Deppen et al report that PET-CT’s specificity for lung cancer was only 40% among 211 patients undergoing resection for presumed lung cancer at Vanderbilt in Nashville, TN, an area endemic for histoplasmosis. Twenty-two of 43 benign nodules were granulomas; most were positive on PET-CT (~60%). Ann Thorac Surg 2011;92:428-433.
Increasing urine output should reduce the risk for contrast nephropathy, as should hustling contrast metal past vulnerable Na-K-Cl transporters using loop diuretics. However, furosemide alone increases the risk for contrast nephropathy. Some hypothesized that was due to diuretic-induced hypovolemia. Briguori et al report results of REMEDIAL-II. They randomized ~300 patients at very high risk for [... read more]
CT angiography is increasingly maligned for its overuse, its likely overdiagnosis of pulmonary emboli, and its radiation risk. The problem is, with >90% sensitivity and specificity, it’s just so damn good. And alternatives like V/Q, even when combined with clinical decision rules, haven’t been seen as providing sufficient accuracy. In a phase II clinical trial, [... read more]
Walker et al give us a nice picture and high-yield tutorial on the reversed halo sign, in this case from cryptogenic organizing pneumonia: J Thorac Imaging 2011;26:w80. (FREE)
Mavros et al did the heavy lifting required to review 998 studies relating in some way to atelectasis and postoperative fever. They felt only 8 of those studies deserved analysis (990 were excluded either for not reporting sufficient data, or not focusing on the question at hand). One study reported an association between atelectasis and [... read more]
Darling et al report findings from the Early Lung PET trial for non-small cell lung cancer. PET-CT had 70% sensitivity and 94% specificity for identifying cancerous mediastinal lymph nodes (with invasive staging as the reference standard). Sounds good. However, among the 22 patients with PET-CT scans positive for mediastinal nodes, 8 did not have cancer [... read more]
Low et al took 320-slice CT scans of the larynxes of 46 people with severe asthma throughout the respiratory cycle. They decided that 23 (50%) had abnormal narrowing of the vocal cords during either inspiration or expiration, and in 9 (19%) the narrowing was severe. This is an experimental modality so the clinical implications are [... read more]
Fragou et al randomized 401 ICU patients to undergo subclavian vein central line placement with guidance either by ultrasound or anatomic landmarks. All cannulations were with an infraclavicular approach. The ultrasound group had a higher success rate (100% vs 87.5%), shorter time to access and fewer number of attempts, and a lower rate of complications. [... read more]
In severe congestive heart failure, lymphatic drainage can increase 10-fold. Pastis et al hypothesize this could result in enlarged mediastinal lymph nodes. They retrospectively examined chest CT scans for 118 patients undergoing heart transplantation. Fifty-three had mediastinal LNs > 1 cm. In the 9 who had post-transplant CT scans available, mediastinal lymph nodes shrank after [... read more]
van der Aalst et al report that in the Dutch lung cancer screening NELSON trial, smokers with 1 or more indeterminate CT scans continued to smoke at the same rate as those with normal CT scans (reported by questionnaire 2 years later). Those with the abnormal CTs did report more attempts at smoking cessation, though. [... read more]
Douma et al compared the Wells score, Geneva score, and the simplified versions of each, combined with D-dimer, on a prospective cohort of 807 patients with suspected PE (~23% of whom were found to have PE). With a negative D-dimer and a low-probability score using any rule, risk of pulmonary embolism was ~0.5%. However, only [... read more]
Salaun et al publish their experience using a simple algorithm for management of 321 consecutive patients with suspected pulmonary embolism at one center in France. The tool sought to avoid CT-angiography (and associated radiation) wherever possible, instead favoring leg ultrasounds and ventilation-perfusion scans. Only the indeterminate cases (a mere 35, or 11%) underwent CT-A. In [... read more]
Exacerbations are known to worsen the long-term clinical course of COPD. Tanabe et al performed serial chest CTs on 60 people with COPD over 2 years; 26 had exacerbations and 34 did not (0.34 exacerbations per person-year). The two groups (exacerbation / no exacerbation) were similar in age, COPD severity, etc. However, those with exacerbations [... read more]
The New York Times reported that hundreds of community hospitals frequently perform two chest CT scans back-to-back (one with, one without IV contrast), while academic centers almost never do. More than 70,000 patients were double-scanned; some hospitals did it >80% of the time on their Medicare chest patients. Defenders say they don’t do it to [... read more]
Canessa et al observed 17 people with untreated obstructive sleep apnea and 15 age-matched healthy controls, performing sleep studies, cognitive testing, and MRIs on all. At baseline, OSA patients had shrinkage in brain areas responsible for memory and executive function (hippocampus, posterior parietal cortex, and superior frontal gyrus, as quantitated by voxel based morphometry) and were neurocognitively impaired [... read more]
Zanobetti et al prospectively evaluated 404 consecutive people presenting to one emergency room for dyspnea with point-of-care ultrasonography (all done by one MD) followed by chest radiograph. In the 118 instances when the tests provided discordant diagnoses, chest CT was obtained and was used as the gold standard. Concordance between US and CXR was high across all [... read more]
Rich et al from U. of Chicago add to the “we said, they said” record on echocardiography’s accuracy in measuring PA pressures (and by implication, whether it can be used to justify oral therapy for PAH without invasive testing). They measured 160 people’s PAP by right heart catheterization and ECHO, both tests within one month; they then [... read more]
COPD’s systemic inflammatory effects are postulated to negatively impact bone turnover. After looking at CT scans, PFTs, and steroid history in 190 current and former smokers, Bon et al found visual emphysema on chest CT was highly correlated with osteopenia/osteoporosis, with an odds ratio of 2.55 that was independent of airflow limitation, age, sex, inhaled/oral [... read more]
Pulmonary hypertension is often “diagnosed” with a tricuspid regurgitant jet velocity > 2.5 m/s on echocardiogram. Bossone et al found that 76 of 615 (12%) trained athletes (strength or endurance) exceeded this number, and suggest the upper limit of normal should be 40 mm Hg in endurance athletes. CHEST 2011;139:788-794.
Establishing mediastinal spread of non-small cell lung cancer (N2-3 disease) precludes surgery and worsens prognosis; whether PET-CT imaging can improve overall accuracy or safely prevent mediastinoscopies is still unknown. Fischer et al re-heat the data from their 2009 NEJM randomized trial in Denmark, with EUS-FNA and mediastinoscopy on 189 NSCLC patients, in which they concluded that the [... read more]