Objective: Blood pressure (BP) is severely elevated at 16.3% and moderately elevated at 27.2% of hospital emergency department (ED) visits. Among ED patients with elevated BP, 50% to 70% have chronic hypertension. The aim of our study was to determine whether elevated systolic blood pressure (SBP) in the ED is associated with increased in-hospital mortality among hypertensive patients. Design and method: We retrospectively retrieved records of adult hypertensive patients who were hospitalized in one medical center during a five-year period (1/2013 – 12/2017). Patients were grouped according to initial ED SBP measurements; <90, 90 – 109, 110 – 139, 140 – 159, 160 – 179, 180 – 199, 200 – 219 and >220, mmHg. We examined the association between SBP measurements in the ED and in-hospital mortality rate, adjusted for the following ED features: demographics, mode of arrival, chief complaint, heart rate, known co-morbidities, laboratory results and type of hospitalization ward. Results: Overall, 198,784 hospitalizations were retrieved. Of those, 71,562 (36%) had a prior history of HTN. Among hospitalized hypertensive patients, adjusted in-hospital mortality rates versus initial ED SBP showed a “J” shape curve. Adjusted mortality rates were: 14.6%, 7.7%, 5.3%, 4.2%, 3.8%, 3.8%, 3.9% and 4.1% for SBP values of <90, 90 – 109, 110 – 139, 140 – 159, 160 – 179, 180 – 199, 200 – 219 and >220, mmHg, respectively. Conclusions: SBP measurements in the range of 140 – 200 mmHg were not associated with increased mortality in hospitalized hypertensive patients. Thus, elevated SBP in these ranges should not be an indication for hospitalization.

OBJECTIVE:To determine the role of abdominal CT in assessment of severity and prognosis of patients with acute gastrointestinal (GI) graft-vs-host disease (GVHD).METHODS:During 2000-2004, 41 patients with a clinical diagnosis of acute GI-GVHD were evaluated. CTs were examined for intestinal and extra-intestinal abnormalities, and correlated with clinical staging and outcome.RESULTS:20 patients had GVHD clinical Stage I-II and 21 had Stage III-IV. 39 (95%) had abnormal CT appearances. The most consistent finding was bowel wall thickening: small (n=14, 34%) or large (n=5, 12%) bowel, or both (n=20, 49%). Other manifestations included bowel dilatation (n=7, 17%), mucosal enhancement (n=6, 15%) and gastric wall thickening (n=9, 38%). Extra-intestinal findings included mesenteric stranding (n=25, 61%), ascites (n=17, 41%), biliary abnormalities (n=12, 29%) and urinary excretion of orally administered gastrografin (n=12, 44%). Diffuse small-bowel thickening and any involvement of the large bowel were associated with severe clinical presentation. Diffuse small-bowel disease correlated with poor prognosis. 8 of 21 patients responded to therapy, compared with 15 of 20 patients with other patterns (p=0.02), and the cumulative incidence of GVHD-related death was 62% and 24%, respectively (p=0.01). Overall survival was not significantly different between patients with diffuse small-bowel disease and patients with other patterns (p=0.31). Colonic disease correlated with severity of GVHD (p=0.04), but not with response to therapy or prognosis (p=0.45).CONCLUSION:GVHD often presented with abdominal CT abnormalities. Diffuse small-bowel disease was associated with poor therapeutic response. CT may play a role in supporting clinical diagnosis of GI GVHD and determining prognosis.

AIM: To determine CT features that can potentially differentiate right tubo-ovarian abscess (TOA) from acute appendicitis (AA; including abscess formation).MATERIALS AND METHODS: The abdominal computed tomography (CT) images of 48 patients with right-sided TOA (average age 39.3 +/- 9.8 years) and 80 patients (average age 53.5 +/- 19.9 years) with AA (24 with peri-appendicular abscess) were retrospectively evaluated. Two experienced radiologists evaluated 12 CT signs (including enlarged, thickened wall ovary, appendix diameter and wall thickness, peri-appendicular fluid collection, adjacent bowel wall thickening, fat stranding, free fluid, and extraluminal gas) in consensus to categorize the studies as either TOA or AA. The diagnosis and the frequency of each of the signs were correlated with the surgical and clinical outcome.RESULTS: Reviewers classified 92% cases correctly (TOA = 85%, AA = 96.3%), 3% incorrectly (TOA = 6.3%, AA = 1.3%); 5% were equivocal (TOA = 8.3%, AA = 2.5%). In the peri-appendicular abscess group reviewers were correct in 100%. Frequent findings in the TOA group were an abnormal ovary (87.5%), pen-ovarian fat stranding (58.3%), and recto-sigmoid wall thickening (37.5%). An abnormal appendix was observed in 2% of TOA patients. Frequent findings in the AA group were a thickened wall (32.5%) and distended (80%) appendix. Recto-sigmoid wall thickening was less frequent in AA (12.5%). The appendix was not identified in 45.8% of the TOA patients compared to 15% AA.CONCLUSIONS: In the presence of a right lower quadrant inflammatory mass, pen-ovarian fat stranding, thickened recto-sigmoid wall, and a normal appearing caecum, in young patients favour the diagnosis of TOA. An unidentified appendix does not contribute to the differentiation between TOA and peri-appendicular abscess. (C) 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

To assess the CT features of sealed rupture of abdominal aortic aneurysm.

AIM: To evaluate the prevalence and localization of the deposition of submucosal fat, the "fat halo sign" (FHS), using computed tomography (CT) in the bowel wall of patients with Crohn's Disease, and to assess its relation to the duration of the disease.MATERIALS AND METHODS: The abdominal CT examinations of 100 consecutive patients were reviewed for the presence of the FHS in the bowel wall. A measurement of less than -10 HU was regarded as indicative of fat. CT findings were correlated with the duration of the disease and statistically tested by simple regression analysis. The patients were divided into two groups: group A included 26 patients with a disease duration of less than 1 year and group B included 73 with a longer disease duration. In one patient disease duration was unknown. To test the relationship between disease duration and FHS the cumulative number of FHS positive and negative patients was plotted against disease duration.RESULTS: The FHS was present in 17 of the 100 patients in 20 bowel segments, mainly in the ileum (10) and the ascending colon (8). The FHS was present in 3.8% in group A and in 21.9% in group B (p < 0.0375).CONCLUSION: The FHS was present in 17% of patients with CD. Its location was mainly in the terminal ileum and ascending colon, typical sites of the disease. Its prevalence was significantly duration dependent. (c) 2007 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

The objective of this study is to report the development of thymic enlargement in adults, mainly associated with chemotherapy for malignancy. The typical CT features of this phenomenon are described. The clinical data and CT studies of 13 adult patients with newly appearing thymic enlargement on CT were reviewed. These patients were followed-up mainly for malignancy. Further follow-up CTs were studied when available. Medical records were reviewed as to the primary disease, its medical treatment and the time of initial appearance of the enlarged thymus in relation to treatment. The study group included 13 adult patients, 12 with malignant disease and one with a slowly resolving pneumonia. The enlarged thymus appeared as a triangular, arrowhead-shaped structure, with a bilobed configuration and convex borders. Density measurements were consistent with homogeneous soft tissue. Location was in the anterior mediastinum, in the normal site of the thymus. In nine patients, follow-up studies were available. The observation period ranged from 5 months to 8 years from the initial appearance of the enlarged thymus. In five of the nine patients, the thymic enlargement resolved after 1-4.5 years. In four of the nine patients, the thymus remained enlarged during a follow-up ranging from 5 months to 2.5 years. Thymic enlargement, while a rare phenomenon in adults, may occur, mainly after chemotherapy. This phenomenon should be included in the differential diagnosis of a soft tissue mass appearing in the anterior mediastinum on follow-up CT in adult patients particularly following treatment for malignancy.

BACKGROUND:Aggressive angiomyxoma is a benign but locally aggressive tumor that occurs mostly in young women. Because excision is often incomplete, the risk of local recurrence is high. This report describes differences in presentation and the importance of accurate preoperative diagnosis of this rare neoplasm.METHODS AND RESULTS:We describe three cases with different presentations. Two were initially misdiagnosed, and local recurrence necessitated reoperation. Accurate diagnosis in the third case was followed by complete excision, with no recurrence.CONCLUSION:Aggressive angiomyxoma should be considered in the differential diagnosis of young women who present with a well-defined mass in the pelvic tissue. Accurate preoperative diagnosis should alert the surgeon to the need for wide excision, which is essential for prevention of local recurrence.

Background: Pheochromocytoma, a rare and usually curable cause of hypertension, is characterized by symptoms and signs related to increased catecholamine secretion. Pregnancy can elicit clinical manifestations of otherwise unrecognized pheochromocytorna.Methods and Results: Four women, ranging in age from 27 to 37 years, were referred to the hypertension clinic with the following presentations: 1) a 35-year-old woman, diagnosed with gestational hypertension and headaches during the third trimester of her pregnancy and 5 months after delivery, was hospitalized with pulmonary edema. Echocardiography revealed severe dilated left ventricular (LV) dysfunction. Cardiac function was normalized after surgical resection of a pheochromocytoma from her left adrenal; 2) a 37-year-old woman suffered from preeclampsia, persistent hypertension and orthostatic hypotension after a cesarean section. A diagnostic work-up revealed a catecholamine-secreting paraganglioma in the retroperitoneum. The patient underwent a laparosopic resection of the tumor; 3) a 27-year-old woman suffered from hypertension and episodes of palpitations, sweating, and dyspnea in the first trimester of her pregnancy. An ultrasound revealed a 5-cm mass in the left adrenal. She underwent a left adrenalectomy at the 17th week of pregnancy, which confirmed the diagnosis of pheochromocytoma; 4) a 34-year-old woman, at the 26th week of pregnancy, presented with an acute loss of vision and blood pressure of 230/140 mm Hg. Fundoscopy showed papilledema with soft exudates in both eyes. Chemical studies were positive and imaging revealed a left adrenal pheochromocytoma. Despite aggressive medical treatment, fetal distress mandated a laparotomy at the end of the 28th week of pregnancy. A healthy newborn was delivered and resection of the adrenal tumor confirmed the diagnosis of pheochromocytoma.Conclusions: Although rare, pheochromocytoma can cause severe peripartum hypertension. Screening for pheochromocytoma, ideally with plasma-free metanephrines, should be considered in cases of peripartum hypertension.

PURPOSE: To prospectively compare the results of coronary artery calcium (CAC) measurements obtained with 55- and 165-mAs electrocardiographically gated multi-detector row computed tomography (CT).MATERIALS AND METHODS: Institutional clinical study review board approval and written informed consent were obtained. Fifty-one consecutive subjects (mean age, 59 years +/- 10) were scanned consecutively by using 165 and 55 mAs. For each examination, the number of lesions, total calcium score (TCS) calculated with Agatston algorithm (130-HU threshold), and calcium mass (in milligrams) were measured. Noise was measured by averaging 1 standard deviation of the CT attenuation values in five consecutive transverse sections of the ascending aorta. Paired t test and Pearson correlation were used to compare measurements between the examinations.RESULTS: By using 55 mAs, CAC was detected (TCS > 0) in all 33 subjects in whom CAC was initially detected with 165 mAs. The mean values of CAC measures with 165 and 55 mAs; respectively, were as follows: number of lesions, 6.2 +/- 9.6 and 6.1 +/- 9.4; TCS, 123 +/- 223 and 126 +/- 225; and calcium mass, 23.25 mg +/- 43 and 24.25 mg +/- 44 (P value was not significant for all parameters). Significant high correlation was found between the two methods for all measures (r > 0.90, P < .01). Similar results were obtained with analysis by coronary vessel. Image noise was 9.3 HU +/- 2.1 with 165 mAs and 14.7 HU +/- 3.9 with SS mAs (P < .001), with a parallel decrease in the volume CT dose index from 12 to 4 mGy.CONCLUSION: Radiation dose can be reduced (eg, 55 mAs) for CAC detection and measurement at multi-detector row CT and provides results comparable to those obtained with 165 mAs. (c) RSNA, 2005

Background: The clinical impact of fused PET/CT data on staging and patient management of Hodgkin disease (HD) and non-Hodgkin lymphoma (NHL) was assessed.Patients and methods: A total of 103 consecutive patients with newly diagnosed NHL (n = 68) and HD (n = 35) were assessed retrospectively. Three comparisons were carried out in an attempt to assess the added value of each modality.Results: For NHL patients, there were significant differences between staging by CT versus PET/CT (P = 0.0001). Disease was upstaged by PET/CT in 31% (mostly in stages I and II) and downstaged in only 1% of patients. In 25% of the patients, the treatment approach was changed according to CT versus PET/CT findings. For HD patients, disease was upstaged by PET/CT in 32% and downstaged by PET/CT in 15% (P = NS). As for NHL, upstaging by PET/CT versus CT was evident mostly for stages I and II. The treatment strategy was altered as determined by CT versus PET/CT in 45% of the patients.Conclusions: The addition of PET/CT to CT changed the management decisions in approximately a quarter of NHL and a third of HD patients, mostly in early disease stages. Thus, PET/CT performed as the initial staging procedure may well obviate the need for additional diagnostic CT in the majority of patients.

Objective The ability of coronary artery calcium (CAC) to predict coronary events has been shown in several studies. We aimed to investigate the hypothesis that CAC as assessed by dual slice spiral computed tomography (DSCT), is an independent risk factor for cardiovascular events in hypertensive patients. Methods We followed 446 participants of INSIGHT (International Nifedipine Study Intervention as Goal for Hypertension Therapy) calcification study, for the incidence of cardiovascular events as a function of CAC and other factors. All were hypertensive, without coronary artery disease (CAD), ages > 55 years and with at least one more major cardiovascular risk factor. All underwent a baseline DSCT and were followed for a mean period of 3.8 ± 0.4 years. All events were documented while the scheduled visits and confirmed by the INSIGHT critical event committee. Results Follow-up was conducted on all participants. 294 patients (66%) had CAC at baseline. Forty-seven patients experienced a first cardiovascular event: acute myocardial infarction (MI), 16; sudden cardiac death, two; unstable angina resulting in revascularization, 14; stroke, 15. The incidence of first cardiovascular events was 3.7 times higher among those who had CAC at baseline than among those who had no CAC (14.5% (41 of 294) versus 3.9% (6 of 152)). Patients who experienced an event were more likely to be males, had had higher prevalence of peripheral vascular disease, longer duration of hypertension, and had higher levels of systolic blood pressure (SBP), glucose, creatinine and uric acid. Adjusting for these covariates, CAC (total coronary calcium score (TCS) > 0) independently predicted cardiovascular events with an odds ratio (OR) of 2.76 [95% confidence interval (CI) 1.09–6.99, P = 0.032]. Conclusion The presence of CAC predicts cardiovascular events in high-risk asymptomatic hypertensive patients.

Introduction. Placental site trophoblastic tumor (PSTT) is a rare variant of gestational trophoblastic disease that has been re-described during the 1970s.Materials and methods. The patients' age at presentation, presenting symptoms, description of last pregnancy, treatment, and outcome were analyzed in five patients diagnosed as PSTT in our department from 1973 to 2003.Results. We describe the clinical outcome of 5 patients with PSTT, four of them were diagnosed and treated since 2001. Mean interval from last pregnancy until diagnosis was 5.1 months (range 0-10 months). Vaginal bleeding was the presenting symptom in all the five patients. Instead of standard hysterectomy followed by chemotherapy, when indicated, one patient underwent fertility preserving management using hysteroscopic resection of the tumor followed by chemotherapy.Conclusions. The combination of operative hysteroscopy and chemotherapy in women with localized disease, who want to preserve their fertility, can be a possible treatment option in highly selected patients. Repeated chemotherapy with EMA/EP, even in patients who relapsed after treatment with EMA/EP for PSTT can induce prolonged remission and even cure. (C) 2004 Elsevier Inc. All rights reserved.

PURPOSETo prospectively assess the 4-year progression rate of coronary artery calcium (CAC) in patients with clinically stable coronary artery disease (CAD) with multi-detector row computed tomography (CT).MATERIALS AND METHODSThe study group consisted of 382 consecutive patients. All underwent baseline dual-sector spiral CT, and CT was repeated at 2 and 4 years later. Progression of CAC was assessed with measurement of the increase in total calcium score (TCS) and with repeated-measures analysis and multivariate linear regression models. Logistic regression model was used to predict incidence of new lesions.RESULTSEighty-seven percent (333 of 382) of the study group were men, with mean age of 65 years +/- 11, and 13% (49 of 382) were women, with mean age of 68 years +/- 11. The average TCS increased after 4 years by sixfold from baseline in the 1st quartile, and by four-, two- and 1.5-fold in the 2nd, 3rd, and 4th quartiles of baseline TCS (P <.01), respectively. Multiple linear regression analysis included age; sex; natural logarithm of baseline TCS; history of hypertension, diabetes mellitus, current smoking, hypercholesterolemia, and lipid-lowering therapy with cholesterol synthesis enzyme inhibitor (statin); and family history of premature CAD. Results demonstrated that natural logarithm of baseline TCS and history of current smoking were independent predictors of the 4th-year natural logarithm of TCS levels (R(2) = 0.85, P <.001). New lesions were diagnosed in 56 (15%) patients. History of statin therapy (odds ratio = 0.35; 95% confidence interval [CI]: 0.16, 0.77; P <.01), age with an increment of 5 years (odds ratio = 0.76; 95% CI: 0.64, 0.90; P =.01), and natural logarithm of baseline TCS (odds ratio = 0.73; 95% CI: 0.62, 0.86; P <.01) were independent predictors for new calcific lesions during 4 years.CONCLUSIONAccelerated progression of CAC during 4 years was found in clinically stable patients with CAD.

Acute graft-versus-host disease (GVHD) is the major treatment-related complication after allogeneic stem-cell transplantation. Acute GVHD of the gastrointestinal (GI) tract is a clinical diagnosis supported by histo-pathological findings. The presenting symptom is most often large volume diarrhea.The volume of diarrhea determines disease stage and prognosis, however its assessment is inconvenient and inaccurate due to low compliance. Moreover, patients (pts) may present with atypical symptoms such as abdominal pain and vomiting. Also, biopsies of the GI-tract may be falsely negative due to patchy involvement or may be contraindicated in pts with severe thrombocytopenia. This study was designed to determine the CT features associated with acute GI GVHD and to evaluate its role in the assessment of severity and prognosis. Thirty-four consecutive pts with symptoms suggestive of acute GI GVHD were evaluated early after presentation by abdominal CT. The median age was 52 years (range, 20–66). Diagnoses included AML (n=10), ALL (n=5), multiple myeloma (n=8), NHL (n=5), CLL (n=4) and others (n=2). The donors were HLA-matches sibling (n=21), 1-Ag mismatched relative (n=2) or matched unrelated (n=11). Nine pts had myeloablative conditioning and 25 had reduced-intensity regimens. None had infectious etiology by standard evaluation. Eighteen pts had clinical stage I–II of GI-GVHD and 14 had clinical stage III–IV by the Glucksberg criteria. Thirty-two pts had pathological finding in CT. The most consistent finding was thickening of the bowel wall, which was limited to the small (n=11) or large bowel (n=5) or involved both (n=16). Involvement was diffuse or segmental. Other manifestations included intestinal dilatation (n=11), mucosal enhancement (n=3) and gastric wall thickening (n=7). Extra-intestinal findings were also common and included mesenteric stranding (n=22), ascites (n=13) and biliary systems abnormalities (n=11). Ten pts had urinary excretion of orally administered gastrografin which is not normally absorbed by an intact intestine. Diffuse thickening of the small bowel wall and/or any involvement of the large intestine were patterns associated with severe clinical presentation. Eleven and 14 of the 16 patients with clinical stage III–IV GI-GVHD had these patterns, respectively, compared to 5 and 7 of the 18 pts with stage I–II disease (p=0.03). Overall, nineteen pts responded to immunesuppressive therapy. Nine pts are alive; 25 died, 13 of complications directly related to GVHD. Diffuse small bowel disease was associated with poor prognosis. Only six of 16 pts showing this pattern responded to immunosuppressive therapy compared to thirteen of 18 pts without this pattern (p=0.05). The cumulative incidence of GVHD-related death was and 56% (95% CI, 37–87) and 25% (95% CI 11–58), respectively (p=0.05), however overall survival was not significantly different in the two groups. In conclusion, abdominal CT may have an important role in the diagnosis of GVHD in atypical presentations and in the prognostic evaluation. Diffuse small intestinal disease and any colon disease are associated with severe clinical disease. Diffuse small intestinal disease is also associated with poor response to therapy and GVHD-related mortality. CT findings may direct the clinician in determining the therapeutic approach.

New onset of seizures in young adults is frequently related to alcohol withdrawal, toxic exposure, central nervous system trauma and neoplasm. We describe a young soldier presenting to the emergency department with seizures and transient coma. On admission, he had hypertension, marked leukocytosis, hyperglycaemia, acidosis, elevated creatinine and elevated creatine phosphokinase of muscle origin. A thorough work-up revealed elevated urinary catecholamines, and a left adrenal mass was found on MRI and MIBG scan. The patient underwent laparoscopic adrenalectomy and completely recovered. This is the first description of seizures as a presenting symptom of phaeochromocytoma.

OBJECTIVE. We describe a possible relationship between inferior vena cava anomalies and extensive thrombosis of the inferior vena cava and the iliac and femoral veins.CONCLUSION. An anomaly of the inferior vena cava should be considered in young patients who present with deep vein thrombosis of the femoral and iliac veins. Coagulation abnormalities, frequently found in these patients, may be a contributory factor.

PURPOSE To compare underlying calcific atherosclerotic lesions in acute versus chronic coronary events in patients with hypertension by using dual-sector spiral computed tomography (CT). MATERIALS AND METHODS Eight hundred eighty-four calcific lesions were analyzed in a cohort of 50 patients (39 men, 11 women; age range, 55-79 years; mean age, 66 years +/- 6 [SD]) with hypertension who sustained a coronary event during 3-year follow-up. All underwent dual-sector spiral CT within 12 months before the event. Twenty-nine patients had an acute event (acute group): acute myocardial infarction, 20; unstable angina pectoris, six; acute ischemia, two; sudden death, one. Twenty-one patients had chronic manifestations of obstructive coronary disease (chronic group): severe stable angina, five; angiographically identified disease, 12; disease requiring angioplasty, two; and disease requiring bypass surgery, two. To examine differences between the two study groups, the chi(2) or Fisher exact test was applied to categorical parameters and the two-sample t test or Wilcoxon rank sum test to quantitative parameters. RESULTS High prevalence of coronary calcium (total coronary calcium score [TCS] >0) was observed in both groups: 93% (27 of 29) in the acute and 95% (20 of 21) in the chronic group. There were 518 lesions in the chronic and 366 in the acute group, with a median number of 35 and nine lesions per patient, respectively (P <.001). The median TCS was 906 for the chronic and 63 for the acute group (P <.01). CONCLUSION A mild degree of calcification characterizes patients with acute coronary events, while diffuse high-attenuation calcific plaques are associated with chronic coronary events.

We report a case of massive pulmonary embolus demonstrated on CT in a young woman presenting with dyspnea, with no known risk factors for embolism. Abdominal CT on further investigation showed a renal tumor invading the left renal vein and the inferior vena cava as the cause of the pulmonary embolus. In a patient presenting with pulmonary artery embolism without venous thrombosis, the differential diagnosis should include an occult tumor as the cause of the embolus.