A Young Woman With Recurrent Episodes of Fever and Cough.

CASE PRESENTATION: A 19-year-old woman presented to pulmonary clinic with recurrent episodes of fevers and productive cough over the last 2 years. She was diagnosed with several episodes of respiratory infection that required antibiotic therapy. Her symptoms improved transiently after antibiotic therapy. However, symptoms continued to recur every 1 to 2 months. She denied any close TB contacts or travel outside the United States. She was a nonsmoker and had no history of immunodeficiency. There was no history of cystic fibrosis or any foreign body aspiration.

ICU Admission Muscle and Fat Mass, Survival, and Disability at Discharge: A Prospective Cohort Study.

BACKGROUND: Skeletal muscle dysfunction occurring as a result of ICU admission associates with higher mortality. Although preadmission higher BMI correlates with better outcomes, the impact of baseline muscle and fat mass has not been defined. We therefore investigated the association of skeletal muscle and fat mass at ICU admission with survival and disability at hospital discharge. METHODS: This single-center, prospective, observational cohort study included medical ICU (MICU) patients from an academic institution in the Unites States. A total of 401 patients were evaluated with pectoralis muscle area (PMA) and subcutaneous adipose tissue (SAT) determinations conducted by CT scanning at the time of ICU admission, which were later correlated with clinical outcomes accounting for potential confounders. RESULTS: Larger admission PMA was associated with better outcomes, including higher 6-month survival (OR, 1.03; 95% CI, 1.01-1.04; P < .001), lower hospital mortality (OR, 0.96; 95% CI, 0.93-0.98; P < .001), and more ICU-free days (slope, 0.044 ± 0.019; P = .021). SAT was not significantly associated with any of the measured outcomes. In multivariable analyses, PMA association persisted with 6 months and hospital survival and ICU-free days, whereas SAT remained unassociated with survival or other outcomes. PMA was not associated with regaining of independence at the time of hospital discharge (OR, 0.99; 95% CI, 0.98-1.01; P = .56). CONCLUSIONS: In this study cohort, ICU admission PMA was associated with survival during and following critical illness; it was unable to predict regaining an independent lifestyle following discharge. ICU admission SAT mass was not associated with survival or other measured outcomes.

Spontaneous pneumomediastinum: an extensive workup is not required.

BACKGROUND: Spontaneous pneumomediastinum is a rare entity usually caused by alveolar rupture and air tracking along the tracheobronchial tree. Despite its benign nature, an extensive workup is often undertaken to exclude hollow viscus perforation. We sought to review our experience with this condition and examine the optimal management strategy. STUDY DESIGN: We conducted a retrospective review of all radiographic pneumomediastinum cases at a tertiary hospital between 2006 and 2011. The main outcomes measures included length of hospital stay, mortality, and need for investigative procedures. RESULTS: Forty-nine patients with spontaneous pneumomediastinum were identified, including 26 male patients (53%). Mean age was 19 ± 9 years. Chest pain was the most common presenting symptom (65%), followed by dyspnea (51%). Forceful coughing (29%) or vomiting (16%) were the most common eliciting factors, and no precipitating event was identified in 41% of patients. Computed tomography was performed in 38 patients (78%) and showed a pneumomediastinum that was not seen on chest x-ray in 9 patients. Esophagography was performed in 17 patients (35%) and was invariably negative for a leak. Thirty-eight patients (78%) were hospitalized for a mean of 1.8 ± 2.6 days. No mortality was recorded. Compared with patients who presented with pneumomediastinum secondary to esophageal perforation, spontaneous pneumomediastinum patients were younger, had a lower white cell count, and were less likely to have a pleural effusion. CONCLUSIONS: Spontaneous pneumomediastinum is a benign entity and rarely correlates with true esophageal perforation. Additional investigation with esophagography or other invasive procedures should be performed selectively with the aim of expediting the patient's care. The prognosis is excellent with conservative management and the risk for recurrence is low.

Improved efficiency of CT interpretation using an automated lung nodule matching program.

OBJECTIVE: The purpose of this study was to assess the impact of an automated program on improvement in lung nodule matching efficiency. MATERIALS AND METHODS: Four thoracic radiologists independently reviewed two serial chest CT examinations from each of 57 patients. Each radiologist performed timed manual lung nodule matching. After 6 weeks, all radiologists independently repeated the timed matching portion using an automated nodule matching program. The time required for manual and automated matching was compared. The impact of nodule size and number on matching efficiency was determined. RESULTS: An average of 325 (range, 244-413) noncalcified solid pulmonary nodules was identified. Nodule matching was significantly faster with the automated program irrespective of the interpreting radiologist (p < 0.0001 for each). The maximal time saved with automated matching was 11.4 minutes (mean, 2.3 ± 2.0 minutes). Matching was faster in 56 of 57 cases (98.2%) for three readers and in 46 of 57 cases (80.7%) for one reader. There were no differences among readers with respect to the mean time saved per matched nodule (p > 0.5). The automated program achieved 90%, 90%, 79%, and 92% accuracy for the four readers. The improvement in efficiency for a given patient using the automated technique was proportional to the number of matched nodules (p < 0.0001) and inversely proportional to nodule size (p < 0.05). CONCLUSION: Use of the automated lung nodule matching program significantly improves diagnostic efficiency. The time saved is proportionate to the number of nodules identified and inversely proportional to nodule size. Adoption of such a program should expedite CT examination interpretation and improve report turnaround time.

Clinical significance of lung nodules reported on abdominal CT.

OBJECTIVE: The objective of our study was to identify the significance of lung nodules reported on abdominal CT. MATERIALS AND METHODS: Abdominal CT reports from a 1-year period were reviewed for the terms "nodule," "nodular," or "mass" in reference to the lung bases. Patients with prior chest or abdominal CT examinations were excluded; the study population included patients with an initial abdominal CT study and at least one follow-up chest or abdominal CT examination. Two thoracic radiologists characterized nodules in consensus. Radiology and clinical records were reviewed for nodule growth and clinical diagnoses. RESULTS: The term "nodule," "nodular," or "mass" in reference to the lung bases was reported in 364 of 12,287 abdominal CT studies (3%). Of 125 patients with no prior CT examination, 42 had undergone follow-up chest CT, abdominal CT, or both. Common imaging indications included abdominal pain (13/42, 31%) and preexisting malignancy (n = 7, 16.7%). Regardless of the indication for imaging, 16 (38.1%) had malignancy that was known (n = 13) or newly diagnosed (n = 3) on the initial abdominal CT. Three of 42 patients (7.1%) had malignant nodules representing metastatic disease: Nodule growth was seen in one patient with preexisting colon cancer, one patient with newly diagnosed metastatic pancreatic cancer, and a third with known bladder cancer. The latter patient had suspected lung metastases that were confirmed on chest CT 1 day later. Three of the 16 patients (18.8%) with preexisting or newly diagnosed cancer had malignant nodules. No malignant nodules were identified without such history. Six patients (14.3%) had an infection. CONCLUSION: Lung nodules incidentally detected on abdominal CT were rarely malignant and were seen only in the setting of an underlying abdominal malignancy. Knowledge of such history is of critical importance to both the clinician and the radiologist. Dedicated chest CT is most useful when assessing pulmonary nodules in patients with localized malignancy.