Ventilation perfusion lung scan in acute pulmonary embolism, a good negative but a bad positive diagnostic test

Provisional diagnosis of acute pulmonary embolism [P.E.] is based on clinical evaluation Definitive diagnosis however, used to be non invasive with Ventilation Perfusion lung scan [V/Q] considered the test of choice pointing to high, intermediate and low probabilities of PE. Diagnostic pulmonary angiography is obviously the golden standard for establishing the final diagnosis of a highly probable PE. The purpose of the present study is to validate the technique of Ventilation Perfusion lung scan through comparison with the directly proven diagnosis via pulmonary angiography. This study was conducted on a total of 20 pts, all having DVT [proven by duplex], with 10 having symptoms suggestive of pulmonary embolism and 10 asymptomatic. Nine were males and 11 were females with a mean age of 41 +/- 16 [range from 16 to 71y.] Following clinical evaluation, including 12 lead ECG and X-ray chest, all pts were subjected to: routine lab. tests, specific lab, tests including arterial blood gases, plasma D-dimer level, FDPs and fibrinogen, transthoracic echocardiography[M-mode and 2D],V/Q lung scan using Tc99m labeled micro aggregated albumin and pulmonary angiography. The latter was performed under hemodynamic monitoring and O2 supplementation, using the trans- venous approach [Sildenger technique] through the right or the left common femoral vein[Internal jugular veins were an alternative in case of iliac or caval thrombosis]. A 6 F pulmonary catheter [angled pigtail] was used for injection of low osmolar iodinated contrast medium. Two views of each lung were performed [The frontal and 45° ipsilateral posterior oblique projections]. Out of the 10 asymptomatic pts only one [10%] had angiographically proven PE compared to 5 out of 10 symptomatic pts [50%]. Corresponding figures for +ve V/Q were 50% and 90% respectively. Compared to the 14 cases without angiographic evidence of PE, the 6 pts with proven PE exhibited significantly higher incidence of dyspnea and chest pain, lower BP, faster respiratory rate, lower PaO2, significantly higher PAP and higher incidence of cyanosis, pulmonary hypertension, TR, RV dilatation. Considering pulmonary angiography as the standard diagnostic tool, all 6 proven cases had +ve V/Q lung scan, while of the remaining 14 unproven cases, V/Q was +ve in 8 i.e sensitivity 100%, specificity 43%, negative predictive value 100%, positive predictive value 43%. In conclusion, compared with the standard pulmonary angiography, ventilation perfusion lung scan proved to be an excellent negative but a bad positive test [sensitivity 100%, specificity 43%, negative predictive value 100%, positive predictive value 43%]. Because of the non invasive nature, V/Q is to be recommended at least as an initial screening test prior to subjecting pts to the invasive technique of pulmonary angiography. Clinical evaluation and bed side objective assessment should not be under estimated as shown by the 10% true incidence of PE in asymptomatic vs 50% in symptomatic cases

Role of decisive markers in diagnosis and outcome of patients with septic shock

This work aimed to assess the potential role of procalcitonin [PCT] and polymorphonuclear [PMN] elastase enzyme in the early diagnosis and early prediction of prognosis in patients with sepsis and septic shock. Twenty patients with septic shock [16 males and 4 females, mean age 50.15 years] together with a second group comprising 10 patients [9 males, mean age 49.2 years] with systemic sepsis without shock were studied. A third group including 20 healthy volunteers matching with age and sex and served as controls. Serum PCT and PMN elastase enzyme levels were estimated on admission for both patients and control groups with other laboratory investigations and clinical parameters. A multivariate discriminate analysis was performed using PCT, PMN elastase enzyme, albumin, alpha-1-antitrypsin, alpha-2 macroglobulin and C-reactive protein [CRP] as independent parameters. The study concluded that serum PCT and PMN elastase enzyme are independent useful diagnostic markers for the early detection of systemic inflammatory response syndrome with or without shock. However, PCT has the advantage over the above mentioned parameters having significantly predictive accuracy of 80%. Procalcitonin, PMN elastase enzyme, alpha-1-antitrypsin, alpha-2-macroglobulin, CRP and albumin could be used for the early prediction of complications of sepsis patients with an overall predictive accuracy of 76.7%

Comparative study between variceal ligation by detachable snare versus banding in bleeding esophageal varices

Varcial bleeding is a very serious complication with a reported mortality rate of 20-50%. Patients who have had a vatriceal hemorrhage are usually treated by endoscopic injection sclerotherapy or band ligation to eradicate the varices. Endoloop ligation is a new technique invented to achieve hemostatis and variceal eradiation. This work included fifty patients with acute esophageal ariceal bleeding, 25 patients were managed by band ligation and the other 25 patients were managed by endoloop ligation. The number of patients who rebelled during the follow-up was smaller in the endoloop group [12%] compared to the band group [28%], yet, this difference did not reach statistical significance. Also, no statistically significant difference was found between the two groups regarding the number of patients who showed complete varicea eradication, the number of active sessions needed to reach variceal eradiation or the incidence of variceal recurrence by the end of follow-up period of six months. It was found that the total cost of endoloop sessions' needed for variceal obliteration was 1163.9 l.e for erach patient, while it was 12.9.9 l.e for band ligaion. Also, the endoloop showed technical advanced over band application including better field of vision, more tight application, good results on junctional varices, and no strain exerted by the device on the endoscope. We can conclude that endoloop ligation is a new promising technique for managing bleeding esophageal varices