Stroke patients may be treated as late as 24 hours after Ictus

A study presented at the European Stroke Organization conference in Prague showed that treatment for severe-stroke patients as late as 24 hours after a stroke can restore brain function.

The study employed a clot-retrieval device from Stryker Corp and was conducted on 206 patients with serious strokes at 32 hospitals in the U.S., Spain, France and Australia.

The researchers suggested that 40% of patients with severe stroke fit in this new window of opportunity. They were able to lower by 73% the risk that a patient would become dependent on another person or health care providers for help in their daily activities.

For the past two decades, the clot dissolving drug tPA was the primary treatment for ischemic stroke. But the drug was useful only until about 4 ½ hours after a stroke. Clot-retrieval devices widened that window to about 6 hours, but brain tissue was considered irreparably damaged after that.

As the results of this study are promising a larger trial should be conducted as initiating treatment in the first 6 hours after ictus is difficult even in the most well organized centers.  As clot retrievers are used approximately in 25,000 cases in the U.S. every year the issue of the length of opportunity to intervene should be settled.  Another issue that should be looked at is the role an intact and complete circle of Willis plays on how patients respond to treatment.  

Breast MRI is the study of choice for women at high risk for breast cancer.

According to a study published in Radiology Lo et al reviewed the outcomes of 3,934 screening breast studies (MRI and mammograms) performed on 1,249 high-risk women. A total of 45 cancers (33 invasive and 12 ductal carcinomas in situ) were diagnosed, 43 were seen with MR imaging and 14 with both mammography and MR imaging.   The cancer detection rate for MR imaging was 21.8 cancers per 1000 examinations and that for mammography was 7.2 cancers per 1000 examinations. Sensitivity and specificity of MR imaging were 96% and 78% respectively, and those of mammography were 31% and 89%, respectively (P < .001).  The researchers reported that all cancers found at screening mammography were also detected on breast MRI.  

The researchers concluded that annual screening mammography adds no value to women that are at high risk for breast cancer especially since they are screened each year with breast MRI.

Coronary Artery Calcium Score may serve as guide for the treatment of Hypertension

A study by McEvoy et al published in Circulation determined that computed tomography of the heart used to detect coronary artery calcium levels (CAC) can assist in the creation of treatment plans for patients with high blood pressure.

Their study tracked 3,733 people whose mean age was 65 years and had a systolic blood pressure between 120 and 179 mm Hg.  During the study period that tracked the enrolled patients for over 10 years 642 events were detected. 

The researchers found that patients with calcium scores of zero who were at high risk of arteriosclerotic heart disease (ASCVD) their incidence of a heart attack or stroke was low. While patients with systolic blood pressure lower than 140 mm Hg and a low risk of heart disease that had a CAC of more than 100 their incidence of a heart attack or stroke was higher.

The authors concluded that CAC scoring and assessment of arteriosclerotic vascular disease may guide in the determination of selecting as a goal to achieve the traditional 140 mm Hg or a lower systolic blood pressure such as 120 mm Hg particularly among patients with an estimated ASCVD risk of 5-15% and prehypertension or mild hypertension.

Sonographic criteria in the diagnosis and treatment of appendicitis.

According to a study by Xu et al published in the Journalof Ultrasound in Medicine ultrasound can provide information regarding the preferred treatment i.e. proceed with appendectomy or try antibiotics first in patients with appendicitis.

The authors reviewed retrospectively sonographic studies of 119 patients with histopathologically proven appendicitis.  The diagnostic criteria and the preferred treatment in patients with suspected appendicitis was the presence or absence of the normally echogenic submucosal layer, the presence of mural hyperemia, periappendiceal fluid, appendicoliths, and hyperechoic periappendiceal fat and the maximum outside diameter.

Thirty-two (27%) of the 119 patients had complicated appendicitis, including 11 with gangrenous appendicitis without perforation and 21 with gangrenous appendicitis and perforation. Loss of the submucosal layer was the only independent significant indicator of complicated appendicitis (P < .001) and provided sensitivity and specificity values of 100.0% and 92.0% respectively.

The researchers concluded if loss of echogenic submucosal layer was detected at sonograpy the diagnosis of complicated appendicitis was likely and, therefore, surgery was necessary. On the other hand, when ultrasound did not show loss of the submucosal layer, antibiotic therapy should be tried, as the likely diagnosis is uncomplicated appendicitis.

MRI and TRUS biopsy in prostate cancer

A paper by Ahmed et al published in the Lancet suggests a quarter of men suspected of having prostate cancer could avoid potentially dangerous biopsies with the help of MRI scans.

The authors did a multicenter study and tested the diagnostic accuracy of Multi-parametric MRI (MP-MRI) and Transrectal ultrasound guided prostate biopsy (TRUS-biopsy) against template prostate mapping biopsy (TPM-biopsy). Men with prostate-specific antigen concentrations up to 15 ng/mL, with no previous biopsy, underwent 1·5 Tesla MP-MRI followed by both TRUS-biopsy and TPM-biopsy.  

The researchers enrolled 740 men, 576 of who underwent 1·5 Tesla MP-MRI followed by both TRUS-biopsy and TPM-biopsies.  Results from TPM-biopsy showed 408 (71%) of the men had cancer, including 230 (40%) men with clinically significant cancer.  When evaluating the 230 men with clinically significant cancer, the MP-MRI had correctly diagnosed 93% of the aggressive cancers, whereas TRUS-biopsy diagnosed only 48% as aggressive. This indicated that MP-MRI was more sensitive than TRUS-biopsy (P < .0001).  Of the 10 men with a negative MP-MRI scan, nine (89%) had no cancer or a harmless cancer.

However, TRUS-biopsy had greater specificity (96% vs. 41%) and positive predictive value (90% vs. 51%; P < .0001 for both) than MP-MRI.  Forty-four (5·9%) of 740 patients reported serious adverse events, including 8 cases of sepsis following biopsy.

This study shows that using the two tests could reduce overdiagnosis of harmless cancers by 5%, prevent one in four men from having an unnecessary biopsy, and improve the detection of aggressive cancers from 48% to 93%.

In conclusion given that prostatic cancer which is the most common cancer in men with about 176,000 new cases and the cause of death in 27,000 patients in the United States in 2013, MP-MRI is a promising diagnostic test in the effort to reducing over-diagnosis of clinically insignificant prostate cancers while improving the detection of clinically significant cancers.

Low Dose CT Lung Cancer Screening

Research by Kinsinger et al published in JAMA Internal Medicine revealed that “low dose CT scans” frequently produce false positives and demand considerable effort by both patients and requesting physicians.

The US Preventive Services Task Force recommends annual lung cancer screening (LCS) with low-dose computed tomography for current and former heavy smokers aged 55 to 80 years.

This clinical demonstration study was conducted at 8 academic VHA hospitals among 93 033 who met the criteria for LCS, 2106 agreed to undergo screening (2028 were men and 78 women; mean [SD] age, 64.9 [5.1] years).

Wide variation in processes and patient experiences occurred among the 8 sites. Of the 2106 patients screened, 1257 (59.7%) had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%) required further evaluation but the findings were not cancer, and 31 (1.5%) had lung cancer. A variety of incidental findings, such as emphysema, other pulmonary abnormalities, and coronary artery calcification, were noted on the scans of 857 patients (40.7%).

In conclusion the research, conducted in more than 2000 high-risk VHA patients aged 55 to 80 years found lung cancer in 1.5% of patients, but around 60% of individuals who were screened had 1 or more nodules that required follow up. In addition, incidental findings were reported in around 40% of patients. It is estimated that implementation of LCS in the VHA 6.7 million patients will lead to approximately 900000 patients being eligible for LCS and will require substantial clinical effort for both patients and staff.