The reliability of Juvenile Arthritis Magnetic Resonance Imaging Scoring system in the evaluation of the shoulder joint in juvenile idiopathic arthritis

Objectives

We aimed to evaluate shoulder joint by magnetic resonance imaging (MRI) using the Juvenile Arthritis Magnetic Resonance Imaging Scoring (JAMRIS) system in children with juvenile idiopathic arthritis (JIA) and to compare clinical, laboratory parameters and disease activity scores with MRI parameters.

Patients and methods

A total of 32 shoulder joints of 20 patients (16 males, 4 females; mean age: 8.9±3.5 years; range, 2.5 to 14 years) with a known diagnosis of JIA and a clinical suspicion of shoulder joint involvement and underwent MRI were included. Reliability was determined by inter- and intra-observer correlation coefficients. Correlation of the clinical and laboratory parameters with JAMRIS scores was done using the non-parametric tests. Sensitivity of clinical examination to detect shoulder joint arthritis was also determined.

Results

Of the 32 joints, 27 joints in 17 patients showed MRI changes. Seven joints in five patients fulfilled the definition of clinical arthritis, all revealed MRI changes. In 25 joints without clinical arthritis, early and late MRI changes were seen in 19 (67%) and 12 (48%) joints, respectively. The inter- and intra-observer correlation coefficients for JAMRIS system were excellent. No correlation was found between MRI parameters, clinical, laboratory, and disease activity scores. The sensitivity of clinical examination to detect shoulder joint arthritis was 25.9%.

Conclusion

The JAMRIS system is reliable and reproducible to determine shoulder joint inflammation in JIA. Detection of shoulder joint arthritis by clinical examination has a poor sensitivity.

Effect of 2-6 weeks of systemic steroids on bone mineral density in children

BACKGROUND

The use of systemic steroids for 6+ weeks in children is associated with decreased bone mineral content (BMC) and density (BMD). However, the effects of a shorter duration of use on BMD are unknown.

PURPOSE

To determine the effect of the use of systemic steroids for 2-6 weeks on BMD and BMC in pediatric patients.

METHODS

Twenty-five pediatric patients (21 with tuberculosis, 2 with systemic juvenile idiopathic arthritis, 1 with inflammatory bowel disease, 1 with autoimmune hemolytic anemia) who received systemic steroids for 2-6 weeks and 25 age- and sexmatched controls were enrolled. BMC, BMD, and z scores of the whole body (WB), lumbar spine (LS), nondominant distal radius (DR), and total body less the head (TBLH) were determined by dual-energy x-ray absorptiometry at baseline, the end of steroid therapy or 6 weeks (whichever was earlier; first follow-up), and at the end of 3 months from baseline (second follow-up) in patients and at baseline in controls. The values were adjusted for confounding variables. Continuous and categorical variables were compared using Student t test and the chi-square test or Fisher exact test, respectively. Pairwise comparisons employed Bonferroni correction.

RESULTS

Statistically significant decreases in BMC, BMD, and all z scores were observed. BMC declined by 5.37%, 2.08%, 1.82%, and 2.27%, and 11.42%, 3.75%, 3.34%, and 4.17% for WB, LS, DR, and TBLH, respectively, at the first and second follow-ups, respectively. Similarly, BMD declined by 2.01%, 2.31%, 2.18%, and 1.70% and 4.59%, 3.76%, 3.14%, and 3.50% for the WB, LS, DR, and TBLH, respectively, at the first and second follow-ups, respectively. A significant negative correlation was found among bone densitometric parameters, duration, and cumulative dose.

CONCLUSION

The use of systemic steroids for 2-6 weeks in pediatric patients decreased the BMD and BMC of trabecular and cortical bones, an effect that persisted after discontinuation.

Magnetic resonance imaging findings in the sternoclavicular joint in juvenile idiopathic arthritis and comparison with clinical examination

OBJECTIVE

The sternoclavicular joint (SCJ), an important link between the appendicular and axial skeleton, though involved in 41% of rheumatoid arthritis patients, has not been studied in juvenile idiopathic arthritis (JIA). Hence, this cross-sectional study was done to delineate the magnetic resonance imaging (MRI) findings in SCJ in JIA and compare with the clinical examination to diagnose SCJ arthritis.

METHODS

Of the 116 JIA patients attending the pediatric rheumatology clinic, twenty-one patients (42 SC joints) were evaluated by 1.5 T MRI using the four components of early and late inflammatory changes-synovial hypertrophy, bone marrow edema (BME), cartilage lesions, and bone erosions. Results were compared with clinical assessment of SCJ arthritis.

RESULTS

Of the 42 SCJ evaluated (21/116 patients), MRI changes were seen in 27 SCJs (15 patients, 12.9% of 116 JIA patients). Early MRI changes were seen in 60% of joints found normal on clinical examination, with as much as 1/4th of them revealing late destructive changes. Synovial hypertrophy, BME, cartilage lesions, and bone erosions were seen in 5, 15, 4, and 10 patients, respectively. Sensitivity and specificity of clinical examinations to evaluate SC joint involvement were 55.5% and 53.3%, respectively.

CONCLUSION

MRI evaluation of the SCJ in JIA revealed findings in 15/21 enrolled patients. BME, bone erosions, synovial hypertrophy, and cartilage lesions were seen in 15, 10, 5, and 4 enrolled patients, respectively. Clinical examination was found to be neither sensitive nor specific. Key Points • MRI could delineate both early and late inflammatory changes in SCJ in JIA. BME, bone erosions, synovial hypertrophy, and cartilage lesions were seen in 15, 10, 5, and 4 enrolled patients, respectively. • The frequency of SC joint involvement in JIA was at least 12.9% of patients in our study. • Clinical examination for evaluating SC joint arthritis has low sensitivity (55.5%) and specificity (53.3%).

Effect of 6-12 Weeks of Systemic Glucocorticoids on Bone Mineral Density in Children

Introduction: Prolonged use of systemic steroids in children is associated with many side-effects including effect on Bone Mineral Density (BMD). Effect of more than three months of systemic steroids on BMD has been studied in children but not the effect of 6-12 weeks duration of steroid. Aim: To evaluate the effect of 6-12 weeks of systemic glucocorticoids on BMD in children. Materials and Methods: A longitudinal observational study was conducted at a Tertiary Care Hospital. Dual Energy X-ray Absorptiometry (DEXA) of Whole Body (WB), Lumbar Spine (LS) and Distal Radius (DR) were done at baseline, end of steroid therapy or third month whichever was earlier and end of six months, on 30 patients receiving systemic steroid (Nephrotic Syndrome (NS)-7, Systemic Onset Juvenile Idiopathic Arthritis (SOJIA)-12, Tubercular Meningitis-11). Age and sex adjusted values of Bone Mineral Content (BMC), BMD and Z scores were analysed. Bone densitometric parameters of Total Body Less the Head (TBLH) were derived from WB values. X-rays of whole spine (antero-posterior and lateral view) were done at baseline and follow-up. Equal number of age and sex matched healthy controls were subjected to biochemical and DEXA scans at baseline. Continuous and categorical variables were compared using Student’s t-test and Fisher-exact test, respectively. Pairwise comparison over period of time was done using Bonferroni correction. Results: Bone densitometric parameters of cases and controls were comparable at baseline. At follow-up statistically significant decrease in BMD was found at all three sites. A statistically significant negative correlation was found between cumulative dose of steroid and duration of steroid treatment with Z score of TBLH. No vertebral fractures were detected at baseline or follow-up. Conclusion: Use of systemic glucocorticoids for 6-12 weeks negatively affects bone mineralisation, not only during therapy but even three months after stopping it.

Evaluation of enthesitis in patients with juvenile idiopathic arthritis by power color and spectral Doppler ultrasonography

OBJECTIVE

Ultrasonography in patients with juvenile idiopathic arthritis (JIA) could potentially be useful for evaluation of enthesitis. The aim of this study was to evaluate enthesitis in patients with JIA quantitatively by power color and spectral Doppler ultrasonography by determining color fraction (CF) and resistive index (RI).

METHODS

A cross-sectional single-center study was performed in 15 (61 entheseal sites) patients with JIA with clinical enthesitis. A total of 9 age and sex matched healthy controls (53 entheseal sites) were also examined and compared. Entheseal sites (quadriceps tendon, patellar tendon, tendo-Achilles, medial and lateral epicondyles of humerus) were examined on USG B mode for tendon thickening, hypo- and hyper-echogenicity, enthesophytes, and cortical erosions/irregularities by power Doppler ultrasound for the presence of Doppler signal and by power color Doppler and spectral Doppler ultrasonography to derive CF and RI respectively.

RESULTS

The mean thickness of entheseal site in patients and controls were 3.55±0.82 mm and 2.8±0.37 mm, respectively (p<0.001). The power Doppler signal was present in 93.4% of patients (p<0.001). The pooled data of all entheseal sites revealed a significantly higher CF in patients (0.08±0.03) than in controls (0.006±0.008) (p<0.001). The mean RI in patients (0.61±0.09) was significantly lower than that in controls (0.92±0.12) (p<0.001). The cut-off of RI (0.7) and CF (0.029) determined by receiver operating curve analysis revealed a diagnostic accuracy of 94.7% and 96.5%, respectively.

CONCLUSION

Evaluation of enthesitis by determining CF and RI via power color Doppler and spectral Doppler is possible in JIA patients.

Neuroimaging in drug resistant epilepsy

Background: Epilepsy is a common serious neurological condition and 30 to 40 % of people with epilepsy have seizures that are not controlled by medication. Patients are considered to have drug resistant epilepsy if disabling seizures continue despite appropriate trials of two anti-epileptic drugs. Most lesions causing drug resistant epilepsy can be detected by 3T MR Imaging using dedicated epilepsy protocol which is crucial for diagnostic and subsequent therapeutic planning with benefit from surgery. We present a review of the major abnormalities related to drug resistant epilepsy, highlighting the key findings of 3 T MRI.Methods: A Cross-sectional Observational study was done in 30 patients. Patients less than 60 yrs of age of either sex, diagnosed with DRE as per ILAE criteria, were included in the study. 3T MRI was performed using dedicated epilepsy protocol, with additional 3D imaging for manual hippocampal volumetric evaluation.Results: About 77% cases showed an MRI abnormality on visual assessment, with additional 16% cases showing abnormal MRI findings on manual hippocampal volumetry. Nearly 50% of the abnormal MRI cases showed Mesial Temporal Sclerosis, followed by neoplasms as etiology of DRE.Conclusions: MR imaging has significantly improved detection of pathologies related to epilepsy, especially with the advent of epilepsy protocol. The total percentage of MRI abnormalities increased after incorporating manual hippocampal volumetry.

Encephalitic presentation of Neonatal Chikungunya: A Case Series

OBJECTIVE

To describe clinical features and early neurological outcomes in neonatal Chikungunya.

METHODS

Clinical, pathological and radiological details of neonates with acute encephalitic features and typical rash, later diagnosed as Chikungunya, are presented. Neurodevelopmental evaluation and imaging was done at discharge/three months.

RESULTS

Abnormal neurological examination with fever was typical presentation in all 13 babies with/without seizures/peri-oral rashes; 12 had persistent neurological abnormalities at discharge. A follow-up at three months revealed continued neurodevelopmental deficits. Neuroimaging abnormalities were seen in eight out of ten cases.

CONCLUSIONS

Perinatal Chikungunya should be considered in neonates presenting within first week with fever, encephalopathy and perioral rashes with/without seizures with history of maternal Chikungunya within last week before delivery.

Endothelial function, arterial wall mechanics and intima media thickness in juvenile idiopathic arthritis

OBJECTIVES

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease of children which might persist into adulthood. Systemic inflammation seen in adult RA patients has been shown to be associated with alteration in endothelial function, arterial wall mechanics and intima media thickness. Our study was planned to assess similar changes in JIA patients.

METHODS

Thirty-one newly diagnosed JIA patients and a similar number of age- and sex-matched controls were enrolled in the study. Endothelial function was assessed by measuring flow mediated dilation and glyceryl trinitrate (GTN)-mediated dilation of the brachial artery. To assess arterial stiffness, various arterial wall mechanic parameters such as cross-sectional compliance, cross-sectional distensibility, shear stress and elastic modulus were derived. Intima media thickness of the common carotid artery was measured as a marker of subclinical atherosclerosis.

RESULTS

The brachial artery diameter at rest was found to be slightly lower in the patients than controls (0.258 ± 0.042 vs. 0.264 ± 0.039; p=0.54). No significant difference was found in flow mediated dilation (17.71 ± 9.26 vs. 16.31 ± 8.23; p=0.53), GTN mediated dilation (25.25 ± 10.02 vs. 23.66 ± 9.79; p=0.53) or FMD: GTN mediated dilation ratio (0.730 ± 0.432 vs. 0.717 ± 0.280; p=0.89) between the cases and controls. There was also no significant difference in carotid artery intima media thickness (0.065 ± 0.0068 vs. 0.068 ± 0.007; p=0.084) between cases and controls. Cases in different subsets of JIA were also analysed separately with regards to FMD, GTN mediated dilation and cIMT but no difference was found between cases in each subset and their controls. Cross-sectional compliance was significantly lower in cases than controls (0.0016 ± 0.0005 vs. 0.002 ± 0.001; p=0.034). Cross-sectional distensibility (0.009 ± 0.003 vs. 0.011 ± 0.006; p=0.14) was also found to be lower whereas diastolic wall shear stress (299.9 ± 47.08 vs. 294.9 ± 59.5; p=0.72) and elastic modulus (1138.5 ± 1085.8 vs. 911 ± 453; p=0.19) were found to be higher in cases as compared to controls. But these differences were not statistically significant. When the subsets were analysed separately for vessel wall indices, cross-sectional compliance was found to be significantly lower in systemic arthritis patients as compared to controls. A high level of intra- and inter-observer agreement was found for all the ultrasonographically evaluated parameters.

CONCLUSIONS

Arterial wall indices were found altered in JIA patients indicating increased arterial stiffness. Larger studies are required to assess endothelial dysfunction, intima media thickness and arterial stiffness in each subset of JIA patients.

Effect of glucocorticoids on serum lipid profile and endothelial function and arterial wall mechanics

OBJECTIVE

To determine the effect of glucocorticoids on lipid profile, endothelial function and arterial wall mechanics in children.

METHODS

Thirty patients who had received glucocorticoids for 4 to 8 wk were compared with 30 age and sex matched healthy controls. Baseline evaluation included weight, height, body mass index (BMI), blood pressure (BP), lipid profile and Ultrasonographic evaluation of brachial artery for endothelial dependant as well as endothelial independent vasodilatation and evaluation of common carotid artery for intima media thickness (IMT) and arterial wall mechanics. All of these parameters were evaluated two more times- after 4 wk of steroid therapy and 2 wk after stopping the drug.

RESULTS

Patients were found to have significant increase in BMI; systolic and diastolic BP; total and LDL cholesterol and carotid IMT and also a decrease in cross sectional compliance (CSC) after 4 wk of steroid therapy (oral prednisolone). However, all these parameters returned towards baseline, 2 wk after stopping the drug. No endothelial dysfunction was observed in these patients.

CONCLUSIONS

Four to eight wk of glucocorticoids use in children leads to reversible changes in BMI, systolic and diastolic BP, total and LDL cholesterol, carotid IMT and CSC.

Multi detector computed tomography (MDCT) evaluation of small bowel obstruction: pictorial review

Small bowel obstruction (SBO) is one of the most perplexing clinical situations encountered by a surgeon in the emergency room. The decision to operate or not depends upon many factors including the probable cause and chances of bowel strangulation/ischemia. The clinical, biochemical and radiological features help the surgeon in making this decision. Plain X-rays have been the mainstay in the radiological diagnosis of SBO and its complications. In the last 20 years, CT scan has ushered in a revolution in establishing the diagnosis of SBO, its causes and complications earlier than the traditional methods and has helped in reducing morbidity and mortality. Here, we have summarised the role of multidetector CT scan in diagnosing various aspects of SBO.

Correlation between microaneurysm closure rate and reduction in macular thickness following laser photocoagulation of diabetic macular edema

AIM

To correlate the microaneurysmal closure rate measured on fundus fluorescein angiography (FFA) with reduction in macular thickness observed on optical coherence tomography (OCT) following laser photocoagulation of diabetic macular edema.

MATERIALS AND METHODS

A prospective observational case series. Fifty patients (50 eyes) of type II diabetes mellitus with clinically significant macular oedema (CSME) underwent focal/grid laser photocoagulation. OCT and FFA were performed at baseline and at 2 and 12 weeks following laser photocoagulation to measure the change in macular thickness and the number of leaking microaneurysms respectively. Statistical analysis was performed using paired-ttest and Pearson's correlation test.

RESULTS

A significant reduction in macular thickness was seen at both 2 (P=0.02) and 12 weeks (P<0.0001), most remarkably in the central 1 mm quadrant. However, microaneurysm closure was only 0.67% at 2 weeks, which increased to 89.6% by 12 weeks. The change in retinal thickness correlated significantly with the decrease in the number of leaking microaneurysms at 12 weeks (r=0.597, P<0.0001), but not at 2 weeks (r=-0.228, P=0.112). On OCT, the final reduction in retinal thickness achieved at 12 weeks from baseline correlated significantly with the initial decrease in retinal thickness at 2 weeks (r=0.66, P<0.0001). However, on FFA, the final closure rate of leaking microaneurysms at 12 weeks from baseline did not correlate with the initial closure rate at 2 weeks (r=-0.039, P=0.413).

CONCLUSION

Following laser photocoagulation for CSME, an OCT at 2 weeks is more informative and better correlates with the final outcome than an FFA at 2 weeks.

The Auckland Cataract Study: 2 year postoperative assessment of aspects of clinical, visual, corneal topographic and satisfaction outcomes

AIM

To assess clinical, visual, computerised corneal topographic, and subjective satisfaction with visual acuity, in a cohort of subjects 2 years after phacoemulsification surgery in a public hospital in New Zealand.

METHODS

Prospective study of a representative sample of 97 subjects (20%) randomly selected from 480 subjects in the original Auckland Cataract Study (ACS) cohort. The clinical assessment protocol was identical to the ACS and included an extensive questionnaire to enable direct comparisons to be made between the two groups.

RESULTS

The study population was predominantly female (66%) with a mean age of 76.3 (SD 9.9) years. New systemic and ocular disease affected 18.4% and 10.3% of subjects respectively, and 10.3% required referral to either a general practitioner (2.1%) or ophthalmologist (8.2%). Mean best spectacle corrected visual acuity (BSCVA) was 0.2 (0.2) logMAR units (6/9 Snellen equivalent), with mean spherical equivalent -0.37 (1.01) dioptres (D) and astigmatism -1.07 (0.70) D 2 years postoperatively, compared to mean BSCVA 0.1 (0.2) logMAR units (6/7.5 Snellen equivalent), spherical equivalent -0.59 (1.07) D, and astigmatism -1.14 (0.77) D 4 weeks after surgery. 94.9% of subjects retained a BSCVA of 6/12 or better, irrespective of pre-existing ocular disease. The overall posterior capsule opacification (PCO) rate was 20.4% and this was visually insignificant in all but 3.1% of eyes that had already undergone Nd:YAG posterior capsulotomy. Orbscan II elevation technology demonstrated corneal stability 2 years after uncomplicated phacoemulsification. Although corneal astigmatism was eliminated in approximately half of the subjects 1 month postoperatively, astigmatism showed a tendency to regress towards the preoperative level with local corneal thickening at the site of incision 2 years after cataract surgery. Of fellow eyes, 61.2% had undergone cataract surgery. Overall, 75.3% of subjects were moderately to very satisfied with their current level of visual acuity.

CONCLUSION

Two years after cataract surgery subjects are generally satisfied with their current level of vision and distance BSCVA is 6/12 or better in the majority of eyes. Although only a minority of eyes develop sufficient PCO to require capsulotomy 10.3% of eyes develop new vision threatening ocular pathology.

The use of adult isolation facilities in a UK infectious diseases unit

The emergence and re-emergence of communicable infections, especially those due to antibiotic resistant nosocomial pathogens, is likely to increase the burden on the limited isolation facilities of the UK. It was our perception, however, that isolation beds are not always used optimally; with patients requiring isolation sometimes being housed in open-bay beds, whilst other non-communicable patients are unnecessarily isolated. The main aim of this study was to test this hypothesis in a regional infectious diseases (ID) unit. A secondary aim was to provide useful data in the development of guidelines for the admission of patients to the new Dundee ID unit. One-third of patients (32% of all patients and 34% of total bed days) admitted to an isolation room in the current Dundee ID unit over a four-month period, were found to have low-risk or non-communicable conditions. In addition, 21 patients initially considered an infection risk, used 102 bed days following resolution of their infection. Evidence for the presence of patients with 'alert' infections housed in the open-bay beds of other wards, whilst low-risk or non-communicable patients are unnecessarily exposed to isolation in the ID unit, is presented. The findings suggest suboptimal use of the current Tayside University Hospitals' isolation facilities. Given the likelihood of high demand for the isolation of patients in the new Dundee ID unit, it is vital that these facilities are used appropriately, thereby minimizing the risk of nosocomial infection transmission and the unnecessary isolation of low-risk patients.

Functional, psychological, and satisfaction outcomes of laser in situ keratomileusis for high myopia

PURPOSE

To identify factors that motivate patients to seek laser in situ keratomileusis (LASIK) treatment for myopia and establish subjective levels of functional improvement and satisfaction across a range of indices after LASIK surgery.

SETTING

The Corneal Diseases and Excimer Laser Research Unit, University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland.

METHODS

In this questionnaire-based, cross-sectional study, an anonymous 34-item questionnaire was forwarded to 50 consecutive patients in a prospective study who had had LASIK for high myopia by a single surgeon at a single center. The questionnaire used visual analog scales, anchored at each end by an adjectival descriptor. The mean preoperative myopia was -10.7 diopters +/- 4.4 (SD). Seventy-six percent of eyes (83% of patients) achieved post-LASIK uncorrected visual acuity (UCVA) of 6/12 or better; 1 eye lost 2 lines of corrected Snellen visual acuity.

RESULTS

A 98% reply rate was achieved. The most common motivating factor for pursuing LASIK was to improve UCVA (88%); only 21% rated improved cosmesis as an important motive. Most patients (81% to 100%) reported functional improvement across the spectrum of visual tasks assessed, although 8.8% reported difficulty with nighttime driving. Ninety-six percent felt their UCVA was as good as anticipated, 97.9% were satisfied with the speed of visual improvement, 93.8% achieved the goals for which they had surgery, 97.9% reported an improved quality of life, and 97.9% were satisfied with the overall outcome of LASIK.

CONCLUSIONS

Using an anonymous, wide-ranging questionnaire, high levels of functional improvement and satisfaction with the speed of visual recovery and outcome were reported by patients after LASIK for high myopia. Nighttime driving symptoms of variable severity were, however, noted by 8.8% of patients, despite high levels of satisfaction with other aspects of visual function.

Percutaneous atherectomy of occlusive peripheral vascular disease: stenoses and/or occlusions

Percutaneous atherectomy was performed using the Simpson Atherocath on 131 patients (87 male, 66%) with a mean age of 65 years. Clinical characteristics included evidence of significant coronary disease in 50%, hypertension in 46%, diabetes in 41%, and prior neurologic deficit in 32% of patients. The indication for atherectomy was claudication in 114 (87%) and rest pain, gangrene, or ulcer in 17 patients (13%). Atherectomy was successfully performed in 136/139 stenoses (98%) and in 56/56 occluded vessels with or without prior balloon angioplasty. No serious complications resulting in limb loss or emergency vascular surgery were encountered. Histopathology of retrieved specimens showed that 66% had atheromatous plaque, 45% had tunica media, and 30% had a form of thrombus. Material obtained from an occluded vessel was more likely to have thrombus and tunica media present than that from a stenosis (P less than 0.02 and P less than 0.05, respectively). Early angiographic follow-up (mean time, 17 weeks) showed a relatively low (17%) lesion recurrence rate. Percutaneous atherectomy can be successfully utilized in stenotic and occluded peripheral arteries with good success and no serious complications; stenoses appear to have a low recurrence rate.

Percutaneous aspiration of a thromboembolus

Percutaneous aspiration of a thromboembolus was successfully performed in 12 out of 13 patients with in situ thrombosis (4 patients), distal embolization (7 patients), or both (2 patients). The flow was improved from TIMI 0 (10 patients, no flow) or TIMI 1 (2 patients, impaired flow) to TIMI 3 (10 patients, normal flow) or TIMI 2 (2 patients, normal but slower flow). A custom-made 8 F Teflon-coated sheath was introduced in the superficial femoral and proximal below-the-knee arteries to aspirate the debris. Distal embolization in below-the-knee arteries was concomitantly treated with short-term intraarterial Urokinase in nine patients. Complications included one in-hospital (not procedure related) death, two patients with below-the-knee amputations (above-the-knee amputation averted), and one transmetatarsal amputation (prior established gangrene present and below-the-knee amputation avoided). The remaining nine patients left the hospital with improved limb status and peripheral pulses. This technique is a rapid, reliable, and efficient method to treat in-situ clot or procedure-related distal embolization as an adjuvant or complement to lytic treatment.

Sickle cell heart disease. Two-dimensional echo and Doppler ultrasonographic findings in the hearts of adult patients with sickle cell anemia

Sickle cell anemia (SCA) is a commonly diagnosed condition in the black population in the United States. With better medical management, patients with SCA are living longer and what were previously uncommon sequelae are being recognized frequently, including those involving the cardiovascular system. Previous reports on the cardiovascular effects of SCA have focused predominantly on children, but the conclusions remain controversial. To study this question further, 40 adult patients with documented SCA were examined using two-dimensional and Doppler cardiac ultrasound. Valvular structures were normal despite an increased incidence of flow murmurs. Abnormalities were found more frequently in the left heart than the right, as manifested primarily by increased left ventricular mass, and left ventricular and left atrial dilatation with preservation of systolic function. Pulmonary hypertension, which was present in two thirds of the sample, was minimal to moderate as assessed by our Doppler technique. The effects of SCA on the heart seem to be minimal and similar to those of other anemias, predominantly confined to the left atrium and ventricle with passive elevation of pulmonary pressures. Clinical murmurs were most often physiologic; there was no association with myxomatous valvular degeneration or mitral valve prolapse.