Israel Medical Association Journal

Background: Open access gastroscopy allows physicians to refer patients for endoscopic procedures without a prior consultation.

Objectives: To compare the safety and efficacy of OAG[1] with gastroscopy performed after a gastroenterological consultation.

Methods: Patients referred for gastroscopy directly (open access) or after consultation with a gastroenterologist, by physicians in the departments of internal medicine and surgery at a major tertiary center, were compared for indications, background disease, outcome and diagnostic yield. The data were collected prospectively over a 5 month period following the introduction of OAG at the center. Physicians in both departments participated in an education program on the indications and procedure of gastroscopy. For each patient referred for OAG the attending physician completed a specially designed questionnaire that had to be signed by a senior physician. Data were managed and analyzed with Excel and SPSS software.

Results: The study sample comprised 494 patients: of whom 236 were referred for OAG and 258 after prior consultation. On multivariate analysis, hospitalization in the department of internal medicine was the only independent factor for OAG. Severe background disease and aspirin treatment had no effect on physician use of OAG, although they served as a “red light” for the gastroenterology consultants. There was no difference in the diagnostic yield of the procedures (26.4% normal findings for OAG and 28.3% for consultations) or in mortality rates. The main indications for referral to gastroscopy in the surgery department were melena, hematemesis, and "coffee grounds," and anemia and vomiting in the internal medicine department.
Conclusions: OAG is feasible and beneficial in an academic medical center setting, with no bias in appropriateness of indications or decrease in the diagnostic yield compared to the traditional approach. More attention should be directed to safety issues by the referring physicians

Background: Coronary heart disease and ischemic stroke are among the leading causes of morbidity and mortality in adults, and cerebrovascular disease is associated with the presence of symptomatic and asymptomatic CHD[1]. Several studies noted an association between coronary calcification and thoracic aorta calcification by several imaging techniques, but this association has not yet been examined in stable angina pectoris patients with the use of spiral computed tomography.

Objectives: To examine by spiral CT the association between the presence and severity of CC[2] and thoracic aorta calcification in patients with stable angina pectoris.

Methods: The patients were enrolled in ACTION (A Coronary Disease Trial Investigating Outcome with Nifedipine GITS) in Israel. The 432 patients (371 men and 61 women aged 40–89 years) underwent chest CT and were evaluated for CC and aortic calcification.

Results: CC was documented in 90% of the patients (n=392) and aortic calcification in 70% (n=303). A significant association (P < 0.05) was found between severity of CC and severity of aortic calcification (as measured by area, volume and slices of calcification). We also found an association between the number of coronary vessels calcified and the presence of aortic calcification: 90% of patients with triple-vessel disease (n=157) were also positive for aortic calcification (P < 0.05). Age also had an effect: 87% of patients ≥ 65 years (n=219) were positive for both coronary and aortic calcification (P = 0.005) while only 57% ≤ 65 (n=209) were positive for both (P = 0.081).

Conclusions: Our study demonstrates a strong association between the presence and severity of CC and the presence and severity of calcification of thoracic aorta in patients with stable angina pectoris as detected by spiral CT.

Background: Protruding aortic atheromas are a potential source of stroke and systemic emboli. The single modality currently available for their detection has been transesophageal echocardiography. However, TEE does not allow full visualization of the upper part of the ascending aorta and proximal aortic arch.

Objectives: To investigate whether double helical computerized tomography- both with and without contrast injection - may represent a useful technique for noninvasive detection of PAA in stroke patients.

Methods: Forty consecutive patients ≥50 years of age who sustained a recent ischemic stroke and/or systemic emboli (within 15 days after the onset of the event) were enrolled in the study and underwent TEE and DHCT without contrast injection using thin slice acquisition (3.2 mm thickness and 1.5 mm reconstruction increment). In addition, the last eight consecutive patients, after obtaining an unenhanced scan, underwent a contrast-enhanced DHCT following peripheral intravenous injection of a small amount of contrast material (15 ml of diatrizoate).

Results: PAAs were demonstrated by TEE in 18 patients (45%); in 16 of them (89%) the atheromas were recognized by DHCT. Of the 22 patients without PAA on TEE, DHCT confirmed their absence in 18 (82%). DHCT yielded a sensitivity of 89%, a specificity of 82%, and an overall accuracy of 85%. The total number of protruding plaques detected by TEE was 43, of which 41 (95%) were correctly identified by DHCT. The mean thickness of the plaques was 5.6±2.4 mm on TEE, and 5.4±2.3 on DHCT (P=NS), with a good correlation between the modalities (γ=0.84). Contrast-enhanced DHCT scans demonstrated absolute equivalence to TEE in aortic areas defined as "clearly visualized by TEE." DHCT detected PAA between the distal ascending aorta and the proximal arch in seven patients; these atheromas were not included in the comparative analysis. In these "occult" areas, DHCT may be superior to TEE.

Conclusions: DHCT without contrast injection using thin slice acquisition may become a useful modality for rapid noninvasive detection of PAA. Contrast-enhanced DHCT scans significantly improve imaging quality and may be superior to TEE in the upper ascending aorta and the proximal arch (areas not well visualized by TEE).

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TEE= transesophgeal echocardiography

PAA= protruding aortic atheroma

DHCT= dual helical computerized tomography