approximately 60% of the children had major abnormalities in their maxillary and ethmoidal sinuses, 35% in the sphenoidal sinuses, and 18% in the frontal sinuses. The most common abnormal finding was mucosal swelling. The mean overall MRI scores correlated significantly with the symptom scores (rs = 0.3). Of the individual symptoms, nasal obstruction, nasal discharge, and fever were significantly related to the MRI scores. Among the 26 children with major abnormalities in the first MRI, the findings subsequently improved significantly (mean [standard deviation] score: 12.7 [5.6] to 5.7 [5.2]), irrespective of the resolution of symptoms. Conclusions: These observations indicate that acute respiratory infection mostly spreads into the paranasal sinuses of children in the form of mucosal edema and that these abnormalities tend to resolve spontaneously without antimicrobial treatment.
Authors’ Abstract
Reason for selecting abstract:
• Imaging findings
Selected by Beverly P. Wood, MD
University of Southern California School of Medicine, Los Angeles
Risk Factors for Intraventricular Hemorrhage in Very Low Birth Weight Premature Infants: A Retrospective Case-Control Study. Nehama Linder, Orli Haskin, Orli Levit, et al. Pediatrics 2003; 111:e590–e595. (N.L., Department of Neonatology, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel; e-mail: linderm@netvision.net.il)
Objective: High-grade intraventricular hemorrhage (IVH) is an important cause of severe cognitive and motor neurologic impairment in very low birth weight infants and is associated with a high mortality rate. The risk of IVH is inversely related to gestational age and birth weight. Previous studies have proposed a number of risk factors for IVH; however, lack of adequate matching for gestational age and birth weight may have confounded the results. The purpose of this study was to identify variables that affect the risk of high-grade IVH, using a retrospective and case-control clinical study. Methods: From a cohort of 641 consecutive preterm infants with a birth weight of <1500 g, 36 infants with IVH grade 3 and/or 4 were identified. A control group of 69 infants, closely matched for gestational age and birth weight, was selected. Maternal factors, labor and delivery characteristics, and neonatal parameters were collected in both groups. Results of cranial ultrasound examinations, whether routine or performed in presence of clinical suspicion, were also collected. Univariate analysis and multivariate logistic regression analysis were performed. Results: High fraction of inspired oxygen in the first 24 hours, pneumothorax, fertility treatment (mostly IVF), and early sepsis were associated with an increased risk of IVH. A higher number of suctioning procedures, a higher first hematocrit, and a relatively low arterial pressure of carbon dioxide during the first 24 hours of life were associated with a lower occurrence. In the multivariate logistic regression model, early sepsis (odds ratio [OR]: 8.19; 95% confidence interval [CI]: 1.55–43.1) and fertility treatment (OR: 4.34; 95% CI: 1.42–13.3) were associated with a greater risk of high-grade IVH, whereas for every dose of antenatal steroid treatment there was a lower risk of high-grade IVH (OR: 0.52; 95% CI: 0.30–0.90) and each decrease in a mmHg unit of arterial pressure of carbon dioxide during the first 24 hours was associated with a lower risk of IVH (OR: 0.91; 95% CI: 0.83–0.98). This multivariate model had a sensitivity of 77%, a specificity of 75%, and a positive predictive value of 76%. The area under the curve derived from the receiver operator characteristic plots is 0.82. Conclusions: Our results confirm that the development of IVH is associated with early sepsis and failure to give antenatal steroid treatment. We propose that fertility treatment (and especially IVF) may be a new risk factor, and more research is needed to assess its role.
Authors’ Abstract
Reason for selecting abstract:
• Case controlled study of risk factors
Selected by Beverly P. Wood, MD
University of Southern California School of Medicine, Los Angeles
Hemophagocytic Lymphohistiocytosis Masquerading as Child Abuse: Presentation of Three Cases and Review of Central Nervous System Findings in Hemophagocytic Lymphohistiocytosis. Laura Rooms, Nancy Fitzgerald, Kenneth L. McClain. Pediatrics 2003; 111:e636–e640. (Baylor College of Medicine, Department of Pediatrics, Houston, Texas)
Hemophagocytic lymphohistiocytosis (HLH) is a rare disease resulting from abnormal proliferation of histiocytes in tissues and organs. Although the disease generally presents with systemic symptoms such as pancytopenia, coagulopathy, and organomegaly, HLH may also present with central nervous system (CNS) manifestations. CNS events can range from irritability to encephalopathy and coma. Retinal and intracranial hemorrhages are among the neuropathologic findings in these children. Patients who present with CNS findings may have symptoms that mimic those of inflicted injury. These children are at risk, therefore, for misdiagnosis as victims of child abuse. Such an error causes not only unnecessary additional trauma to the family but also, more important, a delay in initiating effective therapy. We present 3 cases of children with HLH who initially came to medical attention with neurologic findings, all suspected to be victims of child abuse. Subsequent laboratory evaluations, however, were consistent with the diagnosis of HLH. No additional evidence of child abuse was obtained, and the charges eventually were dropped. Two of the 3 children died from their disease shortly after presentation; the third is surviving with no evidence of HLH several months after allogeneic bone marrow transplantation. Although the diagnosis of child abuse certainly is all too common, clinicians need to be diligent and informed to avoid assigning this label erroneously. Several laboratory findings of HLH may alert physicians to the possibility of this diagnosis. The timely diagnosis of and institution of therapy for HLH may reduce ultimate morbidity and mortality.
Authors’ Abstract
Reason for selecting abstract:
• Mimic of child abuse
Selected by Beverly P. Wood, MD
University of Southern California School of Medicine, Los Angeles
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