Clinical, radiological and histopathological features of patients with familial pulmonary fibrosis.

BACKGROUND: In familial pulmonary fibrosis (FPF) at least two biological relatives are affected. Patients with FPF have diverse clinical features. RESEARCH QUESTION: We aimed to characterize demographic and clinical features, re-evaluate high-resolution computed tomography (HRCT) scans and histopathology of surgical lung biopsies, assess survival and investigate the suitability of risk prediction models for FPF patients. STUDY DESIGN: A retrospective cohort study. METHODS: FPF data (n = 68) were collected from the medical records of Oulu University Hospital (OUH) and Oulaskangas District Hospital between 1 Jan 2000 and 11 Jan 2023. The inclusion criterion was pulmonary fibrosis (PF) (ICD 10-code J84.X) and at least one self-reported relative with PF. Clinical information was gathered from hospital medical records. HRCT scans and histology were re-evaluated. RESULTS: Thirty-seven (54.4%) of the patients were men, and 31 (45.6%) were women. The mean ages of the women and men were 68.6 and 61.7 years, respectively (p = 0.003). Thirty-seven (54.4%) patients were nonsmokers. The most common radiological patterns were usual interstitial pneumonia (UIP) (51/75.0%), unclassifiable (8/11.8%) and nonspecific interstitial pneumonia (NSIP) (3/4.4%). Pleuroparenchymal fibroelastosis (PPFE) was observed as a single or combined pattern in 13.2% of the patients. According to the 2022 guidelines for idiopathic pulmonary fibrosis (IPF), the patients were categorized as UIP (31/45.6%), probable UIP (20/29.4%), indeterminate for UIP (7/10.3%) or alternative diagnosis (10/14.7%). The histopathological patterns were UIP (7/41.2%), probable UIP (1/5.9%), indeterminate for UIP (8/47.2%) and alternative diagnosis (1/5.9%). Rare genetic variants were found in 9 patients; these included telomerase reverse transcriptase (TERT, n = 6), telomerase RNA component (TERC, n = 2) and regulator of telomere elongation helicase 1 (RTEL1, n = 1). Half of the patients died (n = 29) or underwent lung transplantation (n = 5), with a median survival of 39.9 months. The risk prediction models composite physiology index (CPI), hazard ratio (HR) 1.07 (95.0% CI 1.04-1.10), and gender-age-physiology index (GAP) stage I predicted survival statistically significantly (p<0.001) compared to combined stages II and III. CONCLUSIONS: This study confirmed the results of earlier studies showing that FPF patients' radiological and histopathological patterns are diverse. Moreover, radiological and histological features revealed unusual patterns and their combinations.

ICU-treated influenza A(H1N1) pdm09 infections more severe post pandemic than during 2009 pandemic: a retrospective analysis.

BACKGROUND: We compared in a single mixed intensive care unit (ICU) patients with influenza A(H1N1) pdm09 between pandemic and postpandemic periods. METHODS: Retrospective analysis of prospectively collected data in 2009-2016. Data are expressed as median (25th-75th percentile) or number (percentile). RESULTS: Seventy-six influenza A(H1N1) pdm09 patients were admitted to the ICU: 16 during the pandemic period and 60 during the postpandemic period. Postpandemic patients were significantly older (60 years vs. 43 years, p < 0.001) and less likely to have epilepsy or other neurological diseases compared with pandemic patients (5 [8.3%] vs. 6 [38%], respectively; p = 0.009). Postpandemic patients were more likely than pandemic patients to have cardiovascular disease (24 [40%] vs. 1 [6%], respectively; p = 0.015), and they had higher scores on APACHE II (17 [13-22] vs. 14 [10-17], p = 0.002) and SAPS II (40 [31-51] vs. 31 [25-35], p = 0.002) upon admission to the ICU. Postpandemic patients had higher maximal SOFA score (9 [5-12] vs. 5 [4-9], respectively; p = 0.03) during their ICU stay. Postpandemic patients had more often septic shock (40 [66.7%] vs. 8 [50.0%], p = 0.042), and longer median hospital stays (15.0 vs. 8.0 days, respectively; p = 0.006). During 2015-2016, only 18% of the ICU- treated patients had received seasonal influenza vaccination. CONCLUSIONS: Postpandemic ICU-treated A(H1N1) pdm09 influenza patients were older and developed more often septic shock and had longer hospital stays than influenza patients during the 2009 pandemic.

Effect of display type and room illuminance in chest radiographs.

OBJECTIVES: To compare diagnostic accuracy in the detection of subtle chest lesions on digital chest radiographs using medical-grade displays, consumer-grade displays, and tablet devices under bright and dim ambient light. METHODS: Five experienced radiologists independently assessed 50 chest radiographs (32 with subtle pulmonary findings and 18 without apparent findings) under bright (510 lx) and dim (16 lx) ambient lighting. Computed tomography was used as the reference standard for interstitial and nodular lesions and follow-up chest radiograph for pneumothorax. Diagnostic accuracy and sensitivity were calculated for assessments carried out in all displays and compared using the McNemar test. The level of significance was set to p < 0.05. RESULTS: Significant differences in sensitivity between the assessments under bright and dim lighting were found among consumer-grade displays in interstitial opacities with, and in pneumothorax without, Digital Imaging and Communication in Medicine-Grayscale Standard Display Function (DICOM-GSDF) calibration. Compared to 6 megapixel (MP) display under bright lighting, sensitivity in pneumothorax was lower in the tablet device and the consumer-grade display. Sensitivity in interstitial opacities was lower in the DICOM-GSDF calibrated consumer-grade display. CONCLUSIONS: A consumer-grade display with or without DICOM-GSDF calibration or a tablet device is not suitable for reading digital chest radiographs in bright lighting. No significant differences were observed between five displays in dim light. KEY POINTS: • Ambient lighting affects performance of consumer-grade displays (with or without DICOM-GSDF calibration). • Bright light decreases detection of pneumothorax on non-medical displays. • Bright light decreases detection of interstitial opacities on DICOM-GSDF-calibrated, consumer-grade displays. • Dim light is sufficient to detect subtle chest lesions from all displays.

[Good specimens for the diagnosis and assessment of extent of lung cancer]. / Hyvä näytteenotto keuhkosyövän diagnostilkassa ja levinneisyyden arviossa.

In the diagnosis of lung cancer, tissue and cytologic specimens are needed for confirmation of the diagnosis, elucidation of the histologic type of lung cancer, determination of the extent of the cancer, and increasingly also for the molecular biological investigations required for the planning of drug therapy. The site and method of specimen collection are chosen multidisciplinarily on the basis of imaging studies, taking the clinical picture and patient safety into consideration. High-quality and quantitatively representative specimens are required for molecular biological analyses, and assessment of the response to drug therapy or modifying the treatment may require a new sample, which can be a tissue or cytologic specimen or a liquid biopsy.

Safety and biodistribution study of bone marrow-derived mesenchymal stromal cells and mononuclear cells and the impact of the administration route in an intact porcine model.

BACKGROUND AIMS: Bone marrow mononuclear cells (BM-MNCs) and bone marrow-derived mesenchymal stem stromal cells (BM-MSCs) could have therapeutic potential for numerous conditions, including ischemia-related injury. Cells transplanted intravascularly may become entrapped in the lungs, which potentially decreases their therapeutic effect and increases the risk for embolism. METHODS: Twelve pigs were divided into groups of 3 and received (99m)Tc- hydroxymethyl-propylene-amine-oxime-labeled autologous BM-MNCs or allogeneic BM-MSCs by either intravenous (IV) or intra-arterial (IA) transplantation. A whole body scan and single photon emission computed tomography/computed tomography (SPECT/CT) were performed 8 h later, and tissue biopsies were collected for gamma counting. A helical CT scan was also performed on 4 pigs to detect possible pulmonary embolism, 2 after IV BM-MSC injection and 2 after saline injection. RESULTS: The transplantation route had a greater impact on the biodistribution of the BM-MSCs than the BM-MNCs. The BM-MNCs accumulated in the spleen and bones, irrespective of the administration route. The BM-MSCs had relatively higher uptake in the kidneys. The IA transplantation decreased the deposition of BM-MSCs in the lungs and increased uptake in other organs, especially in the liver. Lung atelectases were frequent due to mechanical ventilation and attracted transplanted cells. CT did not reveal any pulmonary embolism. CONCLUSIONS: Both administration routes were found to be safe, but iatrogenic atelectasis might be an issue when cells accumulate in the lungs. The IA administration is effective in avoiding pulmonary entrapment of BM-MSCs. The cell type and administration method both have a major impact on the acute homing.

The occurrence of pneumonia diagnosis among neurosurgical patients: the definition matters.

BACKGROUND: Diagnosis of pneumonia in the hospital setting is a challenge due to the absence of a generally accepted pneumonia definition. METHODS: We prospectively evaluated six different clinical criteria for diagnosing pneumonia--physician's diagnosis (A), was compared to common methods, i.e., general surveillance method (B), consensus clinical criteria (C), and other three criteria (D, E, and F) among 390 neurosurgical patients treated in either the intensive care unit or the neurosurgical ward in a university hospital. RESULTS: The frequencies of pneumonia cases were: group A, 66 (16.9%); group B, 41 (10.1%); and group C, 55 (14.1%). Only 28 pneumonia cases were identified by all three criteria. The kappa values were: between A and B, 0.42 (95% confidence interval, CI; 0.27-0.57); between A and C, 0.49 (95% CI; 0.35-0.63); and between B and C, 0.68 (95% CI; 0.55-0.80). In group A, there were 34 false positive cases according to criterion B and 25 according to criterion C. Pneumonia cases were identified according to criterion D in 13 (3.3%), E in 35 (9.0%), and F in 51 (13.1%) cases, respectively. CONCLUSIONS: There was great variability in the presence of pneumonia among neurosurgical patients, depending on the criteria used. Our results support the idea that a more exact method for pneumonia diagnosis should be implemented to obtain more reliable results in this important infection of hospitalized patients, which is also used for benchmarking purposes. Furthermore, it seems important to treat all clinically suspected pneumonia cases whether or not the surveillance criteria are fulfilled.

Myocardium Assessment by Relaxation along Fictitious Field, Extracellular Volume, Feature Tracking, and Myocardial Strain in Hypertensive Patients with Left Ventricular Hypertrophy.

Background: Previous research has shown impaired global longitudinal strain (GLS) and slightly elevated extracellular volume fraction (ECV) in hypertensive patients with left ventricular hypertrophy (HTN LVH). Up to now, only little attention has been paid to interactions between macromolecules and free water in hypertrophied myocardium. Purpose: To evaluate the feasibility of relaxation along a fictitious field with rank 2 (RAFF2) in HTN LVH patients. Study Type. Single institutional case control. Subjects: 9 HTN LVH (age, 69 ± 10 years) and 11 control subjects (age, 54 ± 12 years). Field Strength/Sequence. Relaxation time mapping (T 1, T 1ρ , and T RAFF2 with 11.8 µT maximum radio frequency field amplitude) was performed at 1.5 T using a Siemens Aera (Erlangen, Germany) scanner equipped with an 18-channel body array coil. Assessment. ECV was calculated using pre- and postcontrast T 1, and global strains parameters were assessed by Segment CMR (Medviso AB Co, Sweden). The parametric maps of T 1ρ and T RAFF2 were computed using a monoexponential model, while the Bloch-McConnell equations were solved numerically to model effect of the chemical exchange during radio frequency pulses. Statistical Tests. Parametric maps were averaged over myocardium for each subject to be used in statistical analysis. Kolmogorov-Smirnov was used as the normality test followed by Student's t-test and Pearson's correlation to determine the difference between the HTN LVH patients and controls along with Hedges' g effect size and the association between variables, respectively. Results: T RAFF2 decreased statistically (83 ± 2 ms vs 88 ± 6 ms, P < 0.031), and global longitudinal strain was impaired (GLS, -14 ± 3 vs - 18 ± 2, P < 0.002) in HTN LVH patients compared to the controls, respectively. Also, significant negative correlation was found between T RAFF2 and GLS (r = -0.53, P < 0.05). Data Conclusion. Our results suggest that T RAFF2 decrease in HTN LVH patients may be explained by gradual collagen accumulation which can be reflected in GLS changes. Most likely, it increases the water proton interactions and consequently decreases T RAFF2 before myocardial scarring.

Diagnostic accuracy of computed tomography imaging of surgically treated acute acalculous cholecystitis in critically ill patients.

BACKGROUND: Acute acalculous cholecystitis (AAC) is a potentially fatal condition mainly affecting critically ill patients. Current experience from computed tomography (CT) findings in AAC is contradictory. METHODS: CT images of 127 mixed medical-surgical intensive care unit patients were retrospectively reviewed for the following findings: bile density, thickness and enhancement of the gallbladder (GB) wall, subserosal edema, greatest perpendicular diameters of the GB, width of extrahepatic bile ducts, gas within the GB, ascites, peritoneal fat edema, and diffuse tissue edema. Forty-three of these patients underwent open cholecystectomy, and 8 patients revealed a normal GB, 26 an edematous GB, and 9 a necrotic AAC. RESULTS: Abnormal CT findings were present in 96% of all the intensive care unit patients. Higher bile density in the GB body and subserosal edema was associated with an edematous GB (specificity, 93.6%; sensitivity, 23.1%). The most specific findings predicting necrotic AAC were gas in the GB wall or lumen, lack of GB wall enhancement, and edema around the GB (specificity, 99.2%, 94.9%, and 92.4%, respectively; and sensitivity, 11.1%, 37.5%, and 22.2%, respectively). CONCLUSIONS: The frequency of nonspecific abnormal findings in the GB of critically ill patients limits the diagnostic value of CT scanning in detecting AAC. However, in the case of totally normal GB findings in CT, the probability of necrotic AAC is low.

Attempt to treat congenital pseudarthrosis of the tibia with mesenchymal stromal cell transplantation.

BACKGROUND AIMS: Congenital pseudarthrosis of the tibia (CPT) caused by neurofibromatosis type 1 (NF1) is a refractory disease occurring in childhood. We present two cases that had failed all earlier treatment attempts and, as a last treatment attempt, the patients were chosen to receive mesenchymal stromal cell (MSC) transplantation prior to amputation. METHODS: The MSC from bone marrow (BM) were harvested from the iliac crest and cultured in osteoinductive medium for 3 weeks. The cultured MSC were injected in solution into BM canals of the tibia and around the resection line or bone defect in a 3-dimensional collagen sponge scaffold. After the MSC transplantation, the patients were monitored during a 10-month follow-up period. In both cases, bone formation at the pseudarthrosis site was observed and two of three treated bone defects healed. For clinical reasons not related to cell transplantation, such as new infection and pseudarthrosis and severe shortening of the leg, both extremities were finally amputated and bone samples were analyzed to evaluate MSC therapy effect and safety. RESULTS: MSC transplantation normalized bone remodeling, promoted bone resorption and improved the overall structure of bone. The number of osteoclasts in the cortical bone was 2-fold higher compared with the monitored situation before MSC transfer. In addition, the mineral content of the bone improved after transplantation. We could see no sign of aberrant bone formation or malignant transformation. CONCLUSIONS: Our data suggest that MSC transplantation is a possibility for treatment of CPT caused by NF1 in less severe cases without adjunct defects.

What Is the Applicability of a Novel Surveillance Concept of Ventilator-Associated Events?

BACKGROUND In 2013, the Centers for Disease Control and Prevention released a novel surveillance concept called the "ventilator-associated event," which focused surveillance on objective measures of complications among patients that underwent invasive ventilations. OBJECTIVE To evaluate the concordance and possible differences in efficacy (ie, disease severity and outcomes) between 2 surveillance paradigms: (1) infection-related ventilator-associated complications (iVAC) and (2) on conventional ventilator-associated pneumonia (VAP). DESIGN Prospective, observational, single-center cohort study. PATIENTS This study included 85 adult patients that received invasive ventilation for at least 2 consecutive calendar days in a 22-bed, adult, mixed medical-surgical intensive care unit in Finland between October 2014 and June 2015. RESULTS Among these patients, 9 (10.1 per 1,000 days of mechanical ventilation) developed iVAC (10.6%) and 20 (22.4 per 1,000 days of mechanical ventilation) developed conventional VAP (23.5%). The iVAC indicators were most often caused by atelectasis and fluid overload. Compared with patients with conventional VAP, patients with iVAC had significantly worse respiratory status but no other differences in disease severity or outcomes. CONCLUSIONS The incidence of conventional VAP was >2-fold that of iVAC, and the surveillance paradigms for VAP and iVAC capture different patterns of disease. Our results suggest that this novel surveillance concept, although based on objective measures of declining oxygenation, actually identified deteriorations of oxygenation due to noninfectious causes. Infect Control Hosp Epidemiol 2017;38:983-988.

Pulmonary embolism after off-pump coronary artery bypass surgery as detected by computed tomography.

BACKGROUND: The incidence of pulmonary embolism (PE) after coronary artery bypass surgery is ill defined. METHODS: Twenty-four patients undergoing off-pump coronary artery bypass surgery were enrolled in a prospective randomized study evaluating a new proximal aortic anastomotic device. Computed tomography was performed postoperatively about 1 week after surgery. RESULTS: Computed tomography showed signs of PE in 6 patients (25%), which were bilateral in 2 cases. None of these patients had symptoms or signs of PE or deep venous thrombosis. CONCLUSIONS: The present findings widen the controversial issue of thromboprophylaxis after cardiac surgery and suggest that low-dose heparin may be indicated after coronary artery bypass surgery.

Spyder aortic connector system in off-pump coronary artery bypass surgery.

PURPOSE: The Spyder aortic connector (Medtronic, Minneapolis, MN) is a new, promising connector device and its safety and efficacy have been evaluated in this study. DESCRIPTION: Twenty-two patients were randomized to proximal vein graft anastomosis with the Spyder aortic connector (Medtronic) or hand-sewn technique. EVALUATION: Twenty patients underwent multi-detector computed tomographic scans of the chest 6 months after surgery to evaluate vein graft patency. We have failed to successfully deploy three Spyder connector devices. Thus in this study we have evaluated the graft patency of 19 hand-sewn grafts and of 19 vein grafts anastomosed with the Spyder anastomotic device. Three vein grafts whose proximal anastomosis was accomplished with the Spyder anastomotic connector were occluded and all hand-sewn vein grafts were patent (16% vs 0%; p = 0.23). Stenosis of the proximal anastomosis was observed in seven vein grafts (37%), accomplished with the Spyder anastomotic connector, and in one (5%) hand-sewn vein graft (p = 0.042). CONCLUSIONS: The results of this study suggest that the use of the Spyder aortic connector device is associated with suboptimal 6-month graft patency.