Thoracic Complications of Liver-Directed Therapy and Interventions.

ABSTRACT: Liver-directed percutaneous and endovascular therapies are effective methods to diagnose and treat various hepatic disorders and malignancies. Because of the close anatomic proximity of the liver to the right hemidiaphragm, pleura, and lung bases, complications can arise involving these structures. Although they are rare, awareness of intrathoracic complications associated with liver-directed therapies and their imaging features will ensure timely detection and management. We aim to review the clinical and imaging features of thoracic complications related to liver-directed therapy and interventions.

The Relationship Between Anti-SSA-52 and Interstitial Lung Disease.

OBJECTIVE: The aims of this study were to assess whether a relationship between anti-SSA-52 and interstitial lung disease (ILD) can be further defined, and to enhance screening, detection, and potentially guide treatment. METHODS: A historical cohort study of 201 patients was conducted at a single tertiary care center between January 1, 2016 and December 31, 2020. All included patients were anti-SSA-52 antibody positive. Chart review was performed for laboratory values, symptoms, pulmonary function tests, treatment, and imaging. Chest computed tomographies were reviewed by chest radiologists. RESULTS: Among anti-SSA-52 antibody-positive patients, ILD was found in 125 (62.2%) compared with 76 (37.8%) with no ILD (p = 0.001). For those with ILD, 78 (62.4%) were diagnosed with connective tissue disease (CTD)-associated ILD, 28 (22.4%) were diagnosed ILD only, and 19 (15.2%) met the criteria for interstitial pneumonia with autoimmune features. In patients with CTD-ILD, 18 (23.0%) had their ILD diagnosis made over 6 months before a CTD diagnosis, and an additional 43 (55.1%) had their ILD and CTD diagnosed within 6 months of each other (p < 0.001). Common computed tomography patterns were nonspecific interstitial pneumonia/organizing pneumonia overlap in 44 (35.2%), 25 (20.0%) nonspecific interstitial pneumonia, and 15 (12%) usual interstitial pneumonia. Twenty-eight (35.9%) had antisynthetase syndrome, followed by 16 (20.5%) with dermatomyositis, 10 (12.8%) with CTD overlap, and 6 (7.7%) with systemic scleroderma. CONCLUSIONS: There was a significant association between anti-SSA-52 antibodies and ILD across a wide spectrum of rheumatological diagnoses. A significant portion of patients were diagnosed with ILD either at the same time or before their CTD diagnosis. Further study will be needed to assess effective treatment and response.

Age Under 30 Years As a Predictor of Poor Survival in a Cohort of Mexican Women With Breast Cancer.

INTRODUCTION: Young women under 30 years with breast cancer (BC) are an emerging challenge. The purpose is to identify prognostic factors for survival in young women under 30 years of age with BC. MATERIAL AND METHODS: A retrospective cohort study was conducted among women younger than or equal to 40 years with BC and who were treated at the State Cancer Center during the period 2012-2017. Overall survival was assessed using the Kaplan-Meier method and the log-rank test. Univariate and multivariate analysis assessed survival predictors using Cox proportional hazards regression model. RESULTS: 282 young women were included. The >30-year-old subgroup showed a significant association with excess weight (P = .002) compared to the <30-year-old group. The <30-year-old subgroup showed a poor overall survival (56.7%), as well as highly significant values in advanced clinical stages, metastatic nodules, metastasis, and neoadjuvant therapy (P < .001). In Model 3 of the multivariate analysis, age <30 years (HR = 3.0; 95% CI 1.1 to 8.6), triple negative subtype (HR = 2.6; 95% CI 1.1 to 6.0), tumor size >5 cm HR = 2.3; 95% CI 1.03 to 5.1), and advanced clinical stages (HR = 6.6 95% CI 1.3 to 35.5) persisted as predictors. CONCLUSIONS: Being very young (<30 years) is a predictor for limited survival compared to the age of 30-40 years, as well as the tumor covariates for a worse prognosis: triple negative subtype, advanced stages, positive lymph nodes, and distant metastases in liver.

Interstitial Lung Disease in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Patients: Comparison With Idiopathic Pulmonary Fibrosis.

BACKGROUND/OBJECTIVE: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) may involve the kidney, respiratory tract, skin, or central and peripheral nervous system. Reports of interstitial lung disease (ILD) in AAV (AAV-ILD) have been increasing. METHODS: We reviewed the medical records of all patients with AAV-ILD between January 1, 2007, and December 31, 2017, and compared their pulmonary involvement to patients with idiopathic pulmonary fibrosis (IPF). RESULTS: We identified 24 patients with AAV-ILD: 14 with microscopic polyangiitis, 8 with granulomatosis with polyangiitis, and 2 with eosinophilic granulomatosis with polyangiitis. Perinuclear or myeloperoxidase ANCA was present in 16 cases (66.7%), whereas cytoplasmic or proteinase 3 ANCA was positive in 8 (33.3%). Usual interstitial pneumonia (UIP) was seen in 11 (45.8%), probable UIP in 1 (4.2%), indeterminate UIP in 2 (8.3%), and an alternate diagnosis in 10 (41.7%), and was further characterized as chronic hypersensitivity pneumonitis-like pattern seen in 6 (25%), nonspecific interstitial pneumonia-like pattern in 3 (12.5%), and cryptogenic organizing pneumonia-like pattern in 1 (4.2%). Forced vital capacity and diffusing capacity declined over time in patients with AAV-ILD. When compared with the IPF cohort, patients with AAV-ILD had intermediate survival and speed of lung function decline (3-year survival in AAV-ILD group was 94% vs 69% in IPF). CONCLUSIONS: Antineutrophil cytoplasmic antibody-associated vasculitis ILD is a progressive and potentially fatal condition. Although most cases in the literature are associated with p-ANCA and positive myeloperoxidase, we found that a third of patients had c-ANCA or granulomatosis with polyangiitis. Our cohort adds experience in this rare manifestation of AAV.

Three-dimensional printing facilitates surgical planning for resection of an atypical cardiac myxoma.

BACKGROUND: Cardiac myxomas are common and account for 50% of primary intracardiac tumors. Atypical locations of cardiac myxoma increase the risk of intraoperative iatrogenic injuries. Herein, we report a case of using three-dimensional printing (3D) to facilitate the removal of an atypical cardiac myxoma in a 63-year-old woman. METHODS AND RESULTS: Mass in the high posterior atrial septum was confirmed through imaging. Due to the potential involvement of the mass to surrounding vital structures, 3D printing of the cardiac mass was performed. The tumor was completely resected via median sternotomy and the resulting defect was repaired with the bovine pericardium. The patient had an uncomplicated postoperative course except for the development of sick sinus syndrome. One-year follow-up showed no tumor recurrent. CONCLUSION: 3D printing technology in patients with atypical cardiac tumors enhances our understanding of the extent of the tumor invasion and facilitates planning the operation to avoid intraoperative complications.

To breathe or not to breathe: a review of artificial airway placement and related complications.

Artificial airway devices are commonly used to provide adequate ventilation and/or oxygenation in multiple clinical settings, both emergent and nonemergent. These frequently used devices include laryngeal mask airway, esophageal-tracheal combitube, endotracheal tube, and tracheostomy tube and are associated with various acute and late complications. Clinically, this may vary from mild discomfort to a potentially life-threatening situation. Radiologically, these devices and their acute and late complications have characteristic imaging findings which can be detected primarily on radiographs and computed tomography. We review appropriate positioning of these artificial airway devices and illustrate associated complications including inadequate positioning of the endotracheal tube, pulmonary aspiration, tracheal laceration or perforation, paranasal sinusitis, vocal cord paralysis, post-intubation tracheal stenosis, cuff overinflation with vascular compression, and others. Radiologists must recognize and understand the potential complications of intubation to promptly guide management and avoid long-term or even deadly consequences.

Myocarditis with normal left ventricular function and troponin of 266.

We are reporting a case, which may represent a new entity within the diagnosis of acute myocarditis. The patient was admitted with new onset atrioventricular block, very high troponin I, peaking at 266ng/mL, and normal left ventricular function. We also used a novel computer tomography technique with delayed enhancement to diagnose myocarditis, as the patient with a permanent pacemaker could not have magnetic resonance imaging.

Anomalous origin of the circumflex artery from the right pulmonary artery.

Anomalous origin of the circumflex artery from the pulmonary artery (ACxAPA) is a rare but clinically significant condition in which the circumflex artery arises from either the main pulmonary artery or one of its main branches. Untreated patients with ACxAPA may develop severe heart failure or sudden cardiac death. Diagnosis is established with either catheter or CT angiography. We present a case of an adult male with no prior known cardiac history who was found to have ACxAPA after presenting to our institution in acute decompensated heart failure.

Characterization of medium and small-scale gold processing operations, wastewaters, and tailings in the Arequipa region of Peru.

Gold cyanidation facilities in the Arequipa Region of Peru are challenged by the availability and quality of water for processing in an arid environment. The facilities reuse decant water which recycles residual cyanide but also undesirable constituents. To understand the impact of intensive water recycling on cyanide and metals concentrations, we collected barren water, decant water, and tailings samples from six gold cyanidation facilities with ore capacities of 10-430 tons per day. Processing facilities in Arequipa recycle all effluents, with decant waters making up 58 ± 11 % of process waters. Decant water contained non-target metals: copper (394 ± 161 mg/L), iron (59 ± 34 mg/L), and zinc (74 ± 42 mg/L). In addition, decant water mean free and complexed cyanide concentrations were 534 ± 129 mg/L and 805 ± 297 mg/L, respectively. Complexed cyanide concentrations remained more constant than free cyanide concentrations with 786 ± 299 mg/L for barren water and 805 ± 297 mg/L for decant water. Cyanide mass balances showed between 21 % and 42 % of unaccounted free cyanide from the start of gold cyanidation and discharge to the tailings storage facility (TSF). Free cyanide estimated losses due to volatilization were 0.8 kg and 2.5 kg of hydrogen cyanide per ton of ore processed at barren water pH of 10.1 and 9.7. Together these results indicate two acute hazards: 1) volatilization of free cyanide during processing and 2) loading and retention of cyanides and metals into TSFs. This study elucidates the extent of uncontrolled vapor phase cyanide release during gold processing operation and contaminant concentrations in the tailings storage facilities. The data highlights the need for improvement oversight, accountability, and regulation of gold processing facilities practicing intensive recycling and zero discharge.

Pertinent reportable incidental cardiac findings on chest CT without electrocardiography gating: review of 268 consecutive cases.

BACKGROUND: Pertinent reportable cardiac findings on non-electrocardiography (ECG)-gated chest CT examinations have become easier to detect given recent advancements in multidetector CT technology. However, those findings are easily overlooked on routine chest CT without ECG gating given residual inherent cardiac motion artifact and non-cardiac indications. PURPOSE: To describe and quantify the types of pertinent reportable cardiac findings that can be detected on chest CT examinations without ECG gating and evaluate how often they were reported. MATERIAL AND METHODS: Two radiologists retrospectively reviewed (blinded to the original interpretation) 268 consecutive routine adult chest CT examinations without ECG gating for the presence of pertinent reportable cardiac findings. Retrospective interpretations were then compared with the original radiological reports. RESULTS: One hundred and sixty-three patients (61%) had pertinent reportable cardiac findings. The findings encountered included: coronary artery disease (n = 131; 80.0%), coronary artery bypass grafts (n = 10; 6.1%), left ventricular aneurysm (n = 1; 0.6%), valve calcification (n = 131; 80.0%), valve repair/replacement (n = 5; 3.1%), pericardial effusion (n = 33; 20.2%), left atrial appendage thrombus (n = 1; 0.6%), cardiac mass (n = 1; 0.6%), and cardiac chamber enlargement (n = 29; 17.8%). On the original radiological reports 22.3% of the pertinent reportable cardiac findings, detected by the two radiologists retrospectively, were not reported. CONCLUSION: Detection of pertinent reportable cardiac findings on routine chest CT examinations without ECG gating is possible. The high volume of chest CT examinations without ECG gating represents an opportunity for radiologists to comment on the presence or absence of cardiac disease which may influence future clinical decisions.

Heart failure due to tension hydrothorax after left pneumonectomy.

Tension hydrothorax is a rare complication of pneumonectomy for pleural mesothelioma and an exceptionally rare cause of heart failure. We describe a patient who had undergone extrapleural pneumonectomy, chemotherapy, and radiation for pleural mesothelioma and who developed heart failure symptoms within months of the completion of treatment. Investigation showed a massive left pleural effusion resulting in tension hydrothorax, mediastinal shift, and evidence of right heart failure with constrictive physiology and low cardiac output. Therapeutic thoracentesis resulted in increase in cardiac output and symptomatic improvement.

Imaging modalities (MRI, CT, PET/CT), indications, differential diagnosis and imaging characteristics of cystic mediastinal masses: a review.

Cystic mediastinal masses have traditionally represented a diagnostic dilemma with differentiation of malignant masses a particular area of concern. Each imaging modality has strengths and weaknesses in mediastinal imaging-computed tomography (CT) offers increased spatial resolution at the cost of poorer soft tissue differentiation and requiring ionizing radiation, while magnetic resonance imaging (MRI) offers superior soft tissue contrast/characterization at significantly greater cost. Ultrasound offers real-time visualization but is operator and tissue dependent. [18F]fluoro-D-glucose (F-18 FDG) positron emission tomography (F-18 FDG PET) CT provides functional information, but poorer spatial resolution. Recent advances have focused upon the use of magnetic resonance imaging to aid in characterization of cystic mediastinal lesions, particularly in the context of indeterminate CT findings. The mediastinum may be divided into three anatomic compartments: prevascular, visceral, and paravertebral. All three compartments extend superiorly from the thoracic inlet and inferiorly to the diaphragm. These compartments provide a useful framework for categorizing normal and pathologic mediastinal processes. In this article, we will review the imaging characteristics of mediastinal cystic lesions via a case-based review divided by anatomical mediastinal compartments. Characteristic imaging features and troubleshooting are particular areas of focus. Normal variants that may mimic cystic pathology are discussed. The roles of CT and MRI will be emphasized. Cases from our institution are presented as illustrative examples.

Invasive Nocardiosis Versus Colonization at a Tertiary Care Center: Clinical and Radiological Characteristics.

Objective: To describe the clinical and radiographic findings in a large cohort of patients with positive cultures for Nocardia emphasizing the differences between invasive disease and colonization. Patients and Methods: We conducted a single-center, retrospective cohort study of 133 patients with a positive Nocardia isolate between August 1, 1998, and November 30, 2018, and a computed tomography (CT) of the chest within 30 days before or after the bacteria isolation date. Results: Patients with colonization were older (71 vs 65 years; P=.004), frequently with chronic obstructive pulmonary disease (56.8% vs 16.9%; P<.001) and coronary artery disease (47.7% vs 27%, P=.021), and had Nocardia isolated exclusively from lung specimens (100% vs 83.1%; P=.003). On CT of the chest, they had frequent airway disease (84.1% vs 51.7%; P<.001). Patients with invasive nocardiosis had significantly (P<.05) more diabetes, chronic kidney disease, solid organ transplant, use of corticosteroids, antirejection drugs, and prophylactic sulfa. They had more fever (25.8% vs 2.3%; P<.001), cutaneous lesions (14.6% vs 0%; P=.005), fatigue (18% vs 0%; P=.001), pulmonary nodules (52.8% vs 27.3%; P=.006), and free-flowing pleural fluid (63.6% vs 29.4%; P=.024). The patterns of nodule distribution were different-diffuse for invasive nocardiosis and peribronchiolar for Nocardia colonization. Conclusion: The isolation of Nocardia in sputum from a patient with respiratory symptoms does not equal active infection. Only by combining clinical and chest CT findings, one could better differentiate between invasive nocardiosis and Nocardia colonization.

The new era of radiology teaching files.

OBJECTIVE: In this article, we describe how we constructed a radiology teaching file that simulates real-life scenarios and discuss some of the advantages it affords. CONCLUSION: Using OsiriX imaging software and iWork Pages, we have created a HIPAA-compliant interstitial lung disease radiology teaching resource that allows the user to navigate through the complete dataset of images for each patient. Integrated within the file is a navigation tool that allows the user to access the patient's clinical report, imaging reports, pulmonary function tests, and pathology report simultaneously. To our knowledge, this is the first teaching file of its kind.

Normal pediatric prevertebral soft-tissue thickness on MDCT.

OBJECTIVE: The thickness of the prevertebral soft tissue (PVST) is instrumental in helping detect cervical spine injuries in the pediatric population. Current parameters for normal PVST thickness in that population are based on lateral radiographs because there have been no studies to date defining age-dependent normal measurements on MDCT. With the increasingly important role of MDCT in the evaluation of pediatric trauma patients, it is necessary to establish normal values for pediatric PVST thickness on MDCT images. Thus, the purpose of this study is to establish the normal thickness of PVST on MDCT of the pediatric population from 0 to 15 years old. MATERIALS AND METHODS: The thickness of the PVST was measured in 139 pediatric trauma patients (age range 0-15 years) who presented to the pediatric emergency department between 2005 and 2008. Patients included in the study were not intubated, had no congenital or acquired osseous abnormality detected on CT, and were discharged from the hospital without a diagnosis of cervical spine or soft-tissue injury. Exclusion criteria included patients with concurrent injury found on head CT or nontraumatic causes of PVST thickening, such as lymphadenopathy or retropharyngeal internal carotid arteries. Patients who were diagnosed with cervical injuries within 1 year after the initial CT examination were also excluded. Each patient was scanned with a cervical collar placing the cervical spine in a neutral or near-neutral position. RESULTS: The smallest variability and calculated SD were at C2 and C6. The upper limits of normal for PVST thickness at C2 were 7.6 mm in patients from 0 to 2 years old, 8.4 mm in patients from 3 to 6 years old, and 6.8 mm in patients from 7 to 10 years old and in those from 11 to 15 years old. At the C6 level, the upper limits were 9.0 mm in patients from 0 to 2 years old, 9.8 mm in patients from 3 to 6 years old, 12.1 mm in patients from 7 to 10 years old, and 14.5 mm in patients from 11 to 15 years old. The upper limit of normal had the highest variability at C3 and C4 for all age groups. CONCLUSION: The thickness of the PVST is important in the detection of underlying injuries to the cervical spine. MDCT is playing an increasingly important role in the evaluation of pediatric trauma patients. We propose the obtained values as the upper limits of normal for PVST thickness on MDCT images in the pediatric population from 0 to 15 years old.

Leptospira Infection in Rural Areas of Urabá Region, Colombia: A Prospective Study.

The objective of this study was to analyze the eco-epidemiological aspects of Leptospira seroprevalence and seroincidence and its associated factors in two municipalities of northwest Colombia. A prospective study was performed in rural areas of Urabá, Antioquia, Colombia. The study enrolled 597 people between November 2015 and January 2016, of which 274 were followed up 1 year later. Serologic testing was performed by a microscopic agglutination. The outcomes were seroprevalent and seroincident cases, and the primary exposure was an outdoor occupation. A binary and mixed-effect multinomial logistic regression model was used to estimate factors associated with seroprevalent or seroincident cases of Leptospira infection. The overall Leptospira seroprevalence was 27.81% (95% confidence interval: 23.62-32.49), and the overall cumulative seroincidence for Leptospira was 14.60% (95% confidence interval: 10.33-20.23). Multivariable analysis showed that factors associated with L. interrogans serogroups seropositivity were outdoor occupation, male gender, older age, the presence of dirt floor in the household, and the presence of piglets and opossums. It also showed that factors associated with other Leptospira species serogroups were the presence of pit latrines and of turkeys. In addition, the multivariable model of seroincident cases of L. interrogans serogroups evidenced outdoor occupations, the presence of rats, and corn cultivation as risk factors. Likewise, the multivariable model for seroincident cases of other Leptospira species showed that the presence of hunting canines and cassava cultivation were risk factors. We found specific factors associated with the transmission of Leptospira serogroups contribute to the understanding of the epidemiology of Leptospira infection in rural areas of Urabá, Colombia.

Atypical Causes of Dyspnea: A Review of Neuromuscular and Chest Wall Disorders that Compromise Ventilation.

Dyspnea is a common presenting symptom among patients with cardiopulmonary diseases. However, several neuromuscular and chest wall conditions are often overlooked and under-recognized causes of dyspnea. These disorders frequently adversely affect the structure and function of the ventilatory pump (diaphragm, accessory muscles of ventilation) and can precipitate respiratory failure despite normal lung parenchyma. Weakened musculature impairs clearance of airway secretions leading to aspiration and pneumonia, further compromising respiratory function. Radiologists should be aware of the pathophysiology and imaging manifestations of these conditions and might suggest them to be causes of dyspnea which otherwise may not have been considered by referring clinicians.