Transition from BOS to RAS impairs prognosis after lung transplantation-CLAD subtype analysis by CT volumetry.

BACKGROUND: Chronic lung allograft dysfunction (CLAD), subclassified into bronchiolitis obliterans syndrome (BOS) or restrictive allograft syndrome (RAS), limits survival after lung transplantation. Information concerning transition from BOS to RAS is limited. We aimed to characterize the lung volume change after BOS diagnosis by computed tomography (CT) volumetry and to determine the incidence, risk factors and clinical significance of BOS to RAS transition. METHODS: CT volumetry measurements were performed from 63 patients with CLAD initially classified as BOS by CT volumetry. BOS patients with lung volume remaining >85% of baseline were classified as persistent BOS, whereas BOS patients whose lung volume permanently decreased to ≤85% of baseline were classified as BOS to RAS transition. RESULTS: During follow-up (median 9.8 years) eight patients (12.7%) were classified as BOS to RAS transition, which decreased recipient (p = 0.004) and graft survival (p = 0.020) in comparison to patients with persistent BOS. Opacities on chest imaging preceded BOS to RAS transition in 88% of patients. Opacities on chest imaging at BOS diagnosis and early CLAD diagnosis after transplantation were risk factors for transition. CONCLUSION: Based on lung volume decrease measured by CT volumetry, a small proportion of BOS patients transitioned to RAS which had an adverse effect on recipient and graft survival.

Chronic lung allograft dysfunction subtype analysis by computed tomography volumetry.

BACKGROUND: Chronic lung allograft dysfunction (CLAD) limits long-term survival after lung transplantation. Of the two subtypes, restrictive allograft syndrome (RAS) is characterized by a larger lung volume decrease and worse prognosis than bronchiolitis obliterans syndrome (BOS). We used computed tomography (CT) volumetry to classify CLAD subtypes and determined their clinical impact. METHODS: Adult primary lung transplants performed 2003-2015 (n = 167) were retrospectively evaluated for CLAD and subclassified with CT volumetry. Lung volume decrease of < 15% from baseline resulted in BOSCT-vol and ≥15% resulted in RASCT-vol diagnosis. Clinical impact of CLAD subtypes was defined, and the prognostic value of different lung function, radiological, and lung volume parameters present at the time of CLAD diagnosis were compared. RESULTS: CLAD affected 43% of patients and was classified with CT volumetry as BOSCT-vol in 89% and RASCT-vol in 11%. Median graft survival estimate in RASCT-vol was significantly decreased compared to BOSCT-vol (1.6 vs. 9.7 years, P = .038). At CLAD onset, RASCT-vol diagnosis (P = .05), increased lung density (P = .007), and more severe FEV1 (P = .004) decline from baseline, increased graft loss risk in multivariate analysis. CONCLUSIONS: CT volumetry serves to identify lung transplant patients with a poor clinical outcome but should be validated in prospective trials.

Automating chest radiograph imaging quality control.

PURPOSE: To automate diagnostic chest radiograph imaging quality control (lung inclusion at all four edges, patient rotation, and correct inspiration) using convolutional neural network models. METHODS: The data comprised of 2589 postero-anterior chest radiographs imaged in a standing position, which were divided into train, validation, and test sets. We increased the number of images for the inclusion by cropping appropriate images, and for the inclusion and the rotation by flipping the images horizontally. The image histograms were equalized, and the images were resized to a 512 × 512 resolution. We trained six convolutional neural networks models to detect the image quality features using manual image annotations as training targets. Additionally, we studied the inter-observer variability of the image annotation. RESULTS: The convolutional neural networks' areas under the receiver operating characteristic curve were >0.88 for the inclusions, and >0.70 and >0.79 for the rotation and the inspiration, respectively. The inter-observer agreement between two human annotators for the assessed image-quality features were: 92%, 90%, 82%, and 88% for the inclusion at patient's left, patient's right, cranial, and caudal edges, and 78% and 89% for the rotation and inspiration, respectively. Higher inter-observer agreement was related to a smaller variance in the network confidence. CONCLUSIONS: The developed models provide automated tools for the quality control in a radiological department. Additionally, the convolutional neural networks could be used to obtain immediate feedback of the chest radiograph image quality, which could serve as an educational instrument.

Analysis of the Histologic Features Associated With Interobserver Variation in Idiopathic Pulmonary Fibrosis.

The histologic manifestation of idiopathic pulmonary fibrosis (IPF) is usual interstitial pneumonia (UIP), which is a good prognostic determinant of survival compared with other histologic interstitial lung disease patterns. According to the current international guidelines, the histologic features of suspected IPF/UIP are divided into 4 categories: UIP, probable UIP, possible UIP, and not UIP pattern. Four pulmonary pathologists who were blinded to clinicoradiologic information reevaluated 50 surgical lung biopsies (83.3%), 6 lung explant (10.0%), and 4 autopsy samples (6.7%) from the FinnishIPF registry (N=60) using the current diagnostic guidelines. Additional histologic features atypical for UIP were also evaluated and compared with clinicora-diologic information. The interobserver agreement of pathologists was examined by Cohen kappa (κ) coefficient; the survival of the patients was estimated with Kaplan-Meier curves. The histologic reevaluation indicated that 38 of 60 patients (63.3%) had definite UIP. Inflammation was the most common additional histologic finding (15/60, 25.0%). The interobserver agreement on histologic diagnosis ranged from slight (κ=0.044) to substantial (κ=0.779). The interobserver agreement varied extensively with regard to the presence of giant cells. The observed histologic features displayed no association with radiologic patterns or survival. Definite UIP and honeycombing findings in high-resolution computed tomography correlated with poor prognosis. A high level of interobserver variability was observed between pathologists, even in this well-defined cohort of IPF patients, which highlights the importance of multidisciplinary decision making in IPF diagnostics and stresses the need for a reassessment of the histologic criteria.

N-terminal Pro-brain Natriuretic Peptide, High-sensitivity Troponin and Pulmonary Artery Clot Score as Predictors of Right Ventricular Dysfunction in Echocardiography.

BACKGROUND: We investigated the ability of cardiac biomarkers and total pulmonary artery (PA) clot score to predict right ventricular dysfunction (RVD) on admission and at seven-month follow-up in subjects with acute pulmonary embolism (APE). METHODS: Sixty-three normotensive patients with APE were divided into two groups: patients with (n= 32, age 58±19 years) and without (n=31, age 55±16 years) echocardiographic RVD. Transthoracic echocardiography (TTE), N-terminal pro-brain natriuretic peptide (NT-proBNP), and high-sensitivity troponin T (hsTnT) were assessed upon arrival and repeated at seven months. Total PA clot score was determined on admission. RESULTS: The age- and sex dependent NT-proBNP on admission, on day 5, and at seven months exhibited the best sensitivity (admission 94%, day 5 100%, seven months 100%) and negative predictive value (NPV) (89%, 100%, 100%) for detecting RVD. Six patients (10%) had persistent RVD at seven months. Total PA clot score showed only low to moderate sensitivity (77%) and PPV (7%) for detection of RVD at seven months. CONCLUSIONS: Normal age- and sex dependent NT-proBNP on admission or measured five days later seems to be useful in exclusion of RVD at follow up. Total PA clot score shows only to be of modest benefit for predicting persistent RVD.

[Endoscopic surgery accelerates recovery from empyema]. / Tähystyskirurgia nopeuttaa empyeemasta toipumista.

The incidence of thoracic empyema is increasing. Early treatment of empyema should focus on optimal drainage and antibiotics. If conventional therapy fails, surgical intervention has to be considered and approximately 30% of all patients require surgery. In a three-year period (2011-2013), 182 patients were operated at Helsinki University Hospital due to pleural empyema. Thoracoscopic decortication was performed on 44% of the patients and 56% underwent open surgery. After thoracoscopy, the patients had a shorter hospital stay and fewer reoperations. Thoracoscopic decortication should therefore be the first-line procedure in the surgical treatment of pleural empyema.

Helical computerized tomography and NT-proBNP for screening of right ventricular overload on admission and at long term follow-up of acute pulmonary embolism.

BACKGROUND: Right ventricular dysfunction (RVD) in acute pulmonary embolism (APE) can be assessed with helical computerized tomography (CT) and transthoracic echocardiography (TTE). Signs of RVD and elevated natriuretic peptides like NT-proBNP and cardiac troponin (TnT) are associated with increased risk of mortality. However, the prognostic role of both initial diagnostic strategy and the use of NT-proBNP and TnT for screening for long-term probability of RVD remains unknown. The aim of the study was to determine the role of helical CT and NT-proBNP in detection of RVD in the acute phase. In addition, the value of NT-proBNP for ruling out RVD at long-term follow-up was assessed. METHODS: Sixty-three non-high risk APE patients were studied. RVD was assessed at admission in the emergency department by CT and TTE, and both NT-proBNP and TnT samples were taken. These, excepting CT, were repeated seven months later. RESULTS: At admission RVD was detected by CT in 37 (59 %) patients. RVD in CT correlated strongly with RVD in TTE (p < 0.0001). NT-proBNP was elevated (≥ 350 ng/l) in 32 (86 %) patients with RVD but in only seven (27 %) patients without RVD (p < 0.0001). All the patients survived until the 7-month follow-up. TTE showed persistent RVD in 6 of 63 (10 %) patients who all had RVD in CT at admission. All of them had elevated NT-proBNP levels in the follow-up compared with 5 (9 %) of patients without RVD (p < 0.0001). CONCLUSIONS: TTE does not confer further benefit when helical CT is used for screening for RVD in non-high risk APE. All the patients who were found to have RVD in TTE at seven months follow-up had had RVD in the acute phase CT as well. Thus, patients without RVD in diagnostic CT do not seem to require further routine follow-up to screen for RVD later. On the other hand, persistent RVD and thus need for TTE control can be ruled out by assessment of NT-proBNP at follow-up. A follow-up protocol based on these findings is suggested.

Reduction in membrane component of diffusing capacity is associated with the extent of acute pulmonary embolism.

Acute pulmonary embolism (PE) often decreases pulmonary diffusing capacity for carbon monoxide (DL,CO), but data on the mechanisms involved are inconsistent. We wanted to investigate whether reduction in diffusing capacity of alveolo-capillary membrane (DM) and pulmonary capillary blood volume (Vc) is associated with the extent of PE or the presence and severity of right ventricular dysfunction (RVD) induced by PE and how the possible changes are corrected after 7-month follow-up. Forty-seven patients with acute non-massive PE in spiral computed tomography (CT) were included. The extent of PE was assessed by scoring mass of embolism. DL,CO, Vc, DM and alveolar volume (VA) were measured by using a single breath method with carbon monoxide and oxygen both at the acute phase and 7 months later. RVD was evaluated with transthoracic echocardiography and electrocardiogram. Fifteen healthy subjects were included as controls. DL,CO, DL, CO/VA, DM, vital capacity (VC) and VA were significantly lower in the patients with acute PE than in healthy controls (P < 0.001). DM/Vc relation was significantly lower in patients with RVD than in healthy controls (P = 0.004). DM correlated inversely with central mass of embolism (r = -0.312; P = 0.047) whereas Vc did not. DM, DL,CO, VC and VA improved significantly within 7 months. In all patients (P = 0.001, P = 0.001) and persistent RVD (P = 0.020, P = 0.012), DM and DL,CO remained significantly lower than in healthy controls in the follow-up. DM was inversely related to central mass of embolism. Reduction in DM mainly explains the sustained decrease in DL,CO in PE after 7 months despite modern treatment of PE.

Assessment of submucosal radiofrequency tonsil reduction by magnetic resonance imaging.

OBJECTIVES: The primary objective was to assess the efficacy of submucosal radiofrequency tonsil reduction (SRFTR) in adults by magnetic resonance imaging (MRI). The secondary objective was to evaluate the morbidity of SRFTR. METHODS: A prospective, longitudinal clinical study with a follow-up time of 12 months was conducted of 10 consecutive patients with the median age of 24.5 years (range 19-55 years) with obstructive palatine tonsil hypertrophy. SRFTR was delivered in an outpatient setting in a tertiary care centre, academic teaching hospital. MAIN OUTCOME MEASURES: The change in tonsillar volume after SRFTR was evaluated with MRI by two radiologists independently and blinded to the treatment results. The morbidity was assessed with a visual analogue scale (VAS), a questionnaire for the pain medication needed, and inflammatory laboratory parameters. VAS and use of pain medication results were compared with those of two earlier cohort groups undergoing conventional tonsillectomy with two different techniques at our department. RESULTS: The tonsil volume reduced significantly with a median reduction in the total tonsil volume of 12.6% (range 3.7-41.5%, pretreatment vs posttreatment volume, p < .01). VAS of the morbidity symptoms and the amount of pain medication needed were significantly lower in the SRFTR group than in the two historical tonsillectomy groups. The laboratory parameters showed a significant change. CONCLUSION: SRFTR in adults with obstructive palatine tonsil hypertrophy is a minimally invasive procedure causing a tonsil volume reduction demonstrated by MRI. The procedure seems to be associated with acceptable morbidity.

Patients referred to an indoor air health clinic: exposure to water-damaged buildings causes an increase of lymphocytes in bronchoalveolar lavage and a decrease of CD19 leucocytes in peripheral blood.

BACKGROUND: Respiratory and other symptoms are often associated with exposure to microbes present in water-damaged buildings. MATERIAL AND METHODS: We examined 82 consecutive patients referred to the Indoor Air Clinic, Helsinki University Hospital, due to symptoms suspected of having been caused by long-term exposure to water damage in the home or workplace. Exposure to water damage was assessed by building inspections and microbial analyses as needed. Bronchoalveolar lavage, lung function measurements, skin prick tests to inhalant allergens and radiological examinations were performed in all patients. Leucocyte subsets in peripheral blood were analysed in 35 patients. RESULTS: Marked water damage was detected in the homes or workplaces of 47 (59%) patients; the remaining 34 patients formed the control group. The exposed group expressed more symptoms in total than the control group: fatigue, conjunctival symptoms, rhinitis with sinusitis, recurrent bronchitis and asthma were more common in the exposed group, but a significant difference was seen only for headache. In BAL (bronchoalveolar lavage) samples, lymphocytes represented 25% of the total cell population in non-smoking-exposed patients compared with 12% in control patients (p=0.004). In peripheral blood, CD19 leucocytes were significantly decreased in the exposed group (7.5% versus 12.3%; p<0.01). CONCLUSIONS: Confirmed exposure to water damage was associated with an increase in symptoms. Exposure to water damage caused a significant change in the cellular composition in BAL fluid (lymphocytosis) and blood (decrease of CD19 cells). The depletion of CD19 leucocytes in peripheral blood may indicate an active immune response in the lungs.

Patients with cartilage-hair hypoplasia have an increased risk for bronchiectasis.

OBJECTIVE: To assess the prevalence, predictors, and course of bronchiectasis in patients with cartilage-hair hypoplasia. STUDY DESIGN: Patients who had undergone high-resolution computed tomography of the lungs or bronchography were included in the study. Hospital records were coorelated for clinical features, respiratory symptoms, and laboratory variables. Imaging studies were correlated for changes suggestive of bronchiectasis and findings correlated with clinical and immunological measurements. RESULTS: The study included 15 patients (5 male; median height Z-score, -7.7) aged from 2 to 39 years (median, 10 years). Cell-mediated immunity was impaired in 79% of the subjects, and humoral immunity was impaired in 71% of the subjects. 8 patients (52%) had bronchiectasis, diagnosed by means of high-resolution computed tomography (n = 6) or bronchography (n = 2). The findings ranged from localized mild dilatation of the airways to severe bronchiectasis with saccular airway dilatation. Bronchiectasis progressed during follow-up in 2 patients. Patients with bronchiectasis tended to have more severe growth failure and more often had defective humoral immunity than the general cartilage-hair hypoplasia population. CONCLUSION: Patients with cartilage-hair hypoplasia are at risk of the development of bronchiectasis.

Intra-abdominal pressure in severe acute pancreatitis.

BACKGROUND: Hospital mortality in patients with severe acute pancreatitis (SAP) remains high. Some of these patients develop increased intra-abdominal pressure (IAP) which may contribute to organ dysfunction. The aims of this study were to evaluate the frequency of increased IAP in patients with SAP and to assess the development of organ dysfunction and factors associated with high IAP. METHODS: During 2001-2003 a total of 59 patients with severe acute pancreatitis were treated in the intensive care unit (ICU) of Helsinki University Hospital. IAP was measured by the intravesical route in 37 patients with SAP. Data from these patients were retrospectively reviewed. RESULTS: Maximal IAP, APACHE II score, maximal SOFA score, maximal creatinine, age and maximal lactate were significantly higher in nonsurvivors. There was a significant correlation of the maximal IAP with the maximal SOFA, APACHE II, maximal creatinine, maximal lactate, base deficit and ICU length of stay. Patients were divided into quartiles according to the maximal IAP. Maximal IAP was 7-14, 15-18, 19-24 and 25-33 mmHg and the hospital mortality rate 10%, 12.5%, 22.2% and 50% in groups 1-4, respectively. A statistically significant difference was seen in the maximal SOFA, ICU length of stay, maximal creatinine and lactate values. The mean ICU-free days in groups 1-4 were 45.7, 38.8, 32.0 and 27.5 days, respectively. The difference between groups 1 and 4 was statistically significant. CONCLUSION: In patients with SAP, increased IAP is associated with development of early organ failure reflected in increased mortality and fewer ICU-free days. Frequent measurement of IAP during intensive care is important in optimizing abdominal perfusion pressure and recognizing patients potentially benefitting from decompressive laparotomy.

Supplemental oxygen is not required in trauma patients treated with IV opiates.

The risk of respiratory depression can prevent the proper use of opioids in trauma patients and lead to use of supplemental oxygen. However, high FiO(2) might contribute to atelectasis formation and consequently to relative hypoxia. Supplemental oxygen also can cause a risk of fire. In a randomized, controlled study we evaluated the need and effects of supplemental oxygen in 13 patients with extremity trauma who were treated pain-free with an intravenous opioid, oxycodone (dose range 6.75-13.6 mg). After opioid injection, 7 patients received 40% supplemental oxygen and 6 were breathing room air. Pulse oxygen saturation (SpO(2)), arterial blood gases, and hemodynamic parameters were monitored for 30 minutes. Atelectasis formation was evaluated with a computed tomography scan. No hypoxia, hypoventilation, or significant atelectasis formation was detected in any of the patients. Accordingly, routinely given supplemental oxygen was not considered necessary in these patients because no complications were seen.

Co-administration of caspofungin and cyclosporine to a kidney transplant patient with pulmonary Aspergillus infection.

A kidney transplant patient on cyclosporine treatment developed focal pneumonia due to Aspergillus fumigatus. The patient was not able to tolerate amphotericin B deoxycholate and was switched to caspofungin. The patient responded favourably without any evidence of toxicity from concomitant use of caspofungin and cylosporine.

Administration of nonionic iodinated contrast medium does not influence the outcome of patients with ischemic brain infarction.

Some reports indicate that exposure to iodinated contrast medium (CM) could worsen the outcome of patients with brain infarction. In this prospective study, we compared the outcome of 77 patients receiving and 128 not receiving nonionic iodinated CM. Stroke severity was assessed by the Scandinavian Prognostic Stroke Score, and outcome by the Rankin Scale. All radiological studies using intravenous or intra-arterial CM were registered. Two nonionic iodinated CM (iopamidol and iohexol) were used. Exposure to CM did not influence case fatality, ability to live at home, ability to walk, disability and stroke severity. Initial stroke severity and arterial hypertension were independent determinants of poor neurological recovery or death. Large infarct, age, male gender, and baseline stroke severity were independent determinants of major disability or death. CM enhancement on CT did not show any harmful effect on stroke severity or outcome. As a conclusion, intravascular administration of nonionic iodinated CM did not influence stroke severity or outcome of our patients.

Bipolar radiofrequency thermal ablation of the soft palate in habitual snorers without significant desaturations assessed by magnetic resonance imaging.

Sleep-disordered breathing, including habitual snoring, is a major health problem. Treatment of primary habitual snoring should be individualized using both conservative and active treatment methods. Active surgical interventions are, however, associated with significant morbidity. Therefore, procedures causing far less morbidity should be preferred. Our aim was to assess the efficacy and acceptability of bipolar radiofrequency thermal ablation of the soft palate in habitual snorers without significant desaturations associated with excessive daytime sleepiness. We treated 20 nonobese habitual snorers (median age, 43 years, range 35-63). All the patients had the major site of obstruction at the level of the soft palate, and they were treated on an outpatient basis in two treatment sessions separated by 1 week. The pretreatment and post-treatment symptoms and findings as well as the overall efficacy of the procedure were evaluated by questionnaires, visual analogue scales, and magnetic resonance imaging. All the questionnaires showed a statistically significant change, indicating decreased snoring and daytime sleepiness. The magnetic resonance studies showed that the procedure induced notable T1-signal alterations in the treated tissue, and when compared with the pretreatment images, certain dimensions of the soft palate were significantly changed. Bipolar radiofrequency thermal ablation of the soft palate seems to be well tolerated and effective regarding primary habitual snorers without significant desaturations associated with excessive daytime sleepiness.