Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department.

PURPOSE: We analyzed the efficacy of a point-of-care ultrasonographic protocol, based on a focused multiorgan examination, for the diagnostic process of symptomatic, non-traumatic hypotensive patients in the emergency department. METHODS: We prospectively enrolled 108 adult patients complaining of non-traumatic symptomatic hypotension of uncertain etiology. Patients received immediate point-of-care ultrasonography to determine cardiac function and right/left ventricle diameter rate, inferior vena cava diameter and collapsibility, pulmonary congestion, consolidations and sliding, abdominal free fluid and aortic aneurysm, and leg vein thrombosis. The organ-oriented diagnoses were combined to formulate an ultrasonographic hypothesis of the cause of hemodynamic instability. The ultrasonographic diagnosis was then compared with a final clinical diagnosis obtained by agreement of three independent expert physicians who performed a retrospective hospital chart review of each case. RESULTS: Considering the whole population, concordance between the point-of-care ultrasonography diagnosis and the final clinical diagnosis was interpreted as good, with Cohen's k = 0.710 (95 % CI, 0.614-0.806), p < 0.0001 and raw agreement (Ra) = 0.768. By eliminating the 13 cases where the final clinical diagnosis was not agreed upon (indefinite), the concordance increased to almost perfect, with k = 0.971 (95 % CI, 0.932-1.000), p < 0.0001 and Ra = 0.978. CONCLUSIONS: Emergency diagnostic judgments guided by point-of-care multiorgan ultrasonography in patients presenting with undifferentiated hypotension significantly agreed with a final clinical diagnosis obtained by retrospective chart review. The integration of an ultrasonographic multiorgan protocol in the diagnostic process of undifferentiated hypotension has great potential in guiding the first-line therapeutic approach.

Lung ultrasound in diagnosing and monitoring pulmonary interstitial fluid.

Chronic heart failure is a complex clinical syndrome often characterised by recurrent episodes of acute decompensation. This is acknowledged as a major public health problem, leading to a steadily increasing number of hospitalisations in developed countries. In decompensated heart failure, the redistribution of fluids into the pulmonary vascular bed leads to respiratory failure, a common cause of presentation to the emergency department. The ability to diagnose, quantify and monitor pulmonary congestion is particularly important in managing the disease. Lung ultrasound (US) is a relatively new method that has gained a growing acceptance as a bedside diagnostic tool to assess pulmonary interstitial fluid and alveolar oedema. The latest developments in lung US are not because of technological advance but are based on new applications and discovering the meanings of specific sonographic artefacts designated as B-lines. Real-time sonography of the lung targeted to detection of B-lines allows bedside diagnosis of respiratory failure due to impairment of cardiac function, as well as quantification and monitoring of pulmonary interstitial fluid. Lung US saves time and cost, provides immediate information to the clinician and relies on very easy-to-acquire and highly reproducible data.

Diffuse neoplasms of the pleural serosa.

This study describes the diffuse neoplastic conditions that may affect pleural membranes. These include mesothelioma, the most important and common malignancy of pleural origin, and metastatic involvement by carcinomas, lymphomas and thymomas. On the basis of diagnostic imaging, we identify the distinctive features of pleural involvement by each of these conditions and provide elements enabling accurate differential diagnosis. Finally, we discuss the best diagnostic approach in the case of suspected primary or secondary neoplastic involvement of pleural membranes.

Metallic staples line mimicking a retained surgical sponge.

The inadvertent loss of surgical sponges remains a dreadful hazard of surgery. We report the case of a patient with a medical history of myotonic dystrophy type 1 who had received a right upper lobectomy for the treatment of a stage IIA (pT1N1M0) well differentiated neuroendocrine carcinoma. In the early postoperative period, aspiration of gastric contents occurred and the patient underwent endotracheal intubation and mechanical ventilation. A follow-up multi-detector computed tomography (MDCT) scan of the chest showed a complex mass in interlobar position with an internal radiopaque serpiginous thread of metallic density which was assumed to represent a retained surgical sponge. Upon surgical exploration, no retained foreign body was found and a zone of recent hemorrhagic infarction, bordered by the line of the mechanical staples used to complete the minor fissure, was removed from the middle lobe. When evaluating patients suspected of having a retained surgical sponge, thoracic surgeons and radiologists should be aware of this potential source of confusion.

Clinical application of lung ultrasound in patients with acute dyspnea: differential diagnosis between cardiogenic and pulmonary causes.

This review discusses the usefulness of bedside lung ultrasound in the diagnostic distinction between the various causes of acute dyspnoea in the emergency department, with special attention to the differential diagnosis of pulmonary oedema and exacerbation of chronic obstructive pulmonary disease (COPD). This is made possible by using mid- to low-end scanners and simple acquisition techniques accessible to both radiologists and clinicians. Major advantages include ready availability at the bedside, the absence of ionising radiation, high reproducibility and cost efficiency. The technique is based on the recognition and analysis of sonographic artefacts rather than direct visualisation of the pulmonary structures. These artefacts are caused by the interaction of water-rich structures and air, called comet tails or B-lines. When such artefacts are widely detected on anterolateral transthoracic lung scans, diffuse alveolar-interstitial syndrome can be diagnosed, which is often a sign of acute pulmonary oedema. This condition rules out exacerbation of COPD as the main cause of acute dyspnoea.

The pulmonary nodule: clinical and radiological characteristics affecting a diagnosis of malignancy.

The role of computed tomography (CT) in the diagnosis of the solitary pulmonary nodule (SPN) is constantly expanding. CT helps to detect a growing number of increasingly small lesions, but, as with chest radiography, the primary goal in the evaluation of small pulmonary nodules is to exclude malignancy. Despite the availability of numerous, variously invasive, diagnostic tests, diagnostic accuracy tends to decline as the size of the nodule decreases. The role of the radiologist is therefore to help the clinician determine the most appropriate management strategy by using all available modalities [CT, magnetic resonance (MR) imaging, positron emission tomography (PET)] and evaluating the patient's clinical history and the imaging features leading to a diagnosis of benignity or malignancy. Imaging features include nodule size, margins, calcifications and fatty component, internal features (cavitations, pseudocavitations, air bronchogram, halo sign), as well as advanced techniques for characterisation (growth rate, contrast enhancement) and management (computer-aided diagnosis, Bayesian analysis, neural networks). The aim of this paper is to summarise the approach to pulmonary nodules from the point of view of the radiologist, oncologist and thoracic surgeon.

Solitary fibrous tumor of the lung: three rare cases of intraparenchymal nodules.

Solitary fibrous tumor (SFT) of the pleura usually presents as a peripheral mass, in contact with the surface of the pleura. However, on occasion, it can occur separately from the pleura, in the lung parenchyma. We describe the radiological and imaging features of three SFTs of the lung, diagnosed in our department, with relevant clinical data. The diagnosis of SFT of the lung, although rare, should be considered in a slow-growing solitary lung parenchymal nodule.

Fibrous tumour of the pleura (SFTP): a proteiform disease. Clinical, histological and atypical radiological patterns selected among our cases.

First described by Klemperer and Rabin in 1931, solitary fibrous tumour of the pleura (SFTP) is a mesenchymal tumour that tends to involve the pleura, although it has also been described in other thoracic areas (mediastinum, pericardium and pulmonary parenchyma) and in extrathoracic sites (meninges, epiglottis, salivary glands, thyroid, kidneys and breast). SFTP usually presents as a peripheral mass abutting the pleural surface, to which it is attached by a broad base or, more frequently, by a pedicle that allows it to be mobile within the pleural cavity. A precise preoperative diagnosis can be arrived at with a cutting-needle biopsy, although most cases are diagnosed with postoperative histology and immunohistochemical analysis of the dissected sample. SFTP, owing to its large size or unusual locations (paraspinal, para-mediastinal, intra-fissural and intraparenchymal), can pose interpretation problems or, indeed, point towards a diagnosis of diseases of a totally different nature. We present some unusual radiographic and computed tomography (CT) images of large SFTP or SFTP located in atypical thoracic locations in patients who underwent surgical resection.

Bronchogenic cysts in the adult: diagnostic criteria derived from the correct use of standard radiography and computed tomography.

PURPOSE: This study was undertaken to identify the radiographic and computed tomography patterns allowing a diagnosis of bronchogenic cyst. MATERIALS AND METHODS: We retrospectively reviewed chest radiographs and CT scans of 21 adults (ten men and 11 women, age range 18-74 years) with a histologically confirmed diagnosis of bronchogenic cyst. RESULTS: Sixteen cysts were located in the mediastinum and five in the lungs. On chest radiography, mediastinal cysts appeared as sharply marginated rounded areas of increased opacity; intrapulmonary cysts also exhibited an air-fluid interface. CT confirmed these morphological features in all cases. In addition, analysis of attenuation values allowed the subdivision of mediastinal cysts into three groups: fluid density (four cases), air density (two cases) and soft-tissue density (ten cases). CONCLUSIONS: All bronchogenic cysts were visualised on chest radiography, but the findings were nonspecific and required further characterisation by CT. The CT findings proved to be diagnostic when cystic attenuation values were evident. When soft-tissue attenuation values were demonstrated, a confident diagnosis was not possible, and other solid lesions had to be considered. In such cases, magnetic resonance imaging may be helpful to ascertain the cystic nature of the lesions.

CT features of solitary fibrous tumour of the pleura: experience in 26 patients.

PURPOSE: The purpose of this study was to identify the typical computed tomography (CT) features of solitary fibrous tumours of the pleura (SFTP) and determine which findings would allow confirmation of the pleural origin or benign behaviour of the tumour. MATERIALS AND METHODS: Twenty-six preoperative CT studies of the chest (23 enhanced and 14 unenhanced) were retrospectively reviewed. RESULTS: Up to 50% of SFTP were larger than 10 cm. At unenhanced CT, they showed homogeneous attenuation in 5 cases (35.7%) and inhomogeneous attenuation in 9 (64.3%). At contrast-enhanced CT, they were inhomogeneous in 21 cases (91.3%), with geographic pattern (61.9% of cases), serpiginous linear areas of enhancement (intralesional vessels) (23.8%), rounded (52.4%) or linear (33.3%) areas of low attenuation (necrosis). CONCLUSIONS: Depending on location, size and histological features, SFTP may produce a large spectrum of findings. Typical CT features of small SFTP were well-defined margins and smooth contours, homogeneous attenuation and right or obtuse angles with the pleura. Larger lesions were characterised by well-defined margins and lobulated contours, geographic pattern in enhanced CT scans, acute angles or smooth tapering margins with the pleura.

The anterior mediastinum: anatomy and imaging procedures.

The mediastinum is divided into compartments (anterior, middle, posterior) on the basis of lateral chest radiographs. Several anatomical and radiological classifications of the mediastinum are reported in the literature. Most mediastinal abnormalities are initially suspected following chest radiography; the need for further investigation and the most appropriate imaging modality are largely dictated by the tentative diagnosis made on this examination. Although routine chest radiography initiates the evaluation of mediastinal disorders, it is rarely diagnostic: notable exceptions are teeth or bones within a mass, which are diagnostic of a teratoma; air/fluid levels suggest an oesophageal origin, hernia, cyst, or abscess. Chest radiography is followed by spiral computed tomography (sCT). However, even sCT with contrast material is occasionally diagnostic (a confident diagnosis can be made of some lesions such as mature teratoma and mediastinal goiter) but is usually sufficient for preoperative evaluation before mediastinotomy or mediastinoscopy: it is instrumental in planning further diagnostic workup. In certain cases, magnetic resonance imaging (MRI) may be complementary to sCT, but its use is not considered routine. Besides, although the anterior mediastinum is suitable for sonographic examination, the diagnostic value of ultrasonography has not been fully exploited. Thyroid scanning with radioactive iodine is useful in identifying and evaluating masses of suspected thyroid origin. The role of fluorodeoxyglucose positron emission tomography (FDG-PET) in mediastinal diseases continues to be evaluated: it has potential for differentiating between benign and malignant disease and is expected to play a more extensive role in the imaging of mediastinal neoplasms in the future. In this paper, the radiological features of masses located in the anterior mediastinum are discussed, with particular reference to radiographic and CT patterns useful to the clinician's everyday practice.

The anterior mediastinum: diseases.

Mediastinal tumours are frequently asymptomatic and first noted on routine chest radiograph. In most cases, evaluation should proceed to spiral computed tomography (sCT) of the chest with iodinated contrast material. The specific location and appearance of tumours on sCT is instrumental in planning further diagnostic and treatment strategies. Primary tumours in the anterior mediastinum account for half of all mediastinal masses. They comprise various benign and malignant neoplasms, but a wide variety of nonneoplastic lesions (developmental, inflammatory) can present as a localised mass in this compartment. The most common primary anterior mediastinal tumours are thymoma, teratoma and lymphoma; all other lesions are rare. Nonneoplastic conditions include thymic cysts, lymphangioma and intrathoracic goitre. Understanding the pathology, clinical presentation, imaging and diagnosis of the major tumour types is instrumental in the safe and efficient work-up of a mediastinal mass. Patients with primary mediastinal masses and cysts will usually undergo surgical resection; radiological and clinical features should prompt limited biopsy specimens followed by oncologic consultation, and chemotherapy or radiotherapy when appropriate. The objective of this review was to examine the role of diagnostic imaging in the management of masses of the anterior mediastinum.

Three-year findings of an early lung cancer detection feasibility study with low-dose spiral computed tomography in heavy smokers.

BACKGROUND: Low-dose spiral computed tomography (sCT) showed a four-fold increase in the detection rate in high-risk subjects and a higher percentage of stage I lung cancer in comparison with chest X-ray. However, there is a considerable discrepancy among studies in the percentage of lung nodules, overall lung cancer and stage I detection rate. SUBJECTS AND METHODS: From April to December 2001, 520 asymptomatic volunteers aged >or=55 years with a history of cigarette smoking >or=20 pack-years and no previous cancer were enrolled to receive an annual sCT of the chest for five consecutive years. RESULTS: Seventy three per cent were male, median age was 59 years and 91% were current smokers. At baseline, nodules >or=5 mm were detected in 114 (22%) undergoing sCT; the size of lung nodules ranged from 5 to 9.9 mm in 81.5% of the cases. Five (1%) cases of lung cancer were detected. In two additional cases a pathological diagnosis of atypical adenomatous hyperplasia was made. Three new cases of lung cancer were detected in the second and third year of the study. One interval case was detected during the third year. CONCLUSIONS: Despite some promising data, convincing evidence from ongoing randomized trials is needed to support the routine use of sCT as a recommended tool for screening of lung cancer.