Acquisitions thérapeutiques en médecine ambulatoire en 2012 [2012 literature findings in ambulatory internal medicine].

In 2012 several articles reported interesting findings for the ambulatory practice in internal general medicine. A negative rapid test for influenza does not rule out that diagnosis. A test assessing the walking speed in the elderly can help determining who would benefit from antihypertensive therapy. Antibiotic treatment has no benefit for acute uncomplicated rhinosinusitis and diverticulitis. Probiotics can reduce the risk of post-antibiotic diarrhea. Daily coffee intake could reduce mortality. Oral supplementation of calcium can be harmful to the cardiovascular system. Subclinical hyperthyroidism should be treated to prevent cardiovascular complications. Aspirin can prevent recurrences in case of a primary thromboembolic event. Local injection of corticosteroids under ultrasonographic guidance for plantar fasciitis can be a safe treatment. Ibuprofen can prevent acute mountain sickness.

Risk factor impact on blood flow velocities and clinical outcomes of stented cervical and intracranial stenoses: preliminary observations.

OBJECTIVES: The role of angioplasty/stenting procedures, neurointerventionist experience, vascular risk factors, medical treatment and blood flow velocities were analysed to identify possible causes of intra-stent restenosis (ISR) following stenting of cervical and/or intracranial arteries, assuming progressive atherosclerosis to be the shared mechanism in both territories. Patients. 26 cerebrovascular patients subjected to stenting of severe (≥85%) symptomatic or asymptomatic carotid stenoses or moderate-to-severe (≥50%) intracranial or vertebral stenoses were included. METHODS: Clinical, radiological and ultrasonographic follow-up data were analysed retrospectively. RESULTS: Overall, stenting of the internal carotid artery (ICA) induced significant reductions in peak systolic velocities at 2 years (96±31cm/s vs. 358.2±24.9cm/s at baseline). The procedure-related ischemic complications rate was 7.4% (one hemispheric stroke and one TIA). The rate of ISR≤50% was 8% in the ICA at 2 years; was 50% in the common carotid artery (CCA) at 1 year, with concomitant distal ICA stenosis in 75% of CCA stenting, but all ISR were asymptomatic. Patients with ISR of the ICA were significantly younger (56.8±4.5 vs. 71.3±3.6 years, P=0.042) and had significantly more risk factors (5.5±0.9 vs. 3±0.3, P=0.012). No ISR≥70% was detected. CONCLUSIONS: ISR is relatively infrequent and, when present, it is mild and asymptomatic. Restenosis is more frequent in younger patients and those with several risk factors, and it may also be related to stenting of previous carotid endarterectomy.

The Atherosclerosis Burden Score (ABS): a Convenient Ultrasound-Based Score of Peripheral Atherosclerosis for Coronary Artery Disease Prediction.

Ultrasonographic detection of subclinical atherosclerosis improves cardiovascular risk stratification, but uncertainty persists about the most discriminative method to apply. In this study, we found that the "atherosclerosis burden score (ABS)", a novel straightforward ultrasonographic score that sums the number of carotid and femoral arterial bifurcations with plaques, significantly outperformed common carotid intima-media thickness, carotid mean/maximal thickness, and carotid/femoral plaque scores for the detection of coronary artery disease (CAD) (receiver operating characteristic (ROC) curve area under the curve (AUC) = 0.79; P = 0.027 to <0.001 with the other five US endpoints) in 203 patients undergoing coronary angiography. ABS was also more correlated with CAD extension (R = 0.55; P < 0.001). Furthermore, in a second group of 1128 patients without cardiovascular disease, ABS was weakly correlated with the European Society of Cardiology chart risk categories (R (2) = 0.21), indicating that ABS provided information beyond usual cardiovascular risk factor-based risk stratification. Pending prospective studies on hard cardiovascular endpoints, ABS appears as a promising tool in primary prevention.

Automatic Segmentation of the Eye in 3D Magnetic Resonance Imaging: A Novel Statistical Shape Model for Treatment Planning of Retinoblastoma.

PURPOSE: Proper delineation of ocular anatomy in 3-dimensional (3D) imaging is a big challenge, particularly when developing treatment plans for ocular diseases. Magnetic resonance imaging (MRI) is presently used in clinical practice for diagnosis confirmation and treatment planning for treatment of retinoblastoma in infants, where it serves as a source of information, complementary to the fundus or ultrasonographic imaging. Here we present a framework to fully automatically segment the eye anatomy for MRI based on 3D active shape models (ASM), and we validate the results and present a proof of concept to automatically segment pathological eyes. METHODS AND MATERIALS: Manual and automatic segmentation were performed in 24 images of healthy children's eyes (3.29 ± 2.15 years of age). Imaging was performed using a 3-T MRI scanner. The ASM consists of the lens, the vitreous humor, the sclera, and the cornea. The model was fitted by first automatically detecting the position of the eye center, the lens, and the optic nerve, and then aligning the model and fitting it to the patient. We validated our segmentation method by using a leave-one-out cross-validation. The segmentation results were evaluated by measuring the overlap, using the Dice similarity coefficient (DSC) and the mean distance error. RESULTS: We obtained a DSC of 94.90 ± 2.12% for the sclera and the cornea, 94.72 ± 1.89% for the vitreous humor, and 85.16 ± 4.91% for the lens. The mean distance error was 0.26 ± 0.09 mm. The entire process took 14 seconds on average per eye. CONCLUSION: We provide a reliable and accurate tool that enables clinicians to automatically segment the sclera, the cornea, the vitreous humor, and the lens, using MRI. We additionally present a proof of concept for fully automatically segmenting eye pathology. This tool reduces the time needed for eye shape delineation and thus can help clinicians when planning eye treatment and confirming the extent of the tumor.

Gravidez após transplante hepático

The objective of the present study is to report a sucessful pregnancy in a 28 year-old female who underwent an orthotopic liver transplantation two years ago due to type I auto immune he patitis. Patient was taking cyclosporin, prednisone and azathioprine for maintenance immunossupression and had good graft function during all the pregnancy. The liver function tests were normal during the pregnancy. Fetal growth was monitored by ultrasonographic examination and showed normal development. At the end of the third trimester, she was subjected to a cesarean bearing a healthy girl weighting 2,320 kg. She was discharged with normal liver functions tests and no complications.

Abscesso intrabdominal tardio pós colecistectomia laparoscópica

Perforation of the gallbladder during laparoscopic cholecystectomy may be associated with intraperitoneal gallstone spillage. Several complications secondary to lost gallstones in the abdominal cavity have been described. We report a rare complication of abdominal abscess secondary to two gallstones left in the abdominal cavity. A 75-year-old female presented with spontaneous drainage of pus through the umbilicus five years after laparoscopic cholecystectomy. An ultrasonographic evaluation of the abdomen revealed a solid mass of 56x26 mm of diameter, with acoustic shadow, localized distal to the umbilicus. At laparotomy, an abscess with two biliary calculi was drained. The patient had good recovery, with no complication.

Gravidez ovariana íntegra: tratamento cirúrgico videolaparoscópico

The intact ovarian pregnancy is an extremely rare condition. We report the case of a 34- years old woman case, nuliparus, with no previous clinical history of pelvic disease. An intact right ovarian pregnancy was diagnosed by a transvaginal ultrasonographic exam. A video-laparoscopy surgery was undertaken and only the ectopic tissue was removed. The authors discuss the effectiveness of the diagnostic tools and the surgical approach.

Predictive factors for voiding dysfunction after transobturator slings

PURPOSE: To identify the predictive factors for voiding dysfunction after transobturator slings. METHODS: We retrospectively reviewed the records of all patients who underwent a transobturator sling between March 2003 and December 2008. A total of 514 women had available data with at least a six-week follow-up. Patients' demographics, preoperative symptoms, urodynamic testing including multichannel voiding studies and surgical variables were tabulated. Voiding dysfunction was defined by a catheterized or ultrasonographic postvoid residual greater than 100 cc (≥six weeks after the procedure) associated with any complaints of abnormal voiding. Univariate logistic regression analysis was performed with respect to postoperative voiding dysfunction. RESULTS: The patient population had a mean age of 58.5±12.9 years. Thirty-three out of 514 patients (6.4%) had postoperative voiding dysfunction according to our definition, and 4 (0.78%) required sling transection. No differences were observed between normal and dysfunctional voiders in age, associated prolapse surgery, preoperative postvoid residual, preoperative urinary flow rate, prior pelvic surgery, and menopausal status. Valsalva efforts during the preoperative pressure flow study was the only predictive factor for postoperative voiding dysfunction, 72.4% dysfunctional versus 27.6% normal (p<0.001). CONCLUSION: Preoperative Valsalva maneuver during the micturition could identify those at risk for voiding dysfunction after transobturator sling, and it should be noted during preoperative counseling.

Correlation between placental thickness in the second and third trimester and fetal weight

PURPOSE: To investigate relationship between placental thickness during the second and third trimesters and placental and birth weights. METHODS: From January 2011 to June 2012, a total of 250 singleton pregnant women presented at our antenatal clinic were enrolled in this prospective study. All recruited women were assessed at the 1st trimester screening for baseline demographic and obstetric data. The placental thickness was measured trans-abdominally by placing the ultrasound transducer perpendicularly to the plane of the placenta, in the area of the cord insertion at second and third trimester. Pearson's correlation analysis was used to establish the degree of relationship between placental thickness and birth and placental weights. RESULTS: Of 250 recruited participants, 205 women were able to complete the study. The mean age of cases was 26.4±5.1. Values of mean birth and placental weights were 305.56±657.0 and 551.7±104.8 grams respectively. Ultrasonographic measures of placental thickness in second and third trimester and changes between them were 21.68±4.52, 36.26±6.46 and 14.67±5.67 mm respectively. There was a significant positive correlation between placental thickness and birth weight in the second and third trimesters (r=0.15, p=0.03; r=0.14, p=0.04 correspondingly). CONCLUSION: According to our study, birth weight has a positive relation with both second and third trimester placental thickness; however, placental thickness change could not predict low birth weight.

A and B mode ultrasonography in preoperative evaluation of lens and posterior segment of dogs eyes with cataract

Ultrasonography of the lens and posterior segment is an indispensable step in the preoperative evaluation of dogs with cataracts, since ophthalmoscopy is not feasible when there is opacification of the lens. This study evaluated the echographic conditions of cataractous lens and fundus of the eye in dogs affected by cataracts. The study was conducted in 30 dogs (56 eyes), 10 males and 20 females, with different types of cataracts at different stages of development. Echography in A and B modes, simultaneously, was carried out for the examination of the lens and posterior segment. The examinations revealed anterior cortical, posterior cortical and nuclear cataract in 12 eyes (21.4%), anterior cortical, posterior cortical, nuclear and posterior capsular in 23 eyes (41%), anterior cortical, posterior cortical and posterior capsular cataract in one eye (1.7%), anterior cortical and nuclear cataract in one eye (1.7%), anterior cortical, nuclear and posterior capsular cataract in five eyes (8.9%), and anterior cortical cataract in seven eyes (12.5%). Abnormal ultrasonographic alterations were observed in the posterior segment in 26 eyes evaluated (46.4%). Vitreal degeneration was detected in 12 eyes (21.4%), images of vitreal exudate or hemorrhage in seven eyes (12.5%), persistence of hyaloid artery in four eyes (7.1%) and lens subluxation in three eyes (5.3%). The results obtained reiterate the importance of ultrasonography in canine patients presented for cataract surgery given that alterations of the posterior segment are difficult to identify in a clinical examination when the lens is opacified.

Abdominal and pelvic ultrasound study of the maned wolf (Chrysocyon brachyurus)

The aim of the present study was the ultrasound characterization of the abdominal and pelvic regions of five maned wolves kept in captivity at the Triage Center of Wild Animals of the Federal University of Viçosa (Centro de Triagem de Animais Silvestres, Universidade Federal de Viçosa). This characterization included descriptions of ultrasonographic aspects and measurements of various structures using B-mode ultrasound. Biometric data were collected to assess the existence of significant linear correlations between these measurements and the measurements obtained by ultrasound. Additionally, hematological and serum biochemistry evaluations of the animals were performed. The ultrasound findings were similar to those available in the literature on domestic dogs, which were used for comparison as a result of the lack of published data regarding maned wolves. The latter species showed characteristics closely resembling those of the former, differing in the spleen and left renal cortex echogenicities, in the appearance of the prostatic and testicular regions and in the hepatic portal vein morphology. In the current study, the biometric values were similar to those previously published; however, no data regarding thoracic perimeter, modified crown-rump length or thoracic depth were found in the literature for this Canidae species. Statistical analysis showed the existence of a strong negative correlation between the modified crown-rump length and left renal length, between the modified crown-rump length and the right renal volume, between the thoracic perimeter and the height at the cranial pole of the left adrenal gland and between the thoracic perimeter and the height at the caudal pole of the left adrenal gland. Laboratory findings, including segmented neutrophil, eosinophil, monocyte and lymphocyte counts and the serum levels of glucose, ALT, alkaline phosphatase, urea, total protein, globulin, creatine phosphokinase, triglyceride, sodium, phosphate, potassium and chloride, were inconsistent with values found by other authors. The ultrasound is a diagnostic imaging method that must be further explored in the medicine of wild animals; therefore, additional research in this area is required.

Serial superficial digital flexor tendon biopsies for diagnosing and monitoring collagenase-induced tendonitis in horses

The purpose of this investigation was to demonstrate the feasibility of a biopsy technique by performing serial evaluations of tissue samples of the forelimb superficial digital flexor tendon (SDFT) in healthy horses and in horses subjected to superficial digital flexor tendonitis induction. Eight adult horses were evaluated in two different phases (P), control (P1) and tendonitis-induced (P2). At P1, the horses were subjected to five SDFT biopsies of the left forelimb, with 24 hours (h) of interval. Clinical and ultrasonographic (US) examinations were performed immediately before the tendonitis induction, 24 and 48 h after the procedure. The biopsied tendon tissues were analyzed through histology. P2 evaluations were carried out three months later, when the same horses were subjected to tendonitis induction by injection of bacterial collagenase into the right forelimb SDFT. P2 clinical and US evaluations, and SDFT biopsies were performed before, and after injury induction at the following time intervals: after 24, 48, 72 and 96 h, and after 15, 30, 60, 90, 120 and 150 days. The biopsy technique has proven to be easy and quick to perform and yielded good tendon samples for histological evaluation. At P1 the horses did not show signs of localised inflammation, pain or lameness, neither SDFT US alterations after biopsies, showing that the biopsy procedure per se did not risk tendon integrity. Therefore, this procedure is feasible for routine tendon histological evaluations. The P2 findings demonstrate a relation between the US and histology evaluations concerning induced tendonitis evolution. However, the clinical signs of tendonitis poorly reflected the microscopic tissue condition, indicating that clinical presentation is not a reliable parameter for monitoring injury development. The presented method of biopsying SDFT tissue in horses enables the serial collection of material for histological analysis causing no clinical signs and tendon damage seen by US images. Therefore, this technique allows tendonitis to be monitored and can be considered an excellent tool in protocols for evaluating SDFT injury.

Ovarian and uterine periovulatory Doppler ultrasonography in bitches

This paper aims to describe the uterine and ovarian ultrasonographic characteristics and Doppler velocimetric features of their arteries in bitches during the periovulatory period. Fifteen estrous cycles in 10 animals were evaluated. The ultrasonographic characteristics, resistance indices (RI) and pulsatility indices (PI) of the uterus and ovaries in each animal were recorded 5 days before and after ovulation (D0). The data were statistically analyzed, and the results were expressed as the mean ± standard error of mean (P<0.05). In results the ultrasonographic features of the uterus were the same on all of the cycles and evaluated days. The uterus had an average diameter of 0.85±0.02cm. An increase in the volume of the ovaries and the diameter of the ovarian follicles were measured. Ovaries had a volume of 0.64±0.06cm³, and the follicles cavities had a diameter of 0.46 ± 0.01 cm on the day of ovulation. After ovulation, it was observed that some follicles not collapse in some cycles. Two days prior to ovulation, the uterine blood perfusion decreased. This decrease remained unchanged until ovulation. Following ovulation, we measured a gradual increase in the uterine perfusion and in the ovarian artery. This artery directed blood flow to the ovaries and increased the intra-ovarian perfusion on the day after ovulation. In conclusion, specific features are observed in the uterus and ovarian ultrasound image and Doppler values of their arteries presented on the periovulatory days and when associated allow to estimate more accurately the date of ovulation.

The role of B-mode ultrasonography in the musculoskeletal anatomical evaluation of the cervical region of the dog spine

This study characterized the normal musculoskeletal anatomy of the cervical segment of the spine of dogs by means of B-mode ultrasonography. The objective was to establish the role of B-mode ultrasonography for the anatomical evaluation of the cervical spine segment in dogs, by comparing the ultrasonographic findings with images by computed tomography and magnetic resonance imaging. The ultrasound examination, in transverse and median sagittal sections, allowed to identify a part of the epaxial cervical musculature, the bone surface of the cervical vertebrae and parts of the spinal cord through restricted areas with natural acoustic windows, such as between the atlanto-occipital joint, axis and atlas, and axis and the third cervical vertebra. The images, on transverse and sagittal planes, by low-field magnetic resonance imaging, were superior for the anatomical identification of the structures, due to higher contrast between the different tissues in this modality. Computed tomography showed superiority for bone detailing when compared with ultrasonography. As for magnetic resonance imaging, in addition to the muscles and cervical vertebrae, it is possible to identify the cerebrospinal fluid and differentiate between the nucleus pulposus and annulus fibrosus of the intervertebral discs. Although not the scope of this study, with knowledge of the ultrasonographic anatomy of this region, it is believed that some lesions can be identified, yet in a limited manner, when compared with the information obtained mainly with magnetic resonance imaging. The ultrasound examination presented lower morphology diagnostic value compared with the other modalities.

Estrus cycle monitoring of captive collared peccaries (Pecari tajacu) in semiarid conditions

Collared peccaries (Peccary tajacu) are among the most hunted species in Latin America due the appreciation of their pelt and meat. In order to optimize breeding management of captive born collared peccaries in semiarid conditions, the objective was to describe and correlate the changes in the ovarian ultrasonographic pattern, hormonal profile, vulvar appearance, and vaginal cytology during the estrus cycle in this species. During 45 days, females (n=4) were subjected each three days to blood collection destined to hormonal dosage by enzyme immunoassay (EIA). In the same occasions, evaluation of external genitalia, ovarian ultrasonography and vaginal cytology were conducted. Results are presented as means and standard deviations. According to hormonal dosage, six estrous cycles were identified as lasting 21.0 ± 5.7 days, being on average 6 days for the estrogenic phase and 15 days for the progesterone phase. Estrogen presented mean peak values of 55.6 ± 20.5 pg/mL. During the luteal phase, the high values for progesterone were 35.3 ± 4.4 ng/mL. The presence of vaginal mucus, a reddish vaginal mucosa and the separation of the vulvar lips were verified in all animals during the estrogenic peak. Through ultrasonography, ovarian follicles measuring 0.2±0.1 cm were visualized during the estrogen peak. Corpora lutea presented hyperechoic regions measuring 0.4±0.2 cm identified during luteal phase. No significant differences (P>0.05) between proportions of vaginal epithelial cells were identified when comparing estrogenic and progesterone phases. In conclusion, female collared peccaries, captive born in semiarid conditions, have an estral cycle that lasts 21.0±5.7 days, with estrous signs characterized by vulvar lips edema and hyperemic vaginal mucosa, coinciding with developed follicles and high estrogen levels.