Determining the optimal interval for imaging surveillance of ascending aortic aneurysms.

BACKGROUND: Cardiovascular guidelines recommend (bi-)annual computed tomography (CT) or magnetic resonance imaging (MRI) for surveillance of the diameter of thoracic aortic aneurysms (TAAs). However, no previous study has demonstrated the necessity for this approach. The current study aims to provide patient-specific intervals for imaging follow-up of non-syndromic TAAs. METHODS: A total of 332 patients with non-syndromic ascending aortic aneurysms were followed over a median period of 6.7 years. Diameters were assessed using all available imaging techniques (echocardiography, CT and MRI). Growth rates were calculated from the differences between the first and last examinations. The diagnostic accuracy of follow-up protocols was calculated as the percentage of subjects requiring pre-emptive surgery in whom timely identification would have occurred. RESULTS: The mean growth rate in our population was 0.2 ± 0.4 mm/year. The highest recorded growth rate was 2.0 mm/year, while 40.6% of patients showed no diameter expansion during follow-up. Females exhibited significantly higher growth rates than men (0.3 ± 0.5 vs 0.2 ± 0.4 mm/year, p = 0.007). Conversely, a bicuspid aortic valve was not associated with more rapid aortic growth. The optimal imaging protocol comprises triennial imaging of aneurysms 40-49 mm in diameter and yearly imaging of those measuring 50-54 mm. This strategy is as accurate as annual follow-up, but reduces the number of imaging examinations by 29.9%. CONCLUSIONS: In our population of patients with non-syndromic TAAs, we found aneurysm growth rates to be lower than those previously reported. Yearly imaging does not lead to changes in the management of small aneurysms. Thus, lower imaging frequencies might be a good alternative approach.

A patient with progressive dyspnoea.

Our case report describes the strong ability of noninvasive diagnostic techniques to detect cardiac involvement in advanced systemic amyloid light chain amyloidosis, which was confirmed at autopsy.

Long-term efficacy and safety of cyclosporin in severe adult atopic dermatitis.

A prospective, open, multicentre study was performed to investigate the efficacy and safety of long-term treatment with cyclosporin in adults with severe atopic dermatitis. Subjects were treated for a maximum of 48 weeks. For the first 8 weeks, cyclosporin was administered at 2.5 mg/kg per day. The dose was then adjusted according to response. Disease activity was monitored using the six-area, six-sign score and the proportion of skin involved. Pruritus and sleep disturbance were assessed using four-point scales. Response was further evaluated on a five-point scale. Adverse events, blood pressure and serum biochemistry were monitored. Tolerability was assessed on a five-point scale. One hundred subjects were enrolled and 65 completed 48 weeks of treatment. Withdrawals occurred due to remission (three), inadequate response (seven), protocol violations (11) and adverse events (14, of which seven were probably treatment related). Cyclosporin produced rapid and highly significant improvements in all indices of disease activity. Sixty-five subjects considered that they had shown a considerable improvement or complete clearance of disease. Most patients relapsed after cessation of treatment, but neither signs nor symptoms had returned to baseline severity 8 weeks later. Blood pressure and serum creatinine levels increased slightly, and in one subject renal impairment was a major factor contributing to withdrawal of the drug. Overall, 85 subjects rated the tolerability of cyclosporin as good or very good. The results indicate that cyclosporin has a place in the long-term treatment of severe atopic dermatitis provided that appropriate patients are selected and careful monitoring is performed.

Recurrent porokeratosis.

A 63-year-old man developed linear, annular and accuminate lesions which showed the histological features of porokeratosis. The lesions cleared spontaneously, recurred several months later and ulcerated, then cleared again. The spontaneous resolution and recurrence of the lesions is a hitherto undescribed pattern of porokeratosis.

Pemphigoid gestationis and neonatal alloimmune thrombocytopenia.

A patient whose second, third and fourth pregnancies were complicated by alloimmune thrombocytopenia, developed pemphigoid gestationis after the fourth pregnancy. The infant was delivered by Caesarean section at 34 weeks gestation. The pemphigoid gestationis resolved promptly after a short course of systemic corticosteroids. A possible association between these two uncommon conditions is discussed.

Cytotoxicity of Fusobacterium ulcerans.

A new species of Fusobacterium, F. ulcerans, was isolated from 46 tropical ulcers. All the isolates had shown identical soluble cell protein patterns on polyacrylamide gel electrophoresis although there were two morphological types with slightly different biochemical properties. A representative strain of each of the two groups was selected for in- vitro cytotoxicity testing on a range of tissue-culture cell lines. Both strains of F. ulcerans induced a marked cytotoxic effect on Vero and Int-407 cells. This effect may contribute to the pathogenesis of tropical ulcers.

The clinical and epidemiologic features of tropical ulcer (tropical phagedenic ulcer).

A comparative survey of patients with tropical ulcer has been carried out in Zambia, Gambia, Southern India and Papua New Guinea. The clinical features, socioeconomic background and nutritional correlates have been compared in 170 patients. In 96% of cases the condition occurred on the foot or lower leg. In only 10 instances did the ulcer last for over six months. There was one patient with a squamous cell carcinoma arising in situ from the ulcer margin. No significant differences in clinical features were seen in the countries surveyed. In all areas apart from southern India most cases were seen in the rural population and in children or teenagers. There was no correlation between the development of an ulcer and nutritional status found in this survey. Evidence is presented that there is an association between tropical ulcer and exposure to mud or slow moving fresh water.

Tropical ulcer--a reappraisal based on recent work.

Tropical ulcer is a disease which predominantly affects young children in the tropics. The course of the disease can be interrupted in the early stages by the administration of antibiotics so it seems likely that infection may play a role. The disease extends rapidly from the initial lesion, a tiny papule, to a large area of necrosis. This makes a toxic factor likely in the pathogenesis. The epidemiology and some of the causative factors of this disease are currently being investigated. Patients with tropical ulcers were assessed, in areas where the disease is still endemic (Gambia, Papua New Guinea, southern India and Fiji), by a paediatrician or a dermatologist. All patients had swabs taken from the ulcers for bacteriological examination. Skin biopsies were taken from the edge of the ulcers as often as possible. The bacteriological samples were transported anaerobically to London where the laboratory work was performed. The results are discussed in relation to previously reported work.

The isolation of fusobacteria from tropical ulcers.

Tropical ulcer is a disease found most commonly in the tropics, although the disease is not confined to those areas. Young children are affected most frequently and the disease is thought to be a polymicrobial infection with fusobacteria, aerobic microorganisms and spirochaetes each playing a role. The fusobacteria have been reported on smears but have not been cultured thus far. We report the isolation and culture of these organisms from 46 ulcers and have also demonstrated the same organisms in skin biopsies from these lesions.

Light and electron microscopic features of tropical ulcer.

The histopathological features of 20 tropical ulcers with the electron microscopic findings on seven biopsy specimens are reported. The main findings were loss of epidermis associated with extensive dermal oedema, infiltration by polymorphonuclear leucocytes, and disruption of collagen bundles. The presence of micro-organisms at the site of tissue damage was shown and compared with the morphology of the organisms grown in culture. The most commonly identified bacteria were pleomorphic rods whose electron microscopic appearances accorded most closely with Fusobacteria grown in vitro. Spirochaetes, identified ultrastructurally as Treponema sp, were also present. There was no evidence of vasculitis to explain the rapid onset of ulceration, but necrotic changes seen in the dermis and the inflammatory cell infiltrate suggest that, associated with cell necrosis, bacteria previously shown in vitro have an important role in the pathogenesis of tropical ulcers.

The infectious aetiology of tropical ulcer--a study of the role of anaerobic bacteria.

We have cultured anaerobic bacteria from patients with tropical ulcers. Fusobacteria were isolated most frequently. Anaerobes were always present, together with aerobes or facultative anaerobes, particularly in early phase ulcers, suggesting that the combination of organisms is important in the pathogenesis of the disease. Spirochaetes were identified in material examined by light and electron microscopy, but were not cultured.

Anaerobic bacteria in tropical ulcer--the application of a new transport system for their isolation.

The successful isolation of anaerobes largely depends on adequate transportation of the specimens after collection. We are investigating the role of anaerobes in the pathogenesis of tropical ulcer and have used Hungate tubes with pre-reduced peptone yeast broth and agar as a transportation system. The medium included 0.05% cysteine and 0.03% sodium formaldehyde sulphoxylate as an Eh buffer. Resazurin 1 microgram/ml seved as an Eh indicator. We found the tubes convenient to use and very reliable at maintaining anaerobiasis.