Afra Yildirim

Differentiating between Subsolid and Solid Pulmonary Nodules at CT: Inter- and Intraobserver Agreement between Experienced Thoracic Radiologists

PURPOSE To quantify the reproducibility and accuracy of experienced thoracic radiologists in differentiating between subsolid and solid pulmonary nodules at CT. MATERIALS AND METHODS The institutional review board of Beth Israel Deaconess Medical Center approved this multicenter study. Six thoracic radiologists, with a mean of 21 years of experience in thoracic radiology (range, 17-22 years), selected images of 10 solid and 10 subsolid nodules to create a database of 120 nodules; this selection served as the reference standard. Each radiologist then interpreted 120 randomly ordered nodules in two different sessions that were separated by a minimum of 3 weeks. The radiologists classified whether or not each nodule was subsolid. Inter- and intraobserver agreement was assessed with a κ statistic. The number of correct classifications was calculated and correlated with nodule size by using Bland-Altman plots. The relationship between disagreement and nodule morphologic characteristics was analyzed by calculating the intraclass correlation coefficient. RESULTS Interobserver agreement (κ) was 0.619 (range, 0.469-0.745; 95% confidence interval (CI): 0.576, 0.663) and 0.670 (range, 0.440-0.839; 95% CI: 0.608, 0.733) for interpretation sessions 1 and 2, respectively. Intraobserver agreement (κ) was 0.792 (95% CI: 0.750, 0.833). Averaged for interpretation sessions, correct classification was achieved by all radiologists for 58% (70 of 120) of nodules. Radiologists agreed with their initial determination (the reference standard) in 77% of cases (range, 45%-100%). Nodule size weakly correlated with correct classification (long axis: Spearman rank correlation coefficient, rs = 0.161 and P = .049; short axis: rs = 0.128 and P = .163). CONCLUSION The reproducibility and accuracy of thoracic radiologists in classifying whether or not a nodule is subsolid varied in the retrospective study. This inconsistency may affect surveillance recommendations and prognostic determinations.

Insights into imaging of aortitis

BackgroundAortitis is a subtype of the more general term “vasculitis”, an inflammatory condition of infectious or noninfectious origin involving the vessel wall. The term “vasculitis” refers to a broad spectrum of diseases with different aetiologies, pathophysiologies, clinical presentations and prognoses. The clinical manifestations are nonspecific, as are the laboratory findings such as pain, fever, weight loss, vascular insufficiency and elevated levels of acute phase reactants, as well as other systemic manifestations, and sometimes may mimic other entities. Thus, if not suspected as part of the initial differential diagnosis, aortitis can be overlooked during the workup of patients with constitutional symptoms and systemic disorders. Methods: Imaging is rarely used for the primary diagnosis, but imaging findings, although nonspecific, can help in the assessment of these patients and is often required for making the final diagnosis. Imaging can be critical in the initiation of appropriate management and therapy. Results: Noninvasive cross-sectional imaging modalities such as contrast-enhanced CT, magnetic resonance (MR) imaging, nuclear medicine and in particular positron emission tomography (PET) are the leading modalities in modern diagnostic imaging of aortitis for both the initial diagnosis and follow-up. Conclusion: This review focusses on the most common manifestations of aortitis with which radiologists should be familiar.Teaching Points• Aortitis is an inflammatory condition of infectious/noninfectious origin involving the vessel wall.• Imaging findings can help in the assessment of aortitis and are often crucial for the final diagnosis.• Contrast-enhanced CT, MRI and PET-CT are used for both the initial diagnosis and follow-up of aortitis.

Congenital thoracic arterial anomalies in adults: a CT overview.

Congenital thoracic arterial anomalies can be incidentally detected in adults from imaging studies performed for other indications. Multidetector computed tomography plays a critical role in the noninvasive assessment of these anomalies and associated cardiac, mediastinal, or parencyhmal changes by providing volumetric data. Radiologists should be familiar with imaging findings of these anomalies to avoid misinterpretation and to establish accurate diagnosis. In this article, we review the imaging characteristics of congenital aortic, pulmonary, and aortopulmonary anomalies with an emphasis on multidetector computed tomography findings. We illustrate the CT findings of congenital arterial anomalies such as double aortic arch, right aortic arch, aortic coarctation, pseudocoarctation, interrupted aortic arch, interruption (absence) of the pulmonary artery, pulmonary artery sling, pulmonary artery stenosis, transposition of great vessels, truncus arteriosus, aortopulmonary window, and patent ductus arteriosus.

The accuracy rate of Alvarado score, ultrasonography, and computerized tomography scan in the diagnosis of acute appendicitis in our center

OBJECTIVE In this study, we aim to compare the relationship between the Alvarado score, ultrasonography, and multislice computerized tomography (CT) findings used for the diagnosis of the patients who presented to our emergency unit with clinical features suggestive of acute appendicitis. MATERIALS AND METHODS Seventy-four patients operated with the diagnosis of acute appendicitis were included in the study. The demographic characteristics of the patients, physical findings, blood parameters, Alvarado scores, the radiological method used for the diagnosis, the surgical methods (open or laparoscopic) and the pathology results were recorded on the standard proforma. The collected data were analyzed with Statistical Package for Social Sciences (SPSS 15 for Windows, SPSS Inc., Chicago, Illinois, USA) computer program. RESULTS During study period, the sensitivity of ultrasonography was found to be as 71.2%, specificity as 46.7%, the positive predictive value (PPV) as 82.2%, the negative predictive value (NPV) as 31.8%, and the accuracy rate was determined as 65.7%. The sensitivity of tomography was determined as 97.2%, the specificity as 62.5%, PPV as 92.1%, and NPV as 83.3%, and the accuracy rate was determined as 90%. The sensitivity of the Alvarado score was calculated as 54%, the specificity as 73.3%, the PPV as 88.2% and the NPV as 29.7%, and the accuracy rate was determined as 57.7%. CONCLUSION In conclusion, computerized tomography (CT) was found to have higher specificity and sensitivity than Alvarado score and USG which are not sufficient on their own for taking the decision for surgery. We also found that CT scan had lower negative laparotomy rate when compared with the other two modalities.

Should bedside sonography be used first to diagnose pneumothorax secondary to blunt trauma

Our purpose was to evaluate the effectiveness of bedside sonography (US) in the detection of pneumothorax secondary to blunt thoracic trauma.

Distal vaginal atresia resulting in obstructive uropathy accompanied by acute renal failure

Children with hydrometrocolpos due to distal vaginal atresia may present with severe obstructive uropathy. Here we report a 27-day-old infant with a hydrometrocolpos causing life-threatening renal failure. Percutaneous drainage of the hydrometrocolpos resulted in dramatically improved clinical and laboratory findings in the patient.

A rare but severe complication of filgrastim in a healthy donor: Splenic rupture

BACKGROUND Granulocyte-colony stimulating factor (G-CSF) is widely administered to donors who provide peripheral blood stem cells (PBSCs) for individuals who undergo hematopoietic stem cell transplants. G-CSF administration is associated with a small but definite risks of serious adverse events like splenic rupture. CASE STUDY In this case, we report a 40 year old women, a healthy donor for her sister who has aplastic anemia, who had sharp left upper abdominal pain on the forth mobilization day. The diagnosis at CT scan was splenic rupture; irregular intrasplenic low-attenuation areas consistent with ruptured spleen and perisplenic high density fluid. Her bidimensional spleen size was 16×6 cm. RESULTS She was followed conservatively. One month later the CT scan signs of rupture disappeared. CONCLUSION We must pay attention to this rare but serious adverse event during filgrastim use.

Performance of Galactomannan Antigen, Beta-d-Glucan, and Aspergillus-Lateral-Flow Device for the Diagnosis of Invasive Aspergillosis

Aspergillus lateral-flow device (LFD) was recently introduced as a practical tool for the diagnosis of invasive aspergillosis (IA). We investigated the performance of Aspergillus-LFD as a point-of-care test for the diagnosis of IA. Serum samples were collected twice weekly from patients who received intensive chemotherapy for acute leukemia, or recepients of allogeneic stem cell transplantation. Aspergillus galactomannan (GM) antigen, 1,3-beta-d-glucan and Aspergillus-LFD tests were carried out according to manufacturers’ recommendations. GM testing was repeated with a modified procedure which was proven to increase the sensitivity. Aspergillus-LFD was performed without applying any pretreatment procedure to allow the kit to fit as a point-of-care test. Fungal infections were categorized according to European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) criteria. A total of 75 neutropenia episodes in 64 patients were prospectively followed between February 2012 and January 2013. Probable IA was diagnosed in 11 patients, probable pulmonary fungal disease was diagnosed in one patient, and rhinocerebral aspergillosis was diagnosed in one patient. Fungemia was detected in two patients. Aspergillus-LFD was positive in serum of a patient with probable IA and in the bronchoalveolar lavage fluid of an other patient with probable IA. Aspergillus-LFD was false positive in serum of two patients. Although there was no radiological finding of IA or documented fungemia, fever resolved after empirical caspofungin therapy in one of these patients. The sensitivity of Aspergillus-LFD as a point-of-care test without any pretreatment of serum sample is low.

Acute pulmonary failure due to pulmonary edema during tocolytic therapy with nifedipine

Calcium-channel blockers (CCB) are the new members of the tocolytic drugs [1]. We report a case of pulmonary edema (PE) associated with tocolytic use of oral nifedipine. According to the available literature, this is the first case of pulmonary edema associated with the use of nifedipine at conventional dose. A 39-year-old, previously healthy, G4P3 was admitted with rupture of membranes. On admission, blood pressure was 120/70 mm Hg, pulse rate was 84 beats/min. Transabdominal ultrasonography showed 33-week-old singleton fetus. Blood tests revealed that white blood cell was 9.7 9 10/mL and C-reactive protein was 12.8 mg/dL. She was started on amoxicillin 1 g intravenously every 6 h, and nifedipine 20 mg orally every 4 h and betamethasone 12 mg intramuscular daily for 2 days. For the first day of her admission, 2,000 cc parenteral fluid was given to the patient and was reduced to 1,000 cc daily. At fourth day of her admission, she complained of dyspnea with sudden onset and a vague chest, and back pain. Her condition rapidly deteriorated and cardiac and respiratory arrest ensued. After the first resuscitation she was intubated. Arterial blood gases at room air showed severe hypoxemia (PaO2: 53, CO2: 26). She was immediately transported to the operating room due to persisted fetal bradycardia, and 1,850 g/28 cm infant, with APGAR scores of 5 at 1 min and 7 at 5 min was delivered via cesarean section. She was admitted to the intensive care unit postoperatively. Chest X-ray showed bilateral haziness with mild pleural effusion and chest computed tomography revealed thickening of interlobular septums, pleural effusion, basal atelectasis, and ground glass pattern suggestive of pulmonary edema (Fig. 1). Left ventricular-ejection fraction was 60 %, and creatine kinase and creatine kinase MB were within normal limits. Intravenous furosemide was started 30 mg every 8 h for the first day and furosemide doses were adjusted thereafter based on the patient’s condition and urine output. After 4 days of the operation, she was discharged with good condition. First reported cases of CCB related pulmonary edema was associated with parenteral tocolytic use of nicardipine [2]. Later, Abbas et al. [3] reported the first case of PE associated with tocolysis with oral nifedipine at a dose of 40 mg for every 6 h in patients with preterm premature rupture of membranes. CCB has negative inotropic effect causing reflex tachycardia that impairs diastolic filling. Moreover, vasodilatation caused by CCBs predominantly affect precapillary rather than post capillary vessels and thus, leading to interstitial fluid accumulation. It seems possible that even at conventional doses, when combined with betamethasone and parenteral fluid infusion, CCB predisposes pregnant patients to the PE as in the present case. In accordance with aforementioned theory and case series, in their comprehensive analysis, Ogunyemi [4] showed that preterm delivery, antenatal steroids, magnesium sulfate, tocolysis and nifedipine use as a tocolytic were independent risk factors for the development of PE. In conclusion, CCB may cause life-threatening complications in pregnant patients taking antenatal steroids and M. S. Kutuk (&) M. T. Ozgun S. Uludag M. Dolanbay Department of Obstetrics and Gynecology, Faculty of Medicine, Gevher Nesibe Hospital, Erciyes University, 38039 Kayseri, Turkey e-mail: mskutuk@erciyes.edu.tr

Acute right-sided colonic diverticulitis mimicking appendicitis: a report of two cases.

We describe two right‐sided diverticulitis cases that presented with marked right iliac fossa tenderness with guarding and rebound and laboratory parameters resembling acute appendicitis. The imaging findings suggested diverticulitis in both cases. One of the patients underwent surgery and the other one was followed up with medical treatment. Awareness of these imaging findings may aid in the diagnosis of right‐sided diverticulitis, which is frequently misdiagnosed and mistreated.