Cardiac imaging: 2022 update.

BACKGROUND: Cardiac imaging is a rapidly expanding and complex field with major recent advances in tissue characterisation and improvements in speed and radiation hygiene during angiography and isotope imaging. Cardiac imaging demand is dominated by the assessment of coronary artery disease (CAD) in Western societies and those with Western diets and lifestyles. OBJECTIVE: The aim of this article is to outline the various modalities available for assessment of cardiac disease. The reader will gain an understanding of the strengths and limitations of these modalities including echocardiography, nuclear imaging and computed tomography. There is also some discussion of current and future technologic advances. DISCUSSION: CAD remains one of the major causes of morbidity and mortality in Australia, and imaging is directed towards diagnosis, prognosis and treatment. In all but remote areas there is now access to either multiphase computed tomography, echocardiography and/or nuclear imaging. Along with the chest X-ray, these modalities provide the major diagnostic tools.

The case for a national service for primary immune deficiency disorders in New Zealand.

Primary immune deficiency disorders (PIDs) are rare conditions for which effective treatment is available. It is critical these patients are identified at an early stage to prevent unnecessary morbidity and mortality. Treatment of these disorders is expensive and expert evaluation and ongoing management by a clinical immunologist is essential. Until recently there has been a major shortage of clinical immunologists in New Zealand. While the numbers of trained immunologists have increased in recent years, most are located in Auckland. The majority of symptomatic PID patients require life-long immunoglobulin replacement. Currently there is a shortage of subcutaneous and intravenous immunoglobulin (SCIG/IVIG) in New Zealand. A recent audit by the New Zealand Blood Service (NZBS) showed that compliance with indications for SCIG/IVIG treatment was poor in District Health Boards (DHBs) without an immunology service. The NZBS audit has shown that approximately 20% of annual prescriptions for SCIG/IVIG, costing $6M, do not comply with UK or Australian guidelines. Inappropriate use may have contributed to the present shortage of SCIG/IVIG necessitating importation of the product. This is likely to have resulted in a major unnecessary financial burden to each DHB. Here we present the case for a national service responsible for the tertiary care of PID patients and oversight for immunoglobulin use for primary and non-haematological secondary immunodeficiencies. We propose that other PIDs, including hereditary angioedema, are integrated into a national PID service. Ancillary services, including the customised genetic testing service, and research are also an essential component of an integrated national PID service and are described in this review. As we show here, a hub-and-spoke model for a national service for PIDs would result in major cost savings, as well as improved patient care. It would also allow seamless transition from paediatric to adult services.

Application of diagnostic and treatment criteria for common variable immunodeficiency disorder.

Common variable immunodeficiency disorder (CVID) is the most frequent symptomatic primary immune deficiency disorder in adults. It probably comprises a spectrum of polygenic disorders, with hypogammaglobulinemia being the overarching feature. While the majority of patients with CVID can be identified with relative ease, a significant proportion can present with minimal symptoms in spite of profound laboratory abnormalities. Here we discuss three patients who were presented to the Auckland Hospital immunoglobulin treatment committee to determine if they qualified for immunoglobulin replacement. Two were asymptomatic with profound laboratory abnormalities while the third patient was severely ill with extensive bronchiectasis. The third patient had less severe laboratory abnormalities compared with the two asymptomatic patients. We have applied four sets of published diagnostic and treatment criteria to these patients to compare their clinical utility. We have chosen these patients from the broad phenotypic spectrum of CVID, as this often illustrates differences in diagnostic and treatment criteria.

Intra-operative fracture in posterior-stabilised total knee arthroplasty.

PURPOSE: To review records of 17 patients who sustained a tibial or femoral intra-operative fracture during primary cemented total knee arthroplasty (TKA) METHODS. Records of 1346 primary cemented TKAs using the NexGen LPS fluted tibial component performed by a single surgeon were reviewed. 12 tibial and 5 femoral intra-operative fractures occurred in 5 men and 12 women aged 54 to 83 (mean, 71.6) years. No patient had any condition that may predispose to osteoporosis. RESULTS: All 12 tibial fractures occurred during hammering down of the final tibial component. They were vertical crack fractures of the anterior cortex of the medial tibial plateau with minimal displacement and did not extend beyond the tip of the tibial stem. Four of the 5 femoral fractures were avulsion fractures in the coronal plane of the medial femoral condyles and occurred during removal of the intercondylar notch. The remaining femoral fracture involved the medial cortex of the medial femoral condyle and occurred during removal of a large medial femoral condyle osteophyte. All fractures were immediately fixed with 3.5-mm partially threaded AO cancellous screws. All patients achieved bone union and good function. CONCLUSION: Intra-operative tibial fractures are more common than femoral fractures; fixation with multiple AO screws achieves good outcome.

Imaging for cardiac disease: a practical guide for general practitioners.

BACKGROUND: Cardiac disease is a major cause of morbidity and mortality in Australia. There are many differentials to the diagnosis of coronary artery disease (CAD). A wide range of radiological investigations are available to help diagnose cardiac conditions. OBJECTIVE: This article seeks to provide an up-to-date pathway to diagnose CAD using the least invasive and most widely available investigations. DISCUSSION: A significant number of patients presenting with chest pain have diagnostic features of CAD and these require little further study. The equivocal group will require risk stratification, generally through a stress-type examination such as nuclear myocardial perfusion study or stress echocardiography. After stratification, further triaging of those at low and intermediate risk will benefit from non-invasive computed tomography coronary angiography. This is a low-risk, high-specificity study performed as an outpatient procedure. The role of the triple rule out study is not yet established but may change the clinical approach in diagnosing the causes of chest pain in future. At this stage, MRI is not viable in terms of availability and duration of study.