Julian Dobranowski

Circulating fibrocytes are an indicator of poor prognosis in idiopathic pulmonary fibrosis.

RATIONALE The clinical management of idiopathic pulmonary fibrosis (IPF) remains a major challenge due to lack of effective drug therapy or accurate indicators for disease progression. Fibrocytes are circulating mesenchymal cell progenitors that are involved in tissue repair and fibrosis. OBJECTIVES To test the hypothesis that assay of these cells may provide a biomarker for activity and progression of IPF. METHODS Fibrocytes were defined as cells positive for CD45 and collagen-1 by flow cytometry and quantified in patients with stable IPF and during acute exacerbation of the disease. We investigated the clinical and prognostic value of fibrocyte counts by comparison with standard clinical parameters and survival. We used healthy age-matched volunteers and patients with acute respiratory distress syndrome as control subjects. MEASUREMENTS AND MAIN RESULTS Fibrocytes were significantly elevated in patients with stable IPF (n = 51), with a further increase during acute disease exacerbation (n = 7; P < 0.001 vs. control subjects). Patients with acute respiratory distress syndrome (n = 10) were not different from healthy control subjects or stable patients with IPF. Fibrocyte numbers were not correlated with lung function or radiologic severity scores, but they were an independent predictor of early mortality. The mean survival of patients with fibrocytes higher than 5% of total blood leukocytes was 7.5 months compared with 27 months for patients with less than 5% (P < 0.0001). CONCLUSIONS Fibrocytes are an indicator for disease activity of IPF and might be useful as a clinical marker for disease progression. This study suggests that quantification of circulating fibrocytes may allow prediction of early mortality in patients with IPF.

Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging.

Background Cricoid pressure (CP) is often used during general anesthesia induction to prevent passive regurgitation of gastric contents. The authors used magnetic resonance imaging to determine the anatomic relationship between the esophagus and the cricoid cartilage (“cricoid”) with and without CP. Methods Magnetic resonance images of the necks of 22 healthy volunteers were reviewed with and without CP. Esophageal and airway dimensions, distance between the midline of the vertebral body and the midline of the esophagus, and distance between the lateral border of the cricoid or vertebral body and the lateral border of the esophagus were measured. Results The esophagus was displaced laterally relative to the cricoid in 52.6% of necks without CP and 90.5% with CP. CP shifted the esophagus relative to its initial position to the left in 68.4% of subjects and to the right in 21.1% of subjects. Unopposed esophagus was seen in 47.4% of necks without CP and 71.4% with CP. Lateral laryngeal displacement and airway compression were demonstrated in 66.7% and 81.0% of necks, respectively, as a result of CP. Conclusion In the absence of CP, the esophagus was lateral to the cricoid in more than 50% of the sample. CP further displaced both the esophagus and the larynx laterally.

The cricoid cartilage and the esophagus are not aligned in close to half of adult patients

PurposeTo determine the frequency and degree of lateral displacement of the esophagus relative to the cricoid cartilage (“cricoid”) using computed tomography (CT) images of normal necks.MethodsFifty-one cervical CT scans of clinically normal patients were reviewed retrospectively. Esophageal diameter, distance between the midline of the cricoid and the midline of the esophagus, and distance between the lateral border of the cricoid and the lateral border of the esophagus were measured.ResultsLateral esophageal displacement was observed in 49% (25/51) of CT images. When present, the mean length of displaced esophagus relative to the midline of the cricoid was 3.3 mm ± SD 1.3 mm. Of those with lateral displacement, 64% had esophageal displacement beyond the lateral border of the cricoid (mean 3.2 mm ± SD 1.2 mm). There is a relatively normal distribution of the grouped measures of percentage of esophageal diameter that is displaced. Of those with displacement, 48% had over 15% of the total width of the esophagus displaced laterally and 20% had over 20% of the esophageal width displaced laterally.ConclusionThere is a 49% frequency of some degree of lateral displacement of the esophagus relative to the cricoid.RésuméObjectifDéterminer la fréquence et le degré de déplacement latéral de l’œsophage relativement au cartilage cricoïde («cricoïde») en utilisant les Images tomodensltométriques cervicales normales.MéthodeCinquante et une Images de tomodensltométrle cervicale de patients diniquement normaux ont été revues rétrospectivement. Le diamètre œsophagien, la distance entre la ligne médiane du cricoïde et celle de l’œsophage et la distance entre le bord latéral du cricoïde et celui de l’œsophage ont été mesurées.RésultatsLe déplacement latéral de l’œsophage a été observé dans 49% (25/51) des Images. Lorsqu’il était présent, il était en moyenne de 3,3 mm ± 1,3 mm d’écart type par rapport à la ligne médiane du cricoïde. Soixantequatre pour cent des déplacements latéraux de l’œsophage allaient au delà du bord latéral du cricoïde (moyenne de 3,2 mm ± 1,2 mm d’écart type). Nous avons noté une distribution relativement normale des mesures groupées de pourcentage de diamètre œsophagien déplacés. De ces déplacements, 48% présentaient plus de 15% de la largeur totale de l’œsophage déplacé latéralement et 20% avaient plus de 20% de déplacement.ConclusionLa fréquence de déplacement latéral de l’œsophage d’un certain degré par rapport au cricoïde est de 49%.

Emphysematous Pyelonephritis: Complicated Urinary Tract Infection in Diabetes

Renal emphysema is rare condition that may affect diabetic patients. Radiographic demonstration of gas limited to the collecting system is often treated with antibiotics. However, intraparenchymal gas requires early nephrectomy because mortality rates are high without surgical intervention.

Inadequacy of intravenous heparin therapy in the initial management of venous thromboembolism

To determine the adequacy of initial anticoagulation by intravenous heparin for patients who have deep venous thrombosis (DVT), and the factors that influence delayed anticoagulation, independent, duplicate chart review of 63 consecutive patients who had venography-proven DVT was conducted. Adequate heparinization (AH) was defined as an activated partial thromboplastin time (PTT) of more than 1.5 times the normal laboratory control. The proportions of patients achieving AH within 24 hours and 48 hours of initial heparin bolus were 46% and 62%, respectively. Patients who weighed more were less likely to achieve AH (p<0.05), while patients receiving care from the thromboembolism service were more likely to achieve AH (p<0.05). Low initial infusion rate was strongly but not significantly predictive of inadequate anti-coagulation (p=0.06). The mean heparin bolus and initial infusion rates were significantly lower than those suggested in the literature (p<0.01). The AH rates were comparable to historical controls but suboptimal compared with the rates of 66% at 24 hours and 81% at 48 hours reported in association with heparin nomogram use (p<0.05). A heparin nomogram is likely to achieve consistently higher rates of adequate heparinization.

Procedures in gastrointestinal radiology

This book presents several gastrointestinal radiology techniques. Contrast studies are emphasized as well as endoscopic procedures, thus enabling the radiologist to choose the appropriate technology. Each procedure is discussed with reference to materials, patient preparation. positioning, technical factors, and potential problems. Patient-radiologist interaction before, during, and after the results of the study are emphasized.

Upper Gastrointestinal Tract

There is continuing controversy over whether endoscopy or barium meal should be performed for examination of the upper gastrointestinal (GI) tract [1]. For gastroesophageal reflux disease, the barium swallow study is the preferred initial examination and often the only investigation required [2,3]. Barium swallow better detects motor abnormalities [2], but encoscopy is needed for barium-negative dysphagia and for biopsy of strictures [4]. In acute odynophagia or food impaction, endoscopy should be the initial examination (when possible) because barium destroys the endoscopic view and endoscopy often is required in these patients for foreign body removal. Endoscopy can, however, miss tumors of the gastroesophageal junction. If endoscopy is used as the initial esophageal investigation in a patient with dysphagia and this study is negative, a follow-up barium swallow should be performed.

Technical Aspects of Imaging of the Gastrointestinal Tract

Radiological technology is a rapidly growing and changing profession, and dedicated technologists should continually strive to improve their knowledge, understanding, and skills. As health care professionals, they have an important role to play on the radiological team.

Pediatric Gastrointestinal Examinations

Children are not small adults. The signs, symptoms, and disease in pediatric patients often differ considerably from those in adults. A history gathered from parents suggesting a gastrointestinal cause for symptoms may be misleading. The clinician has to evaluate the entire patient and take a complete history to ensure that unnecessary examinations are not performed. It behooves the radiologist to be aware of these problems in diagnosis, and to develop a close rapport with the clinicians to ensure that the patient receives no unnecessary radiation or discomfort in solving a diagnostic dilemma.