Accuracy of computed tomography in differentiating perforated from nonperforated appendicitis, Taking histopathology as the gold standard.

Introduction Acute appendicitis is one of the more common causes of acute abdominal pain. It occurs when the lumen of the appendix is obstructed, leading to inflammation and finally perforation. The preoperative differentiation of perforated from nonperforated appendicitis is important and helpful to define prognosis and determine an adequate therapeutic approach, including consideration for nonsurgical treatment. This study recommends computed tomography (CT), a noninvasive method of investigation, be used frequently in clinically suspected cases of perforated appendicitis in the Pakistani population for better patient outcomes. Objective To determine the diagnostic accuracy of CT in differentiating perforated from nonperforated appendicitis by using histopathology as the gold standard. Material and methods A total of 236 patients with a clinical suspicion of appendicitis were included in this study. CT was performed in Liaquat National Hospital and Medical College. At the time of scanning, intravenous contrast was administered. Histopathology was used as the diagnostic gold standard. CT findings were documented using a proforma. The patient was returned to the referring department and followed after surgery for histopathology. Results Sensitivity, specificity, and positive and negative predictive values, as well as the accuracy of CT in the detection of perforated appendicitis, was 71.4%, 90.7%, 62.5%, 93.6%, and 87.3%, respectively. Conclusion CT findings can be used to select patients with perforated appendicitis for initial nonoperative management

Varied percutaneous and endovascular management of large iatrogenic profunda femoris artery pseudoaneurysm

The case of an elderly male diagnosed with a large iatrogenic pseudoaneurysm arising from the profunda femoris artery on ultrasound examination is presented. The immediate postoperative period was uneventful; however later he developed leg swelling and mild oozing at the incision site. In view of deranged renal function CT angiogram was not done and decision was made to treat the pseudoaneurysm with percutaneous thrombin injection. Almost complete thrombosis was achieved however a small residual portion remained patent near the neck. Later limited contrast angiography was done which re-demonstrated a small anneurysm. Instead of embolizing the vessel completely repeat prolonged balloon inflation was done which later showed no further filling of the pseudoaneurysm

Utility of limited protocol magnetic resonance imaging lumbar spine for nerve root compression in a developing country, is it accurate and cost effective?

STUDY Design: Cross sectional study.PURPOSE: To determine the accuracy of the screening magnetic resonance study of the lumbar spine in the diagnosis of nerve root compression in cases of low back pain as compared to the routine magnetic resonance imaging (MRI) study of the lumbar spine.OVERVIEW OF LITERATURE: No local study has been conducted for this purpose. In an international study, the reported sensitivity and specificity of screening MRI lumbar spine protocol in the detection of nerve root compression are 54% and 100% respectively.Methods: Patients of both genders older than 20 years of age with low back pain of any duration or any severity who were referred to the radiology department of Aga Khan University Hospital for MRI of their lumbar spine were evaluated. Two sets of MRI imaging were recruited for each patient: one labeled as \u27screening\u27 and the other labeled as \u27routine\u27. The findings of screening MRI were compared with the findings of the routine MRI study.Results: A total of 109 patients fulfilling the inclusion criteria were included in this study. The diagnostic accuracy, specificity and sensitivity of the screening protocol in our study was 100%, 100% and 100%, respectively in comparison with the routine MRI lumbar spine study for the detection of nerve root compression.CONCLUSIONS: Our data proved that the MRI screening study is a highly accurate tool, and its findings are comparable to the routine study for the detection of nerve root compression especially in cases of lumbar spondylosis

Diagnostic efficiency of multidetector computed tomography in the evaluation of clinically equivocal cases of acute appendicitis with surgical correlation

Acute appendicitis is one of the most frequent causes of lower abdominal pain and requires immediate surgical intervention. The diagnosis often poses a lot of challenge even to experienced surgeon. Those patients with equivocal symptoms may require different imaging modalities like radiography, contrast examination and ultrasound with limited utility. Multidetector computed tomography (MDCT) used in suspected acute appendicitis has, however, resulted in improved diagnostic accuracy and also reduction of negative surgeries. Objective We intend to determine the diagnostic efficiency of MDCT in clinically equivocal cases of acute appendicitis correlating it with surgical/histopathological findings. Materials and methods A group of 116 patients was included in this study. Spiral MDCT was performed in all these cases after administration of oral and intravenous contrast. All these patients underwent surgery and the CT findings were correlated with histopathology. Out of these 116 patients, 60 patients were male and 56 female. The age range was from three to seventy years and mean age was 28+1 years. Results The results proved that MDCT had a sensitivity of 97.5%, specificity of 97.0%, and accuracy of 97.4% for the diagnosis of appendicitis with one false positive and two false negative cases. The study showed 100% accuracy in diagnosing acute appendicitis in children. In 33 patients, an alternate cause was identified with CT. The alternate diagnosis made on CT findings was consistent with the final diagnosis in 27 (81.8%) of 33 patients in whom there was no evidence of acute appendicitis. The clinical diagnosis disagreed with the CT diagnosis in six patients (18.18%). Conclusion Our study verifies that MDCT plays an important role in evaluation and consequent management of equivocal cases of acute appendicitis. MDCT is also able to diagnose appendicitis or detect alternative diagnosis in pediatric population

Needle stick injuries--risk and preventive factors: a study among health care workers in tertiary care hospitals in Pakistan.

BACKGROUND: Health care workers (HCWs) are at substantial risk of acquiring blood borne infections such as HIV, Hepatitis-B and Hepatitis-C through needle stick injuries (NSIs). This study aimed to assess the proportion of NSIs and their associated factors among HCWs and also to identify the areas in which preventive efforts might be directed to protect against this occupational hazard. METHODOLOGY: A cross-sectional study was conducted in two tertiary care hospitals of Pakistan representing both private and public health sector. A total of 497 HCWs (doctors and nurses) were interviewed using a structured questionnaire. Data was collected from January to May 2008. RESULTS: Overall, 64% of the HCWs were exposed to at least one NSI during their career; among them 73% reported NSIs for two or more times. Factors found to be highly associated with NSIs were those practicing this occupation for more than five years (p \u3c 0.001: OR = 5.92; 95% CI = 3.45-10.16) and working as nurse than doctor (p 0.001: OR = 2.12; 95% CI = 1.35-3.32). Having received booster dose of hepatitis B vaccine (p 0.02: OR = 1.85; 95% CI = 1.10-3.11), working in surgical specialty (p \u3c 0.01: OR = 1.6; 95% CI = 1.09-2.51) and being a female (p 0.03: OR = 1.52; 95% CI = 1.04-2.22) were also found to be associated with NSIs. Most commonly reported reason for NSIs was injecting medicine and drawing blood (42%) followed by two-handed recapping of needle (37%). Only, 34% of study subjects were vaccinated against hepatitis B infection. Overall, HCWs had inadequate practices regarding standard precautions such as availability of gloves/protective cloths (40%) and infection control guidelines/protocols (10%) respectively in their working places. CONCLUSION: In addition to very high rates of NSIs, low safety practices including inadequate vaccination coverage, unavailability of infection control guidelines and other preventive facilities were reported in this study. Prevention of occupational infections among HCWs should be a priority. Formal training, by health authorities in the local area, about safe practices and availability of preventive facilities should be ensured regarding NSIs among HCWs

Frequency of severity of disability in patients with grade iII lumbar neural foraminal stenosis on magnetic resonance imaging

Background Low back pain is a common condition and carries substantial socioeconomic implications. Magnetic resonance imaging (MRI) is the imaging modality of choice with lumbar neural foraminal stenosis being one of the most common causes of lower back pain syndromes. Studies have shown a lack of correlation between patients\u27 severity of disability and radiologically determined nerve root constriction. Therefore, the goal of this study will be to determine the frequency of severity of disability in patients with severe (i.e., grade III) lumbar neural foraminal stenosis on MRI to ascertain the impact of MRI diagnosis on clinical outcomes. Materials and methods Two hundred fifty patients of either gender with a history of backache referred for MRI were included by purposive sampling. Of these 250 patients, 27 patients had grade II lumbar neural foraminal stenosis, and 21 had grade I neural foraminal stenosis on MRI and were excluded. Thirty-two patients had a spinal infection (e.g., tuberculosis), and 24 patients had a history of trauma. Further, 31 patients were having follow-up scans for previously diagnosed lumbar neural foraminal stenosis. Hence, after excluding these cases, 115 patients were enrolled in this cross-sectional study with grade III lumbar neural foraminal stenosis on MRI. Results The mean age was 51 years (range: 20 to 82 years). Most of the patients (55.6%) were older than 50 years. The most common site of grade III lumbar neural foraminal stenosis was L4-L5 (56.5%). According to the Oswestry disability index, 47 patients (40.9%) had a severe disability, 32 (27.8%) had a moderate disability, 16 (13.9%) were diabled, 14 (12.2%) had a mild disability, and six (5.2%) were bedridden. Conclusions While MRI is the imaging modality of choice in degenerative lumbar spinal stenosis, clinical disabilities can be more extensive than what radiological findings may indicate in approximately 40% of the cases. Therefore, lumbar spinal stenosis should be a neuro-radiological diagnosis, and surgical decisions should be based on clinical scenarios in addition to MRI findings

Stents and stent mimickers in endovascular management of wide-neck intracranial aneurysms

Subarachnoid hemorrhage due to a ruptured cerebral aneurysm is a disastrous event accounting for approximately 5%-15% of all stroke cases and has a high mortality rate. One of the major goals in the management of these patients is to prevent rebleeding by securing the aneurysm either surgically or by endovascular means. Endovascular treatment is considered the first line of treatment for intracranial aneurysms; however, wide-neck aneurysms (WNAs) are specifically difficult to treat by endovascular means due to the difficulty in achieving a stable coil mass inside the aneurysm sac. To overcome this problem, assisted endovascular treatment techniques and devices have evolved over the years. Amongst these, stent-assisted coiling (SAC) techniques provide a scaffold for coil embolization. The concept of the stent-assisted technique inspired creative pioneers to invent new tools like the PulseRider (Pulsar Vascular, Inc. CA, USA) and the pCONUS (Phenox GmbH, Germany), which are a great help in managing wide-neck and bifurcation aneurysms. The concept of stent within stents and its related hemodynamic effect has led to the novel development of flow diverters for reconstructing the arterial wall and correcting the hemodynamic disturbances. In this article, we review the stents and stent-like devices currently in practice for the endovascular management of wide-neck and branch intracranial aneurysms

To identify the features differentiating peritoneal tuberculosis from carcinomatosis on CT scan abdomen taking omental biopsy as a gold standard

OBJECTIVE: To differentiate peritoneal tuberculosis from carcinomatosis on computed tomography scan of abdomen, taking omental biopsy as the gold standard.. METHODS: This retrospective diagnostic accuracy review of cases was conducted at Aga Khan University Hospital, Karachi, and comprised patient\u27s medical record files from February 2007 to February 2016. Computed tomography scan findings were compared with diagnosis made on the basis of histopathology. Multiple logistics regression analysis was done and sensitivity and specificity were tested through Pearson chi square test. RESULTS: Of the 98 patients identified, 62(63.2%)were found to be cases of disseminated tuberculosis and 36(36.7%) were diagnosed as malignant on histopathology. Computed tomography features were significantly specific to differentiate abdominal tuberculosis from carcinomatosis (p=0.004). On computed tomography,4 findings showed statistical significance: Smooth thickening of the peritoneum (p\u3c0.001), abdominal mass (p=0.03), lymph node necrosis (p=0.024) and high-density ascitic fluid (p\u3c0.001). Out of these, smooth thickening of the peritoneum (sensitivity=77%; specificity=86.1%) and high-density ascitic fluid (sensitivity=68.9%; specificity=72.2%) were more specific findings. Overall, the sensitivity and specificity of computed tomography was found to be 88.5% and 83.3%, respectively. CONCLUSIONS: Although no single finding on a computed tomography scan was diagnostic proof of peritoneal tuberculosis, a combination of findings could reliably distinguish between peritoneal tuberculosis and carcinomatosis

Acquired Uterine Vascular Anomaly: Experience from a tertiary care center in Pakistan

Objective: To retrospectively review imaging findings and the outcomes of uterine artery embolization (UAE) in symptomatic uterine vascular anomalies. Methods: We identified 15 cases of acquired uterine vascular anomaly from 2010 to 2020 who were evaluated with ultrasound, computed tomography, and magnetic resonance imaging, either alone or in combination. All patients had history of dilatation and curettage or uterine instrumentation. They underwent angiography and embolization of the uterine arteries. Primary outcome post embolization was assessed clinically and/or in combination with ultrasound. Post procedure pregnancies were also recorded. Results: Non-invasive imaging was abnormal in all patients, however this pre intervention imaging was unable to accurately classify the type of vascular anomaly except in the case of pseudoaneurysm. Conventional angiography showed uterine artery hyperemia in 6, arteriovenous malformation in 7 and pseudoaneurysm in 2 patients. The technical success rate was 100% with no repeat embolization needed. Follow up ultrasound in 12 patients revealed resolution of abnormal findings, remaining three were normal on clinical follow up. Seven patients (46.7%) had a normal pregnancy, 15.7 months after the procedure (range 4-28 months). Conclusion: UAE is a safe and effective management option for intractable severe bleeding in patients with uterine vascular anomaly post instrumentation and is seen not to impair future pregnancy. Keywords: Uterine artery embolization; Pseudoaneurysm; Arteriovenous malformation; Ultrasound; Computed tomography; Magnetic resonance imaging

Embolization with Histoacryl Glue of an Anastomotic Pseudoaneurysm following Surgical Repair of Abdominal Aortic Aneurysm

We report a 62-year-old female who had surgical repair of abdominal aortic aneurysm with a bifurcated graft 2 years ago. She presented with a distal anastomotic pseudoaneurysm which was successfully embolized with histoacryl glue. Only one such similar case has been reported in the literature so far (Yamagami et al. (2006))