CT pulmonary angiography findings in HIV-infected patients referred for suspected pulmonary thrombo-embolic disease.

BACKGROUND: South Africa bares a significant burden of HIV and imaging is commonly performed as part of the workup for respiratory distress. OBJECTIVES: The aim of this study was to document the prevalence of pulmonary thrombo-embolic disease (PTED) and other findings in HIV-infected patients referred for CT pulmonary angiography (CTPA) for suspected PTED. METHOD: Forty CTPA studies of documented HIV-infected individuals investigated for suspected PTED during a 1-year period were retrieved, anonymised and interpreted by three consultant radiologists. Inter-reader reliability was calculated using Free Marginal multi-rater Kappa. RESULTS: Fourteen of the forty cases (35%) were positive for PTED. In the pulmonary embolism (PE)-positive group, 57.14% had peripheral disease and 42.86% had both peripheral and central disease. Associated findings in the PE-positive cases were pulmonary infarcts (17.5%), mosaic attenuation (17.5%) and linear atelectasis (7.5%). The most common incidental findings were solid pulmonary nodules (52.5%), non-wedge-shaped consolidation (45%), cardiomegaly (52.5%) and enlarged intra-thoracic lymph nodes (52.5%). Thirty per cent of the study population had findings related directly to the presence of PTED, whilst most cases in the study (77.5%) had pulmonary findings unrelated to PTED. In the PE-negative cases, 55% reported emergent findings that warranted immediate or urgent medical attention. CONCLUSION: Computed tomography pulmonary angiography imaging is critical for diagnosing PE. However, further investigation into the judicious application of CTPA in HIV-infected patients with suspected PTED is required, as CTPA findings in most of the cases in this study were unrelated to PE.

Endovascular treatment of ophthalmic artery aneurysms: ophthalmic artery patency following flow diversion versus coil embolization.

BACKGROUND AND PURPOSE: The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carotid artery aneurysms while maintaining patency of covered side branches. The purpose of this retrospective matched cohort study is to evaluate the effect of flow diversion on the patency of the ophthalmic artery when treating ophthalmic artery aneurysms. METHODS: A retrospective review of our prospectively collected institutional database identified 19 ophthalmic artery aneurysms treated with a PED. These were matched according to aneurysm diameter in a 1:2 fashion to ophthalmic artery aneurysms treated via coil embolization, although it is important to note that there was a statistically significance difference in the neck diameter between the two groups (p=0.045). Clinical and angiographic outcomes were recorded and analyzed. RESULTS: On follow-up angiography, decreased flow through the ophthalmic artery was observed in 26% of the PED cohort and 0% of the coil embolization cohort (p=0.003). No ophthalmologic complications were noted in either cohort. Complete occlusion at 12 months was more common following PED treatment than coil embolization (74% vs 47%; p=0.089), although lower than reported in previous trials. This may be due to inflow into the ophthalmic artery keeping the aneurysm patent. Retreatments were more common following coil embolization than PED (24% vs 11%), but this was not significant (p=0.304). Permanent morbidity rates were not significantly different between the PED (11%) and coil embolization (3%) cohorts (p=0.255). CONCLUSIONS: Our results suggest that ophthalmic artery aneurysms may be adequately and safely treated with either the PED or coil embolization. However, treatment with the PED carries a higher risk of impeding flow to the ophthalmic artery, although this did not result in clinical sequelae in the current study.

Vitamin D deficiency: appropriate replenishment therapies and the effects of vitamin D toxicity.

An 84-year-old patient diagnosed with a vitamin D deficiency was given a prescription for ergocalciferol (vitamin D2) 50,000 units weekly. The prescription was incorrectly filled for ergocalciferol 50,000 units daily. Incorrect therapy continued for two months. The patient's vitamin D level increased from < 7.0 ng/mL to 100 ng/mL over a six-month span. The patient complained of decreased appetite and significant weight loss and presented with an elevated International Normalized Ratio at a pharmacist-run anticoagulation clinic. In conjunction with the physician, the pharmacist discontinued vitamin D therapy and monitored levels.Vitamin D plays an integral role in the body's ability to absorb calcium and regulate calcium homeostasis. Further benefits have been reported regarding the role of vitamin D in muscle strength, cardiovascular health, and in preventing osteoporosis and falls. Vitamin D deficiency is widespread in the older adult population as a result of low dietary intake, decreased sun exposure, decreased intrinsic vitamin D production, and decreased vitamin D receptor activity. Replenishment using high-dose ergocalciferol is one common replenishment therapy. Patients also are able to supplement with nonprescription vitamin D products of varying strengths. While many older patients can be expected to have vitamin D deficiencies, pharmacists should be aware of appropriate replenishment therapies and correct dosing of different vitamin D products. Pharmacists also should be familiar with possible toxic effects of vitamin D, particularly as public awareness of benefits continues to increase.