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article-30466_19 | Transfusion Iron Overload -- History and Physical | To better assess the patient, clinicians should know how long they have been transfusion dependent, how many transfusions they receive per year, and their compliance with a chelation regimen. Most patients with transfusion iron overload typically suffer from fatigue, breathlessness, and pale skin, which are the underlying symptoms of anemia. The first presenting symptom is often delayed puberty. The remaining complaints vary based on the organ systems affected. [17] | Transfusion Iron Overload -- History and Physical. To better assess the patient, clinicians should know how long they have been transfusion dependent, how many transfusions they receive per year, and their compliance with a chelation regimen. Most patients with transfusion iron overload typically suffer from fatigue, breathlessness, and pale skin, which are the underlying symptoms of anemia. The first presenting symptom is often delayed puberty. The remaining complaints vary based on the organ systems affected. [17] |
article-30466_20 | Transfusion Iron Overload -- History and Physical -- General | Weight loss Fatigue Arthralgias Pallor Breathlessness | Transfusion Iron Overload -- History and Physical -- General. Weight loss Fatigue Arthralgias Pallor Breathlessness |
article-30466_21 | Transfusion Iron Overload -- History and Physical -- Cardiac | Cardiac symptoms are typically due to heart failure. Orthopnea Dyspnea Lower extremity edema Paroxysmal nocturnal dyspnea | Transfusion Iron Overload -- History and Physical -- Cardiac. Cardiac symptoms are typically due to heart failure. Orthopnea Dyspnea Lower extremity edema Paroxysmal nocturnal dyspnea |
article-30466_22 | Transfusion Iron Overload -- History and Physical -- Endocrine | Symptoms related to the endocrine system are due to iron deposition in the pancreas, thyroid, and pituitary gland. Delayed puberty Delayed menarche Polyuria, polydipsia, polyphagia due to diabetes Short stature | Transfusion Iron Overload -- History and Physical -- Endocrine. Symptoms related to the endocrine system are due to iron deposition in the pancreas, thyroid, and pituitary gland. Delayed puberty Delayed menarche Polyuria, polydipsia, polyphagia due to diabetes Short stature |
article-30466_23 | Transfusion Iron Overload -- History and Physical -- Gastrointestinal | Gastrointestinal symptoms are due to cirrhosis. Abdominal pain and distension Hematemesis Melena Cognitive deficits, sleep disturbance, bradykinesia, hyperreflexia, rigidity, myoclonus, and asterixis due to encephalopathy Physical examination findings vary according to the extent and duration of iron overload. Patients with transfusion iron overload may present with the following: [18] Bronze or grey skin color Bruising Dwarfism Cachexia Delayed breast development in pubertal girls Soft, small testes in males Hepatomegaly Ascites Caput medusa Jugular venous distension Lower extremity edema Pleural effusion | Transfusion Iron Overload -- History and Physical -- Gastrointestinal. Gastrointestinal symptoms are due to cirrhosis. Abdominal pain and distension Hematemesis Melena Cognitive deficits, sleep disturbance, bradykinesia, hyperreflexia, rigidity, myoclonus, and asterixis due to encephalopathy Physical examination findings vary according to the extent and duration of iron overload. Patients with transfusion iron overload may present with the following: [18] Bronze or grey skin color Bruising Dwarfism Cachexia Delayed breast development in pubertal girls Soft, small testes in males Hepatomegaly Ascites Caput medusa Jugular venous distension Lower extremity edema Pleural effusion |
article-30466_24 | Transfusion Iron Overload -- Evaluation | To date, no single lab test exists to mark iron overload. A serum ferritin level is an inexpensive and widely available way of assessing transfusion iron overload. A patient with thalassemia with a ferritin measurement >2500 ng/dL has an 80% greater chance of cardiac-related mortality. [19] However, an inflammatory disorder, malignancy, metabolic syndrome, renal failure, liver disease, and excessive alcohol intake can all lead to elevated ferritin levels making a single result an unreliable indicator of iron overload. [20] [21] Most guidelines recommend obtaining serial serum ferritin and transferrin saturation levels every 3 months for a more accurate assessment of the body's iron level. [22] The ferritin level cutoff point for iron toxicity varies in the literature from 1000 ng/mL to 3000 ng/mL. Limitations of ferritin testing are the lack of specificity and interpatient variability. | Transfusion Iron Overload -- Evaluation. To date, no single lab test exists to mark iron overload. A serum ferritin level is an inexpensive and widely available way of assessing transfusion iron overload. A patient with thalassemia with a ferritin measurement >2500 ng/dL has an 80% greater chance of cardiac-related mortality. [19] However, an inflammatory disorder, malignancy, metabolic syndrome, renal failure, liver disease, and excessive alcohol intake can all lead to elevated ferritin levels making a single result an unreliable indicator of iron overload. [20] [21] Most guidelines recommend obtaining serial serum ferritin and transferrin saturation levels every 3 months for a more accurate assessment of the body's iron level. [22] The ferritin level cutoff point for iron toxicity varies in the literature from 1000 ng/mL to 3000 ng/mL. Limitations of ferritin testing are the lack of specificity and interpatient variability. |
article-30466_25 | Transfusion Iron Overload -- Evaluation | Serum iron levels are high in patients with iron overload, and the total iron-binding capacity (TIBC) is low. Serum and total body iron results depend on the method used. [19] Transferrin saturation is easy to measure but far from perfect. A transferrin saturation of over 50% indicates a high iron load. However, this is a dynamic number and could vary with inflammation. | Transfusion Iron Overload -- Evaluation. Serum iron levels are high in patients with iron overload, and the total iron-binding capacity (TIBC) is low. Serum and total body iron results depend on the method used. [19] Transferrin saturation is easy to measure but far from perfect. A transferrin saturation of over 50% indicates a high iron load. However, this is a dynamic number and could vary with inflammation. |
article-30466_26 | Transfusion Iron Overload -- Evaluation | NTBI and LPI are specific markers for iron overload and may be valuable in monitoring clinical response to chelation therapy. Further studies and standardization of assays are necessary before the routine use of NTBI and LPI levels. | Transfusion Iron Overload -- Evaluation. NTBI and LPI are specific markers for iron overload and may be valuable in monitoring clinical response to chelation therapy. Further studies and standardization of assays are necessary before the routine use of NTBI and LPI levels. |
article-30466_27 | Transfusion Iron Overload -- Evaluation | MRI is the gold standard for long-term liver and cardiac iron level monitoring. Cardiac T2* MRI has a better prognostic value in predicting cardiac risk. [23] T2*, measured in milliseconds, is the time required for the organ to lose approximately two-thirds of its signal. A reciprocal relationship exists between T2* and iron concentration as it shortens as iron concentration increases. A T2* <20 ms indicates an increased likelihood of impaired left ventricular ejection fraction (LVEF). Most guidelines recommend a cardiac and liver MRI once a year. If the liver iron concentration (LIC) is more than 0.15 mg/g dry weight (DW) or cardiac dysfunction is present, repeat the MRI every 6 months. If the LIC is normal, repeat the MRI every 2 years. Calculate the LIC using atomic absorption spectrophotometry on tissue obtained from the liver biopsy. MRI of the pancreas is not a good predictor of iron deposition in the pancreas. The severity classifications of iron overload in the liver are: [24] | Transfusion Iron Overload -- Evaluation. MRI is the gold standard for long-term liver and cardiac iron level monitoring. Cardiac T2* MRI has a better prognostic value in predicting cardiac risk. [23] T2*, measured in milliseconds, is the time required for the organ to lose approximately two-thirds of its signal. A reciprocal relationship exists between T2* and iron concentration as it shortens as iron concentration increases. A T2* <20 ms indicates an increased likelihood of impaired left ventricular ejection fraction (LVEF). Most guidelines recommend a cardiac and liver MRI once a year. If the liver iron concentration (LIC) is more than 0.15 mg/g dry weight (DW) or cardiac dysfunction is present, repeat the MRI every 6 months. If the LIC is normal, repeat the MRI every 2 years. Calculate the LIC using atomic absorption spectrophotometry on tissue obtained from the liver biopsy. MRI of the pancreas is not a good predictor of iron deposition in the pancreas. The severity classifications of iron overload in the liver are: [24] |
article-30466_28 | Transfusion Iron Overload -- Evaluation | Mild < 7 mg/g dry weight Moderate 7 to 15 mg/g dry weight Severe >15 mg/g dry weight | Transfusion Iron Overload -- Evaluation. Mild < 7 mg/g dry weight Moderate 7 to 15 mg/g dry weight Severe >15 mg/g dry weight |
article-30466_29 | Transfusion Iron Overload -- Evaluation | A liver biopsy is the standard of care when MRI is not available. However, patient compliance and risk of bleeding have limited its use. Hepatic iron stores are an indicator of total body iron stores. Additional necessary testing is: Free thyroxine (T4); Thyroid-stimulating hormone (TSH); Calcium; Phosphate; 25-OH vitamin D; Fasting blood sugar; Hemoglobin A1c; Alanine aminotransferase and aspartate aminotransferase; Echocardiography; and Bone density testing. [22] | Transfusion Iron Overload -- Evaluation. A liver biopsy is the standard of care when MRI is not available. However, patient compliance and risk of bleeding have limited its use. Hepatic iron stores are an indicator of total body iron stores. Additional necessary testing is: Free thyroxine (T4); Thyroid-stimulating hormone (TSH); Calcium; Phosphate; 25-OH vitamin D; Fasting blood sugar; Hemoglobin A1c; Alanine aminotransferase and aspartate aminotransferase; Echocardiography; and Bone density testing. [22] |
article-30466_30 | Transfusion Iron Overload -- Treatment / Management | Vitamin C enhances iron absorption from food. Patients should avoid vitamin C, alcohol, and iron supplements. Iron chelation therapy is the standard of care to prevent and reverse iron overload. Ideally, prophylactic iron chelation therapy begins before clinically significant iron overload occurs. | Transfusion Iron Overload -- Treatment / Management. Vitamin C enhances iron absorption from food. Patients should avoid vitamin C, alcohol, and iron supplements. Iron chelation therapy is the standard of care to prevent and reverse iron overload. Ideally, prophylactic iron chelation therapy begins before clinically significant iron overload occurs. |
article-30466_31 | Transfusion Iron Overload -- Treatment / Management | Non-transferrin-bound iron and iron deposited in the liver are the most susceptible to chelation. When to begin chelation therapy depends on when the patient became transfusion dependent and the current damage. The current standard is to begin chelation therapy after 1 to 2 years of consistent or 15 to 20 transfusions. Patients with serum ferritin levels that exceed 1000 to 1500 mcg/L, liver iron levels >3 to 5 mg/g dry weight, or a cardiac T2* of less than 20 ms also warrant chelation therapy. These values correspond to approximately 120 to 200 mL of transfused RBCs/kg. The American Academy of Pediatrics recommends a serum ferritin level < 1500 ng/mL or liver iron < 7 mg/g dry weight for children. The success of therapy significantly depends on patient adherence. Therefore, the treatment regimen should be adjusted to improve patient compliance. | Transfusion Iron Overload -- Treatment / Management. Non-transferrin-bound iron and iron deposited in the liver are the most susceptible to chelation. When to begin chelation therapy depends on when the patient became transfusion dependent and the current damage. The current standard is to begin chelation therapy after 1 to 2 years of consistent or 15 to 20 transfusions. Patients with serum ferritin levels that exceed 1000 to 1500 mcg/L, liver iron levels >3 to 5 mg/g dry weight, or a cardiac T2* of less than 20 ms also warrant chelation therapy. These values correspond to approximately 120 to 200 mL of transfused RBCs/kg. The American Academy of Pediatrics recommends a serum ferritin level < 1500 ng/mL or liver iron < 7 mg/g dry weight for children. The success of therapy significantly depends on patient adherence. Therefore, the treatment regimen should be adjusted to improve patient compliance. |
article-30466_32 | Transfusion Iron Overload -- Treatment / Management | Commonly used chelators in the United States are deferoxamine (DFO), deferiprone, and deferasirox. Before initiating or altering iron chelation therapy, assess patients' iron loading and previous chelation rates. | Transfusion Iron Overload -- Treatment / Management. Commonly used chelators in the United States are deferoxamine (DFO), deferiprone, and deferasirox. Before initiating or altering iron chelation therapy, assess patients' iron loading and previous chelation rates. |
article-30466_33 | Transfusion Iron Overload -- Treatment / Management | Deferoxamine, administered as a continuous intravenous or subcutaneous infusion, is the treatment of choice for transfusion iron overload. Deferoxamine helps prevent diabetes, cardiac disease, and cirrhosis. In the body, deferoxamine chelates circulating and tissue iron and eliminates it in urine and bile. | Transfusion Iron Overload -- Treatment / Management. Deferoxamine, administered as a continuous intravenous or subcutaneous infusion, is the treatment of choice for transfusion iron overload. Deferoxamine helps prevent diabetes, cardiac disease, and cirrhosis. In the body, deferoxamine chelates circulating and tissue iron and eliminates it in urine and bile. |
article-30466_34 | Transfusion Iron Overload -- Treatment / Management | In contrast, deferasirox is an orally active iron chelator that eliminates chelated iron in bile. [25] Once daily dosing and cost make deferasirox more appealing to patients. However, the potential adverse effects of gastrointestinal bleeding, agranulocytosis, neutropenia, thrombocytopenia, hepatic fibrosis, and kidney failure may limit its use. | Transfusion Iron Overload -- Treatment / Management. In contrast, deferasirox is an orally active iron chelator that eliminates chelated iron in bile. [25] Once daily dosing and cost make deferasirox more appealing to patients. However, the potential adverse effects of gastrointestinal bleeding, agranulocytosis, neutropenia, thrombocytopenia, hepatic fibrosis, and kidney failure may limit its use. |
article-30466_35 | Transfusion Iron Overload -- Treatment / Management | Both deferoxamine and deferasirox monotherapy significantly reduce cardiac and hepatic siderosis. [25] [26] An average deferoxamine dose of 51 mg/kg at least five days weekly reduces the LIC level by 6.4 mg/g DW. [27] An average deferasirox dose of 30 mg/kg daily reduces the LIC level by 3.1 to 7.8 mg/g DW. [28] The dose of iron-chelating agents is frequently titrated based on serum ferritin, liver, and cardiac imaging. The goal is to keep the serum ferritin level under 1000 mcg/L, the cardiac T2* over 20 ms, and the LIC less than 3 mg/g DW. [29] [30] [31] In young children, the dose of deferoxamine should not exceed 25 to 30 mg/kg to minimize adverse effects. Pregnant or breastfeeding patients should avoid chelation therapy. [7] | Transfusion Iron Overload -- Treatment / Management. Both deferoxamine and deferasirox monotherapy significantly reduce cardiac and hepatic siderosis. [25] [26] An average deferoxamine dose of 51 mg/kg at least five days weekly reduces the LIC level by 6.4 mg/g DW. [27] An average deferasirox dose of 30 mg/kg daily reduces the LIC level by 3.1 to 7.8 mg/g DW. [28] The dose of iron-chelating agents is frequently titrated based on serum ferritin, liver, and cardiac imaging. The goal is to keep the serum ferritin level under 1000 mcg/L, the cardiac T2* over 20 ms, and the LIC less than 3 mg/g DW. [29] [30] [31] In young children, the dose of deferoxamine should not exceed 25 to 30 mg/kg to minimize adverse effects. Pregnant or breastfeeding patients should avoid chelation therapy. [7] |
article-30466_36 | Transfusion Iron Overload -- Treatment / Management -- Maintenance Therapy | Maintenance therapy prevents tissue damage from iron overload. [32] A LIC of more than 15 mg/g dry weight, serum ferritin >2500 μg/L, or cardiac T2* MRI <20 ms indicates inadequate chelation. If there is cardiac iron overload, cardiac iron chelation becomes the primary goal of therapy. Not all patients achieve adequate chelation on one iron chelator. Many patients will need their treatment revised, sometimes needing a higher dose, a different chelator, or a combination of chelators. If transfusional requirements are exceptionally high, more than 200 to 220 mL packed red cells/kg/year, splenectomy can reduce the iron uptake from transfusions. Liver and heart transplantation are considerations for patients who have end-stage disease. | Transfusion Iron Overload -- Treatment / Management -- Maintenance Therapy. Maintenance therapy prevents tissue damage from iron overload. [32] A LIC of more than 15 mg/g dry weight, serum ferritin >2500 μg/L, or cardiac T2* MRI <20 ms indicates inadequate chelation. If there is cardiac iron overload, cardiac iron chelation becomes the primary goal of therapy. Not all patients achieve adequate chelation on one iron chelator. Many patients will need their treatment revised, sometimes needing a higher dose, a different chelator, or a combination of chelators. If transfusional requirements are exceptionally high, more than 200 to 220 mL packed red cells/kg/year, splenectomy can reduce the iron uptake from transfusions. Liver and heart transplantation are considerations for patients who have end-stage disease. |
article-30466_37 | Transfusion Iron Overload -- Differential Diagnosis | Medical conditions that mimic transfusion iron overload are: Hemochromatosis; Cardiomyopathy; Acute inflammatory conditions; Malignancy; Arthritis; Diabetes; Hepatitis C; Human immunodeficiency virus (HIV) infection; and Dysmetabolic hyperferritinemia. [33] | Transfusion Iron Overload -- Differential Diagnosis. Medical conditions that mimic transfusion iron overload are: Hemochromatosis; Cardiomyopathy; Acute inflammatory conditions; Malignancy; Arthritis; Diabetes; Hepatitis C; Human immunodeficiency virus (HIV) infection; and Dysmetabolic hyperferritinemia. [33] |
article-30466_38 | Transfusion Iron Overload -- Pertinent Studies and Ongoing Trials | Several novel concepts that may help effectively treat iron overload and the patient's overall survival are under investigation. A randomized controlled trial on amlodipine, a calcium channel blocker as an adjuvant iron chelator, shows a significant decrease in myocardial iron concentration. [34] Several phase 2 studies have shown improved adherence with a film-coated oral tablet of deferasirox compared to a dispersible tablet. [35] Gene therapy is another promising option to reduce the transfusion requirement by improving endogenous erythropoiesis. [36] A janus kinase (JAK2) inhibitor and hepcidin analog are additional investigational therapies. [37] [38] | Transfusion Iron Overload -- Pertinent Studies and Ongoing Trials. Several novel concepts that may help effectively treat iron overload and the patient's overall survival are under investigation. A randomized controlled trial on amlodipine, a calcium channel blocker as an adjuvant iron chelator, shows a significant decrease in myocardial iron concentration. [34] Several phase 2 studies have shown improved adherence with a film-coated oral tablet of deferasirox compared to a dispersible tablet. [35] Gene therapy is another promising option to reduce the transfusion requirement by improving endogenous erythropoiesis. [36] A janus kinase (JAK2) inhibitor and hepcidin analog are additional investigational therapies. [37] [38] |
article-30466_39 | Transfusion Iron Overload -- Prognosis | Without chelation therapy, the likelihood of death due to arrhythmia or heart failure is high in late childhood or early adolescence. The prognosis of individuals with iron overload depends heavily on early detection and adherence to preventive measures. Cardiac toxicity and endocrine toxicity are reversible, but the outcomes may vary. Since the introduction of preventive iron chelating therapy (ICT), there has been a consistent improvement in the quality of life and survival of individuals with transfusion iron overload. [39] These individuals continue to face an elevated risk of developing malignancies, and their overall mortality rate is three times higher than that of the general population. [40] | Transfusion Iron Overload -- Prognosis. Without chelation therapy, the likelihood of death due to arrhythmia or heart failure is high in late childhood or early adolescence. The prognosis of individuals with iron overload depends heavily on early detection and adherence to preventive measures. Cardiac toxicity and endocrine toxicity are reversible, but the outcomes may vary. Since the introduction of preventive iron chelating therapy (ICT), there has been a consistent improvement in the quality of life and survival of individuals with transfusion iron overload. [39] These individuals continue to face an elevated risk of developing malignancies, and their overall mortality rate is three times higher than that of the general population. [40] |
article-30466_40 | Transfusion Iron Overload -- Complications | Without chelation therapy, the likelihood of death due to arrhythmia or heart failure is high in late childhood or early adolescence. The prognosis of individuals with iron overload depends heavily on early detection and adherence to preventive measures. Cardiac toxicity and endocrine toxicity are reversible, but the outcomes may vary. Since the introduction of preventive iron chelating therapy (ICT), there has been a consistent improvement in the quality of life and survival of individuals with transfusion iron overload. These individuals continue to face an elevated risk of developing malignancies, and their overall mortality rate is three times higher than that of the general population. | Transfusion Iron Overload -- Complications. Without chelation therapy, the likelihood of death due to arrhythmia or heart failure is high in late childhood or early adolescence. The prognosis of individuals with iron overload depends heavily on early detection and adherence to preventive measures. Cardiac toxicity and endocrine toxicity are reversible, but the outcomes may vary. Since the introduction of preventive iron chelating therapy (ICT), there has been a consistent improvement in the quality of life and survival of individuals with transfusion iron overload. These individuals continue to face an elevated risk of developing malignancies, and their overall mortality rate is three times higher than that of the general population. |
article-30466_41 | Transfusion Iron Overload -- Complications -- Complications of Transfusion Iron Overload | Long-term complications of transfusion iron overload are: Liver cirrhosis hepatic failure cardiomyopathy cardiac conduction defects heart failure diabetes hypogonadism malignancy hypoparathyroidism adrenal insufficiency and need for stress dose steroids hypothyroidism; and arthropathy. [40] Dilated cardiomyopathy is the most common cause of early death. | Transfusion Iron Overload -- Complications -- Complications of Transfusion Iron Overload. Long-term complications of transfusion iron overload are: Liver cirrhosis hepatic failure cardiomyopathy cardiac conduction defects heart failure diabetes hypogonadism malignancy hypoparathyroidism adrenal insufficiency and need for stress dose steroids hypothyroidism; and arthropathy. [40] Dilated cardiomyopathy is the most common cause of early death. |
article-30466_42 | Transfusion Iron Overload -- Complications -- Deferoxamine | Retinal damage causing night blindness, visual field loss, and retinal pigmentation High-tone sensorineural hearing loss Growth and bone defects in children causing rickets-like bone lesions, metaphyseal changes, and spinal damage Calculate a therapeutic index as the mean daily dose (mg/kg)/current serum ferritin (μg/L). If this is < 0.025 at all times, these side effects of DFO do not occur. | Transfusion Iron Overload -- Complications -- Deferoxamine. Retinal damage causing night blindness, visual field loss, and retinal pigmentation High-tone sensorineural hearing loss Growth and bone defects in children causing rickets-like bone lesions, metaphyseal changes, and spinal damage Calculate a therapeutic index as the mean daily dose (mg/kg)/current serum ferritin (μg/L). If this is < 0.025 at all times, these side effects of DFO do not occur. |
article-30466_43 | Transfusion Iron Overload -- Complications | Children should be monitored for visual and auditory deficits every 6 months, and adults every 12 months. Monitor children's growth regularly. Sitting height compared to total height can help signify early spinal growth defects. [41] [42] [43] [44] [45] | Transfusion Iron Overload -- Complications. Children should be monitored for visual and auditory deficits every 6 months, and adults every 12 months. Monitor children's growth regularly. Sitting height compared to total height can help signify early spinal growth defects. [41] [42] [43] [44] [45] |
article-30466_44 | Transfusion Iron Overload -- Complications -- Deferasirox | Nausea, vomiting, and diarrhea Elevated liver transaminases Acute kidney injury Auditory and visual changes | Transfusion Iron Overload -- Complications -- Deferasirox. Nausea, vomiting, and diarrhea Elevated liver transaminases Acute kidney injury Auditory and visual changes |
article-30466_45 | Transfusion Iron Overload -- Complications | Establish baseline renal function. Check renal function monthly or weekly for the first month if the patient has additional renal risk factors. Adjust the dose accordingly based on renal function. [46] [47] [46] | Transfusion Iron Overload -- Complications. Establish baseline renal function. Check renal function monthly or weekly for the first month if the patient has additional renal risk factors. Adjust the dose accordingly based on renal function. [46] [47] [46] |
article-30466_46 | Transfusion Iron Overload -- Complications -- Deferiprone | Agranulocytosis Elevated liver transaminases Arthropathy Zinc deficiency Monitor CBC weekly for the first year and every 2 weeks subsequently. Discontinue therapy if transaminases more than twice normal consistently. Give zinc supplements. | Transfusion Iron Overload -- Complications -- Deferiprone. Agranulocytosis Elevated liver transaminases Arthropathy Zinc deficiency Monitor CBC weekly for the first year and every 2 weeks subsequently. Discontinue therapy if transaminases more than twice normal consistently. Give zinc supplements. |
article-30466_47 | Transfusion Iron Overload -- Deterrence and Patient Education | Patients with illnesses like thalassemia, aplastic anemia, sickle cell disease, and myelodysplastic syndrome are often transfusion-dependent. Each time the body receives a blood transfusion, it receives approximately 200 to 250 mg of extra iron. The human body has no physiological process to eliminate extra iron. After multiple blood transfusions, the excess iron accumulates in the liver, heart, pancreas, pituitary, and thyroid. This accumulation will lead to liver cirrhosis, cardiomyopathy, heart failure, hypothyroidism, hypogonadism, diabetes, and delayed puberty. | Transfusion Iron Overload -- Deterrence and Patient Education. Patients with illnesses like thalassemia, aplastic anemia, sickle cell disease, and myelodysplastic syndrome are often transfusion-dependent. Each time the body receives a blood transfusion, it receives approximately 200 to 250 mg of extra iron. The human body has no physiological process to eliminate extra iron. After multiple blood transfusions, the excess iron accumulates in the liver, heart, pancreas, pituitary, and thyroid. This accumulation will lead to liver cirrhosis, cardiomyopathy, heart failure, hypothyroidism, hypogonadism, diabetes, and delayed puberty. |
article-30466_48 | Transfusion Iron Overload -- Deterrence and Patient Education | Iron chelation therapy involves medication given intravenously, subcutaneously, or orally that will bind and eliminate extra iron in the body. Chelation therapy helps prevent cirrhosis, damage to the heart, and diabetes. Healthcare professionals will monitor the body's total iron stores with serial blood tests. The current recommendations are to monitor serum ferritin levels every 3 months and a serum iron panel annually. An annual MRI, or biopsy of the liver if MRI is unavailable, monitors the iron content in those organs. Obtain an MRI every 3 to 6 months for patients with heart failure and intensive chelation therapy. [19] Blood glucose, vitamin D, calcium, and thyroid levels are also monitored. | Transfusion Iron Overload -- Deterrence and Patient Education. Iron chelation therapy involves medication given intravenously, subcutaneously, or orally that will bind and eliminate extra iron in the body. Chelation therapy helps prevent cirrhosis, damage to the heart, and diabetes. Healthcare professionals will monitor the body's total iron stores with serial blood tests. The current recommendations are to monitor serum ferritin levels every 3 months and a serum iron panel annually. An annual MRI, or biopsy of the liver if MRI is unavailable, monitors the iron content in those organs. Obtain an MRI every 3 to 6 months for patients with heart failure and intensive chelation therapy. [19] Blood glucose, vitamin D, calcium, and thyroid levels are also monitored. |
article-30466_49 | Transfusion Iron Overload -- Deterrence and Patient Education | Chelation therapy is vital to improving long-term survival. Discussion with the patient and family about the advantages and disadvantages of chelation therapy is vital to improve the patient's compliance. [7] Patients will be closely monitored to prevent adverse outcomes from the chelation medications. Patients should avoid iron-rich foods like red meat, beans, spinach, and excess vitamin C. | Transfusion Iron Overload -- Deterrence and Patient Education. Chelation therapy is vital to improving long-term survival. Discussion with the patient and family about the advantages and disadvantages of chelation therapy is vital to improve the patient's compliance. [7] Patients will be closely monitored to prevent adverse outcomes from the chelation medications. Patients should avoid iron-rich foods like red meat, beans, spinach, and excess vitamin C. |
article-30466_50 | Transfusion Iron Overload -- Enhancing Healthcare Team Outcomes | Patients who are transfusion-dependent face many challenges. They suffer from the symptoms of chronic anemia, can spend much time receiving transfusions and chelation therapy, experience significant medical costs, and face potential early mortality. Communication among interprofessional healthcare team members, including primary care, hematology, psychiatry, psychology, nursing, cardiology, gastroenterology, endocrinology, ophthalmology, audiology, and other healthcare staff, is essential to prevent, diagnose, and manage transfusion iron overload. | Transfusion Iron Overload -- Enhancing Healthcare Team Outcomes. Patients who are transfusion-dependent face many challenges. They suffer from the symptoms of chronic anemia, can spend much time receiving transfusions and chelation therapy, experience significant medical costs, and face potential early mortality. Communication among interprofessional healthcare team members, including primary care, hematology, psychiatry, psychology, nursing, cardiology, gastroenterology, endocrinology, ophthalmology, audiology, and other healthcare staff, is essential to prevent, diagnose, and manage transfusion iron overload. |
article-30466_51 | Transfusion Iron Overload -- Enhancing Healthcare Team Outcomes | Adherence to follow-up and iron-chelation therapy has improved morbidity and mortality overall. [48] Transfusion iron overload has a multiorgan impact. A supportive interprofessional team aware of the underlying risks, complications of recurrent transfusions, and potential adverse effects of chelation therapy is essential in providing comprehensive care. Each team member must ensure the patient is adequately screened and treated within their designated specialty, distribute up-to-date treatment information to the rest of the team, and check that the patient has care scheduled with the additional members. The psychological effect of long-term transfusion therapy is common, and early evaluation of depression, anxiety, and other disorders is essential. Consideration of the financial implications for long-term treatment is also important. A patient-centered team approach will reduce overall morbidity and mortality. | Transfusion Iron Overload -- Enhancing Healthcare Team Outcomes. Adherence to follow-up and iron-chelation therapy has improved morbidity and mortality overall. [48] Transfusion iron overload has a multiorgan impact. A supportive interprofessional team aware of the underlying risks, complications of recurrent transfusions, and potential adverse effects of chelation therapy is essential in providing comprehensive care. Each team member must ensure the patient is adequately screened and treated within their designated specialty, distribute up-to-date treatment information to the rest of the team, and check that the patient has care scheduled with the additional members. The psychological effect of long-term transfusion therapy is common, and early evaluation of depression, anxiety, and other disorders is essential. Consideration of the financial implications for long-term treatment is also important. A patient-centered team approach will reduce overall morbidity and mortality. |
article-30466_52 | Transfusion Iron Overload -- Review Questions | Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article. | Transfusion Iron Overload -- Review Questions. Access free multiple choice questions on this topic. Click here for a simplified version. Comment on this article. |
article-31877_0 | EMS Utilization Of Electrocardiogram In The Field -- Introduction | The capability for advanced cardiovascular life support (ACLS) crews to perform a 12-lead ECG in the prehospital setting has been expanding throughout healthcare worldwide over the past several decades. This has been helped along by several organizations including the American College of Cardiology Foundation (ACCF), American Heart Association Task Force (AHA), and the European Society of Cardiology (ESC). These have all released policies recommending that a 12-lead ECG per performed at the point of first medical contact (FMC) for patients with signs or symptoms consistent with acute ST-elevation myocardial infarction (STEMI). [1] [2] This is defined as a 12-lead ECG that is performed by a paramedic on an ACLS unit that is either interpreted in the field or transmitted to a hospital emergency department or coronary care unit (CCU) for interpretation. | EMS Utilization Of Electrocardiogram In The Field -- Introduction. The capability for advanced cardiovascular life support (ACLS) crews to perform a 12-lead ECG in the prehospital setting has been expanding throughout healthcare worldwide over the past several decades. This has been helped along by several organizations including the American College of Cardiology Foundation (ACCF), American Heart Association Task Force (AHA), and the European Society of Cardiology (ESC). These have all released policies recommending that a 12-lead ECG per performed at the point of first medical contact (FMC) for patients with signs or symptoms consistent with acute ST-elevation myocardial infarction (STEMI). [1] [2] This is defined as a 12-lead ECG that is performed by a paramedic on an ACLS unit that is either interpreted in the field or transmitted to a hospital emergency department or coronary care unit (CCU) for interpretation. |
article-31877_1 | EMS Utilization Of Electrocardiogram In The Field -- Introduction | The ultimate goal of the prehospital ECG is to generate an early diagnosis of STEMI and ensure that the patient is managed appropriately given the location of the patient and the capability of local healthcare facilities. Preferably, patients should be transported to a percutaneous coronary intervention (PCI)-capable center with a goal of FMC of a definitive intervention in 90 minutes or less. This can mean bypassing closer, non-PCI capable hospitals. However, if it is impossible to reach FMC to a device in less than 120 minutes, the patient will require fibrinolytic therapy, if eligible. AHA and ACCF recommendations leave this decision to the discretion of the emergency medical service (EMS) providers to make it to a PCI-capable hospital promptly or to head to the nearest hospital for fibrinolytic therapy. Early fibrinolytic therapy has been shown beneficial in reducing morbidity and mortality in patients with acute STEMI who cannot reach a PCI-capable center. In the United States, this is primarily performed at rural, non-PCI-capable facilities. Several European countries including the United Kingdom have produced numerous studies showing that fibrinolytic therapy performed in the field, by a trained paramedic, with a physician or in conjunction with a physician at a nearby facility reviewing the prehospital ECG can be safe and significantly decrease reperfusion time in an acute STEMI. This is not widely adopted in the United States due to the lack of funding and training in rural areas where this would see the most benefit. [2] | EMS Utilization Of Electrocardiogram In The Field -- Introduction. The ultimate goal of the prehospital ECG is to generate an early diagnosis of STEMI and ensure that the patient is managed appropriately given the location of the patient and the capability of local healthcare facilities. Preferably, patients should be transported to a percutaneous coronary intervention (PCI)-capable center with a goal of FMC of a definitive intervention in 90 minutes or less. This can mean bypassing closer, non-PCI capable hospitals. However, if it is impossible to reach FMC to a device in less than 120 minutes, the patient will require fibrinolytic therapy, if eligible. AHA and ACCF recommendations leave this decision to the discretion of the emergency medical service (EMS) providers to make it to a PCI-capable hospital promptly or to head to the nearest hospital for fibrinolytic therapy. Early fibrinolytic therapy has been shown beneficial in reducing morbidity and mortality in patients with acute STEMI who cannot reach a PCI-capable center. In the United States, this is primarily performed at rural, non-PCI-capable facilities. Several European countries including the United Kingdom have produced numerous studies showing that fibrinolytic therapy performed in the field, by a trained paramedic, with a physician or in conjunction with a physician at a nearby facility reviewing the prehospital ECG can be safe and significantly decrease reperfusion time in an acute STEMI. This is not widely adopted in the United States due to the lack of funding and training in rural areas where this would see the most benefit. [2] |
article-31877_2 | EMS Utilization Of Electrocardiogram In The Field -- Introduction | Therefore, the prehospital, 12-lead ECG is an important tool that can be considered in triaging a patient with symptoms concerning for an acute STEMI and transport the patient either to the nearest non-PCI capable hospital, directly to a PCI-capable hospital, or directly to the nearest cardiac catheterization laboratory (CCL). | EMS Utilization Of Electrocardiogram In The Field -- Introduction. Therefore, the prehospital, 12-lead ECG is an important tool that can be considered in triaging a patient with symptoms concerning for an acute STEMI and transport the patient either to the nearest non-PCI capable hospital, directly to a PCI-capable hospital, or directly to the nearest cardiac catheterization laboratory (CCL). |
article-31877_3 | EMS Utilization Of Electrocardiogram In The Field -- Issues of Concern | The main goal of the prehospital ECG is to identify a STEMI more quickly, leading to a more timely intervention in the appropriate candidates. Several studies have shown that decreased FMC-to-device times have improved morbidity and mortality. An effective way of decreasing the time to PCI is activating the cardiac catheterization lab from the prehospital setting and bypassing the emergency department in qualified facilities. This is a large undertaking for any health system, requiring an interprofessional effort between the EMS services, emergency department staff, interventional cardiologist, and the CCL staff. There have been some reservations about “false positive” ECGs from the field. The fear is that there will be an unnecessary utilization of resources involved with activating the CCL, as well as the possible iatrogenic injuries and adverse outcomes associated with the procedure itself. [1] [2] | EMS Utilization Of Electrocardiogram In The Field -- Issues of Concern. The main goal of the prehospital ECG is to identify a STEMI more quickly, leading to a more timely intervention in the appropriate candidates. Several studies have shown that decreased FMC-to-device times have improved morbidity and mortality. An effective way of decreasing the time to PCI is activating the cardiac catheterization lab from the prehospital setting and bypassing the emergency department in qualified facilities. This is a large undertaking for any health system, requiring an interprofessional effort between the EMS services, emergency department staff, interventional cardiologist, and the CCL staff. There have been some reservations about “false positive” ECGs from the field. The fear is that there will be an unnecessary utilization of resources involved with activating the CCL, as well as the possible iatrogenic injuries and adverse outcomes associated with the procedure itself. [1] [2] |
article-31877_4 | EMS Utilization Of Electrocardiogram In The Field -- Clinical Significance -- Prehospital 12-lead ECGs can significantly reduce to time to definitive treatment for STEMI when performed on those with symptoms concerning for acute STEMI. | Patients who have an ECG performed prehospital may bypass a hospital without PCI capabilities to significantly reduce time to definitive intervention. One study with 344 patients demonstrated that a median door to balloon time was 69 minutes for those who had an ECG performed in the field, interpreted by paramedics, and taken directly to a PCI-capable facility. This compared to a median of a 123-minute door to balloon in patients referred from an emergency department physician at a non-PCI capable facility. This study also demonstrated that 80% versus 12% of patients met the 90-minute door-to-balloon time goal when first arriving at a non-PCI capable center. [3] | EMS Utilization Of Electrocardiogram In The Field -- Clinical Significance -- Prehospital 12-lead ECGs can significantly reduce to time to definitive treatment for STEMI when performed on those with symptoms concerning for acute STEMI. Patients who have an ECG performed prehospital may bypass a hospital without PCI capabilities to significantly reduce time to definitive intervention. One study with 344 patients demonstrated that a median door to balloon time was 69 minutes for those who had an ECG performed in the field, interpreted by paramedics, and taken directly to a PCI-capable facility. This compared to a median of a 123-minute door to balloon in patients referred from an emergency department physician at a non-PCI capable facility. This study also demonstrated that 80% versus 12% of patients met the 90-minute door-to-balloon time goal when first arriving at a non-PCI capable center. [3] |
article-31877_5 | EMS Utilization Of Electrocardiogram In The Field -- Clinical Significance -- Prehospital 12-lead ECGs can significantly reduce to time to definitive treatment for STEMI when performed on those with symptoms concerning for acute STEMI. | Patients who bypass the emergency department based on a prehospital ECG have significantly decreased FMC to reperfusion. This was demonstrated in a study by the American Heart Association with 12,581 STEMI patients. In this study, 10.5% of patients were able to bypass the emergency department based on a prehospital ECG and go directly to the CCL. These patients had a median FMC to definitive treatment of 68 minutes versus 88 minutes. While ideally, the 10.5% emergency department bypass rate would be higher, this study found the bypass rate significantly varied in different health systems depending on their resources, training, and system protocols. The study did demonstrate that the emergency department was more likely to be bypassed during the daytime when more staffing and resources are present in the hospital. [4] | EMS Utilization Of Electrocardiogram In The Field -- Clinical Significance -- Prehospital 12-lead ECGs can significantly reduce to time to definitive treatment for STEMI when performed on those with symptoms concerning for acute STEMI. Patients who bypass the emergency department based on a prehospital ECG have significantly decreased FMC to reperfusion. This was demonstrated in a study by the American Heart Association with 12,581 STEMI patients. In this study, 10.5% of patients were able to bypass the emergency department based on a prehospital ECG and go directly to the CCL. These patients had a median FMC to definitive treatment of 68 minutes versus 88 minutes. While ideally, the 10.5% emergency department bypass rate would be higher, this study found the bypass rate significantly varied in different health systems depending on their resources, training, and system protocols. The study did demonstrate that the emergency department was more likely to be bypassed during the daytime when more staffing and resources are present in the hospital. [4] |
article-31877_6 | EMS Utilization Of Electrocardiogram In The Field -- Clinical Significance -- Reduction in Mortality in STEMI Patients | A study based on Britain’s Myocardial Ischemia National Audit Project (MINAP), 288,990 patients were documented to come to the Emergency Department between 2005 and 2009 by EMS and were ultimately admitted with a diagnosis of STEMI on NSTEMI. Analysis showed that there was reduced 30-day mortality in patients who had a prehospital ECG performed at 8.6% versus 11.4%. A 30-day mortality reduction was also seen in patients with NSTEMI with a prehospital ECG at 5.9% versus 6.5%. Multiple studies have reproduced findings that decreasing time to reperfusion has a significant decrease in mortality. [1] [2] [5] | EMS Utilization Of Electrocardiogram In The Field -- Clinical Significance -- Reduction in Mortality in STEMI Patients. A study based on Britain’s Myocardial Ischemia National Audit Project (MINAP), 288,990 patients were documented to come to the Emergency Department between 2005 and 2009 by EMS and were ultimately admitted with a diagnosis of STEMI on NSTEMI. Analysis showed that there was reduced 30-day mortality in patients who had a prehospital ECG performed at 8.6% versus 11.4%. A 30-day mortality reduction was also seen in patients with NSTEMI with a prehospital ECG at 5.9% versus 6.5%. Multiple studies have reproduced findings that decreasing time to reperfusion has a significant decrease in mortality. [1] [2] [5] |
article-31877_7 | EMS Utilization Of Electrocardiogram In The Field -- Clinical Significance -- Concern for Increased “False Positive” CCL Activation with Prehospital 12-lead ECGs Used for Diagnosis | False-positive CCL activations have been a controversial topic. A true, false-positive rate is difficult to obtain because it varies a great deal from the health system to health system and from study to study with rates anywhere from 9% to over 50%. Over the past 2 decades, with an emphasis on increased FMC to reperfusion time, there appears to be an overall trend upward in false-positive activations. One retrospective study in Los Angeles showed that there was a 7.8% higher rate of false-positive activations from the prehospital setting. However, another study showed a 5% decrease in false-positive CCL activations with successful transmission of the ECG to the PCI-capable facility. [6] [7] [8] | EMS Utilization Of Electrocardiogram In The Field -- Clinical Significance -- Concern for Increased “False Positive” CCL Activation with Prehospital 12-lead ECGs Used for Diagnosis. False-positive CCL activations have been a controversial topic. A true, false-positive rate is difficult to obtain because it varies a great deal from the health system to health system and from study to study with rates anywhere from 9% to over 50%. Over the past 2 decades, with an emphasis on increased FMC to reperfusion time, there appears to be an overall trend upward in false-positive activations. One retrospective study in Los Angeles showed that there was a 7.8% higher rate of false-positive activations from the prehospital setting. However, another study showed a 5% decrease in false-positive CCL activations with successful transmission of the ECG to the PCI-capable facility. [6] [7] [8] |
article-31877_8 | EMS Utilization Of Electrocardiogram In The Field -- Clinical Significance -- Concern for Increased “False Positive” CCL Activation with Prehospital 12-lead ECGs Used for Diagnosis | A study with 485 patients, including 77 false-positive CLL activations, showed 7 cases of transient acute kidney injury without other major complications. This also showed that the hospital cost was relatively minor in false activation cases. The largest concern was a cardiac catheterization delaying the diagnosis and treatment of another potentially life-threatening pathology, such as pulmonary embolism or aortic dissection. | EMS Utilization Of Electrocardiogram In The Field -- Clinical Significance -- Concern for Increased “False Positive” CCL Activation with Prehospital 12-lead ECGs Used for Diagnosis. A study with 485 patients, including 77 false-positive CLL activations, showed 7 cases of transient acute kidney injury without other major complications. This also showed that the hospital cost was relatively minor in false activation cases. The largest concern was a cardiac catheterization delaying the diagnosis and treatment of another potentially life-threatening pathology, such as pulmonary embolism or aortic dissection. |
article-31877_9 | EMS Utilization Of Electrocardiogram In The Field -- Clinical Significance -- Summary | A prehospital ECG is an effective tool to triage patients with STEMI-like symptoms to enhance their transport to the appropriate facility, and ultimately, reperfusion. While some studies have shown that a prehospital ECG can cause a short delay from time on the scene to hospital arrival, the prehospital ECG ultimately enhances FMC to reperfusion greatly and has an associated mortality benefit. While there is concern about possible false-positive CCL activations, the overall benefits of the ECG outweigh issues from these activations. This overall benefit leads to multiple interprofessional and international organizations promoting prehospital 12-lead ECGs. Health systems should work closely with their emergency departments, CCL team, interventional cardiologists, and EMS services to implement a program to screen patients with potential acute, STEMI-like symptoms with a prehospital 12-lead ECG. | EMS Utilization Of Electrocardiogram In The Field -- Clinical Significance -- Summary. A prehospital ECG is an effective tool to triage patients with STEMI-like symptoms to enhance their transport to the appropriate facility, and ultimately, reperfusion. While some studies have shown that a prehospital ECG can cause a short delay from time on the scene to hospital arrival, the prehospital ECG ultimately enhances FMC to reperfusion greatly and has an associated mortality benefit. While there is concern about possible false-positive CCL activations, the overall benefits of the ECG outweigh issues from these activations. This overall benefit leads to multiple interprofessional and international organizations promoting prehospital 12-lead ECGs. Health systems should work closely with their emergency departments, CCL team, interventional cardiologists, and EMS services to implement a program to screen patients with potential acute, STEMI-like symptoms with a prehospital 12-lead ECG. |
article-31877_10 | EMS Utilization Of Electrocardiogram In The Field -- Review Questions | Access free multiple choice questions on this topic. Comment on this article. | EMS Utilization Of Electrocardiogram In The Field -- Review Questions. Access free multiple choice questions on this topic. Comment on this article. |
article-36278_0 | Neuroanatomy, Falx Cerebri -- Introduction | The falx cerebri is a sickle-shaped structure formed from the invagination of the dura mater into the longitudinal fissure between the cerebral hemispheres. The falx cerebri is anchored posteriorly to the internal occipital protuberance, travels superiorly to the corpus callosum, and anchors anteriorly to the crista galli forming a sail-like structure between the cerebral hemispheres. The falx cerebri contains blood vessels, nerves, and is a common site of falcine meningiomas and age-related calcification. [1] | Neuroanatomy, Falx Cerebri -- Introduction. The falx cerebri is a sickle-shaped structure formed from the invagination of the dura mater into the longitudinal fissure between the cerebral hemispheres. The falx cerebri is anchored posteriorly to the internal occipital protuberance, travels superiorly to the corpus callosum, and anchors anteriorly to the crista galli forming a sail-like structure between the cerebral hemispheres. The falx cerebri contains blood vessels, nerves, and is a common site of falcine meningiomas and age-related calcification. [1] |
article-36278_1 | Neuroanatomy, Falx Cerebri -- Structure and Function | The brain is enveloped by three membranes, the pia mater, arachnoid mater, and dura mater. These three membranes are collectively called the meninges. The dura mater is the strong, fibrous outermost membrane which provides a double layer of protection within the cranial cavity. The two layers of dura mater within the neurocranium are the periosteal layer which adheres directly to the inner neurocranium and meningeal layer which surrounds the brain tissue along with the arachnoid and pia mater. The meningeal dura mater invaginates between brain regions to form dural partitions - the falx cerebri, falx cerebelli, tentorium cerebelli, and sellar diaphragm. | Neuroanatomy, Falx Cerebri -- Structure and Function. The brain is enveloped by three membranes, the pia mater, arachnoid mater, and dura mater. These three membranes are collectively called the meninges. The dura mater is the strong, fibrous outermost membrane which provides a double layer of protection within the cranial cavity. The two layers of dura mater within the neurocranium are the periosteal layer which adheres directly to the inner neurocranium and meningeal layer which surrounds the brain tissue along with the arachnoid and pia mater. The meningeal dura mater invaginates between brain regions to form dural partitions - the falx cerebri, falx cerebelli, tentorium cerebelli, and sellar diaphragm. |
article-36278_2 | Neuroanatomy, Falx Cerebri -- Structure and Function | The falx cerebri separates the cerebral hemispheres and provides channels, known as dural sinuses, for blood and cerebral spinal fluid to drain. The falx cerebri is a sail-like structure which is anchored posteriorly at the internal occipital protuberance, superiorly to the periosteal dura mater, and anteriorly to the crista galli which sits above the ethmoid bone. [2] The superior and inferior sagittal sinuses form from spaces between the meningeal dura mater folds which make up the falx cerebri. The superior sagittal sinus follows the superior margin of the falx cerebri and the inferior sagittal sinus follows the free margin of the falx cerebri above the corpus callosum. These sinuses receive cerebral spinal fluid from the arachnoid granulation and blood from meningeal and bridging veins which drain from the dura and neural tissue. The blood from the superior sagittal sinus and inferior sagittal sinus eventually drain into the internal jugular veins and finally into the systemic circulation. [3] | Neuroanatomy, Falx Cerebri -- Structure and Function. The falx cerebri separates the cerebral hemispheres and provides channels, known as dural sinuses, for blood and cerebral spinal fluid to drain. The falx cerebri is a sail-like structure which is anchored posteriorly at the internal occipital protuberance, superiorly to the periosteal dura mater, and anteriorly to the crista galli which sits above the ethmoid bone. [2] The superior and inferior sagittal sinuses form from spaces between the meningeal dura mater folds which make up the falx cerebri. The superior sagittal sinus follows the superior margin of the falx cerebri and the inferior sagittal sinus follows the free margin of the falx cerebri above the corpus callosum. These sinuses receive cerebral spinal fluid from the arachnoid granulation and blood from meningeal and bridging veins which drain from the dura and neural tissue. The blood from the superior sagittal sinus and inferior sagittal sinus eventually drain into the internal jugular veins and finally into the systemic circulation. [3] |
article-36278_3 | Neuroanatomy, Falx Cerebri -- Embryology | The three meningeal layers derive from the meninx primitiva, which is meningeal mesenchyme. The arachnoid and pia form from the leptomenix and the dura mater from the pachymeninx. While the pia mater and arachnoid mater originate from neural crest cells, the dura mater develops from the mesoderm. The dura mater forms a single layer of protection around the developing spinal cord but forms a double layer around the skull, eventually forming the periosteal and meningeal dural membranes. The process is similar to how the parietal and visceral layers of the peritoneum form in the abdominal cavity. The dura mater is a continuous membrane that forms a double layer membrane by folding in on itself where two layers of cells form in the peripheral mesenchyme - the thicker forms the periosteal dura and the thinner, the meningeal dura. As the brain develops, the meningeal dural layer invaginates between the brain regions forming dural partitions. Interruptions in brain development such as semi-lobar holoprosencephaly can prevent the dural partitions from forming appropriately. [4] [5] | Neuroanatomy, Falx Cerebri -- Embryology. The three meningeal layers derive from the meninx primitiva, which is meningeal mesenchyme. The arachnoid and pia form from the leptomenix and the dura mater from the pachymeninx. While the pia mater and arachnoid mater originate from neural crest cells, the dura mater develops from the mesoderm. The dura mater forms a single layer of protection around the developing spinal cord but forms a double layer around the skull, eventually forming the periosteal and meningeal dural membranes. The process is similar to how the parietal and visceral layers of the peritoneum form in the abdominal cavity. The dura mater is a continuous membrane that forms a double layer membrane by folding in on itself where two layers of cells form in the peripheral mesenchyme - the thicker forms the periosteal dura and the thinner, the meningeal dura. As the brain develops, the meningeal dural layer invaginates between the brain regions forming dural partitions. Interruptions in brain development such as semi-lobar holoprosencephaly can prevent the dural partitions from forming appropriately. [4] [5] |
article-36278_4 | Neuroanatomy, Falx Cerebri -- Blood Supply and Lymphatics | The falx cerebri receives its blood supply primarily from two vessels. The anterior portion of the falx receives its blood supply from the anterior meningeal artery, also known as the anterior falx artery or anterior falcine artery, which arises from the anterior ethmoidal artery. [6] The posterior falx receives its blood supply from the posterior meningeal artery, which is a branch of the ascending pharyngeal artery. The lymphatic drainage of the falx cerebri occurs via the meningeal lymphatic vessels which run parallel to the dural sinuses. These lymphatic vessels drain primarily along a similar path as the dural sinuses eventually exiting the jugular foramen and emptying into the deep cervical lymph nodes. A minority of lymph from the falx cerebri drains anteriorly through the cribriform plate into the lymphatics of the nasal mucosa. Lymphatic of the meninges differs from the lymphatics of the systemic system in a couple of ways. First, the lymphatics mostly lack valves which, in the body, prevent the retroactive flow of lymph because lymphatics are a low-pressure system. Second, the lymphatics are thinner and follow closely with the venous drainage of the meninges with few branch points. [7] [8] [9] | Neuroanatomy, Falx Cerebri -- Blood Supply and Lymphatics. The falx cerebri receives its blood supply primarily from two vessels. The anterior portion of the falx receives its blood supply from the anterior meningeal artery, also known as the anterior falx artery or anterior falcine artery, which arises from the anterior ethmoidal artery. [6] The posterior falx receives its blood supply from the posterior meningeal artery, which is a branch of the ascending pharyngeal artery. The lymphatic drainage of the falx cerebri occurs via the meningeal lymphatic vessels which run parallel to the dural sinuses. These lymphatic vessels drain primarily along a similar path as the dural sinuses eventually exiting the jugular foramen and emptying into the deep cervical lymph nodes. A minority of lymph from the falx cerebri drains anteriorly through the cribriform plate into the lymphatics of the nasal mucosa. Lymphatic of the meninges differs from the lymphatics of the systemic system in a couple of ways. First, the lymphatics mostly lack valves which, in the body, prevent the retroactive flow of lymph because lymphatics are a low-pressure system. Second, the lymphatics are thinner and follow closely with the venous drainage of the meninges with few branch points. [7] [8] [9] |
article-36278_5 | Neuroanatomy, Falx Cerebri -- Nerves | The falx cerebri receives its innervation from all three branches of the trigeminal nerve and receives sympathetic fibers predominantly from the superior cervical ganglia. Additionally, the falx may receive additional innervation from the dorsal rami of cervical nerves 1,2, and 3, the hypoglossal nerve, and recurrent branches of the vagus nerve. [10] [11] | Neuroanatomy, Falx Cerebri -- Nerves. The falx cerebri receives its innervation from all three branches of the trigeminal nerve and receives sympathetic fibers predominantly from the superior cervical ganglia. Additionally, the falx may receive additional innervation from the dorsal rami of cervical nerves 1,2, and 3, the hypoglossal nerve, and recurrent branches of the vagus nerve. [10] [11] |
article-36278_6 | Neuroanatomy, Falx Cerebri -- Muscles | There are no muscle attachments to, or within the falx cerebri. The only muscle cells associated with the meninges are the smooth muscle cells of the vasculature which run within the meninges. | Neuroanatomy, Falx Cerebri -- Muscles. There are no muscle attachments to, or within the falx cerebri. The only muscle cells associated with the meninges are the smooth muscle cells of the vasculature which run within the meninges. |
article-36278_7 | Neuroanatomy, Falx Cerebri -- Physiologic Variants | Agenesis of the falx cerebri has been documented and usually correlates with other developmental complications. Falx cerebri agenesis in individuals without other neural symptoms is exceptionally rare. Additionally, a persistent falcine sinus occurs in patients where the straight sinus fails to form during development or is thrombosed. [12] | Neuroanatomy, Falx Cerebri -- Physiologic Variants. Agenesis of the falx cerebri has been documented and usually correlates with other developmental complications. Falx cerebri agenesis in individuals without other neural symptoms is exceptionally rare. Additionally, a persistent falcine sinus occurs in patients where the straight sinus fails to form during development or is thrombosed. [12] |
article-36278_8 | Neuroanatomy, Falx Cerebri -- Surgical Considerations | The falx cerebri is a significant surgical landmark for neurosurgeons accessing the lateral ventricles via an interhemispheric transcallosal approach. Agenesis or partial agenesis of the falx cerebri allows the cerebral hemispheres to adhere and prevent midline transcallosal surgical access to the ventricles. [13] | Neuroanatomy, Falx Cerebri -- Surgical Considerations. The falx cerebri is a significant surgical landmark for neurosurgeons accessing the lateral ventricles via an interhemispheric transcallosal approach. Agenesis or partial agenesis of the falx cerebri allows the cerebral hemispheres to adhere and prevent midline transcallosal surgical access to the ventricles. [13] |
article-36278_9 | Neuroanatomy, Falx Cerebri -- Clinical Significance | In addition to the pathologies that affect all of the dural structures (e.g., bacterial meningitis), the falx cerebri is clinically significant in two common scenarios. First, the falx cerebri is the site of falcine meningiomas which account for approximately ~8.5% of intracranial meningiomas. These meningiomas are benign and form well-circumscribed, usually round masses attached to the dura. Meningiomas primarily arise from arachnoidal cap cells and can cause seizures. Headaches, nausea, and vomiting are common manifestations due to increased intracranial pressure following its significant growth. Biopsy findings will show tumor cells depending on the grade of the tumor and also showing syncytial nests, which may calcify into psammoma bodies. [14] [15] Symptomatic meningiomas are often removed surgically with occasional preoperative embolization to reduce its size and intraoperative bleeding. Practitioners can follow the principle of adequate exposure, devascularisation, intracapsular decompression, and then followed by complete excision. Damage to the sagittal sinus, thereby leading to bleeding and air embolism and malignant brain edema due to venous infarction is the main intraoperative concern. Therefore, study regarding the patency of the sinus, its probable invasion by the tumor and the status of the collateral vessels is of paramount importance while formulating the management plan of these tumors especially for tumors attached to the middle and posterior third of the superior sagittal sinus. | Neuroanatomy, Falx Cerebri -- Clinical Significance. In addition to the pathologies that affect all of the dural structures (e.g., bacterial meningitis), the falx cerebri is clinically significant in two common scenarios. First, the falx cerebri is the site of falcine meningiomas which account for approximately ~8.5% of intracranial meningiomas. These meningiomas are benign and form well-circumscribed, usually round masses attached to the dura. Meningiomas primarily arise from arachnoidal cap cells and can cause seizures. Headaches, nausea, and vomiting are common manifestations due to increased intracranial pressure following its significant growth. Biopsy findings will show tumor cells depending on the grade of the tumor and also showing syncytial nests, which may calcify into psammoma bodies. [14] [15] Symptomatic meningiomas are often removed surgically with occasional preoperative embolization to reduce its size and intraoperative bleeding. Practitioners can follow the principle of adequate exposure, devascularisation, intracapsular decompression, and then followed by complete excision. Damage to the sagittal sinus, thereby leading to bleeding and air embolism and malignant brain edema due to venous infarction is the main intraoperative concern. Therefore, study regarding the patency of the sinus, its probable invasion by the tumor and the status of the collateral vessels is of paramount importance while formulating the management plan of these tumors especially for tumors attached to the middle and posterior third of the superior sagittal sinus. |
article-36278_10 | Neuroanatomy, Falx Cerebri -- Clinical Significance | The second common clinical scenario occurs in traumatic brain injury leading to a substantial anterior cranial fossa extradural hematoma or the frontal contusions. They can cause significant mass effect forcing the ipsilateral cingulate gyrus to herniate under the falx cerebri leading to subfalcine herniation. [16] | Neuroanatomy, Falx Cerebri -- Clinical Significance. The second common clinical scenario occurs in traumatic brain injury leading to a substantial anterior cranial fossa extradural hematoma or the frontal contusions. They can cause significant mass effect forcing the ipsilateral cingulate gyrus to herniate under the falx cerebri leading to subfalcine herniation. [16] |
article-36278_11 | Neuroanatomy, Falx Cerebri -- Review Questions | Access free multiple choice questions on this topic. Comment on this article. | Neuroanatomy, Falx Cerebri -- Review Questions. Access free multiple choice questions on this topic. Comment on this article. |
article-27612_0 | Predictive Medicine -- Definition/Introduction | Healthcare in the United States is primarily based on diagnosing and treating the disease. Consider several of the most prominent medical advances of the past century: Antibiotics to treat various infections Cardiac catheterization to treat the obstructed coronary vessel(s) Beta-blockers to treat high blood pressure [1] [2] | Predictive Medicine -- Definition/Introduction. Healthcare in the United States is primarily based on diagnosing and treating the disease. Consider several of the most prominent medical advances of the past century: Antibiotics to treat various infections Cardiac catheterization to treat the obstructed coronary vessel(s) Beta-blockers to treat high blood pressure [1] [2] |
article-27612_1 | Predictive Medicine -- Definition/Introduction | Though widely accepted to result in better outcomes at lower costs, preventative medicine has received far less fanfare. One issue is that preventive medicine is less profitable than other measures. Another problem is that our understanding of individual disease risk is lacking. For example, while we know that risk factors such as smoking and pollution increase a population’s rate of lung cancer, we cannot reliably predict the risk of lung cancer in a given individual even if smoking and pollution status is known; after all, not every person who smokes or lives next to a freeway develops lung cancer. As a result, our current approach to preventative medicine is to apply a one-fits-all intervention universally; seatbelts, vaccinations, diet, and exercise are prime examples. | Predictive Medicine -- Definition/Introduction. Though widely accepted to result in better outcomes at lower costs, preventative medicine has received far less fanfare. One issue is that preventive medicine is less profitable than other measures. Another problem is that our understanding of individual disease risk is lacking. For example, while we know that risk factors such as smoking and pollution increase a population’s rate of lung cancer, we cannot reliably predict the risk of lung cancer in a given individual even if smoking and pollution status is known; after all, not every person who smokes or lives next to a freeway develops lung cancer. As a result, our current approach to preventative medicine is to apply a one-fits-all intervention universally; seatbelts, vaccinations, diet, and exercise are prime examples. |
article-27612_2 | Predictive Medicine -- Definition/Introduction | However, when considering additional preventative measures, there is a limited understanding of individual risk for a disease. If new interventions were applied entirely, vast resources would be wasted implementing those measures on individuals who were never at risk for that outcome. For instance, consider the waste, complications, and moral implications in a hypothetical scenario of performing universal mastectomies to prevent breast cancer. | Predictive Medicine -- Definition/Introduction. However, when considering additional preventative measures, there is a limited understanding of individual risk for a disease. If new interventions were applied entirely, vast resources would be wasted implementing those measures on individuals who were never at risk for that outcome. For instance, consider the waste, complications, and moral implications in a hypothetical scenario of performing universal mastectomies to prevent breast cancer. |
article-27612_3 | Predictive Medicine -- Issues of Concern | Predictive medicine is a relatively new medical subspecialty, yet the concept is not novel. In the most basic terms, predictive medicine utilizes specific laboratory and genetic tests to determine an individual's probability of developing a disease. Biomarkers have been commonly used in oncology. Still, the aim is to increase the use of similar biomarkers to predict the more common clinical disorders seen in everyday life. | Predictive Medicine -- Issues of Concern. Predictive medicine is a relatively new medical subspecialty, yet the concept is not novel. In the most basic terms, predictive medicine utilizes specific laboratory and genetic tests to determine an individual's probability of developing a disease. Biomarkers have been commonly used in oncology. Still, the aim is to increase the use of similar biomarkers to predict the more common clinical disorders seen in everyday life. |
article-27612_4 | Predictive Medicine -- Issues of Concern -- Predictive Medicine | Ideally, we would calculate a person’s risk for breast cancer or any other disease and intervene appropriately. This is the goal of predictive medicine: obtaining and cataloging characteristics about individual patients, analyzing that data to predict the patient’s risk for an outcome of interest, predicting which treatment might be most effective for which individual, and then intervening before the outcome occurs.Traditionally, predictive medicine was exclusively confined to the realm of genetics. It was once thought that genetics would revolutionize medicine, and genetics and genomics have improved our ability to predict individual risk for some diseases (eg, the BRCA gene and breast cancer) and predict which treatment will be more effective in a given individual (eg, therapy directed at a molecular target in cancer). However, genetics-based risk prediction has proven to be of limited benefit for reasons including (1) whole-genome sequencing is still relatively expensive and not currently covered by insurance, and (2) the majority of diseases afflicting the population today is multifactorial. For example, heart disease is influenced not only by genetics but also by age, diet, exercise, and stress levels. Collecting and organizing this data for analysis is invaluable. | Predictive Medicine -- Issues of Concern -- Predictive Medicine. Ideally, we would calculate a person’s risk for breast cancer or any other disease and intervene appropriately. This is the goal of predictive medicine: obtaining and cataloging characteristics about individual patients, analyzing that data to predict the patient’s risk for an outcome of interest, predicting which treatment might be most effective for which individual, and then intervening before the outcome occurs.Traditionally, predictive medicine was exclusively confined to the realm of genetics. It was once thought that genetics would revolutionize medicine, and genetics and genomics have improved our ability to predict individual risk for some diseases (eg, the BRCA gene and breast cancer) and predict which treatment will be more effective in a given individual (eg, therapy directed at a molecular target in cancer). However, genetics-based risk prediction has proven to be of limited benefit for reasons including (1) whole-genome sequencing is still relatively expensive and not currently covered by insurance, and (2) the majority of diseases afflicting the population today is multifactorial. For example, heart disease is influenced not only by genetics but also by age, diet, exercise, and stress levels. Collecting and organizing this data for analysis is invaluable. |
article-27612_5 | Predictive Medicine -- Issues of Concern -- Predictive Medicine | The Big Data Revolution [3] | Predictive Medicine -- Issues of Concern -- Predictive Medicine. The Big Data Revolution [3] |
article-27612_6 | Predictive Medicine -- Issues of Concern -- Predictive Medicine | Though never formally quantified, healthcare data has already been collected on a titanic scale; every vital sign, medical chart, and radiology image from every clinic, pharmacy, and hospital collectively represent only a tiny fraction of data points available for analysis. Social media, billing, census, and more data also include information contributing to healthcare outcomes. The amount of data increases exponentially as data collection, storage, and processing prices decrease. All this data, coupled with newer computer-based analytic techniques, such as machine learning, make up the so-called "Big Data Revolution." With big data, predictive medicine may soon be able to quantify individual risk for various healthcare outcomes and determine optimal, personalized treatment options. Other industries have already taken advantage of this revolution and are continuing to refine their predictive applications: banks can predict a customer’s risk of defaulting on a loan, and social media websites predict the type of advertisement to which a user is most likely to respond, and insurance companies predict how likely an individual is to file a claim. Most importantly, these industries have developed the software and workflow infrastructure needed to deploy these analyses on the front lines of their operations in real-time. | Predictive Medicine -- Issues of Concern -- Predictive Medicine. Though never formally quantified, healthcare data has already been collected on a titanic scale; every vital sign, medical chart, and radiology image from every clinic, pharmacy, and hospital collectively represent only a tiny fraction of data points available for analysis. Social media, billing, census, and more data also include information contributing to healthcare outcomes. The amount of data increases exponentially as data collection, storage, and processing prices decrease. All this data, coupled with newer computer-based analytic techniques, such as machine learning, make up the so-called "Big Data Revolution." With big data, predictive medicine may soon be able to quantify individual risk for various healthcare outcomes and determine optimal, personalized treatment options. Other industries have already taken advantage of this revolution and are continuing to refine their predictive applications: banks can predict a customer’s risk of defaulting on a loan, and social media websites predict the type of advertisement to which a user is most likely to respond, and insurance companies predict how likely an individual is to file a claim. Most importantly, these industries have developed the software and workflow infrastructure needed to deploy these analyses on the front lines of their operations in real-time. |
article-27612_7 | Predictive Medicine -- Clinical Significance | To achieve its goals, predictive medicine must provide applicable insights about outcomes that have not yet occurred and deliver these personalized insights to frontline healthcare providers such as physicians, midlevel practitioners, and nurses at the point of patient contact. Otherwise, predictive medicine's potential is reduced to an academic novelty: compelling in theory but impractical in clinical practice. | Predictive Medicine -- Clinical Significance. To achieve its goals, predictive medicine must provide applicable insights about outcomes that have not yet occurred and deliver these personalized insights to frontline healthcare providers such as physicians, midlevel practitioners, and nurses at the point of patient contact. Otherwise, predictive medicine's potential is reduced to an academic novelty: compelling in theory but impractical in clinical practice. |
article-27612_8 | Predictive Medicine -- Clinical Significance | Effective adoption and implementation require significant efforts to purchase, develop, and refine the IT infrastructure and advocate for this next generation of data-based medicine. Success requires the alignment of incentives across all stakeholders—from the medical software companies developing these tools to the medical center administration investing in the infrastructure to the healthcare providers ultimately responsible for using these tools appropriately. Assuming full adoption, predictive medicine faces additional new challenges. With the unprecedented acquisition and utilization of healthcare and healthcare-related data, HIPAA and data security become even more prominent issues. Philosophically, there are likely to be ongoing debates about the use and overuse of these technologies and their effect on clinical acumen and medical practice, just as there is ongoing criticism regarding the overuse of CTs and other imaging modalities.None of these challenges are insurmountable, and the potential benefits at this time appear to be worth the effort. With the Affordable Care Act's shift from quantity-based healthcare payment reimbursement to a value-based reimbursement system, stakeholders should be even more compelled to closely examine the cost savings and quality improvements afforded by predictive medicine and big data. Only time can tell if predictive medicine lives up to its potential. [4] [5] | Predictive Medicine -- Clinical Significance. Effective adoption and implementation require significant efforts to purchase, develop, and refine the IT infrastructure and advocate for this next generation of data-based medicine. Success requires the alignment of incentives across all stakeholders—from the medical software companies developing these tools to the medical center administration investing in the infrastructure to the healthcare providers ultimately responsible for using these tools appropriately. Assuming full adoption, predictive medicine faces additional new challenges. With the unprecedented acquisition and utilization of healthcare and healthcare-related data, HIPAA and data security become even more prominent issues. Philosophically, there are likely to be ongoing debates about the use and overuse of these technologies and their effect on clinical acumen and medical practice, just as there is ongoing criticism regarding the overuse of CTs and other imaging modalities.None of these challenges are insurmountable, and the potential benefits at this time appear to be worth the effort. With the Affordable Care Act's shift from quantity-based healthcare payment reimbursement to a value-based reimbursement system, stakeholders should be even more compelled to closely examine the cost savings and quality improvements afforded by predictive medicine and big data. Only time can tell if predictive medicine lives up to its potential. [4] [5] |
article-27612_9 | Predictive Medicine -- Clinical Significance | The biggest problem with predictive medicine is the validity of the available tests. No test is 100% sensitive and 100% specific. Hence, false positives and negatives are expected when applying any test to predict disease. Cost and ethics are also major concerns when it comes to genetic testing to predict disease. When applying genetic tests to predict disease, one can never negate the role of the environment or lifestyle. Plus, the reliability of genetic testing is not 100%. With cost containment a priority in healthcare, empirical ordering of predictive tests may not be practical or realistic for the entire population. | Predictive Medicine -- Clinical Significance. The biggest problem with predictive medicine is the validity of the available tests. No test is 100% sensitive and 100% specific. Hence, false positives and negatives are expected when applying any test to predict disease. Cost and ethics are also major concerns when it comes to genetic testing to predict disease. When applying genetic tests to predict disease, one can never negate the role of the environment or lifestyle. Plus, the reliability of genetic testing is not 100%. With cost containment a priority in healthcare, empirical ordering of predictive tests may not be practical or realistic for the entire population. |
article-27612_10 | Predictive Medicine -- Clinical Significance | While big data results have helped yield valuable clinical variables that are potentially associated with patient clinical outcomes of interest, one must appreciate the limitations of big data. Indeed, several reports have been made regarding potential miscoding and/or incorrect diagnostic coding that can ultimately result in inconclusive or potentially incorrect statistical conclusions. | Predictive Medicine -- Clinical Significance. While big data results have helped yield valuable clinical variables that are potentially associated with patient clinical outcomes of interest, one must appreciate the limitations of big data. Indeed, several reports have been made regarding potential miscoding and/or incorrect diagnostic coding that can ultimately result in inconclusive or potentially incorrect statistical conclusions. |
article-27612_11 | Predictive Medicine -- Clinical Significance | Several authors have proposed utilizing big data results and their statistically and clinically relevant variables as a "flashlight" to highlight larger groups of relevant variables to be applied at the institutional level as part of more customized statistically relevant analyses to mitigate these limitations. [6] [7] | Predictive Medicine -- Clinical Significance. Several authors have proposed utilizing big data results and their statistically and clinically relevant variables as a "flashlight" to highlight larger groups of relevant variables to be applied at the institutional level as part of more customized statistically relevant analyses to mitigate these limitations. [6] [7] |
article-27612_12 | Predictive Medicine -- Nursing, Allied Health, and Interprofessional Team Interventions | Since predictive medicine can help identify patients at greatest risk for an adverse outcome, nursing staff must understand predictive medicine and the importance of the data they collect. This includes accurate and appropriate data collection, proper assessment technique, and communicating to clinician staff when a patient presents with "red flags," indicating they are an at-risk individual. | Predictive Medicine -- Nursing, Allied Health, and Interprofessional Team Interventions. Since predictive medicine can help identify patients at greatest risk for an adverse outcome, nursing staff must understand predictive medicine and the importance of the data they collect. This includes accurate and appropriate data collection, proper assessment technique, and communicating to clinician staff when a patient presents with "red flags," indicating they are an at-risk individual. |
article-27612_13 | Predictive Medicine -- Review Questions | Access free multiple choice questions on this topic. Comment on this article. | Predictive Medicine -- Review Questions. Access free multiple choice questions on this topic. Comment on this article. |
article-131258_0 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Continuing Education Activity | Intestinal or bowel ultrasound is a non-invasive examination method of the gastrointestinal tract. It is a complementary examination of the more common abdominal ultrasound for providers who use ultrasound as part of their practice. Ultrasound does not involve radiation and is, therefore, safe for pregnant women and children and for patients that require repeated radiological examination. Operator technique and time allocation serve as potential limitations to this exam. This activity highlights the role of the interprofessional team in incorporating intestinal ultrasound in clinical practice and reviews its technique, equipment used, and limitations. | Sonography Intestinal Assessment, Protocols, and Interpretation -- Continuing Education Activity. Intestinal or bowel ultrasound is a non-invasive examination method of the gastrointestinal tract. It is a complementary examination of the more common abdominal ultrasound for providers who use ultrasound as part of their practice. Ultrasound does not involve radiation and is, therefore, safe for pregnant women and children and for patients that require repeated radiological examination. Operator technique and time allocation serve as potential limitations to this exam. This activity highlights the role of the interprofessional team in incorporating intestinal ultrasound in clinical practice and reviews its technique, equipment used, and limitations. |
article-131258_1 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Continuing Education Activity | Objectives: Describe the importance of intestinal ultrasound in clinical practice and the techniques used in screening by ultrasound. Summarize the anatomical landmarks of intestinal ultrasound. Review the different indications for intestinal ultrasound and the pathologies potentially seen on imaging. Describe the potential role of ultrasound in evaluating infectious and inflammatory bowel disease. Access free multiple choice questions on this topic. | Sonography Intestinal Assessment, Protocols, and Interpretation -- Continuing Education Activity. Objectives: Describe the importance of intestinal ultrasound in clinical practice and the techniques used in screening by ultrasound. Summarize the anatomical landmarks of intestinal ultrasound. Review the different indications for intestinal ultrasound and the pathologies potentially seen on imaging. Describe the potential role of ultrasound in evaluating infectious and inflammatory bowel disease. Access free multiple choice questions on this topic. |
article-131258_2 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Introduction | Intestinal or bowel ultrasound is a non-invasive sonographic exam of the gastrointestinal tract. It acts as a complementary examination to the standard abdominal ultrasound exam and offers clinical data that could be beneficial in patients unable to obtain CT or MRI examinations for various reasons. [1] Intestinal ultrasound also provides the option of being portable to those patients who are immobile. [2] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Introduction. Intestinal or bowel ultrasound is a non-invasive sonographic exam of the gastrointestinal tract. It acts as a complementary examination to the standard abdominal ultrasound exam and offers clinical data that could be beneficial in patients unable to obtain CT or MRI examinations for various reasons. [1] Intestinal ultrasound also provides the option of being portable to those patients who are immobile. [2] |
article-131258_3 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Introduction | As a hollow organ, the gastrointestinal system contains air and fluid. While fluid is considered a good acoustic medium, the air is a poor acoustic medium that typically impairs ultrasound imaging. Thus patient preparation often improves the diagnostic quality of ultrasound evaluation of the small and large bowel. Bowel ultrasound can be used in the detection, diagnosis, and follow-up of various gastrointestinal illnesses. Ultrasound does not involve radiation and is, therefore, safe for pregnant women and children and for patients that require repeated radiological examination. Operator technique and time allocation serve as potential limitations to this exam. [3] [4] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Introduction. As a hollow organ, the gastrointestinal system contains air and fluid. While fluid is considered a good acoustic medium, the air is a poor acoustic medium that typically impairs ultrasound imaging. Thus patient preparation often improves the diagnostic quality of ultrasound evaluation of the small and large bowel. Bowel ultrasound can be used in the detection, diagnosis, and follow-up of various gastrointestinal illnesses. Ultrasound does not involve radiation and is, therefore, safe for pregnant women and children and for patients that require repeated radiological examination. Operator technique and time allocation serve as potential limitations to this exam. [3] [4] |
article-131258_4 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology | Normal bowel anatomy as determined by ultrasound differs from other radiological techniques and its histological appearance under light microscopy. Multiple diagnostic scoring systems are present to detect gastrointestinal diseases . [5] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology. Normal bowel anatomy as determined by ultrasound differs from other radiological techniques and its histological appearance under light microscopy. Multiple diagnostic scoring systems are present to detect gastrointestinal diseases . [5] |
article-131258_5 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology | Normal bowel wall appearance and thickness: Normal bowel wall consists of five layers, each differing in echogenicity, allowing some degree of discerning these layers from each other. Normal bowel diameter depends on the segment of the intestine interrogated. Bowel wall thickness is the most important feature in intestinal ultrasound assessment and an important parameter used in detecting intestinal disease. Thickness is determined by measuring all of the wall strata from the lumen interface to the serosa. Typically wall thickness between 3 to 4 mm is considered normal, except for the gastric wall, which could range up to 5 or 6 mm. [6] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology. Normal bowel wall appearance and thickness: Normal bowel wall consists of five layers, each differing in echogenicity, allowing some degree of discerning these layers from each other. Normal bowel diameter depends on the segment of the intestine interrogated. Bowel wall thickness is the most important feature in intestinal ultrasound assessment and an important parameter used in detecting intestinal disease. Thickness is determined by measuring all of the wall strata from the lumen interface to the serosa. Typically wall thickness between 3 to 4 mm is considered normal, except for the gastric wall, which could range up to 5 or 6 mm. [6] |
article-131258_6 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology | Normal bowel diameter: Pathology of the small and large bowel can manifest as an obstructive or paralytic process causing dilatation of the bowels. As such, bowel loop diameter can help in assessing for pathology. As a rule of thumb, the small intestine diameter may not exceed 2.5 to 3 cm. Similarly, the large intestine typically does not exceed 5 cm in diameter. [7] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology. Normal bowel diameter: Pathology of the small and large bowel can manifest as an obstructive or paralytic process causing dilatation of the bowels. As such, bowel loop diameter can help in assessing for pathology. As a rule of thumb, the small intestine diameter may not exceed 2.5 to 3 cm. Similarly, the large intestine typically does not exceed 5 cm in diameter. [7] |
article-131258_7 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology | Echo pattern: Although the arrangement of wall layers does not correlate with histological layers exactly, this stratification is still important in identifying diseases by detecting loss of stratification. The lumen of the gut interface: hyperechoic The mucosa: hypoechoic The submucosa: hyperechoic The muscularis propria: hypoechoic The serosa: hyperechoic | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology. Echo pattern: Although the arrangement of wall layers does not correlate with histological layers exactly, this stratification is still important in identifying diseases by detecting loss of stratification. The lumen of the gut interface: hyperechoic The mucosa: hypoechoic The submucosa: hyperechoic The muscularis propria: hypoechoic The serosa: hyperechoic |
article-131258_8 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology | Vascularity: Determining abnormal vascularity, such as hyperemia or neovascularization, is important in diagnosing different intestinal diseases such as edema, inflammation, or malignancy. This is usually assessed by color doppler accompanying the usual greyscale evaluation on ultrasound examination. [8] Another critical parameter in sonographic bowel evaluation is assessing the appearance of large vessels supplying the gastrointestinal system, including the superior mesenteric artery, inferior mesenteric artery, and celiac trunk. Evaluating the superior and inferior mesenteric veins and portal and splenic veins can also provide important diagnostic information. | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology. Vascularity: Determining abnormal vascularity, such as hyperemia or neovascularization, is important in diagnosing different intestinal diseases such as edema, inflammation, or malignancy. This is usually assessed by color doppler accompanying the usual greyscale evaluation on ultrasound examination. [8] Another critical parameter in sonographic bowel evaluation is assessing the appearance of large vessels supplying the gastrointestinal system, including the superior mesenteric artery, inferior mesenteric artery, and celiac trunk. Evaluating the superior and inferior mesenteric veins and portal and splenic veins can also provide important diagnostic information. |
article-131258_9 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology | Motility: Motility represents a subjective measure of assessing bowel health and is operator-dependent. Peristalsis is limited in cases of inflammation of the bowel or fibrous strictures. Increased peristalsis is present in diarrhea, celiac disease, and intestinal obstruction, among other causes. [9] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology. Motility: Motility represents a subjective measure of assessing bowel health and is operator-dependent. Peristalsis is limited in cases of inflammation of the bowel or fibrous strictures. Increased peristalsis is present in diarrhea, celiac disease, and intestinal obstruction, among other causes. [9] |
article-131258_10 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology | Compressibility : Non-compressible bowel could indicate an inflammatory or malignant change in the bowel wall as infiltrative neoplasms result in the loss of the normal pliability of the bowel wall. [10] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology. Compressibility : Non-compressible bowel could indicate an inflammatory or malignant change in the bowel wall as infiltrative neoplasms result in the loss of the normal pliability of the bowel wall. [10] |
article-131258_11 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology | Other important signs that could be found on intestinal ultrasound and be an indication of the underlying disease: Mesenteric fat: Mainly assessed from the epigastrium to the right iliac fossa. Increased thickness >6mm is associated with an abnormality, such as an inflammatory process like diverticulitis. Extraluminal gas: This usually indicates luminal perforation at the site of pathology. | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology. Other important signs that could be found on intestinal ultrasound and be an indication of the underlying disease: Mesenteric fat: Mainly assessed from the epigastrium to the right iliac fossa. Increased thickness >6mm is associated with an abnormality, such as an inflammatory process like diverticulitis. Extraluminal gas: This usually indicates luminal perforation at the site of pathology. |
article-131258_12 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology -- Different Scoring Systems In Intestinal Ultrasound | The use of regular ultrasound or bubble contrast (contrast-enhanced ultrasound CEUS) is a common medical practice in Europe and North America. [11] Different scoring systems have been evaluated, but no universal scoring system has been proven effective to date. Most of the scoring systems include various parameters to include bowel wall thickness, wall stratification, detection of fistula formation, ascites, mesenteric fat, lymph nodes, compressibility, peristalsis, and inflammatory signs in the bowel wall with color doppler. [2] [12] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology -- Different Scoring Systems In Intestinal Ultrasound. The use of regular ultrasound or bubble contrast (contrast-enhanced ultrasound CEUS) is a common medical practice in Europe and North America. [11] Different scoring systems have been evaluated, but no universal scoring system has been proven effective to date. Most of the scoring systems include various parameters to include bowel wall thickness, wall stratification, detection of fistula formation, ascites, mesenteric fat, lymph nodes, compressibility, peristalsis, and inflammatory signs in the bowel wall with color doppler. [2] [12] |
article-131258_13 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology -- Different Scoring Systems In Intestinal Ultrasound | A simple ultrasound score that can be used for Crohn disease monitoring was validated through clinical studies. The authors claimed that it could be used in follow-up in lieu of endoscopy for Crohn disease patients. [13] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology -- Different Scoring Systems In Intestinal Ultrasound. A simple ultrasound score that can be used for Crohn disease monitoring was validated through clinical studies. The authors claimed that it could be used in follow-up in lieu of endoscopy for Crohn disease patients. [13] |
article-131258_14 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology -- The Difference in Wall Thickness in Children with Crohn Disease | The normal bowel thickness in children is typically less than 2 mm, similar to that of adults. Intestinal ultrasound is helpful in the detection and follow-up of Crohn disease in children. [14] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Anatomy and Physiology -- The Difference in Wall Thickness in Children with Crohn Disease. The normal bowel thickness in children is typically less than 2 mm, similar to that of adults. Intestinal ultrasound is helpful in the detection and follow-up of Crohn disease in children. [14] |
article-131258_15 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications | Intestinal ultrasound is a non-invasive procedure that could be ancillary to the more frequently performed abdominal ultrasound. Some clinicians can use it as the initial examination of choice depending on operator comfort using an ultrasound machine and image interpretation. [15] [16] [17] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications. Intestinal ultrasound is a non-invasive procedure that could be ancillary to the more frequently performed abdominal ultrasound. Some clinicians can use it as the initial examination of choice depending on operator comfort using an ultrasound machine and image interpretation. [15] [16] [17] |
article-131258_16 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Acute Abdomen | Acute appendicitis: Different compression techniques are used to assess for acute appendicitis. The diagnostic signs on ultrasound are a noncompressible, enlarged blind-ending tubular structure representing an inflamed appendix in the right iliac fossa. [18] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Acute Abdomen. Acute appendicitis: Different compression techniques are used to assess for acute appendicitis. The diagnostic signs on ultrasound are a noncompressible, enlarged blind-ending tubular structure representing an inflamed appendix in the right iliac fossa. [18] |
article-131258_17 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Acute Abdomen | Acute diverticulitis: Ultrasound can demonstrate bowel wall thickening, diverticulosis, and foci of varying echogenicity, along with hyperechoic pericolic inflammatory fat. [19] Perforation can manifest as foci of dirty shadowing representing gas. | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Acute Abdomen. Acute diverticulitis: Ultrasound can demonstrate bowel wall thickening, diverticulosis, and foci of varying echogenicity, along with hyperechoic pericolic inflammatory fat. [19] Perforation can manifest as foci of dirty shadowing representing gas. |
article-131258_18 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Acute Abdomen | Ischemic colitis: An increase in the colon wall diameter >5 mm (typically involving the left colon), with loss of bowel wall stratification can be seen. Absent or markedly increased vascular flow on color doppler can also be demonstrated. [20] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Acute Abdomen. Ischemic colitis: An increase in the colon wall diameter >5 mm (typically involving the left colon), with loss of bowel wall stratification can be seen. Absent or markedly increased vascular flow on color doppler can also be demonstrated. [20] |
article-131258_19 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Acute Abdomen | Intestinal obstruction: Intestinal ultrasound is not the most conclusive method for diagnosing intestinal obstruction due to the gaseous distension associated with obstruction. However, if small bowel loops are distended with fluid, this can be assessed on sonography to some degree. Rarely the underlying cause of obstruction(such as in the setting of a large mass a) can be visualized. The small bowel diameter is typically greater than 2.5 cm in the setting of obstruction, while the length of the obstructed segment typically needs to be greater than 10 cm, with affected bowel loops typically distended with fluid or debris. [21] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Acute Abdomen. Intestinal obstruction: Intestinal ultrasound is not the most conclusive method for diagnosing intestinal obstruction due to the gaseous distension associated with obstruction. However, if small bowel loops are distended with fluid, this can be assessed on sonography to some degree. Rarely the underlying cause of obstruction(such as in the setting of a large mass a) can be visualized. The small bowel diameter is typically greater than 2.5 cm in the setting of obstruction, while the length of the obstructed segment typically needs to be greater than 10 cm, with affected bowel loops typically distended with fluid or debris. [21] |
article-131258_20 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Acute Abdomen | Enlargement of mesenteric lymph nodes: While paraaortic lymph nodes are typically too deep for adequate visualization, mesenteric lymph nodes can often be seen. [22] This can include enlarged mesenteric lymph nodes adjacent to a thickened ileum in the setting of Crohn disease-related inflammation or generalized adenopathy as in sclerosing mesenteritis. | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Acute Abdomen. Enlargement of mesenteric lymph nodes: While paraaortic lymph nodes are typically too deep for adequate visualization, mesenteric lymph nodes can often be seen. [22] This can include enlarged mesenteric lymph nodes adjacent to a thickened ileum in the setting of Crohn disease-related inflammation or generalized adenopathy as in sclerosing mesenteritis. |
article-131258_21 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Chronic Diseases or Non-urgent Conditions | Crohn disease: Ultrasound has a limited role in evaluating Crohn disease but can be used as a screening or follow-up modality in assessing for complications of Crohn disease. Sonographic findings can often be nonspecific. Findings include loss of peristalsis, mural hyperemia of the affect bowel, fibrofatty proliferation as evidenced by a hyperechoic layer surrounding the bowel wall, and small bowel wall thickening. Additional findings include a loss of compressibility and bowel wall fibrosis which can mimic normal bowel wall submucosa. Other nonspecific findings include mesenteric lymphadenopathy and intraperitoneal fluid. [23] Complications of Crohn disease can also be seen including abscess formation and fistula formation. [24] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Chronic Diseases or Non-urgent Conditions. Crohn disease: Ultrasound has a limited role in evaluating Crohn disease but can be used as a screening or follow-up modality in assessing for complications of Crohn disease. Sonographic findings can often be nonspecific. Findings include loss of peristalsis, mural hyperemia of the affect bowel, fibrofatty proliferation as evidenced by a hyperechoic layer surrounding the bowel wall, and small bowel wall thickening. Additional findings include a loss of compressibility and bowel wall fibrosis which can mimic normal bowel wall submucosa. Other nonspecific findings include mesenteric lymphadenopathy and intraperitoneal fluid. [23] Complications of Crohn disease can also be seen including abscess formation and fistula formation. [24] |
article-131258_22 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Chronic Diseases or Non-urgent Conditions | Ulcerative colitis: Ultrasound can demonstrate increased bowel wall thickness of the rectosigmoid colon typically measuring greater than 4 mm in ulcerative colitis patients. Loss of wall haustrations, wall stratification, hyperemia on power color doppler, and enlarged mesenteric fat can also be seen. [25] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Chronic Diseases or Non-urgent Conditions. Ulcerative colitis: Ultrasound can demonstrate increased bowel wall thickness of the rectosigmoid colon typically measuring greater than 4 mm in ulcerative colitis patients. Loss of wall haustrations, wall stratification, hyperemia on power color doppler, and enlarged mesenteric fat can also be seen. [25] |
article-131258_23 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Chronic Diseases or Non-urgent Conditions | Infectious diseases (bacterial enteritis, tuberculous enteritis, pseudomembranous colitis, amebic or parasitic enteritis, ascariasis): Depending on the bacterial or parasitic organism, findings can range from nonspecific wall thickening secondary to inflammation, localized fluid collections(such as in the setting of a hydatid cyst), or in rare cases the actual parasite can be visualized(such as in the setting of ascariasis). [26] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Chronic Diseases or Non-urgent Conditions. Infectious diseases (bacterial enteritis, tuberculous enteritis, pseudomembranous colitis, amebic or parasitic enteritis, ascariasis): Depending on the bacterial or parasitic organism, findings can range from nonspecific wall thickening secondary to inflammation, localized fluid collections(such as in the setting of a hydatid cyst), or in rare cases the actual parasite can be visualized(such as in the setting of ascariasis). [26] |
article-131258_24 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Chronic Diseases or Non-urgent Conditions | Colorectal and gastric cancers: Malignancy can have various shapes from a focal endophytic (or even occasionally an exophytic mass) or infiltrative wall thickening (either circumferential or involving limited portions of the wall circumference). [27] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Chronic Diseases or Non-urgent Conditions. Colorectal and gastric cancers: Malignancy can have various shapes from a focal endophytic (or even occasionally an exophytic mass) or infiltrative wall thickening (either circumferential or involving limited portions of the wall circumference). [27] |
article-131258_25 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Chronic Diseases or Non-urgent Conditions | Peritoneal metastasis: Peritoneal metastasis can often manifest as multi-focal masses adhering to the bowel with increased vascularity. Associated complex ascitic fluid can also be seen on occasion. [28] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Chronic Diseases or Non-urgent Conditions. Peritoneal metastasis: Peritoneal metastasis can often manifest as multi-focal masses adhering to the bowel with increased vascularity. Associated complex ascitic fluid can also be seen on occasion. [28] |
article-131258_26 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Chronic Diseases or Non-urgent Conditions | Appendiceal mucoceles are often well visualized on ultrasound, especially when large, and typically appear as a unilocular mass and have been described to have a "whipped cream" appearance. [29] | Sonography Intestinal Assessment, Protocols, and Interpretation -- Indications -- Chronic Diseases or Non-urgent Conditions. Appendiceal mucoceles are often well visualized on ultrasound, especially when large, and typically appear as a unilocular mass and have been described to have a "whipped cream" appearance. [29] |
article-131258_27 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Contraindications | There are no contraindications to this non-invasive procedure. When appropriate, such as in the setting of acute pain, when available and clinically appropriate, CT imaging should be prioritized over sonographic imaging of the bowel. | Sonography Intestinal Assessment, Protocols, and Interpretation -- Contraindications. There are no contraindications to this non-invasive procedure. When appropriate, such as in the setting of acute pain, when available and clinically appropriate, CT imaging should be prioritized over sonographic imaging of the bowel. |
article-131258_28 | Sonography Intestinal Assessment, Protocols, and Interpretation -- Equipment | In the bowel-ultrasound, the sonographer uses the same equipment as the normal abdominal ultrasound but requires more experience to detect abnormalities in the intestinal wall. The bowel screening can start with the common convex low-frequency probe (3.5 to 5 MHz) used in a standard abdominal ultrasound examination. Detailed visualization of the bowel can be performed using a linear high-frequency (4 to 13 MHz) probe, as it possesses high resolution. [9] When possible, it is better to use tissue harmonic imaging (THI) owing to the additional diagnostic information it can provide regarding bowel wall, lumen, and fluid content. | Sonography Intestinal Assessment, Protocols, and Interpretation -- Equipment. In the bowel-ultrasound, the sonographer uses the same equipment as the normal abdominal ultrasound but requires more experience to detect abnormalities in the intestinal wall. The bowel screening can start with the common convex low-frequency probe (3.5 to 5 MHz) used in a standard abdominal ultrasound examination. Detailed visualization of the bowel can be performed using a linear high-frequency (4 to 13 MHz) probe, as it possesses high resolution. [9] When possible, it is better to use tissue harmonic imaging (THI) owing to the additional diagnostic information it can provide regarding bowel wall, lumen, and fluid content. |
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