Clinical Relevance of Computed Tomography Pulmonary Venography.

BACKGROUND: In clinical routine, the pulmonary contrast-enhanced chest computer tomography (CT) is usually focussed on the pulmonary arteries. The purpose of this pictorial essay is to raise the clinicians' awareness for the clinical relevance of CT pulmonary venography. CASE PRESENTATION: A pictorial case series illustrates the clinical consequences of different pulmonary venous pathologies on systemic, pulmonary and bronchial circulation. CONCLUSION: Computed tomography pulmonary venography must be considered before atrial septal defect (ASD) closure and pulmonary lobectomy. Computed tomography pulmonary venography should be considered for patients with right ventricular overload and pulmonary hypertension, as well as for patients with unclear recurrent pulmonary infections, progressive dyspnoea, pleural effusions, haemoptysis, and for patients with respiratory distress after lung-transplantation.

Identification of the biosynthetic gene cluster for 3-methylarginine, a toxin produced by Pseudomonas syringae pv. syringae 22d/93.

The epiphyte Pseudomonas syringae pv. syringae 22d/93 (Pss22d) produces the rare amino acid 3-methylarginine (MeArg), which is highly active against the closely related soybean pathogen Pseudomonas syringae pv. glycinea. Since these pathogens compete for the same habitat, Pss22d is a promising candidate for biocontrol of P. syringae pv. glycinea. The MeArg biosynthesis gene cluster codes for the S-adenosylmethionine (SAM)-dependent methyltransferase MrsA, the putative aminotransferase MrsB, and the amino acid exporter MrsC. Transfer of the whole gene cluster into Escherichia coli resulted in heterologous production of MeArg. The methyltransferase MrsA was overexpressed in E. coli as a His-tagged protein and functionally characterized (K(m), 7 mM; k(cat), 85 min(-1)). The highly selective methyltransferase MrsA transfers the methyl group from SAM into 5-guanidino-2-oxo-pentanoic acid to yield 5-guanidino-3-methyl-2-oxo-pentanoic acid, which then only needs to be transaminated to result in the antibiotic MeArg.

Net reclassification improvement with serial biomarkers and bed-sided spirometry to early predict the need of organ support during the early post-transplantation in-hospital stay in allogeneic HCT recipients.

To predict the need of intensive care unit admission with organ support during the transplantation hospital stay in 101 consecutives allogeneic hematopoietic cell transplantation (allo-HCT) recipients the added predictive utility of three times per week Copeptin, MR-proADM, MR-proANP, NT-proBNP, IL-6, Procalcitonin, D-dimer and three times per week bed-sided pulmonary function test was determined in comparison with an index model. The index model was calculated by multivariate regression analysis out of the patients' routine laboratory parameters. To calculate the added predictive utility of the investigated markers the Δ-AUC and the continuous net reclassification improvement (cNRI + 2 to - 2), splitted for events and non-events were calculated for each marker in comparison with the index model. According to the Δ-AUC, none of the parameters improved risk prediction. In contrast, the cNRI was significantly improved for events and non-events by Copeptin (event 0.75, p value 0.0013; non-event 0.4, p value 0.000079) and for events by NT-proBNP (0.6, p value 0.018). D-dimer and PCT significantly predicted the non-event. Of the spirometry parameters, the FEF50% improved prediction of event and non-event according to the cNRI model. Our data support the additional serial analysis of Copeptin and NT-proBNP in allo-HCT recipients during the transplantation hospital stay.

Percutaneous transluminal angioplasty of proximal subclavian artery stenosis after left internal mammary to left anterior descending artery bypass surgery.

A patient is described who underwent percutaneous transluminal angioplasty, through a brachial approach, of a high grade stenosis at the proximal portion of the left subclavian artery 1.5 years after coronary artery bypass grafting including left internal mammary to left anterior descending artery anastomosis. Symptoms of class IV angina, vertebrobasilar insufficiency and occupational arm claudication that developed after bypass surgery were promptly relieved after balloon dilation. Percutaneous transluminal angioplasty of the subclavian artery can be performed safely and provides an alternative to carotid-subclavian or axillary-axillary bypass surgery for treatment of internal mammary artery graft malfunction.

Comparison of intravenous digital subtraction angiography and conventional arteriography in defining renal anatomy.

Intravenous digital subtraction renal angiography (IV-DSRA) is frequently used in the preoperative evaluation of living-related (LR) kidney donors. However, the true accuracy of IV-DSRA in the donor population is difficult to assess since abnormalities of the kidney and its circulation are uncommon in this group. Therefore, we evaluated IV-DSRA in a group of patients more likely to have anomalies and abnormalities that would affect LR donor selection, donor nephrectomy, and subsequent transplantation. Hypertensive adults being evaluated for renovascular hypertension had IV-DSRA and conventional renal arteriograms, which were interpreted independently. We determined the accuracy of IV-DSRA, compared with conventional arteriography, in detecting multiple renal arteries, renal artery stenosis, fibromuscular dysplasia, and abnormal renal parenchyma. Technically unsatisfactory studies were excluded from analysis. Of 59 patients evaluated, 37 had abnormalities or anomalies. IV-DSRA failed to detect 28 of 50 findings in these 37 patients. In 21 patients with multiple renal arteries, IV-DSRA underestimated the number of main renal arteries in 8. Significant renal artery stenosis, present in 16 patients, was undetected by IV-DSRA in 3 of these patients. Mild fibromuscular dysplasia was not detected by IV-DSRA in any of the 5 patients with this condition, and abnormalities of renal parenchyma were not detected in 6 of the 8 patients with scarred or cystic kidneys. When compared with conventional renal arteriography in a hypertensive population, the IV-DSRA does not accurately detect abnormalities of the kidney and its circulation. If these data are confirmed in nonhypertensive subjects, preoperative evaluation of LR kidney donors using IV-DSRA alone may fail to detect potentially important anatomic abnormalities.

Bismuth subsalicylate in the treatment of acute diarrhea in children: a clinical study.

Bismuth subsalicylate (BSS) and placebo were evaluated in a double-blind, placebo-controlled study as adjunct to rehydration therapy in 123 children, aged 4 to 28 months, hospitalized with acute diarrhea. The dosing regimen was 20 mg/kg five times daily for 5 days. Significant benefits were noted in the BSS group compared with placebo as manifested by decreases in stool frequency and stool weights and an improvement in stool consistency, significant improvement in clinical well-being, and shortening of the disease duration. Patients treated with BSS had a significant reduction in duration of hospital stay (6.9 days) compared with placebo-treated patients (8.5 days). Also, intravenous fluid requirements decreased significantly more rapidly and to a greater degree in the BSS-treated group. Bismuth subsalicylate was associated with clearance of pathogenic Escherichia coli from the stools in 100% of cases but was not different from placebo in rotavirus elimination. Bismuth subsalicylate was well tolerated with no reported adverse effects. Blood bismuth and serum salicylate levels were well below levels considered toxic. In this study, BSS provided effective adjunctive therapy for acute diarrhea, allowing children to get well sooner with less demand on the nursing and hospital staff.

Biliary cytodiagnosis. Bile sampling for cytology.

The records of 121 patients who presented for PTC and biliary drainage within a five-year period were reviewed. Fifty-eight bile samples had been obtained from 38 of these patients for cytologic analysis. Malignancy was detected in 14 of 32 patients with carcinoma (sensitivity 44%). Repeat sampling was positive in four of nine patients whose initial specimen contained no tumor cells. Bile duct carcinoma, pancreatic carcinoma, and metastatic disease were all detected. An approach to biliary cytodiagnosis is offered that, it is hoped, will further minimize future false negative results.

Infectious complications of percutaneous biliary drainage.

The infectious complications of percutaneous biliary drainage were reviewed in 132 patients with obstructive jaundice. Cholangitic or septic episodes occurred more frequently in patients with malignant (54%) than in those with benign (22%) disease, and frequently were not related to catheter insertions or manipulations. The frequency and mechanisms of bacterial colonization of bile and blood in patients with obstructive jaundice before and after biliary drainage are reviewed. The significant morbidity and mortality related to postdrainage infectious episodes is stressed, and the efficacy of antibiotic prophylaxis is discussed. The significant risks and complications of percutaneous biliary drainage must be considered prior to catheter placement, particularly in the most debilitated patients.

Pulmonary embolism.

Pulmonary embolism is a common medical problem whose incidence is likely to increase in our aging population. Although it is life-threatening, effective therapy exists. The treatment is not, however, without significant complications. Thus, accurate diagnosis is important. Unfortunately, the clinical manifestations of pulmonary embolism are nonspecific. Furthermore, in many patients the symptoms of an acute embolism are superimposed on underlying chronic heart or lung disease. Thus, a high index of suspicion is needed to identify pulmonary emboli. Laboratory parameters, including arterial oxygen tensions and electrocardiography, are as nonspecific as the clinical signs. They may be more useful in excluding another process than in diagnosing pulmonary embolism. The first radiologic examination is the chest radiograph, but the clinical symptoms are frequently out of proportion to the findings on the chest films. Classic manifestations of pulmonary embolism on the chest radiograph include a wedge-shaped peripheral opacity and a segmental or lobar diminution in vascularity with prominent central arteries. However, these findings are not commonly seen and, even when present, are not specific. Even less specific findings include cardiomegaly, pulmonary infiltrate, elevation of a hemidiaphragm, and pleural effusion. Many patients with pulmonary embolism may have a normal chest radiograph. The chest radiograph is essential, however, for two purposes. First, it may identify another cause of the patient's symptoms, such as a rib fracture, dissecting aortic aneurysm, or pneumothorax. Second, a chest radiograph is essential to interpretation of the radionuclide V/Q scan. The perfusion scan accurately reflects the perfusion of the lung. However, a perfusion defect may result from a variety of etiologies. Any process such as vascular stenosis or compression by tumor may restrict blood flow. In addition, areas of the lung that are not well ventilated will be poorly perfused. Thus, a ventilation scan and a chest radiograph are essential to optimal interpretation of the perfusion scan. Ventilation/perfusion scans are interpreted as degrees of probability of pulmonary embolism. Emboli are not present in patients with a normal V/Q scan. An embolus is unlikely (10%-15%) among patients with a low-probability V/Q scan. However, small emboli that are nonocclusive may be present, and pulmonary arteriography may be used to further evaluate patients with a high clinical suspicion of pulmonary embolus.(ABSTRACT TRUNCATED AT 400 WORDS)

Encapsulation of proteins and peptides in milkfat: encapsulation efficiency and temperature and freezing stabilities.

Encapsulation of aqueous protein solution was most efficient when the butter and protein solution emulsion was at 58 degrees C before dispersion into water, although encapsulation efficiencies were high between 46 and 66 degrees C. Capsules could be produced with no emulsifiers and an emulsion temperature of 66 degrees C but no capsules were formed when emulsion temperature was lowered to 38 degrees C. Capsules with encapsulated beta-casein peptides and with proteose peptone had similar low-temperature stabilities with a loss of about 10 per cent of the peptides after 24 h at 4 degrees C. However, capsules with beta-casein peptides were slightly more stable above 26 degrees C. Little diffusion of the haemoglobin from capsules occurred at less than 20 degrees C but above 32 degrees C capsules destabilized and the haemoglobin diffused out of the capsules. Capsules were stable after freezing at -90 degrees C and -18 degrees C and could be thawed and redispersed; a 15-25 per cent loss of capsules was observed during freezing. Concentrating capsules by removing all or one-half of the dispersion fluid did not increase stability to freezing.

Technique to facilitate percutaneous nephrostomy in non-obstructed kidneys.

A technique for performing antegrade pyelography during nephrotomy is described--puncture with a 21-gauge, 20-cm Cope needle, placement of a 0.018-inch SMG mandril "coat-hanger"-shaped guidewire, with the needle exchanged for a 3-French multi-sidehole dilator. Use of the 3-French dilator provides more security and less trauma to the renal pelvis; nephrotomy time is also curtailed. In 25 patients the technique was used successfully with 2 minor complications.

Intraarterial digital subtraction angiography in hypertensive azotemic patients.

Ten intraarterial digital subtraction angiography studies in nine azotemic patients were reviewed to assess the technical adequacy and the effect of contrast load on renal function. All studies were of diagnostic quality. In only two of 10 studies was there a mild transient deterioration in the degree of renal insufficiency. Intraarterial digital subtraction angiography is a reliable method that can be used to evaluate the renal arteries, even in the presence of azotemia.

Percutaneous transluminal angioplasty in diabetic patients: an effective treatment modality.

Percutaneous transluminal angioplasty (PTA) was performed for nonhealing ulcers, severe claudication, or rest pain in 10 patients with diabetes mellitus. Twenty-two atherosclerotic lesions were dilated in 15 extremities, including 16 iliofemoral arteries and 6 superficial femoral arteries. The procedure was technically successful in all patients and 8 of 9 (89%) with clinical follow-up showed improvement clinically after the procedure. Diabetes is not a contraindication to PTA; rather this modality can be used effectively to control and treat peripheral vascular insufficiency in diabetic patients.

CT assistance for fluoroscopically guided transthoracic needle aspiration biopsy.

Five cases are presented that illustrate the utility of obtaining limited CT prior to fluoroscopically guided biopsy in patients who have lung or mediastinal lesions that cannot be adequately localized by chest radiography. Each case describes a unique setting in which the CT images facilitate accurate and safe biopsy needle placement. The rare requirement for biopsy using CT alone, which can be considerably more time consuming, is emphasized.

Pulmonary arteriography in the high-risk patient.

Pulmonary arteriography is an invasive but relatively safe diagnostic procedure. It is generally believed that the presence of pulmonary hypertension is one risk factor that increases the likelihood of a major complication. To assess the magnitude of risk, the reports on 1,434 patients who underwent pulmonary arteriography were retrospectively reviewed, and the occurrence of complications in the 388 (27%) patients with pulmonary hypertension was noted. Major complications related to contrast material injection (excluding allergic reactions) occurred in 30 (2%) of the 1,434 examinations and included two deaths from acute cor pulmonale. Six complications occurred in the 388 patients with pulmonary hypertension and/or elevated right ventricular end-diastolic pressure (RVEDP). The two deaths occurred in patients with severe pulmonary hypertension and elevated RVEDP. Most patients with severe cardiopulmonary compromise tolerated angiography well. The increased risk of studying this group of patients is modest and must be weighed against the potential therapeutic benefits to the patient.

Intravenous digital subtraction angiography in the preoperative evaluation of renal masses.

Intravenous digital subtraction angiography (DSA) was performed in 23 patients with renal masses to document tumor extension into the main renal vein or inferior vena cava. The DSA findings were compared with computed tomographic as well as surgical and pathologic findings. Additional data regarding the number of renal arteries present and the relative vascularity of the tumor were also gathered. DSA documented 17 true-negative renal veins, three true-positive renal veins, and one false-negative renal vein. Two patients could not hold their breath long enough to evaluate the renal vein. In 17 of 19 cases, single renal arteries to the affected kidney were correctly identified. In three patients, two renal arteries to the involved kidney were correctly identified. The renal masses were avascular in two patients, hypovascular in five, moderately vascular in eight, and hypervascular in seven. In one case the mass was out of the field of view, and vascularity was not evaluated. In these patients, DSA was an accurate and relatively noninvasive method to assist in the preoperative evaluation of renal masses.