Computed tomography for evaluation of abdominal wall hernias-what is the value of the Valsalva maneuver?

PURPOSE: To investigate the differences in the visibility and size of abdominal wall hernias in computed tomography (CT) with and without Valsalva maneuver. METHODS: This single-center retrospective study included consecutive patients who underwent abdominal CTs with Valsalva maneuver between January 2018 and January 2022. Inclusion criteria was availability of an additional non-Valsalva CT within 6 months. A combined reference standard including clinical and surgical findings was used. Two independent, blinded radiologists measured the hernia sac size and rated hernia visibility on CTs with and without Valsalva. Differences were tested with a Wilcoxon signed rank test and McNemar's test. RESULTS: The final population included 95 patients (16 women; mean age 46 ± 11.6 years) with 205 hernias. Median hernia sac size on Valsalva CT was 31 mm compared with 24 mm on non-Valsalva CT (p < 0.001). In 73 and 82% of cases, the hernias were better visible on CT with Valsalva as compared to that without. 14 and 17% of hernias were only visible on the Valsalva CT. Hernia visibility on non-Valsalva CT varied according to subtype, with only 0 and 3% of umbilical hernias not being visible compared with 43% of femoral hernias. CONCLUSIONS: Abdominal wall hernias are larger and better visible on Valsalva CT compared with non-Valsalva CT in a significant proportion of patients and some hernias are only visible on the Valsalva CT. Therefore, this method should be preferred for the evaluation of abdominal wall hernias.

Diagnostic performance of CT with Valsalva maneuver for the diagnosis and characterization of inguinal hernias.

PURPOSE: Inguinal hernias are mainly diagnosed clinically, but imaging can aid in equivocal cases or for treatment planning. The purpose of this study was to evaluate the diagnostic performance of CT with Valsalva maneuver for the diagnosis and characterization of inguinal hernias. METHODS: This single-center retrospective study reviewed all consecutive Valsalva-CT studies between 2018 and 2019. A composite clinical reference standard including surgery was used. Three blinded, independent readers (readers 1-3) reviewed the CT images and scored the presence and type of inguinal hernia. A fourth reader measured hernia size. Interreader agreement was quantified with Krippendorff's α coefficients. Sensitivity, specificity, and accuracy of Valsalva-CT for the detection of inguinal hernias was computed for each reader. RESULTS: The final study population included 351 patients (99 women) with median age 52.2 years (interquartile range (IQR), 47.2, 68.9). A total of 381 inguinal hernias were present in 221 patients. Sensitivity, specificity, and accuracy were 85.8%, 98.1%, and 91.5% for reader 1, 72.7%, 92.5%, and 81.8% for reader 2, and 68.2%, 96.3%, and 81.1% for reader 3. Hernia neck size was significantly larger in cases correctly detected by all three readers (19.0 mm, IQR 13, 25), compared to those missed by all readers (7.0 mm, IQR, 5, 9; p < 0.001). Interreader agreement was substantial (α = 0.723) for the diagnosis of hernia and moderate (α = 0.522) for the type of hernia. CONCLUSION: Valsalva-CT shows very high specificity and high accuracy for the diagnosis of inguinal hernia. Sensitivity is only moderate which is associated with missed smaller hernias.

Reduced and standard field-of-view diffusion weighted imaging in patients with rectal cancer at 3 T-Comparison of image quality and apparent diffusion coefficient measurements.

PURPOSE: To compare a zoomed EPI-DWI (z-EPI) with a standard EPI-DWI (s-EPI) in the primary diagnostics of rectal cancer and assess its potential of reduced image artifacts. METHOD: 22 therapy-naïve patients with rectal cancer underwent rectal MRI at a 3 T-system. The protocols consisted of a z-EPI DWI and s-EPI DWI sequence. Images were assessed by two independent and experienced readers regarding overall image quality and artifacts on a 5-point Likert scale, as well as overall sequence preference. In a lesion-based analysis, tumor and lymph node detection were rated on a 4-point Likert scale. Apparent diffusion coefficient (ADC) measurements were performed. RESULTS: Overall Image quality score for z-EPI and s-EPI showed no statistically significant differences (p = 0.80/0.54, reader 1/2) with a median score of 4 ("good" image quality) for both sequences. The image quality preference rank for z-EPI and s-EPI was given the category 'no preference' in 64 % (reader 1) and 50 % (reader 2). Most artifact-related scores (susceptibility, motion and distortion) did not show reproducible significant differences between z-EPI and s-EPI. The two sequences exhibited comparable, mostly good and excellent quality scores for tumor and lymph node detection (p = 0.19-0.99). ADC values were significantly lower for z-EPI than for s-EPI (p = 0.001/0.002, reader 1/2) with good agreement of ADC measurements between both readers. CONCLUSION: Our data showed comparable image quality and lesion detection for the z-EPI and the s-EPI sequence in MRI of rectal cancer, whereas the mean ADC of the tumor was significantly lower in z-EPI compared to s-EPI.

Thyroid cancer yield in patients with Graves' disease.

The management of thyroid nodules in patients with Graves' disease remains an issue both of concern and controversy for those who care for these patients. At one time, thyroid cancer in patients with thyrotoxicosis was considered to be extremely rare, but this perception has proven to be incorrect. Several studies have demonstrated both an increased incidence of nodules and of thyroid cancer in patients with Graves' disease, with cancer rates varying from as low as 1% to as high as 9% of cases. These divergent estimates of malignancy rates in Graves' disease have predictably led to variability in management recommendations. Considerable controversy also exists as to whether or not thyroid cancer behaves more aggressively in patients with Graves' disease. Anecdotal experience and a number of studies have suggested an increased aggressiveness of papillary and follicular thyroid cancer in patients with Graves' disease, but these findings are not universal. Underlying both issues of the incidence and aggressiveness of thyroid cancer is the role of thyrotropin (thyroid stimulating hormone, TSH) in the development and stimulation of thyroid cancer. The association between TSH and thyroid cancer has long been known. TSH has a central role in thyroid growth and normal functioning and appears to play a similar part in the growth and development of thyroid cancer. The close relationship of TSH to the stimulating TSH-R antibodies (TSH-R AB) seen in Graves' disease has led to the perception that thyroid cancer occurring in the setting of Graves' disease may become more aggressive as a result of stimulation by these autoantibodies. This article will summarize the existing literature pertaining to thyroid cancer in Graves' disease, and suggest an evidence-based approach to the management of these patients.

Epidemiology of drug exposure and adverse drug reactions in two swiss departments of internal medicine.

AIMS: To explore drug exposure, frequency of adverse drug reactions (ADRs), types of ADRs, predisposing risk factors and ADR-related excess hospital stay in medical inpatients. METHODS: Structured data regarding patient characteristics, 'events' (symptoms, laboratory results), diagnoses (ICD10) and drug therapy were collected using a computer-supported data entry system and an interface for data retrieval from electronic patient records. ADR data were collected by 'event monitoring' to minimize possible bias by the drug monitor. The causality of each event was assessed in relation to disease(s) and drug therapy. RESULTS: The analysis included 4331 (100%) hospitalizations. The median observation period was 8 days. The median number of different drugs administered per patient and day was 6 and varied between 4 (Q1 ) and 9 (Q3 ) different drugs in 50% of all hospital days. In 41% of all hospitalizations at least one disease-unrelated event could be possibly attributed to drug therapy. Clinically relevant ADRs occurred in 11% of all hospitalizations. In 3.3% of all hospitalizations ADRs were the cause of hospital admission. The incidence of possibly ADR-related deaths was 1.4. Factors predisposing for clinically relevant ADRs were female gender and polypharmacy. ADR-related excess hospital stay accounted for 8. 6% of hospital days. CONCLUSIONS: These data demonstrate the feasibility of the developed 'event monitoring' system for quantitative analysis of ADRs in medical inpatients. With increasing numbers of recorded patients the pharmacoepidemiological database provides a valuable tool to study specific questions regarding drug efficacy and safety in hospitalized patients.

Cardiovascular responses to light isometric and aerobic exercise in 21- and 59-year-old males.

The effects of aging on the cardiovascular response to continuous light isometric and aerobic exercise remains to be determined. Thus, the purpose of this study was to compare the cardiovascular response of young and older males during light handgrip and cycle ergometry exercise. Blood pressure, heart rate, rate pressure product, as well as pre-ejection period (derived from impedance cardiography) were obtained for 15 young [mean (SE) age: 21 (0.7) years] and 15 older males [59 (0.8) years] during and after light handgrip exercise and cycle ergometry. The parasympathetic influence on the heart was also assessed through a time-series analysis of heart period variability (HPVts). Both during and when recovering from the handgrip exercise and cycle ergometry, the older subjects exhibited a significantly higher absolute systolic and diastolic blood pressure, and rate pressure product, and a lower HRVts than the young subjects. Relative to baseline, the change in pre-ejection period was lower for the young subjects during the handgrip and cycle ergometry, tasks. These results indicate that although the sympathetic influence on both the myocardium and the vasculature was less pronounced in the older males, the aging cardiovasculature was under greater hemodynamic stress both during rest and during exposure to light isometric and aerobic challenge.

[Ulcer + ulcer]. / Ulcus + Ulcus.

We report on an elderly woman suffering from an acutely bleeding duodenal ulcer. Apart from old age and a history of gastrointestinal ulcer there were no risk factors detectable. However, clinical examination revealed that the patient had put a diclofenac hydroxyethylpyrrolidine plaster, which had been prescribed for lower back pain, inadvertently on a large ulcus cruris. The diclofenac serum concentration was 80 mu/l corresponding to a therapeutic serum level. This case demonstrates that false application of new pharmaceutical formulation may lead to inadvertent side-effects.

Cardiovascular response of young and older males to mental challenge.

Blood pressure, heart rate, rate pressure product, heart rate variability, stroke volume, cardiac output, peripheral resistance, and cardiac contractility derived from impedance cardiography were obtained from 15 young and 15 old males during and after the Stroop task. The old group demonstrated significantly higher absolute heart rate, systolic and mean arterial pressure, peripheral resistance, and rate pressure product, and lower cardiac output, stroke volume, and heart rate variability both during and recovering from Stroop. The young group showed significantly greater relative heart rate increase at the start of Stroop, higher relative levels of contractility during and recovering, and greater relative levels of peripheral resistance during and recovering from Stroop. Overall, old compared to young subjects possessed greater absolute but smaller relative cardiovascular responses during and recovering from Stroop. These results suggest that although the aging cardiovasculature may be less reactive, it may be under greater hemodynamic stress both during rest and mental challenge.

Urinary symptoms, sexual intercourse and significant bacteriuria in male patients attending STD clinics.

OBJECTIVE: To assess the relationship between sexual behaviour, urinary symptoms, urinalysis and bacteriuria in men attending STD clinics. DESIGN: A prospective study recording sexual behaviour, urinary symptoms and collecting mid-stream urine specimens. SETTING: Two West Midlands STD clinics, UK. SUBJECTS: 1086 new male patients. RESULTS: 704 patients had had sexual intercourse (SI) within 14 days of testing, 424 had urinary symptoms and 122 had pyuria. All 13 patients with positive culture had SI < 14 days before testing, urinary symptoms and pyuria. No association was found between sexual orientation, type of SI, number of sexual partners, condom usage and bacteriuria. CONCLUSION: Bacteriuria does not behave as an STD but SI may be a factor in acquiring bacteriuria. Dysuria with or without urethral discharge is the most predictive symptom of bacteriuria. Pyuria has a high sensitivity for predicting bacteriuria among males.

Comparison of shoulder injury in collegiate- and master's-level swimmers.

The need to investigate shoulder injury in swimmers other than the young and elite is evident, as all ages and levels are represented in the 100 million Americans who classify themselves as swimmers. To investigate the differences between young, highly competitive collegiate swimmers and older, less elite swimmers, a survey questionnaire was distributed to 100 collegiate and 100 master's swim teams. Questions regarding swimming routines, performance standards, and several possible predisposing factors associated with "swimmer's shoulder," as implicated in the literature, were investigated. As expected, the results revealed that the collegiate group swam the higher yardage, with considerably faster times in both the 50- and the 1,000-yd freestyle, and more than double the number of workouts per week. However, the collegiate and master's group reported similar percentages, 47 and 48%, respectively, experiencing shoulder pain lasting 3 weeks or more, despite the lesser distances and intensities associated with the latter group. Chi-square analysis revealed no association between shoulder pain and perceived level of flexibility, hand paddle usage, or breathing side for either group. However, over 50% of the swimmers with shoulder pain in both groups perceived that increased intensities and/or distance provoked shoulder pain, indicating that fatigue may be the issue to avoid and on which to focus. Strengthening the muscles of the shoulder, specifically those shown to have a propensity to fatigue, provides a strong defense against injury, as fatigue of the shoulder muscles may be the initial antecedent to swimmer's shoulder. These results give the swimmer, coach, and medical practitioner feedback to consider for a swimmer of any age or level.

Evaluation of the significance of Mycoplasma hominis and Ureaplasma urealyticum in female genital tract infection--a retrospective case note study.

Routine screening for sexually transmitted diseases in new patients attending the Genitourinary Clinic in Stoke-on-Trent includes a culture for Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU). A retrospective study was carried out on 400 female patients to ascertain whether there were any significant differences between the group positive for MH and UU and the negative control group. The positive group were found to be younger on average, but to have similar sexual histories to the negative control group. An association was found between the presence of genital mycoplasmas and Gardnerella vaginalis. An odourous vaginal discharge was more common in the positive group. Erythromycin was ineffective in eradicating the organisms in 62.5% of patients with MH, and 70% of those with UU. Continuing work is required to identify those women in whom the presence of MH or UU could have pathogenic effects. Treatment regimens for this group of women need to be carefully reassessed, in the light of increasing antibiotic resistance.

Humoral antibody response in patients with herpes genitalis: analysis of factors influencing the pattern of disease.

An investigation was made of the diagnosis of herpes genitalis, the prediction of virus type and the likelihood and frequency of clinical and asymptomatic recurrences in relation to a history of herpes labialis, the virus type isolated from genital lesions and the humoral antibody status against HSV 1 and 2. Diagnosis of herpes genitalis correlated negatively with mean neutralising antibody levels against HSV type 1 and type 2 but positively with the variance of neutralising antibody levels in sequential sera. Virus type in patients with initial episodes was best predicted by initial and mean type 2 antibody levels and in patients with recurrent disease by the ratio of type 1 to type 2 antibody by radioimmune assay. The likelihood and frequency of clinical and asymptomatic recurrences was higher in patients where HSV type 2 was isolated. The likelihood of recurrences in patients with initial episodes was related to high initial neutralising antibody levels against type 2 and to low primary antibody responses against type 1 while frequency of recurrences was best related to low initial antibody levels against type 1 in combination with high levels against type 2. These data will be useful in diagnosis of herpes genitalis. Prediction of the likelihood and frequency of clinical and asymptomatic recurrences will facilitate advice concerning prognosis and risk factors to patients and their consorts.

Control of herpes simplex virus infections of the genital tract by vaccination.

The apparent increasing incidence of herpes simplex virus infections of the genital tract has focused attention on the efficacy of vaccination in preventing infection or modifying established disease. Results of an 'open trial' using a DNA-free inactivated virus subunit vaccine have shown that vaccination of subjects at risk of contracting infection from their sexual partner reduced the transmission rate from 34% in unvaccinated controls to 0.5%. In a separate study, vaccination of patients who had experienced their first overt attack of herpes genitalis (the initial clinical episode) had significantly fewer recurrences over the follow-up period of 12 months than the unvaccinated control group. The results, we feel, justify a placebo controlled trial.

Augmentation of the neutralisation test for type 1 HSV: evidence of high representation of neutralising antibody in the adult community.

Optimal neutralisation of type 1 herpes simplex virus was obtained by reacting undiluted human serum with virus for 4 h at 37 degrees C, followed by addition of antihuman globulin for 20 min; under these conditions it was possible to detect neutralising antibody activity in 40 of 45 human sera (88%) previously adjudged to be negative by conventional neutralisation tests.

Efficacy of vaccine Ac NFU1 (S-) MRC 5 given after an initial clinical episode in the prevention of herpes genitalis.

A subunit antigenoid vaccine, Ac NFU1 (S-) MRC 5, was used in patients who had had a clinical episode of herpes genitalis. The rate of recurrence was compared with that in unvaccinated patients to determine the efficacy of vaccination in preventing recurrence and spread of the virus in the community. Seven of 22 (31%) vaccinated patients had eight recurrences after the initial clinical episode; in contrast there were 51 recurrences in 17 of 20 (85%) unvaccinated patients. Although further studies are needed, the results indicate that the vaccine may prevent recurrent episodes of herpes genitalis and thereby reduce the dissemination of this virus in the population.