The role of imaging in malignant pleural mesothelioma: an update after the 2018 BTS guidelines.

Malignant pleural mesothelioma (MPM) is a primary malignancy of the pleura and is associated with a poor outcome. The symptoms and signs of malignant mesothelioma present late in the natural history of the disease and are non-specific, making the diagnosis challenging and imaging key. In 2018, the British Thoracic Society (BTS) updated the guideline on diagnosis, staging, and follow-up of patients with MPM. These recommendations are discussed in this review of the current literature on imaging of MPM. It is estimated MPM will continue to cause serious morbidity and mortality in the UK late into the 21st century, and internationally, people continue to be exposed to asbestos. We aim to update the reader on current and future imaging strategies, which could aid early diagnosis of pleural malignancy and provide an update on staging and assessment of tumour response.

Potentials and limitations of low-concentration contrast medium (150 mg iodine/ml) in CT pulmonary angiography.

AIM: To assess the feasibility of producing diagnostic multidetector computed tomography (MDCT) pulmonary angiography with low iodine concentration contrast media (150 mg iodine/ml) in patients with suspected acute pulmonary embolism. MATERIALS AND METHODS: Ninety-five randomized patients underwent MDCT (64 row) pulmonary angiography with 100ml iopromide either at low concentration (LC) of 150 mg iodine/ml (n=45) or high concentration (HC) of 300 mg iodine/ml (n=50), delivered at the rate of 5 ml/s via a power injector. Two experienced radiologists, blinded to the concentration used, subjectively assessed the diagnostic quality and confidence using a four-point scale [1=poor (not diagnostic), 2=satisfactory, 3=good, 4=excellent]. Attenuation values (in HU) were measured in the main proximal branches of the pulmonary arteries. RESULTS: The median diagnostic quality score for both observers was 3.5 (interquartile range 3-4) in the HC group and 2.5 (interquartile range 1.5-3) in the LC group (p<0.01). The median diagnostic confidence score for both observers was 4 (interquartile range 3-4) in the HC group and 3 (interquartile range 1.5-4) in the LC group (p<0.01). Both observers rated examinations as diagnostic in 69% of cases in the LC group, compared with 96% of cases in the HC group. Good interobserver agreement was found in both groups (K value 0.72 in the LC group and 0.73 in the HC). Obesity, poor scan timing, and dilution by venous return of non-opacified blood were the main reasons for a reduction in diagnostic quality of examinations in the LC group. CONCLUSION: Despite a 50% reduction of contrast medium dose in comparison to the standard technique, 150 mg iodine/ml can produce diagnostic MDCT pulmonary angiogram studies in the absence of obesity or high cardiac output and hyper-dynamic pulmonary circulation. Reducing the dose of contrast media would minimize the risk of contrast nephropathy in patients at risk of this complication, particularly those suffering from congestive heart failure in whom intravenous hydration is contraindicated.

Car safety seats for children: rear facing for best protection.

OBJECTIVE: To compare the injury risk between rear-facing (RFCS) and forward-facing (FFCS) car seats for children less than 2 years of age in the USA. METHODS: Data were extracted from a US National Highway Traffic Safety Administration vehicle crash database for the years 1988-2003. Children 0-23 months of age restrained in an RFCS or FFCS when riding in passenger cars, sport utility vehicles, or light trucks were included in the study. Logistic regression models and restraint effectiveness calculations were used to compare the risk of injury between children restrained in RFCSs and FFCSs. RESULTS: Children in FFCSs were significantly more likely to be seriously injured than children restrained in RFCSs in all crash types (OR=1.76, 95% CI 1.40 to 2.20). When considering frontal crashes alone, children in FFCSs were more likely to be seriously injured (OR=1.23), although this finding was not statistically significant (95% CI 0.95 to 1.59). In side crashes, however, children in FFCSs were much more likely to be injured (OR=5.53, 95% CI 3.74 to 8.18). When 1 year olds were analyzed separately, these children were also more likely to be seriously injured when restrained in FFCSs (OR=5.32, 95% CI 3.43 to 8.24). Effectiveness estimates for RFCSs (93%) were found to be 15% higher than those for FFCSs (78%). CONCLUSIONS: RFCSs are more effective than FFCSs in protecting restrained children aged 0-23 months. The same findings apply when 1 year olds are analyzed separately. Use of an RFCS, in accordance with restraint recommendations for child size and weight, is an excellent choice for optimum protection up to a child's second birthday.

Transient femoral nerve palsy associated with a synovial cyst of the hip in a patient with spinal cord injury.

We report a case of local compression-induced transient femoral nerve palsy in a 46-year-old man. He had previously undergone surgical release of the soft tissues anterior to both hip joints because of contractures following spinal injury. An MRI scan confirmed a synovial cyst originating from the left hip joint, lying adjacent to the femoral nerve. The cyst expanded on standing, causing a transient femoral nerve palsy. The symptoms resolved after excision of the cyst.

Multislice helical CT: the value of multiplanar image reconstruction in assessment of the bronchi and small airways disease.

We examined 23 consecutive patients (11 males and 12 females with mean age of 56 years) with possible airway diseases to assess the impact of multiplanar image reconstruction (MPR) on the degree of confidence and accuracy in diagnosing bronchial abnormalities and emphysema. The thorax was scanned contiguously at 1 mm slice thickness using Siemens Volume Zoom Multislice CT scanner. Images were reconstructed at 1 mm slice thickness (lung windows L-600HU W-1600HU utilizing high spatial frequency algorithm) in the axial (10 mm apart), sagittal (4 images per lung) and coronal (6 images) plane. Paddle wheel image reconstructions were also performed in the assessment of bronchiectasis. Axial images were assessed with and without the help of MPR by three chest radiologists at two separate occasions (at least 4 weeks apart). The presence of bronchiectasis, emphysema and bronchiolitis in each lobe was documented on a confidence scale of 0 to 3. The overall mean confidence for each observer with and without MPR was compared. Consensus diagnosis was used as the gold standard for the assessment of the diagnostic accuracy of each observer. A confidence score of 2 or more for any lobe was considered diagnostic of the particular airway disease. The diagnostic accuracy for each observer with and without MPR was compared. Consensus reporting diagnosed bronchiectasis in 7 patients (30.4%), bronchiolitis in 5 patients (21.7%) and emphysema in 12 patients (52%). MPR did not increase the confidence of assessing the different abnormalities for all observers but improvement in diagnosing bronchiectasis was noted in two observers. The improvement did not reach statistical significance. However, agreement between observers in the diagnosis of bronchiectasis and emphysema was improved when the MPR images were used in conjunction with standard axial imaging (Kappa statistic improved from 0.29 to 0.54 for bronchiectasis and from 0.7 to 0.81 for emphysema). Agreement on the diagnosis of bronchiolitis was not improved by MPR for all observers. Our results suggest that MPR seems to improve the confidence in diagnosing bronchiectasis and emphysema.

The incidence of thyroid abnormalities in adults irradiated for lymphoma.

The aim of the study was to investigate the incidence of thyroid abnormalities in neck irradiated lymphoma patients. Of the 298 patients who had irradiation to the neck for lymphoma between 1966-1988, 174 were found to be alive and free of disease. These patients were invited to participate in the study. From the 174, 93 were able to participate (group 1). Two control groups were recruited; both were sex and aged matched. One group (group 2) consisted of lymphoma patients who were treated with chemotherapy (n=39) or irradiation to areas other than the neck (n=16). The other group (group 3) consisting of healthy volunteers (n=35) recruited from hospital staff and minor surgery attendees, had never had lymphoma or radiotherapy. All participants were required to complete a past medical history and thyroid symptom questionnaire, had blood taken for assays of thyroid stimulating hormone (TSH), thyroglobulin antibodies, thyroid peroxidase antibodies, sodium iodide symporter antibodies and TSH receptor antibodies and underwent ultrasound and clinical examination of the neck. A significant percentage of patients who had been irradiated in the neck had abnormalities on ultrasound, compared to groups 2 and 3 (77% vs 42% vs 24%). Abnormal TSH levels were found to be significantly more common in neck irradiated patients compared to the other groups (50% vs 9% vs 5%). There is a clear difference between neck irradiated patients and control groups. The importance of screening irradiated patients for thyroid abnormalities is re-emphasised.

Components of a proper hospital discharge for elders.

SIGNIFICANCE: Effective discharge planning is a vital link in continuity of care for elders. Previous studies identify problems with planning for elders' discharge from the hospital and problems elders encounter managing care post-discharge. However, little attention has been given to identifying effective discharge planning processes. Explicating the components of effective discharge planning is critical to replicate the process in other health care settings and predict post-discharge outcomes. PURPOSE: The purpose of this study was to identify the components of effective discharge planning for elders and factors that impede planning. METHODS: Ethical approvals were obtained from the University and National Health Service (NHS) Trust. Qualitative methods were used and data were collected from two wards in a 78-bed geriatric rehabilitation hospital that was part of a National Health Service Trust serving Southwest London. Data included semi-structured interviews and documents related to discharge planning, care delivery, and community resources. A total of 24 semi-structured interviews were conducted with health care professionals who were part of the hospital's multidisciplinary team, those affiliated with the Community Trust that provided aftercare, elders, and family carers. RESULTS: Participants consistently used the term "proper discharge" when referring to effective discharge planning. The multidisciplinary team comprised a vital context for a proper discharge. The findings indicated that three circles of communication were central in a four stage discharge process. Different circles of communication were key at different stages. CONCLUSIONS: The findings provide insights for educating nurses about effective planning practices and examining the global significance of impediments to a proper hospital discharge.

Interventions for women as family caregivers.

Family caregivers are the mainstay of long-term care, as they enable chronically ill elders and children to remain at home. The majority of family caregivers are women and historically their caregiving role has been viewed as an extension of their roles as wife and mother. Although numerous studies report the stresses associated with family caregiving and are predictors of burden, less attention has been given to interventions for family caregivers. The objective of this review is to examine reports of interventions to reduce family caregiver burden, to consider their implications for nursing practice, and to identify directions for future nursing research.