Role of computed tomography angiography in the evaluation of haemoptysis in children: Decoding the abnormal vessels.

Background & objectives: Haemoptysis in children is potentially life-threatening. In most cases, the bleeding arises from the systemic circulation, and in 5-10 per cent of cases, it arises from the pulmonary circulation. The role of computed tomography angiography (CTA) in this setting is important. This study was undertaken (i) to study the role of single-phase split-bolus dual energy contrast-enhanced multidetector row CTA (DECTA) in the evaluation of haemoptysis in children; (ii) to analyze the patterns of abnormal vascular supply in the various aetiologies encountered. Methods: A retrospective study of 86 patients who underwent split bolus DECTA for the evaluation of haemoptysis was performed. Final diagnoses were categorized as normal computed tomography, active tuberculosis (TB), post-infectious sequelae, non-TB active infection, cystic fibrosis (CF), non-CF bronchiectasis, congenital heart disease (CHD), interstitial lung disease, vasculitis, pulmonary thromboembolism and idiopathic pulmonary haemosiderosis. Abnormal bronchial arteries (BAs) and non-bronchial systemic collateral arteries (NBSCs) were assessed for number and site and their correlation with underlying aetiologies. Results: A total of 86 patients (45 males, age from 0.3 to 18 yr, mean 13.88 yr) were included in the study; among these only two patients were less than five years of age. The most common cause of haemoptysis was active infection (n=30), followed by bronchiectasis (n=18), post-infectious sequelae (n=17) and CHD (n=7). One hundred and sixty five abnormal arteries were identified (108 BA and 57 NBSC), and were more marked in bronchiectasis group. Interpretation & conclusions: Active infections and bronchiectasis are the most common causes of haemoptysis in children. While post-infectious sequelae are less common, in patients with haemoptysis, the presence of any abnormal arteries correlates with a more frequent diagnosis of bronchiectasis. NBSCs are more common in post-infectious sequelae and CHD.

Complementary Role of Intervention Radiology in Palliative Care in Oncology Setting.

Owing to advances in treatment of cancer, there has been increase in life expectancy. Palliative care aims at improving quality of life of patients suffering from malignancy and is now recognized as a separate subspecialty. Management of cancer patients needs a multidisciplinary approach, and radiology has a key role to play at every step of it. Interventional radiology has broadened its scope immensely over the last decade with development of newer and less invasive applications useful in oncology and palliative care. The role of interventional radiologists begins from obtaining tissue for histopathological examination and extends to controlling disease spread with ablation or chemoembolization, to managing the tumor-related complications and relieving stressful symptoms such as dyspnea and pain. This article aims to review the interventional radiologist's arsenal in managing patients with malignancies with a special emphasis on palliative care, providing a more holistic approach in improving the quality of life of cancer patients.

Imaging findings as predictors of the site of bleeding in patients with hemoptysis: Comparison between split-bolus dual-energy CT angiography and digital subtraction angiography.

PURPOSE Systemic to pulmonary vasculature shunting (SPS) is an important finding to identify the probable site of bleeding, especially in multicentric parenchymal lung disease. The purpose of this study was to evaluate the value of imaging findings, which can locate SPS on dual-energy computed tomography angiography (DECTA), and correlate with digital subtraction angiography (DSA), which was considered as a gold standard. METHODS Retrospective analysis of 187 patients (148 males, 39 females, mean age: 43.7 ± 15.1 years) between October 2014 and November 2018 who underwent both DECTA and DSA. Computed tomography angiography was performed using dual-source (80 and 140kV), 2 × 128 slice equipment, using 50-80mL iodinated contrast (400mg iodine/mL). These patients were divided into shunting (group A) and non-shunting groups (group B), based on the presence or absence of signs of shunting on DECTA. Group A had 98 and group B had 89 patients. We analyzed the following imaging signs for identifying SPS: (1) non-tapering pulmonary artery sign, (2) clustering of vessels sign, and (3) significant differential attenuation sign (>25 HU difference in attenuation between segmental pulmonary arteries of shunting side and normal non-shunting side was considered significant). The correlation was done with DSA to identify the presence of SPS. RESULTS In 187 patients, 281 lobes were evaluated to look for the signs of shunting from systemic artery to pulmonary vessels on DECTA. A total of 98 patients who showed signs of shunting on DECTA presented 135 lobes with parenchymal, with or without pleural, abnormalities. Of these, 84 patients had one or more aspergilloma in the lobe where shunting was seen. In one patient, a specific artery could not be cannulated due to a tortuous course; hence, all arteries which were seen on CTA causing shunting were also seen on DSA. Non-tapering pulmonary artery segmental branches were seen in 97 (99%) patients, clustering of systemic vessels was seen in 90 (91.8%) patients, and significant attenuation difference was seen in 74 (75.5%) patients. In the rest of the 89 patients, 146 lobes were assessed but no signs of shunting were seen on DECTA. Nine arteries in 8 patients showed shunting on DSA, while the rest did not show any shunting. Digital subtraction angiography correlation showed 96.4%, 100%, 100%, and 93.8% of sensitivity, specificity, positive predictive value, and negative predictive value, respectively, for DECTA in detecting SPS on a per artery basis. CONCLUSION The proposed signs on DECTA help in identifying the systemic vessels that cause shunting, and hence, the most likely bleeding site, which aids in planning the endovascular management by targeting specific arteries in case of multicentric disease. Being the gold standard, DSA is an ideal modality for detecting very small SPSs and in classifying the latter.

Chemotherapy-induced pulmonary complications in cancer: Significance of clinicoradiological correlation.

Chemotherapy while revolutionizing cancer management by improving survival and quality of life; is also associated with several adverse effects. Lung is the most common organ affected in chemotherapy-related complications, due to either drug toxicity or more commonly due to infections caused by immunosuppression and less commonly due to immune-mediated injury. Radiology, when used in combination with clinical and lab data, can help reach the specific diagnosis or narrow down the differentials. The common radiological patterns of drug toxicity include pulmonary interstitial and airway infiltrates, diffuse alveolar damage, nonspecific interstitial pneumonia, eosinophilic pneumonia, cryptogenic organizing pneumonia, pulmonary hemorrhage, edema and hypertension. Cancer patients are immunosuppressed due to the underlying malignancy itself or due to therapy and are prone to a gamut of opportunistic infections including viral, bacterial, fungal and mycobacterial pathogens. Immune reconstitution inflammatory syndrome (IRIS), a well-known complication in HIV, is now being increasingly recognized in non-HIV patients with immunosuppression. Engraftment syndrome is specifically seen following hematopoietic stem cell transplant during neutrophil recovery phase. Pulmonary involvement is frequent, causing a radiological picture of noncardiogenic pulmonary edema. Thus, radiology in combination with clinical background and lab parameters helps in detecting and differentiating various causes of pulmonary complications. This approach can help alter potentially toxic treatment and initiate early treatment depending on the diagnosis.

Hydatid cyst of gall bladder masquerading as carcinoma: A rare case report with review of literature.

Hydatid disease is a parasitic infestation caused by Echinococcus, most commonly Echincoccus granulosus. Liver is the most common location followed by lungs. Hydatid involvement of gall bladder is a very rare entity, which masqueraded as gall bladder cancer. Here, we attempt to highlight the relevance of this rare disease and discuss this unique case of a 60-year-old male, who presented with gall bladder mass, abdominal pain, and vomiting. The patient was eventually diagnosed as Hydatid disease. The patient has been treated on medical management and has shown improvement. The manuscript has discussed diagnosis and management of disease along with review of literature.

Single-phase Split-bolus Dual Energy Computed Tomography Angiography for Evaluation of Hemoptysis: A Novel Application.

PURPOSE: The purpose of this study was to assess feasibility and overall utility of single-phase split-bolus dual energy computed tomography (DECT) angiography (DECTA) for evaluation of hemoptysis, and to establish an injection protocol for evaluation of hemoptysis, by comparing 2 contrast injection protocols. MATERIALS AND METHODS: Using dual-source (80 and 140 kV), 2×128-slice equipment, DECTA was performed using 400 mg iodine/mL, 50 to 80 mL iodinated contrast in 257 patients (189 male individuals, 68 female individuals, age range: 15 to 76 y) presenting with hemoptysis. Initially, 50 patients were randomized into 2 groups for 2 different injection protocols (A and B). Images were assessed quantitative and qualitatively. Later, 207 patients were randomized using protocol B, which was technically simpler, and single-CT acquisition, for simultaneous opacification of systemic and pulmonary vessels. RESULTS: Injection protocol A resulted in higher vessel attenuation, both in the aorta and in the pulmonary artery and its segmental branches; however, the difference was not statistically significant. No significant difference was noted in signal-to-noise ratio, contrast-to-noise ratio, as well as subjective image quality parameters. Overall optimal opacification of both systemic and pulmonary arteries was achieved in 247/257 patients. A total of 308 abnormal bronchial arteries were noted. A total of 392 nonbronchial systemic arteries were noted, the majority arising from posterior intercostals and subclavian artery branches. The pulmonary source of hemoptysis was identified in 9 patients (3 pulmonary thromboembolisms, 5 pulmonary artery pseudoaneurysms, and 1 pulmonary venous ectasia). CONCLUSION: Combined DECTA is a novel technique that enables simultaneous evaluation of both systemic and pulmonary vascular cause of hemoptysis in a single acquisition with small contrast dose. Both injection protocols "A" and "B" were equally efficacious in simultaneous opacification of both the aorta and pulmonary arteries. To the best of our knowledge, such a protocol has never been described for hemoptysis evaluation.

Growth Characteristics Modeling of Mixed Culture of Bifidobacterium bifidum and Lactobacillus acidophilus using Response Surface Methodology and Artificial Neural Network

Different culture conditions viz. additional carbon and nitrogen content, inoculum size and age, temperature and pH of the mixed culture of Bifidobacterium bifidum and Lactobacillus acidophilus were optimized using response surface methodology (RSM) and artificial neural network (ANN). Kinetic growth models were fitted for the cultivations using a Fractional Factorial (FF) design experiments for different variables. This novel concept of combining the optimization and modeling presented different optimal conditions for the mixture of B. bifidum and L. acidophilus growth from their one variable at-a-time (OVAT) optimization study. Through these statistical tools, the product yield (cell mass) of the mixture of B. bifidum and L. acidophilus was increased. Regression coefficients (R2) of both the statistical tools predicted that ANN was better than RSM and the regression equation was solved with the help of genetic algorithms (GA). The normalized percentage mean squared error obtained from the ANN and RSM models were 0.08 and 0.3%, respectively. The optimum conditions for the maximum biomass yield were at temperature 38°C, pH 6.5, inoculum volume 1.60 mL, inoculum age 30 h, carbon content 42.31% (w/v), and nitrogen content 14.20% (w/v). The results demonstrated a higher prediction accuracy of ANN compared to RSM.

Growth characteristics modeling of Lactobacillus acidophilus using RSM and ANN

The culture conditions viz. additional carbon and nitrogen content, inoculum size, age, temperature and pH of Lactobacillus acidophilus were optimized using response surface methodology (RSM) and artificial neural network (ANN). Kinetic growth models were fitted to cultivations from a Box-Behnken Design (BBD) design experiments for different variables. This concept of combining the optimization and modeling presented different optimal conditions for L. acidophilus growth from their original optimization study. Through these statistical tools, the product yield (cell mass) of L. acidophilus was increased. Regression coefficients (R²) of both the statistical tools predicted that ANN was better than RSM and the regression equation was solved with the help of genetic algorithms (GA). The normalized percentage mean squared error obtained from the ANN and RSM models were 0.06 and 0.2%, respectively. The results demonstrated a higher prediction accuracy of ANN compared to RSM.