Pulmonary Langerhan's cell histocystosis presenting with bilateral simultaneous pneumothoraces - Case report.

We describe the case of a young male, with no significant medical history, who presented to the Emergency Department (ED) with severe respiratory compromise. He suffered a respiratory arrest shortly after presentation. An initial chest x-ray performed post intubation revealed bilateral pneumothoraces with evidence of abnormal underlying lungs. Through a series of investigations, he was diagnosed with Pulmonary Langerhans Cell Histocystosis. In this article, we outline the initial presentation, subsequent acute management and the clinical course pertaining to this man's presentation. We believe this is the first reported presentation of bilateral simultaneous pneumothoraces, with previously unknown Pulmonary Langerhans Cell histiocytosis (PLCH).

Inpatient Capacity Management during COVID-19 Pandemic: The Yale New Haven Hospital Capacity Expansion Experience.

The 2019 SARS-CoV2 virus presented a capacity demand scenario for Yale New Haven Hospital. The response was created with a focus on clinical needs, but was also driven by the unique characteristics of the buildings within our institution. These physical characteristics were considered in the response as a safety measure as little was known about the transmissibility risk in the acute hospital setting of SARS-CoV2 at the time of response. The lessons learned in capacity expansion to meet the potentially catastrophic demand for acute care services due to a novel, poorly understood pathogen are discussed here.

Cardiac MRI and CT features of inheritable and congenital conditions associated with sudden cardiac death.

Cardiac MRI (CMR) and electrocardiogram (ECG)-gated multi-detector computed tomography (MDCT) are increasingly important tools in the identification and assessment of cardiac-related disease processes, including those associated with sudden cardiac death (SCD). While the commonest cause of SCD is coronary artery disease (CAD), in patients under 35 years inheritable cardiomyopathies such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy are important aetiologies. CMR in particular offers both accurate delineation of the morphological abnormalities associated with these and other conditions and the possibility for risk stratification for development of ventricular arrhythmias with demonstration of macroscopic scar by delayed enhancement imaging with intravenous gadolinium.

CT and MR imaging findings in patients with acquired heart disease at risk for sudden cardiac death.

Noninvasive imaging is an important screening and diagnostic tool in conditions associated with sudden cardiac death. The most common cause of sudden cardiac death is coronary artery disease, with myocarditis, cardiac sarcoidosis, and dilated and infiltrative cardiomyopathies being less common acquired causes. Common risk factors for sudden cardiac death, regardless of the disease process, include severe ventricular dysfunction and the presence of macroscopic scar seen at delayed contrast material-enhanced imaging. Recent advances in electrocardiographically (ECG) gated cardiac magnetic resonance (MR) imaging and multidetector computed tomography (CT) have led to increased referrals for cross-sectional imaging; thus, cardiac radiologists should be familiar with the disease entities associated with sudden cardiac death. Inflammatory processes and cardiomyopathies are best depicted with cardiac MR imaging. Steady-state free precession cine sequences coupled with inversion-recovery prepared gradient-echo T1-weighted sequences performed after the intravenous administration of gadolinium-based contrast material should form the basis of cardiac MR imaging protocols for cardiomyopathy. A clinical history that is suggestive of myocardial ischemia, specific requests to exclude coronary artery disease, or contraindications for MR imaging may imply that multidetector CT would be more appropriate. Nevertheless, both cardiac MR imaging and ECG-gated multidetector CT offer robust diagnosis and risk stratification for individual disease processes associated with sudden cardiac death.

Coexistent sarcoidosis and lymphangioleiomyomatosis in a patient with cystic lung disease.

A 45-year-old lady presented acutely with pleuritic chest pain, haemoptysis, and dyspnoea. Her background was significant for a 1.4 cm renal angiomyolipoma, and she was an ex-smoker without any relevant family history. A computed tomography (CT) pulmonary angiogram was negative for a pulmonary embolism but demonstrated diffuse cystic change throughout both lungs. A bronchoscopy confirmed a normal endobronchial tree, and pulmonary function tests demonstrated moderate airways obstruction, with reversibility and a normal diffusion capacity for carbon monoxide (DLCO). A video-assisted thoracoscopic surgery (VATS) lung biopsy showed non-caseating granulomas, and serum angiotensin converting enzyme (ACE) was elevated consistent with a diagnosis of pulmonary sarcoidosis. Further sectioning indicated focal areas that stained positive for Human Melanoma Black 45 (HMB-45), confirming lymphangioleiomyomatosis (LAM). A diagnosis of cystic lung disease secondary to coexistent sarcoidosis and LAM was made.

Conversion of a Conference Room into a Low-Acuity Inpatient Medical Unit: A Creative Response to Influenza-Related Surge.

The 2017-2018 influenza season was associated with high demand for both emergency department (ED) care and inpatient acute care for influenza-like illness (ILI). This high demand resulted in increased numbers of inpatients and ED patients, including prolonged ED length of stay. A large, urban, academic medical center in a cold-weather region was limited in its ability to expand its footprint to create de novo locations of care, such as temporary outbuildings or tents. As such, a large conference room was rapidly converted and placed in service as a temporary inpatient unit for adults requiring inpatient admission. LOGISTICS AND IMPLEMENTATION: The logistical, infection prevention, safety, information technology, staffing, and other concerns of creating a clinical environment during a high demand scenario is challenging. However, the lessons learned in this study are reproducible despite the complexity of this issue. CONCLUSION: This is believed to be the first published account of successful conversion of a nonclinical area to an operational clinical unit in response to a surge in demand for hospital care and admission. This may be a valid option for hospitals of all sizes as part of a surge or disaster plan.

Renal cortical lesions in patients with autoimmune pancreatitis: a clue to differentiation from pancreatic malignancy.

AIM: To describe the occurrence of renal cortical lesions (RCLs) in patients with autoimmune pancreatitis (AIP). METHODS: This retrospective study was approved by our research ethics board; informed consent was waived. Systematic search of CT scan reports in 5-year interval yielded 17 patients with AIP (male:female; 11:6, age 18-80 years). A consecutive group of 22 patients with pancreatic adenocarcinoma was used as control (male:female; 10:12, age 42-76 years). The CT scans of the two groups were mixed and randomized. Two blinded radiologists independently reviewed the kidneys for the presence of wedge-shaped RCLs. Fisher's exact test was used to determine statistical significance. Consensus review of all imaging of positive patients with AIP and RCLs and three additional patients identified anecdotally was performed. RESULTS: Both readers independently identified the same 6/17 (35%) patients in the study group and 0/22 in the control group with two or more RCLs. This difference was statistically significant (p=0.004). The sensitivity, specificity, positive and negative predictive values of RCLs in the differentiation of AIP from pancreatic adenocarcinoma were 35%, 100%, 100%, and 67%, respectively. To the six AIP patients with RCLs, we added three more identified anecdotally. In 7/9, >5 RCLs were seen which were wedge-shaped and cortical-based, ranging from <1 to 4cm. Typical pancreatic findings of AIP were noted in all, with the gland affected focally in 5/9 patients. CONCLUSION: We have shown the presence of multiple renal cortical lesions which occur in approximately 35% of our AIP patient population.

Association of an Opioid Standard of Practice Intervention With Intravenous Opioid Exposure in Hospitalized Patients.

Importance: Opioids are commonly used to treat pain in hospitalized patients; however, intravenous administration carries an increased risk of adverse effects compared with oral administration. The subcutaneous route is an effective method of opioid delivery with favorable pharmacokinetics. Objective: To assess an intervention to reduce intravenous opioid use, total parenteral opioid exposure, and the rate of patients administered parenteral opioids. Design, Setting, and Participants: A pilot study was conducted in an adult general medical unit in an urban academic medical center. Attending physicians, nurse practitioners, and physician assistants who prescribed drugs were the participants. Use of opioids was compared between a 6-month control period and 3 months following education for the prescribers on opioid routes of administration. Interventions: Adoption of a local opioid standard of practice, preferring the oral and subcutaneous routes over intravenous administration, and education for prescribers and nursing staff on awareness of the subcutaneous route was implemented. Main Outcomes and Measures: The primary outcome was a reduction in intravenous doses administered per patient-day. Secondary measures included total parenteral and overall opioid doses per patient-day, parenteral and overall opioid exposure per patient-day, and daily rate of patients receiving parenteral opioids. Pain scores were measured on a standard 0- to 10-point Likert scale over the first 5 days of hospitalization. Results: The control period included 4500 patient-days, and the intervention period included 2459 patient-days. Of 127 patients in the intervention group, 59 (46.5%) were men; mean (SD) age was 57.6 (18.5) years. Intravenous opioid doses were reduced by 84% (0.06 vs 0.39 doses per patient-day, P < .001), and doses of all parenteral opioids were reduced by 55% (0.18 vs 0.39 doses per patient-day, P < .001). In addition, mean (SD) daily parenteral opioid exposure decreased by 49% (2.88 [0.72] vs 5.67 [1.14] morphine-milligram equivalents [MMEs] per patient-day). The daily rate of patients administered any parenteral opioid decreased by 57% (6% vs 14%; P < .001). Doses of opioids given by oral or parenteral route were reduced by 23% (0.73 vs 0.95 doses per patient-day, P = .02), and mean daily overall opioid exposure decreased by 31% (6.30 [4.12] vs 9.11 [7.34] MMEs per patient-day). For hospital days 1 through 3, there were no significant postintervention vs preintervention differences in mean reported pain score for patients receiving opioid therapy: day 1, -0.19 (95% CI, -0.94 to 0.56); day 2, -0.49 (95% CI, -1.01 to 0.03); and day 3, -0.54 (95% CI, -1.18 to 0.09). However, significant improvement was seen in the intervention group on days 4 (-1.07; 95% CI, -1.80 to -0.34) and 5 (-1.06; 95% CI, -1.84 to -0.27). Conclusions and Relevance: An intervention targeting the use of intravenous opioids may be associated with reduced opioid exposure while providing effective pain control to hospitalized adults.

Imaging features of sclerosed hemangioma.

OBJECTIVE: The purpose of this study was to review the imaging features of sclerosed hemangioma. CONCLUSION: In our series, suggestive features of sclerosed hemangiomas include geographic outline, capsular retraction, decrease in size over time, and loss of previously seen regions of enhancement. Additional features include presence of transient hepatic attenuation difference (THAD), rim enhancement, and nodular regions of intense enhancement as seen in typical hemangiomas. Although not pathognomonic, some features of sclerosed hemangioma can suggest it as a diagnostic possibility and lead to biopsy rather than more extensive intervention.

Subclinical bovine spongiform encephalopathy infection in transgenic mice expressing porcine prion protein.

The bovine-porcine species barrier to bovine spongiform encephalopathy (BSE) infection was explored by generating transgenic mouse lines expressing the porcine prion protein (PrP) gene. All of the porcine transgenic (poTg) mice showed clinical signs of BSE after intracerebral inoculation with a high-titer BSE inoculum. The protease-resistant PrP (PrP(res)) was detected in 14% (3 of 22) of the BSE-infected poTg mice by immunohistochemical or immunoblot analysis. Despite being able to infect 42% (5 of 12) of control mice, a low-dose BSE inoculum failed to penetrate the species barrier in our poTg mouse model. The findings of these infectivity studies suggest that there is a strong species barrier between cows and pigs. However, after second-passage infection of poTg mice using brain homogenates of BSE-inoculated mice scoring negative for the incoming prion protein as inoculum, it was possible to detect the presence of the infectious agent. Thus, porcine-adapted BSE inocula were efficient at infecting poTg mice, giving rise to an incubation period substantially reduced from 300 to 177 d after inoculation and to the presence of PrP(res) in 100% (21 of 21) of the mice. We were therefore able to conclude that initial exposure to the bovine prion may lead to subclinical infection such that brain homogenates from poTg mice classified as uninfected on the basis of the absence of PrP(res) are infectious when used to reinoculate poTg mice. Collectively, our findings suggest that these poTg mice could be used as a sensitive bioassay model for prion detection in pigs.

Increased fluoro-deoxy-D-glucose uptake on positron emission tomography-computed tomography postbronchoalveolar lavage: a potential cause of radiologic misinterpretation.

Cytologic analysis of bronchoalveolar lavage (BAL) fluid is used for lung cancer diagnosis. We describe a patient with a history of rectal carcinoma who presented with a new lung mass. BAL was performed, with positron emission tomography-computed tomography the following day. There was mildly increased fluoro-deoxy-D-glucose uptake in areas of the lung parenchyma with new ground-glass opacification. This created ambiguity in staging, clarified 2 weeks later by a computed tomography showing complete resolution of the ground-glass opacity. Clinicians should be aware that BAL may cause increased pulmonary fluoro-deoxy-D-glucose uptake, making accurate radiologic interpretation problematic. We suggest that to optimize positron emission tomography-computed tomography, studies should not be performed within 24 hours of BAL.

Abolition of respiratory-motion artifact in computed tomography coronary angiography with ultrafast examinations: a comparison between 64-row and 320-row multidetector scanners.

PURPOSE: To compare the incidence of respiratory artifact in computed tomography (CT) coronary angiography performed with 64-row and 320-row multidetector scanners and to assess its effect on coronary evaluability. METHODS: A retrospective review of consecutive coronary angiograms performed on a 64-row multidetector CT from March to April 2007 (group 1: 115 patients, 63 men; mean age [standard deviation] 59.6 +/- 12.8 years) and on a 320-row multidetector CT from March to April 2008 (group 2: 169 patients, 89 men; mean [SD] age 57.9 +/- 11.6 years). Two cardiac radiologists assessed the occurrence of respiratory artifact and coronary evaluability in studies with respiratory artifacts. Unevaluable coronary segments because of motion at the same anatomical level of the respiratory artifact were considered unevaluable because of this artifact. The association between the occurrence of respiratory artifact and patient biometrics, medication, and scan parameters was examined. RESULTS: Respiratory artifacts were detected in 9 of the 115 patients from group 1 (7.8%) and in none of the 169 patients from group 2 (P < .001). Group 1 had longer scan times (median, 9.3 seconds; range, 7.5-14.4 seconds) compared with group 2 (median, 1.5 seconds; range, 1.1-3.5 seconds; P < .001). In group 1, 4 patients (3.5%) showed unevaluable coronary segments because of respiratory artifacts, and the CT coronary angiography was repeated in 1 patient (0.9%). CONCLUSIONS: Respiratory artifacts are important in CT coronary angiography performed with 64-row multidetector scanners and impair the diagnostic utility of the examination in up to 3.5% of the studies. These artifacts can be virtually eliminated with a faster scan time provided by 320-row multidetector CT.

Value of the unenhanced phase for detection of hepatocellular carcinomas 3 cm or less when performing multiphase computed tomography in patients with cirrhosis.

OBJECTIVE: To determine whether unenhanced images are of added benefit to dual-phase computed tomography (CT) for detection of hepatocellular carcinomas (HCCs) 3 cm or less. METHODS: Thirty-six patients with cirrhosis underwent unenhanced, arterial and portal venous phase CT, 17 with pathologically proven HCCs 3 cm or less and 19 without HCC. Two radiologists reviewed dual-phase images with and without unenhanced images. Presence or absence of HCC in each segment (n = 324) and subjective added benefit of unenhanced images were recorded. RESULTS: For readers 1 and 2, unenhanced CT was subjectively helpful in 16 (5%) of 324 and 23 (7%) of 324 segments. Sensitivity and area under the receiver operating characteristic curve were identical for dual-phase versus triple-phase images for reader 1 (82.4% and 0.882) and reader 2 (100% and 0.997). CONCLUSIONS: Addition of unenhanced to dual-phase CT does not statistically significantly increase the diagnostic accuracy or sensitivity for HCCs 3 cm or less.