To repeat or not to repeat: Radiologists demonstrated more decisiveness than their fellow radiographers in reducing the repeat rate during mobile chest radiography

INTRODUCTION

Radiologists and radiographers play a complementary role in providing an optimal image quality with decrease radiation dose and proper diagnosis during chest radiographs. We aim Investigate years of experience among radiologists and radiographers on perception of image quality and its impact on repeat rate when evaluating portable pediatric chest radiographs.

METHODS

IRB approved retrospective study consisted of randomly selected images (n = 131) of pediatric portable chest radiographs. Images were blindly assessed by four radiologists and four radiographers. Readers were asked to assess qualitative and quantitative image quality by rating: image quality, decision to repeat and image technique. All data was compared employing Pearson's Correlation, Visual grading characteristic (VGC) and Cohens' kappa analyses.

RESULTS

Image quality: Radiologists (88.4%) rated images as excellent significantly more than radiographers (11.6%), and radiographers (90.1%) as poor significantly more than radiologists (9.9%) (p < 0.05). Repeat: Radiologists (57%) decided not to repeat images significantly more than radiographers (43%) (p < 0.05). Image technique: Radiologists rated images as acceptable (65%) and excellent (97.7%) significantly more than radiographers (35% and 2.3% respectively) (p < 0.05), whereas radiographers (84%) assessed image technique as poor significantly more than radiologists (16%) (p < 0.05). VGC: radiographers had slightly better qualitative evaluation of image quality than radiologists. An association between image quality (p < 0.002) and repeat decision (p < 0.044) with years of experience was established when comparing years of experience with image assessment rubric, while no association was noted with image technique (p < 0.9).

CONCLUSION

Radiologists demonstrated more decisiveness than their fellow radiographers in reducing the repeat rate of portable pediatric chest radiographs. Interestingly, years of experience only seem to affect image technique and image quality assessment among radiologists.

IMPLICATIONS FOR PRACTICE

Continuous education of radiographers and close collaboration with radiologists is crucial to achieve optimal image quality and low radiation doses.

First data on Pneumocystis jirovecii colonization in patients with respiratory diseases in North Lebanon

Pneumocystis colonization may play a role in transmission and local inflammatory response. It was explored in patients with respiratory diseases in North Lebanon. Overall prevalence reached only 5.2% (95% CI 2.13–10.47) but it was higher (17.3%) in the subpopulation of patients with chronic obstructive pulmonary disease (COPD). COPD was the only factor associated with a significantly increased risk of colonization. mtLSU genotyping revealed predominance of genotype 2, identified in five patients (71.4%), including one patient who had co-infection with genotype 3. These first data in North Lebanon confirm Pneumocystis circulation among patients with respiratory diseases and the potential for transmission to immunocompromised patients.

Predictors of intra-operative parathyroid hormone decline in subjects operated for primary hyperparathyroidism by minimally invasive parathyroidectomy

BACKGROUND

The predictors of intra-operative PTH (IOPTH) decline during minimally invasive parathyroidectomy (MIP) for primary hyperparathyroidism have been but poorly studied.

MATERIALS AND METHODS

This retrospective study included 108 patients who underwent MIP for a single adenoma. Serum calcium and phosphorus were measured before surgery and 1 day post-operatively. IOPTH was measured before (intra-operative preincision or PTHt0) and 10 min after removal of the adenoma (PTHt10). The Modification of Diet in Renal Disease (MDRD) equation was used to estimate the glomerular filtration rate. The weight of the adenoma was assessed in all the subjects.

RESULTS

The sex ratio female/male was 5.37 with a mean age of 57.3 yr. The mean pre- and postoperative values were for calcium 2.80 and 2.19 mmol/l, respectively (p<0.0001) and for phosphorus 0.90 and 1.16 mmol/l, respectively (p<0.0001). The PTH dropped from a mean value of 184.8 to 50.8 pg/ml 10 min after adenoma resection with a mean drop of 69.7%. Thirteen patients (12%) did not achieve a PTH fall of more than 50%. In a bivariate analysis, age, an MDRD<60 ml/min and weight of adenoma were inversely associated with IOPTH fall (p=0.009, p=0.004, and p<0.001, respectively) while gender, body mass index, hypertension, diabetes, pre-operative phosphorus and calcium had no significant effects. In the multivariate analysis, age, weight of adenoma, and MDRD were still independent negative predictors of the IOPTH fall (p=0.01, p=0.018, and p<0.001, respectively).

CONCLUSION

Our results suggest that during MIP the presence of a parathyroid adenoma with a high weight, in an elderly subject or in a subject with altered renal function, will result in a lesser degree of IOPTH fall.

The defensive role of lysozyme in human gingiva in inflammatory periodontal disease

BACKGROUND AND OBJECTIVE

The presence of lysozyme in human gingiva has not previously been demonstrated. In this study, we looked for evidence for the potential role of lysozyme as a protector of gingival elastic fibres. The objective of this study was also to determine the ex vivo susceptibility to hydrolysis of gingival elastic fibres from patients with or without periodontal disease by human leukocyte elastase and by human cathepsin G.

MATERIALS AND METHODS

Using gingival tissue sections from eight control, 10 gingivitis and 10 periodontitis patients, we evaluated the area fraction occupied by gingival elastic fibres (after selective staining) by the use of automated image analysis. In the ex vivo experiments, serial tissue sections from four control, four gingivitis, four young periodontitis and four aged periodontitis patients were submitted to the action of human leukocyte elastase and cathepsin G, after which enzymatic activities were determined by image analysis. Indirect immunodetection of lysozyme was also done on tissue sections for all patients included in this study.

RESULTS

Large variations of the area fraction occupied by elastic fibres were observed in human gingiva from young and aged patients with and without periodontal disease. In control and gingivitis patients, leukocyte elastase and cathepsin G had high comparable elastin solubilizing activities. With young and aged periodontitis patients, the two serine proteinases had weak elastin solubilizing activities. Lysozyme appeared to be present at the periphery of gingival elastic fibres in periodontitis patients.

CONCLUSION

Lysozyme can be considered an important natural protector of elastic fibres in pathological gingiva.

Large hepatic mesenchymal hamartoma leading to mid-trimester fetal demise

This report describes a fetus with a large multiloculated cystic liver mass. Two small abdominal cysts were seen on ultrasound at 19 weeks of gestation but the patient was referred to us at 23 weeks, after the mass had grown to 8.0 x 5.6 x 7.0 cm, displacing intra-abdominal organs, heart and diaphragm. There was a small amount of ascites but no hydrops. There was polyhydramnios and a thick hyperechoic placenta. After detailed sonograms and MRI suggested the diagnosis of cystic mesenchymal hamartoma of the liver, cyst decompression was favored and consent was obtained. Unfortunately, absence of fetal cardiac activity was noted on the day of the planned intervention. Autopsy confirmed the diagnosis and demonstrated placental changes consistent with mesenchymal stem villous hyperplasia of the placenta. Large fetal cystic abdominal masses that compress the heart, lungs and other organs may benefit from prenatal decompression. This is the first report of cystic hamartoma of the liver apparent on second-trimester sonography, and the fourth time such a lesion is associated with fetal or neonatal death out of 11 cases diagnosed prenatally.

Neonatal alloimmune thrombocytopenia due to anti-HPA-2b (anti-Koa)

Most severe cases of neonatal alloimmune thrombocytopenia (NAIT) are due to anti-HPA-1a (anti-PlA1) antibodies. We report a case of NAIT due to anti-HPA-2b that resulted in in utero intracranial hemorrhage.A 33-year-old G2P1A0 Caucasian woman had a routine ultrasound at 34 weeks. The fetus appeared to have a left hemispheric hematoma. IVIG, 1g/kg, was started immediately and administered weekly until delivery. One day after receiving the first dose of IVIG, fetal platelet count was 18 x 10(9)/L, and Hb was 116 g/L. Eleven mL of matched platelets compatible by monoclonal antibody immobilization of platelet antigens (MAIPA) assay were transfused in utero, raising the platelet count to 62 x 10(9)/L. Repeat transfusions were done later that week and 1 week later, with pretransfusion counts of 19 x 10(9)/L and 16 x 10(9)/L, respectively. Delivery by C section was done at 35.5 weeks, after the third platelet transfusion. Platelet count at birth was 77 x 10(9)/L. Drainage of the hematoma was performed after transfusion. Testing with a solid phase ELISA revealed reactivity against GP1b/IX. MAIPA testing after platelet treatment with the protease inhibitor leupeptin demonstrated the presence of anti-HPA-2b. On PCR-SSP the mother was HPA-2a homozygous, the father was HPA-2a/2b. Antibodies against the HPA-2b antigen located on the GP1b/IX complex have been reported in rare cases of NAIT. Testing is complicated by proteolytic degradation of the antigen-bearing fragment. Compatible platelets are easily found since approximately 85 percent of donors are HPA-2a/2a.

Outcome of the prenatally diagnosed congenital cystic adenomatoid lung malformation: a Canadian experience

Congenital cystic adenomatoid malformation of the lung (CCAM) is diagnosed by prenatal ultrasonography with an increasing frequency but controversy persists as to its prognosis and prenatal management.

METHOD

A multi-institutional study of cases of CCAM diagnosed antenatally identified by ultrasonographers and by a review of hospital charts.

RESULTS

We obtained 48 cases from five centers. We estimate the incidence of CCAM at 1:25,000 to 1:35,000 pregnancies. The incidence of voluntary abortions was 15% (7/48), of spontaneous abortions 2% (1/41) and of postnatal death 10% (4/40). One of the postnatal deaths was from trisomy 18. Of the 7 aborted fetuses, 2 had multiple malformations and 1 had severe hydrops and oligohydramnios; the other 4 had a large mass with mediastinal displacement but without hydrops. When pregnancy was allowed to continue, 56% of the lesions regressed spontaneously, even though one third of these had initial progression. In 17 cases (42%) the mediastinal shift corrected itself, sometimes by simple growth of the fetus but most often by a decrease in the size of the lung mass. In 1 fetus, repeated needle decompressions followed by double-pigtail catheter drainage of large cysts allowed regression of hydrops. Despite this, neonatal death occurred from pulmonary hypoplasia.

CONCLUSION

CCAM can lead to fetal or neonatal demise from hydrops, lung hypoplasia, prematurity or severe associated malformations, but has a good prognosis in the majority of cases.

Surfactant levels after reversible tracheal occlusion and prenatal steroids in experimental diaphragmatic hernia

BACKGROUND/PURPOSE

In normal lungs, fetal tracheal occlusion (TO) induces lung growth but decreases the number of type II cells; this is remedied if TO is released (TR) before delivery. In the current study, the effects of TO with or without TR on pulmonary structure and surfactant were assessed in the ovine model in which lung hypoplasia was induced by creation of a diaphragmatic hernia (CDH).

METHODS

A left-sided CDH was created in fetal lambs at 80 days gestation; TO was done at 108 days; and TR at 129 days. All ewes were given 1 dose of glucocorticoids at 135 days. At 136 days, the fetus was delivered. Lung weight to body weight ratio, mean terminal bronchiole density, type II cell density, bronchoalveolar lavage fluid (BAL) phosphatidylcholine (PC), BAL surfactant protein A (SP-A) and B (SP-B), and lung tissue SP-A and SP-B were assessed in CDH, CDH with TO, CDH with TO and TR, and controls.

RESULTS

CDH lungs were hypoplastic and structurally immature, but had increased type II cell density. TO with or without TR caused lung growth with normalization of lung parenchymal architecture and type II cell density. Although the BAL SP-A and BAL SP-B were similar in all 4 groups, the BAL PC was low in CDH with or without TO or TR. Also, lung tissue SP-B levels were low in CDH with or without TO or TR. However, lung tissue SP-A levels were normal in CDH, but low in CDH with TO with or without TR.

CONCLUSIONS

Despite the finding that lung morphology was improved in CDH with TO with or without TR animals, surfactant content and composition remained abnormal. Although surfactant secreted early by the fetus into alveolar spaces contained normal levels of BAL SP-A and BAL SP-B, the low levels of BAL PC and low lung tissue stores of SP-B indicate that these experimental lambs may experience respiratory insufficiency soon after birth. This implies that prophylactic surfactant at birth might be beneficial for CDH.

Psychosocial correlates of pain attributions in women with dyspareunia

The relationship between patients' causal attributions for pain and biopsychosocial measures was investigated in a sample of 100 women with dyspareunia. Independently of findings from the gynecological examinations, causal attributions were related to adjustment. More specifically, the women who made psychosocial attributions reported higher pain scores, higher levels of psychological distress, lower levels of marital adjustment, more problems with sexual function, and more frequent reports of sexual assault. The relationship between psychosocial causal attributions for pain and psychosocial distress may be clinically useful in the multidisciplinary treatment of this and other pain disorders, regardless of actual physical pathology.

Prenatal percutaneous needle drainage of cystic sacrococcygeal teratomas

Prenatal ultrasound (US) permits in utero diagnosis of sacrococcygeal teratoma (SCT), follow-up of tumor size, and the early identification of complications, allowing for a more timely and appropriate delivery. The recommended management of large SCTs is delivery by cesarean section (CS) to prevent dystocia, tumor rupture, hemorrhage, and death. However, even delivery by CS can be difficult, necessitating a large hysterotomy that adds to maternal morbidity. The authors report two cases of cystic SCTs in which prenatal percutaneous drainage allowed for an uncomplicated vaginal delivery. In the first case, a large unilocular cystic SCT was diagnosed at 31 weeks' gestation on prenatal US. The fetal presentation was breech, and the mass was steadily increasing in size, preventing spontaneous version. At 37 5/7 weeks, the cyst was percutaneously drained under US guidance allowing for successful external version. Repeat drainage just before induction of labor permitted a successful vaginal delivery. In the second case, the cystic SCT was percutaneously drained just before induction of labor at full term, again allowing for an uncomplicated vaginal delivery. Prenatal percutaneous needle drainage of cystic SCTs offers an alternative to CS that results in decreased risks for both mother and fetus.

Affect and marital adjustment in women's rating of dyspareunic pain

OBJECTIVE

To investigate the extent to which depressive symptomatology, anxiety, and marital adjustment mediate pain ratings in women suffering from dyspareunia.

METHOD

Seventy-six women with dyspareunia were administered the depression and anxiety scales of Derogatis's Brief Symptom Inventory and the McGill Pain Questionnaire. They also underwent a manual-visual gynecological examination, an ultrasound, and a colposcopy in an attempt to identify potential evidence and type of organicity.

RESULTS

Depressive symptomatology, anxiety, and marital adjustment together accounted for a significant amount of the variance in pain ratings, although only anxiety and marital adjustment were independent predictors of pain ratings in the entire group of women with dyspareunia. When multiple regression analyses were then applied to different diagnostic subgroups of dyspareunia, the independent predictors of pain rating varied depending on the findings from the gynecological examinations.

CONCLUSION

Affect and marital adjustment appear to be significant predictors of dyspareunic pain rating, although the independent contribution of psychosocial variables may vary depending on the presence and type of organic findings.

Biopsychosocial profile of women with dyspareunia

OBJECTIVE

To compare biopsychologic profiles of women with dyspareunia with a matched no-pain control sample, and to determine whether dyspareunia subtypes based on physical findings have different psychosocial profiles from matched controls.

METHODS

One hundred and five women with dyspareunia and 105 matched no-pain control women underwent standard gynecologic examination, endovaginal ultrasound, and colposcopy. They also completed a structured interview inquiring about pain other than dyspareunia, sexual function, and history of abuse, the Brief Symptom Inventory, the Sexual Opinion Survey, and the Locke-Wallace Marital Adjustment Scale.

RESULTS

In comparison with women who do not experience pain with intercourse, the dyspareunia sample was found to have more physical pathology on examination, and they reported more psychologic symptomatology, more negative attitudes toward sexuality, higher levels of impairment in sexual function, and lower levels of marital adjustment. They did not report more current or past physical or sexual abuse. However, when the undifferentiated dyspareunia sample was divided into subtypes based on physical findings from the gynecologic examinations, the pattern of significant differences from controls varied according to dyspareunia subtype. Elevated psychologic symptomatology and relationship maladjustment were confined to the subtype with no discernible physical findings who reported levels of sexual function not significantly different from matched controls. The vulvar vestibulitis subtype suffered the highest levels of sexual impairment, although this subtype was not characterized by higher levels of psychologic symptoms than controls.

CONCLUSION

As an undifferentiated group, women with dyspareunia have more physical pathology, psychologic distress, sexual dysfunction, and relationship problems. However, this pattern of differences appears to vary depending on the presence and type of physical findings evident on examination. Dyspareunia is a heterogeneous disorder requiring comprehensive gynecologic and psychosocial assessment to determine differentiated treatment strategies.

Transvaginal intratubal methotrexate treatment of ectopic pregnancy

OBJECTIVE

To evaluate the efficacy of transvaginal intratubal methotrexate (MTX) treatment of tubal ectopic pregnancy (EP).

SETTING

Outpatient setting in University Hospital.

PATIENTS

Forty women with early EP and rising serum beta-human chorionic gonadotropin (beta-hCG) levels.

INTERVENTION

Transvaginal intratubal administration of MTX (1 mg/kg body weight).

MAIN OUTCOME MEASURES

Success was defined as declining serum beta-hCG to undetectable levels, no tubal dilatation on ultrasound examination, and no further intervention was required.

RESULTS

Treatment was associated with a 70% success rate. No difference was found in the success rate between women with an embryo (76.9%) and those with no embryo in their fallopian tubes (66.7%). The initial serum beta-hCG levels were also not different between patients who were successfully treated and those who failed to respond to the treatment. Despite declining serum beta-hCG levels, tubal rupture occurred in two patients.

CONCLUSIONS

Treatment of EP by transvaginal MTX administration is associated with a 70% success rate. This is independent of the presence of an embryo or the initial serum beta-hCG levels. Rupture of EP can still occur despite low and declining serum beta-hCG levels.

Syndrome of mental retardation and distal arthrogryposis in sibs

Two sisters presented with a syndrome of characteristic facial anomalies and distal arthrogryposis. The older sister is now 4 years old and is severely mentally retarded. Her sister died of respiratory failure due to hypoplastic lungs shortly after birth. The occurrence of this potentially lethal syndrome in 2 sisters with unaffected parents suggests autosomal recessive inheritance.