Association between Drainage-Dependent Prolonged Air Leak after Partial Lung Resection and Clinical Outcomes: A Prospective Cohort Study.

Rationale: Prolonged air leak (PAL) after partial lung resection can occur owing to surgical complications or in the presence of residual thoracic space. The former type results in drainage-independent PAL (DIPAL), whereas the latter type results in drainage-dependent PAL (DDPAL). DDPAL is described after thoracentesis in patients with nonexpandable lung, where the thoracostomy tube can be discontinued safely despite an ongoing air leak. This distinction is clinically relevant, as in the presence of DDPAL, tube thoracostomy can be safely discontinued without the need for further interventions. Objectives: To determine the frequency and clinical relevance of DDAPL and DIPAL in patients with PAL after partial lung resection. Methods: We prospectively identified consecutive patients with PAL after partial lung resection. Pleural manometry was performed 3-5 days after surgery. Pleural pressure was measured for 20 minutes after clamping the thoracostomy tube. DDPAL was diagnosed if the end-expiratory pleural pressure remained stable after plateauing in the absence of respiratory symptoms. Results: Of 225 patients who underwent lung resection, we identified 22 (10%) who had PAL. Twenty patients had adequate pleural manometry readings. The majority, 16/20 (80%), had DDPAL and had lower median hospital length of stay than those with DIPAL (6.9 vs. 11 days; P = 0.02). All patients with DIPAL required reexploration surgery, whereas only one patient with DDPAL underwent reexploration surgery. Conclusions: Most PALs after partial lung resection are DDPAL. Patients with DDPAL have lower hospital length of stay and less need for reexploration surgery than those with DIPAL.

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.

A 67-Year-Old Woman With Progressive Dyspnea and Innumerous Pulmonary Nodules.

CASE PRESENTATION: A 67-year-old woman, who recently immigrated to the United States from Afghanistan, presented to the hospital after sustaining a mechanical fall. She had no significant medical history and was not on any medication routinely. She denied any fever, night sweats, weight loss, shortness of breath, or hemoptysis. The patient had no prior personal history or exposure to TB. Results of a previous purified protein derivative skin test upon immigration were negative.

Blastomycosis in the Capital District of New York State: A Newly Identified Emerging Endemic Area.

BACKGROUND: The Centers for Disease Control and Prevention and New York State Department of Health recently identified the Capital District of New York (CDNY) as an emerging endemic area for blastomycosis. However, no clinical or epidemiological description of blastomycosis in the CDNY has been published. METHODS: We performed a retrospective analysis of blastomycosis cases at Albany Medical Center (AMC) and Albany Stratton Veterans Affairs Medical Center (VAMC) from January 1, 2000, through June 1, 2019. Patients were identified via an institution-approved informatics system at the hospital's microbiology laboratory. RESULTS: We identified 20 patients diagnosed with blastomycosis over the past 2 decades. There was a nearly 9-fold increase in the annual number of cases in 2016-2019 compared with 2000-2015. The majority of patients resided in the CDNY (90%), and 65% lived within the Mohawk River valley. Most cases (85%) were assumed to be malignancies or non-mycotic infections prior to diagnosis, with median time between presentation and diagnosis of 53 days. CONCLUSIONS: Our data support recent reports that blastomycosis is an emerging disease in the CDNY. Most patients were misdiagnosed as malignancy or non-mycotic infection, which led to treatment delays.

ICU admission body composition: skeletal muscle, bone, and fat effects on mortality and disability at hospital discharge-a prospective, cohort study.

BACKGROUND: Reduced body weight at the time of intensive care unit (ICU) admission is associated with worse survival, and a paradoxical benefit of obesity has been suggested in critical illness. However, no research has addressed the survival effects of disaggregated body constituents of dry weight such as skeletal muscle, fat, and bone density. METHODS: Single-center, prospective observational cohort study of medical ICU (MICU) patients from an academic institution in the USA. Five hundred and seven patients requiring CT scanning of chest or abdomen within the first 24 h of ICU admission were evaluated with erector spinae muscle (ESM) and subcutaneous adipose tissue (SAT) areas and with bone density determinations at the time of ICU admission, which were correlated with clinical outcomes accounting for potential confounders. RESULTS: Larger admission ESM area was associated with decreased odds of 6-month mortality (OR per cm2, 0.96; 95% CI, 0.94-0.97; p < 0.001) and disability at discharge (OR per cm2, 0.98; 95% CI, 0.96-0.99; p = 0.012). Higher bone density was similarly associated with lower odds of mortality (OR per 100 HU, 0.69; 95% CI, 0.49-0.96; p = 0.027) and disability at discharge (OR per 100 HU, 0.52; 95% CI, 0.37-0.74; p < 0.001). SAT area was not significantly associated with these outcomes' measures. Multivariable modeling indicated that ESM area remained significantly associated with 6-month mortality and survival after adjusting for other covariates including preadmission comorbidities, albumin, functional independence before admission, severity scores, age, and exercise capacity. CONCLUSION: In our cohort, ICU admission skeletal muscle mass measured with ESM area and bone density were associated with survival and disability at discharge, although muscle area was the only component that remained significantly associated with survival after multivariable adjustments. SAT had no association with the analyzed outcome measures.

Cannabinoid Oil Vaping-Associated Lung Injury and its Radiographic Appearance.

BACKGROUND: Lung injury associated with cannabinoid oil vaping is rapidly becoming a serious public health concern. We describe the clinical and radiographic presentations of 5 patients with lung injury associated with vaping cannabinoid oils seen at a single institution. RESULTS: Of the 5 patients with suspected vaping-associated lung injury seen at our institution, 4 required supplemental oxygen, and all these 4 were admitted to the hospital. Three patients required admission to the intensive care unit. None of the patients required mechanical ventilation. All patients demonstrated a consistent radiologic appearance of diffuse bilateral ground-glass lung opacities that spared the extreme periphery. Three patients underwent bronchoalveolar lavage, which revealed lipid-laden macrophages in 2 of them. All patients were successfully discharged from the hospital. Four received only supportive care, while the fifth required intravenous followed by oral corticosteroids. CONCLUSIONS: We report the clinical and radiographic presentation of 5 patients at our institution with cannabinoid oil vaping-associated lung injury. All patients displayed a consistent chest radiographic pattern of injury. Most responded to supportive care, although one required the addition of corticosteroids. Bronchoalveolar lavage results suggest that this injury may related to a toxic form of lipoid pneumonia.

Colon cancer laterality is associated with atherosclerosis and coronary artery disease.

BACKGROUND: Primary right-sided colon cancer (RCC) is associated with a higher mortality than left-sided colon cancer (LCC), but the etiology of this phenomenon remains unclear. We sought to study whether cancer laterality is associated with the prevalence of clinical coronary artery disease, calcific atherosclerosis as measured by computed tomography (CT), and cardiovascular risk factors. METHODS: We conducted a single center retrospective study of 546 participants who had previously been diagnosed with colon cancer between January 2005 and December 2014. The presence of coronary and aortic calcifications was assessed by CT in 486 of these patients. We examined the prevalence of clinical cardiovascular disease (CAD) (prior myocardial infarction or revascularization), comorbidities, coronary and aortic calcification in patients with RCC (n=261) and LCC (n=285). Logistic regression analysis was performed to assess the likelihood of clinical CAD and calcific atherosclerosis by cancer laterality. RESULTS: Compared to patients with LCC, patients with RCC were more likely to have hypertension, hyperlipidemia, hypothyroidism and clinical CAD. In the patients with available CT scans, RCC was associated with higher prevalence of coronary, thoracic, and abdominal calcifications than LCC. On univariate and multivariate analyses, RCC was associated with higher likelihood of clinical CAD (adjusted risk ratio 2.15, 95% CI, 1.37-3.38, P=0.001) as well as radiological evidence of calcific atherosclerosis compared to LCC. CONCLUSIONS: we found that both clinical CAD and vascular calcifications are prevalent in patients with colon cancer, and are independently increased in patients with RCC compared to LCC.

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.

Assessment of Mediastinal Lymph Node Size in Pneumococcal Pneumonia with Bacteremia.

INTRODUCTION: The significance of mediastinal lymphadenopathy in bacterial pneumonia is unclear. METHODS: We performed a retrospective analysis of mediastinal lymph node size determined by chest CT in patients with bacteremic pneumococcal pneumonia. All patients who had positive blood cultures for streptococcus pneumonia over an 11-year period and had a chest CT scan (index CT) within 2 weeks of the positive blood culture were included in the study. Two thoracic radiologists and one pulmonologist independently examined the index CT plus any chest CT scans performed prior (pre-CT) or after (post-CT) the bacteremic episode. RESULTS: The study cohort of 49 patients was 57% male, 65% White, with mean age of 53 (SD = 20) years. Mediastinal lymphadenopathy was detected in 25/49 (51%) of the cases. The mean size of the largest mediastinal lymph node in short axis was 0.99 (SD = 0.71), ranging from 0.0 to 2.05 cm. There was no correlation noted between the number of lobes involved with pneumonia, and the size of the largest mediastinal lymph node (p = 0.33) or the number of pathologically enlarged mediastinal lymph nodes (p = 0.08). There was a statistically significant increase in the mean size of the largest lymph node between the pre-CT and index-CT group (p = 0.02), and decrease between the index-CT group and the post-CT (p = 0.03). CONCLUSION: Pneumococcal pneumonia with bacteremia is associated with mild mediastinal lymph node enlargement. The presence of marked mediastinal lymphadenopathy (short axis LN size > 2 cm) should not be assumed from pneumococcal pneumonia.

A necrotic tonsillar lesion: An unusual presentation of disseminated histoplasmosis.

We report a case of tonsillar histoplasmosis with hematogenous dissemination in a woman receiving infliximab for Crohn's disease. She also had a history of sarcoidosis. Due to the unusual location and confounding medical history, our case provided a diagnostic dilemma. Histoplasma infection was confirmed histologically, and the patient responded well to appropriate treatment.

A 23-Year-Old Man With Recurrent Hemoptysis.

A 23-year-old white man was admitted to the hospital for evaluation of recurrent hemoptysis. He denied any other associated symptoms, including dyspnea, chest pain, productive cough, wheezing, fever, or weight loss. He had no significant past medical history and was not taking any medication. He had no significant family history for cardiopulmonary diseases.

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.

Impact of a computer-aided detection (CAD) system integrated into a picture archiving and communication system (PACS) on reader sensitivity and efficiency for the detection of lung nodules in thoracic CT exams.

The objective of this study is to assess the impact on nodule detection and efficiency using a computer-aided detection (CAD) device seamlessly integrated into a commercially available picture archiving and communication system (PACS). Forty-eight consecutive low-dose thoracic computed tomography studies were retrospectively included from an ongoing multi-institutional screening study. CAD results were sent to PACS as a separate image series for each study. Five fellowship-trained thoracic radiologists interpreted each case first on contiguous 5 mm sections, then evaluated the CAD output series (with CAD marks on corresponding axial sections). The standard of reference was based on three-reader agreement with expert adjudication. The time to interpret CAD marking was automatically recorded. A total of 134 true-positive nodules, measuring 3 mm and larger were included in our study; with 85 ≥ 4 and 50 ≥ 5 mm in size. Readers detection improved significantly in each size category when using CAD, respectively, from 44 to 57 % for ≥3 mm, 48 to 61 % for ≥4 mm, and 44 to 60 % for ≥5 mm. CAD stand-alone sensitivity was 65, 68, and 66 % for nodules ≥3, ≥4, and ≥5 mm, respectively, with CAD significantly increasing the false positives for two readers only. The average time to interpret and annotate a CAD mark was 15.1 s, after localizing it in the original image series. The integration of CAD into PACS increases reader sensitivity with minimal impact on interpretation time and supports such implementation into daily clinical practice.

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.

Quantitative assessment of percentage of lung parenchyma visualized on cardiac computed tomographic angiography.

RATIONALE AND OBJECTIVES: The purpose of the study was to quantitatively assess the percentage of total lung parenchyma visualized on cardiac computed tomographic angiography (CTA) using standard and tight-coned fields of view (FOVs). MATERIALS AND METHODS: The authors evaluated lung volumes in 43 electrocardiogram-gated cardiac CTAs performed as part of triple rule-out/chest pain protocol CTAs over a 9-month period. Using a commercially available software package, a quantitative tissue differentiation analysis was performed using a threshold of -750 Hounsfield units to segment air in the lungs. Using each triple rule-out data set as a starting point, measurements of lung volume were performed with 2 cardiac CTA FOV scenarios, obtained by excluding the periphery of the triple rule-out volume: (1) standard cardiac CTA FOV typically used and recommended by the manufacturer and (2) tight cardiac CTA FOV maximally coned to the heart. For each scenario, the volume of the lung within the restricted FOV was compared with the overall volume of the lungs derived from the triple rule-out study, expressed as a percentage. RESULTS: On the standard cardiac CTA FOV typically used at our institution, a mean of 58% of the lung parenchyma is included with wide variability (range, 26%-86%). On the severely limited FOV, a mean of 14% (range, 7.5%-22%) of the lung parenchyma is included. CONCLUSIONS: The percentage of lung parenchyma included in a standard FOV is considerable, although this can be mitigated by using a tight FOV, with potential exclusion of part of the cardiac anatomy. Interpreters of cardiac CTA images should have adequate training and skill in evaluating structures outside the heart.