Background The sensitivity and specificity of exercise testing have never been studied simultaneously against an objective quantification of arterial stenosis. Aims were to define the sensitivity and specificity of several exercise tests to detect peripheral artery disease (PAD), and to assess whether or not defined criteria defined in patients suspected of having a PAD show a difference dependent on the resting ABI. Methods In this prospective study, consecutive patients with exertional limb pain referred to our vascular center were included. All patients had an ABI, a treadmill exercise-oximetry test, a second treadmill test (both 10% slope; 3.2km/h speed) with post-exercise pressures, and a computed-tomography-angiography (CTA). The receiver-operating-characteristic curve was used to define a cut-off point corresponding to the best area under the curve (AUC; [CI95%]) to detect arterial stenosis ≥50% as determined by the CTA. Results Sixty-three patients (61+/-11 years-old) were included. Similar AUCs from 0.72[0.63–0.79] to 0.83[0.75–0.89] were found for the different tests in the overall population. To detect arterial stenosis ≥50%, cut-off values of ABI, post-exercise ABI, post-exercise ABI decrease, post-exercise ankle pressure decrease, and distal delta from rest oxygen pressure (DROP) index were ≤0.91, ≤0.52, ≥43%, ≥20mmHg and ≤-15mmHg, respectively (p<0.01). In the subset of patients with an ABI >0.91, cut-off values of post-exercise ABI decrease (AUC = 0.67[0.53–0.78]), and DROP (AUC = 0.67[0.53–0.78]) were ≥18.5%, and ≤-15mmHg respectively (p<0.05). Conclusion Resting ABI is as accurate as exercise testing in patients with exertional limb pain. Specific exercise testing cut-off values should be used in patients with normal ABI to diagnose PAD.
outine use of whole-body CT in the initial assessment of patients with severe trauma following a motor vehicle crash (MVC) is widely accepted and recommended by Advanced Trauma Life Support guidelines (1). It enables accurate diagnosis of injuries, even those not suspected at physical examination (2-4). Several retrospective studies have suggested that whole-body CT could reduce mortality in comparison to standard x-rays plus selective CT (5-9). However, in a prospective randomized trial, the REACT -2 study group (10) recently reported no reduction in mortality by using immediate whole-body CT in comparison to conventional imaging plus selective CT for patients suspected of having severe or life-threatening injuries. Nevertheless, many patients with an injury severity score lower than 16 were included. Furthermore, whole-body CT is responsible for a higher amount of radiation dose delivered to patients (10-12). In view of the known risks of injected CT (radiation exposure, renal and allergy risks, time, and cost) (13,14), debate continues about the risk-to-benefit ratio of systematic whole-body CT when no injury is clinically suspected. Indications for whole-body CT in France are based on the Vittel criteria. These criteria include physiologic variables, kinetic components (mechanism of injury), anatomic injuries, and resuscitation prior to admission (15). Vittel criteria were initially used for field triage and were later adopted for whole-body CT indications, which is performed when at least one criterion is present. An initial study (2) reported that 30% of wholebody CT examinations showed clinically unsuspected injuries when systematically performed for presence of one or more Vittel criterion. Only 15% of these wholebody CT-depicted injuries were considered to change patient treatment. Moreover, 64% of whole-body CT demonstrated no abnormalities. These findings underline the lack of specificity of the Vittel criteria as applied to whole-body CT for trauma.
Background Identifying the 30% of adhesive small bowel obstructions (aSBO) for which conservative management will require surgery is essential. The association between the previously described radiological score and failure of the conservative management of aSBO remains to be confirmed in a large prospective multicentric cohort. Our aim was to assess the risk factors of failure of the conservative management of aSBO considering the radiological score. Material and Methods This prospective observational study took place in 15 French centers over 3 months. Consecutive patients experiencing aSBO with no early surgery were included. The six radiological features from the Angers radiological computed tomography (CT) score were noted (beak sign, closed loop, focal or diffuse intraperitoneal liquid, focal or diffuse mesenteric haziness, focal or diffuse mesenteric liquid, and diameter of the most dilated small bowel loop > 40 mm). Results Two hundred and seventy nine patients with aSBO were screened. Sixty patients (21.5%) underwent early surgery, and 219 (78.5%) had primary conservative management. In the end, 218 patients were included in the analysis of the risk factors for conservative treatment failure. Among them, 162 (74.3%) had had successful management while for 56 (25.7%) management had failed. In multivariate analysis, a history of surgery was not a significant risk factor for the failure of conservative treatment (OR = 0.11; 95%CI = 0–1.23). A previous episode of aSBO was protective against the failure of conservative treatment (OR = 0.36; 95%CI = 0.15–0.85) and an Angers CT score ≥ 5 as the only individual risk factor (OR = 2.39; 95%CI = 1.01–5.69). Conclusion The radiological score of aSBO is a promising tool in improving the management of aSBO patients. A first episode of aSBO and/or a radiological score ≥5 should lead physicians to consider early surgical management.
Objective We aimed to assess the effects of remote ischemic pre-conditioning (RIPC) on the incidence of contrast-induced nephropathy (CIN) after an intravenous (IV) or intra-arterial injection of contrast medium (CM) in patient and control groups. Materials and Methods This prospective, randomized, single-blinded, controlled trial included 26 patients who were hospitalized for the evaluation of the feasibility of transcatheter aortic valve implantation and underwent investigations including contrast-enhanced computed tomography (CT), with Mehran risk scores greater than or equal to six. All the patients underwent four cycles of five minute-blood pressure cuff inflation followed by five minutes of total deflation. In the RIPC group (n = 13), the cuff was inflated to 50 mm Hg above the patient's systolic blood pressure (SBP); in the control group (n = 13), it was inflated to 10 mm Hg below the patient's SBP. The primary endpoint was the occurrence of CIN. Additionally, variation in the serum levels of cystatin C was assessed. Results One case of CIN was observed in the control group, whereas no cases were detected in the RIPC group ( p = 0.48, analysis of 25 patients). Mean creatinine values at the baseline, 24 hours after injection of CM, and 48 hours after injection of CM were 88 ± 32 µmol/L, 91 ± 28 µmol/L and 82 ± 29 µmol/L, respectively ( p = 0.73) in the RIPC group, whereas in the control group, they were 100 ± 36 µmol/L, 110 ± 36 µmol/L, and 105 ± 34 µmol/L, respectively ( p = 0.78). Cystatin C values (median [Q1, Q3]) at the baseline, 24 hours after injection of CM, and 48 hours after injection of CM were 1.10 [1.08, 1.18] mg/L, 1.17 [0.97, 1.35] mg/L, and 1.12 [0.99, 1.24] mg/L, respectively ( p = 0.88) in the RIPC group, whereas they were 1.11 [0.97, 1.28] mg/L, 1.13 [1.08, 1.25] mg/L, and 1.16 [1.03, 1.31] mg/L, respectively ( p = 0.93), in the control group. Conclusion The risk of CIN after an IV injection of CM is very low in patients with Mehran risk score greater than or equal to six and even in the patients who are unable to receive preventive hyperhydration. Hence, the Mehran risk score may not be an appropriate method for the estimation of the risk of CIN after IV CM injection.
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