Meletios A. Kanakis

The diagnostic value of ultrasonography-derived edema of the temporal artery wall in giant cell arteritis: a second meta-analysis

BackgroundUltrasonography of temporal arteries is not commonly used in the approach of patients with suspected giant cell arteritis (GCA) in clinical practice. A meta-analysis of primary studies available through April 2004 concluded that ultrasonography could indeed be helpful in diagnosing GCA. We specifically re-examined the diagnostic value of the ultrasonography-derived halo sign, a dark hypoechoic circumferential thickening around the artery lumen, indicating vasculitic wall edema, in GCA.MethodsOriginal, prospective studies in patients with suspected GCA that examined ultrasonography findings of temporal arteries using the ACR 1990 classification criteria for GCA as reference standard, published through 2009, were identified. Only eight studies involving 575 patients, 204 of whom received the final diagnosis of GCA, fulfilled technical quality criteria for ultrasound. Weighted sensitivity and specificity estimates of the halo sign were assessed, their possible heterogeneity was investigated and pooled diagnostic odds ratio was determined.ResultsUnilateral halo sign achieved an overall sensitivity of 68% (95% CI, 0.61-0.74) and specificity of 91% (95% CI, 0.88-0.94) for GCA. The values of inconsistency coefficient (I2) of both sensitivity and specificity of the halo sign, showed significant heterogeneity concerning the results between studies. Pooled diagnostic odds ratio, expressing how much greater the odds of having GCA are for patients with halo sign than for those without, was 34 (95% CI, 8.21-138.23). Diagnostic odds ratio was further increased to 65 (95% CI, 17.86-236.82) when bilateral halo signs were present (sensitivity/specificity of 43% and 100%, respectively). In both cases, it was found that DOR was constant across studies.ConclusionTemporal artery edema demonstrated as halo sign should be always looked for in ultrasonography when GCA is suspected. Providing that currently accepted technical quality criteria are fulfilled, halo signs sensitivity and specificity are comparable to those of autoantibodies used as diagnostic tests in rheumatology. Validation of revised GCA classification criteria which will include the halo sign may be warranted.

Colour duplex sonography of temporal arteries before decision for biopsy: a prospective study in 55 patients with suspected giant cell arteritis.

Although a temporal artery biopsy is the gold standard for the diagnosis of giant cell arteritis (GCA), there is considerable evidence that characteristic signs demonstrated by colour duplex sonography (CDS) of the temporal arteries may be of diagnostic importance. We aimed to test the hypothesis that CDS can replace biopsy in the algorithm for the approach to diagnose GCA. Bilateral CDS was performed in consecutive patients older than 50 years with clinically suspected GCA, as well as in 15 age- and gender-matched control subjects with diabetes mellitus and/or stroke and 15 healthy subjects, to assess flow parameters and the possible presence of a dark halo around the arterial lumen. Unilateral temporal artery biopsy was then performed in patients with suspected GCA, which was directed to a particular arterial segment in case a halo was detected in CDS. Final diagnoses, after completion of a 3-month follow-up in 55 patients, included GCA (n = 22), polymyalgia rheumatica (n = 12), polyarteritis nodosa, Wegeners, and Adamantiades-Behçets diseases (n = 3), and neoplastic (n = 8) and infectious diseases (n = 10). A dark halo of variable size (0.7–2.0 mm) around the vessel lumen was evident at baseline CDS in 21 patients (in 12 and 9 uni- or bilaterally, respectively) but in none of the controls. The presence of unilateral halo alone yielded 82% sensitivity and 91% specificity for GCA, whereas the specificity reached 100% when halos were found bilaterally. Blood-flow abnormal parameters (temporal artery diameter, peak systolic blood-flow velocities, stenoses, occlusions) were common in GCA and non-GCA patients, as well as in healthy and atherosclerotic disease-control, elderly subjects. At follow-up CDS examinations performed at 2 and 4 weeks after initiation of corticosteroid treatment for GCA, halos disappeared in all 18 patients (9 and 9, respectively). We conclude that CDS, an inexpensive, non-invasive, and easy-to-perform method, allows a directional biopsy that has an increased probability to confirm the clinical diagnosis. Biopsy is not necessary in a substantial proportion of patients in whom bilateral halo signs can be found by CDS.

Etiopathogenesis of Behçet's disease with emphasison the role of immunological aberrations

Behçets disease (BD) is a chronic multisystemic inflammatory disorder of unknown origin consisting of oral aphthous ulcers, ocular symptoms, skin lesions, and genital ulcerations. It has many features in common with systemic vasculitides and is more prevalent in countries along the ancient Silk route. Immune-mediated mechanisms play a major role in the pathogenesis of the disease, and inflammatory mediators are also involved. BD is not considered to be an autoimmune disorder, and the character of the disease needs to be clarified. Immunological aberrations in BD have been extensively studied by many investigators; genetic factors have been related to disease susceptibility, but their exact role in the development of disease is uncertain. Environmental factors such as infectious agents have also been implicated in the etiology of BD. However, the etiopathogenesis of the disease remains to be elucidated. Factors involved in the immunopathogenesis of BD with emphasis on the role of immunological aberrations are analyzed in this review.

Raynaud's phenomenon is correlated with elevated systolic pulmonary arterial pressure in patients with systemic lupus erythematosus:

In patients with Systemic lupus erythematosus (SLE), Raynaud phenomenon (RP) is frequently present and associated with pulmonary hypertension (PHT). Elevated pulmonary artery systolic pressure (PASP) is an indicator of PHT and can be estimated noninvasively. We attempt to explore the significance of RP in SLE and to correlate it with clinical and serological parameters of the disease. The study population consisted of 34 patients (age, sex and disease duration matched) who fulfilled the revised SLE criteria of the American College of Rheumatology, and were categorized into two groups: Group 1 had patients having SLE and RP (2 males/15 females, mean age 45 ± 18 years) and group 2 had patients with SLE but without RP (3 males/14 females, mean age 40 ± 14 years. Detailed cardiac ultrasound was performed including measurement of PASP, while clinical and serological features of both groups were collected and correlated. Significant differences were shown in the presence of arterial hypertension (P < 0.05), arthralgias (P < 0.005), arthritis (P < 0.05), myalgias (P < 0.05), alopecia (P < 0.05) and PASP (P < 0.0001). No difference was observed among the cardiac ultrasound indices and the ejection fraction between the two groups. PASP was significantly correlated with RP, while no correlation was observed regarding the disease duration. In patients with SLE, the presence of RP was associated with elevation in PASP. Further investigation is needed to clarify the significance of this relation. Lupus (2007) 16, 505—508.

Evaluation of current therapeutic strategies in Behçet's disease.

Behçet’s disease (BD) is a chronic relapsing vasculitis with multifunctional pathogenesis. The mucocutaneous and ocular lesions are the commonest manifestations, but BD also affects the musculoskeletal, intestinal, cardiac, and central nervous system. BD therapy is based on the suppression of the inflammatory process, using immunomodulating and immunosuppressive agents. In selected cases, invasive procedures may be required.

Deconstructing laparoscopic competence in a virtual reality simulation environment.

BACKGROUND Virtual reality (VR) simulators play a substantial role in modern medical education and have generated several performance parameters that are not always standardized and open to clear and easy interpretation. Consequently, our study objective was to investigate how these parameters contribute to the enhancement of key competencies in laparoscopic surgical skills. METHODS We recruited 20 residents and 8 experienced surgeons to participate in this study. The residents were trained on 5 basic tasks (4 of them at two difficulty levels) using a commercially available VR simulator. Study participants also performed an additional 3 complex tasks before and after training for assessment purposes. The experienced surgeons served as controls and so only performed the assessment tasks. Performance parameters were grouped to reflect errors in dexterity, safety, and technical skill. These errors, as well as the parameters of time and instrument velocity, were analyzed during training and assessment. RESULTS Performance for training tasks demonstrated notable learning curves for most of the parameters that were measured (ie, plateaus varied between the second and seventh VR training session). Velocity was influenced least by the training (3 of the 5 tasks), while time and dexterity were influenced most (all 5 tasks and for both difficulty levels). In the assessment tasks, technical skill was improved (P < .05) for some study participants, but this improvement was not demonstrated in all of the complex procedures tested (eg, bowel suturing). There was a significant improvement in safety (all 3 tasks; P < .05), and time to completion and dexterity (both of them in 2 tasks; P < .05). Experienced surgeons scored at a greater level than VR-trained residents in terms of time (all tasks; P < .05), safety and technical skill (bowel suturing; P < .05), as well as dexterity (adhesiolysis and bowel suturing; P < .05). CONCLUSION VR simulation training contributed markedly to the enhancement of key surgical competencies of residents. The proposed mapping of the simulator parameters may help program directors and trainees evaluate important competency domains during VR-based surgical training.

Chylothorax complicating thoracic surgery: conservative or early surgical management?

Postoperative chylothorax is a rare complication in thoracic surgery. There is considerable controversy concerning the management of chylothorax with some physicians favoring conservative treatment while others favor a surgical one. Considering the current surgical experience with VATS and by reviewing the problems and outcome of conservative management, the guidelines regarding timing of surgery in patients with chylous leak need to be revised.

Minimal Invasive Coronary Artery Fistula Ligation

A coronary artery fistula was surgically ligated in a 38-year-old woman via a left anterior mini-thoracotomy without the use of cardiopulmonary bypass. In selected cases, this surgical approach can provide an excellent surgical exposure for coronary artery fistula ligation. It also offers an excellent cosmetic result and shorter hospital stay.

Evaluating the effectiveness of virtual reality simulation training in intravenous cannulation.

Introduction: This article focuses on the effectiveness of virtual reality (VR) simulation training for intravenous (IV) cannulation. We analyzed the learning process in skills acquisition from groups with limited experience in comparison with the performance of experts. Methods: Novices (n = 20) and intermediates (n = 23) trained on nine IV cannulation scenarios with a high-fidelity VR simulator (Virtual IV). Another three scenarios were performed before and after training (pre- and postassessment). Pre-/postassessment was also undertaken by a group of 10 experts for comparative evaluation. Performance metrics included the completion time and an error score that was obtained after quantitative analysis of the errors committed during training. The learning curves were evaluated by recording the number of attempts required to successfully perform each training scenario. A performance was considered successful when the error score was below a predetermined threshold. Results: The learning curves of intermediates and novices demonstrated a clear plateau at the sixth and eighth scenario, respectively. These plateaus were reached after 15 (intermediates) and 23 (novices) attempts. There was a highly significant reduction in the time and errors between pre- and postassessment (P < 0.01). Before training, the performance (errors, time) of the three groups was significantly different to one another (novices: lowest, experts: highest, P < 0.05). After training, the performance of intermediates and novices was equivalent to that of the experts (P > 0.1). Intermediates committed fewer critical and more noncritical errors than novices, and vice versa (P < 0.05). Conclusions: Simulation training enhanced the skills of inexperienced subjects significantly. The VR simulator demonstrated construct validity for three different levels of experience. The number of attempts over a series of equal difficulty scenarios provides a valuable alternative to the traditional measures of the learning curve.

Nodular lung calcifications following varicella zoster virus pneumonia

A 39-year-old woman suffering from psoriasis was referred for evaluation of mild arthralgias of the small joints of the hands of recent onset. During diagnostic workup, a chest X-ray revealed multiple randomly scattered, well-defined, dense nodular densities with calcification ranging from 1mm to 1cm (Figure 1A and B). The patient reported no complaints whatsoever. Apart from the psoriatic exanthema of the elbows, the clinical examination of the patient was negative and her laboratory …