Angela D. Tasker

Smoking related COPD and facial wrinkling: is there a common susceptibility?

Background: Cigarette smoking causes accelerated facial wrinkling and predisposes to chronic obstructive pulmonary disease (COPD). However, it has long been recognised that there is a subgroup of susceptible smokers who are at increased risk of developing airflow obstruction. We have tested the hypothesis that there is a common susceptibility for the development of COPD and facial wrinkling in cigarette smokers. Methods: One hundred and forty nine current and ex-smokers were recruited from a family based study of COPD genetics, 68 (45.6%) of whom fulfilled the definition of COPD. 124 (83.2%) had no or minor facial wrinkling (Daniell <IV) and 25 (16.8%) were wrinkled (Daniell score ⩾IV). Generalised estimating equations were used to adjust for familial correlations between related individuals and the potential confounding effects of age and pack years smoked. Results: Forced expiratory volume in 1 second (FEV1) was significantly lower in those with wrinkles than in those without (mean difference in FEV1 % predicted −13.7%, 95% CI −27.5 to 0.0, pu200a=u200a0.05) and facial wrinkling was associated with a substantially increased risk of COPD (adjusted OR 5.0, 95% CI 1.3 to 18.5, p<0.02). The Daniell score correlated with the extent of emphysema on the CT scan (p<0.05) and facial wrinkling was also associated with a greater risk of more extensive emphysema (adjusted OR 3.0, 95% CI 1.0 to 9.3, pu200a=u200a0.05). Conclusion: Facial wrinkling is associated with COPD in smokers, and both disease processes may share a common susceptibility. Facial wrinkling in smokers may therefore be a biomarker of susceptibility to COPD.

Dual-energy CT pulmonary angiography: a novel technique for assessing acute and chronic pulmonary thromboembolism

Dual-energy computed tomography (DECT) involves the acquisition of CT datasets using two different photon spectra. Recent advances in CT technology, particularly the introduction of dualsource CT systems, have led to renewed interest in the application of DECT techniques. A dual-source CT system (Somatom Definition, Siemens Medical Solutions, Forchheim, Germany) has two x-ray tubes and two detectors that are mounted on the gantry at a 90 angular offset. The tubes can be operated at identical kilovoltage exposures to provide high temporal resolution (83 ms) for cardiac imaging or alternatively, they can be operated at two different energies. Hounsfield unit values for low atomic number materials (such as soft tissues) do not vary much with the kilovoltage exposure; however, materials with high atomic numbers, such as iodine, exhibit very differing degrees of attenuation at 80 kV compared with 140 kV. This effect can be exploited to obtain spectral information and differentiate iodine from other materials by acquiring datasets at two different energy levels. The ability of a dual-source system to simultaneously acquire two spiral acquisitions during the same phase of contrast enhancement excludes temporal changes in enhancement between acquisitions and spatial misregistration, which are the major limiting factors when attempting to apply this technique using a single-source system.

Ventilation-perfusion scintigraphy to predict postoperative pulmonary function in lung cancer patients undergoing pneumonectomy

OBJECTIVEnThe American College of Chest Physicians (ACCP) recommends using quantitative perfusion scintigraphy to predict postoperative lung function in lung cancer patients with borderline pulmonary function tests who will undergo pneumonectomy. However, previous scintigraphic data were gathered on small cohorts more than a decade ago, when surgical populations were significantly different with respect to age and sex compared with typical lung cancer patients undergoing pneumonectomy in 2005. We therefore revisited the use of V/Q scintigraphy in pneumonectomy patients in predicting postoperative pulmonary function and the appropriateness of current clinical guidelines.nnnCONCLUSIONnContrary to ACCP guidelines, we found that ventilation scintigraphy alone provided the best correlation between the predicted and actual postoperative values and recommend its use to predict postoperative lung function. However, scintigraphic techniques may underestimate postoperative lung function, so caution is required before unnecessarily preventing a patient from undergoing surgery that offers a potential cure.

Sirolimus-induced pneumonitis following liver transplantation.

Sirolimus‐induced pneumonitis has emerged as a potentially serious complication in renal transplantation but only single case reports of this condition have been described after liver transplantation (LT), where experience with sirolimus is relatively limited. We report our experience, the largest to date, of sirolimus‐induced pneumonitis following LT. Between 1999 and 2006, 186 liver transplant patients received sirolimus‐based immunosuppression, after initial therapy with calcineurin inhibitors (CNIs). All cases of sirolimus‐induced pneumonitis were recorded and a retrospective review of the case notes of such patients was undertaken for the purpose of this analysis. Of 186 liver transplant patients receiving sirolimus, 4 (2.2%) developed pneumonitis that was attributed to the drug; the time from starting sirolimus to presentation was varied (1.5‐30 months). The most common presenting symptoms were dyspnea, cough and fatigue. The median sirolimus level at the time of diagnosis was 9.7 ng/mL (range, 7‐19.5 ng/mL). All patients in the series underwent thoracic computed tomography, which showed similar changes in all patients, and lung biopsy, which revealed features consistent with a drug‐induced pneumonitis. In all 4 patients, sirolimus‐induced pneumonitis resolved following cessation of therapy but took weeks to months for complete recovery. In conclusion, sirolimus‐induced pneumonitis occurred in at least 2% of liver transplant recipients and should be suspected in patients who develop respiratory symptoms while on sirolimus. Although it may be life threatening, early recognition and cessation of sirolimus can lead to complete resolution of pneumonitis. Liver Transpl 13:853–856, 2007.

IMAGING THE AIRWAYS: HEMOPTYSIS, BRONCHIECTASIS, AND SMALL AIRWAYS DISEASE

Advances in technology have increased the contribution of radiology in understanding and evaluating diseases of the airways. In patients with hemoptysis, CT is now established as a complementary technique to bronchoscopy, or as an alternative to bronchoscopy in selected cases. The introduction of high-resolution CT has improved the detection and assessment of bronchiectasis and small airways disease, allowed better correlation between pathologic changes and radiologic appearances, and provided new insights into possible links between small airways disease and bronchial disease.

Pulmonary thromboembolism with thrombus trapped in a patent foramen ovale — the “floating thrombus sign” on CTPA

We present two patients investigated using computed tomography (CT) and found to have a thrombus lodged within a patent foramen ovale (PFO) in association with pulmonary embolism. One patient was managed with emergency surgical embolectomy because of the risk of fragmentation and systemic embolization, and the other was managed conservatively because of significant pulmonary hypertension and inferred high surgical risk. Free-floating thrombus straddling a PFO has been previously reported using transoesophageal echocardiography (TOE); however, the CT appearance of this entity has not been previously documented. The detection of thrombus trapped within a PFO is an important finding with significant management implications for the patient. These cases highlight the importance of reviewing the interatrial septum on CT examinations of the thorax.

MDCT features of cardiothoracic sources of stroke

Multidetector computed tomography (MDCT) is widely used in the assessment of cardiothoracic disease and provides high-resolution images of the heart, great vessels, and lungs. A range of cardiothoracic conditions can precipitate stroke, including intracardiac thrombus, right-to-left shunts, and diseases of the thoracic aorta. Many of these conditions may be identified on non-electrocardiogram (ECG)-gated studies, but the advent of high temporal resolution ECG-gated MDCT provides superior anatomical delineation. Radiologists should be familiar with the pathogenesis and CT features of cardiothoracic conditions that can precipitate stroke as their early identification to enables appropriate management and prognostic decisions.

The clinical impact of high resolution computed tomography in patients with respiratory disease

ObjectiveHigh resolution computed tomography is widely used to investigate patients with suspected diffuse lung disease. Numerous studies have assessed the diagnostic performance of this investigation, but the diagnostic and therapeutic impacts have received little attention.MethodsThe diagnostic and therapeutic impacts of high resolution computed tomography in routine clinical practice were evaluated prospectively. All 507 referrals for high-resolution computed tomography over 12xa0months in two centres were included. Requesting clinicians completed questionnaires before and after the investigation detailing clinical indications, working diagnoses, confidence level in each diagnosis, planned investigations and treatments.ResultsThree hundred and fifty-four studies on 347 patients had complete data and were available for analysis. Following high-resolution computed tomography, a new leading diagnosis (the diagnosis with the highest confidence level) emerged in 204 (58%) studies; in 166 (47%) studies the new leading diagnosis was not in the original differential diagnosis. Mean confidence in the leading diagnosis increased from 6.7 to 8.5 out of 10 (pu2009<u20090.001). The invasiveness of planned investigations increased in 23 (7%) studies and decreased in 124 (35%) studies. The treatment plan was modified after 319 (90%) studies.ConclusionsThoracic high-resolution computed tomography alters leading diagnosis, increases diagnostic confidence, and frequently changes investigation and management plans.

Vein graft pseudoaneurysm

An 81-year-old man underwent a routine chest x -ray examination (fig 1) before cystoscopy performed to investigate painless haematuria; he was otherwise well. This showed a 10 cm lobulated mass adjacent to the right heart border. Also noted were midline sternotomy wires from coronary artery bypass graft (CABG) surgery performed 23 years previously. He was a non-smoker and had no other significant medical history. Cystoscopy revealed carcinoma in situ, which was effectively treated with electrocautery, and he was subsequently referred to …

Broadening the scope of thoracic oncological intervention: a novel minimally invasive method for the diagnosis of primary cardiac lymphoma

Primary cardiac lymphoma is a rare and aggressive form of non-Hodgkins lymphoma. It presents with non-specific symptoms which depend on the degree of cardiac infiltration. Appropriate management and early initiation of therapy depends on an understanding of the imaging characteristics and early histological diagnosis. Obtaining histology can be challenging. This is more widely performed using endomyocardial biopsy. However, this technique is associated with recognised morbidity and mortality. We present a novel diagnostic method for the investigation of myocardial and pericardial lesions. This is the first documented case of the diagnosis of primary cardiac lymphoma using endobronchial ultrasound. Endobronchial ultrasound has a well-documented and excellent safety profile.