A Skinfold Imitating a Pneumothorax.

Following surgical procedures in thoracic surgery a chest X-ray is routinely performed and its necessity is rarely questioned. However, there are differences in the time frame of such radiological procedures. Especially after minor procedures such as mediastinoscopy there is a wide variation from a chest X-ray immediately after surgical intervention to an image only on the following day. Also, in some hospitals patients undergo only clinical but no radiological examination. No recommendations are available in the literature. Following video-mediastinoscopy with good visualisation of all structures it appeared that a chest X-ray could be waived. 95 consecutive patients were prospectively randomised into two groups, either receiving chest X-ray four hours postoperatively or no chest X-ray. All patients were clinically examined on the evening of the day of mediastinoscopy. 48 % of the patients had a chest X-ray, 52 % did not and underwent only clinical examination. No surgical revision was necessary in either group, no difference in therapeutic consequences was noted. As a result we discontinued chest X-rays after mediastinoscopy. There are only sparse data concerning postoperative chest X-rays in thoracic surgery patients. In a study on children and young adults undergoing a Nuss procedure routine radiological examination was substituted by clinical indication resulting in a lower rate of thoracic drain placement. A chest X-ray to document the location of the metal bar prior to discharge was felt to be sufficient. In patients undergoing cardiac procedures daily routine chest X-rays on the intensive care ward were replaced by on-demand X-ray in a study without any change in length of stay, readmission or mortality. The same was found for chest X-rays following drain removal in cardiac patients: routine radiological examination seems not to be indicated. As a consequence of our own observational study on mediastinoscopy we have discontinued postoperative X-ray as the patients are examined clinically. All other patients undergoing thoracic surgery procedures who are observed in the intensive care unit receive the first chest X-ray in the morning following surgery. Only if complete expansion of the lung is warranted (pleurodesis, pneumothorax) an X-ray is performed on the day of surgery.

Mandibular invasion in oral squamous cell carcinoma: investigation by clinical examination and orthopantomogram

Đặt vấn đề: Bệnh tim bẩm sinh là dị tật bẩm sinh phổ biến nhất và là nguyên nhân tử vong hàng đầu trong năm đầu đời. Siêu âm tim có vai trò quan trọng trong chẩn đoán, tuy nhiên, không phải tất cả các bác sĩ đều có thể tiếp cận với kĩ thuật này. Do đó, X-quang ngực là một công cụ quan trọng trong đánh giá ban đầu những trẻ nghi ngờ có bệnh lý tim, phổi. Mục tiêu: Mô tả vai trò của lâm sàng và X-quang ngực trong phát hiện các bệnh tim bẩm sinh thường gặp. Đối tượng và phương pháp nghiên cứu: Gồm 71 bệnh nhi được chẩn đoán tim bẩm sinh qua thăm khám lâm sàng và xác định bằng siêu âm tim Doppler tại trung tâm Nhi khoa, bệnh viện Trung ương Huế từ tháng 4/2020 đến tháng 3/2021. Thiết lập nghiên cứu mô tả cắt ngang. Kết quả: Tỷ lệ phát hiện nhĩ trái và nhĩ phải lớn lớn trên X-quang lần lượt là 4,2% và 21,1%. Tỷ lệ phát hiện bóng tim lớn, lớn thất trái, lớn thất phải trên X-quang ngực thẳng và lâm sàng lần lượt là: 54,9% và 12,7%; 29,6% và 49,3%; 16,9% và 19,7%. Kết luận: Tỷ lệ phát hiện lớn nhĩ trên X-quang ngực thẳng thấp. Khả năng phát hiện tim lớn trên Xquang ngực thẳng tốt hơn khám lâm sàng, trong khi với lớn thất trái và thất phải, khả năng phát hiện khi thăm khám lâm sàng tốt hơn. Kết hợp lâm sàng và Xquang ngực giúp tăng khả năng phát triện các triệu chứng.

Splenic cysts are rare lesions with a documented prevalence of 0.07% to 2%. Primary splenic cysts have an epithelial lining. A 32-year-old female presented with a complaint of abdominal pain and a dragging sensation on the left side. On examination, a soft lump was palpable 20 cm below the left costal margin. A Computed Tomography (CT) scan of the abdomen revealed splenomegaly and a large, smooth-walled cyst. The diagnostic work-up for splenic cysts typically involves a combination of clinical assessment, imaging studies, and laboratory tests. The imaging modalities can provide information about the size, location, and nature of the cyst. Ultrasound can confirm the cystic nature of the lesion, while CT and Magnetic Resonance Imaging (MRI) offer more detailed visualisation of the cyst’s internal structure, septations, and wall characteristics. Radiological examination may not be sufficient to differentiate between various types of splenic cysts. In endemic regions, it is difficult to distinguish from non-parasitic cysts based on imaging alone and additional diagnostic measures are necessary. Cyst fluid examination, such as fluid amylase, titre of echinococcus and other biomarkers, may aid in differentiating between cysts in the pancreatic tail, parasitic cysts and malignancy. Image-guided biopsy or partial or complete splenectomy, and histopathological examination are necessary for definitive diagnosis. In this case, the cyst on histopathological examination showed features of a primary splenic mesothelial cyst. Primary splenic mesothelial cysts are extremely rare lesions with a documented prevalence of 0.07% to 2%. There is limited available literature, which merits the documentation of this case report. The various classifications of splenic cysts, clinico-radiological and morphological findings of mesothelial cysts are discussed in this case report.

Successful treatment of uncontrollable posttraumatic intracranial hypertension with dihydroergotamin in a child.

Acute right heart failure revealing delayed traumatic right-sided diaphragmatic hernia: Case report and literature review

Background:The postoperative settings in cardiothoracic intensive care unit (ICU) patients pose a certain risk with pulmonary dysfunction causing morbidity and mortality. Lung ultrasound (LUS) has a potential to supplant or replace Chest X-rays (CXR) in these subset of patients, who will require bed side pulmonary pathology diagnosis and interventions.Aims and Objectives:Aim of the study is to compare the diagnosis predicted from LUS to the diagnosis made from routine bedside CXR and to find the degree of agreement in diagnosis made by both modalities in different cardiopulmonary pathologies in ICUs.Materials and Methods:Prospective observational study involving 250 postoperative patients, admitted in cardio-thoracic and vascular ICU of a tertiary referral centre. LUS was done in the study patients after the scheduled CXR in the immediate postoperative period and postoperative day one. Findings of pulmonary pathologies by each imaging modality were independently interpreted by two different team of specialist investigators. The findings were evaluated for the degree of agreement between the two imaging modalities using Cohen's kappa statistical test.Results:CXR and LUS imaging showed substantial agreement in the diagnosing cardiopulmonary pathologies (κ = 0.652) in the immediate postoperative period as well as on the postoperative day one (κ = 0.740). For specific cardiopulmonary pathologies, the degree of agreement was moderate for pleural effusion (κ = 0.561), substantial for atelectasis (κ = 0.673) and interstitial edema (κ = 0.707) and perfect for pneumothorax (κ = 0.931).Conclusions:LUS can effectively replace CXR with reduction in radiation exposure in the immediate postoperative period and also in the follow up period. It can be used as a bedside diagnostic and monitoring tool in postoperative cardiothoracic and ICUs for diagnosing pneumothorax, pleural effusion, atelectasis and interstitial edema.

Combat-related thoracic trauma (CRTT) is a significant contributor to morbidity and mortality of the casualties from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Penetrating, blunt, and blast injuries are the most common mechanisms of trauma to the chest. Imaging plays a key role in the battlefield management of CRTT casualties. This work discusses the imaging manifestations of thoracic injuries from blunt trauma and blast injury, emphasizing epidemiology and diagnostic clues seen during OEF and OIF. The assessment of radiologic findings in patients who suffer from combat-related blunt thoracic trauma and blast injury is the basis of this work. The imaging modalities for this work include multi-detector computed tomography (MDCT) and chest radiography. Multiple imaging modalities are available to imagers on or near the battlefront, including radiography, fluoroscopy, and MDCT. MDCT with multi-planar reconstructions is the most sensitive imaging modality available in combat hospitals for the evaluation of CRTT. In modern combat, blunt and blast injuries account for a significant portion of CRTT. Individual body armor converts penetrating trauma to blunt trauma, leading to pulmonary contusion that accounted for 50.2% of thoracic injuries during OIF and OEF. Flail chest, a subset of blunt chest injury, is caused by significant blunt force to the chest and occurs four times as frequently in combat casualties when compared with the civilian population. Imaging features of CRTT have significant diagnostic and prognostic value. Pulmonary contusions on chest radiography appear as patchy consolidations in the acute setting with ill-defined and non-segmental borders. MDCT of the chest is a superior imaging modality in diagnosing and evaluating pulmonary contusion. Contusions on MDCT appear as crescentic ground-glass opacities (opacities through which lung interstitium and vasculature are still visible) and areas of consolidation that often do not respect the anatomic boundaries of the affected lobes. Additionally, small pulmonary contusions may exhibit sub-pleural sparing and may distinguish contusion from pneumonia or other lung pathology. Although pulmonary laceration is typically the result of penetrating trauma, laceration may also be caused by displaced rib fractures or significant shearing forces on the lung without penetrating injury. Because of elastic recoil of the normal pulmonary parenchyma surrounding the injury, pulmonary lacerations may present as late as 48-72 h after injury. Pulmonary lacerations may appear similar to pulmonary contusions on chest radiography initially and will require MDCT for definitive diagnosis. Blast injury is a defining injury of modern combat. Blast lung injury is initially diagnosed with chest radiography, where the pattern of lung opacities has previously been described by clinicians as "batwing" or "butterfly" because of its central appearance in the lung. "Peribronchovascular" may be a more accurate description of primary blast lung based on its appearance on MDCT. This pattern may differentiate primary blast lung injury from other causes of thoracic trauma. CRTT continues to be a significant contributor to the morbidity and mortality of those injured during OEF and OIF. The distinct injury patterns and atypical imaging manifestations of blunt trauma and blast lung injury are important to recognize early because of the acuity of this patient population and the influence of accurate diagnosis on clinical management.

Chronic Obstructive Pulmonary Disease (COPD) is the top cause of death worldwide and a growing health care burden. Advanced COPD often causes pulmonary hypertension, affecting around 20% of patients. Severe PAH in COPD patients reduces median survival by 40 months. Early pulmonary hypertension identification in COPD patients is crucial. Physical examination, chest x-ray, ECG, and ECHO are non-invasive PAH screening procedures. This study found pulmonary hypertension in COPD patients by assessing chest X-ray, electrocardiographic, and echocardiographic findings and their correlation with ECG alterations. The study followed the cross-sectional observational study, in the national academy of medical sciences (NAMS), Bir Hospital, Kathmandu-Nepal. Patients who visited OPD or admitted with signs and symptoms of COPD diagnosed clinically, radiologically and/or by pulmonary function test (PFT), both male and female, in Bir Hospital. Each individual was chosen by simple random sampling method. N=100 cases were selected randomly by lottery over a period of one year. Patient’s chart, patients’s OPD card or structural questionnaire were used as the research instrument where Patients were selected for data collection by simple random sampling method like lottery among those who visited OPD or admitted in ward of Bir hospital with diagnosis of COPD by history, physical and radiological examination and/or PFT criteria. The highest COPD prevalence was in people 70 or older (42%), with 66% of these being women. The most common risk factor for COPD was smoking (75%). Chest x-ray abnormalities most often were significant pulmonary conus (76%) and cardiomegaly (63%).The majority of ECG abnormalities in COPD patients with pulmonary artery hypertension were P-pulmonale (84%), R/S ratio <1 in V5 or V6, right axis deviation (49%), and right bundle branch block (41%).83% of patients met RVH ECG criteria. Hence it concluded that ECHO is better than ECG and chest x-ray at detecting pulmonary hypertension in COPD, but ECG has good specificity and sensitivity for RVH and pulmonary hypertension, so chest x-ray and ECG should be routine testing.

While chest X-ray (CXR) is an efficient tool for expeditious detection of life-threatening injury, chest computed tomography (CCT) is more sensitive albeit with added time, cost, and radiation. Thus far, there is limited evidence and lack of consensus on the best imaging practices. We sought to determine the association between imaging modality and outcomes in isolated blunt thoracic trauma. The 2017-2020 TQIP database was queried for adult patients who sustained isolated blunt chest trauma and underwent chest imaging within 24 hours of admission. Patients who underwent CCT were 2:1 propensity-score-matched to those who underwent CXR. The primary outcome was mortality, and the secondary outcomes were hospital and ICU length of stay (LOS), ICU admission, need for and days requiring mechanical ventilation, complications, and discharge location. Propensity score matching yielded 17716 patients with CCT and 8861 with CXR. While bivariate analysis showed lower 24-hr (CCT .2% vs CXR .4%, P = .0015) and in-hospital mortality (CCT 1.2% vs CXR 1.5%, P = .0454) in the CCT group, there was no difference in survival probability between groups (P = .1045). A higher percentage of CCT patients were admitted to the ICU (CCT 26.9% vs CXR 21.9%, P < .0001) and discharged to rehab (CCT .8% vs CXR .5%, P = .0178). CT offers no survival benefit over CXR in isolated blunt thoracic trauma. While CCT should be considered if clinically unclear, CXR likely suffices as an initial screening tool. These findings facilitate optimal resource allocation in constrained environments.

Older trauma patients are reported to receive lower levels of care than younger adults. Differences in clinical management between adult and older trauma patients hold important information about potential trauma system improvement targets. The aim of this study was to compare prehospital and early in-hospital management of adult and older trauma patients, focusing on time-critical interventions and radiological examinations. Retrospective analysis of the Norwegian Trauma Registry for 2015 through 2018. Trauma patients 16 years or older met by a trauma team and with New Injury Severity Score of 9 or greater were included, dichotomized into age groups 16 years to 64 years and 65 years or older. Prehospital and emergency department clinical management, advanced airway management, chest decompression, and admission radiological examinations was compared between groups applying descriptive statistics and appropriate statistical tests. There were 9543 patients included, of which 28% (n = 2711) were 65 years or older. Older patients, irrespective of injury severity, were less likely attended by a prehospital doctor/paramedic team (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.57-0.71), conveyed by air ambulance (OR, 0.65; 95% CI, 0.58-0.73), and transported directly to a trauma center (OR, 0.86; 95% CI, 0.79-0.94). Time-critical intervention and primary survey radiological examination rates only differed between age groups among patients with New Injury Severity Score of 25 or greater, showing lower rates for older adults (advanced airway management: OR, 0.60; 95% CI, 0.47-0.76; chest decompression: OR, 0.46; 95% CI, 0.25-0.85; x-ray chest: OR, 0.54; 95% CI, 0.39-0.75; x-ray pelvis: OR, 0.69; 95% CI, 0.57-0.84). However, for the patients attended by a doctor/paramedic team, there were no management differences between age groups. Older trauma patients were less likely to receive advanced prehospital care compared with younger adults. Older patients with very severe injuries received fewer time-critical interventions and radiological examinations. Improved dispatch of doctor/paramedic teams to older adults and assessment of the impact the observed differences have on outcome are future research priorities. Therapeutic/Care Management; Level III.

Prescription practice and yield of chest radiography in the management of children presenting to the French pediatric emergency department with non-traumatic chest pain

In Brief The presence of a persistent left-sided superior vena cava is a rare venous return anomaly. There have been numerous reports in the literature describing placement of central venous catheters and transvenous pacemaker wires successfully into the right side of the heart through a persistent left-sided vena cava and the coronary sinus. An 84-year-old male developed acute cardiogenic pulmonary edema resulting in respiratory failure requiring assisted ventilation. His electrocardiograms revealed findings consistent with left ventricular hypertrophy. Subsequently, he developed cardiogenic shock complicated by asystolic cardiac arrest from which he was quickly resuscitated with epinephrine and atropine. A pulmonary artery catheter was placed via the right internal jugular vein without any complications. A transvenous pacemaker was successfully inserted through the left internal jugular vein for complete heart block. The postprocedure chest radiograph demonstrated a normally placed pulmonary artery catheter and the presence of the pacemaker wire along the left side of the heart. Thoracic computed tomography (CT) confirmed that the pacemaker wire extended through a persistent left-sided superior vena cava into a superficial cardiac vein. We present an unusual and previously unreported case of malposition of a temporary transvenous pacemaker wire into a superficial cardiac vein via a persistent left-sided superior vena cava. Critical care physicians should be aware of this congenital anomaly while placing central venous catheters from the left side, particularly in patients with other congenital cardiac defects. When the position is uncertain, imaging modalities, particularly CT, will be helpful in defining the course of central venous catheter. As critical care practitioners, we routinely place central venous catheters, which are not without risk. An unusual case of malposition of a temporary transvenous pacemaker wire into a superficial cardiac vein via a persistent left-sided superior vena cava is reported. Knowledge of this congenital anomaly during placement of central venous catheters from the left side is imperative, particularly in patients with other congenital cardiac defects. Imaging modalities such as computed tomography, angiography, and echocardiography can be helpful in delineating central venous catheter malposition.

of the study is the visualisation of normal pulmonary ventilation in healthy volunteers and the evaluation of abnormalities in patients with different lung diseases using 3He magnetic resonance imaging (3He-MRI). Hyperpolarized 3He gas (V = 300 ml, p = 3 x 10(5) Pa, polarised to 35-45% by optical pumping, provided in special glass cells) was inhaled by eight healthy volunteers and ten patients with different lung diseases. A 3D FLASH sequence (TR = 11.8 ms; TE = 5 ms; matrix 144 x 256, FOV 350 mm, section thickness 7-10 mm, coronal orientation) was performed in a single breath-hold (22-42 s). Clinical and radiological examinations were available for correlation. The studies were successfully carried out in 8/8 volunteers and in 8/10 patients. The central airways were constantly visualised with intermediate to high signal intensity. The lung parenchyma of volunteers with normal ventilatory function showed rather homogeneous intermediate to high signal, whereas patients with chronic obstructive lung disease and/or pneumonia presented severe signal inhomogeneities. Space-occupying lesions and pleural effusion caused large areas with little or no signal. The represented the lesion and adjacent ventilatory disturbances whose extent had not been presumed from chest x-ray or CT. The spatial resolution was higher than in ventilation scintigraphy. 3He MRI is a promising new modality for the assessment of pulmonary ventilation and its anomalies.

BACKGROUND:Untreated or undertreated, pulmonary tuberculosis could cause severe complications until death. After treatment, residual lesions might occur. The presence of residual lesions is varied, including fibrosis, cavity, bronchiectasis and calcification. Transforming growth factor-β (TGF-β) is a cytokine associated with lung inflammation, which plays a role in lung fibrosis. However, only a few studies have assessed the serum level of TGF-β in post-treatment tuberculosis patients.AIM:The main objective of this study was to determine the correlation between TGF-β levels and pulmonary fibrosis in patients with pulmonary tuberculosis.DESIGN:A group of 51 patients that had undergone anti-tuberculosis treatment were observed, consisting of 31 men, 20 women. Of all patients, there were 26 people with a smoking history, including 25 men and 1 woman. All patients had been recovered, confirmed by the clinical state, laboratory and radiology examination. The ELISA test was performed to measure TGF-β level, while the chest X-ray was used to look for the occurrence of pulmonary fibrosis.RESULTS:The mean level of TGF-β in patients with a lesion (+) was 7628.02 (SD: ± 4928.38) while the mean level of TGF-β in patients with a lesion (-) was 2315.11 (SD: ± 505.83). The statistical test showed a significant relationship between TGF-β level and fibrosis lesion (p < 0.001).CONCLUSION:TGF-β level was significantly higher in post-tuberculosis patients with pulmonary fibrosis.