Dual-source

CT

for

chest

pain

assessment

Comprehensive

CT

angiography

protocols

offering

a

simultaneous

evaluation

of

pulmonary

embolism

coronary

stenoses

and

aortic

disease

are

gaining

attractiveness

with

recent

CT

technology

The

aim

of

this

study

was

to

assess

the

diagnostic

accuracy

of

a

specific

dual-source

CT

protocol

for

chest

pain

assessment

One

hundred

nine

patients

suffering

from

acute

chest

pain

were

examined

on

a

dual-source

CT

scanner

with

ECG

gating

at

a

temporal

resolution

of

ms

using

a

body-weight-adapted

contrast

material

injection

regimen

The

images

were

evaluated

for

the

cause

of

chest

pain

and

the

coronary

findings

were

correlated

to

invasive

coronary

angiography

in

patients

-LRB-

-RRB-

The

files

of

patients

with

negative

CT

examinations

were

reviewed

for

further

diagnoses

Technical

limitations

were

insufficient

contrast

opacification

in

six

and

artifacts

from

respiration

in

three

patients

The

most

frequent

diagnoses

were

coronary

stenoses

valvular

and

myocardial

disease

pulmonary

embolism

aortic

aneurysm

and

dissection

Overall

sensitivity

for

the

identification

of

the

cause

of

chest

pain

was

Correlation

to

invasive

coronary

angiography

showed

sensitivity

and

negative

predictive

value

for

coronary

stenoses

Dual-source

CT

offers

a

comprehensive

robust

and

fast

chest

pain

assessment

Introduction

Comprehensive

CT

angiography

protocols

for

a

complete

assessment

of

the

thoracic

vessels

often

referred

to

as

triple

rule

out

protocols

are

used

in

the

differential

diagnosis

of

chest

pain

increasingly

often

-LSB-

-RSB-

These

protocols

aim

to

opacify

pulmonary

and

coronary

arteries

as

well

as

the

aorta

simultaneously

to

rule

out

pulmonary

embolism

coronary

artery

disease

and

aortic

aneurysm

or

dissection

in

a

single

exam

With

ECG

gating

the

acquired

images

of

the

coronary

arteries

should

have

a

similar

diagnostic

accuracy

as

a

specific

coronary

CT

angiography

Quite

a

few

studies

have

meanwhile

shown

the

feasibility

of

a

simultaneous

evaluation

of

these

vascular

territories

in

one

single

breathhold

scan

with

a

good

sensitivity

in

the

identification

of

the

cause

of

chest

pain

-LSB-

-RSB-

Also

recent

studies

indicate

that

coronary

CT

angiography

can

be

helpful

for

a

fast

and

cost-effective

triage

of

chest

pain

patients

-LSB-

-RSB-

So

far

a

major

limitation

of

these

studies

especially

in

acutely

ill

patients

is

the

restricted

image

quality

of

the

coronary

arteries

in

high

heart

rates

-LSB-

-RSB-

The

administration

of

beta-blockers

to

lower

heart

rates

is

general

practice

in

and

CT

-LSB-

-RSB-

However

this

approach

is

time

consuming

and

limited

by

contraindications

and

a

sufficient

reduction

of

the

heart

rate

can

not

be

achieved

in

many

acutely

ill

patients

Initial

studies

of

dual-source

CT

-LRB-

DSCT

-RRB-

cardiac

imaging

have

shown

a

robust

image

quality

and

a

very

good

diagnostic

accuracy

of

coronary

CT

angiography

even

in

high

heart

rates

-LSB-

-RSB-

Additionally

a

more

comprehensive

cardiac

assessment

including

wall

motion

and

valve

function

is

possible

with

DSCT

-LSB-

-RSB-

The

aim

of

this

study

was

to

assess

the

diagnostic

accuracy

of

a

specific

dual-source

CT

protocol

for

chest

pain

assessment

regarding

a

follow-up

for

other

findings

and

coronary

angiography

in

patients

in

whom

coronary

artery

disease

could

not

be

reliably

excluded

as

standard

of

reference

Materials

and

methods

Patients

One

hundred

nine

consecutive

patients

-LSB-

women

men

median

age

-LRB-

-RRB-

years

-RSB-

were

prospectively

enrolled

in

the

trial

The

study

was

approved

by

the

institutional

review

board

and

informed

written

consent

was

obtained

from

every

patient

prior

to

the

examination

All

patients

with

acute

chest

pain

were

eligible

for

the

study

if

referred

by

a

colleague

after

initial

diagnostic

workup

including

physical

examination

ECG

and

serum

levels

of

creatinine

and

TSH

Exclusion

criteria

were

positive

ECG

changes

or

troponine

test

severe

ventricular

arrhythmia

a

history

of

severe

allergoid

reaction

to

iodinated

contrast

material

renal

insufficiency

and

young

age

below

years

Also

severe

dyspnea

with

inability

to

hold

the

breath

for

at

least

s

was

regarded

as

exclusion

criterion

The

patients

were

asked

to

hold

their

breath

for

approximately

s

prior

to

the

examination

If

the

breathhold

could

not

be

maintained

the

patient

was

excluded

from

the

study

and

seven

otherwise

eligible

patients

had

to

be

excluded

for

this

reason

Heart

rates

were

ranging

from

to

bpm

Beta-blockers

were

not

administered

in

preparation

of

the

scan

Eighteen

patients

had

known

coronary

artery

disease

and

were

on

continuous

oral

beta

blocker

medication

One

patient

had

a

known

chronic

aortic

dissection

Examination

Examinations

were

acquired

on

a

DSCT

Somatom

Definition

-LRB-

Siemens

Forchheim

Germany

-RRB-

in

supine

position

A

coronal

topogram

was

scanned

to

plan

the

spiral

acquisition

which

included

the

whole

chest

from

the

first

ribs

to

the

diaphragm

The

level

of

the

carina

was

defined

as

the

trigger

point

where

the

second

tube

is

switched

on

additionally

The

volume

and

flow

rate

of

the

contrast

material

-LRB-

Ultravist

Schering

Germany

-RRB-

were

adapted

to

the

patient

's

body

weight

as

described

elsewhere

-LSB-

-RSB-

according

to

Table

A

bolus

tracking

technique

was

used

to

assess

the

transit

time

of

the

contrast

agent

For

this

purpose

a

region

of

interest

was

defined

in

the

ascending

aorta

to

detect

the

arrival

of

the

contrast

material

bolus

in

images

scanned

at

intervals

and

the

scan

was

initiated

with

a

delay

of

s

if

the

density

increased

more

than

Hounsfield

units

-LRB-

HU

-RRB-

The

patient

was

then

instructed

to

hold

his

breath

at

a

mild

inspiratory

position

and

the

spiral

scan

was

started

The

parameters

for

the

acquisition

in

craniocaudal

direction

were

gantry

rotation

time

tube

voltage

effective

tube

current

with

collimation

and

double

Z-sampling

The

pitch

and

the

tube

current

modulation

were

adapted

automatically

to

the

heart

rate

of

the

patient

Pitch

values

ranged

between

and

whereas

the

full

tube

current

was

only

applied

at

of

the

cardiac

cycle

for

heart

rates

below

bpm

and

between

and

for

higher

heart

rates

Scan

duration

was

s.

Table

contrast

material

injection

protocolWeight

-LRB-

kg

-RRB-

Volume

-LRB-

ml

-RRB-

Flow

-LRB-

ml/s

-RRB-

501063.5551113.7601163.9651214.0701254.2751304.3801344.5851384.6901424.7951464.91001505.01051545.11101575.21151615.41201645.5

Image

reconstruction

Continuous

ECG-gated

axial

slices

and

coronal

images

of

the

whole

chest

were

reconstructed

with

a

temporal

resolution

of

ms

using

a

soft

kernel

-LRB-

-RRB-

Slice

thickness

of

mm

and

increment

were

applied

to

avoid

artificial

inhomogenities

in

the

lung

parenchyma

due

to

undersampling

with

gating

Additionally

axial

slices

of

the

heart

were

reconstructed

for

a

limited

range

from

the

carina

to

the

diaphragm

with

a

field

of

view

slice

thickness

and

increment

using

a

convolution

kernel

If

stents

had

been

implanted

an

additional

reconstruction

was

performed

using

a

kernel

to

reduce

blooming

and

enhance

the

depiction

of

the

lumen

For

ECG

gating

a

single

segment

reconstruction

algorithm

utilizing

quarter

scan

segments

from

both

detectors

was

applied

to

achieve

a

temporal

resolution

of

ms

and

delays

were

set

to

ms

and

of

the

cardiac

cycle

for

the

initial

reconstructions

Also

axial

slices

with

thickness

and

increment

were

reconstructed

with

a

kernel

for

the

whole

cardiac

cycle

at

intervals

for

dynamic

evaluation

Diagnostic

evaluation

The

examinations

were

read

by

two

radiologists

in

consensus

immediately

after

the

exam

including

a

review

of

axial

and

coronal

slices

for

evaluation

of

pulmonary

embolism

and

aortic

disease

-LRB-

Figs.

and

-RRB-

Additionally

a

complete

cardiac

workup

-LRB-

Figs.

and

-RRB-

was

done

using

a

workstation

-LRB-

Multimodality

Workplace

Siemens

Forchheim

Germany

-RRB-

to

interactively

browse

multiplanar

reconstructions

and

volume-rendered

images

if

necessary

Multiphase

reconstructions

were

reviewed

as

cine

loops

of

the

heart

with

interactive

browsing

of

dynamic

short

and

long-axis

sections

The

coronary

artery

tree

was

extracted

using

region-growing

algorithms

and

curved

multi-planar

reformats

were

created

for

review

-LRB-

Fig.

b

-RRB-

In

case

of

motion

artifacts

additional

reconstructions

with

an

optimized

delay

were

available

If

these

still

did

not

resolve

motion

artifacts

sufficiently

to

make

a

sufficient

diagnostic

evaluation

feasible

the

depiction

of

the

respective

coronary

artery

segment

was

rated

as

non-diagnostic

and

excluded

from

further

analysis

Additionally

the

multiphase

reconstructions

were

reviewed

to

assess

wall

motion

abnormalities

and

valvular

disease

-LRB-

Fig.

-RRB-

Fig.

grade

stenosis

-LRB-

arrows

-RRB-

of

the

left

anterior

descending

coronary

artery

a

Curved

multiplanar

reconstruction

along

the

centerline

of

the

vessel

b

Orthogonal

curved

multiplanar

reconstruction

c

Left

anterior

oblique-cranial

projection

at

invasive

angiography

d

Respective

right

anterior

oblique

projectionFig

scar

-LRB-

arrows

-RRB-

from

a

myocardial

infarction

in

the

territory

of

the

left

anterior

descending

coronary

artery

a

Diastolic

mid-ventricular

short

axis

view

b

Systolic

short

axis

view

c

Diastolic

left

two-chamber

view

d

Systolic

two-chamber

view

Note

the

dyskinesia

bulging

out

of

the

anterior

wall

e

Multiplanar

reconstruction

of

the

left

anterior

descending

coronary

artery

Note

the

stent

-LRB-

white

arrow

-RRB-

in

the

proximal

vessel

which

had

been

implanted

after

interventional

re-perfusion

of

the

occluded

vessel

Indication

for

invasive

angiography

was

evaluated

by

a

cardiologist

based

on

CT

and

clinical

findings

Invasive

angiography

was

always

initiated

if

significant

coronary

artery

disease

could

not

be

reliably

excluded

in

CT

and

there

was

no

other

evident

pathology

explaining

the

symptoms

Selective

catheterization

and

coronary

angiography

were

performed

by

an

experienced

cardiologist

using

a

transfemoral

arterial

approach

and

standard

Seldinger

technique

At

least

three

standard

projections

including

a

left

anterior

oblique

a

right

anterior

oblique

and

a

left

anterior

and

cranial

projection

were

acquired

for

both

coronary

arteries

For

quantitative

coronary

assessment

-LRB-

QCA

-RRB-

analysis

a

densitometrical

analysis

of

two

projection

images

was

performed

using

the

Quant-Cor

QCA

software

-LRB-

Siemens

Erlangen

-RRB-

Conventional

coronary

angiograms

of

patients

were

available

for

correlation

A

third

reader

correlated

the

findings

in

the

reports

to

invasive

coronary

angiography

and

performed

dose

calculations

which

were

based

on

the

dose

length

product

given

in

the

patient

protocol

of

the

CT

scanner

Also

he

reviewed

the

files

of

patients

with

initially

negative

results

for

further

diagnoses

in

the

subsequent

months

The

readers

of

the

initial

CT

images

were

unaware

of

any

findings

from

conventional

angiography

and

most

invasive

angiographies

were

performed

to

further

evaluate

or

treat

lesions

detected

in

CT.

Thus

the

cardiologists

performing

the

coronary

angiography

were

mostly

aware

of

the

CT

findings

Statistical

analysis

Continuous

variables

are

given

as

median

and

range

Ninety-five

percent

confidence

intervals

were

calculated

using

MedCalc

software

-LRB-

MedCalc

Software

Mariakerke

Belgium

-RRB-

Diagnostic

accuracy

was

calculated

as

sensitivity

specificity

positive

and

negative

predictive

values

based

on

standard

contingency

tables

Results

Technical

success

The

scans

were

acquired

from

all

patients

without

severe

adverse

events

Although

previously

tested

three

patients

were

unable

to

hold

their

breath

for

the

duration

of

the

scan

which

resulted

in

artifacts

in

the

lower

part

of

the

chest

rendering

the

coverage

and

depiction

of

the

coronary

arteries

insufficient

for

diagnostic

evaluation

All

examinations

showed

an

adequate

contrast

enhancement

of

the

pulmonary

arteries

the

coronary

arteries

and

the

aorta

except

for

six

examinations

In

two

the

bolus

was

too

short

due

to

hemodynamic

parameters

making

the

assessment

of

pulmonary

embolism

only

possible

in

the

central

arteries

In

three

examinations

an

erroneous

administration

of

a

smaller

volume

of

contrast

material

caused

a

weak

opacification

of

the

pulmonary

arteries

and

in

one

examination

overall

opacification

was

too

weak

-LRB-

HU

-RRB-

for

coronary

artery

assessment

Patient

findings

The

diagnoses

in

the

patient

population

were

spread

over

the

different

organs

and

vascular

territories

quite

evenly

-LRB-

Table

-RRB-

Ten

patients

had

pulmonary

embolism

-LRB-

Fig.

-RRB-

and

three

had

morphological

signs

of

chronic

pulmonary

hypertension

Twelve

patients

showed

other

non-vascular

pulmonary

findings

including

pneumonic

consolidation

in

four

patients

and

edema

from

left

heart

failure

in

four

cases

Thirty-seven

patients

had

coronary

atherosclerosis

and

in

of

these

patients

stenoses

were

rated

as

hemodynamically

significant

-LRB-

-RRB-

-LRB-

Fig.

-RRB-

Three

coronary

arteries

were

occluded

Fifteen

patients

had

had

bypass

surgery

and

five

bypass

graft

vessels

were

occluded

One

bypass

was

rated

as

stenotic

but

invasive

angiography

showed

a

patent

lumen

and

a

very

slow

runoff

There

were

non-coronary

cardiac

findings

including

valvular

disease

in

seven

patients

Among

those

there

were

four

cases

of

aortic

stenosis

one

bicuspid

aortic

valve

and

one

with

vegetations

from

endocarditis

In

one

patient

an

insufficiency

of

tricuspid

valve

leaflets

was

diagnosed

Three

patients

had

had

aortic

valve

replacement

and

the

valve

prostheses

worked

normally

Seven

patients

showed

an

abnormal

global

or

regional

wall

motion

with

pulmonary

congestion

in

four

cases

Areas

of

myocardial

infarction

were

noted

in

three

patients

-LRB-

Fig.

-RRB-

Other

non-coronary

cardiac

findings

were

left

ventricular

hypertrophy

scars

from

myocarditis

and

ventricular

thrombi

Among

the

aortic

pathologies

there

were

seven

aneurysms

five

dissections

-LRB-

Fig.

-RRB-

one

case

of

intramural

hematoma

and

one

acute

rupture

with

active

bleeding

into

the

mediastinum

Incidental

vascular

findings

were

a

lusorian

artery

and

a

right

descending

aorta

with

Kommerell

's

diverticulum

-LRB-

Fig.

-RRB-

Another

frequent

finding

was

neoplastic

lesions

partially

with

unknown

primary

cancer

Three

patients

had

disseminated

pulmonary

metastases

one

patient

had

a

previously

known

lymphoma

and

one

an

esophageal

cancer

In

patients

there

were

no

findings

that

were

regarded

as

the

main

cause

of

chest

pain

The

review

of

the

files

of

those

patients

in

a

follow-up

showed

additional

diagnoses

in

two

patients

One

had

intermittent

arrhythmia

that

was

identified

as

the

cause

of

chest

pain

The

other

patient

developed

pleural

effusion

and

was

diagnosed

to

have

pleuritis

In

the

other

patients

there

was

no

evidence

of

the

cause

of

chest

pain

in

follow-up

Considering

those

results

as

correct-negative

the

sensitivity

of

the

protocol

in

the

identification

of

the

cause

of

chest

pain

amounts

to

Specificity

can

be

estimated

at

based

on

these

data

although

the

exact

significance

of

the

findings

for

chest

pain

is

frequently

unclear

and

may

therefore

be

regarded

as

arbitrary

Fig.

multiplanar

reconstruction

of

the

lower

lobe

pulmonary

arteries

showing

emboli

in

the

lobar

and

segmental

arteriesFig

of

the

descending

aorta

a

Multiplanar

reconstruction

Arrows

indicate

the

depiction

of

the

left

coronary

artery

in

the

gated

reconstruction

-LRB-

black

arrow

-RRB-

the

dissection

membrane

-LRB-

white

arrow

-RRB-

and

the

junction

between

the

gated

scan

and

the

non-gated

scan

which

had

been

continued

in

this

case

to

include

the

whole

extent

of

the

dissection

-LRB-

outlined

arrow

-RRB-

b

Angulated

para-coronal

reconstruction

showing

the

topographyFig

's

diverticulum

-LRB-

arrows

-RRB-

a

Volume-rendered

reconstruction

showing

the

origin

from

the

aortic

arch

and

the

course

of

the

subclavian

artery

Note

the

median-right

course

of

the

descending

aorta

ventral

to

the

spine

b

Curved

multiplanar

reconstruction

showing

the

proximity

to

the

tracheaTable

found

in

the

study

Vascular

of

Correlation

to

invasive

angiography

The

conventional

coronary

angiograms

that

were

available

for

correlation

of

the

coronary

findings

were

evaluated

in

a

segment-based

and

a

patient-based

analysis

Thirty-two

coronary

artery

segments

-LRB-

-RRB-

of

these

patients

were

excluded

from

analysis

due

to

small

size

or

insufficient

visualization

in

CT.

Of

the

patients

had

evidence

of

coronary

atherosclerosis

in

CT.

Nineteen

stenoses

were

rated

as

potentially

hemodynamically

relevant

with

more

than

stenosis

in

CTA

but

invasive

angiography

confirmed

only

of

those

whereas

the

other

were

overrated

There

were

no

false-negative

results

i.e.

all

the

stenoses

had

been

cited

in

CTA

although

it

has

to

be

taken

into

account

that

the

indication

for

invasive

angiography

was

frequently

derived

from

CTA

findings

Thus

sensitivity

specificity

positive

and

negative

predictive

value

amounted

to

and

respectively

in

the

segment-based

analysis

In

the

patient-based

analysis

all

patients

with

significant

stenoses

were

identified

There

were

two

patients

with

completely

negative

CTA

and

symptoms

very

suggestive

of

coronary

ischemia

who

had

additional

invasive

angiography

and

both

of

them

remained

negative

The

overrated

stenoses

occurred

in

patients

with

other

significant

stenoses

Thus

CTA

achieved

full

diagnostic

accuracy

in

correlation

to

invasive

angiography

for

this

patient-based

analysis

The

database

of

the

coronary

angiography

laboratory

was

screened

for

those

patients

who

had

not

initially

been

examined

invasively

and

there

were

no

readmissions

for

angiography

within

months

after

inclusion

of

the

last

patient

Radiation

exposure

As

the

patient

protocols

had

not

been

archived

in

all

patients

there

were

only

dose-length

products

available

for

calculation

Based

on

a

conversion

factor

of

for

chest

exams

the

estimated

equivalent

dose

ranged

between

mSv

in

low

heart

rates

with

strict

dose

modulation

to

mSv

in

tall

patients

with

heart

rates

around

bpm

which

resulted

in

a

wide

pulsing

interval

of

with

a

still

quite

low

pitch

below

Overall

the

median

radiation

exposure

was

mSv

-LRB-

CI

-RRB-

Discussion

CT

angiography

can

be

regarded

as

the

modality

of

choice

for

the

assessment

of

pulmonary

embolism

and

aortic

disease

in

acute

care

-LSB-

-RSB-

The

fast

volume

coverage

that

has

become

available

with

recent

CT

technology

has

triggered

efforts

for

a

combined

assessment

of

these

pathologies

and

the

additional

evaluation

of

the

coronary

arteries

would

make

the

protocol

a

universal

diagnostic

tool

for

chest

pain

assessment

-LSB-

-RSB-

Quite

a

few

studies

showed

the

feasibility

of

this

approach

based

on

CT

technology

with

temporal

resolution

in

the

area

of

ms

but

also

indicated

that

coronary

CTA

still

represented

the

limitation

of

the

method

due

to

the

high

incidence

of

high

heart

rates

that

made

coronary

assessment

unreliable

-LSB-

-RSB-

Recent

studies

have

shown

that

diagnostic

images

of

the

coronary

arteries

can

be

obtained

reliably

with

dual-source

CT

even

in

very

high

heart

rates

-LSB-

-RSB-

Thus

dual-source

CT

was

expected

to

greatly

improve

the

diagnostic

accuracy

of

the

combined

CT

protocol

and

our

results

indicate

that

this

assumption

was

correct

There

were

no

examinations

rated

as

non-diagnostic

because

of

blurring

of

the

coronary

arteries

due

to

high

heart

rates

There

were

six

exams

with

partially

insufficient

contrast

opacification

which

mainly

affected

pulmonary

artery

evaluation

and

three

examinations

with

breathing

artifacts

that

impeded

coronary

assessment

but

otherwise

the

main

coronary

artery

segments

were

reliably

assessable

This

is

reflected

in

the

detailed

analysis

of

the

coronary

CT

angiography

in

relation

to

invasive

angiography

in

which

only

of

coronary

artery

segments

were

excluded

mainly

due

to

very

small

size

in

distal

vessel

segments

and

side

branches

Regarding

the

diagnostic

accuracy

the

excellent

performance

in

the

patient-based

analysis

confirms

that

the

method

can

be

very

helpful

for

fast

patient

triage

However

it

has

to

be

acknowledged

that

stenoses

were

quite

frequently

rated

as

potentially

relevant

in

CTA

so

that

invasive

angiography

was

not

only

necessary

for

intervention

but

also

for

definite

diagnosis

Also

some

false-positive

results

would

have

to

be

expected

in

larger

patient

groups

Still

it

has

to

be

emphasized

that

a

valid

relevant

diagnosis

could

be

made

in

of

the

patients

and

in

relevant

diseases

were

ruled

out

Regarding

sensitivity

for

the

cause

of

chest

pain

the

value

of

in

the

present

study

is

somewhat

higher

than

the

observed

in

a

study

on

ECG-gated

thoracic

CTA

-LSB-

-RSB-

and

compares

well

with

an

initial

DSCT

study

that

reported

a

sensitivity

of

-LSB-

-RSB-

In

of

patients

there

were

findings

such

as

coronary

atherosclerosis

or

vascular

variants

that

were

not

immediately

relevant

as

a

reason

for

chest

pain

but

that

are

still

valuable

information

for

further

patient

management

Comparing

the

results

of

coronary

CTA

correlation

in

this

study

sensitivity

specificity

positive

and

negative

predictive

values

of

and

are

comparable

to

an

initial

study

by

Scheffel

et

al.

-LSB-

-RSB-

They

observed

respective

values

of

and

for

dual-source

CT

coronary

CTA

without

heart

rate

control

in

a

high

pretest-probability

group

although

the

rate

of

non-assessable

segments

was

remarkably

low

compared

to

in

our

study

The

somewhat

higher

negative

and

lower

positive

prediction

may

be

attributed

to

a

more

sensitive

diagnostic

reading

in

our

group

of

acutely

ill

patients

In

a

similar

CT

study

by

Nikolaou

et

al.

-LSB-

-RSB-

respective

values

of

and

with

non-assessable

segments

were

recorded

for

an

intermediate

likelihood

population

with

strict

heart

rate

control

These

values

suggest

that

a

similar

accuracy

can

be

achieved

with

DSCT

without

beta

blockers

Due

to

the

variability

in

body

size

and

habitus

the

equivalent

doses

calculated

from

dose

length

products

are

only

correct

for

less

than

half

of

the

population

and

therefore

can

only

serve

as

rough

estimations

The

median

value

of

mSv

is

about

twice

that

of

coronary

artery

CTA

with

dual-source

CT

but

only

moderaltely

higher

than

that

for

coronary

CTA

alone

with

single-source

CT

-LSB-

-RSB-

The

increase

is

mainly

related

to

the

high

heart

rates

in

this

acute

patient

group

that

require

a

wider

pulsing

interval

for

the

reconstruction

of

systolic

images

The

longer

coverage

including

the

upper

chest

contributes

rather

little

to

the

dose

because

it

is

acquired

normally

with

only

one

tube

switched

on

Therefore

performing

coronary

CTA

alone

without

coverage

of

the

upper

chest

would

save

only

little

of

the

dose

in

this

patient

group

Thus

the

additional

dose

from

the

longer

coverage

is

well

invested

considering

the

diagnostic

value

Also

comparing

DSCT

to

single

source

CTA

the

high

diagnostic

accuracy

of

DSCT

can

be

regarded

as

well

invested

dose

compared

to

single

source

scanners

in

which

the

dose

can

be

estimated

to

be

higher

for

this

patient

group

because

the

pitch

would

have

to

be

reduced

to

apply

multi-segment

reconstruction

algorithms

-LSB-

-RSB-

and

pulsing

would

mostly

have

to

be

switched

off

to

yield

diagnostic

examinations

with

optimized

reconstructions

-LSB-

-RSB-

Also

considering

alternative

diagnostic

approaches

for

the

evaluation

of

chest

pain

for

example

including

pulmonary

CTA

aortic

CTA

and

invasive

coronary

angiography

this

combination

would

result

in

a

higher

total

patient

dose

-LSB-

-RSB-

Magnetic

resonance

imaging

would

be

an

alternative

modality

for

the

assessment

of

pulmonary

embolism

and

aortic

pathology

and

an

MR

exam

of

myocardial

wall

motion

and

perfusion

could

serve

as

a

method

to

rule

out

hemodynamically

relevant

coronary

pathology

without

radiation

exposure

-LSB-

-RSB-

However

the

limited

availability

and

the

long

examination

times

currently

let

such

an

approach

seem

less

applicable

in

a

clinical

setting

-LSB-

-RSB-

Several

limitations

of

this

study

have

to

be

acknowledged

One

limitation

is

the

exclusion

of

patients

with

the

evidence

of

an

acute

coronary

syndrome

based

on

ECG

or

serum

markers

which

causes

a

bias

in

the

assessment

of

the

diagnostic

accuracy

of

coronary

CTA

Another

limitation

is

the

lacking

correlation

to

other

diagnostic

approaches

in

the

evaluation

of

pulmonary

embolism

and

aortic

disease

Of

course

additional

ventilation/perfusion

scintigraphy

and

aortic

MRI

would

be

desirable

for

study

purposes

but

can

not

be

justified

considering

the

necessary

time

and

the

encroachment

of

acutely

ill

patients

and

the

involved

radiation

exposure

Also

additional

invasive

coronary

angiography

of

the

patients

without

coronary

findings

would

be

helpful

to

assess

the

actual

negative

predictive

value

but

the

application

of

this

invasive

procedure

involving

radiation

exposure

to

patients

with

other

pathologies

would

of

course

not

be

acceptable

The

follow-up

of

the

coronary

angiography

database

that

showed

no

readmissions

at

least

confirms

the

unlikelihood

of

relevant

coronary

artery

stenoses

in

these

patients

The

fact

that

immediately

therapy-relevant

findings

in

all

vascular

districts

were

represented

and

quite

evenly

distributed

in

our

patient

population

emphasizes

that

a

combined

protocol

can

be

a

valuable

tool

for

diagnostic

workup

of

acute

unclear

chest

pain

In

conclusion

the

specific

dual-source

CT

protocol

for

chest

pain

assessment

proved

to

be

a

very

helpful

tool

offering

a

fast

diagnostic

workup

and

patient

triage

O O O B I O O B I O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O B O O O O O O O O O O O O B B O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O B I O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B I O O O O O O O O O O O O O O O O O

chest pain
ct angiography
coronary artery disease
pulmonary
embolism
aortic dissection


Textiloma : a case of foreign body mimicking a spinal mass Items such as cotton or gauze pads can be mistakenly left behind during operations . Such foreign materials -LRB- called textilomas or gossypibomas -RRB- cause foreign body reaction in the surrounding tissue . The complications caused by these foreign bodies are well known , but cases are rarely published because of medico-legal implications . Some textilomas cause infection or abscess formation in the early stage , whereas others remain clinically silent for many years . Here , we describe a case of textiloma in which the patient presented with low-back pain 4 years after lumbar discectomy . Imaging revealed an abcess-like mass in the lumbar epidural space . Introduction Textiloma and gossypiboma are non-medical terms used to describe a mass of cotton matrix that is left behind in a body cavity during an operation -LSB- 9 , 18 , 20 -RSB- . Such foreign bodies can often mimic tumors or abscesses clinically or radiologically . Although these masses and their associated complications may occur , they are rarely reported due to medico-legal implications -LSB- 7 -RSB- . Most cases of textiloma in the literature have been connected with abdominal or thoracic surgery , very few have been linked with spinal surgery . From 1965 to 2006 , only 32 cases of spinal or paraspinal textiloma have been documented in the literature -LSB- 1 , 3 -- 7 , 9 , 10 , 12 , 14 , 16 , 19 -- 21 -RSB- . Here , we describe a case in which cotton , a foreign body , was left behind during an operation for lumbar disc herniation . The patient presented 4 years later with a symptomatic mass in the lumbar epidural space , and imaging indicated a possible abscess . Case A 62 year old woman presented a complaint of low-back pain . She had had this problem for 1 year , and the pain had been radiating to her left calf for 1 month . The patient had undergone surgery for lumbar disc herniation 4 years prior to presentation . Physical examination indicated good health status . There was no tenderness , swelling or erythema at the incision site . The straight leg-raising test was positive at 60 ° on the left . The patient 's left hamstring muscle strength was 4/5 , and she had diminished patellar deep tendon reflex on that side . Routine laboratory testing -LRB- complete blood count , erythrocyte sedimentation rate , blood biochemistry panel -RRB- revealed nothing abnormal . Magnetic resonance imaging -LRB- MRI -RRB- of the lumbosacral spine showed the laminectomy defect at L3 and a mass lesion in the posterior paravertebral region at this level . The mass appeared hypointense to spinal cord tissue on T1-weighted images and hyperintense on T2-weighted images . Injection of contrast medium revealed an enhanced hyperintense rim around a hypointense center -LRB- Figs. 1 , 2 -RRB- . The lesion was interpreted as a possible epidural abscess . At surgery , a foreign body composed of cotton was found and was completely removed -LRB- Fig. 3 -RRB- . No infection or abscess was detected . Histological examination of the tissues around the material revealed only chronic inflammatory infiltration and granuloma formation . One month after the operation , there were no abnormal findings either on physical examination or on MRI of the lumbosacral spine . Fig. 1MRI of the lumbosacral spine showing the mass lesion in the posterior paravertebral regionFig . 2The sagittal section of MRI showing the left laminectomy at L3 vertebra and the mass lesionFig . 3Cotton materials extracted from the patient during the operation Discussion Cotton pads , towels and sponges are used to achieve hemostasis during surgical procedures , including dissection for intervertebral disc herniation and other spinal problems . Although precautions are taken to avoid leaving such materials behind , mistakes do happen and the resultant foreign bodies can cause various clinical and radiological manifestations -LSB- 1 , 5 , 8 , 12 -RSB- . In the early period after surgery , these forgotten materials can lead to infections and abscess formation . However , some remain clinically asymptomatic for many years , and then cause a foreign body reaction in the surrounding tissue , with new clinical signs indicating significant mass effect -LSB- 3 , 5 , 6 , 15 , 22 -RSB- . Cotton is not the only material that can lead to such problems . The literature contains reports of other hemostatic materials -LRB- such as gelfoam and Surgicel -RRB- causing foreign body reactions that could not be distinguished from recurrent tumors on MRI -LSB- 9 , 13 -RSB- . The introduction of MRI has made it possible to diagnose most foreign bodies accurately . Findings differ according to the radiological modality that is used to investigate the patient . Cotton sponges and cotton fibers exhibit characteristic features on plain radiographs , whereas the findings on computerized tomography and ultrasonography are less diagnostic -LSB- 3 , 6 , 11 , 12 , 14 , 16 , 20 -RSB- . The MRI appearance of foreign materials that are left behind during surgery can differ greatly depending on the time since the operation and the type of foreign body reaction that occurs . There are two types of foreign body reactions : aseptic fibrous tissue reaction , which involves adhesion formation , encapsulation and granuloma formation , or the exudative-type tissue reaction , which leads to abscess formation -LSB- 3 , 6 , 8 , 14 -- 16 , 18 , 22 -RSB- . Karcnik et al. -LSB- 7 -RSB- reported a case of foreign body reaction that manifested in a later period after an anterior cervical fusion operation . MRI showed a granuloma that was hypointense on T1-weighted images and hyperintense on T2-weighted images , and that mimicked a solid tumor . In general , most lesions caused by foreign bodies are hypointense on T1-weighted images and hyperintense on T2-weighted images -LSB- 3 , 5 , 8 , 15 , 16 -RSB- . In our case , the MRI findings were consistent with an epidural abscess , but direct observations at surgery , microbiologic testing and pathologic examination revealed no infection . Foreign bodies that are left behind during operations may organize and increase in size but such changes are not correlated with time . To date , the case reported by Taylor et al. -LSB- 17 -RSB- features the longest period from surgery to manifestation of symptoms . They detected an intrapulmonary foreign body 43 years after thoracotomy . The longest reported interval in the neurosurgery literature is 40 years . In that case , a cotton pad was left posterior to the lumbosacral vertebrae during a laminectomy operation , and the material eventually caused a cavitary lesion -LSB- 16 -RSB- . Our patient developed a textiloma 4 years after lumbar disc surgery . Civil lawsuits brought against surgeons for surgical complications are becoming more frequent , and this is prompting surgical teams to be even more careful . It is possible to to overlook cotton and gauze pads in the surgical field . Such materials should always have a tag that allows them to be easily located and removed , and all materials that are placed in the wound temporarily , must be counted many times with meticulous care . Cotton pads are not safe because they can break into fragments during manipulation ; other materials are preferred for securing hemostasis . Once hemostasis is achieved , the operative site should be flushed with saline and carefully examined for foreign materials .

O O O O O B I O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


Complementary and Alternative Medicine for Chronic Prostatitis/Chronic Pelvic Pain Syndrome To discuss challenges concerning treatment for chronic prostatitis/chronic pelvic pain syndrome -LRB- CP/CPPS -RRB- and review complementary and alternative medical -LRB- CAM -RRB- therapies being evaluated for this condition , we performed a comprehensive search of articles published from 1990 -- 2005 using the PubMed , Medline databases . Data from the articles were abstracted and pooled by subject . Keywords cross-searched with CP/CPPS included : complementary , alternative , integrative , therapies , interventions , nutrition , antioxidants , herbs , supplements , biofeedback and acupuncture . Listed articles with no abstracts were not included . Various CAM therapies for CP/CPPS exist including biofeedback , acupuncture , hyperthermia and electrostimulation . Additionally , a variety of in vitro and in vivo studies testing herbal and nutritional supplements were found . Saw palmetto , cernilton and quercetin were the most frequently tested supplements for CP/CPPS . Although many CAM therapies demonstrate positive preliminary observations as prospective treatments for CP/CPPS , further exploratory studies including more randomized , controlled trials are necessary for significant validation as treatment options for this complex disorder . Introduction and Characterization of Prostatitis Chronic prostatitis/chronic pelvic pain syndrome -LRB- CP/CPPS -RRB- is of significant interest in urology and accounts for up to 2 million office visits per year -LRB- 1 -RRB- . Currently , there are multiple approaches to the management of CP/CPPS depending on the classification of the related symptoms . However , there are no absolute findings or laboratory tests employed and diagnosis is often one of exclusion . In 1995 , the National Institutes of Health established an International Prostatitis Collaborative Network in order to construct a new classification of prostatitis syndromes and better define chronic prostatitis -LRB- 2,3 -RRB- . The categories are now documented as follows : Category 1 . Acute bacterial prostatitisCategory 2 . Chronic bacterial prostatitisCategory 3 . Chronic prostatitis/chronic pelvic pain syndrome A. InflammatoryB . Non-inflammatoryCategory 4 . Asymptomatic inflammatory prostatitis . While most patients report a primary subjective symptom of local pain and/or dysuria , the clinical presentation of acute versus chronic prostatitis varies . Laboratory cultures are standardly employed to detect bacterial involvement and this testing along with other diagnostic criteria determines each classification . Men with Category 1 , acute prostatitis , frequently present with dysuria , fever , malaise , myalgia -LRB- non-specific -RRB- and positive culture analysis that often reveals coliform bacteria . This imparts to standard antibiotic treatment with good prognosis for recovery and minimal recurrence . Patients with Category 2 , chronic bacterial prostatitis , present with similar symptoms as those with acute prostatitis . However , the frequency of symptoms -LRB- duration > 3 months -RRB- , recurrent urinary tract infections and additional diagnostic tests including analysis of lower urinary tract cultures contribute to its diagnosis as Category 2 prostatitis -LRB- 2 -RRB- . Men with Category 4 , asymptomatic inflammatory prostatitis , do not present with subjective symptoms . This diagnosis is often discovered via laboratory findings such as the positive presence of white blood cells in prostatic secretions or in prostate tissue during routine evaluation for other disorders -LRB- 1 -RRB- . Comparative to the total number of prostatitis cases reported , the majority of representative cases are Category 3 , CP/CPPS -LRB- 1,4 -RRB- . This diagnosis is usually one of exclusion , as bacterial etiology acute or chronic is ruled out . Other exclusion criteria include urogenital cancer , urethral stricture and neurologic disease affecting the bladder . However , the patient may still present with polyuria , dysuria , generalized myalgia or specific pelvic pain , urethral discharge , voiding dysfunction , sexual dysfunction and negative impact on quality-of-life -LRB- QOL -RRB- . The presentation of this symptom set is now termed Category 3 , CP/CPPS . Categories 3A and 3B are further differentiated by the presence or absence of inflammatory blood cells in prostatic secretions and seminal fluid , respectively -LRB- 4,5 -RRB- . Table 1 further outlines the characteristics and treatment options of Category 3 prostatitis . Due to the complexity in diagnosing CP/CPPS , the National Institutes of Diabetes and Digestive and Kidney Diseases funded the Chronic Prostatitis Collaborative Research Network -LRB- CPCRN -RRB- in 1995 -LRB- 2,3 -RRB- . This network was fundamental in the construction and validation of the National Institutes of Health Chronic Prostatitis Symptom Index -LRB- NIH-CPSI -RRB- , which was implemented in 1999 -LRB- 3 -RRB- . The index has become a valid measure that quantifies the qualitative experience of men with CP/CPPS and addresses three different aspects of CP/CPPS : pain , function and QOL -LRB- 3,6 -RRB- . The formation of the CPCRN and the advent of the NIH-CPSI have better characterized diagnosis and treatment for CP/CPPS , but challenges still exist . While standard treatment options including anti-inflammatory agents , analgesics and alpha-blockers are often prescribed , impact on QOL is another factor often overlooked in the treatment and management of CP/CPPS -LRB- 1,4,5,7 -RRB- . The focus on QOL , anecdotal data , epidemiological studies and the increased popularity and validation of herbal , complementary and alternative medicine -LRB- CAM -RRB- has led to exploration of the utility of CAM therapies as treatments for CP/CPPS -LRB- 8 -RRB- . CAM therapies including biofeedback , acupuncture , heat therapy , electrostimulation , herbal and nutritional supplements will be discussed below . CAM Background CAM , as defined by the National Center for Complementary and Alternative Medicine -LRB- NCCAM -RRB- , is a group of diverse medical and health care systems , practices and products that are not presently considered part of conventional medicine . Conventional medicine is further defined as medicine as practiced by holders of MD -LRB- medical doctor -RRB- or DO -LRB- doctor of osteopathy -RRB- degrees -LRB- 9 -RRB- . Though the list of what therapies or practices considered to be CAM changes continually , the pool of both practitioners of CAM modalities and patients utilizing CAM services continues to grow within the United States and globally -LRB- 9 -RRB- . The inclusion of CAM practices in urology is also being implemented in the clinic . Many groups such as the Committee of Complementary and Alternative Medicine within the American Urological Association -LRB- AUA -RRB- recognize the integration of non-conventional therapies into urological clinical practice . Additionally , both public demand for CAM therapies and their testing and validation within health science research centers has increased -LRB- 8,10,11 -RRB- . It has been suggested that many urological conditions possessing subjective and QOL components such as in benign prostatic hyperplasia -LRB- BPH -RRB- , chronic prostatitis , voiding , erectile dysfunction and cancer prevention and survivorship might be particularly amenable to CAM treatment strategies -LRB- 10 -RRB- . This review will focus on current CAM therapies found in the literature for CP/CPPS . CAM Therapies for CP/CPPS Biofeedback Biofeedback therapy is considered a mind -- body technique that utilizes a monitoring machine to assist people in controlling bodily functions such as heart rate , blood pressure and muscle tension . This therapy has been studied for its efficacy in urological conditions such as incontinence , prolapse , pediatric voiding dysfunction and CP/CPPS -LRB- 12 -- 17 -RRB- . The hypothesis of biofeedback 's mechanism of action in treating CP/CPPS is based on the principle that maximum muscle contraction prompts maximum muscle relaxation . This mechanism addresses the chronic pain aspect of CP/CPPS and focuses on muscular reeducation , which may ultimately provide symptom relief -LRB- 13 -- 15 -RRB- . Two studies testing the value of biofeedback therapy for CP/CPPS yielded positive results . The first study assessed 62 patients who were refractory to conventional therapy -LRB- such as antibiotics and/or alpha-blockers -RRB- for greater than half a year . These patients were treated utilizing the Urostym Biofeedback equipment five times a week for 2 weeks with a stimulus intensity of 15 -- 23 mA and duration of 20 min . The NIH-CPSI index noted a significant overall reduction in score -LRB- P < 0.01 -RRB- and no side effects were reported during the trial -LRB- 13 -RRB- . A second pilot study evaluated biofeedback therapy in 19 men with pelvic floor tension and CP/CPPS . These results demonstrated significant improvement in pain scores as measured by the AUA symptom index -LRB- P = 0.001 -RRB- . While this study focused on testing the effect of biofeedback therapy in treating the symptoms associated with CP/CPPS , it also implicated the presence of pelvic floor tension contributing to pain and the paramount importance of muscular reeducation for its treatment -LRB- 15 -RRB- . These initial , positive biofeedback studies may warrant larger randomized clinical trials to confirm safety and efficacy as well as explore the mechanism of action of biofeedback therapy . Acupuncture Acupuncture is a traditional Chinese method of medical treatment involving the insertion of fine , single-use , sterile needles in acupoints according to a system of channels and meridians that was developed by early practitioners of Traditional Chinese Medicine -LRB- TCM -RRB- over 2000 years ago . The needles are stimulated by manual manipulation , electrical stimulation or heat -LRB- 18 -RRB- . Currently , acupuncture is often used with TCM and it is a recognized health profession with strict licensure and regulatory status in 40 states -LRB- 19 -RRB- . Common applications include acupuncture as a complementary therapy for cancer patients undergoing chemotherapy or radiotherapy , for conditions involving pain such as migraines and back pain , and for relieving the impact of stress among patients with chronic conditions . The precise physiological mechanism of action of acupuncture is unknown but a variety of hypotheses exist . For example , acupuncture analgesia is thought to be mediated by central nervous system -LRB- CNS -RRB- mechanisms of pain control via the release of specific neurotransmitters , such as endorphins -LRB- 20 -- 23 -RRB- . Additionally , there are significant data which suggest that acupuncture treatment can decrease inflammation and relieve pain -LRB- 24,25 -RRB- . Data suggesting the ability of acupuncture treatment to decrease pain , positively impact QOL and potentially modulate inflammation and/or affect the CNS has suggested it as potential therapeutic option for men with CP/CPPS . While a number of studies listed in other journals test the utility of acupuncture treatment for CP/CPPS -LRB- 26 -RRB- only two medline listed pilot studies are shown testing acupuncture treatment in patients with CP/CPPS . The first study examined whether acupuncture improved pain , voiding symptoms and QOL in 12 men with CP/CPPS . This study reported a significant decrease in total NIH-CPSI pain , urinary and QOL scores -LRB- P < 0.05 -RRB- over 6 weeks of treatment and an average 33 weeks of follow-up -LRB- 27 -RRB- . The mechanism of action addressed in this paper suggests a neuropathic model of CP/CPPS and the hypothesis that acupuncture , if considered a neuromodulatory therapy , may provide a therapeutic option for men with CP/CPPS -LRB- 27 -RRB- . A second study tested acupuncture treatment for CP/CPPS patients with intrapelvic venous congestion . This study of 10 patients receiving 5 weeks of acupuncture treatment also reported a significant decease in NIH-CPSI pain and QOL scores -LRB- P < 0.05 , P < 0.01 -RRB- . While the study reported no serious adverse events , the mechanism of action was not addressed -LRB- 28 -RRB- . The promising clinical outcome of both studies testing acupuncture for CP/CPPS implies that larger studies are required to confirm the utility of acupuncture in this patient population . High Frequency Electrostimulation Only one study in English was found utilizing electrostimulation for chronic prostatitis . This study tested a new , high frequency , urethral -- anal prototype stimulation device in men with CP/CPPS twice weekly for 5 weeks . The results demonstrated a significant decrease in the NIH-CPSI -LRB- P = 0.0002 -RRB- with no urethral , anal complaints or other side effects -LRB- 29 -RRB- . The authors suggest that due to the positive results , simple technology and ability to be self-administered , this new device may have utility in the treatment of CP/CPPS . However , further studies and standardization of the electrostimulation device are essential . Hyperthermia Anecdotal evidence and a few clinical trials have suggested heat therapy or hyperthermia as a treatment option for men with CP/CPPS . Its mechanism of action is based on the application of heat to the prostate to relieve pain . An excellent review by Zeitlin -LRB- 30 -RRB- discusses the lack of literature concerning hyperthermia and CP/CPPS . The review notes a variety of pitfalls in hyperthermia research including variation and lack of standardization of treatment . These concerns are applicable to both the type of heat utilized such as interstitial heat or microwaves and variation in its application , either transrectally or transurethrally . The review also suggests that the hyperthermia instruments used were not validated and outcome measures were subjective . However , the review implies that utilization of a quantitative assessment tool , applied statistics and greater documentation of therapy type may offer hyperthermia a better opportunity to be evaluated as a potential therapy for CP/CPPS -LRB- 30 -RRB- . We also discovered the paucity of literature described by Zeitlin and only three listed clinical trials utilizing hyperthermia . The first study analyzed a group of 45 men with chronic abacterial prostatitis or prostadynia who underwent 6 weekly , 1 h sessions of local deep microwave hyperthermia -LRB- 42.5 + / − 0.5 °C -RRB- to the prostate . Although the authors report encouraging results in the decrease of pain , these subjective patient assessments were not quantified by the NIH-CPSI or other index for CP/CPPS -LRB- 31 -RRB- . A second abstract discussed a randomized , sham-controlled comparative study utilizing transrectal microwave hyperthermia in 80 men with CP/CPPS . While this abstract noted a 75 % symptomatic improvement in the treatment group , the study was available as an abstract only with no statistical significance or descriptive methodology reported -LRB- 32 -RRB- . A third study also tested transrectal microwave hyperthermia for both chronic non-infectious and infectious prostatitis . While the study design incorporated obtaining measurement of prostatic secretions , uroflowmetry and transrectal color Dopplerographic mapping , the results from the study were not abstracted as the article was in Russian -LRB- 33 -RRB- . Herbal and Nutritional Supplements Herbal and nutritional supplement therapies have been most widely investigated for their utility in CP/CPPS and other prostate conditions such as BPH -LRB- 34 -- 40 -RRB- . While many formulations have been cited for their use in a wide variety of urological conditions , saw palmetto , pollen extract and quercetin were the supplements found with specific application to CP/CPPS . While most herbal and nutritional supplements contain a wide variety of synergistic ingredients upon compositional analysis , some of the active components such as phytosterols or antioxidants are listed in Fig. 1 . Saw palmetto Saw palmetto -LRB- Serenoa repens -RRB- garnered much attention in urology based on a great deal of anecdotal evidence regarding its prostate specific properties . It is widely used in many Asian , African and European countries and compositional analysis of the berry of S. repens exhibits sterols and free fatty acids as its major constituents -LRB- 41 -RRB- . Initial studies suggested that the efficacy of saw palmetto may be similar to that of the pharmaceutical enzyme inhibitors such as finasteride . This preliminary data prompted the exploration of mechanism , utility and efficacy of saw palmetto in in vitro analysis and in clinical trial settings . While a number of trials have examined saw palmetto use for symptoms related to BPH -LRB- 34 -- 39 -RRB- , only a few have focused on it specifically for CP/CPPS -LRB- 42 -- 44 -RRB- . The first study compared the safety and efficacy of saw palmetto berry supplement versus finasteride in men with Category 3 , CP/CPPS . This prospective , open label 1 year study randomized 64 men to the saw palmetto or finasteride group , respectively . After 1 year of treatment , the NIH-CPSI score decreased from 23.9 to 18.1 in the finasteride group -LRB- P < 0.003 -RRB- and from 24.7 to 24.6 in the saw palmetto group -LRB- P = 0.41 -RRB- . While significance was only achieved in the finasteride treatment arm , it was notable that at the end of the trial 41 and 66 % of participants opted to continue the therapies of saw palmetto and finasteride , respectively , regardless of achieved statistical significance -LRB- 42 -RRB- . The second clinical trial from China examined the effects of prostadyn sabale capsules containing saw palmetto berry in patients with CP/CPPS . While 125 men reported positive outcome and the NIH-CPSI was used as a primary end point , the article is only available in Chinese and the manufacturer , active constituents of the capsules and statistical significance was not reported -LRB- 43 -RRB- . A third multicenter study testing a saw palmetto abstract called Permixon analyzed the response of Permixon therapy in 61 patients with Category 3B prostatitis . While 65 % of the Permixon group reported improvement based on the Patients Subjective Global Assessment -LRB- SGA -RRB- , the total NIH-CPSI and the pain , voiding and QOL/impact domains of the NIH-CPSI , statistical significance was not reported -LRB- 44 -RRB- . Additionally , prostate volume was unchanged in both the treatment and control groups . While this multicenter study suggests that Permixon may provide clinical benefit for CP/CPPS 3B , the dosages and components of the Permixon product were not listed in the abstract . The assessments of saw palmetto studies for CP/CPPS are far fewer than those for BPH . However , marked and continued progress in molecular studies , increased mechanistic data and more clinical trials in CP/CPPS are warranted to ascertain the utility and reproducibility of saw palmetto use in men with chronic prostatitis . Pollen Extract : Cernilton Pollen extract is traditionally collected from the flowers of various plant types and it contains carbohydrates , fat , protein , vitamins and minerals -LRB- 41 -RRB- . The particular pollen extract named cernilton has been suggested to benefit a variety of urological conditions . Anecdotal evidence and references from traditional herbal texts have implicated cernilton 's potent anti-inflammatory properties and potential in treating symptomatic relief of urinary pain and dysfunction often present in both CP/CPPS -LRB- 41 -RRB- and BPH -LRB- 45,46 -RRB- . In vitro studies demonstrate a variety of experimentation on this particular extract including histopathological analysis of its effect on cell proliferation , apoptosis , serum cytokines and testosterone -LRB- 47,48 -RRB- . The literature also lists quite a few clinical trials on pollen extract ; however , five are in the Japanese language and one in the German language -LRB- 45,48 -- 52 -RRB- . While many of these studies report the positive activity of pollen extract and suggest its usefulness for CP/CPPS , data from these studies were not abstracted due to unavailability and translation of the articles . One available study testing pollen extract reported a 78 % favorable response of men with chronic prostatitis taking Cernilton ® pollen extract at a dosage of 1 tablet TID for 6 months -LRB- 53 -RRB- . While this study reported favorable results , the study was published in 1993 and similar subsequent larger phase clinical trials are not evident to further elucidate the possible utility of pollen extract in men with CP/CPPS . Quercetin Quercetin is known chemically as a mixture of 2 - -LRB- 3,4-dihydroxyphenyl -RRB- -3,5,7-trihydroxy-4H-1-benzopyran-4-one and 3,3 ′ ,4 ′ ,5,7-pentahydroxy flavone . It belongs to a group of polyphenolic substances known as flavonoids and is a member of the class of flavonoids called flavonols . It is commonly found in the plant kingdom in the rinds and barks of certain foods such as onions , grapes and green tea -LRB- 41 -RRB- . Since quercetin is thought to have antioxidant , anti-inflammatory , antiviral , immunomodulatory , anticancer , gastroprotective and antiallergy activities it has been studied for a variety of conditions -LRB- 54 -- 56 -RRB- . One prospective , randomized , double-blind , placebo-controlled trial was performed to test the action of this bioflavonoid in men with CP/CPPS . This placebo-based study assessed 30 men with CP/CPPS to receive the bioflavonoid quercetin , 500 mg twice daily or the placebo pill for 1 month . Significant change in the NIH-CPSI score was observed in the quercetin -LRB- P = 0.003 -RRB- versus the placebo group , who had an insignificant mean improvement in the NIH-CPSI score -LRB- 57 -RRB- . While this was the only clinical trial found testing quercetin for CP/CPPS , the positive outcome supports the need for further study including cost analysis of quercitin therapy in this patient population . Other Herbal Agents for Prostatitis Finally , a wide variety of herbal compounds not previously discussed were found during this review , many of which are commonly used in the TCM herbal material medica . Some of the compounds are Nan mi qing capsules containing Rheum palmatum and Rx . astragalus memberanaceus , Ye Ju Hua Shuan , an herbal suppository of Flos Chrysanthemi Indici and a variety of other formulae or capsules of which the ingredients were not listed -LRB- 58 -- 62 -RRB- . Initial in vitro studies examining some of the herbal compounds effects on markers of inflammation such as thromboxanes -LRB- TBX2 -RRB- and 6-keto-PGF1-α are promising as the link between chronic inflammation in CP/CPPS is still under investigation -LRB- 58 -RRB- . While the preliminary reports of additional herbal compounds are encouraging , a number of difficulties exist in the extraction of this data . Namely , the articles are in the Chinese or other language and data including the ingredients , constituents and other practices including good manufacturing are unable to be assessed . While this conundrum exists for many herbal agents despite their historical use in a variety of traditional herbal medicine systems , testing of safety and utility are still necessary . However , the variety of herbal agents available offers a large source to draw from and the possibility that other herbal products might be beneficial in the treatment of CP/CPPS . Conclusions A summary of the reviewed literature is outlined in Table 2 and a variety of CAM modalities tested in patients with CP/CPPS include practitioner-based therapies such as biofeedback , hyperthermia , acupuncture and electrostimulation , and biological-based therapies including herbal and nutritional supplements . As the challenges in treating this complex and chronic disorder remain , further evidence of efficacious CAM treatment options for men with CP/CPPS is needed . Thus far , promising data on the function and efficacy of certain CAM therapies suggest their potential as treatment options for this patient population . Further exploratory studies including more in vitro studies of herbal products , mechanistic data , cost analysis and randomized , controlled trials will assist in validation of certain CAM therapies as permanent treatment options for men with CP/CPPS -LRB- 63,64 -RRB- .

O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O B O B O O O O O O O O O O O O O O O O O B O B O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O B B O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

acupuncture
alternative medicine
biofeedback
chronic prostatitis
herbs
hyperthermia
supplements