image: Radiology Assistant Ground-Glass Nodules: If Growing, Assume Cancer Blair Westerly, MD The more CT scans that are performed, the more ground-glass opacities (GGO’s) are seen and what to do with these abnormalities can be difficult to ascertain for clinicians. With the National Lung Cancer Screening Trial showing a mortality benefit from low dose CT [... read more]
image: Wikimedia Inferior Vena Cava Filters: What’s the Harm? Do inferior vena cava filters actually create more harm than health? That’s the provocative question being posed by authors and editorialists in JAMA Internal Medicine. Inferior vena cava filters are frequently placed after a pulmonary embolism (PE) or deep venous thrombosis (DVT) in patients with a [... read more]
Visual learners can see continuous positive airway pressure (CPAP) work for obstructive sleep apnea in realtime in this NEJM video. But how on earth does someone sleep inside an MRI machine? See the Sleep Apnea Video
In Most Patients with Pulmonary Embolism, Central Clot is Worse than Peripheral by Brett Ley, MD Pulmonary embolism (PE) presents with a wide range of clinical severity and course. Management decisions (level of care, length of observation, and aggressive therapies such as thrombolysis) are generally based on a patient’s risk of a poor outcome. Guidelines recommend risk [... read more]
The use of positron emission tomography — better known as PET scans — has grown dramatically over the past 15 years, thanks to their seemingly magical ability to identify foci of undetected metastatic cancer. But PET scans’ perceived high accuracy in diagnosing metastatic non-small cell lung cancer (NSCLC) — a published 94% sensitivity and 83% [... read more]
The American College of Chest Physicians (ACCP) has issued its long-awaited recommendations on lung cancer screening with chest CT — and far from a ringing endorsement of screening, they are conservative and subdued, emphasizing the potential risks of an uncontrolled approach to lung cancer screening in the general population. The American Society of Clinical Oncology [... read more]
The American Lung Association has become the largest advisory body to recommend lung cancer screening for high-risk people, advising nearly all people aged 55-74 with a 30+ pack-year smoking history (the entry criteria for the National Lung Screening Trial, or NLST) to undergo low-dose CT scanning to detect early lung cancer. The National Comprehensive Cancer Network, [... read more]
New Lung Tissue Growth Discovered: Is Some Lung Regeneration Possible? Lung regeneration has never been thought possible in adults. But Steven Mentzer et al from Brigham and Women’s at Harvard reported a case of a 33 year old woman who had an apparent 64% increase in the number of functioning alveoli in her left lung, during [... read more]
Contrast-induced nephropathy (kidney damage) is a serious problem that can occur after many medical tests and procedures, but coronary angiography (cardiac catheterization) is the main culprit. People with pre-existing renal disease are most susceptible to contrast-induced nephropathy (CIN) — about 1 in 8 of them develop a “bump” in creatinine of >0.5 mg/dL after cardiac [... read more]
Acute Deep Venous Thrombosis (DVT) of the Arm: from the ACCP Guidelines, 9th Ed. The ACCP published its 9th edition of their clinical practice guidelines for prevention and treatment of venous thromboembolism (VTE) in February 2012, and we’re summarizing the 801-page long document by topic. (See also the other sections of the 9th edition ACCP recommendations.) Here we review the section on [... read more]
(image: Wikipedia) As one after another specialty society endorses routine lung cancer screening with chest CT scans, we all know a Nodule Storm is coming to a pulmonology clinic near you. Thankfully, smart people are asking how we can systematically and successfully handle this soon-to-be-common outpatient clinical problem. Most of these many thousands of nodules [... read more]
Pulmonologists become fairly good semi-professional chest radiologists simply by showing up, paying attention and working hard during their training, and making an effort to keep learning throughout their careers. We have the advantage over radiologists of actually being able to “clinically correlate” the findings with what’s really going on, and to integrate that into our understanding [... read more]
Diagnosis of Deep Venous Thrombosis (DVT) of the Lower Extremity from the ACCP / Chest Guidelines, 9th Ed. The ACCP recommendations for diagnosis of DVT of the leg are based on these principles of safety: Reducing overall false-negatives to 2% or less (as defined by symptomatic DVT or PE within 3-6 months after a negative test); [... read more]
Inferior Vena Cava Filters for Prevention of Pulmonary Embolism from the ACCP Guidelines, 9th Ed. Inferior vena cava filters should generally be placed in patients with acute pulmonary embolism (PE) or deep venous thrombosis (DVT) who have a contraindication to anticoagulation, according to the ACCP’s recommendations. The ACCP recommends against placing an IVC filter in patients [... read more]
(image: flickrCC) Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA), when performed by skilled physicians, reduces the need for mediastinoscopy and unnecessary thoracotomies with their associated morbidity, and is poised to permanently alter the landscape of lung cancer diagnosis and staging. Prior to 2008, Medicare seemed to recognize the potential value of EBUS by paying hospitals [... read more]
It’s time to revise the traditional approach to the management of pulmonary nodules, abandon the concept of a “solitary pulmonary nodule,” and update our cognitive strategy incorporating the changes in practice and decision-making brought by the frequency of chest CT scanning and its vastly increased sensitivity over chest films of the old era. So say David Ost and Michael Gould, in their concise [... read more]
The 5-year results of the Danish Lung Cancer Screening Trial (DLCST) were reported in the April 2012 Thorax, and they show no mortality benefit from annual screening for lung cancer with chest CT. Rather, it appeared that more harmless early stage cancers were identified through screening — “overdiagnosis” of cancers that would never have advanced [... read more]
Westermark sign: a focal area of decreased lucency on a plain chest film with an abrupt cut-off in the pulmonary artery, corresponding to a central occlusive pulmonary embolism. A.S. Krishnan and Tristan Barrett share a nice example of the Westermark sign in the March 15 New England Journal.
Mazen Albeldawi and Rohit Makkar of the Cleveland Clinic bring us a free image in the New England Journal of what the bronchial tree looks like when a barium swallow test goes horribly awry. This patient had a very poor outcome, particularly unfortunate since this was an elective test. The New England Journal also ran a previous [... read more]
When someone with a pneumothorax lies supine — as in the 23-year old man described in this New England Journal mini-case from Saweera Sabbar and Eric James Nilles of Rashid Trauma Center in Dubai, UAE — air rises laterally and caudally, and creates displacement downward and medially of the hemidiaphragm, displaying as the “deep sulcus [... read more]