The ultrasound compression sign to diagnose temporal giant cell arteritis shows an excellent interobserver agreement.

OBJECTIVES: To compare the diagnostic performance between a vascular specialist and a rheumatologist not familiar with vascular ultrasound when applying the compression sign for the diagnosis of temporal arteritis. METHODS: Sixty consecutive patients with suspicion of giant cell arteritis were examined by both examiners. Compression of the temporal artery on both sides (stem and both branches) was performed to define whether signs of vasculitis, no vasculitis or an indefinite result were present. Each examiner was blinded to the result of the other. RESULTS: In 59/60 patients, the examiners found an identical result. The interobserver agreement (Krippendorf alpha) was 0.92. CONCLUSIONS: The new compression sign for the diagnosis of temporal arteritis is a simple and robust sonographic marker with an excellent interobserver agreement.

Temporal artery compression sign--a novel ultrasound finding for the diagnosis of giant cell arteritis.

PURPOSE: In patients with suspected giant cell arteritis (GCA), a search for the perivascular halo sign, a sophisticated color duplex ultrasound (CDU) finding, at experienced centers reliably identifies inflamed temporal arteries (TA). We tested whether TA compression in patients with GCA, a simple, largely operator-independent maneuver, elicits contrasting echogenicity between the diseased artery wall and the surrounding tissue (compression sign). MATERIALS AND METHODS: 80 individuals with suspected GCA were prospectively enrolled in this single-center study. In all study participants, bilateral ultrasound examination of the TA established the presence/absence of the halo and compression sign. A positive compression sign was defined as visibility of the TA upon transducer-imposed compression of the artery. Based on ACR criteria, a team of specialized physicians independently grouped patients as GCA versus non-GCA. RESULTS: 43/80 study participants were grouped as GCA. Both the halo sign and the compression sign were positive in 34/43 patients in the GCA group, and negative in all 37/37 of the non-GCA group, resulting in a sensitivity of 79 % and a specificity of 100 % for both the halo and the compression sign. CONCLUSION: In this cohort of individuals with suspected GCA, the halo sign and the compression sign were equal in their diagnostic performance. The simplicity of the compression sign suggests a level of reliability warranting further evaluation.

Use of biomarkers or echocardiography in pulmonary embolism: the Swiss Venous Thromboembolism Registry.

BACKGROUND: Cardiac biomarkers and echocardiography for assessing right ventricular function are recommended to risk stratify patients with acute non-massive pulmonary embolism (PE), but it remains unclear if these tests are performed systematically in daily practice. DESIGN AND METHODS: Overall, 587 patients with acute non-massive PE from 18 hospitals were enrolled in the Swiss Venous Thromboembolism Registry (SWIVTER): 178 (30%) neither had a biomarker test nor an echocardiographic evaluation, 196 (34%) had a biomarker test only, 47 (8%) had an echocardiogram only and 166 (28%) had both tests. RESULTS: Among the 409 (70%) patients with biomarkers or echocardiography, 210 (51%) had at least one positive test and 67 (16%) had positive biomarkers and right ventricular dysfunction. The ICU admission rates were 5.1% without vs. 5.6% with testing (P = 0.78), and thrombolysis or embolectomy were performed in 2.8% vs. 4.9%, respectively (P = 0.25). In multivariate analysis, syncope [odds ratio (OR): 3.49, 95% confidence interval (CI): 1.20-10.15; P = 0.022], tachycardia (OR: 2.31, 95% CI: 1.37-3.91; P = 0.002) and increasing age (OR: 1.02; 95% CI: 1.01-1.04; P < 0.001) were associated with testing of cardiac risk; outpatient status at the time of PE diagnosis (OR: 2.24, 95% CI: 1.49-3.36; P < 0.001), cancer (OR: 1.81, 95% CI: 1.17-2.79; P = 0.008) and provoked PE (OR: 1.58, 95% CI: 1.05-2.40; P = 0.029) were associated with its absence. CONCLUSION: Although elderly patients and those with clinically severe PE were more likely to receive a biomarker test or an echocardiogram, these tools were used in only two-thirds of the patients with acute non-massive PE and rarely in combination.

Cardiac troponin testing and the simplified Pulmonary Embolism Severity Index. The SWIss Venous ThromboEmbolism Registry (SWIVTER).

A low simplified Pulmonary Embolism Severity Index (sPESI), defined as age ≤80 years and absence of systemic hypotension, tachycardia, hypoxia, cancer, heart failure, and lung disease, identifies low-risk patients with acute pulmonary embolism (PE). It is unknown whether cardiac troponin testing improves the prediction of clinical outcomes if the sPESI is not low. In the prospective Swiss Venous Thromboembolism Registry, 369 patients with acute PE and a troponin test (conventional troponin T or I, highly sensitive troponin T) were enrolled from 18 hospitals. A positive test result was defined as a troponin level above the manufacturers assay threshold. Among the 106 (29%) patients with low sPESI, the rate of mortality or PE recurrence at 30 days was 1.0%. Among the 263 (71%) patients with high sPESI, 177 (67%) were troponin-negative and 86 (33%) troponin-positive; the rate of mortality or PE recurrence at 30 days was 4.6% vs. 12.8% (p=0.015), respectively. Overall, risk assessment with a troponin test (hazard ratio [HR] 3.39, 95% confidence interval [CI] 1.38-8.37; p=0.008) maintained its prognostic value for mortality or PE recurrence when adjusted for sPESI (HR 5.80, 95%CI 0.76-44.10; p=0.09). The combination of sPESI with a troponin test resulted in a greater area under the receiver-operating characteristic curve (HR 0.72, 95% CI 0.63-0.81) than sPESI alone (HR 0.63, 95% CI 0.57-0.68) (p=0.023). In conclusion, although cardiac troponin testing may not be required in patients with a low sPESI, it adds prognostic value for early death and recurrence for patients with a high sPESI.

Long-term anticoagulation treatment for acute venous thromboembolism in patients with and without cancer. The SWIss Venous ThromboEmbolism Registry (SWIVTER) II.

In patients with acute cancer-associated thrombosis, current consensus guidelines recommend anticoagulation therapy for an indefinite duration or until the cancer is resolved. Among 1,247 patients with acute venous thromboembolism (VTE) enrolled in the prospective Swiss Venous Thromboembolism Registry (SWIVTER) II from 18 hospitals, 315 (25%) had cancer of whom 179 (57%) had metastatic disease, 159 (50%) ongoing or recent chemotherapy, 83 (26%) prior cancer surgery, and 63 (20%) recurrent VTE. Long-term anticoagulation treatment for >12 months was more often planned in patients with versus without cancer (47% vs. 19%; p<0.001), with recurrent cancer-associated versus first cancer-associated VTE (70% vs. 41%; p<0.001), and with metastatic versus non-metastatic cancer (59% vs. 31%; p<0.001). In patients with cancer, recurrent VTE (OR 3.46; 95%CI 1.83-6.53), metastatic disease (OR 3.04; 95%CI 1.86-4.97), and the absence of an acute infection (OR 3.55; 95%CI 1.65-7.65) were independently associated with the intention to maintain anticoagulation for >12 months. In conclusion, long-term anticoagulation treatment for more than 12 months was planned in less than half of the cancer patients with acute VTE. The low rates of long-term anticoagulation in cancer patients with a first episode of VTE and in patients with non-metastatic cancer require particular attention.

["Arteriosclerotic" aneurysm of the abdominal aorta]. / "Arteriosklerotisches" Aneurysma der Aorta abdominalis.

We present a patient with an aortic aneurysm and the epidemiology, etiology, screening, symptoms and therapeutic options of abdominal aortic aneurysms are discussed. A widening of the abdominal aorta >3 cm is termed aortic aneurysm. As patients with aortic aneurysm are mostly oligosymptomatic until rupture occurs and an estimated 30,000 patients annually die from ruptured aortic aneurysm in the US a screening of the population at greatest risk (smokers, familial predisposition) is recommended. Screening is best done by ultrasound. Noninvasive therapy is limited to antiplatelet therapy and optimal adjustment of risk factors. For definitive treatment endovascular aortic repair (EVAR) is considered an established alternative to open surgery with lower 30 days mortality but higher reintervention rate.

[Check-up, what else?]. / Check-up, was sonst?

Evidence-based check-up does not only include medical history and physical examination but consultation with regard to recommended vaccinations, screening for cancer and cardiovascular risk factors. Patients with PAD are at high risk for cardiovascular events but frequently claudication is not mentioned during anamnesis, thus specific attention to exercise-dependent leg discomfort is necessary. Recognition of PAD related symptoms is important because it may implicate secondary cardiovascular prevention and specific therapeutic options including walking exercise and endovascular revascularisation exist.

["Good Morning, Doctor, I'm Flying to Australia Next Week!"]. / "Herr Doktor, ich fliege nächste Woche nach Australien!"

Travel-related venous thromboembolism (VTE) is probably less frequent than previously suspected and becomes relevant when a flight lasts eight hours or more. Usually, general measures such as avoiding constrictive clothing or dehydration and doing gymnastics and walking around in the cabin are sufficient for preventing VTE. Compression stockings can be recommended when risk factors for VTE are present. Low molecular weight heparins in prophylactic dosage should be considered after previous VTE.

Giant arteriovenous fistula after implantation of a percutaneous left ventricular assist device.

INTRODUCTION: Percutaneous left ventricular assist devices are an important tool in the management of patients with severe cardiogenic shock. Limited experiences concerning vascular complications after long term implantation of these devices exist. We report on a large arteriovenous fistula after placement of a left ventricular assist device, which has not been described in the literature. The arteriovenous fistula was of clinical relevance because it represented a supplementary cardiac burden in a patient with impaired left ventricular function after a severe myocardial infarction.

Selective loss of extracellular matrix proteins is linked to biophysical properties of varicose veins assessed by ultrasonography.

BACKGROUND: Dilatation and enhanced distensibility are specific biophysical properties of varicose veins. Both can be assessed by ultrasonography. The aim of this study was to analyse correlations between the vein wall protein content and these two biophysical properties of varicose veins. METHODS: Twenty-seven patients having surgery for varicose veins and six control patients with normal veins undergoing arterial bypass surgery were examined clinically and with ultrasonography the day before surgery. Fifty-two varicose and six control vein rings were harvested and analysed histopathologically and morphometrically; vascular tissue microarrays incorporated 116 vein wall sectors. RESULTS: Elastin loss in the adventitia (P = 0.010) and reduction of type III collagen in the intima and media (P = 0.004) were observed in varicose veins. Elastin loss correlated negatively with vein diameter at rest (P = 0.005), whereas loss of type III collagen in the intima correlated negatively with the increase in vein diameter at the Valsalva manoeuvre (P < 0.001). CONCLUSION: Loss of elastin and type III collagen occurs in varicose veins and can be assessed with ultrasonography in vivo by measuring vein diameter and distensibility.