Review of ocular syphilis

Davis, Janet L. “Ocular syphilis.” Current opinion in ophthalmology 25.6 (2014):513-8.

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What is the preferred imaging modality for necrotizing fasciitis?

Magnetic resonance imaging (MRI) is the most effective method for documenting the soft tissue lesions and evaluating their distribution.

In practice, several key points deserve emphasis:
• the absence of MRI abnormalities of the intermuscular fasciae virtually rules out necrotizing fasciitis
• the presence of gas (signal-free areas on all sequences) is highly specific but rare
• extensive thickening of the intermuscular fasciae with an appearance suggesting incomplete vascularization supports a diagnosis of necrotizing fasciitis
• the presence of lesions confined to the peripheral fasciae and to small portions of the adjacent intermuscular fasciae is of borderline significance

Malghem, Jacques, et al. “Necrotizing fasciitis: contribution and limitations of diagnostic imaging.” Joint bone spine 80.2 (2013):146-54.

A very important point is that imaging studies play only an ancillary role and must never delay the surgical treatment of deep necrotizing fasciitis, a condition whose outcomes, including patient survival, depend heavily on the promptness of appropriate therapy

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Diagnosing Chronic thromboembolic pulmonary hypertension

Go to: Chronic thromboembolic pulmonary hypertension (CTEPH)

Select Diagnosis on the left.

Making the diagnosis:
-suspect chronic thromboembolic pulmonary hypertension in patients with(1, 2)
-symptoms of progressive dyspnea on exertion and exercise intolerance
-pulmonary hypertension and history compatible with, but not limited
to, pulmonary embolism
-unexplained pulmonary hypertension
-diagnosis of chronic thromboembolic pulmonary hypertension typically includes
all of the following(1)
-pulmonary hypertension as demonstrated by transthoracic
echocardiography (TTE) and confirmed by right heart catheterization
-systolic pulmonary artery pressure > 40 mm Hg, and mean pulmonary
artery pressure > 25 mm Hg at rest
-pulmonary vascular resistance > 3 Wood units (240 dynes-second-cm-5)
-abnormal pulmonary angiogram or ventilation-perfusion (V/Q) scan showing
persistent obstruction of main, lobar, segmental, or subsegmental pulmonary
arteries despite 3 months of therapeutic anticoagulation
-exclusion of other causes of pulmonary hypertension including exclusion of
left-sided heart disease by pulmonary capillary wedge pressure < 15 mm Hg

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Review of calciphylaxis

Nigwekar, Sagar U, et al. “Calciphylaxis: risk factors, diagnosis, and treatment.” American journal of kidney diseases 66.1 (2015):133-46.

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Review of pyoderma gangrenosum

Gameiro, Ana, et al. “Pyoderma gangrenosum: challenges and solutions.” Clinical, Cosmetic and Investigational Dermatology 8(2015):285-93.

Posted in Diagnosis, EUH, Prognosis, Therapy | Tagged

Use of cholesterol in diagnosis of exudative effusion

Results of systematic review state, “The diagnosis of an exudate was most accurate if cholesterol in the pleural fluid was greater than 55 mg/dL (LR [likelihood ratio] range, 7.1-250), lactate dehydrogenase (LDH) was greater than 200 U/L (LR, 18; 95% CI, 6.8-46), or the ratio of pleural fluid cholesterol to serum cholesterol was greater than 0.3 (LR, 14; 95% CI, 5.5-38). A diagnosis of exudate was less likely when all Light’s criteria (a ratio of pleural fluid protein to serum protein >0.5, a ratio of pleural fluid LDH to serum LDH >0.6, or pleural fluid LDH >two-thirds the upper limit of normal for serum LDH) were absent (LR, 0.04; 95% CI, 0.02-0.11).”

Wilcox, M E, et al. “Does this patient have an exudative pleural effusion? The Rational Clinical Examination systematic review.” JAMA: the Journal of the American Medical Association 311.23 (2014):2422-31.

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When should a head CT be performed prior to a lumbar puncture?

Lumbar puncture/Procedure considerations/Neuroimaging in Dynamed

The section on Testing to Consider Prior to Performing an LP in DynaMed’s entry for lumbar puncture summarizes two prospective cohort studies and lists clinical findings such as age and aspects of clinical history and specific neurologic findings that were predictive of cranial lesions that contraindicated LP: age > 60 years, immunocompromised status, history of central nervous system disease, history of seizure within 1 week, abnormal level of consciousness, and focal findings on neurological exam.

Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-33. 235 patients with suspected meningitis received CT before lumbar puncture. RESULTS: Abnormal CT in 24% of patients in the study; 5% had evidence of a mass effect. Factors associated with an abnormal head CT were age ≥ 60 years, immunocompromised, history of CNS disease, history of seizure within one week before presentation.

Gopal AK Cranial computed tomography before lumbar puncture: a prospective clinical evaluation. Arch Intern Med. 1999 Dec 13-27;159(22):2681-5. Of 113 patients with urgent circumstances necessitating CT, 15% of CTs showed new lesions but only 2.7% had lesions that contraindicated LP

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