[ ISSN : 2573-3680 ]
Intravenous Urography (IVU) has been used in emergency departments for the evaluation of patients with acute renal and urinary tract colic. A non-contrast computed tomography (NCCT) is rapidly becoming the preferred imaging modality for the evaluation of patients with suspected renal colic. The purpose of this work is to investigate whether NCCT can replace IVU as the primary modality for the evaluation of patients with acute renal colic in radiology departments at four hospitals from the perspective of comprehensive diagnosis of both techniques. The methods employed in this study monitor and review the radiological investigation records of 520 patients with acute renal calculi who visited four hospitals between April 2016 and March 2017 and analyse the use of IVU and NCCT. Patients have been adopted based on their radiological examinations records for renal colic in four hospitals. NCCT showed a more comprehensive diagnosis and a short study time, whereas IVU indicated a lower radiation dose and better cost-effectiveness. An intravenous urogram (IVU) showed 81% sensitivity and 89% specificity, while non-contrast computed tomography (NCCT) had sensitivity and specificity of 95% and 97%, respectively. In conclusion, NCCT is highly sensitive and specific for renal and ureteral calculi but the challenges it faces are that CT examination generates higher radiation doses compared to examination by IVU, even when using a low radiation dose CT protocol
The renal system is the one of the most common organs to be affected by renal calculi. Urolithiasis and renal colic are common conditions affecting up to 15% of the population during their lifetime [1]. The incidence is approximately 122 in 100,000 outpatient visits; recurrence rates of urinary calculi can reach 50% in 10 years [2]. Intravenous Urogram (IVU) has been used for renal colic investigation but it requires an intravenous contrast with inherent potential toxicity [3].
The accuracy of imaging modalities, such as plain radiography (kidney, ureters, bladder (KUB)), IVU, ultrasound (US), and magnetic resonance imaging (MRI) are the most common radiographic models for different procedures. The sensitivity of plain radiography ranges from 45% to 60%, thus providing limited value for the diagnosis of renal stones [4].
US have demonstrated sensitivity as high as 79% but are less useful in obese patients and in those with mid-ureteral calculi [5]. MRI is highly accurate for diagnosing hydronephrosis in patients presenting with renal colic but it requires conscious sedation, particularly for child patients, which entails a protracted procedure as well as being a claustrophobic experience, particularly owing to the use of a long tunnel. Recently, multi-slice computed tomography has demonstrated a sensitivity and specificity for diagnosing patients with renal colic [6] which has encouraged radiologists to favour using this technique. This is because it offers relative advantages over the other models, especially regarding imaging by IVU. However, it requires high radiation doses.
The selected methodology for this study is retrospectively reviewed radiological examinations for 520 patients with renal colic who were referred to the radiology departments of four hospitals between April 2016 and March 2017.
A prospective study is conducted regarding values of NCCT and IVU in detection of renal calculi performed by radiologists in these 4 hospitals. Probing of the renal stone exposed by conventional X-ray and CT scans for a specific number of cases was done in each hospital.
IVU was taken in a standard fashion with 80-100 mL of nonionic contrast medium. NCCT was executed using multi-slice CT scanners. The anatomic and collimation region between the twelfth thoracic vertebral region and symphysis pubis was exposed. CT scans were taken with 3-mm collimation on a pitch of 1.5 and no contrast medium was given. Statistical graphs were created using Microsoft Excel ver. 10 (Microsoft Office Inc., USA). There was a change in the proportion of patients who underwent imaging studies during the study period. The percentages of patients in the four hospitals have been identified through existing radiological investigations records for each hospital. Cases that have not completed the conditions for the investigation of renal colic were excluded.
The rate of cases in each of the four hospitals for 520 patients have been adopted based on the radiology departments records that were found and that had a radiological examination for renal colic in the period from April 2016 to March 2017. 65% of the patients in hospitals that tend not to use NCCT scanning for patients with renal colic relied on CT, whereas 35% used IVU.
The mean age of the patients was 20.5 ± 50.10 years. Of the 520 patients, 74.9% were men. They visited radiology departments for renal colic investigation at the four hospitals: 30.8% of the patients attended A-Hospital, (300 beds); 25.9% attended B-Hospital, (150 beds); 24.5% attended C-Hospital 100 beds; and 18.8% attended D-Hospital, (200 beds).
Of the patients who attended A-hospital, 145 were evaluated by NCCT, IVU was performed for 6 patients (0.5%) and 4 patients were confirmed by conventional CT. In B-hospital, a total of 135 patients were evaluated immediately by NCCT, with 16 patients relying on IVU. At C-hospital, 60 patients were assessed by NCCT. A further 68 patients were assessed by conventional X-ray (KUB) and then followed by IVU; with 2% of them being confirmed by conventional CT. At D-hospital, 96 patients were evaluated by IVU and 80 patients were referred for conventional CT for confirmation (see Figure 1).
Figure 1: The ratio of patients at each hospital receiving radiologic investigations.
NCCT and IVU were performed to diagnose renal stones at the renal collecting system, ureter and urinary bladder from April 2016 to March 2017 in all hospitals. For both techniques, radiographic images were selected for each anatomical location. 40.2% were diagnosed at the renal collecting system (Figure 2), 39.7% were diagnosed with ureter stones (Figure 3), and 20.1% for urinary bladder (Figure 4).
Figure 2: Radiographic images diagnosed at the renal collecting system.
Figure 3: Radiographic images diagnosed at the ureter stones.
Figure 4: Radiographic images diagnosed at the urinary bladder
The proportion of patients diagnosed by NCCT at all locations increased significantly to 83%, whereas just 17% of patients had IVU (Table 1).
Table 1: Patient’s ratio in (%) diagnosed with renal colic in the 4 hospitals.
The reliability of diagnosis (no need confirmation), cost, study time and radiation exposure of NCCT and IVU are illustrated in Table 2.
Table 2: Comparison of comprehensive diagnosis, cost, study time and radiation exposure among imaging modalities.
Whereas NCCT showed a more comprehensive diagnosis in a short study time, IVU required a lower radiation dose and offered better cost-effectiveness. An intravenous urogram, IVU showed 81% in sensitivity and 89% specificity (Figure 5). In the case of NCCT, its sensitivity and specificity were 95% and 97% respectively.
This study has demonstrated that there was a significant increase in the use of NCCT for patients with renal colic in the 4 hospitals during the period from March 2016 to April 2017. Previous studies have demonstrated that CT has been introduced to evaluate renal colic and it has proved to be an effective modality for the diagnosis of urinary calculi [6,7].
In this work, the use of alternative imaging modalities (i.e. CT or IVU) were monitored, thereby demonstrating that CT use significantly increased and IVU use decreased in most 4 hospitals during the period of study. In three hospitals (A, B and D) between 2016 and 2017, fewer IVU procedures were ordered for patients with renal colic than were ordered to follow-up. Although the number of IVU procedures increased significantly at C-hospital, it would be thought that this was incongruous because follow-up CT was performed in just 5% of cases. Compared with IVU, the reported sensitivity of NCCT for evaluating patients with suspected renal calculi was 95% and its specificity was 97% [8,9]. NCCT showed higher sensitivity and specificity than did IVU in this respect because all urinary tract calculi could be identified by NCCT [10].
Moreover, NCCT could evaluate the severity of the ureter obstructions [11].
The advantage of NCCT over IVU is the rapid image acquisition time, advanced image quality, and the fact that it can be performed without requiring a contrast medium, thereby avoidingany risk of contrast-induced adverse reactions, which can occur in patients who undergo IVU [12].
IVU was the traditional examination for the assessment of urinary stone disease and it does provide physiological information relating to the degree of obstruction. However, it could give falsepositive results due to phleboliths adjacent to the ureter. In some cases, NCCT may be needed to detect it in the ureter. Urinary calculi might be un-diagnosable with IVU in patients who had urographic findings of unilateral ureteral obstruction due to small stone size or a lack of stone radiolucency [13]. The drawbacks with IVU are that patients with renal colic associated with renal insufficiency have contraindications for IVU owing to the potential nephrotoxicity of the contrast material. IVU is less sensitive than CT, especially for small or non-obstructing stones [11]. Patients with urinary calculi are at increased risk of excessive radiation exposure due to the repetition of radiographic examinations [14,15].
There is also concern about an increased cancer risk resulting from the radiation exposure associated with repeatable medical imaging [16]. The disadvantage with NCCT is the high radiation exposure [17]. Although examination costs vary among hospitals; many of them charge less for CT scans that are performed without a contrast medium because the use of NCCT eliminates the cost of the contrast medium. Conversely, the cost of CT equipment is higher than that required for IVU but the room time for CT is less than that for IVU [18].
Most radiologists in four hospitals tend to be more comfortable with NCCT investigation for renal colic cases. NCCT when compared with IVU is a relatively quick test to perform for the evaluation of patients with suspected renal colic. NCCT is highly sensitive and specific for renal and ureteral calculi. More importantly, it allows visualisation of alternative pathology.
In addition, secondary signs are seen that assist with determining obstructions and are helpful if no stone is visualised as phleboliths, which can simulate a stone, are rarely seen in young adults. It is believed that NCCT allows for rapid triage and localisation of kidney stones. In spite of the advantages offered by this technique, it requires higher radiation doses than IVU. In contrast, IVU provides more information with regards to the function of the urinary system. This study may contribute to the issue of the privatization of radiology departments in hospitals of the Ministry of Health.
1. Parmar MS. “Clinical review, Kidney stones”. BMJ. 2004; 328: 1420.
Alrwaili A. A Non-Contrast Computed Tomography and Intravenous Urography Interrogation in Patients with Renal Colic at Hospitals. SM J Clin Med. 2018; 4(2): 1036.
The purpose of this statement is none other than to highlight the importance of ethical standards and quality required in basic and applied research currently being done so we can subsequently inform health care professionals of new developments that are taking place in this area.
Ma. Esperanza Rodríguez-van Lier*
Chemotherapy is commonly used in cancer treatment. So far, chemotherapy agents can be categorized into three types: classical chemotherapeutic drugs, molecular target agents and cellular machineries target drugs.
Ziyou Wang1,2 and Zunnan Huang1,2*
Blood transfusion can cause some transfusion adverse reactions. In order to understand the incidence of adverse transfusion reactions, we performed a meta-analysis in Chinese hospitals. Of 809 literatures, seven studies involving a total of 211, 050 patients with blood transfusion treatment were included in this meta-analysis. Meta-analysis showed that the total incidence of adverse reactions was 0.4% [95% CI (0.2, 0.9), P < 0.0001]. Further subgroup analysis showed that the incidence of febrile and allergic reactions was 0.2% [95% CI (0.1, 0.5), P < 0.0001] and 0.2% [95% CI (0.1, 0.3), P < 0.0001], respectively. The common blood components caused adverse reactions were red blood cell, plasama, and platelet in clinical practice.
Yulu Gao1 , Qinyun Li2 , Zongshuai Gao2 , Yunxia Zhu4 , Yanqiu Liao5 , Changtai Zhu2 *# , Yongning Sun3 *#
Background: CT scanning remains one of the most routinely used diagnostic tools in a setting of Interstitial Lung Disease (ILD). New and improved technologies, such as High Resolution Computer Tomography (HRCT) have revolutionized the quality of imaging, leading to a prominent increase in number of incidental findings that may or may not be of any clinical significance. The aim of this study was to evaluate the prevalence of incidental findings on thoracic CT and their clinical significance.
Methods: Retrospective analysis was conducted on a cohort of 84 patients referred to our academic center as cases of ILD. Patients were referred for further evaluation between January 2000 and January 2014 and were followed over the disease course. CT scans were done annually as part of clinical management and patients were screened for any incidental findings. All incidental findings were reviewed, recorded in a clinical database and followed up on subsequent visits.
Results: 25 (30%) patients were found to have incidental findings. Liver abnormalities were found in 12 (14.29 %) patients. 11(13.10 %) patients were reported to have coronary artery calcifications. 5 (5.95 %) and 3 (3.57%) patients had thyroid abnormalities and renal cysts, respectively. A malignant lesion was found in 1 patient each in liver and thyroid abnormality subgroup.
Conclusion: Incidental findings are common on thoracic CT scans providing valuable and unexpected findings which warrant investigation by health care providers to exclude malignant processes.
Sonu Sahni1,2*, Sameer Verma1,2, Reeju S Thomas1 , Barbara Capozzi3 and Arunabh Talwar1,2
Hepatitis C Virus infection (HCV) is an increasing public health concern with an estimated 184 million people infected worldwide and approximately 350.000 yearly deaths from HCV-related complications.
Nesrine Gamal and Pietro Andreone*
We report a case of large cell undifferentiated lung carcinoma in a middle aged patient with previously treated tuberculosis and scarring. 20 pack years of smoking history was noted. He presented with metastasis at multiple sites including trochanter, liver and acute bilateral lateral rectus palsy. Chest radiography showed fibrosis of right upper zone with homogenous opacity. Sputum examination for AFB was negative. Computerized tomography of the thorax showed an irregular heterogeneously enhancing mass involving right upper lobe with cavitation, necrosis along with lymph node involvement and the erosion of the 4th rib with liver metastasis. Radiography of hip joint was suggestive of lesser trochanteric metastasis. MRI brain was suggestive of mass at base of brain in parasellar area. Fine needle aspiration cytology and CT guided biopsy confirmed undifferentiated large cell carcinoma of lung. Tuberculosis and smoking may increase the risk of lung scarring and malignancy and pulmonary scarring may be associated with increased lung carcinoma in ipsilateral lung. Clinician needs to be more sensitive to look for malignancy association particularly in patient with or previously treated for tuberculosis and even more emphasis to be laid if scarring of lung is observed.
Sreenivasa Rao Sudulagunta1 *, Shyamala Krishnaswamy Kothandapani2 , Mahesh Babu Sodalagunta3 , Hadi Khorram2 , Mona Sepehrar4 and Zahra Noroozpour1
Systemic Sclerosis (SSc) is a connective tissue disease characterized by fibrosis of the skin and internal organs, pronounced alterations in the microvasculature and frequent cellular and humoral immunity abnormalities. The rheumatic involvement of SSc is polymorphic and can reveal the disease or may appear during the course of its progression. Musculoskeletal involvement is dominated by non specific arthralgia, polyarthritis, and bony resorption especially acro-osteolysis. The diagnosis of these rheumatic manifestations is generally based on x rays examination. Musculoskeletal involvement in SSc is generally relieved with Non Steroidal Anti-Inflammatory Drugs (NSAID) or low dose of corticotherapy. The immunosuppressive therapy is used in corticoid-resistant or corticoid-dependent forms such us méthotrexate. The aim of our review is to presents an overview of the different osteoarticular and muscular involvement in SSc, their diagnosis and management.
Nessrine Akasbi*, Fatima Ezzahra Abourazzak and Taoufik Harzy
Sedigheh Mirhashemi1 , Mohammad Hosein Kalantar Motamedi1 *, Amir Hossein Mirhashemi2 and Hamid Reza Rasouli1
We encountered two autopsy cases of huge cardiomegaly with over 1000g in weight. Histochemical characteristics were examined using conventional staining including HE and Azan stains and immunohistochemical staining using antibodies against Complement Component 9 (CC9), RNA Binding Protein Motif 3(RBM3), Endothelial Type NO Synthase (eNOS) and Hypoxic Inducible Factor1α (HIF1). The reactive area with anti CC9 antibody, which presumed to be a marker of hypoxic change of myocardium, overlapped with eosinophilic area by HE and basophilic one by Azan. Although the reactive area with anti CC9 antibody showed relatively weak in the cytoplasm by anti eNOS antibody and no in the nucleus of cardiocytes with anti RBM3 antibody, outside of the reactive area with anti CC9 antibody there were intensive reactivity with anti eNOS antibody in cytoplasm and in a nucleus with anti RBM3 antibody. Anti HIF1 antibody showed weak reactivity with cytoplasm of endocardial cardiocytes and no with cytoplasm of cardiocytes in another area. The results obtained from the present cases revealed that the hypoxic change was equivalent even though the cause of cardiomegaly was deferred between two cases, and conventional staining such as HE and Azan utilized to detect hypoxic change in the heart and immunohistochemical studies seemed to be a useful tool for clarifying the cascade of hypoxic changes in the myocardium.
Satoshi Furukawa1,2*, Mayumi Kataoka1 , Satomu Morita1,2, Akari Uno2 , Masahito Hitosugi2 , Hiroshi Matsumoto1,3 and Katsuji Nishi1,2
A 45-year-old woman with multiple sclerosis was admitted to our hospital after out of hospital cardio-pulmonary resuscitation. The first ECG showed ventricular fibrillation. Following direct current defibrillation and mechanical reanimation, spontaneous circulation was restored and the ECG unremarkable without any signs of ischemia. Coronary angiography showed unobstructed coronary arteries Figure 1, (Panel A). Left ventriculography revealed apical wall obstruction, suggestive of apical aneurysm (Panel B, supplementary videos). Transthoracic echocardiography and Cardiac Magnetic Resonance Imaging (CMR) eventually lead to the diagnosis of a rare case of Apical Hypertrophic Cardiomyopathy (AHC) with ace of spades-form (Panel C,D). The patient underwent Cardioverter-Defibrillator Implantation (ICD) and amiodarone medical therapy for secondary prophylaxis. Patient’s family history and screening for HCM were unsuspicious.
Wiedemann S# *, Heidrich FM# , Speiser U and Strasser RH