The association between gut microbiome and growth in infants with cystic fibrosis

BACKGROUND

In cystic fibrosis (CF), pathophysiologic changes in the gastrointestinal tract lead to malnutrition and altered gut microbiome. Microbiome alterations have been linked to linear growth, gut inflammation and respiratory manifestations. Elucidating these gut microbiome alterations may provide insight into future nutritional management in CF.

METHODS

Infants were followed for 12-months at four sites in the United States (US-CF) and Australia (AUS-CF). 16S rRNA gene sequencing was performed on longitudinal stool samples. Associations between microbial abundance and age, antibiotic prophylaxis, malnutrition, and breast feeding were evaluated using generalized linear mixed models. Taxonomic and predictive functional features were compared between groups.

RESULTS

Infants with CF (N = 78) were enrolled as part of a larger study. AUS-CF infants had higher mean weight-for-age z-scores than US-CF infants (p = 0.02). A subset of participants (CF N = 40, non-CF disease controls N = 10) provided stool samples for microbiome analysis. AUS-CF infants had lower stool alpha diversity compared to US-CF infants (p < 0.001). AUS-CF infants had higher relative abundance of stool Proteobacteria compared to US-CF infants which was associated with antibiotic prophylaxis (p < 0.001). Malnutrition (weight-for-age <10th percentile) was associated with depleted Lactococcus (p < 0.001). Antibiotic prophylaxis (p = 0.002) and malnutrition (p = 0.012) were linked with predicted decreased activity of metabolic pathways responsible for short chain fatty acid processing.

CONCLUSIONS

In infants with CF, gut microbiome composition and diversity differed between the two continents. Gut microbial diversity was not linked to growth. The relationship between malnutrition and antibiotic prophylaxis with reduced SCFA fermentation could have implications for gut health and function and warrants additional investigation.

Cardiac involvement in hydrocarbon inhalant toxicity — role of cardiac magnetic resonance imaging: A case report

BACKGROUND

We report a patient who was diagnosed with toxic myopericarditis secondary to hydrocarbon abuse using cardiac magnetic resonance imaging (CMR).

CASE SUMMARY

A 25-year-old male presented to emergency department with chest pain for 3 d. Patient also reported sniffing hydrocarbon containing inhalant for the last 1 year. Labs showed elevated troponin and electrocardiography was suggestive of acute pericarditis. Echocardiogram showed left ventricular (LV) ejection fraction (EF) of 40%. Given patient’s troponin elevation and reduced EF, cardiac catheterization was performed which showed normal coronaries. CMR was performed for myocardial infarction with non-obstructive coronary arteries evaluation. CMR showed borderline LV function with edema in mid and apical LV suggestive of myocarditis.

CONCLUSION

CMR can be used to diagnose toxic myopericarditis secondary to hydrocarbon abuse.

Photon beam audits for radiation therapy clinics: a pilot mailed dosemeter study in Turkey

A thermoluminescent dosemeter (TLD) mailed dose audit programme was performed at five radiotherapy clinics in Turkey. The intercomparison was organised by the University of Wisconsin Radiation Calibration Laboratory (UWRCL), which was responsible for the technical aspects of the study including reference irradiations, distribution, collection and evaluation. The purpose of these audits was to perform an independent dosimetry check of the radiation beams using TLDs sent by mail. Acrylic holders, each with five TLD chips inside and instructions for their irradiation to specified absorbed dose to water of 2 Gy, were mailed to all participating clinics. TLD irradiations were performed with a 6 MV linear accelerator and (60)Co photon beams. The deviations from the TL readings of UWRCL were calculated. Discrepancies inside the limits of ±5 % between the participant-stated dose, and the TLD-measured dose were considered acceptable. One out of 10 beams checked was outside this limit, with a difference of 5.8 %.

Extracellular purines are biomarkers of neutrophilic airway inflammation

Purinergic signalling regulates airway defence mechanisms, suggesting that extracellular purines could serve as airway inflammation biomarkers in cystic fibrosis (CF). The purines adenosine triphosphate (ATP), adenosine diphosphate (ADP), adenosine monophosphate (AMP) and adenosine were measured in sputum from 21 adults (spontaneously expectorated from seven CF patients, induced from 14 healthy controls) to assess normal values and CF-associated changes. Subsequently, purine levels were measured in bronchoalveolar lavage fluid (BALF) from 37 children (25 CF patients, 12 disease controls) and compared with neutrophil counts, presence of airway infection and lung function. To noninvasively assess airway purines, ATP levels were measured using luminometry in exhaled breath condensate (EBC) from 14 children with CF and 14 healthy controls, then 14 CF children during a pulmonary exacerbation. Both ATP and AMP were elevated in sputum and BALF from CF subjects compared with controls. In BALF, ATP and AMP levels were inversely related to lung function and strongly correlated with neutrophil counts. In EBC, ATP levels were increased in CF relative to controls and decreased after treatment of CF pulmonary exacerbation. The purines adenosine triphosphate and adenosine monophosphate are candidate biomarkers of neutrophilic airways inflammation. Measurement of purines in sputum or exhaled breath condensate may provide a relatively simple and noninvasive method to track this inflammation.

Relationships among xylem transport, biomechanics and storage in stems and roots of nine Rhamnaceae species of the California chaparral

Here, hypotheses about stem and root xylem structure and function were assessed by analyzing xylem in nine chaparral Rhamnaceae species. Traits characterizing xylem transport efficiency and safety, mechanical strength and storage were analyzed using linear regression, principal components analysis and phylogenetic independent contrasts (PICs). Stems showed a strong, positive correlation between xylem mechanical strength (xylem density and modulus of rupture) and xylem transport safety (resistance to cavitation and estimated vessel implosion resistance), and this was supported by PICs. Like stems, greater root cavitation resistance was correlated with greater vessel implosion resistance; however, unlike stems, root cavitation resistance was not correlated with xylem density and modulus of rupture. Also different from stems, roots displayed a trade-off between xylem transport safety from cavitation and xylem transport efficiency. Both stems and roots showed a trade-off between xylem transport safety and xylem storage of water and nutrients, respectively. Stems and roots differ in xylem structural and functional relationships, associated with differences in their local environment (air vs soil) and their primary functions.

Relationships among xylem transport, biomechanics and storage in stems and roots of nine Rhamnaceae species of the California chaparral

Here, hypotheses about stem and root xylem structure and function were assessed by analyzing xylem in nine chaparral Rhamnaceae species. Traits characterizing xylem transport efficiency and safety, mechanical strength and storage were analyzed using linear regression, principal components analysis and phylogenetic independent contrasts (PICs). Stems showed a strong, positive correlation between xylem mechanical strength (xylem density and modulus of rupture) and xylem transport safety (resistance to cavitation and estimated vessel implosion resistance), and this was supported by PICs. Like stems, greater root cavitation resistance was correlated with greater vessel implosion resistance; however, unlike stems, root cavitation resistance was not correlated with xylem density and modulus of rupture. Also different from stems, roots displayed a trade-off between xylem transport safety from cavitation and xylem transport efficiency. Both stems and roots showed a trade-off between xylem transport safety and xylem storage of water and nutrients, respectively. Stems and roots differ in xylem structural and functional relationships, associated with differences in their local environment (air vs soil) and their primary functions.

Mechanisms for tolerating freeze-thaw stress of two evergreen chaparral species: Rhus ovata and Malosma laurina (Anacardiaceae)

The response to freeze-thaw stress was examined for two co-occurring evergreen species, Malosma laurina and Rhus ovata. Laboratory and field experiments on adults and seedlings were made in the spring and winter in 1996 and again on adults in 2003 and 2004. Laboratory and field results indicated that the stem xylem for adults of M. laurina and R. ovata were similarly susceptible to freezing-induced cavitation (percentage loss of conductivity = 92 ± 2.6% for R. ovata and 90 ± 4.2% for M. laurina at ≤ -6°C). In contrast, leaves of M. laurina were more susceptible to freezing injury than leaves of R. ovata. Among seedlings in the field, leaves of M. laurina exhibited freezing injury at -4°C and total shoot mortality at -7.2°C, whereas co-occurring seedlings of R. ovata were uninjured. Surprisingly, R. ovata tolerates high levels of freezing-induced xylem embolism in the field, an apparently rare condition among evergreen plants. Rhus ovata avoids desiccation when xylem embolism is high by exhibiting low minimum leaf conductance compared to M. laurina. These results suggest a link between minimum leaf conductance and stem hydraulics as a mechanism permitting the persistence of an evergreen leaf habit in freezing environments.

The response of lif thermoluminescence dosemeters to photon beams in the energy range from 30 kV x rays to 60Co gamma rays

The energy response of standard (TLD-100) and high-sensitivity (TLD-100H) LiF thermoluminescence dosemeters (TLDs) has been studied for photon beams with mean energies from about 25 keV to 1100 keV. Canadian primary standards for air kerma were used to establish the air kerma rates for each of the photon beams. TLDs were mounted in a PMMA holder and the air kerma response was measured as a function of energy. The EGSnrc Monte Carlo code was used to model the TLD holder and calculate the absorbed dose to the TLD chip per unit air kerma for each beam. The measured and calculated results were combined to obtain the intrinsic dose response of the TLD chip. Broadly, our results are consistent with existing data, which show a marked difference in the energy dependence of the two materials. However, the precision of our measurements (standard uncertainty of about 0.6%) has permitted the identification of features that have not been noted before. In particular, the energy dependence of the two materials is quite different in the important energy region delimited by 137Cs and 60Co gamma rays.

Observational evidence for an active surface reservoir of solid carbon dioxide on Mars

High-resolution images of the south polar residual cap of Mars acquired in 1999 and 2001 show changes in the configuration of pits, intervening ridges, and isolated mounds. Escarpments have retreated 1 to 3 meters in 1 martian year, changes that are an order of magnitude larger than can be explained by the sublimation of water ice, but close to what is expected for sublimation of carbon dioxide ice. These observations support a 35-year-old conjecture that Mars has a large surface reservoir of solid carbon dioxide. The erosion implies that this reservoir is not in equilibrium with the present environment and that global climate change is occurring on Mars.

Bronchodilator responsiveness in normal infants and young children

Several studies have demonstrated that normal infants exhibit bronchoconstriction after inhalation of nonspecific agonists and that the induced airway narrowing can be reversed by the inhalation of a beta-agonist. However, there are very limited data on baseline airway tone and the airway response to a beta-agonist in this subject population. The purpose of our study was to evaluate in normal infants baseline airway responsiveness to the inhaled beta-agonist, albuterol, using changes in maximal expiratory flows. Forty-one healthy infant volunteers with no history of respiratory disease or recurrent wheezing (ages 5.4 to 141.4 wk) were studied. Maximal expiratory flow- volume curves were obtained at baseline and 10 min after inhalation of albuterol (n = 28) or placebo (n = 13) using a metered-dose inhaler with a spacer. The mean percent change was significantly greater (p < 0.05) in the albuterol versus placebo group for FEV(0.5) (2.2% versus -1.5%), FEF(75%) (10.6% versus -3.1%), and FEF(85%) (12.9% versus 0.5%). Six of 28 albuterol-treated infants demonstrated increases in FEF(75%) greater than two standard deviations from the mean change in FEF(75%) seen in the placebo group. These infants were younger and more frequently exposed to maternal smoking during pregnancy. We conclude that normal healthy infants have overall levels of baseline airway tone that are similar to that reported in adults and older children; however, among the infants we evaluated the response to an inhaled bronchodilator was greatest in the youngest infants and in those exposed to tobacco smoking.

KEYWORDS

airway responsiveness; asthma; tobacco smoke; infant pulmonary function; bronchodilator

Obliquely oriented superior accessory fissure of the lower lobe of the lung: CT evaluation of the normal appearance and effect on the distribution of parenchymal and pleural opacities

PURPOSE

To review computed tomographic (CT) and radiographic features of an oblique superior accessory fissure in the lower lobe of the lung.

MATERIALS AND METHODS

CT scans in 34 patients with a prospectively identified accessory fissure of the lower lobe were reviewed and correlated with chest radiographs (31 patients). The fissure and its relationship to segmental bronchovascular structures were evaluated on transverse scans. Three-dimensional (3D) shaded surface display (SSD) reconstructions were obtained from spiral volume data (six patients).

RESULTS

Thirty-four patients had 36 accessory fissures (26 right, 10 left). Four of the 36 accessory fissures were manifested by a normal fissure line; two, by slight thickening or minimal linear atelectasis; 16, by thicker linear or subsegmental atelectasis; two, by contiguous tumor infiltration; one, by adjacent consolidation; and 11, by intrafissural extension of pleural fluid. Analysis of bronchovascular structures revealed that this fissure was the superior accessory fissure. The 3D SSD reconstructions demonstrated an oblique orientation. On frontal radiographs, presence of this fissure correlated with a curvilinear band of atelectasis coursing inferomedially and obliquely from its intersection with the lateral aspect of the major fissure toward the infrahilar region on the right and the heart border on the left. Chest radiographs also showed intrafissural extension of pleural fluid.

CONCLUSION

A superior accessory fissure of the lower lobe, more common on the right than on the left, can be identified at transverse CT. Contrary to previous descriptions, it may be oblique, as findings on transverse images suggest and 3D SSD reconstructions confirm. Its presence correlates with characteristic patterns of atelectasis and pleural fluid collection on conventional radiographs.

Flow limitation in infants assessed by negative expiratory pressure

Forced expiratory flows by the rapid compression technique are often used to assess airway function in infants; however, it remains unclear as to whether flow limitation (FL) is achieved. Studies in adults have used negative expiratory pressure (NEP) at the airway opening as a noninvasive technique to assess whether FL is achieved. An increase in flow with NEP indicates that FL has not been achieved, whereas no increase in flow with NEP indicates FL has been achieved. In the adult studies, the change in flow was assessed by visual inspection of the flow-volume curve. We evaluated whether NEP could be used to assess FL during forced expiration in infants. In addition, we quantified the change in flow secondary to NEP. We applied -5 cm H(2)O NEP to four infants during forced expiratory maneuvers. The step increase in flow with NEP was always less than 5% at high jacket compression pressures and consistent with FL. For one subject, FL was also confirmed from isovolume pressure flow-curves measured with an esophageal catheter. We conclude that NEP can be used in infants to assess FL during forced expiratory maneuvers by the rapid compression technique.

Neurally mediated hypotension in fatigued Gulf War veterans: a preliminary report

BACKGROUND

Many patients with chronic fatigue syndrome (CFS) have neurally mediated hypotension when subjected to head-up tilt, suggesting autonomic nervous system dysfunction. Some Gulf War veterans have symptoms similar to CFS. Whether they also tend to have neurally mediated hypotension is unknown.

METHODS

We performed 3-stage tilt-table testing on 14 Gulf War veterans with chronic fatigue, 13 unfatigued control Gulf War veterans, and 14 unfatigued control subjects who did not serve in the Gulf War. Isoproterenol was used in stages 2 and 3 of the tilt protocol.

RESULTS

More fatigued Gulf War veterans than unfatigued control subjects had hypotensive responses to tilt (P < 0.036). A positive response to the drug-free stage 1 of the tilt was observed in 4 of 14 fatigued Gulf War veterans versus 1 of 27 unfatigued control subjects (P < 0.012). Heart rate and heart rate variation during stage 1 was significantly greater in the fatigued group (P < 0.05).

CONCLUSION

We conclude that more fatigued Gulf War veterans have neurally mediated hypotension than unfatigued control subjects, similar to observations in CFS. Autonomic nervous system dysfunction may be present in some fatigued Gulf War veterans.

The relationship between xylem conduit diameter and cavitation caused by freezing

The centrifuge method for measuring the resistance of xylem to cavitation by water stress was modified to also account for any additional cavitation that might occur from a freeze-thaw cycle. A strong correlation was found between cavitation by freezing and mean conduit diameter. On the one extreme, a tracheid-bearing conifer and diffuse-porous angiosperms with small-diameter vessels (mean diameter <30 μm) showed no freezing-induced cavitation under modest water stress (xylem pressure = -0.5 MPa), whereas species with larger diameter vessels (mean >40 μm) were nearly completely cavitated under the same conditions. Species with intermediate mean diameters (30-40 μm) showed partial cavitation by freezing. These results are consistent with a critical diameter of 44 μm at or above which cavitation would occur by a freeze-thaw cycle at -0.5 MPa. As expected, vulnerability to cavitation by freezing was correlated with the hydraulic conductivity per stem transverse area. The results confirm and extend previous reports that small-diameter conduits are relatively resistant to cavitation by freezing. It appears that the centrifuge method, modified to include freeze-thaw cycles, may be useful in separating the interactive effects of xylem pressure and freezing on cavitation.

Parenchymal and pleural findings in patients with and patients without acute pulmonary embolism detected at spiral CT

PURPOSE

To compare the frequencies of parenchymal abnormalities and pleural effusions in patients with and patients without acute pulmonary embolism (PE) detected at spiral computed tomography (CT).

MATERIALS AND METHODS

Contrast material-enhanced spiral CT scans obtained in 92 patients clinically suspected of having acute PE were retrospectively reviewed. The presence or absence of parenchymal abnormalities and pleural effusions was noted. The presence of filling defects consistent with central or peripheral PE was recorded.

RESULTS

Twenty-eight patients had CT evidence of PE. Central emboli were evident in 27 (96%) of these patients; 23 (82%) had concomitant central and peripheral emboli, and four (14%) had only central emboli. One patient had an isolated subsegmental clot. Parenchymal abnormalities were seen in 24 (86%) patients with PE and 56 (88%) patients without PE. Atelectasis, the most common finding, was present in 20 (71%) patients with PE and 41 (64%) patients without PE. The only parenchymal abnormality significantly associated with PE was peripheral wedge-shaped opacity, which was seen in seven (25%) patients with PE and three (5%) patients without PE (odds ratio, 6.78; 95% CI = 1.60, 28.62). Pleural effusions were seen in 16 (57%) patients with PE and 36 (56%) patients without PE. In 25 (39%) patients without PE, there were additional CT findings that might suggest an alternative explanation for the acute clinical presentation.

CONCLUSION

Parenchymal and pleural findings at CT are of limited value for differentiating patients with PE from those without PE.

Forced expiratory maneuvers in very young children. Assessment of flow limitation

The application of negative expiratory pressure (NEP) to the airway opening during forced expiratory maneuvers has recently been described as a noninvasive method to assess whether flow limitation is achieved in adults. This methodology has great potential for extending the measurement of forced expiratory maneuvers to young children who may not produce maximal efforts as reproducibly as adults. We used NEP to assess flow limitation in 10 children between 3 and 5 yr of age. NEP was well tolerated by all subjects. With the application of NEP, there was not a step increase in flow, a finding consistent with flow limitation for the subjects. In addition to visual inspection, we proposed a method to quantify the change in flow during a short NEP. The flow-volume curves obtained with and without NEP were visually the same, other than the flow transients produced by NEP. The calculated values of FVC and FEF25-75 were not significantly different when measured from flow- volume curves with and without NEP. There was a statistically significant increase in FEV1 with NEP; however, the group mean increase in FEV1 was less than 2%. We conclude that NEP may be a useful technique to determine whether flow limitation has been achieved in young children performing forced expiratory maneuvers.

Response of chaparral shrubs to below-freezing temperatures: acclimation, ecotypes, seedlings vs. adults

Leaf death due to freezing was examined for four, co-occurring species of chaparral shrubs from the Santa Monica Mountains of southern California, Rhus laurina (= Malosma laurina), R. ovata, Ceanothus megacarpus, and C. spinosus. Measurements were made on seedlings vs. adults for all species, and for Rhus spp. in winter vs. summer, and at a warm vs. a cold site. We used four methods to determine the temperature for 50% change in activity or cell death (LT(50)) of leaves: (1) electrical conductivity (electrolyte leakage into a bathing solution), (2) photosynthetic fluorescent capacity (Fv/Fm), (3) percentage of palisade mesophyll cells stained by fluorescein diacetate vital stain, and (4) visual score of leaf color (Munsell color chart). In all four species seedlings were found to be more sensitive to freezing temperatures than were adults by 1°-3°C. For adults the LT(50) ranged from -5°C for Rhus laurina in the summer to -16°C for Rhus ovata in the winter. The LT(50) of R. ovata located at a colder inland site was 4C lower than R. ovata at the warmer coastal site just 4 km apart, suggesting ecotypic differences between R. ovata at the two sites. Both R. laurina and R. ovata underwent significant winter hardening. At the cold site, R. ovata acclimated by 6°C on average, while R. laurina acclimated by only 3°C. These results were consistent with species distributions and with field observations of differential shoot dieback between these two congeneric species after a natural freeze-thaw event in the Santa Monica Mountains.

Web-based digital radiology teaching file: facilitating case input at time of interpretation

OBJECTIVE

Our goal was to develop a software system that allows easy and rapid input of digital radiology images and text reports, at the time of interpretation, into an easily searchable electronic teaching file database using the Internet and the World-Wide Web protocols, servers, and browsers.

CONCLUSION

Using the Internet, the World-Wide Web, and our software system, we can rapidly input digital radiology images and associated text reports into an easily searchable database accessed by privileged users. This inexpensive and simple method for building a digital teaching file database allows cross-platform access for users who have a Web browser.

Intestinal stem cell division and genetic diversity. A computer and experimental analysis

Somatic mutations are expected to arise with age. This process is accelerated in mice lacking the DNA mismatch repair gene Pms2. The distributions of microsatellite alleles present in small patches of normal Pms2 -/- intestines revealed a general increase in genetic diversity or the number of mutations with age. However, the patterns were complex with different distributions and variances present within a single mouse. Computer simulations indicate that the experimental data are consistent with mutation rates between 0.0020 and 0.0025 mutations per division, nonrandom cell death, and an effective population size of 20 or fewer cells. Small numbers of cells exacerbate the random accumulation of mutations expected of a stochastic mutation process. The computer simulations and experimental data are consistent with known patterns of intestinal development and renewal by small numbers of stem cells and demonstrate relatively high mutation rates in histologically normal epithelium. These findings provide background for the analysis of microsatellite mutations in normal and tumor tissue lacking mismatch repair and further support the hypothesis that microsatellite loci can function as molecular tumor clocks.

Chest radiography in the ICU

Proper positioning and assessment of abnormalities and complications of the above-mentioned devices have a significant impact on the management of critically ill patients in the intensive care unit (ICU). The timely assessment of new or rapidly evolving findings is critical. Optimal radiographic technique, availability of images to the clinicians, and rapid reporting by the radiologist all serve to maximize the efficacy of bedside chest radiography in the ICU. Sometimes, changes in cardiopulmonary status may only be appreciated on chest radiographs (CXRs). Complications from ventilatory assistance, such as barotrauma, occur frequently and must be detected promptly. The position of monitoring devices, an important component of critical care management, is best checked radiographically. Indications for CXRs and the recommended frequency for repeat follow-up CXRs are based on the existing literature and the consensus of an expert panel formed by the American College of Radiology.

Aspiration of a large pneumothorax resulting from transthoracic needle biopsy

PURPOSE

To determine whether simple aspiration of air from the pleural space could obviate chest tube placement in patients with a large pneumothorax after transthoracic needle biopsy.

MATERIALS AND METHODS

Seventeen patients, who developed a large pneumothorax (> 30%) during computed tomographic (CT)-guided transthoracic needle biopsy and otherwise would have required chest tube placement, underwent percutaneous aspiration of the pneumothorax while on the CT scanner table. Air was aspirated from the pleural space by using an 18-gauge intravenous catheter attached to a three-way stopcock and a 50-mL syringe. The patients were positioned with the puncture site down after aspiration of the pneumothoraces and oxygen was administered both during and after the procedure.

RESULTS

The pneumothorax was almost completely aspirated in all 17 patients. Twelve (70%) patients did not require chest tube placement. Follow-up chest radiographs obtained 2 and 4 hours after the procedure revealed complete or almost complete resolution of the pneumothorax in eight (47%) patients and partial recurrence of a small, stable pneumothorax in four (24%) patients. The remaining five (29%) patients had recurrence of their pneumothorax, which ultimately required chest tube placement.

CONCLUSION

Percutaneous catheter aspiration of a large biopsy-induced pneumothorax is safe and easy to perform and may obviate chest tube placement.

Pitfalls in CT-guided transthoracic needle biopsy of pulmonary nodules

Successful performance of transthoracic needle biopsy of pulmonary nodules under computed tomographic (CT) guidance requires both accurate placement of the needle tip within the nodule and withdrawal of an adequate sample from the lesion. Failure to complete the biopsy procedure or to establish a definitive tissue diagnosis may be due to a number of factors. Potential pitfalls in transthoracic needle biopsy include technical factors related to the patient, CT scanning, or the biopsy needle; factors related to the size, location, or internal characteristics of the nodule or to an abnormality within adjacent parenchyma; and complications that may occur during transthoracic needle biopsy, such as pneumothorax or parenchymal hemorrhage. Awareness of how these pitfalls may be avoided or minimized should help expedite the performance of transthoracic needle biopsy and increase the likelihood of a diagnostic result.

Juxtaphrenic peak in upper and middle lobe volume loss: assessment with CT

PURPOSE

To investigate the anatomic basis for the juxtaphrenic peak (JP) in upper and/or middle lobe volume loss through radiographic and computed tomographic (CT) correlation.

MATERIALS AND METHODS

Chest radiographs and CT scans were reviewed in 32 patients with upper or middle lobe volume loss. The study included 33 cases of volume loss: 12 affected the left upper lobe; 12, the right upper lobe; five, the right upper and middle lobes; and four, the middle lobe. JPs and linear opacities identified on chest radiographs were correlated with juxtadiaphragmatic structures on CT scans.

RESULTS

A JP was identified in 22 of 33 (67%) cases, including nine of 12 (75%) with left upper lobe volume loss and eight of 12 (67%) with right upper lobe, four of five (80%) with combined upper and middle lobe, and one of four (25%) with middle lobe volume loss. The JP was due to an inferior accessory fissure in 14 of 22 (64%) cases. Other causes included a medial septum and an accessory fissure other than the inferior accessory fissure.

CONCLUSION

The JP sign is seen in the majority of cases with upper lobe or combined upper and middle lobe volume loss. The sign is most commonly related to an inferior accessory fissure.

Needle-tip repositioning during computed-tomography-guided transthoracic needle aspiration biopsy of small deep pulmonary lesions: minor adjustments make a big difference

The aim of the study was to determine whether a thin-gauge transthoracic biopsy needle would be deflected from a straight path as it passed through lung tissue, and whether partially withdrawing the needle and reinserting it while applying pressure could significantly change the degree of deflection. Using a cadaver lung, we showed that the needle tip was deflected, on average, 2.5 mm from a straight path in a direction opposite to the bevel. The reinsertion technique using pressure caused the average deflection to increase to 6.3 mm, a significant difference from the previous value. We have found this technique to be useful in the performance of transthoracic needle aspiration biopsy of small deep pulmonary nodules where differences in positioning of the needle tip by only a few millimeters can achieve the correct, rather than an indeterminate, diagnosis.

Accuracy and efficacy of chest radiography in the intensive care unit

In summary, the chest radiograph has only moderate accuracy in visualizing opacification caused by cardiopulmonary abnormalities and may be quite nonspecific as to etiology, whereas it has high diagnostic accuracy for detecting malpositioning of tubes and lines. While focal parenchymal abnormalities are usually visualized on chest radiographs, identification of concomitant abnormalities when ARDS or PE already exist is more difficult. Atelectasis, aspiration, pneumonia, pulmonary hemorrhage, pulmonary thromboembolism, atypical cardiogenic edema, asymmetric ARDS, and neoplasms may be indistinguishable. Repeat chest radiographs and different views may be helpful, as the progression and time course of various etiologies can be quite different. On the other hand, Winer-Muram et al found that review of prior radiographs and clinical data did not improve the diagnostic accuracy for either ARDS or pneumonia. Pleural effusions may even be difficult to distinguish from parenchymal processes, particularly when the patient is in the supine position. Additional views with the patient in a different position--semi-erect, decubitus, or cross-table lateral--may be of assistance. In most cases, pneumothorax is readily detected. Additional studies such as the decubitus view occasionally may be necessary for further evaluation when there is uncertainty about the findings. Subcutaneous air is readily visualized radiographically. Pneumomediastinum and interstitial pulmonary emphysema may be more difficult to see. It is well known that CT allows visualization of much smaller abnormal air collections than radiography. Despite this lack of sensitivity and specificity of chest films, studies have shown that up to 65% of daily films in the ICU reveal significant and/or unsuspected abnormalities that may change the patient's diagnosis or management. Based on these results, the consensus opinion of the ACR Expert Panel found that daily chest radiographs are indicated on patients with acute cardiopulmonary problems and those receiving mechanical ventilation. Patients who require cardiac monitoring but are otherwise stable require only an initial admission film. Additional radiographs are indicated only when a new device is placed or when there is a specific question regarding cardiopulmonary status. It is also noteworthy that despite the chest film being the most commonly ordered radiologic examination for inpatients, there are no comprehensive studies evaluating its cost-effectiveness. Although several studies have done a very limited cost accounting of the potential savings by eliminating routine films in the evaluation of specific subsets of patients, overall impact on patient outcome has not been investigated. Thus, a true assessment of cost-effectiveness has yet to be determined.

Variability in lesion depth on prone and supine CT scans of the chest: implications for the accuracy of transthoracic needle aspiration biopsy

Transthoracic needle biopsy of the lung is often performed fluoroscopically in the prone position; nodule depth measurements are made from accompanying computed tomographic (CT) scans performed supine. We evaluated the effect of prone and supine positioning on the effect of nodule depth as measured from the skin surface. Twenty consecutive patients having CT-guided biopsy performed in the prone position were assessed. Nodule depth from posterior skin surface to nodule was compared with prebiopsy supine CT scan. Nodules above the carina showed minimal change in depth. Those below the carina showed considerable variability, with depth changes < or = 4.0 cm. Awareness of the magnitude of the potential effect of patient position on lesion depth should be helpful in reducing the likelihood of false negative results in fluoroscopically guided biopsy.

Pneumothorax during fluoroscopic biopsy: effect on nodule depth

Transthoracic needle aspiration biopsy of lung nodules is often performed under fluoroscopic guidance after measurement of lesion depth on preliminary computed tomography (CT) scans is obtained. We evaluated the change in depth of nodules in 10 patients in whom pneumothorax developed during CT-guided biopsy. We observed that nodule depth changed by an amount equal to the size of the pneumothorax. Awareness of the potential effect of pneumothorax on lesion depth should be helpful in reducing the likelihood of false-negative results with CT-assisted fluoroscopic biopsy when only single-plane fluoroscopy is available.

Appropriate window and level settings in CT-guided biopsies

The purpose of this study was to investigate the factors that help determine the needle tip location during computed tomographic (CT)-guided thin needle aspirations. We devised a model using a bottle filled with air, mineral oil, and water into which we could insert a needle. We then obtained CT images using both 5- and 10-mm slice thicknesses and determined the Hounsfield units (HUs) in regions of interest surrounding the needle shaft and some distance away from the needle shaft. We demonstrated that the presence of the needle increases the average HUs of the background both in the same region of interest and in the region of interest some distance from the needle. This effect is seen in air, fat, and water and thus occurs regardless of the attenuation of the background medium. A decrease in slice thickness causes this effect to be even more marked. These experimental results coincided with the theoretical results obtained from an equation that approximates the HUs of the pixels.

Percutaneous CT biopsy of chest lesions: an in vitro analysis of the effect of partial volume averaging on needle positioning

OBJECTIVE

Accurate needle biopsy of chest lesions requires knowledge of both the direction of the needle and the exact location of the tip of the needle. The purpose of this study was to analyze and illustrate the relationships between the location of the nodule, the size of the nodule, the CT slice thickness, and the needle length. An understanding of these relationships should minimize localization errors due to partial volume averaging and thus increase the accuracy of biopsies.

MATERIALS AND METHODS

Geometric principles were used to determine mathematical relationships between the size of the nodule, the CT slice thickness, the length of the needle, and the direction of the needle. A styrofoam model simulating the patient and the lesion to be sampled was developed so that radiographs and CT scans of the model could be obtained with different needle placements to illustrate the phenomenon of partial volume averaging.

RESULTS

The accuracy of the CT-guided biopsy can be increased by reducing the CT slice thickness, using longer needles, minimizing the distance to be traversed within the patient, and maximizing the portion of the lesion contained in the CT section used for needle tip localization. Mathematical equations developed from the in vitro model can be used to select the most appropriate CT section and the best length and angle of the needle. CT scans of the model illustrate the use of these equations.

CONCLUSION

We found these principles helpful in improving the accuracy of CT needle biopsies, particularly when the lesions are very small and when an angled approach is required. Ideally, the smallest possible CT slice thickness and the longest possible needles should be used, but some practical limitations exist.

Angulated needle placement in CT-guided percutaneous needle biopsy of the thorax

Computed tomography (CT)-guided percutaneous needle biopsy is often necessary to evaluate small intrathoracic lesions. Not infrequently, an overlying structure such as a rib or vessel precludes insertion of the biopsy needle within the CT slice containing the lesion. Insertion and angulation of the needle at a site within an adjacent CT slice is then required. In order to determine the optimal skin-entry site and degree of angulation for biopsy needle insertion, we analyzed the geometric relationship between lesion depth, needle length, and needle angulation.