Prevalence of pulmonary embolism among patients with recent onset of dyspnea on exertion. A cross-sectional study.

BACKGROUND: Exertional dyspnea is a frequently encountered complaint in clinical practice. However, the prevalence of pulmonary embolism (PE) among patients with dyspnea on exertion has not been reported. OBJECTIVE: The objective of this study was to assess the prevalence of objectively confirmed PE among consecutive patients visiting an emergency department because of recent onset of exertional dyspnea. METHODS: Patients aged ≤75 years with recent (<1 month) marked exertional dyspnea had a systematic workup for PE, irrespective of concomitant signs or symptoms of venous thromboembolism and alternative explanations for dyspnea. PE was excluded on the basis of a low pretest clinical probability and normal age-adjusted D-dimer. All other patients had computed tomography pulmonary angiography. An interim analysis after inclusion of 400 patients would stop recruitment if the 95% confidence interval (CI) of the PE prevalence had a lower limit exceeding 20%. RESULTS: The study was prematurely terminated after the inclusion of 417 patients. In 134 patients (32.1%), PE was excluded based on low clinical probability and normal D-dimer. PE was found in 134 (47.3%) of the remaining 283 patients, for an overall prevalence of 32.1% (95% CI, 27.8-36.8). PE was present in 40 of 204 (19.6%) patients without other findings suspicious for PE and in 94 of 213 patients (44.1%) with such findings. PE involved a main pulmonary artery in 37% and multiple lobes in 87% of the patients. CONCLUSION: The angiographic demonstration of PE is common in patients presenting with recent onset of marked exertional dyspnea, including 20% without other findings suggesting pulmonary embolism.

Minimally invasive management of rare giant Bochdalek hernia in adults.

Bochdaleck hernia (BH) is a congenital diaphragmatic hernia that presents after birth with respiratory symptoms and needs surgical treatment in the neonatal period. However, there are some rare cases of adult presentation, which require surgery to avoid complications. BHs can be treated through several approaches, including laparoscopy. Laparoscopic treatment of a giant BH was successfully attempted on a woman affected by multiple myeloma, with severe dyspnoea and dysphagia. Preoperative work-up included chest X ray, CT-scan and MRI. The whole stomach, duodenum, the small bowel, the right and transverse colon, most descending colon and the pancreas were herniated into the thorax. The herniated viscera were totally reduced into the abdominal cavity and the large defect of the left diaphragm repaired with a biosynthetic web scaffold especially designed for diaphragmatic reconstruction. Finally, to avoid a compartment syndrome in an abdomen with not enough room for the reduced viscera, an extended right colectomy with extracorporeal anastomosis was carried out through a mini-laparotomy. At seven-month follow-up, the patient is symptomless and control CT scan showed no hernia recurrence. Laparoscopic repair of large symptomatic adult BHs can be performed successfully with significant clinical improvement, even in difficult cases and fragile patients.

Interpretability of coronary CT angiography performed with a novel whole-heart coverage high-definition CT scanner in 300 consecutive patients with coronary artery bypass grafts.

AIMS: Coronary CT angiography (CCTA) is an accurate non-invasive tool for the evaluation of coronary artery bypass graft (CABG). However, inability to sustain a long breath-hold, high heart rate (HR) and atrial fibrillation may affect image quality. Moreover, radiation exposure is still a matter of some concern. A scanner combining 0.23-mm spatial resolution, new iterative reconstruction and fast gantry rotation time has been recently introduced in the clinical field. The aims of our study were to evaluate interpretability, radiation exposure and diagnostic accuracy of CCTA performed with the latest generation of cardiac-CT scanners compared to invasive coronary angiography (ICA) in the assessment of bypass grafts, and non-grafted and post-anastomotic native coronary arteries. METHODS AND RESULTS: We prospectively enrolled 300 patients undergoing clinically indicated CCTA with a 16-cm z-axis coverage, 256-detector rows, and 0.28-sec gantry rotation time scanner. Coronary artery and graft interpretability, image quality and effective dose (ED) were assessed in all patients and diagnostic accuracy was evaluated in a subgroup of 100 patients who underwent ICA. Mean HR during the scan was 69.6 ±â€¯10.8. Sinus rhythm was present in 118 patients with HR < 75 bpm and in 112 patients with HR ≥ 75 bpm, while 70 patients had atrial fibrillation. CABG interpretability was 100%. Compared to ICA, CCTA was able to correctly detecting occlusions or significant stenoses of all CABG segments. Overall interpretability of native coronary segments was 95.6%. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of coronary arteries were 98.3%, 97.4%, 93.1%, 99.3% and 96.5%, respectively. The diagnostic accuracy in a patient based analysis was 95.2%. Mean ED was 3.14 ±â€¯1.7 mSv. CONCLUSIONS: The novel whole-heart coverage CT scanner allows to evaluating CABG and native coronary arteries with excellent interpretability and low radiation exposure even in the presence of unfavorable heart rhythm.

A case of arrhythmogenic right ventricular cardiomyopathy with biventricular involvement.

We reported a case of a young adult male aged 18 years admitted in our institution for syncope during a basketball match. No previous symptoms were reported. Electrocardiogram (ECG) showed T-wave inversion in the anterior leads and an incomplete right bundle branch block. Surprisingly, a complete echocardiographic evaluation demonstrated the presence of severe right ventricular enlargement with significant wall motion abnormalities, apical aneurysm and reduced systolic function. Cardiac Magnetic Resonance was pathognomonic for a fibro-fatty replacement of both ventricles. We decided for a subcutaneous defibrillator implantation and, after inducing a ventricular fibrillation to test the device status, epsilon wave appeared on the ECG. This clinical scenario depicted an advanced arrhythmogenic right ventricular cardiomyopathy at its first clinical manifestation.

Prognostic Significance of Neutrophil-to-lymphocyte Ratio in the Framework of the 8th TNM Edition for Breast Cancer.

BACKGROUND/AIM: To investigate whether neutrophil-to-lymphocyte ratio (NLR) might represent an additional biological criterion able to identify patients with worse prognosis within the 8th edition TNM prognostic staging system for breast cancer (BC). PATIENTS AND METHODS: Pre-treatment NLR was retrospectively analyzed in 475 BC women prospectively followed for a mean time of 3.8 years. The optimal NLR cutoff, identified by ROC analysis, was set at 2. RESULTS: Elevated pre-treatment NLR was associated with worse disease-free survival (DFS) (HR=2.28) and overall survival (OS) (HR=3.39). The prognostic value of NLR was mostly evident in stage I BC (HR for DFS=2.89; HR for OS=1.30), in whom NLR significantly stratified patients who developed distant metastasis (HR= 4.62), but not local recurrence. CONCLUSION: NLR might provide important information in risk stratification, especially in stage I BC patients in whom the presence of a high NLR might raise the question as to whether they should be more aggressively managed.