Imaging manifestations of IgG4-related disease.

IgG4-related disease is a multisystem immune-mediated disorder associated with lesions manifesting an IgG4-rich plasma cell infiltrate and often raised serum IgG4 concentrations. The disease can mimic neoplastic, infective, and inflammatory processes due to features such as development of masses or organ enlargement. Prompt consideration of this diagnosis is essential to avoid unnecessary investigations and offer appropriate treatments, which can include steroids and other immunosuppressive agents. Although histology is typically diagnostic, imaging is critical to assess disease burden, determine biopsy targets, and evaluate response to treatment. Characteristic imaging features can also point towards the diagnosis in the absence of biopsy. This review highlights these features, as well as more atypical findings, grouped by organ or system. Differential diagnoses are emphasised. The full spectrum of imaging methods is discussed. Whole-body imaging with integrated 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/computed tomography (CT) has an evolving role in the detection of multi-organ involvement and subsequent follow-up.

Provision of a "same-day" ultrasound service in an inner-city NHS trust: report on experience and lessons learned after the first 2 years.

AIM: To assess the effect of changing from an "appointment" to a "same-day" ultrasound (US) service on referral pattern, departmental workload, and patient satisfaction. MATERIALS AND METHODS: To reduce US waiting time of 3 weeks for routine examinations, a "same-day" service was started for outpatients and general practitioner (GP) patients in September 2006. To examine the effect of this change a retrospective assessment was performed of workload during 1 week in June 2006 (appointments only) and the same week in 2008, 22 months after the implementation of the new service. Distance travelled by patients and waiting time was recorded. Patient satisfaction with the service was assessed by questionnaire in September 2008. RESULTS: Hospital referrals remained stable, but GP referrals increased from 99 to 367 (270%) and distance travelled by patients increased from a median of 3.1 km (range 0.1-12.1 km) in 2006 to 4.8 km (range 0.2-19.8 km) in 2008 (p<0.001). Non-local GP referrals increased from 20/99 in 2006 (20%) to 198/367 in 2008 (54%). The increased workload was managed by flexible working by radiologists and two additional sonographers. Departmental waiting time increased for all patients with same-day patients waiting a median of 35 min (interquartile range 19-60 min). Ninety-one percent (79/87) of same-day patients rated the service excellent or good, but many requested better information on the waiting time. CONCLUSION: There is a demand from GPs for same-day US, and it is feasible in a large hospital with flexible radiology working and increased sonographic staffing. Unless adjacent hospitals offer a similar service, continuing rise in demand could overwhelm the service.

Observer accuracy in the detection of pulmonary nodules on CT: effect of cine frame rate.

AIM: To assess the effect of cine frame rate on the accuracy of the detection of pulmonary nodules at computed tomography (CT). MATERIALS AND METHODS: CT images of 15 consecutive patients with (n = 13) or without (n = 2) pulmonary metastases were identified. Initial assessment by two thoracic radiologists provided the "actual" or reference reading. Subsequently, 10 radiologists [board certified radiologists (n = 4) or radiology residents (n = 6)] used different fixed cine frame rates for nodule detection. Within-subjects analysis of variance (ANOVA) was used to evaluate the data. RESULTS: Eighty-nine nodules were identified by the thoracic radiologists (median 8, range 0-29 per patient; median diameter 9 mm, range 4-40 mm). There was a non-statistically significant trend to reduced accuracy at higher frame rates (p=0.113) with no statistically significant difference between experienced observers and residents (p = 0.79). CONCLUSION: The accuracy of pulmonary nodule detection at higher cine frame rates is reduced, unrelated to observer experience.

Perforation of gastrointestinal tract by poorly conspicuous ingested foreign bodies: radiological diagnosis.

Perforation of gastrointestinal (GI) tract by ingested bone fragments, toothpicks and dentures is rare but remains an important life-threatening condition, and the outcomes are poorer when the diagnosis is delayed. Invariably, clinical and radiographic diagnosis is difficult as most patients will have no recollection of ingesting a foreign body, whereas these subtle objects are often not visible on radiographs. In search for the diagnosis, CT is the modality of choice, but ultrasound imaging may be first requested in patients presenting with symptoms of acute appendicitis, cholecystitis, pyelonephritis or pelvic inflammatory disease when an ingested foreign body is not considered. Although ultrasound has limited value in depicting a foreign body, it can frequently uncover secondary signs of perforation. However, the rarity of this condition combined with non-specific clinical presentation and the propensity of these small perforating objects to be subtle makes establishing the correct diagnosis by the radiologist challenging. Therefore, understanding of the appearances of GI perforation seen on CT images or general abdominal ultrasound will aid the radiologist in the diagnosis of this important yet often unsuspected condition. This will lead to earlier diagnosis and surgical management. In this article, we illustrate the spectrum of CT, radiographic and ultrasound imaging features seen in GI perforation caused by swallowed bone fragments, toothpicks, cocktail sticks and dentures.

MR angiographic diagnosis of cerebral venous sinus thrombosis following allogeneic bone marrow transplantation.

Allogeneic bone marrow transplantation is frequently associated with neurological complications, particularly intracerebral bleeds and infections. Cerebral venous sinus thrombosis has only rarely been reported following allogeneic transplants. We report three cases of cortical venous thrombosis following allografting for acute lymphoblastic leukaemia. Two patients received marrow from HLA-identical siblings and one from an unrelated donor. Two of the patients presented with grand mal seizures and one presented with a headache. No neurological abnormalities were found upon clinical examination and lumbar puncture was normal in all three cases. In two of the patients computed tomography (CT) of the brain was normal and in the third showed non-specific abnormalities. Magnetic resonance imaging (MRI) with MR angiography (MRA) demonstrated cerebral venous sinus thrombosis in all three patients. In conclusion, cerebral venous sinus thrombosis should be considered in the differential diagnosis when neurological symptoms occur following allogeneic bone marrow transplantation. We therefore advocate the use of MRA for unexplained neurological symptoms post-allograft since without it cerebral venous sinus thrombosis may easily be missed.

The effects of maternal position and cardiac output on intrapulmonary shunt in normal third-trimester pregnancy.

OBJECTIVE: To assess the effect of pregnancy, maternal position, and cardiac output on intrapulmonary shunting (Qs/Qt) in normotensive nulliparous women near term. METHODS: Ten normotensive nulliparas between 36 and 38 weeks' gestation underwent pulmonary artery catheterization (via the subclavian route) and radial artery canalization. Baseline assessments were made with subjects in the left lateral recumbent position after a 30-minute stabilization period. Measurements were obtained sequentially in the left lateral, right lateral, supine, knee-chest, sitting, and standing positions. Each position change was followed by a 10-minute pre-measurement stabilization period. Cardiac output was measured via the thermodilution technique. Blood samples were obtained simultaneously from the pulmonary and radial arteries and analyzed in duplicate for oxygen content with a blood gas analyzer. Qs/Qt was calculated using the classic shunt equation. Statistical analysis was performed by analysis of variance of repeated measures of Qs/Qt and maternal position. The relationship of Qs/Qt to maternal cardiac output was evaluated by the correlation coefficient. Significance was defined as P < .05. RESULTS: Directly measured Qs/Qt averaged 15.3% in left lateral, 15.2% in right lateral, 13.9% in supine, 12.8% in knee-chest, 13.8% in sitting, and 13.0% in standing positions. There was no statistically significant correlation between Qs/Qt and cardiac output (R2 = 0.11, not significant). CONCLUSION: This is the first report of directly measured Qs/Qt in normal pregnant women in the third trimester. Qs/Qt values reported in pregnancy are higher than those reported in nonpregnant individuals.

Third-trimester arterial blood gas and acid base values in normal pregnancy at moderate altitude.

OBJECTIVE: To report arterial blood gas and acid base values of normal nulliparous patients at moderate altitude for commonly used maternal positions. METHODS: Ten normotensive nulliparous women between 36 and 38 weeks' gestation volunteered to undergo radial and pulmonary artery cannulation as part of a larger study. Following instrumentation, baseline assessments were made in the left lateral recumbent position after a 30-minute stabilization period. Sequential measurements were then obtained in the left lateral, right lateral, supine, knee-chest, sitting, and standing positions. Blood samples were analyzed in duplicate for oxygen content on a blood gas analyzer. Statistical analysis was performed by analysis of variance of repeated measures with significance defined at P < or = .05. RESULTS: There was no significant difference in arterial blood gas or acid base values between any positions in this antepartum population of term healthy women. The composite mean values were as follows: pH 7.46, arterial carbon dioxide pressure (PaCO2) 26.6 mmHg, arterial oxygen pressure 88.3 mmHg, bicarbonate 18.2 mEq/L, saturated arterial hemoglobin level 0.96. CONCLUSION: Arterial blood gas and acid base values are not altered by maternal position in the late third trimester of pregnancy. The PaO2 in these women studied at moderate altitude was lower than previously reported for healthy pregnant women studied at sea level. Appropriate interpretation of arterial blood specimens of pregnant women should take into account both the pregnancy and altitude at which the women reside.

Serial measurements of serum creatine kinase are of most use in the exclusion of acute myocardial infarction in patients with a history of heart disease.

Rapid sequential measurements of serum CK were assessed in the diagnosis and exclusion of acute myocardial infarction (MI) in 94 patients presenting to St Thomas' Hospital, London, with acute chest pain of less than 12 h duration. A blood sample was taken from patients on admission to hospital and then a second sample was taken within 12 h of admission. Serum CK activity was assayed on both samples and delta log10 (serum CK) per hour calculated to distinguish infarct from non-infarct using a discriminant value of 0.015. Ninety-six per cent of patients with acute MI were diagnosed on the basis of clinical history and electrocardiographic evidence alone, and did not require biochemical confirmation. Serial estimation of serum CK contributed positively towards the exclusion of acute MI in 77% of patients who presented with chest pain and who had a previous history of heart disease, but towards only 11% of cases in the absence of a history of heart disease.

Sagittal vertebral body fractures: magnetic resonance imaging features.

Isolated sagittal vertebral body fractures are rare and the plain radiographic diagnosis may be difficult. We report two cases, confirmed by CT, and describe the subtle MRI features which comprised increased signal intensity only on the midline sagittal T2 weighted images. In one case, the information from MRI significantly altered the patient's management by leading to a change from surgical to conservative treatment.

Functional renal perfusion imaging with colour mapping: is it a useful adjunct to spiral CT of in the assessment of abdominal aortic aneurysm (AAA)?

AIM: To ensure optimal timing with pre-operative spiral CT for abdominal aortic aneurysms (AAA), an initial 'timing' single level CT is commonly performed with a small bolus of contrast. This can be exploited to obtain adjunct functional information on renal perfusion. We have investigated the potential of this to measure renal perfusion, to produce colour renal perfusion maps and to predict surgical outcome in infrarenal aortic aneurysm assessment. METHODS: We studied 21 patients being assessed for repair of infrarenal AAA. Prior to the spiral CT, a single level through the renal hili and aorta was scanned after the intravenous injection of 25 ml of contrast given at 10 ml/s. Ten 1 s duration scans were performed from 8 to 30 s after injection. Optimal timing for CT angiography can then be determined. Time-density curves were then drawn for both kidneys and aorta using regions of interest (ROIs) or pixel-by-pixel analysis. Renal cortical perfusion was measured using both ROI analysis and pseudocolour perfusion images. Following previous work, perfusion was calculated as the peak upslope of the tissue time density curve divided by peak aortic enhancement. RESULTS: Cortical mean perfusion averaged 2.48 ml/min per ml (range 0.8-3.7 ml/min per ml n = 34) and the values obtained agreed with literature expectations. Follow up in the 10 patients proceeding to AAA repair suggest low mean perfusion values and predict a raised postoperative creatinine (P < 0.05) CONCLUSIONS: Additional functional data and imaging can be obtained from the initial timing scan of a CT study, without requiring a dedicated study.

Are there indications for partial rib resection in patients with adolescent idiopathic scoliosis treated with Cotrel-Dubousset instrumentation?

In adolescent idiopathic scoliosis the cosmetically unacceptable rib prominence is one of the main reasons patients seek treatment. Ninety-eight patients were reviewed with Cotrel-Dubousset (CD) instrumentation (average follow-up, 27 months; average preoperative curve, 53 degrees) and 27 patients with Harrington instrumentation and rib resection (average follow-up, 43 months; average preoperative curve, 52 degrees). Of the 98 patients who had CD instrumentation, 15 underwent concomitant rib resection. Of the 83 patients without rib resection, 71 (72%) were rated satisfactory and 12 unsatisfactory by cosmetic criteria based on residual rib deformity. These results were compared to those of 27 patients receiving Harrington rod instrumentation and rib resection, of whom 23 (85%) were rated as satisfactory. All 15 patients with CD and rib resection were rated satisfactory. The CD patients were then redivided into two groups (rib resection indicated or rib resection not indicated) as follows: the 12 unsatisfactory CD patients without rib resection (in whom a rib resection should have been done) were grouped with the 15 CD patients who underwent rib resection, for a total of 27 rib resections indicated, or 28%. This group was compared to the 71 satisfactory CD patients without rib resection (rib resection not indicated). Patients with a rib prominence of > 15 degrees preoperatively had or should have had a rib resection. Patients with a higher chance of needing rib resection included those with a curve severity greater than 60 degrees, curve flexibility less than 20%, a preoperative rib prominence > 10 degrees, or intraoperative curve correction of less than 50%.

The efficacy of intrapartum fetal surveillance when fetal pulse oximetry is added to cardiotocography.

OBJECTIVE: To determine if oxygen saturation measurement with pulse oximetry (SpO2) in combination with cardiotocograghy (CTG), improves the assessment of the intrapartum fetal condition. STUDY DESIGN: Four expert obstetricians individually evaluated 119 cases that were monitored during labor: during the first session the CTG data were available, and in the second session CTG and SpO2 data were evaluated. They were instructed to indicate the need for intervention and to estimate the umbilical artery pH. RESULTS: In the non-acidotic group (umbilical artery pH > or = 7.15, n = 112) the average(+/-S.D.) number of interventions decreased from 27(+/-17) to 16(+/-9) when SpO2 was available. This reduction in number of interventions resulted in an significantly increased specificity for two referees. In the acidotic group (n = 7) the average number of interventions also decreased, from 6(+/-2) to 4(+/-2), and as a consequence the sensitivity decreased. The pH estimate based on CTG + SpO2 was higher in both acidotic and non-acidotic fetuses than the estimated pH based on CTG alone. CONCLUSION: In this study all referees intervened less frequently when SpO2 was used as an adjunct to CTG. This resulted in fewer unnecessary operative interventions, but may also lead to unidentified fetal acidosis. The number of acidotic newborns (n = 7) was too small, however, to draw definite conclusions. Larger studies should address the efficacy of SpO2 in detecting fetal compromise before clinical use can be advocated.

An uncommon intestinal manifestation of feline infectious peritonitis: 26 cases (1986-1993).

OBJECTIVE: To provide information on an uncommon intestinal manifestation of feline infectious peritonitis (FIP). DESIGN: Retrospective case series. ANIMALS: 26 cats with FIP that had apparently solitary mural intestinal lesions. PROCEDURE: Histologic records of cats for which FIP had been diagnosed by examination of the surgical biopsy specimens were reviewed. Slides of tissue samples from cats identified in the histologic record as having had intestinal lesions were reviewed by the investigators, and records of cats that appeared to have had solitary mural intestinal lesions were included in the study. Information including signalment; history; physical examination findings; results of hematologic, serum biochemical, and serologic analyses; findings at surgery; and results of histologic examination of biopsy specimens were retrieved from these records and supplemented by medical records and additional information obtained from veterinarians submitting the biopsy samples. ABC immunoperoxidase staining was used to detect FIP virus antigen in tissues from cats whose records were selected for inclusion in the study. RESULTS: 26 of 156 cats with a histologic diagnosis of FIP had apparently solitary mural intestinal lesions. Predominant clinical signs were diarrhea and vomiting for 3 months or less before biopsy. All cats had a mass, believed to be a neoplasm, in the colon or ileocecocolic junction. Affected intestine was markedly thickened, nodular, firm, and white, with multifocal pyogranulomas extending throughout the wall of the intestine on histologic examination. Associated lymph nodes were large. Results of immunohistochemical staining were positive for FIP virus. Most cats were euthanatized or died within 9 months of histologic results, many with signs of multisystemic FIP. CLINICAL IMPLICATIONS: The apparent focal nature of intestinal lesions at surgery leads to a different clinical picture than usually seen with FIP, and masses often are believed to be neoplasms. Diagnosis of FIP is important to prevent exposure and infection of other cats. Evaluation of the entire abdominal cavity, biopsy of visible lesions as well as surrounding organs, and postmortem examination are recommended.

Management of the intrapartum patient in the intensive care unit: preparing for delivery.

Caring for a critically ill obstetric patient requires a thorough understanding of both the pathophysiology of the disease and the physiologic changes that accompany pregnancy and childbirth. This article addresses the care of an intrapartum patient in an intensive care unit. Physiologic aspects of the labor and delivery process are reviewed with emphasis on nursing assessments and interventions. Additionally, techniques for delivery of the neonate are presented.

Pregnancy-induced hypertension: understanding severe preeclampsia and the HELLP syndrome.

Pregnancy-induced hypertension (PIH) is a multisystem disease with life-threatening complications requiring expert nursing and medical management. Nurses caring for critically ill patients with this disease must be knowledgeable about the pathophysiologic occurrences of PIH as well as the protocols for anticonvulsant and antihypertensive therapy. This article presents the hemodynamic alterations of preeclampsia, the pathophysiology of the disease, and principles of acute management.

Aeromedical transfer of preterm labor patients.

Obstetric patients are transported by air quite frequently. We evaluated transport times, obstetric outcomes, air-versus-ground transport costs, and related data on 22 helicopter aeromedical transports of pregnant patients with preterm labor. We found no significant differences between patients who delivered and those who did not when comparing transport time (167.1 +/- 41.9 minutes versus 177.1 +/- 56.2 minutes), air distance of transport (122.9 +/- 44.8 miles versus 143.6 +/- 23.8 miles), and other outcome measures. No deliveries occurred in flight. Air transport costs were significantly greater than estimated ground transfer ($4613.64 +/- $581.12 versus $604.02 +/- $306.38; P < .01). Two-way air transfer of preterm labor patients over moderate distances is more costly than contracted ground transfer costs at our institution.

Ultrasound detection of colonic polyps: perspective.

Colorectal cancer is often preventable if the precursor adenoma is detected and removed. Although ultrasound is clearly not one of the widely accepted screening techniques, this non-invasive and radiation-free modality is also capable of detecting colonic polyps, both benign and malignant. Such colon lesions may be encountered when not expected, usually during general abdominal sonography. The discovery of large colonic polyps is important and can potentially help reduce the incidence of a common cancer, whereas detection of a malignant polyp at an early stage may result in a curative intervention. This pictorial review highlights our experience of sonographic detection of colonic polyps in 43 adult patients encountered at our institutions over a 2-year period. 4 out of 50 discovered polyps were found to be malignant lesions, 3 polyps were hyperplastic, 1 polyp was a hamartomatous polyp and the rest were benign adenomas. The smallest of the detected polyps was 1.3 cm in diameter, the largest one was 4.0 cm (mean 1.7 cm; median 1.6 cm). In each case, polyps were discovered during a routine abdominal or pelvic examination, particularly when scanning was supplemented by a brief focused sonographic inspection of the colon with a 6-10 MHz linear transducer. In this paper, we illustrate the key sonographic features of different types of commonly encountered colonic polyps in the hope of encouraging more observers to detect these lesions, which may be subtle.

Applications of transrectal ultrasound in prostate cancer.

Transrectal ultrasound (TRUS) was first developed in the 1970s. TRUS-guided biopsy, under local anaesthetic and prophylactic antibiotics, is now the most widely accepted method to diagnose prostate cancer. However, the sensitivity and specificity of greyscale TRUS in the detection of prostate cancer is low. Prostate cancer most commonly appears as a hypoechoic focal lesion in the peripheral zone on TRUS but the appearances are variable with considerable overlap with benign lesions. Because of the low accuracy of greyscale TRUS, TRUS-guided biopsies have become established in the acquisition of systematic biopsies from standard locations. The number of systematic biopsies has increased over the years, with 10-12 cores currently accepted as the minimum standard. This article describes the technique of TRUS and biopsy and its complications. Novel modalities including contrast-enhanced modes and elastography as well as fusion techniques for increasing the sensitivity of TRUS-guided prostate-targeted biopsies are discussed along with their role in the diagnosis and management of prostate cancer.