Colleen Bergin

Pneumocystis carinii pneumonia: CT and HRCT observations.

We examined the chest radiography, CT, and high resolution CT (HRCT) of 14 patients with proven Pneumocystis carinii pneumonia. We compared the radiographic and HRCT patterns of abnormal lung parenchyma with histologic sections obtained in those 11 patients who had had transbronchial lung biopsies. Diffuse bilateral perihilar airspace disease was the most common radiographic pattern. Both CT and HRCT showed “ground glass” opacity in the lungs, through which the vessels remained visible in all patients. No enlarged lymph nodes or pleural effusions were seen in patients without associated lymphoproliferative disorders.

Lymph node enlargement in pulmonary arterial hypertension due to chronic thromboembolism

The aim of this study was to determine the prevalence and location of enlarged mediastinal and hilar lymph nodes in patients with pulmonary arterial hypertension (PAH) due to chronic pulmonary thromboembolism (CPTE) and to identify possible causes. Thoracic CT images of 85 patients (43 men and 42 women, aged 18–80 years) with PAH in whom CPTE was confirmed at surgery (n = 75) or angiography and angioscopy (n = 10) were evaluated by two thoracic radiologists to determine the presence, size and location of lymph nodes more than 1 cm in the short axis. The presence of pleural and pericardial effusions and parenchymal abnormalities were also noted. Enlarged lymph nodes were identified in 38 patients (44.7%), including 11 with possible causes of lymphadenopathy other than CPTE. In the 27 patients with CPTE alone, 67 enlarged lymph nodes were detected (average 2.5 per patient). Nine patients had three or more enlarged lymph nodes. The most common sites of lymph node enlargement were American Thoracic Society locations 7 (n = 13), 6 (n = 10), 11L (n = 9), 10R (n = 7) and 4R (n = 7). Pleural and pericardial effusions were more common in patients with CPTE who also had lymphadenopathy than in the group with no lymphadenopathy (P < 0.05). Lymph node enlargement is common in patients with PAH caused by CPTE. The frequent association of lymphadenopathy with pleural and pericardial effusions suggest a possible pathophysiological mechanism of increased lymphatic flow caused by right heart failure.

Adequacy of brain and spinal blood supply with antegrade cerebral perfusion in a rat model

OBJECTIVE The purpose of this study was to examine whether different techniques used for antegrade cerebral perfusion could account for variation in the perfusion adequacy of the brain and spinal cord. METHODS Selected vessels were ligated in 30 rats, recreating a selection of approaches used in aortic arch surgery for patients undergoing circulatory arrest with antegrade cerebral perfusion. Filling of spinal and cerebral vessels was mapped after cannulation and perfusion with E20, gelatin/India ink, or buffered saline/India ink. Three clinical approaches were replicated: unilateral perfusion, bilateral perfusion, and bilateral perfusion with additional left subclavian artery perfusion. Filling of the spinal arteries via the common carotid arteries or the subclavian arteries alone was examined. Penetration of the marker was analyzed histologically. RESULTS The control experiments achieved maximal arterial filling of both brain and spinal cord at gross and microscopic levels. Unilateral and bilateral antegrade cerebral perfusion provided comprehensive arterial filling of all cerebral vessels with all vascular markers. In contrast, only bilateral antegrade cerebral perfusion provided complete spinal cord perfusion with all markers. Unilateral antegrade cerebral perfusion with a viscous marker resulted in significantly reduced spinal cord arterial filling. Examination of the relative importance of either both common carotid arteries alone or both subclavian arteries alone, in terms of their adequacy of subsequent arterial filling of the spinal cord, showed severe impairment of spinal cord perfusion with either technique. Thus perfusion of both common carotid arteries resulted in only the proximal 30% of the spinal cord arteries being filled, whereas perfusion of both subclavian arteries resulted in only the proximal 40% of the spinal cord arteries being filled. CONCLUSIONS Approaches to antegrade cerebral perfusion using the brachiocephalic and left common carotid arteries together gave good perfusion of both the brain and the spinal cord. Brachiocephalic perfusion alone gave good cerebral perfusion but showed some significant limitation in spinal cord perfusion with one vascular marker. Complete spinal cord perfusion with all markers under conditions of antegrade cerebral perfusion required some contribution from both the carotid system and the subclavian system together. Selected perfusion of either system alone was very inadequate for spinal cord perfusion.

Fast SE MRI of the chest: parameter optimization and comparison with conventional SE imaging.

Objective This study was performed to optimize scanning parameters for fast spin echo (FSE) T2-weighted scans of the chest and to compare FSE T2-weighted images with conventional spin echo (CSE) T2-weighted scans. Materials and Methods Thirty-nine FSE T2-weighted scans of the chest were obtained in 12 subjects to determine the effect of cardiac gating (with gating n = 20; without gating n = 19) and combinations of nutnber of excitations (NEX) (2,4,8,16) and echo train length (ETL) (2,4,8,16) on scan quality and visibility of thoracic structures. An additional 15 chest MR examinations consisting of FSE T2− and CSE T1-, proton-density- (PD), and T2-weighted scans were obtained in 15 patients with a variety of thoracic abnormalities. The FSE T2-weighted scans were compared with CSE T2-weighted scans, and the combination of CSE T1− and FSE T2-weighted scans was compared with the combination of CSE PD- and T2-weighted scans. Results Little difference in image quality was found between cardiac-gated and nongated FSE scans. Increasing the ETL resulted in increased motion artifact. Forty lesions were detected with FSE and 42 lesions with CSE T2-weighted scans. Fifty-three lesions were detected with the combination of CSE T1− and FSE T2-weighted sequences, whereas 44 lesions were detected with the combination of CSE PD- and T2-weighted scans. Conclusion The combination of cardiacgated CSE T1− and non-cardiacgated FSE T2-weighted scans was 20% more sensitive and twice as fast as the combination of cardiacgated CSE PD- and T2-weighted scans. Index Terms Magnetic resonance imaging—Fast spin echo imaging—Thorax—Magnetic resonance imaging, techniques.

Low-dose erythropoietin treatment is not associated with clinical benefits in severely anaemic Jehovah's Witnesses: a plea for a change.

BACKGROUND Jehovahs Witnesses who refuse blood transfusion have high mortality. Erythropoietin (EPO) has been used as an alternative to blood transfusion. The optimal dosing of EPO in anaemic Jehovahs Witnesses is unknown. The aim of our study was to evaluate the clinical benefits of treatment with a low dose (<600 IU/kg/week) of epoietin beta (EPO-β). MATERIALS AND METHODS This was an observational study, retrospectively considering a 10-year period during which 3,529 adult Jehovahs Witnesses with a total of 10,786 hospital admissions were identified from databases of four major public hospitals in New Zealand. Patients with severe symptomatic anaemia (haemoglobin <80 g/L) who were unable to tolerate physical activity were included in the study. Patients treated without EPO were assigned to the conventional therapy group and those treated with EPO to the EPO treatment group. RESULTS Ninety-one Jehovahs Witnesses met the eligibility criteria. Propensity score matching yielded a total of 57 patients. Patients treated with conventional therapy and those treated with EPO had similar durations of severe anaemia (average difference 6.25 days, 95% confidence interval [CI]: -3.77-16.27 days; p=0.221). The mortality rate among Jehovahs Witnesses treated with conventional therapy was 4.68 per year (95% CI: 2.23-9.82), while that in those treated with EPO was 2.77 per year (95% CI: 0.89-8.60). Treatment with EPO was associated with a mortality ratio of 0.59 (95% CI: 0.1-2.6; p=0.236). Both groups of patients had similar in-hospital survival (p=0.703). DISCUSSION Treatment with low-dose EPO-β was not associated with either shorter duration of severe anaemia or a reduction in mortality.

Sonographic findings in acute puerperal endometritis: The hypoechoic rim sign and endomyometrial junction indistinctness

To evaluate the accuracy of the sonographic subserosal hypoechoic rim sign and endomyometrial junctional indistinctness in identifying patients with acute endometritis during the puerperal period.

Sonographic findings in acute puerperal endometritis

To evaluate the reliability of the sonographic subserosal hypoechoic rim sign and endomyometrial junction indistinctness in distinguishing patients with acute puerperal endometritis from other common postpartum complications, particularly those with retained products of conception.

Pericardial empyema after cardiac surgery: a diagnostic challenge: Images for surgeons

Pericardial effusions after cardiac surgery develop in approximately 10% of patients. Post-operative pericardial effusions are associated with cardiac tamponade and arrhythmias. They can become infected leading to acute mediastinitis (AM). We describe a patient with pericardial empyema after cardiac surgery. A 72-year-old man re-presented to Auckland City Hospital 6 weeks following surgery for mitral valve repair and tricuspid annuloplasty. He had a 2-day history of non-productive cough, shortness of breath, lethargy and low-grade fever. History revealed that on the 11th post-operative day, 2 days after discharge from his cardiac surgery, he was readmitted to another hospital with a pericardial effusion, which was drained percutaneously with removal of 800 mL of fluid over 3 days. Microbiology culture yielded a light growth of Staphylococcus epidermidis but this was not treated. On subsequent admission to our hospital, 32nd post-operative day, he was in atrial fibrillation with ventricular rate of 130 beats/ min and stable vital signs. Physical examination revealed mild skin erythema over the lower end of the chest wound and sternal nonunion. Blood tests demonstrated anaemia; haemoglobin concentration of 102 g/L; normal white blood cell, neutrophil and lymphocyte counts; C-reactive protein concentration of 65 mg/L (normal range: 0–5 mg/L); and estimated glomerular filtration rate of 88 mL/min/1.73 m. The chest X-ray showed mild cardiomegaly (Fig. 1) which raised concern for possible recurrence of his pericardial effusion. Echocardiography demonstrated a large 12 × 4.1 cm organized pericardial collection around the anterolateral aspect of the left ventricle without evidence of tamponade. Computed tomography scan performed 1 day later showed a large well-defined left-sided gas-containing fluid collection in the pericardial space with peripheral vascular enhancement. This measured approximately 400 mL (134 × 105 × 56 mm) (Fig. 2). Bilateral pleural effusions were larger on the right side and interval sternal wire unfolding with widening of the sternotomy was evident. The patient underwent an emergency sternal re-exploration. During surgery, the metal cable wires were found to cut the left hemisternum into four pieces with sternal non-union. There was pus between the sternal edges and a large amount of purulent fluid with fibrinous debris was found in a pericardial pocket lateral to the left ventricle and atrium. With identification of the pericardium, pericardial incision was extended to the left over the left ventricle and fibrinous septae separating pericardial empyema from the remainder of pericardial cavity were divided. The heart, pericardial cavity and sternal wound were washed out with normal saline solution. Fluid from both pleural spaces was evacuated and pleural and retrosternal 14-Fr Redivac drains were placed. The fragments of left hemisternum were brought together and opposed to the right hemisternum with metal wires. After sternal re-wiring, the presternal Redivac drain was inserted and the chest wound was closed in layers. Intraoperative pericardial tissue culture yielded a moderate growth of S. epidermidis resistant to flucloxacillin and susceptible to vancomycin. The patient was treated with intravenous vancomycin therapy and had an uneventful recovery. On the day of transfer Fig. 1. Frontal chest X-ray of the patient.

Aortocoronary artery dissection: a partial aortic root remodelling, aortic valve repair and coronary artery bypass

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