Airway Mucus Plugs on Chest Computed Tomography Are Associated with Exacerbations in COPD.

Rationale/Objective: Acute exacerbations (AEs) of chronic obstructive pulmonary disease (COPD) are associated with significant morbidity and mortality. Whether mucus plugs are associated with prospective exacerbations has not been examined extensively. METHODS: Mucus plugs were visually-identified on baseline chest computed tomography (CT) scans from smokers with Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades 2-4 COPD enrolled in two multicenter cohort studies: Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) and COPDGene. Associations between ordinal mucus plug score categories (0/1-2/≥3) and prospectively-ascertained AEs, defined as worsening respiratory symptoms requiring systemic steroids and/or antibiotics (moderate-to-severe) and/or ER/hospitalization (severe), were assessed using multivariable-adjusted zero-inflated Poisson regression; subjects were exacerbation-free at enrollment. RESULTS: Among 3,250 participants in COPDGene (mean±SD age 63.7±8.4 years, FEV1 50.6%±17.8% predicted, 45.1% female) and 1,716 participants in ECLIPSE (age 63.3±7.1 years, FEV1 48.3%±15.8% predicted, 36.2% female), 44.4% and 46.0% had mucus plugs, respectively. The incidence rates of AEs were 61.0 (COPDGene) and 125.7 (ECLIPSE) per 100 person-years. Relative to those without mucus plugs, the presence of 1-2 and ≥3 mucus plugs was associated with increased risk (adjusted rate ratio, aRR [95%CI]=1.07[1.05-1.09] and 1.15[1.1-1.2] in COPDGene; aRR=1.06[1.02-1.09] and 1.12[1.04-1.2] in ECLIPSE, respectively) for prospective moderate-to-severe AEs. The presence of 1-2 and ≥3 mucus plugs was also associated with increased risk for severe AEs during follow-up (aRR=1.05[1.01-1.08] and 1.09[1.02-1.18] in COPDGene; aRR=1.17[1.07-1.27] and 1.37[1.15-1.62] in ECLIPSE, respectively). CONCLUSION: CT-based mucus plugs are associated with an increased risk for future COPD AEs.

Airway-Occluding Mucus Plugs and Mortality in Patients With Chronic Obstructive Pulmonary Disease.

Importance: Airway mucus plugs are common in patients with chronic obstructive pulmonary disease (COPD); however, the association of airway mucus plugging and mortality in patients with COPD is unknown. Objective: To determine whether airway mucus plugs identified on chest computed tomography (CT) were associated with increased all-cause mortality. Design, Setting, and Participants: Observational retrospective analysis of prospectively collected data of patients with a diagnosis of COPD in the Genetic Epidemiology of COPD cohort. Participants were non-Hispanic Black or White individuals, aged 45 to 80 years, who smoked at least 10 pack-years. Participants were enrolled at 21 centers across the US between November 2007 and April 2011 and were followed up through August 31, 2022. Exposures: Mucus plugs that completely occluded airways on chest CT scans, identified in medium- to large-sized airways (ie, approximately 2- to 10-mm lumen diameter) and categorized as affecting 0, 1 to 2, or 3 or more lung segments. Main Outcomes and Measures: The primary outcome was all-cause mortality, assessed with proportional hazard regression analysis. Models were adjusted for age, sex, race and ethnicity, body mass index, pack-years smoked, current smoking status, forced expiratory volume in the first second of expiration, and CT measures of emphysema and airway disease. Results: Among the 4483 participants with COPD, 4363 were included in the primary analysis (median age, 63 years [IQR, 57-70 years]; 44% were women). A total of 2585 (59.3%), 953 (21.8%), and 825 (18.9%) participants had mucus plugs in 0, 1 to 2, and 3 or more lung segments, respectively. During a median 9.5-year follow-up, 1769 participants (40.6%) died. The mortality rates were 34.0% (95% CI, 32.2%-35.8%), 46.7% (95% CI, 43.5%-49.9%), and 54.1% (95% CI, 50.7%-57.4%) in participants who had mucus plugs in 0, 1 to 2, and 3 or more lung segments, respectively. The presence of mucus plugs in 1 to 2 vs 0 and 3 or more vs 0 lung segments was associated with an adjusted hazard ratio of death of 1.15 (95% CI, 1.02-1.29) and 1.24 (95% CI, 1.10-1.41), respectively. Conclusions and Relevance: In participants with COPD, the presence of mucus plugs that obstructed medium- to large-sized airways was associated with higher all-cause mortality compared with patients without mucus plugging on chest CT scans.

Microvascular Flow Imaging: A State-of-the-Art Review of Clinical Use and Promise.

Vascular imaging with color and power Doppler is a useful tool in the assessment of various disease processes. Assessment of blood flow, from infarction and ischemia to hyperemia, in organs, neoplasms, and vessels, is used in nearly every US investigation. Recent developments in this area are sensitive to small-vessel low velocity flow without use of intravenous contrast agents, known as microvascular flow imaging (MVFI). MVFI is more sensitive in detection of small vessels than color, power, and spectral Doppler, reducing the need for follow-up contrast-enhanced US (CEUS), CT, and MRI, except when arterial and venous wash-in and washout characteristics would be helpful in diagnosis. Varying clinical applications of MVFI are reviewed in adult and pediatric populations, including its technical underpinnings. MVFI shows promise in assessment of several conditions including benign and malignant lesions in the liver and kidney, acute pathologic abnormalities in the gallbladder and testes, and superficial lymph nodes. Future potential of MVFI in different conditions (eg, endovascular repair) is discussed. Finally, clinical cases in which MVFI correlated and potentially obviated additional CEUS, CT, or MRI are shown.

Vascular complications in cases of acute pancreatitis - CT scan based study.

OBJECTIVE: To record the incidence of vascular complications in cases of acute pancreatitis. METHODS: This retrospective, cross-sectional study was performed at the Liaquat National Hospital, Karachi, from October 31, 2012 to October 31, 2014, and comprised computerised records and computerised tomography scan images related to cases of pancreatitis. RESULTS: Of the 210 patients included, 97(46.19%) were men and 113(53.81%) were women. A total of 24(11.4%) patients had thrombosis of splanchnic vasculature, of which the most frequently thrombosed vessel was the splenic vein, in 17(70.8%) patients; followed by the portal vein, 11(45.8%); and the superior mesenteric vein,4(16.7%). CONCLUSIONS: The incidence of vascular thrombosis was low, but not uncommon in patients of severe acute pancreatitis.

Hysterosalpingographic evaluation of primary and secondary infertility.

OBJECTIVE: To determine the pathological patterns of fallopian tubes and uterus on hysterosalpingogrphy (HSG) examination in cases of infertility. METHODS: Two years retrospective charts review of patients referred to our centre for HSG evaluation of infertility, from July 2008 to July 2010. RESULTS: Four thousand one hundred eight hysterosalpingograms were carried out at our centre during the study period. Out of these, 1999 (48.6%) were primary infertility cases while the 2109 (51.3%) were of secondary infertility. Mean age of presentation for primary infertility was 30 years and 35 years for secondary infertility. Bilateral free peritoneal spill was noted in 60% of cases. Unilateral tubal blockage was present in 15% and bilateral tubal blockage in 10% of patients. Bilateral hydrosalpinx was present in 10% of patients and unilateral loculated spill was found in 5% of patients with primary infertility. Patients with uterine congenital anomalies were also evaluated and the frequency of bicornuate uterus was 4%, unicornuate uterus was 2% and uterine didelphys was 0.2%. CONCLUSIONS: Infertile patients who underwent HSG were mostly in older age group with secondary infertility being slightly more common emphasizing early work up and care. Most of the patients with primary infertility had normal HSG examination. To our knowledge this is the largest data for HSG to be presented from Pakistan.

Increased incidence of adrenal gland injury in blunt abdominal trauma: a computed tomography-based study from Pakistan.

OBJECTIVE: To determine the frequency of adrenal injuries in patients presenting with blunt abdominal trauma by computed tomography (CT). METHODS: During a 6 month period from January 1, 2011 to June 30, 2011, 82 emergency CT examinations were performed in the setting of major abdominal trauma and retrospectively reviewed for adrenal gland injuries. RESULTS: A total of 7 patients were identified as having adrenal gland injuries (6 males and 1 female). Two patients had isolated adrenal gland injuries. In the other 5 patients with nonisolated injuries, injuries to the liver (1 case), spleen (1 case), retroperitoneum (2 cases) and mesentery (4 cases) were identified. Overall 24 cases with liver injuries (29%), 11 cases with splenic injuries (13%), 54 cases with mesenteric injuries (65%), 14 cases (17%) with retroperitoneal injuries and 9 cases with renal injuries were identified. CONCLUSION: Adrenal gland injury is identified in 7 patients (11.7%) out of a total of 82 patients who underwent CT after major abdominal trauma. Most of these cases were nonisolated injuries. Our experience indicates that adrenal injury resulting from trauma is more common than suggested by other reports. The rise in incidence of adrenal injuries could be attributed to the mode of injury.

Silent Airway Mucus Plugs in COPD and Clinical Implications.

BACKGROUND: Airway mucus plugs are frequently identified on CT scans of patients with COPD with a smoking history without mucus-related symptoms (ie, cough, phlegm [silent mucus plugs]). RESEARCH QUESTION: In patients with COPD, what are the risk and protective factors associated with silent airway mucus plugs? Are silent mucus plugs associated with functional, structural, and clinical measures of disease? STUDY DESIGN AND METHODS: We identified mucus plugs on chest CT scans of participants with COPD from the COPDGene study. The mucus plug score was defined as the number of pulmonary segments with mucus plugs, ranging from 0 to 18, and categorized into three groups (0, 1-2, and ≥ 3). We determined risk and protective factors for silent mucus plugs and the associations of silent mucus plugs with measures of disease severity using multivariable linear and logistic regression models. RESULTS: Of 4,363 participants with COPD, 1,739 had no cough or phlegm. Among the 1,739 participants, 627 (36%) had airway mucus plugs identified on CT scan. Risk factors of silent mucus plugs (compared with symptomatic mucus plugs) were older age (OR, 1.02), female sex (OR, 1.40), and Black race (OR, 1.93) (all P values < .01). Among those without cough or phlegm, silent mucus plugs (vs absence of mucus plugs) were associated with worse 6-min walk distance, worse resting arterial oxygen saturation, worse FEV1 % predicted, greater emphysema, thicker airway walls, and higher odds of severe exacerbation in the past year in adjusted models. INTERPRETATION: Mucus plugs are common in patients with COPD without mucus-related symptoms. Silent mucus plugs are associated with worse functional, structural, and clinical measures of disease. CT scan-identified mucus plugs can complement the evaluation of patients with COPD.

Computed tomography of coronary artery atherosclerosis: A review.

Coronary artery atherosclerosis resulting in ischemic cardiac disease is the leading cause of mortality in the United States. In symptomatic patients, invasive diagnostic methods like catheter angiography, intravascular ultrasound, or vascular endoscopy may be used. However, for primary prevention of atherosclerotic coronary artery disease in asymptomatic patients, non-invasive methods are more commonly utilized like stress imaging, single-photon emission computed tomography (SPECT) and coronary artery calcification scoring. Coronary computed tomographic angiography (CCTA) is an excellent diagnostic tool for detection of coronary artery plaque and ability to identify resultant stenoses with an excellent negative predictive value which can potentially result in optimal exclusion of the presence of coronary artery disease. Long term follow up after a negative CCTA has repeatedly demonstrated very low incidence of future adverse coronary events, attesting its predictive value. CCTA based management is associated with improved CAD outcome in stable angina. Coronary CTA is valuable in acute chest pain evaluation in the emergency department helping in better triage. CT perfusion and CT-FFR are both very promising tools for assessment of hemodynamic significance of coronary artery stenosis.

Coronary artery anomalies evaluation with cardiac computed tomography: A review.

Coronary artery anomalies involve either their origin, course, or termination of the vessel. Coronary artery anomalies are congenital and relatively few develop symptoms, which can include potentially serious effects like arrhythmia, chest pain, syncope, myocardial infarction, or sudden death. Conventional coronary angiography has been used extensively in the past few decades for evaluation of coronary anomalies. With recent advancements in the software and hardware, noninvasive nature, and excellent temporal and spatial resolution; coronary computed tomographic angiography (CTA) is now the mainstay in the diagnosis of coronary arterial anomalies. Many studies have shown better performance of cardiac CTA compared to invasive angiography in detection of anomalous coronary arteries.

Non coronary applications of cardiac computed tomography: A review.

Acquired heart diseases including valvular pathologies and conduction abnormalities, along with coronary artery disease make cardiovascular disease one of the major causes of mortality and morbidity worldwide. Advances in cardiac computed tomography (CCT) have led to markedly improved image quality for assessment of several coronary and noncoronary cardiac abnormalities. With the latest versions of CT scanners, image acquisition can be completed within a few seconds, in a single breath hold and with much less radiation exposure, thus making CT an even more attractive diagnostic tool with its high temporal and excellent spatial resolution. Additional advantages are its noninvasive nature, wide availability, fast image acquisition and ability to provide additional data about the cardiac structure, function, valvular motion, and presence or absence of valvular vegetation, mass or intracardiac thrombus. These factors can result in change in management in many valvular pathologies pre- and post-intervention, and in electrophysiological procedures. The goal of this article is to review applications of cardiac CT in non-coronary indications including valvular assessment, pulmonary vein isolation procedure, and left atrial appendage evaluation for its transcatheter occlusion.

Cardiac computed tomographic evaluation of coronary artery calcification: A review.

Vascular calcification is most commonly due to atherosclerosis. It has been well documented that absence of coronary calcification on a chest CT (CCT) is associated with low cardiovascular events and good prognosis. High CT calcium scores often result in a higher incidence of cardiovascular events and worse survival. In asymptomatic patients with an intermediate risk for coronary artery disease, numerous studies have shown Coronary Calcium Scoring (CCS) has prognostic relevance and incremental prognostic value over conventional risk stratification. CT detected calcium score plays important role in patient management. This article will review various CT based coronary artery calcium scoring methods.

Role of computed tomography in adult congenital heart disease: A review.

Due to advances in cardiac surgery, perioperative care and transcatheter interventions, the majority of infants with congenital heart disease (CHD) now survive and reach adulthood. Transthoracic Echocardiography (TTE) is considered the primary imaging modality in evaluation of patients with CHD. However, in adults it can be limited due to several reasons. Although cardiac magnetic resonance (CMR) is extremely useful in evaluating cardiac morphology and function, it is not widely available, takes a long time to obtain images, and cannot be done in severely ill patients or patients that have claustrophobia. Due to high spatial and temporal resolution, isotropic imaging fast imaging and wide availability, multidetector computed tomography (MDCT) has emerged as an excellent alternative modality in the evaluation of adult congenital heart disease (ACHD). It can be performed on patients with hardware and those with claustrophobia, due to shorter image acquisition time. In this article, the commonly encountered congenital heart disorders in adults are reviewed, whether incidentally discovered on a computed tomography (CT), on a CT done to evaluate sequela of unknown CHD, or known treated CHD. To appropriately perform and evaluate CT imaging for postoperative correction or palliation congenital heart disease in adults, the imager should know the detailed cardiac anatomy, details of the operative technique used, and be familiar with the common short and long term post-operative complications.

Cardiac mass evaluation with cardiac computed tomography: A review.

Cardiac masses are rare and include both benign and malignant neoplasms as well as pseudo-tumors. The goal of imaging in patients with suspected cardiac mass is to: (1) confirm presence of a mass; (2) determine the mass' location in the heart; (3) characterize the mass to determine if it is benign or malignant; and (4) evaluate its relationship and effect on adjacent structures. Echocardiography is often the first to detect and assess cardiac structures as it is widely available, non-invasive, and can be done bedside. Echo can also determine if the myocardium or pericardium is involved. Cardiac Magnetic Resonance Imaging (MRI) is often the second modality of choice to evaluate a cardiac mass. Cardiac Computed Tomography (CCT) is an excellent alternative modality with high spatial and temporal resolution, which is widely available, fast, and can be performed in patients with cardiac hardware. We will discuss the role of computed tomography (CT) in the evaluation of various cardiac masses.

Coronary computed tomographic angiography: A review of the techniques, protocols, pitfalls, and radiation dose.

Coronary computed tomographic angiography (CCTA) is a viable alternative to catheter coronary angiography for several clinical indications, chiefly because it is fast and non-invasive. For effective clinical use of CCTA, various technical and patient factors should be considered. In this brief review article, we discuss the indication and contraindications for CCTA, technical requirements for CCTA including radiation dose, patient preparation principles, image post-processing, and pitfalls and artifacts of CCTA.

Review of pericardial disease on computed tomography.

Echocardiography has long been the mainstay in the evaluation of cardiac and pericardial disease. As computed tomography (CT) has advanced, it has become a valuable partner in the imaging of the pericardium. The advantages of CT include a larger field of view, multiplanar reconstruction and increased discrimination between various soft tissues and fluids. CT is less operator dependent and can more easily, and reproducibly, image areas of the pericardium for which echocardiography has poor windows such as the right pericardium. The introduction of EKG gating has decreased cardiac motion artifact and can allow functional evaluation although echocardiography remains the primary source of real-time imaging of cardiac and valve motion. It is essential for the skilled cardiac imager to understand the strengths and weaknesses of CT and its role in the definition and assessment of pericardial disease.

A Rare Pulmonary-Systemic Connection: Levoatriocardinal Vein.

Levoatriocardinal vein is a rare persistent connection between pulmonary and systemic venous circulation that might result in bidirectional shunt and paradoxical embolism.

Primary mediastinal germ cell tumor--successful curative resection following chemotherapy--a case report.

Primary mediastinal germ cell tumours are relatively rare and account for only a small portion of all the mediastinal tumours. We present a case of a primary mediastinal germ cell tumour in a 14 years old Afghani boy.