Recent Advances in T1 and T2 Mapping in the Assessment of Fulminant Myocarditis by Cardiac Magnetic Resonance.

PURPOSE OF REVIEW: This review was undertaken to summarise recent data relating to T1 and T2 relaxation times in the assessment of myocarditis using cardiac MRI, and the effect new studies have had on the established diagnostic criteria, leading to recently proposed revised criteria for the cardiac MRI assessment of myocarditis. RECENT FINDINGS: In 2018, updates to the 2009 Lake Louise Criteria (LLC) were proposed, based on studies showing improved accuracy of T1 mapping techniques over T1 signal intensity ratio-based imaging, although for the detection of myocardial oedema either T2-weighted images or increased T2 relaxation times can be used. Non-ischaemic distribution of scar on late gadolinium-enhanced (LGE) T1-weighted imaging remains in the newly revised criteria, which, although can have low sensitivity due to fibrosis presenting diffusely or due to CMR being performed early in the disease process before scar formation, remains in the LLC due to its high specificity. Early gadolinium enhancement has been removed from the LLC, as T1 quantification has higher diagnostic accuracy for the detection of myocardial injury. In the CMR assessment of myocarditis, T1 and T2 quantifications are now recommended over T1- and T2-weighted imaging. Late gadolinium enhancement in a non-ischaemic pattern remains in the updated criteria, whereas early gadolinium enhancement has been superseded by T1 quantification.

Otogenic pneumocephalus: case report and review of the literature.

We report a case of a 70 year old lady who presented to the accident and emergency department with a three day history of left sided otalgia, drowsiness and confusion. On admission her temperature was 39 degrees C, glascow coma scale was 14/15 and otoscopy revealed a left sided otitis media. There was no sign of CSF otorrhoea or mastoiditis. Neuro-otological examination was normal. High resolution CT scan of temporal bones and brain showed evidence of pneumocephalus near the left cerebello-pontine angle and posterior to the left petrous bone. No focal parenchymal pathology, intra-cranial bleed or defect in the tegmen was noted. The patient responded very well to conservative management in the form of high dose intravenous antibiotics. We would like to emphasise that this complication of otitis media should be borne in mind when an elderly patient presents with otalgia and confusion.

Adverse prognosis associated with the metabolic syndrome in established coronary artery disease: data from the EUROPA trial.

OBJECTIVE: To assess the prevalence of metabolic syndrome, and its effect on cardiovascular morbidity and mortality in patients with established coronary disease and to explore the inter-relationships between metabolic syndrome, diabetes, obesity and cardiovascular risk. METHODS: The presence of metabolic syndrome was determined in 8397 patients with stable coronary disease from the European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease, with mean follow-up of 4.2 years. Metabolic syndrome was defined using a modified version of the National Cholesterol Education Programme criteria. RESULTS: Metabolic syndrome was present in 1964/8397 (23.4%) of the population and significantly predicted outcome; relative risk (RR) of cardiovascular mortality = 1.82 (95% CI 1.40 to 2.39); and fatal and non-fatal myocardial infarction RR = 1.50 (95% CI 1.24 to 1.80). The association with adverse outcomes remained significant after adjustment, RR of cardiovascular mortality after adjustment for conventional risks and diabetes = 1.39 (95% CI 1.03 to 1.86). In comparison with normal weight subjects without diabetes or metabolic syndrome, normal weight dysmetabolic subjects (with either diabetes or metabolic syndrome) were at substantially increased risk of cardiovascular death (RR = 4.05 (95% CI 2.38 to 6.89)). The relative risks of cardiovascular death for overweight and obese patients with dysmetabolic status were nominally lower (RR = 3.01 (95% CI 1.94 to 4.69) and RR = 2.35 (95% CI 1.50 to 3.68), respectively). CONCLUSIONS: Metabolic syndrome is associated with adverse cardiovascular outcome, independently of its associations with diabetes and obesity. A metabolic profile should form part of the risk assessment in all patients with coronary disease, not just those who are obese.

Second round cancers: how many were visible on the first round of the UK National Breast Screening Programme, three years earlier?

The first round screening films of 100 women who had cancers detected in the second round of the NHS Breast Screening Programme, were reviewed blindly, and then retrospectively, with knowledge of the site of the subsequent cancer. On initial blind viewing of the first screening mammograms, a lesion, later histologically proven to be the cancer, was correctly identified in 25 false-negative lesions. However, 51 false positive lesions which did not develop into cancer were also identified. Review with knowledge of the site of the lesions at second round screening identified an additional 19 false negative lesions. The mammographic features of the 25 false negative lesions initially identified on blind review were ill-defined masses (52%), architectural distortion (20%), asymmetrical densities (16%), enlarged lymph nodes (8%) and a well defined lesion (4%). Sixteen of these lesions were classified as minimal change, suspicious change in four, clearly malignant in three and benign in two. Forty-eight percent of the false negative lesions occurred in the established review areas of the breast. On retrospective review, 25% of incident round screen detected breast cancers were potentially detectable on the previous screening mammograms and the majority of these lesions were ill-defined masses that were more likely to occur in the 'review areas' of the breast. However, only 7% demonstrated mammographic features that were clearly recognized as suspicious of malignancy. We therefore recommend that radiologists involved in screen reading should pay particular attention to abnormalities occurring in the so-called review areas.

Direct access MRI for general practitioners--influence on patient management.

At the Kent and Canterbury Hospital between April 1994 and September 1995, 170 magnetic resonance imaging (MRI) examinations were requested by 58 different general practitioners by direct access. By use of a retrospective postal questionnaire, information regarding subsequent patient management was obtained and compared with the proposed management, had MRI not been available. Speed of diagnosis with a consultant opinion was shown to be a major advantage compared with conventional outpatient referral. Hospital outpatient referral was avoided in 55/135 (41%) patients. In 20/83 (24 %) patients who were subsequently referred, the speciality to which the patient was referred was changed as a result of the MRI, ensuring more appropriate initial referral. Twenty-three of 54 (43%) general practitioners have said that they have changed their request pattern for plain radiographs now that they have direct access to MRI. We have shown MRI to be valuable to the general practitioner for patient management decisions and so we recommend that MRI should be available to general practitioners by direct access.

Pancreatic abnormalities and AIDS related sclerosing cholangitis.

OBJECTIVES: Biliary tract abnormalities are well recognised in AIDS, most frequently related to opportunistic infection with Cryptosporidium, Microsporidium, and cytomegalovirus. We noted a high frequency of pancreatic abnormalities associated with biliary tract disease. To define these further we reviewed the clinical and radiological features in these patients. METHODS: Notes and radiographs were available from two centres for 83 HIV positive patients who had undergone endoscopic retrograde cholangiopancreatography for the investigation of cholestatic liver function tests or abdominal pain. RESULTS: 56 patients had AIDS related sclerosing cholangitis (ARSC); 86% of these patients had epigastric or right upper quadrant pain and 52% had hepatomegaly. Of the patients with ARSC, 10 had papillary stenosis alone, 11 had intra- and extrahepatic sclerosing cholangitis alone, and 35 had a combination of the two. Ampullary biopsies performed in 24 patients confirmed an opportunistic infection in 16. In 15 patients, intraluminal polyps were noted on the cholangiogram. Pancreatograms were available in 34 of the 45 patients with papillary stenosis, in which 29 (81%) had associated pancreatic duct dilatation, often with associated features of chronic pancreatitis. In the remaining 27 patients, final diagnoses included drug induced liver disease, acalculous cholecystitis, gall bladder empyema, chronic B virus hepatitis, and alcoholic liver disease. CONCLUSION: Pancreatic abnormalities are commonly seen with ARSC and may be responsible for some of the pain not relieved by biliary sphincterotomy. The most frequent radiographic biliary abnormality is papillary stenosis combined with ductal sclerosis.

Antegrade catheterization of the brachial artery for embolizing a sarcoma of the forearm.

A case is described in which embolization of an alveolar soft part sarcoma, involving a forearm, was successfully achieved via cannulation of the brachial artery. The procedure was performed safely and more easily from this direct approach.

Sonographic prediction of a normal or abnormal ERCP in suspected AIDS related sclerosing cholangitis.

AIM: We have assessed the ability of ultrasound to predict an abnormal ERCP examination in patients with suspected AIDS related Sclerosing Cholangitis (ARSC). PATIENTS AND METHODS: The ultrasound (US) and ERCP findings of fifty patients with clinically suspected AIDS cholangiopathy were reviewed. The diagnosis was suspected due to right upper quadrant pain and cholestatic liver function tests. RESULTS: Of the 50 patients investigated the US findings were normal in 18 (36%). Seventeen of these patients subsequently had a normal ERCP. The other patient showed changes suggestive of mile ARSC. Thirty-two (64%) patients showed a variety of abnormalities on US. Of these, 22 had typical changes of ARSC on ERCP. The remaining 10 patients also had abnormal ERCP examinations. The final diagnosis in these 10 patients included pancreatitis (5), biliary calculi (2), AIDS related lymphoma (2) and acute cholecystitis with an empyema of the gallbladder (1). CONCLUSION: In this study, US is 98% accurate in the prediction of a normal or abnormal ERCP examination, with a sensitivity of 97% and a specificity of 100%. This data suggests that ERCP will produce little additional information in these patients if US of the bile ducts is normal.

Prenatal diagnosis of amniotic band syndrome in a methadone user: review of the literature and a case report.

We present a case and review of the literature of an amniotic band causing malformation in the distal forearm in a baby born to a methadone-dependent mother. This diagnosis was made prenatally at the routine 18-20-week gestation anomaly ultrasound scan. Histology of the amniotic band postpartum revealed hair shafts within its structure. This has not previously been documented, nor has an association of this syndrome with systematic abuse of methadone. The fact that this anomaly could be detected by prenatal ultrasound scanning is of value in the counselling of high-risk pregnancies such as this.

MR imaging features of an intracochlear acoustic schwannoma.

We present a very unusual case of an acoustic neuroma involving the left cochlea and internal auditory canal of a 24-year-old man. Clinical suspicion was aroused when the patient presented with a left total sensorineural hearing loss and continuing vertigo. The diagnosis was made pre-operatively with MRI after initial CT scanning was normal. The tumour was removed via a transotic approach. This case report demonstrates the MRI features of an intracochlear schwannoma and emphasizes the importance of MRI in patients with significant auditory and clinical abnormalities with normal CT scans of the relevant region.