CT Surgery Research Articles

Time to CT and Surgery for HPB Trauma in Scotland Prior to the Introduction of Major Trauma Centres

To assess the time taken to CT and emergency surgery for trauma patients with an injury to liver, spleen or pancreas prior to the introduction of major trauma centres (MTCs) in Scotland. A search was performed of the Scottish Trauma Audit Group database for any patient with relevant injuries over a 2-year period. Primary outcome measures were time to CT and emergency surgery. Patient demographics were also recorded. A total of 211 patients were identified of whom 23 had more than one organ affected. There were a total of 234 injuries (123 liver, 99 splenic and 12 pancreatic) in these patients. A total of 160 injuries (75.8%) suffered blunt trauma. Of 211 patients, 157 underwent emergency CT with a median time to scan of 73min (range 4-474). Hospitals provisionally designated as MTCs were 9min faster than non-MTCs in time to CT. There was no difference in time of day. Ninety-nine patients had surgery within 24h at a median time of 200min. Twenty-five patients with hypotension on presentation took a median time of 130min. Only 44 patients (27%) had a CT or emergency surgery within the expected MTC target of 1h. Thirty-nine patients required transfer to another centre. Current management of patients with abdominal trauma and haemodynamic instability remains sub-optimal in Scotland when compared to recognized performance indicators of CT and emergency surgery within 1h. Implementation of a major trauma network in Scotland should improve access to emergency radiology and surgery and efforts to shorten current timelines should improve patient outcomes.

OA22.07 Correlation of CT Scan Based Tumor Volume Measurement to Actual Resected Tumor Volume - A New T-Factor?

Tumor volume has been reported to be a valuable prognosticator for malignant pleural mesothelioma (MPM) survival. We wanted to assess the precision of CT scan based preoperatively measured tumor volume when correlated to the actual resected tumor weight and tumor volume after pleurectomy/decortication. From 10/2012 – 06/2016 the tumor weight of surgery specimens was measured in 32 patients undergoing macroscopic complete resection by (extended) pleurectomy/decortication ((e)P/D). The median tumor weight of all patients was (n=32) 443g (95-783g). In all patients tumor volume was measured in the CT or PET-CT scans performed before surgery as described previously (Frauenfelder 2011). Tumor volume of the resected specimen was additionally measured in 21 patients. Relations between tumor weight, tumor volume at surgery, CT-volume, cT stage and pT stage were analyzed using Spearman rank correlation. Median time between CT scan and surgery was 18 days (range 1-48). The analysis revealed a moderate correlation between CT tumor volume and weight (p=0.001, correlation coefficient 0.58, CT volume and tumor volume at surgery showed strong correlation (p=0.001, correlation coefficient 0.65). No significant correlation was observed between cT stage and tumor weight (p=0.1, correlation coefficient 0.31), but a moderate correlation between cT stage and CT volume (p=0.001, correlation coefficient 0.58) as well as specimen volume (p=0.008, correlation coefficient 0.58). There was a moderate correlation of tumor weight with pT stage (p=0.02, correlation coefficient 0.42), but no correlation of CT volume (p=0.1, correlation coefficient 0.31) as well as specimen volume with the pT stage (p=0.2, correlation coefficient 0.32). The correlation between preoperatively assessed CT tumor volume and volume of the resected specimen showed a strong correlation. To assess the prognostic role of CT measured tumor volume a correlation to prognosis has to be performed before implementation as a new T-factor.

Massive Submucosal Esophageal Tear from Meat Impaction in Candida Esophagitis

Candida species are commensal organisms of different mucous membranes in healthy individuals with the esophagus being a common site of colonization. Candida esophagitis involves the superficial mucosa and transmural invasive candida infection is rare even in immunocompromised patients. Here we report a 49 year-old male who presented with hematemesis after a piece of steak was stuck in his esophagus. He was found on upper endoscopy to have deep esophageal tears, extensive ulcerations and whitish plaque. Biopsies were positive for candida esophagitis and he was subsequently diagnosed with HIV. The patient is a 49 year-old male with history of hypertension that presents with a food impaction in his esophagus after eating steak. He tried to relieve the impaction with self-induced vomiting without relief followed by multiple episodes of hematemesis associated with dysphagia, odynophagia, and severe chest pain. He reports being in usual state of health prior to that incident. He is not on chronic steroids, PPI, or anticoagulant and denies any history of NSAIDs or alcohol abuse. Physical examination was negative for any icteric sclera, palpable crepitus over chest wall or neck, or abdominal findings. CT chest showed no radiopaque foreign body or pneumomediastinum. On emergent EGD the findings were two large submucosal esophageal tears extending 27 to 37 cm from the incisors, diffuse whitish plaques covering the upper esophagus extending to the distal esophagus, and ulcerations of esophageal mucosa but no obvious perforation or food bolus in the esophagus. He was admitted under CT surgery and was kept NPO, on IVF, IV antibiotics and antifungal. Tissue biopsy of the esophagus revealed acute and chronic esophagitis, abundant candida and bacteria. He was positive on HIV screening with a viral load 12,214 and absolute CD4 count 169. A barium esophagram revealed no contrast extravasation. Candida esophagitis is known to occur in immunocompromised hosts but severe complications (i.e perforation, fistula) with esophageal candidiasis are rare and have been mainly reported in diabetic patients with renal transplantations and patients with hematologic malignancy. Unlike eosinophilic esophagitis, food impaction is not often seen in candida esophagitis. The unique highlights of this case are the absence of any prior esophageal or constitutional symptoms and the extent of esophageal mucosal injury sustained from the food impaction in the setting of esophageal candidiasis.Figure 1Figure 2Figure 3

CT scan and Diagnostic Peritoneal Lavage: towards a better diagnosis in the area of nonoperative management of blunt abdominal trauma

BackgroundThe diagnosis of small bowel and mesenteric injuries (BBMI) after blunt abdominal trauma remains difficult, which results in delayed treatment and increased mortality and morbidity. Diagnostic peritoneal lavage (DPL) in patients with 1 or 2 abnormal CT findings that are suggestive of BBMI was proposed, but the rate of unnecessary surgical exploration remains high. Patients and methodsBlunt abdominal trauma patients with 1 or 2 CT findings predictive of BBMI from 2001 to 2014 underwent a DPL with calculation of a cell count ratio (CCR) dividing the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid by the WBC/RBC ratio in peripheral blood. Surgical exploration of the abdomen was performed immediately in cases with a CCR≥1. CT findings, DPL and surgery results, and global outcome were analyzed. ResultsThirty-seven were included in the study (27 males, median age of 30 years (range, 17–69 years)). Exploratory laparotomy was performed in 24 patients (65%). Sixteen patients (67%) had BBMI: 7 hollow organ perforations or tears (29%), including 4 bowel resection with primary anastomosis and 3 single sutures, and 9 patients had mesenteric injuries. CT findings associated with BBMI and hollow organ perforation were large peritoneal effusion (p=0.02) and small bowel wall abnormalities (p=0.002). No postoperative complications were observed. Sensitivity and specificity of DPL for the diagnosis of bowel injuries were respectively 100% (CI 95% [59–100]) and 43% (CI 95% [25–63]). The sensitivity remained 100% (CI 95% [59–100]) when the ratio was ≥4 (n=10 patients), and the specificity reached 90% (CI 95% [73–98]). ConclusionDPL is sensitive for the diagnosis of BBMI in stable trauma patients with 1 or 2 unexplained CT abnormalities, but specificity is low with a high rate of nontherapeutic laparotomy in case of CCR≥1. Indications for exploratory laparotomy could be restricted to patients with a CCR≥4 to improve the specificity of diagnosis management.

A glimpse into the future of TAVR

Important differences still exist in the management of patients who receive TAVR in Europe and in the USA. Provisional participation of cardiovascular surgeons and imaging cardiologists, use of TEE, general anesthesia with endotracheal intubation, and length of stay are some of the major differences which may define the future of TAVR in the USA. TAVR procedure will most likely be performed without CT surgery presence and with limited echocardiographic imaging guidance in USA in the near future as it is already being done in Europe.

Analyzing the Impact of Implementing a Systems-Based Hematologist into the Healthcare Delivery System at an Academic Medical Center

There remains a clinical shortage of benign hematologists to manage the growing number of patients with non-malignant yet life-threatening and chronic blood diseases. The American Society of Hematology proposed creating System-Based Hematologist (SBH) positions to meet this need. The purpose of this study was to provide quantitative data regarding the impact that a SBH has on health care delivery in both the inpatient and outpatient settings. In 2011, the Department of Medicine successfully negotiated a Medical Directorship position for a SBH for the MUSC Health System. The position functions within the hospital as a part of the Medical Acute Critical Care Service Line, and the clinical service run by the SBH conducts inpatient consults daily. A benign hematology outpatient clinic was also established and is located on the hospital campus. In the years 2013-2014, clinic referrals of new patients grew 20% and the inpatient consult service grew by 38%. The SBH managed all hemophilia admissions from the emergency room and the use of recombinant blood products was reduced by an average of 35% per patient. The SBH evaluated the performance characteristics of the ROTEM instrument, recommended the instrument be purchased by the hospital for clinical use and collaborated to establish algorithms to guide replacement therapy. In CT Surgery, an anesthesiologist was trained in ROTEM and blood management who then served as the champion that implemented the ROTEM-based system for intra- and post- operative CABG care. From 2013 to 2014, we found that the use of FFP in CABG patients decreased from 25.8% to 12.7%. Platelet usage per patient dropped from 0.72 to 0.43. Cryoprecipitate decreased from 0.37 to 0.2 per patient. A ROTEM -based algorithm was also implemented to manage pre-procedure replacement therapy in patients with a coagulopathy from chronic liver disease. This protocol has led to reduction in fresh frozen plasma use from 3 units per patient to 0.4 units per patient, and has eliminated the use of pre-procedure INR correction as a target for promoting hemostasis. The ROTEM-guided algorithm resulted in safe and satisfactory outcomes for all liver disease patients requiring interventional procedures, as well as substantial cost savings. In addition, the SBH established a heparin-induced thrombocytopenia monitoring program. The EMR was specifically modified to provide guidance regarding calculating the 4T score and decision support for heparin-platelet factor 4 antibody testing and use of heparin alternatives. The SBH consults on patients that have positive heparin-platelet factor 4 assays and helps guide safe anticoagulation therapies in those patients that require treatment. Following the implementation of this program, serotonin release assays were reduced by 70% and there was also a substantial reduction in the use of direct thrombin inhibitors of 78%. Clinical outcomes in all patients today have been satisfactory with no major thrombotic complications apart from one patient that could not receive anticoagulation due to recent surgery, who fully recovered despite having DVT/PE. One patient that had a negative heparin platelet factor 4 assay became positive upon repeat testing and suffered arterial thrombosis that has resolved without any residual deficit. The SBH also educates medical students, interns, residents and fellows in the inpatient and outpatient settings. The addition of a nurse practitioner was necessary as the program has developed a rapid access anemia clinic to diagnose and treat pre-and post-op anemia. The MUSC SBH position is transitioning to play a role in a patient blood management program that will serve the entire healthcare network. In conclusion, this study documents a SBH can reduce cost of HITT management, blood product utilization in CABG and pre-procedure management of the coagulopathy in chronic liver disease as well as hemophilia management. The clinical services provided by the SBH in the clinics and outpatient setting can further enhance the education of students, residents and fellows in academic medical centers. The SBH must have the administrative support to initiate and implement programs through productive collaboration with colleagues within the health care system.The ASH program to encourage implementation of SBH positions and training should provide rewarding career opportunities for hematologists interested in non-malignant hematologic disorders. DisclosuresNo relevant conflicts of interest to declare.

Abstract 13586: Early Initiation of Oral Intake in Adult Patients After Cardiothoracic Surgery is Safe and Reduces Thirst: Results of a Randomized Clinical Trial

Aim: Tradition-based care dictates that patients fast for several hours post-cardiothoracic (CT) surgery due to concerns for adverse events (nausea, vomiting, dysphagia, aspiration pneumonia), although evidence is lacking to support this practice. Prolonged fasting causes patients significant distress from thirst. Our aim was to determine the effect of an early liberal regimen of ice chips and water on adverse events and thirst after CT surgery. We hypothesized that a liberal regimen vs. usual care (UC) would not increase adverse events and would reduce thirst. Method: We used a randomized controlled trial design with a sample of 149 patients from an 18-bed CTICU. Written informed consent was obtained and patients were randomized to UC (6-hour fast post-extubation) or liberal regimen during the pre-operative visit. After fasting 1 hour post-extubation, patients in the liberal regimen were first assessed with a 6-item protocol for oral intake readiness, and then offered ice chips. An hour later, they were advanced to water. Results: The mean age was 66±12.4 years; 73.8% were male; 91.3% had coronary artery and/or valve surgery. The two groups were equivalent except for the post-operative mean dose of ketorolac that was higher in the UC group (p=.04). The table below shows no differences in nausea, vomiting, or dysphagia between the UC vs. liberal group, and no aspiration pneumonia. Complaints of high thirst levels 6 hours after extubation were greater in the UC group. In analysis adjusted for relevant demographic and clinical variables (logistic regression), patients in the liberal group were less likely to report high thirst levels, compared with UC patients (B=-.299, OR=.273, 95% CI .118-.630). Conclusion: Early initiation of ice chips and water post-extubation after CT surgery was not associated with adverse events, but was associated with significantly less thirst. In appropriate patients, early oral intake can reduce thirst, a distressing symptom.

Factors that may improve outcomes of early traumatic brain injury care: prospective multicenter study in Austria

BackgroundExisting evidence concerning the management of traumatic brain injury (TBI) patients underlines the importance of appropriate treatment strategies in both prehospital and early in-hospital care. The objectives of this study were to analyze the current state of early TBI care in Austria with its physician-based emergency medical service. Subsequently, identified areas for improvement were transformed into treatment recommendations. The proposed changes were implemented in participating emergency medical services and hospitals and evaluated for their effect.Methods14 Austrian centers treating TBI patients participated in the study. Between 2009 and 2012 all patients with Glasgow Coma Scale score < 13 and/or AIS head > 2 within 48 h after the accident, were enrolled. Data were collected in 2 phases: in the first phase data of 408 patients were analyzed. Based on this, a set of recommendations expected to improve outcomes was developed by the study group and implemented in participating centers. Recommendations included time factors (transport to appropriate trauma center, avoiding secondary transfer), adequate treatment strategies (prehospital fluid and airway management, anesthesia, ventilation), monitoring (pulse oximetry and blood pressure monitoring in all patients, capnography in ventilated patients) for prehospital treatment. In the emergency department focus was on first CT scan as soon as possible, short interval between CT scan and surgery and early use of thrombelastometry to optimize coagulation. Following implementation of these recommendations, data on 325 patients were collected and analyzed in phase 2. Final analysis investigated the impact of the recommendations on patient outcomes.ResultsPatients in both data collection phases showed comparable demographic and injury severity characteristics. Treatment changes, especially in terms of fluid management, monitoring and normoventilation as well as thrombelastometry measurements were implemented successfully in phase 2, and led to significant improvement of patient outcomes. Hospital mortality was reduced from 31 % to 23 %. We found a lower rate of unfavorable outcomes, a significant increase in unexpected survivors and more patients with unexpected favorable outcomes as well.ConclusionsThe results of this study clearly demonstrate that the outcomes of TBI patients can be improved with appropriate early care.

Risk factors for urolithiasis in dogs with congenital extrahepatic portosystemic shunts: 95 cases (1999-2013).

To identify risk factors for urolithiasis in dogs with congenital extrahepatic portosystemic shunts (EHPSSs) and to determine whether portoazygos shunts were associated with increased risk of urolithiasis at the initial evaluation for EHPSS. Retrospective case series. Dogs (n = 95) with EHPSSs confirmed via CT angiography or surgery. Medical records from 1999 to 2013 were reviewed. Variables of interest included signalment, previous medical management, and results of urinalysis, urolith analyses, and diagnostic imaging. Univariable and multivariable logistic regression analyses for assessment of risk factors for urolithiasis at the time of initial EHPSS evaluation were performed. The dogs' median age was 0.9 years (range, 0.2 to 12.6 years). Among the 95 dogs, 27 (28.4%) and 68 (71.6%) had portoazygos and portocaval shunts, respectively. Urinalysis was performed for 79 (83.2%) dogs, 29 (36.7%) of which had crystalluria (mainly ammonium urate and struvite crystals). Uroliths were present in 34 of 95 (35.8%) dogs; 16 of 17 uroliths analyzed were composed of ammonium urate. Portoazygos shunts were not associated with significantly increased odds of urolithiasis at the time of the initial evaluation for EHPSS. However, the odds of urolithiasis was significantly increased for male dogs, older dogs, and dogs that received previous medical treatment. In dogs with EHPSS, shunt morphology was not associated with increased odds of urolithiasis at the initial evaluation. Male dogs, older dogs, and dogs having received medical management for EHPSS prior to initial evaluation should be considered at increased risk for development of urolithiasis.

Abstract 19335: Not Your Typical Atrial Flutter

Case: Mr M. presented to the emergency room with two months of progressive shortness of breath and was found to be in atrial flutter with 2:1 conduction at a rate of 140 bpm. His medical history was significant for tobacco use, etoh abuse, and hypertension. Key objective findings included tachycardia, hypoxia an elevated JVP, bibasilar crackles, a summation gallop, and lower extremity edema. His work up included an echocardiogram that illustrated a globally depressed EF (15-20%) and a large “worm like” mass that was free floating and extended into the RV. Management: A heparin drip was already infusing as the initial plan included cardioversion. Since the patient remained hemodynamically stable and there was no evidence of concurrent deep vein thrombosis, a TEE was performed to fully evaluate the mass and to assess the intra-atrial septum for right to left shunting. The TEE with 3D renderings demonstrated a mobile 0.8 x 10 cm mass most consistent with a thrombus that intermittently prolapses through the tricuspid valve into the RV. CT surgery was consulted and discussed the options of thrombolysis vs surgical thrombectomy. Due to the size and apparent dense organization of the thrombus, surgical thrombectomy was performed. When the right atrium was opened after initiation of bypass, there was no visible clot. The main PA was explored and without evidence of the thrombus. As bypass flow decelerated, the clot proceeded into the RA from the IVC cannula. The attached picture illustrates the thrombus removed from the RA and associated echo images. Discussion: Right atrial or ventricular thrombi in transit in hypoxic patients create a challenging clinical dilemma, as distal embolization may be fatal. In this case we chose to surgically remove the thrombus instead of the more commonly employed thrombolytic therapy. The determining factors included clot organization, relative patient stability, and surgical candidacy.

Cephalic index correlates poorly with intracranial volume in non-syndromic scaphocephalic patients.

This study aims to compare pre- and postoperative cephalic indexes (CI) with corresponding segmented intracranial volumes (SIV) obtained from volumetric CT in scaphocephalic patients. Twenty-four patients (17 boys) who had undergone cranial vault remodeling due to scaphocephaly were compared from 3D-CT imaging datasets. The mean age of the patients at preoperative CT imaging was 5.5 months, and that at 1-year postoperative imaging, 21.5 months. The mean interval between preoperative CT imaging and surgery was 3.3 months. Pearson's correlation was used to test the correlation of both pre- and postoperative CI with SIV. A paired t test was used to compare differences in the pre- and postoperative mean values of CI and SIV. CI correlated poorly with intracranial volume both preoperatively (r = 0.274) and postoperatively (r = 0.128). The mean preoperative CI was 65.92 (range 57.99-73.97), and the mean postoperative, CI 70.24 (range 60.23-75.57). The mean preoperative intracranial volume was 877.79 cm(3) (range 638-1,256), and the 1-year postoperative volume, 1,249.04 cm(3) (range 1,039-1,529). The mean values of both CI and SIV increased significantly after surgery. In one patient, the CI in postoperative measurements was smaller, whereas in all patients, the postoperative SIV was larger than the preoperative intracranial volume. The mean percentage increase in CI was 6.6 %, whereas the mean increase in SIV was 43.1 %. Cephalic index correlates poorly with intracranial volume in non-syndromic scaphocephalic patients. For some patients, surgery and growth resulted in only subtle or no change in CI despite a notable increase in intracranial volume.

MP12-17 VARIABILITY OF PIXEL BRIGHTNESS INTENSITY CAN BE USED TO FURTHER CHARACTERIZE A STONE’S COMPOSITION

You have accessJournal of UrologyImaging/Radiology III1 Apr 2014MP12-17 VARIABILITY OF PIXEL BRIGHTNESS INTENSITY CAN BE USED TO FURTHER CHARACTERIZE A STONE’S COMPOSITION Yaniv Larish, Leonard Glickman, and Jay A. Motola Yaniv LarishYaniv Larish More articles by this author , Leonard GlickmanLeonard Glickman More articles by this author , and Jay A. MotolaJay A. Motola More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.452AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Non-contrast CT (NCCT) is the gold standard of imaging in the diagnosis of urinary calculi. Composition of stones can be determined based on a stone’s pixel brightness intensity as measured by mean Hounsfield units (mHU) with varying degrees of certitude. In this study, we sought to evaluate the variability of pixel intensity by measuring the standard deviation of HU values (HUsd) within specific stone types to improve the accuracy of determining a stone’s composition. METHODS A single-institution, retrospective, chart review was performed from June 2009 to July 2013 identifying patients with GU calculi. All patients had a NCCT scan of the abdomen and pelvis which confirmed the presence of a GU stone. All calculi were treated with endoscopic management during which stone specimen was retrieved for analysis. Stone composition was determined by infrared spectroscopy. CT scans were reviewed by two urologists who were blinded to the stone’s chemical composition. The radiographic characteristics of the stone, including mHU and HUsd were measured. RESULTS 155 patients with 191 distinct stone episodes were identified. Patients with multiple stones in a single renal unit were excluded from analysis. The mean time between CT scan and surgery was 27 days. 72%, 17%, 6%, and 5% of the stones were composed of calcium oxalate (CaOx), uric acid (UrA), calcium phosphate (CP), and cystine (CY), respectively. Inter-rater reliability demonstrated good agreement between the two reviewers (r=0.89 and 0.74 for mHU and HUsd respectively). The mHU values were 697.78, 425.83, 706.86, and 634.67 for CaOx, UrA, CP, and CY, respectively. There was a significant difference when comparing UrA to each of the other three stone types: CaOx, CP, and CY (p<.0001, 0.0028, 0.0482, respectively). The HUsd values were 126.22, 61.56, 128.22, and 60.16 for CaOx, UrA, CP, and CY, respectively. There was a significant difference comparing UrA to CaOx and to CP (p<.0001, 0.0008, respectively) and a significant difference comparing CY to CaOx and to CP (p= 0.0001 and 0.0034 respectively). CONCLUSIONS The HU information obtained from CT scans has been limited to the mHU number. The HUsd is a previously ignored and readily obtainable variable that should be used to increase the clinician’s confidence in determining a stone’s composition and guiding treatment. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e112 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Yaniv Larish More articles by this author Leonard Glickman More articles by this author Jay A. Motola More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Appearance of Subchondral Bone in Computed Tomography Is Related to Cartilage Damage in Osteochondral Lesions of the Talar Dome

Osteochondral lesions of the talar dome (OLT) involve the articular cartilage and/or subchondral bone. The subchondral bone plate plays an important role in cartilage metabolism. We hypothesized that the findings of subchondral bone on CT image would be related to the cartilage damage of OLT. The purpose of this study was to evaluate the relationship between the arthroscopic and CT findings focused on subchondral bone. Thirty-one ankles diagnosed as OLT were analyzed. All patients underwent CT, MRI, and arthroscopic surgery. The CT findings for both the cystic and fragment lesions were classified into 3 types. The 3 types for the cystic lesion ankles were irregular shape, round shape with sclerotic wall, and irregular shape with opening to an articular cavity. The 3 types for the fragment lesion were no bone absorption, bed absorption without fragment absorption, and bed sclerosis and fragment absorption. The subchondral bone findings on CT were compared with International Cartilage Repair Society (ICRS) grades and arthroscopic grading. All round and sclerotic cystic lesions revealed cartilaginous flap lesions with a nearly normal cartilage surface. An irregular shape with opening revealed an unstable lesion with severely damaged cartilage. As for fragment lesions, no absorption revealed a stable lesion with a nearly normal cartilage surface. Bed absorption revealed an unstable lesion with a nearly normal cartilage surface. Fragment absorption with bed sclerosis showed an unstable lesion with severely damaged cartilage. There was a significant difference between CT findings and ICRS grade or arthroscopic findings (both P < .01), while there was no significant difference with MRI grading. The diagnosis of cartilage status by CT was better than MRI. CT findings for OLT based on subchondral bone related to cartilage damage. This study showed that CT was a useful tool for evaluating cartilage damage in OLT. Level III, comparative case series.

Effects of gustatory nerve transection and/or ovariectomy on oral capsaicin avoidance in rats

The incidence of chronic oral pain such as burning mouth syndrome is greater in peri-menopausal females, and was postulated to be associated with gustatory nerve damage. We investigated whether bilateral transection of the chorda tympani, with or without accompanying ovariectomy, affected oral capsaicin avoidance in rats. Female rats had restricted access to 2 bottles, 1 bottle containing capsaicin (concentration range: 0.33–33μM/L) and the other vehicle. Percent volume of capsaicin consumption and lick counts were measured. The concentration series was tested before and 0.5, 3, 6, 9, and 12months after the following surgical procedures: (a) bilateral transection of the chorda tympani (CTx); (b) ovariectomy (OVx); (3) CTx plus OVx; or (4) sham CT surgery. Before surgery there was a concentration-dependent decrease in licks and volume of capsaicin consumed, with a threshold between 0.1 and 0.3ppm. The majority of drink licks occurred during the first 9minutes of access. Over the 12-month test period, the CTx group did not exhibit reduced capsaicin consumption, and consumed significantly more capsaicin at 6 and 9months postsurgery. Rats in the OVx group consistently consumed significantly less capsaicin and exhibited significantly higher counts of capsaicin-evoked Fos-like immunoreactivity in the dorsomedial trigeminal subnucleus caudalis (Vc) compared to all other treatment groups. That CTx, with or without OVx, did not enhance capsaicin avoidance indicates that damage to the gustatory system does not disinhibit trigeminal nociceptive transmission.

CT analysis of dehiscent sigmoid plate presenting as pulsatile tinnitus

To evaluate the CT the characteristics of dehiscent sigmoid plate accompanied with pulsatile tinnitus (PT). Dual phase contrast enhancement CT data of 15 PT patients were analyzed retrospectively. Dehiscent sigmoid plate was located on the same side of PT in all patients. Thirteen defects had been showed in both CT images and surgery. Among of them, eight defects located on the descending segment, 3 on the superior curve, and the other 2 defects involved the superior curve and descending segment of sigmoid sinus simultaneously. The maximum anteroposterior and vertical diameters of defect measured in CT images were significant larger than that measured during surgery. There were still 5 defects showed in CT images, which did not been found during surgery. Among 9 patients with unilateral dominant brain venous systems, all the dehiscent sigmoid plates were seen on the dominant side. The other 2 patients showed co-dominant brain venous systems, whose the dehiscent sigmoid plates were on the left side. In addition, extensive pneumatized temporal bone filled with air was found in all patients. Dehiscent sigmoid plate commonly located on the anterior, lateral, or anterolateral wall of the superior curve or descending segment of the sigmoid plate, which usually coexist with the strong unilateral dominant brain venous system and extensive temporal bone pneumatization.

Computed tomography features of incidentally detected diffuse thyroid disease.

Objective. This study aimed to evaluate the CT features of incidentally detected DTD in the patients who underwent thyroidectomy and to assess the diagnostic accuracy of CT diagnosis. Methods. We enrolled 209 consecutive patients who received preoperative neck CT and subsequent thyroid surgery. Neck CT in each case was retrospectively investigated by a single radiologist. We evaluated the diagnostic accuracy of individual CT features and the cut-off CT criteria for detecting DTD by comparing the CT features with histopathological results. Results. Histopathological examination of the 209 cases revealed normal thyroid (n = 157), Hashimoto thyroiditis (n = 17), non-Hashimoto lymphocytic thyroiditis (n = 34), and diffuse hyperplasia (n = 1). The CT features suggestive of DTD included low attenuation, inhomogeneous attenuation, increased glandular size, lobulated margin, and inhomogeneous enhancement. ROC curve analysis revealed that CT diagnosis of DTD based on the CT classification of “3 or more” abnormal CT features was superior. When the “3 or more” CT classification was selected, the sensitivity, specificity, positive and negative predictive values, and accuracy of CT diagnosis for DTD were 55.8%, 95.5%, 80.6%, 86.7%, and 85.6%, respectively. Conclusion. Neck CT may be helpful for the detection of incidental DTD.

Hepatitis C Virus–Infected Resident: End of Residency, End of Career?

Robert M. Sade, MD Every surgeon faces the possibility of becoming infected by a bloodborne pathogen during the course of an operation. Cardiothoracic surgeons are among those with the highest risk because of the confined, deep spaces in which we operate. The possibility of cross-infection between surgeon and patient has been recognized since the existence of bloodborne viruses has been known, but came into high relief in the early days of the human immunosuppressive virus epidemic of the 1980s. Hepatitis C virus (HCV) is the most common such infection, affecting 2.7–3.9 million Americans (about 1–1.5% of the U.S. population). [1] The number of cardiothoracic operations carried out annually is well over 300,000, suggesting that cardiothoracic surgeons face roughly 3,000 potential exposures every year. The number of surgeons who become infected is unknown, is probably low, but definitely occurs.[2] The CDC has no guidelines for surgeons who become infected with HCV, but recommends standard precautions for all health care personnel—this would seem especially important in the operating room where the risk of transmission is particularly high. Once infected, a surgeon can transmit the virus to a patient during surgery, but this risk is apparently very low.[3] The consequences of infection with a bloodborne pathogen are most notably worrisome when the infected surgeon is a resident in training, because the stigma of such an infection may affect the chances of the resident finding a position when his training is completed. We present a case of an infected resident and a difficulty faced by his residency director: he must write a letter of recommendation (LOR) to accompany the residents job applications. The Case of the Unlucky Resident and the Perplexed Director A resident becomes infected with HCV, probably from an incidental sharp injury during a routine cardiac surgery operation. He is later found to have high HVC RNA titers and cannot participate in the training program for a year while treated with interferon. His titers fall over the course of the year to a level that the infectious diseases consultants declare to be compatible with the resident resuming his place on the CT surgery team, including in the operating room. The well-liked and respected resident completes his residency successfully and the CT faculty believes he is clinically well-prepared and technically competent to start working independently in either private practice or an academic setting. He still has a low HCV titer, and is deemed by the infectious diseases consultants to be able to operate safely, posing minimal risk to his patients. His residency director is writing a LOR for job applications. The director believes that anyone who learns that the applicant is HCV positive is unlikely to hire him, perhaps to the point that he cannot get a job at all as a CT surgeon. He also believes that the information about the resident’s HCV status is relevant to his job application, so perhaps should be disclosed in the letter he is writing. Should the director disclose the resident’s HCV status?

EComment. Criticism on a new marking technique for lung nodules identification

We have read with interest the paper by Kawada and colleagues focusing on the preoperative marking of small lung nodules resectable by thoracoscopic wedge resection [1]. As the authors underline, various marking procedures for localization have been already described. However, each one of these techniques is affected by different disadvantages [2]. When a preoperative marker is needed, we usually use the percutaneous CT-guided hook-wire placement method. We are conscious that this procedure is affected by possible complications such as pneumothorax, haemothorax, air embolism, and the disadvantages of an additional radiation exposure. In our experience with hook-wire placement, we only observed pneumothorax, usually low entity. However, chest tube placement is always required to avoid tension pneumothorax during mechanical ventilation at the subsequent surgical operation. Therefore, we think that the first advantage of the intrathoracic stamping method proposed by Kawada and colleagues is avoidance of the risks associated with visceral pleural puncture. The second possible advantage we identify in this method is that the use of an opaque marker lying on the skin, instead of a percutaneous hook-wire, reduces the possibility of accidental marker removal before surgery, and allows placement one or two days before operation. Lastly, although we do not have experience with the stamping method, we think that, in the event of adhesions, thoracoscopic pleural debridement could be performed more easily without a hook-wire inside the chest cavity. We identified as a possible disadvantage, the need to place the patient in the same position during CT scan and surgery, with the risk of dye spreading inside the pleural cavity, hence losing marking precision. In conclusion, we congratulate the authors who have described this new method. More data should be useful to definitively confirm its utility and safety. Conflict of interest: none declared

Role of plain radiography and CT angiography in the evaluation of obstructed total anomalous pulmonary venous connection

Obstructed total anomalous pulmonary venous connection (TAPVC) is frequently misdiagnosed as pulmonary disease and without operative correction early death is common. It is important to make a correct diagnosis before surgery. The purpose of this study was to describe the chest radiographic features of obstructed TAPVC and compare CT angiography with transthoracic echocardiography in the evaluation of obstructed TAPVC. Eighteen children with obstructed TAPVC were assessed. Their clinical and imaging data were retrospectively reviewed. The characteristic radiographic findings were analyzed and compared with surgical results, and the diagnostic accuracy of CT angiography and transthoracic echocardiography was evaluated in terms of pulmonary venous drainage and obstruction detection. The common radiographic features included pulmonary venous congestion or edema or both (16 of 18 cases, 89%), and absence of cardiomegaly (12 of 18 cases, 67%). CT angiography correctly diagnosed TAPVC and clearly revealed the draining sites in all children (five with supracardiac TAPVC, three with cardiac TAPVC, eight with infracardiac TAPVC and two with mixed TAPVC). The diagnostic agreement between CT angiography and surgery was 100%. Transthoracic echocardiography only correctly revealed the draining sites in 11 children (5 with supracardiac TAPVC, 2 with cardiac TAPVC and 4 with infracardiac TAPVC). The diagnostic agreement between transthoracic echocardiography and surgery was 61%. The diagnostic accuracy of CT angiography was higher than that of transthoracic echocardiography (P = 0.0156). Thirty-four sites of obstruction were correctly detected by CT angiography (11 in the mediastinum, 1 at the diaphragmatic level, 9 below the diaphragm and 13 stenotic individual pulmonary veins in the lung). The diagnostic agreement between CT angiography and surgery was 92%. Transthoracic echocardiography only correctly detected 15 sites of obstruction (11 in the mediastinum, 1 at the diaphragmatic level and 3 below the diaphragm). The diagnostic agreement between transthoracic echocardiography and surgery was 41%. The rate of detection for sites of obstruction with transthoracic echocardiography was much lower than that of CT angiography (P = 0.0002). In children with obstructed TAPVC, plain radiographs usually show a characteristic pattern of pulmonary venous congestion or edema, or both, and a normal cardiac silhouette. CT angiography is superior to transthoracic echocardiography in the evaluation of pulmonary venous drainage and obstruction, especially in children with infracardiac and mixed TAPVC.

BERRY SYNDROME—TWO CASES OF SUCCESSFUL PREOPERATIVE AND POSTOPERATIVE ECHOCARDIOGRAPHY EVALUATION

ObjectivesBerry syndrome is a very rare congenital cardiovascular anomaly. We report two infant cases in 2011.12–2012.1.MethodsBoth the two cases were diagnosed by echocardiography, and were validated by CT scan and...