[Pleural effusion in chronic obstructive pulmonary medicine (COPD) patients in a medical intensive care unit: characteristics and clinical implications].

BACKGROUND: Pleural effusions are common among patients admitted to an Intensive-Care Unit (ICU). AIM: To retrospectively assess the role of pleural effusions in chronic obstructive pulmonary disease (COPD) patients admitted to a Medical ICU (MICU). PATIENTS AND METHODS: We reviewed records of patients admitted over 12-months to the MICU with a diagnosis of COPD. We colLected clinical and laboratory data for their entire MICU stay. A radiologist reviewed all chest radiographs to determine the presence and estimated volume of pleural effusions. RESULTS: A total of 100 consecutive patients with COPD admitted to the MICU were included; 32 (32%) developed pleural effusions. COPD exacerbations were more common among patients without pleural effusion. Congestive heart failure (CHF) exacerbations were more common among patients with pleural effusions (p=0.001 and p=0.006, respectively). The length of stay was significantly longer among COPD patients with a pleural effusion (19 +/- 8 days) than those without it (14 +/- 3 days, p=0.001). The mortality rate was similar (40%) in both groups. Only patients with a large or unexplained effusion (19%) underwent thoracocentesis. In all cases, the pleural fluids were transudate and confirmed the diagnosis of CHF. CONCLUSIONS: Pleural effusion is common among COPD patients admitted to a MICU. Most are due to CHF and parapneumonic effusions and respond well to treatment of the underlying problem.

Spontaneous suburothelial hemorrhage in coagulopathic patients: CT diagnosis.

OBJECTIVE: The objective of our study was to identify and describe the spectrum of CT findings in patients with coagulopathy-induced suburothelial hemorrhage involving the renal collecting system. CONCLUSION: CT findings of suburothelial hemorrhage are often subtle and are best appreciated on unenhanced CT scans because of the high density of the hemorrhage. After contrast injection, uniformly thickened soft tissue enveloping the collecting system is suggestive of this condition. Clinical information regarding the presence of coagulopathy is essential for the radiologist to entertain this relatively rare diagnosis.

Pulmonary complications following laparoscopic adjustable gastric banding.

Laparoscopic adjustable silicone banding (LAP-BAND) has rapidly gained acceptance and is now considered the most common bariatric operation. The accumulated experience with LAP-BAND has established this surgical method as safe and effective. However, no data have been issued concerning pulmonary complications following the procedure. We have recently experienced 3 cases of pulmonary complications following LAP-BAND surgery: 1 patient with pulmonary cavitation and 2 with bronchiectasis. Pulmonary physicians should be aware of the possibility of long-term pulmonary complications in patients who have undergone LAP-BAND surgery.

Systemic Thrombolysis Therapy is Associated With Improved Outcomes Among Patients With Acute Pulmonary Embolism and Respiratory Failure.

BACKGROUND: Thrombolytic therapy is widely accepted for massive pulmonary embolism (PE) due to the high mortality risk associated with standard anticoagulation alone. Its role in submassive PE, however, has remained controversial. We aimed to evaluate whether the selective use of systemic thrombolytic therapy with intravenous tissue plasminogen activator (IV-tPA) improves the survival of patients with submassive PE at increased risk for clinical deterioration. METHODS: A total of 184 consecutive patients diagnosed with acute PE by chest thoracic angiography (CTA) were included in a retrospective study. Pulmonary artery obstruction and right/left ventricular dysfunction were evaluated by CTA and echocardiography. Medical history and simplified PE Severity Index (sPESI) were assessed at diagnosis. Hemodynamic and respiratory status were recorded at diagnosis, admission to pulmonary unit and prior to thrombolytic therapy. Patient survival was assessed at 30 of 90 days from diagnosis by CTA. RESULTS: All low risk patients (36%) per sPESI survived. Among the 117 remaining patients, 31% received IV-tPA. Respiratory failure was associated with decreased age-adjusted survival (P = 0.005). Among patients with respiratory failure selected for IV-tPA, age-adjusted survival was improved significantly compared to others (P = 0.043). CONCLUSIONS: Thrombolytic therapy for hemodynamically stable PE patients with respiratory failure may improve survival. TRIAL REGISTRATION: MMC-0216-14.

Peripheral blood telomere alterations in ground glass opacity (GGO) lesions may suggest malignancy.

A ground glass opacity (GGO) lung lesion may represent early stage adenocarcinoma, which has an excellent prognosis upon prompt surgical resection. However, GGO lesions have broad differential diagnoses, including both benign and malignant lesions. Our objective was to study telomere length and telomerase activity in patients with suspected lung cancer in which GGO was the predominant radiographic feature. Knowledge of telomere biology may help distinguish malignant from benign radiographic lesions and guide risk assessment of these lesions. Peripheral blood samples were taken from 22 patients with suspected adenocarcinoma with the GGO radiographic presentation. Multidisciplinary discussion confirmed the need for surgery in all cases. We used an age and gender-matched group without known lung disease as a control. Telomere length and aggregates were assessed by quantitative fluorescence in situ hybridization (QFISH) and quantitative PCR. Cell senescence was evaluated by senescence-associated heterochromatin foci. Subjects with GGO lesions had a higher percentage of lymphocytes with shorter telomeres (Q-FISH, P = 0.003). Furthermore, relative telomere length was also reduced among the GGO cases (qPCR, P < 0.05). Increased senescence was observed in the GGO group compared to controls (P < 0.001), with significant correlation between the senescence-associated heterochromatin foci and aggregate formation (r = -0.7 and r = -0.44 for cases and controls, respectively). In conclusion, patients with resectable early adenocarcinoma demonstrate abnormal telomere length and cell senescence in peripheral blood leukocytes compared to control subjects. Abnormal telomere biology in the peripheral blood may increase suspicion of early adenocarcinoma among patients with GGO lesions.

Abdominal CT findings in nontraumatic colorectal perforation.

Colorectal perforation is an emergent medical condition in which the diagnosis and the etiology are often established on CT, the common imaging modality used for evaluating the acute abdomen. The cardinal, direct CT features suggesting perforation are extraluminal air and enteric contrast, added by secondary signs of bowel pathology, such as focal bowel wall thickening and bowel wall defect. This pictorial review will illustrate the CT findings of colorectal perforation caused by various clinical entities.

Fitz-Hugh-Curtis Syndrome Consequent to a Wound Infection Following Removal of a Peritoneal Dialysis Catheter.

Fitz-Hugh-Curtis syndrome (FHCS) is a condition characterized by inflammation of the liver capsule (perihepatitis) and adjacent peritoneal surfaces. We report a case of FHCS developing in a peritoneal dialysis (PD) patient in whom catheter removal due to recurrent peritonitis was complicated by post-operative wound infection. To the best of our knowledge, this is the first case description of FHCS in the context of PD.

Positive intraluminal bowel contrast on computed tomography following oral ingestion of kayexelate.

Our study presents the computed tomography (CT) manifestations of orally ingested kayexelate (a powdered form of sodium polystyrene sulphonate) used to treat hyperkalemia. Five patients with whom kayexalate appeared as high-attenuating intraluminal enteric content, similar to oral contrast material or leakage of intravascular contrast, are reported. Radiologists should be familiar with its appearance as it may mimic oral or vascular contrast within the gastrointestinal tract, a finding that may lead to a diagnostic error or misinterpretation.

Increased detection of early vascular abnormalities after renal biopsies by color Doppler sonography.

OBJECTIVE: The purpose of this study was to assess the frequency of abnormal vascular findings after renal biopsies as detected by color and pulsed Doppler sonography. METHODS: With both color and pulsed Doppler sonography, we examined 77 patients who underwent a renal biopsy of a native kidney. The examination was carried out before and immediately after the biopsy. A follow-up sonographic assessment was performed 24 hours later. If abnormal vascular findings were detected, the patients were reexamined after 2 weeks or even for a longer period. RESULTS: Tissue samples suitable for histologic diagnosis were obtained in 94% of the biopsies. In 17 of 77 patients, changes were observed in the color and pulsed Doppler examination immediately after the biopsy. A small localized flow disturbance was diagnosed in 10 kidneys, and a color tract was seen in 7. In 1 case, this tract was associated with a small localized flow disturbance. In 2 other patients, a localized flow disturbance was detected only in the examination performed 24 hours after the biopsy. Eight of the 10 flow disturbances diagnosed immediately after the biopsy and all tracts were not visible at the 24-hour follow-up examination. All these vascular findings were undetectable on sonographic examination without color and pulsed Doppler imaging. CONCLUSIONS: The results indicate that vascular lesions, detectable with color and pulsed Doppler sonography, are not rare findings early after renal biopsies. These vascular findings show a high rate of spontaneous resolution within the first 24 hours.

Extrarenal manifestations of severe acute pyelonephritis: CT findings in 21 cases.

The aim of this study is to report the extrarenal computerized tomography (CT) findings in patients with acute pyelonephritis (APN). Twenty-one CT examinations of 20 patients [19 women and one man, with ages ranging from 18 to 57 years (mean -35.2 years)], presenting either with a clinical diagnosis of APN (n=17) or with a suspected acute appendicitis, fever of unknown origin, and adult respiratory distress syndrome, one in each, were retrospectively reviewed. None had a known preexisting systemic disease. Results showed that renal abnormalities were seen on CT in all patients. In addition, ascites was detected in all women patients associated with subcutaneous edema in five of them. A thickened gallbladder wall was found in 19 cases, all were women, and periportal tracking and a dilated inferior vena cava in 17 CTs. Pleural effusion and thickened interlobular septa were present in 16 and 15 studies, respectively. Relevant laboratory findings included hypoalbuminemia in 14, elevated liver enzymes in 11, hypocholesterolemia in nine, and elevated LDH levels in six cases. In conclusion, radiologists should be familiar with the extrarenal imaging features of APN that may be seen on CT, and on ultrasonography as well, and should look for renal abnormalities to diagnose a clinically unsuspected APN. Alternatively, APN should be included in the differential diagnosis of systemic diseases that cause gallbladder wall thickening to avoid misdiagnosing it as acute cholecystitis.

Small bowel obstruction due to a paracecal hernia: computerized tomography diagnosis.

The role of computerized tomography (CT) in evaluating patients with small bowel obstruction (SBO) has been extensively described in the current literature. We report a rare case of SBO related to a surgically proven paracecal hernia, diagnosed on an abdominal CT scan preoperatively.

Computed tomographic features of afferent loop syndrome: pictorial essay.

ALS, a rare condition, is often difficult to diagnose clinically but has a characteristic CT appearance as a U-shaped, fluid-filled tubular structure crossing the midline between the abdominal aorta and the superior mesenteric artery. Radiologists should be familiar with this rare entity, as awareness of its pathognomonic CT features will aid in establishing the correct diagnosis as well as in offering a tentative etiology as a guide for treatment.

Acute epiploic appendagitis: CT findings in 33 cases.

Acute epiploic appendagitis (AEA) is a benign self-limiting process presenting with acute abdominal pain often misdiagnosed clinically as either diverticulitis or appendicitis, but which has a pathognomonic CT appearance. The CT findings in 33 adult patients diagnosed by CT over a 33-month period as having AEA were retrospectively reviewed. The study group included 24 men and 9 women, with a mean age of 44.6 years. The mean age of the male patients was lower than that of the female patients, 40.9 vs 54.7 years. All patients presented with acute abdominal pain, mainly in the left ( n=21) and right ( n=9) lower quadrants, with localized tenderness in all patients and peritoneal irritation in 15 of them. Low-grade fever was found in 8 patients and mild leukocytosis in 16. Characteristic CT findings of an oval fatty mass with central streaky densities and surrounded by mesenteric stranding adjacent to the serosal surface of the colon were seen in all cases. Additional findings included mural thickening of the juxtaposed colon in 16 patients and peritoneal fluid in 7. One patient underwent surgery on the basis of an erroneous diagnosis of acute appendicitis. As CT is often used nowadays to evaluate various acute abdominal complaints, it may be the first imaging modality by which AEA is diagnosed. AEA should be included in the differential diagnosis in young male patients with localized left lower abdominal pain and tenderness.

Computed tomographic features of intraperitoneal fat-containing lesions: pictorial essay.

Abdominal CT, which is a common imaging modality performed for a variety of clinical indications, provides an important tool in the diagnosis and evaluation of various lesions with fatty components affecting the peritoneal cavity and its contents.

CT findings in patients with small bowel obstruction due to phytobezoar.

The role of CT in evaluating patients with small bowel obstruction (SBO) has been extensively described in the current literature. We present the CT findings of SBO due to a phytobezoar, afterwards surgically confirmed, in 5 men and 1 woman (aged 32-89 years) out of 95 patients diagnosed by CT as having SBO in a 44-month period. These six patients underwent abdominal CT prior to operation and the CT findings were retrospectively reviewed. All six patients presented with clinical symptoms and signs of SBO; three of them had undergone gastric surgery 13, 17, and 22 years earlier, respectively. In all six cases, CT showed an ovoid intraluminal mass, 3 x 5 cm in size and of a mottled appearance, at the transition zone between dilated and collapsed small bowel loops. This was in contrast to feces-like material (the "small bowel feces sign"), seen within dilated small bowel loops in nine patients with SBO, and was typically longer. As CT is frequently performed for suspected SBO, an ovoid, short intraluminal mottled mass seen at the site of an obstruction may be regarded as a pathognomonic preoperative sign of an obstructing phytobezoar.