Computed tomography versus invasive coronary angiography: design and methods of the pragmatic randomised multicentre DISCHARGE trial.

OBJECTIVES: More than 3.5 million invasive coronary angiographies (ICA) are performed in Europe annually. Approximately 2 million of these invasive procedures might be reduced by noninvasive tests because no coronary intervention is performed. Computed tomography (CT) is the most accurate noninvasive test for detection and exclusion of coronary artery disease (CAD). To investigate the comparative effectiveness of CT and ICA, we designed the European pragmatic multicentre DISCHARGE trial funded by the 7th Framework Programme of the European Union (EC-GA 603266). METHODS: In this trial, patients with a low-to-intermediate pretest probability (10-60 %) of suspected CAD and a clinical indication for ICA because of stable chest pain will be randomised in a 1-to-1 ratio to CT or ICA. CT and ICA findings guide subsequent management decisions by the local heart teams according to current evidence and European guidelines. RESULTS: Major adverse cardiovascular events (MACE) defined as cardiovascular death, myocardial infarction and stroke as a composite endpoint will be the primary outcome measure. Secondary and other outcomes include cost-effectiveness, radiation exposure, health-related quality of life (HRQoL), socioeconomic status, lifestyle, adverse events related to CT/ICA, and gender differences. CONCLUSIONS: The DISCHARGE trial will assess the comparative effectiveness of CT and ICA. KEY POINTS: • Coronary artery disease (CAD) is a major cause of morbidity and mortality. • Invasive coronary angiography (ICA) is the reference standard for detection of CAD. • Noninvasive computed tomography angiography excludes CAD with high sensitivity. • CT may effectively reduce the approximately 2 million negative ICAs in Europe. • DISCHARGE addresses this hypothesis in patients with low-to-intermediate pretest probability for CAD.

Atypical, polyarticular lipoma arborescens in a child.

Introduction: Lipoma arborescens is a rare, tumor-like lesion commonly involving synovial joints and less commonly bursae and synovial tendon sheaths. Case Outline: We report a case of a 12-year-old boy with symmetric involvement of the bicipitoradial bursae, synovial sheaths of extensor compartments of both hands and medial ankles. The diagnosis of polyarticular lipoma arborescens was proposed on magnetic resonance (MR) imaging and this diagnosis was histologically proven after biopsy of the bursae and later by open surgery of the synovial sheath of the right ankle tendons. Literature search was performed and twelve cases with polyarticular involvement were analyzed. Lipoma arborescens commonly involves suprapatellar recess of the knee and very rarely other joints or bursae. Histological analysis revealed an accompanying non-necrotizing granulomatous synovial inflammation. Conclusion: Polyarticular lipoma arborescens is a rare entity and symmetrical involvement of the joints other than the knees is exceedingly rare. MR imaging plays a significant role in the diagnostic protocol, and the characteristic fatty signal on MR imaging is highly suggestive of lipoma arborescens.

Computer simulation of thromboexclusion of the complete aorta in the treatment of chronic type B aneurysm.

The purpose of this computational study was to examine the hemodynamic parameters of the velocity fields, shear stress, pressure and drag force field in the complex aorta system, based on a case of type B aortic dissection. The extra-anatomic reconstruction of the complete aorta and bipolar exclusion of the aneurysm was investigated by computational fluid dynamics. Three different cases of the same patient were analyzed: the existing preoperative condition and two alternative surgical treatment options, cases A and B, involving different distal aorto-aortic anastomosis sites. The three-dimensional Navier-Stokes equations and the continuity equation were solved with an unsteady stabilized finite element method. The aorta and large tube graft geometries were reconstructed based on CT angiography images to generate a patient-specific 3D finite element mesh. The computed results showed velocity profiles with smaller intensity in the aorta than in the graft tube in the postoperative case. The shear stress distribution showed low zones around 0.5 Pa in the aneurysm part of the aorta for all three cases. Pressure distribution and, particularly, drag force had much higher values in the preoperative aneurysm zones (7.37 N) than postoperatively (2.45 N), which provides strong evidence of the hemodynamic and biomechanical benefits of this type of intervention in this specific patient. After assessing the outcome obtained with each of the two alternatives A and B, for which we found no significant difference, it was decided to use option A to treat the patient. In summary, computational studies could complement surgical preoperative risk assessment and provide significant insight into the benefits of different treatment alternatives.