Primary hyperparathyroidism: can ultrasonography be the only preoperative diagnostic procedure?

PURPOSE: The purpose of our study was to assess the role of ultrasonography (US) before surgical treatment of primary hyperparathyroidism. MATERIALS AND METHODS: We retrospectively evaluated 77 patients (60 women, 17 men; mean age 59 years) with primary hyperparathyroidism who underwent parathyroid US prior to surgery. Sixty-five of 77 (84%) patients had undergone (99m)Tc- sestamibi (MIBI) scintigraphy. The results were correlated with the surgical and histopathological findings. RESULTS: Surgery revealed 85 abnormal parathyroid glands in 77 patients (70 adenomas, 15 hyperplasias). The locations of the parathyroid glands were typical cervical (n=77), thyrothymic ligament (n=3), carotid sheath (n=2), and mediastinum (n=3). In two patients, intrathyroid microadenoma was diagnosed by histopathology. Seventy-four enlarged glands in 64 patients were correctly identified at US. Per-patient sensitivity and positive predictive values, respectively, were 84% (64/76) and 99% (64/65) for US, 68% (44/65) and 100% (44/44) for scintigraphy and 91% (59/65) and 98% (59/60) for both techniques combined. We weighed 63 out of 85 glands, obtaining a value of 1,004+/-1,564 mg; 460 mg (mean+/-standard deviation; median). CONCLUSIONS: Preoperative detection and localisation of enlarged parathyroid glands can be based on US, an inexpensive and widely available method, limiting the use of scintigraphy to those cases with negative and/or doubtful findings on US.

Risk factors for treatment failure in patients with severe acute cardiogenic pulmonary oedema.

Intubation is necessary in 7 to 20% of patients with severe acute cardiogenic pulmonary oedema despite optimal treatment. This study evaluated the usefulness of parameters largely available in clinical practice to predict the need for intubation in a population of acute cardiogenic pulmonary oedema patients treated with medical therapy and continuous positive airway pressure. The present retrospective cohort study involved 142 patients with severe acute cardiogenic pulmonary oedema who were admitted to coronary care or the intensive care unit of a university hospital and were treated by an in-hospital protocol. Physiological measurements and blood gas samples were evaluated at 'baseline' (just after admission), 'early' (one to three hours after beginning treatment) and 'late' (eight to 10 hours after beginning treatment). Twenty-two patients (15.5%) required intubation. A systolic blood pressure at admission lower than 140 mmHg was significantly associated with a higher risk for intubation, while hypercapnic patients or those with a reduced left ventricular ejection fraction at admission did not show a worse prognosis. A simple score based on largely available parameters (1 point for each: age >78 years, systolic blood pressure <140 mmHg at admission, arterial blood gas acidosis and heart rate >95 bpm at early time) is proposed. The rate of intubation according to this score ranged from 0% (score of 0) to 90% (score of 3). Our study found that simple parameters available in clinical practice are significantly associated with the need for intubation in acute cardiogenic pulmonary oedema patients treated with continuous positive airway pressure and medical therapy. A simple score to evaluate the need for endotracheal intubation is proposed.

Prognostic value of 64-slice coronary angiography in diabetes mellitus patients with known or suspected coronary artery disease compared with a nondiabetic population.

PURPOSE: This study aimed to determine the prognostic value of coronary angiography with multislice computed tomography (MSCT) in a population of diabetic subjects with known or suspected ischaemic heart disease compared with a nondiabetic control population. MATERIALS AND METHODS: Forty-nine patients with type 2 diabetes mellitus (DM) [group 1; mean age 67.7+/-8.8 years; 32 men; mean body mass index (BMI) 28+/-3.9] and 49 patients without DM (group 2, with similar demographic and clinical characteristics) were studied with MSCT coronary angiography to exclude the presence of ischaemic coronary artery disease (CAD). Each group comprised 26 patients (53%) with no history of ischaemic coronary disease and 23 patients (47%) with a history of myocardial infarction and/or myocardial revascularisation. Clinical follow-up was performed by analysing correlations between the rate of cumulative cardiac events (cardiac death, nonfatal myocardial infarction, unstable angina, and myocardial revascularisation), the severity of CAD identified on MSCT, and the presence of DM as a cardiovascular risk factor. RESULTS: At mean follow-up of 20 months, univariate analysis of survival showed significant differences between the two groups (group 1 vs. group 2, p=0.046). Moreover, the cumulative cardiac event rate correlated significantly with the presence of significant CAD (>50% stenosis) in both groups (group 1: p=0.003; group 2: p=0.0004). CONCLUSIONS: Event-free survival is significantly lower in the diabetic population compared with the normal control population (p=0.046) and is closely correlated with the presence of significant CAD. MSCT is an effective method for stratifying such risk and, together with high diagnostic accuracy, provides additional prognostic value.

MDCT of 220 consecutive patients with suspected acute pulmonary embolism: incidence of pulmonary embolism and of other acute or non-acute thoracic findings.

PURPOSE: This study was undertaken to evaluate the incidence of pulmonary embolism (PE) and other clinically relevant thoracic findings discovered on contrast-enhanced multidetector computed tomography (MDCT) examination in patients with a suspicion of acute PE. MATERIALS AND METHODS: We retrospectively reviewed 220 reports of 40-row MDCT exams in consecutive patients (101 men, 119 women; mean age 55 years+/-18) suspected for acute PE. Presenting symptoms and risk factors were recorded. Image quality and incidence of PE and other clinically relevant thoracic findings were evaluated. RESULTS: MDCT were diagnostic in 96.8% of patients. Nineteen patients (8.6%) were positive for PE. Signs and symptoms were present in 82.7% (182) and risk factors in 38.2% (84) of the population. Clinically relevant thoracic findings were detected in 45.9% (101) of the patients. Ten patients had PE and other thoracic findings. Half of the patients (110) had neither PE nor other clinically relevant thoracic findings. CONCLUSIONS: Chest MDCT, with an excellent overall image quality, provided an explanation for the clinical presentation in about 50% of emergency department patients studied and was useful in detecting PE and other thoracic diseases with symptoms mimicking PE. However, half of the exams were negative.

Prevalence and characteristics of coronary artery disease in a population with suspected ischemic heart disease using CT coronary angiography: correlations with cardiovascular risk factors and clinical presentation.

PURPOSE: This study was undertaken to describe the correlation between the distribution of coronary artery disease (CAD) in a symptomatic population with suspected ischaemic heart disease, cardiovascular risk factors (RF) and clinical presentation. MATERIALS AND METHODS: we studied 163 patients (mean age 65.5 years; 101 men and 62 women) referred for multidetector computed tomography coronary angiography (MDCT-CA) to rule out CAD. The patients had no prior history of revascularisation or myocardial infarction. We analysed how the characteristics of CAD (severity and type of plaque) can change with the increase in RF and how they are related to different clinical presentations. RESULTS: patients were divided into three groups according to the number of RF: zero or one, two or three, and four or more. The percentage of coronary arteries with no plaque, nonsignificant disease and significant disease was 55%, 41% and 4%, respectively, in patients with zero or one RF; 27%, 51% and 22%, respectively, in patients with two or three RF; and 19%, 38% and 44%, respectively, in patients with four or more RF. Plaque in patients with nonsignificant disease was mixed in 65%, soft in 18% and calcified in 17%. The percentage of coronaries with no plaque in the three RF groups was 50%, 20% and 0% in patients with typical chest pain and 46%, 24% and 12% in those with atypical pain. The percentage of significant disease in patients with typical pain was 0%, 47% and 86% and in those with atypical pain 4%, 20% and 29%. CONCLUSIONS: MDCT plays an important role in the identification of CAD in patients with suspected ischaemic heart disease. Severity and type of disease is highly correlated with RF number and assumes different characteristics according to clinical presentation.

Multislice computed tomography coronary angiography: clinical applications.

Cardiac and coronary computed tomography (CT) is becoming increasingly common in clinical practice. Even if there is no well-established evidence, this diagnostic modality is so strong and effective and, in skilled hand, it can be readily used in clinical practice. After learning its potential and the technical limits, this tool could be used for risk stratification as well as for revascularization evaluation. In this review, we will describe the results of present literature, clinical applications at present considered suitable to CT technology (i.e. 64-slice and dual-source scanners) and future applications and innovations.