Seda Ozbek

Phenotyping of Chronic Obstructive Pulmonary Disease Using the Modified Bhalla Scoring System for High-Resolution Computed Tomography

BACKGROUND Identifying different phenotypes of chronic obstructive pulmonary disease (COPD) is important for both therapeutic options and clinical outcome of the disease. OBJECTIVE To characterize the phenotypes of COPD according to high-resolution computed tomography (HRCT) findings; and to correlate HRCT scores obtained using the modified Bhalla scoring system with clinical and physiological indicators of systemic inflammation. METHODS The present study included 80 consecutive patients with stable COPD. HRCT scans were evaluated by two independent radiologists according to the modified Bhalla scoring system. RESULTS Fifty-four patients exhibited morphological changes on HRCT examination while 26 had no pathological findings. Patients with HRCT findings had lower spirometric measurements and higher levels of inflammation, and reported more exacerbations in the previous year compared with patients with no findings on HRCT. Patients with morphological changes were classified into one of three groups according to their HRCT phenotype(s): emphysema (E) only, E + bronchiectasis (B)⁄peribronchial thickening (PBT) or B⁄PBT only. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1⁄FVC ratio, C-reactive protein (CRP) levels and the number of exacerbations among the groups were significantly different. Pairwise comparisons between the E only and E+B⁄PBT groups showed significantly lower FVC, FEV1 and FEV1⁄FVC values, and higher CRP levels and number of exacerbations compared with the B⁄PBT group. No significant differences were found between the E+B⁄PBT and the B⁄PBT groups. An inverse correlation was found between the total HRCT score and FVC, FEV1 and FEV1⁄FVC; the correlation was positive with CRP level, erythrocyte sedimentation rate and number of exacerbations. CONCLUSION The present study exposed the intimate relationship between phenotype(s) characterized by HRCT and scoring for morphological abnormalities; and clinical and functional parameters and inflammatory markers. The inclusion of HRCT among routine examinations for COPD may provide significant benefits both in the management and prognosis of COPD patients.

Congenital left ventricular wall abnormalities in adults detected by gated cardiac multidetector computed tomography: clefts, aneurysms, diverticula and terminology problems.

OBJECTIVES Our aim was to evaluate congenital left ventricular wall abnormalities (clefts, aneurysms and diverticula), describe and illustrate imaging features, discuss terminology problems and determine their prevalence detected by cardiac CT in a single center. MATERIALS AND METHODS Coronary CT angiography images of 2093 adult patients were evaluated retrospectively in order to determine congenital left ventricular wall abnormalities. RESULTS The incidence of left ventricular clefts (LVC) was 6.7% (141 patients) and statistically significant difference was not detected between the sexes regarding LVC (P=0.5). LVCs were single in 65.2% and multiple in 34.8% of patients. They were located at the basal to mid inferoseptal segment of the left ventricle in 55.4%, the basal to mid anteroseptal segment in 24.1%, basal to mid inferior segment in 17% and septal-apical septal segment in 3.5% of cases. The cleft length ranged from 5 to 22 mm (mean 10.5 mm) and they had a narrow connection with the left ventricle (mean 2.5 mm). They were contractile with the left ventricle and obliterated during systole. Congenital left ventricular septal aneurysm that was located just under the aortic valve was detected in two patients (0.1%). No case of congenital left ventricular diverticulum was detected. CONCLUSION Cardiac CT allows us to recognize congenital left ventricular wall abnormalities which have been previously overlooked in adults. LVC is a congenital structural variant of the myocardium, is seen more frequently than previously reported and should be differentiated from aneurysm and diverticulum for possible catastrophic complications of the latter two.

Comparison of apparent diffusion coefficient values among different MRI platforms: a multicenter phantom study

PURPOSE We aimed to compare apparent diffusion coefficient (ADC) values among magnetic resonance imaging (MRI) scanners from different vendors. MATERIALS AND METHODS We used a custom-made phantom solution consisting of distilled water, 0.9% NaCl, 25% NaCl, and shampoo for diffusion-weighted MRI (DW-MRI) examinations. DW-MRI was performed with similar sequence parameters using six different 1.5 Tesla MR scanners (scanners A-F). ADC maps were automatically constructed for all DW-MR images (b factors of 0 and 1000 s/mm(2)). ADC measurements were performed using regions of interest and seven different software programs, including four different postprocessing workstations, two different picture archiving and communication systems, and operator console software for each MR scanner. RESULTS The ADC values generated by scanners A and F were higher and those of scanner B were lower than those generated by the other scanners (P = 0.002). The intravendor difference in the ADC values averaged from scanners D, E, and F was statistically significant (P < 0.001). The difference between the ADC values obtained by scanners C and E was not statistically different (P = 0.15). CONCLUSION ADC values may differ among different MRI systems used for DW-MRI. Thus, the MRI vendor should be considered when using DW-MRI in a clinical setting.

An investigation of the anatomical variations of left atrial appendage by multidetector computed tomographic coronary angiography

PURPOSE The left atrial appendage (LAA) is usually known as a long, tubular, hooked structure derived from the left atrium. However, it varies widely in terms of anatomical shape. In this study, anatomical shape variations of the LAA were investigated and classified in vivo in a large group of patients by multidetector computed tomography (MDCT) coronary angiography. MATERIALS AND METHODS The study included 320 consecutive patients (223 men and 97 women, with a mean age of 58 years) who underwent MDCT coronary angiography. MDCT was performed with a 64-detector-row computed tomographic scanner. LAA anatomical variations were classified as five main types and further divided into subtypes. In addition, we gave the classifications descriptive names according to the anatomical external appearance of the LAA: horseshoe (type 1), hand-finger (type 2a), fan (type 2b), wing (type 2c), hook (type 3), wedge (type 4) and swan (type 5) shapes. The types and subtypes of the LAA variations and the presence of thrombus were recorded. RESULTS In our study, the LAA tip orientation was used and the LAA was divided into type 1, type 2a, 2b, 2c, type 3, type 4 and type 5 in 44 (13.8%), 65 (20.3%), 155 (48.4%), 8 (2.5%), 27 (8.4%), 6 (1.9%) and 15 (4.7%) patients, respectively. LAA thrombus was detected in four patients (1.25%), who had classified LAA shapes of type 2a and type 2b. CONCLUSIONS The LAA has multiple anatomical shape variations. We demonstrated previously undefined new shape types of LAA. Knowledge of LAA variations is important in order to avoid procedure-related complications when ablative treatment is to be performed or if surgical procedures are indicated in this region. MDCT coronary angiography provides important and detailed information about determining and evaluating these variations before undertaking a planned procedure in this region.

Optimal angle of needle entry for internal jugular vein catheterization with a neutral head position: a CT study.

Purpose: The aim of this study is to determine the optimal angle of needle entry in the sagittal plane for internal jugular vein (IJV) catheterization with the central approach while the head is in the neutral position. Methods: The contrast–enhanced carotid artery computed tomography angiographies of 123 consecutive patients were retrospectively reviewed. The point of merger between the sternal and clavicular heads of the sternocleidomastoid muscle was assumed as a clinical entry (CE) point. The angle between CE point and the center of the IJV, the depth, diameter of the vessels and the degree of overlap between the IJV and carotid artery (CA) were measured. Results: The angles between the CE point and the center of the IJVs were similar, 7° ± 13° medial and 8° ± 12° medial on the right and the left side, respectively. The center of IJVs from the CE point was between 0° and 16° toward the medial in 79.8% on the right side and 89.9% on the left side of patients. The diameters of the right IJVs were greater than the left IJVs (p = 0.001). The depth from the skin and overlap between IJV and CA did not vary between the two sides. Conclusions: When a central approach is used for right internal jugular vein (RIJV) cannulation with a neutral head position, the orientation of the angle of needle entry (i.e., 16°) medially in the sagittal plane may quadruple the success rate of RIJV catheterization compared to the success rate of a laterally oriented angle of entry as recommended by the classic method.

Relationship between the Right Internal Jugular Vein and Carotid Artery at Ipsilateral Head Rotation

Ultrasound-guided right internal jugular vein catheterization (RIJV) should be the first choice to decrease the catheter-related complications in high-risk hemodialysis patients. For this procedure, clinicians should identify the optimum positions of the RIJV, including its lower overlap with the carotid artery (CA) and high cross-sectional area of the vein. The aim of this prospective randomized study to evaluate the effects of mild ipsilateral head rotation combined with Trendelenburg position on RIJV cross-sectional area and its relation to the CA in adult patients. Forty ASA I–II patients who were undergoing elective surgery were enrolled for this study. The subjects were asked to remain supine in the 15–20° Trendelenburg position. Two-dimensional ultrasound was then used to measure the degree of overlap between the RIJV and CA, the cross-sectional area of the RIJV. These measurements were compared between head rotation to the >30° left, <30° left, neutral, and <30° right positions. When the head was in the >30° left position, overlap was seen in 38 of 40 patients (95%). As the head was rotated from >30° left to <30° right, the CA-RIJV overlap (from 95% to 57.5%), and the cross-sectional area (from 14.2 mm to 8.7 mm) significantly decreased. In conclusion, when the head was turned to <30° right, the CA-RIJV overlap significantly decreased, and the cross-sectional area also decreased. When clinicians determine the optimal head position before RIJV cannulation, it is important to consider the advantages and disadvantages of the different head positions from >30° left to <30° right.

Relationship between color M-mode echocardiography flow propagation and cardiac iron load on MRI in patients with thalassemia major.

PURPOSE Myocardial iron overload remains an important problem and results in cardiac dysfunction in patients with thalassemia major (TM). The ratio of color M-mode flow propagation velocity to early diastolic transmitral flow velocity (E/Vp) in echocardiography is a marker of increased left ventricular filling pressure, which is independent of preload, afterload, and heart rate. We examined the relationship between E/Vp and iron loading in patients with TM using cardiac magnetic resonance imaging (MRI). MATERIALS AND METHODS Twenty-one TM patients and 21 age-matched healthy controls were enrolled in the study. Transmitral flow, pulmonary vein velocities, and Vp were obtained by two blinded echocardiographers. Left ventricular isovolumetric relaxation time (IVRT) was measured in the apical long axis by echocardiography. All patients also underwent MRI for cardiac T2* evaluation of iron overload. An increased E/Vp was defined as > 1.5. RESULTS The E/Vp ratio was increased in TM patients compared with control subjects (1.7±0.4 and 1.2±0.2, P < 0.01, respectively). There was no correlation between E/Vp and cardiac T2* value. E/Vp was significantly correlated with IVRT (r=0.51, P = 0.02). In addition, the cardiac T2* value was comparable in patients with an E/Vp > 1.5 and E/Vp ≤1.5 (21.1±9.8 ms vs. 22.3±8.0 ms, P = 0.80, respectively). CONCLUSION E/Vp may be a marker of diastolic abnormality that is independent from myocardial iron load in TM patients with preserved left ventricular function.

Left femoral vein is a better choice for cannulation in children: a computed tomography study.

Central venous catheters are often required in emergency rooms and intensive care and/or those undergoing major surgical procedures. In this study, we aimed to gain a better understanding of the anatomy of the femoral vessel in relation to central venous cannulation.

Seeing is believing: ultrasound-guided internal jugular vein cannulation.

• Volume 115 • Number 6 www.anesthesia-analgesia.org 1471 REFERENCES 1. Troianos CA, Hartman GS, Glas KE, Skubas NJ, Eberhardt RT, Walker JD, Reeves ST. Guidelines for performing ultrasound guided vascular cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 2012;114:46–72 2. Troianos CA, Kuwik RJ, Pasqual JR, Lim AJ, Odasso DP. Internal jugular vein and carotid artery anatomic relation as determined by ultrasonography. Anesthesiology 1996;83:43–8 3. Lamperti M, Subert M, Cortellazzi P, Vailati D, Borrelli P, Montomoli C, D’Onofrio G, Caldiroli D. Is a neutral head position safer than 45-degree neck rotation during ultrasoundguided internal jugular vein cannulation? Results of a randomized controlled clinical trial. Anesth Analg 2012;114:777–84 4. FellerKopman D. Ultrasoundguided internal jugular access: a proposed standardized approach and implications for training and practice. Chest 2007;132:302–9

Radiologic findings of a traumatic urethral diverticulum with stones in an infertile male patient

Urethral diverticulum is rarely encountered in male patients. Although postmicturition dribble, pain and infection are usually present, infertility is rarely reported in urethral diverticulum. We present a case with urethral diverticulum associated with infertility, which was diagnosed radiologically.