A preliminary study to propose a diagnostic algorithm for PET/CT-detected incidental breast lesions: application of BI-RADS lexicon for US in combination with SUVmax.

OBJECTIVES: To develop a diagnostic algorithm for positron emission tomography (PET)-detected incidental breast lesions using both breast imaging reporting and data system (BI-RADS) and maximum standardized uptake value (SUVmax) criteria. METHODS: Fifty-six PET-detected incidental breast lesions from 51 patients, which were subsequently investigated by breast ultrasound within 1 month of the PET study, constituted the study cohort and they were finally verified by tissue diagnosis or a 2-year follow-up. Based on the maximum specificity with sensitivity > 60.0% and maximum sensitivity with specificity > 60.0%, two SUVmax cutoff values were calculated at 2 and 3.7. BI-RADS ≥ 4 was considered as highly suspicious for malignancy. The diagnostic accuracies were estimated for SUVmax levels above or below the cutoff points combined with the BI-RADS suspicion level. RESULTS: Overall, 46 benign and 10 malignant lesions were studied. The diagnostic characteristics of SUVmax ≥ 2, SUVmax ≥ 3.7, and BI-RADS ≥ 4 were 80.0%, 60.0%, and 80.0% for sensitivity, 73.9%, 95.7%, and 92.7% for specificity, and 75.0%, 89.3%, and 90.2% for accuracy, respectively. When the SUVmax threshold was set at 2, combined with BI-RADS suspicion level, the sensitivity, specificity, and accuracy were 100.0%, 69.6%, and 75.0%, respectively. The results for SUVmax threshold set at 3.7 combined with BI-RADS were 90.0%, 91.3%, and 91.1% for the sensitivity, specificity, and accuracy, respectively. A diagnostic algorithm was accordingly generated. CONCLUSION: The need for biopsy should be justified in low BI-RADS lesions presenting with high SUVmax at 3.7 or higher. The biopsy of patients with high B-IRADS and low SUVmax could be preserved. KEY POINTS: • A diagnostic algorithm was developed for PET-detected incidental breast lesions using both BI-RADS and SUVmax criteria. • Diagnostic performance was calculated separately and conjunctively for SUVmax ≥ 2, SUVmax ≥ 3.7, and BI-RADS ≥ 4. • The need for biopsy can be justified in BI-RADS < 4 lesions with SUVmax ≥ 3.7. Lesions with BI-RADS < 4 and indeterminate SUVmax (2 < SUVmax < 3.7) benefit from a short-interval follow-up. BI-RADS < 4 lesions with SUVmax < 2 may confidently be scheduled for routine screening.

CT-measured pulmonary artery diameter as an independent predictor of pulmonary hypertension in cystic fibrosis.

PURPOSE: The role of computed tomography (CT) scan, as a promising prognostic imaging modality in cystic fibrosis (CF), has been widely investigated, focusing on parenchymal abnormalities. The aim of the present study was to evaluate the diagnostic performance of thoracic vascular parameters on CT to detect pulmonary hypertension (PH). MATERIAL AND METHODS: CF patients who contemporaneously underwent CT and echocardiography were retrospectively enrolled. Baseline characteristics in addition to pulmonary artery diameter (PAD) and pulmonary to aortic (PA/A) ratio were compared between cohorts with and without PH, based on the results of echocardiography separately in paediatric patients (< 18) and adults (≥ 18). RESULTS: Of a total 119 CF patients, 39 (32.8%) had PH (paediatric: 23/78, 29.5%, adult: 16/41, 39%). In paediatric CF patients, mean age, HCo3, PCo2, and pulmonary artery diameter (PAD) were significantly higher in the PH group compared to the non-PH group. Mean pulmo however, only PAD remained as the independent predictor of PH based on multivariate analysis (overall: 22.86 mm [±3.86] vs. 18.43 mm [±4.72], p = 0.005, paediatric patients: 22.63 mm [±4.4] vs. 17.10 mm [±4.64], p = 0.03). Using a cut off of 19.25 mm, the diagnostic performance of PAD to detect PH was found to be as follows: sensitivity = 82%, specificity = 70%, and accuracy = 73.1%. No significant difference was demonstrated in PAD between PH and non-PH groups in adults with CF (23.19 [±3.60] vs. 21.34 [±3.49], p = 0.7). CONCLUSIONS: In CF patients, PAD revealed an age-dependent performance to detect PH. PAD can be applied to predict pulmonary hypertension in paediatric CF patients and may be recommended to be routinely measured on follow-up chest CT scan in childhood CF.

Transmission electron microscopy study of suspected primary ciliary dyskinesia patients.

Primary ciliary dyskinesia (PCD) is a rare autosomal recessive condition often presenting with chronic respiratory infections in early life. Transmission electron microscopy (TEM) is used to detect ciliary ultrastructural defects. In this study, we aimed to assess ciliary ultrastructural defects using quantitative methods on TEM to identify its diagnostic role in confirming PCD. Nasal samples of 67 patients, including 37 females and 30 males (20.3 ± 10.7 years old), with suspected PCD symptoms were examined by TEM. The most common presentations were bronchiectasis: 26 (38.8%), chronic sinusitis: 23 (34.3%), and recurrent lower respiratory infections: 21 (31.3%). Secondary ciliary dyskinesia, including compound cilia (41.4%) and extra-tubules (44.3%), were the most prevalent TEM finding. Twelve patients (17.9%) had hallmark diagnostic criteria for PCD (class 1) consisting of 11 (16.4%) outer and inner dynein arm (ODA and IDA) defects and only one concurrent IDA defect and microtubular disorganization. Also, 11 patients (16.4%) had probable criteria for PCD (class 2), 26 (38.8%) had other defects, and 18 (26.9%) had normal ciliary ultrastructure. Among our suspected PCD patients, the most common ultrastructural ciliary defects were extra-tubules and compound cilia. However, the most prevalent hallmark diagnostic defect confirming PCD was simultaneous defects of IDA and ODA.

Interleukin 9 serum level and single nucleotide polymorphism in patients with asthma.

BACKGROUND: Asthma is a chronic inflammatory disease of airways which accounts for a huge economic, morbidity and mortality burden. There are different cytokines that contribute to asthma pathophysiology. Learning about these cytokines leads to attaining novel anti-inflammatory treatments for asthma control. OBJECTIVES: The objective of this study is to investigate the association between interleukin-9 serum level and gene polymorphism with asthma susceptibility. METHODS: This was a case-control study of 70 asthmatic patients and 77 healthy control adults aged 18-60. Asthma diagnosis and severity were based on physician diagnosis, pulmonary function test (PFT) and 2016 guild line of Global Initiative for Asthma (GINA). Interleukin 9(IL -9) serum level was measured using sandwich enzyme linked immunosorbent assay.  IL9 promoter single nucleotide polymorphism (SNP) (rs2069882) was also assessed using Real-Time PCR System. RESULTS: There was no significant association between IL-9 SNP polymorphism and asthma. IL-9 serum level was significantly associated with asthma susceptibility (p value= 0.016) and absolute eosinophil count (AEC) (P value=0.033) however its corelation with atopic asthma type, asthma sivierity and Immunoglubin E serum level were not statistically significant. CONCLUSION: Although there was no association between IL-9 SNP and asthma, but IL-9 serum level was significantly correlated with asthma susceptibility and AEC.

Langerhans cell histiocytosis of the lung and thyroid, co-existing with papillary thyroid cancer.

A 24-year-old man presented to our center with a huge goiter compressing his airway. He had a previous diagnosis of Langerhans cell histiocytosis (LCH) of the lung. Core needle biopsy was consistent with histiocytosis. Thyroidectomy was performed. A very invasive mass was encountered at the time of surgery. Histopathology result was consistent with an invasive papillary cancer of thyroid co-occurring with LCH. Although association of LCH with different malignancies has been reported, co-existing invasive papillary thyroid cancer and LCH is a rare combination.

Value and Safety of High Flow Oxygenation in the Treatment of Inpatient Asthma: A Randomized, Double-blind, Pilot Study.

This study was aimed to compare the value and safety of high-flow nasal cannula (HFNC) and conventional oxygen therapy (COT) in patients with asthma exacerbation. In this randomized double-blind study, forthy patients with moderate-to-severe asthma exacerbations, aged 18 years or older were enrolled. Patients were randomly assigned to receive either HFNC or COT for 24 hours. Dyspnea scale, O2 saturation, spirometer indexes, respiratory and heart rate, and arterial blood gas (ABG) were compared within 2 and 24 hours of intervention. Dyspnea scale decreased significantly from 7.58±1.04 to 6.45±0.51 (p=0.000), and from 7.84±1.7 to 6.89±0.9 (p=0.049) within 2 hours in HFNC and COT groups, respectively. In the HFNC group, forced expiratory volume in one second (FEV1) was 1.48 ±0.94 L at the time of admission and increased to 1.61±0.66 L (p=0.19) and 1.82±0.92 L (p=0.003) after 2 and 24 hours of experience, respectively. In addition, in the COT group, FEV1 increased from 1.43±0.65 L to 1.46±0.53 L and 1.64±0.6 L in the respective time-points, (p=0.071, 0.079). PaO2 and O2 saturation increased significantly in both groups during the first 2 hours. Two patients in the HFNC group had the complaint of nasal irritation and the device-produced heat; while one patient in the COT group needed more respiratory care. HFNC could be a therapeutic option for asthma exacerbation among adult patients after considering the patient's selection.

Role of Innate Lymphoid Cells in Lung Disease.

Innate lymphoid cells (ILCs) are identified as novel population of hematopoietic cells which protect the body by coordinating the innate immune response against a wide range of threats including infections, tissue damages and homeostatic disturbances. ILCs, particularly ILC2 cells, are found throughout the body including the brain. ILCs are morphologically similar to lymphocytes, express and release high levels of T-helper (Th)1, Th2 and Th17 cytokines but do not express classical cell-surface markers that are associated with other immune cell lineages. Three types of ILCs (ILC1, 2 & 3) have been reported depending upon the cytokines produced. ILC1 cells encompass natural killer (NK) cells and interferon (IFN)-g releasing cells; ILC2 cells release the Th2 cytokines, IL-5, IL-9 and IL-13 in response to IL-25 and IL-33; and ILC3 cells which release IL-17 and IL-22. ILC2 cells have been implicated inmucosal reactions occurring in animal models of allergic asthma and virus-induced lung disorders resulting in the regulation of airway remodeling and tissue homeostasis. There is evidence for increased ILC2 cell numbers in allergic responses in man but little is known about the role of ILCs in chronic obstructive pulmonary disease (COPD). Further understanding of the characteristics of ILCs such as their origin, location and phenotypes and function would help to clarify the role of these cells in the pathogenesis of various lung diseases. In this review we will focus on the role of ILC2 cells and consider their origin, function,location and possible role in the pathogenesis of the chronic inflammatory disorders such as asthma and COPD.

Flow cytometry applications in the study of immunological lung disorders.

The use of flow cytometry in the clinical laboratory has grown substantially in the past decade. Flow cytometric analysis provides a rapid qualitative and quantitative description of multiple characteristics of individual cells. For example, it is possible to detect the cell size and granularity, aspects of DNA and RNA content and the presence of cell surface and nuclear markers which are used to characterize the phenotype of single cells. Flow cytometry has been used for the immunophenotyping of a variety of specimens including whole blood, bone marrow, serous cavity fluids, (cerebrospinal fluid) CSF, urine and all types of body fluids. The technique has also been applied to human bronchoalveolar lavage (BAL) fluid, peritoneal fluids and blood. In this review, we describe the current status of the application of flow cytometry as a diagnostic tool in various lung diseases. We focus on the analysis of BAL cell composition in chronic obstructive lung disease (COPD), asthma, lung cancer, sarcoidosis, tuberculosis and idiopathic eosinophilic pneumonia (IEP).

Association between Severity of Chronic Obstructive Pulmonary Disease and Lung Function Tests.

BACKGROUND: The burden of chronic obstructive pulmonary disease (COPD) is quite high and its prevalence is increasing. We aimed to evaluate the correlation of COPD severity according to the American Thoracic Society (ATS) criteria with spirometric measurements in patients admitted to the emergency ward. MATERIALS AND METHODS: In this cross-sectional descriptive study, 50 randomly selected patients with COPD admitted to the emergency ward in a tertiary care center were evaluated. The COPD severity according to the ATS criteria was measured and its association with spirometric findings was evaluated. The statistical analysis was performed by SPSS software and the Kendall's tau-b correlation test. RESULTS: The mean age (±standard deviation) was 64.3 ± 11.3 years. Twelve percent were females and 88 percent were males. The COPD severity, according to the ATS criteria, was mild in 16%, moderate in 48%, severe in 32% and very severe in four percent. There was a statistically significant correlation between total lung capacity (TLC) and COPD severity (P = 0.013, r = 275). Besides, there was a statistically significant correlation between functional residual capacity (FRC) and COPD severity (P = 0.022, r = 255). Age, sex, and the other spirometric findings especially FEV1 and FVC had no association with COPD severity (P > 0.05). CONCLUSION: According to the obtained results, it is concluded that determining the COPD severity according to the ATS criteria may help the physicians to estimate the patients' prognosis and therapeutic planning. However, the spirometric measurements may not be replaced by ATS criteria.

Evaluation of plethysmography for diagnosis of postintubation tracheal stenosis.

OBJECTIVES: Post-intubation tracheal stenosis is a serious disease caused by cuff pressure during tracheal intubation. The reported prevalence of post-intubation tracheal stenosis is 10%-22% in intubated patients. Invasive diagnostic methods based on fiberoptic or rigid bronchoscopy are suggested for initial assessment and treatment. This study aimed to evaluate plethysmography as an alternative diagnostic tool for post-intubation tracheal stenosis. We also assessed the relationship between plethysmography and bronchoscopy findings in patients with post-intubation tracheal stenosis. METHODS: The sample included 30 patients who were admitted to our intensive care unit or surgical ward during the course of a year, and diagnosed with post-intubation tracheal stenosis. All patients underwent plethysmography and rigid bronchoscopy. The relationship between the plethysmography and bronchoscopy findings was examined. RESULTS: Stricture intensity had the strongest correlation with upper airway resistance (p = 0.001). The relationship of length of stricture to forced expiratory volume in 1 s and maximum expiratory flow 50 and 75 was significant in univariate analysis, and to reserve volume and total lung capacity in multivariate analysis. CONCLUSION: Significant relationships were found between plethysmography variables and rigid bronchoscopy findings in patients with post-intubation tracheal stenosis, and some formulas were developed to give an alternative estimate of stricture severity, without bronchoscopy.

Performance assessment of Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score II in a referral respiratory intensive care unit in Iran.

BACKGROUND/PURPOSE: Nowadays, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) scoring systems have drawn much attention for the evaluation and prediction of disease process in patients admitted to intensive care units (ICUs). To use these scoring tools, their predicting power must be initially validated for the target patients. This study was conducted to evaluate the performance of these two scoring systems in an ICU for respiratory diseases in Iran. MATERIAL AND METHODS: All records of patients admitted during a 1-year period were retrospectively reviewed, and the APACHE II and SAPS II scores were calculated accordingly. Information gathering was performed using a questionnaire. RESULTS: A total of 415 records were used. The mean age of patients was 49.28 ± 0.94 years. Using receiver operating-characteristic curve, cutoff points for 80% sensitivity and specificity of mortality prediction for APACHE and SAPS scores were 13.5 and 27.5, respectively. Calibration and discrimination studies indicated an acceptable status for both scales, but APACHE II scoring system seemed to show rewarding outcomes. CONCLUSION: Results indicate that APACHE II scoring system can be considered as a reliable method for predicting mortality in our referral respiratory ICU.

Evaluation of maximum O2 consumption: using ergo-spirometry in severe heart failure.

Although sport-physiologists have repeatedly analyzed respiratory gases through exercise, it is relatively new in the cardiovascular field and is obviously more acceptable than standard exercise test, which gives only information about the existence or absence of cardiovascular diseases (CVDs). Through the new method of exercise test, parameters including aerobic and anaerobic are checked and monitored. 22 severe cases of heart failure, who were candidates of heart transplantation, referring to Massih Daneshvari Hospital in Tehran from Nov. 2007 to Nov. 2008 enrolled this study. The study was designed as a cross-sectional performance and evaluated only patients with ejection fraction less than 30%. O2 mean consumption was 6.27±4.9 ml/kg/min at rest and 9.48±3.38 at anaerobic threshold (AT) exceeding 13 ml/kg/min in maximum which was significantly more than the expected levels. Respiratory exchange ratio (RER) was over 1 for all patients. This study could not find any statistical correlations between VO2 max and participants' ergonomic factors such as age, height, weight, BMI, as well as EF. This study showed no significant correlation between VO2 max and maximum heart rate (HR max), although O2 maximum consumption was rationally correlated with expiratory ventilation. This means that the patients achieved maximum ventilation through exercise in this study, but failed to have their maximum heart rate being led probably by HF-induced brady-arrhythmia or deconditioning of skeletal muscles.

Improving the Practice of Nutrition Therapy in the NRITLD Critically Ill Patients: An International Quality Improvement Project.

BACKGROUND: In previous decades several studies have been performed demonstrating that providing appropriate nutritional support to intensive care unit patients affects complications, time of mechanical ventilation, length of ICU stay, and risk of death. In this study we provided a report of nutrition statuses in Masih Daneshvari's ICU as compared to 156 ICUs from 20 countries that participated in an international nutrition survey. MATERIALS AND METHODS: All patients admitted to an intensive care unit during a specified one-month period who required artificial nutrition were included in this study. Characteristics of patients, performance of nutrition practices, and ICU outcomes were registered for all patients and compared with data from 156 other intensive care units from various countries around the world. RESULTS: Twenty patients, of which 11(55%) were males and 9(45%) were females, were included in this study. The median age was 50.5 yrs (IQR: 40.5-56.0). Seventeen (85%) of them had EN nutrition only, 2(10%) had PN nutrition only, and 1(5%) had both EN and PN nutrition during their stay in the ICU. The adequacy of calorie intake was 67.6% (vs. 61.1% in all 157 ICUs) and the adequacy of protein intake was 84.9% (vs. 56.7% in 157 ICUs). CONCLUSION: In our ICU, enteral feeding was superior to parenteral feeding. Also we considered early initiation of enteral feeding within 48 hours following ICU admission. We just used polymeric formula during this study. As a result of formula variation limits, we overestimated calories and protein needs. Glutamine and Selenium supplementations have not been used yet for patient in our ICU, regardless of their proven benefits in oxidative stress conditions like pulmonary diseases. Therefore, limited use of supplementations like selenium is inevitably among the disadvantages of Masih Daneshvari Hospital's ICU, which is a tertiary-care center for chronic pulmonary diseases.

Extralobar sequestration in anterior mediastinum with pericardial agenesis.

We report a very rare case of extralobar sequestration and pericardial agenesis in a 22-year-old man. A computed tomographic (CT) scan demonstrated an anterior mediastinal mass. No aberrant artery was preoperatively identified. The patient underwent surgery with an impression of thymoma. An extralobar sequestration receiving its blood supply from the left pulmonary artery, accompanied with pericardial agenesis, was noted at the time of operation. The anterior mediastinum is an unusual site for extralobar sequestions. It is recommended to include extralobar sequestration in the differential diagnosis of anterior mediastinal masses, even if the aberrant artery is not recognized on the computed tomographic scan.

The effects of air pollution on acute respiratory conditions.

OBJECTIVE: Air pollution and its potential health effects are very important worldwide. It is particularly problematic in densely populated cities of developing countries that suffer from a lack of both short- and long-term programmes for air pollution control. We decided to study the short-term effects of air pollution on lung health by assessing the relationship between the levels of six air pollutants and emergency visits for asthma and COPD exacerbations in Tehran, Iran. METHODOLOGY: We monitored the daily attendances for acute respiratory conditions (asthma attacks and COPD exacerbations) to the emergency departments of five major hospitals together with the daily concentrations of six major pollutants during a 5-month period in Tehran. The association between these acute respiratory conditions and the levels of air pollutants was determined by multiple stepwise regression. RESULTS: A correlation was observed between the number of hospital admissions for asthma and the weekly mean concentration of nitrogen dioxide (P < 0.05). The 3-day and 10-day mean concentrations of sulphur dioxide were also found to be directly associated with the number of asthma admissions during this period (P < 0.05). No direct correlation was observed for other variables. CONCLUSION: This study further emphasizes the deleterious effects of air pollution on respiratory health in major populated cities such as Tehran and suggests that increased attention needs to be given to urgent control of air pollution problems.