Radiographic Abnormalities Research Articles

TO STUDY CLINICORADIOLOGICAL PROFILE OF IDIOPATHIC PULMONARY FIBROSIS (IPF) PATIENTS

Background - The term "interstitial lung disease" (ILD), or diffuse parenchymal lung disease (DPLD), represents a group of about 200 distinct disorders. Idiopathic pulmonary brosis (IPF) is one of the most severe forms of IIP. This study aims to observe clinicoradiological prole of idiopathic pulmonary brosis patients. A cross-sectional observational study (inpatients and out Methods- patients) visiting the Department of Respiratory Medicine, Gandhi Medical College, Bhopal for the period of 18 months from November 2019 to April 2021, diagnosed to have Idiopathic Pulmonary Fibrosis (IPF) by HRCT who meet the inclusion and exclusion criteria. The incidence of IPF is higher in males as Resultcompared to females. It appears mainly between the fth and seventh decades of life ,the mean age of IPF was 58.86 ± 11.93, and the maximum number of patients came under the age of 51–60 years .In this study, breathlessness and cough were the predominant symptoms in denitive UIP. The severity of breathlessness is higher in denitive UIP. In our study every patient with IPF, we found to have an abnormal chest xray. Hence, chest xray should be the rst investigation in any suspected case of IPF. The commonest chest radiographic abnormality in patients with IPF is peripheral reticular opacity, most marked at the bases. In this study, the most common HRCT Chest ndings in IPF patients were reticulations, subpleural and basal involvement, and brosis. In this study, the most common pattern of idiopathi Conclusion- c pulmonary brosis was denitive UIP and most common age group was 51–60 years old and IPF reveals a male predominance. Clubbing was found in 39.4% of patient's maximum with denitive UIP (28.8%). On auscultation, the most common ndings are ne crackles and the most common ndings on HRCT are reticulations So, the nal diagnosis of IPF is a multidisciplinary approach. Further study is needed with a larger sample size to understand the disease in detail.

Bifid Intratemporal facial nerves in an adult without other congenital anomalies.

To describe a case of bifid intratemporal facial nerves without associated middle or inner ear abnormalities encountered on computed tomography (CT) imaging during preoperative preparation for unilateral cochlear implant placement in an adult male with profound sensorineural hearing loss (SNHL). A rare case of bilateral bifid intratemporal facial nerves in an adult male is presented. The finding's impact on approach to safe cochlear implantation is discussed. Bifurcation of the intratemporal facial nerve is rarely seen and is usually associated with congenital middle or inner ear anomalies. A unique case of bilateral bifid intratemporal facial nerves without other middle or inner ear abnormalities was encountered incidentally on CT imaging during preparation for unilateral cochlear implant placement in an adult male with profound SNHL. The nerve was bifid along the mastoid segment with a nerve branch traversing through the facial recess precluding safe traditional approach to cochlear implant placement. Accessory stylomastoid foramina were noted bilaterally. Unilateral subtotal petrosectomy was performed with successful implantation and excellent hearing outcome. No additional clinical or radiographic otologic abnormalities were noted. Abnormal bifurcation of the facial nerve may occur in adults without other middle or inner ear anomalies. This case highlights the importance of independent imaging review by the surgeon and vigilance to potential rare anatomic aberrations of the facial nerve during cochlear implantation. IV.

Chest computed-tomography 1 day before the diagnosis of coronavirus disease 2019.

A 63-year-old man presented for the further examination of chest radiographic abnormality to exclude lung cancer on November 14, 2022. For annual screening of lung cancer, he had visited another division of our hospital on October 21, 2022. A nodule with irregular margins was pointed out by the low-dose chest computed-tomography (CT) (Figure 1(a)). He had flu-like symptoms with a fever of 39.0° after returning home, then he had been diagnosed coronavirus disease 2019 (COVID-19) by polymerase chain reaction test on October 22, 2022. After 10 days isolation and his symptom recovery, he visited us on November 14, 2022. Chest CT performed on the same day revealed small ground-glass opacity (GGO), which seemed to be in recovery phase (Figure 1(b)). We diagnosed the series of radiological findings as the pneumonia caused by COVID-19 infection. Although bilateral GGO and consolidation were reported as the predominant imaging characteristics in COVID-19, chest CT manifestations can vary in different patients and stages.1 This case is interesting, since the radiological findings of COVID-19 might have the possibility to mimic those of lung cancer. Clinicians should be aware of this characteristic radiological manifestation especially in case of early stage and mild COVID-19. All authors have contributed significantly, and that all authors are in agreement with the content of the manuscript: Conception/Design: Hiromichi Yamane and Nagio Takigawa; Collection of data: Nobuaki Ochi and Yasunari Nagasaki; Data analysis and interpretation: all authors; Manuscript writing: all authors; Final approval of manuscript: all authors. We thank Ms. Miki Nomura, a medical secretary of Sumitomo-Besshi Hospital Cancer Center, for her great effort on the clinical data collection. All authors listed on this manuscript have no conflicts of interest concerning this study.

Post COVID Interstitial Lung Abnormalities-Incidence and Management.

This review aims to summarize the available literature to identify the incidence and risk factors for persistent interstitial lung abnormalities (ILAs) following hospitalization for COVID-19. The current and prospective treatment options are reviewed in an effort to help pulmonary practitioners care for this burgeoning patient population. Statistical modeling suggests that 11.7% of all patients hospitalized with COVID-19 have irreversible fibrotic features on long-term follow-up imaging. The available evidence suggests that up to 30% of patients have ILAs following COVID-19 hospitalization. The radiographic abnormalities improve or resolve in a majority of these patients. However, estimates suggest that up to one-third of these patients have irreversible fibrotic features. Clinical trials of the impact of anti-fibrotic agents are ongoing. As there continue to be thousands of COVID-19 hospitalizations in the USA each week, the management of post-COVID ILAs will become a common problem for the pulmonary practitioner.

Sternal Abnormalities on Thoracic Radiographs of Dogs and Cats.

Evaluation of the sternum is part of the routine examination of small animal thoracic radiographs. However, descriptions on frequency and type of abnormalities are lacking. This retrospective observational study aimed to describe abnormal radiographic findings of the sternum in a cross-section of client-owned dogs and cats undergoing thoracic radiography between 1 January 2019 and 1 January 2021 for reasons unrelated to diseases of the sternum. The study population consisted of 777 dogs (mean age, 7.3 ± 3.9 years) and 183 cats (mean age, 7.3 ± 5.1 years). Sternal abnormalities were observed in 189/777 (24%) dogs and 53/183 (29%) cats, mostly around the intersternebral cartilages, accounting for 32/80 (40%) dogs and 20/35 (57%) cats. This was followed by an abnormal number of sternal segments (8% dogs, range 3-9 sternebrae; 15% cats, range 7-9 sternebra). Pectus excavatum was observed in 6/777 (0.8%) dogs and 6/183 (3%) cats, and pectus carinatum in 18/777 (2%) dogs and 2/183 (1%) cats. Post-traumatic changes, such as subluxation, were observed in nine dogs (1.1%) and three cats (1.6%). Presumed prostatic carcinoma metastasis and malignant lymphoma were observed in two dogs (0.2%). Incidental radiographic sternal abnormalities are common in cats and dogs but mostly of unknown clinical relevance.

A Case Report of Prolonged Bradycardia in Clay Shoveler’s Fracture: Presentation and Narrative Review

A spinal cord injury is an uncommon discovery in a clay-shoveler’s fracture. Multiple syncope could be caused by bradycardia which followed a spinal cord injury. These combination findings adds its rarity. This case report aim to share awareness among physicians of the rare complication of spinal cord injury and its management. This descriptive report also narratively review other literature. Physicians should aware of SCIWORA (Spinal Cord Injury Without Radiographic Abnormalities), neurogenic shock and prolonged bradycardia as one of its complications and it may warrant a cardiac pace maker to avoid cardiac arrest and other complication.

Artificial intelligence-reported chest X-ray findings of culture-confirmed pulmonary tuberculosis in people with and without diabetes

ObjectivesWe applied computer-aided detection (CAD) software for chest X-ray (CXR) analysis to determine if diabetes affects the radiographic presentation of tuberculosis. MethodsFrom March 2017-July 2018, we consecutively enrolled adults being evaluated for pulmonary tuberculosis in Karachi, Pakistan. Participants had same-day CXR, two sputum mycobacterial cultures, and random blood glucose measurement. We identified diabetes through self-report or glucose >11.1mMol/L. We included participants with culture-confirmed tuberculosis for this analysis. We used linear regression to estimate associations between CAD-reported tuberculosis abnormality score (range 0.00 to 1.00) and diabetes, adjusting for age, body mass index, sputum smear-status, and prior tuberculosis. We also compared radiographic abnormalities between participants with and without diabetes. Results63/272 (23%) of included participants had diabetes. After adjustment, diabetes was associated with higher CAD tuberculosis abnormality scores (p < 0.001). Diabetes was not associated with frequency of CAD-reported radiographic abnormalities apart from cavitary disease; participants with diabetes were more likely to have cavitary disease (74.6% vs 61.2% p = 0.07), particularly non-upper zone cavitary disease (17% vs 7.8%, p = 0.09). ConclusionsCAD analysis of CXR suggests diabetes is associated with more extensive radiographic abnormalities and with greater likelihood of cavities outside upper lung zones.

Characteristics of donor lungs declined on site and impact of lung allocation policy change

ObjectiveNational and institutional data suggest an increase in organ discard rate (donor lungs procured but not implanted) after a new lung allocation policy was introduced in 2017. However, this measure does not include on-site decline rate (donor lungs declined intraoperatively). The objective of this study is to examine the impact of the allocation policy change on on-site decline. MethodsWe used a Washington University (WU) and our local organ procurement organization (Mid-America Transplant [MTS]) database to abstract data on all accepted lung offers from 2014 to 2021. An on-site decline was defined as an event in which the procuring team declined the organs intraoperatively, and the lungs were not procured. Logistic regression models were used to investigate potentially modifiable reasons for decline. ResultsThe overall study cohort comprised 876 accepted lung offers, of which 471 donors were at MTS with WU or others as the accepting center and 405 at other organ procurement organizations with WU as the accepting center. At MTS, the on-site decline rate increased from 4.6% to 10.8% (P = .01) after the policy change. Given the greater likelihood of non-local organ placement and longer travel distance after policy change, the estimated cost of each on-site decline increased from $5727 to $9700. In the overall group, latest partial pressure of oxygen (odds ratio [OR], 0.993; 95% confidence interval [CI], 0.989-0.997), chest trauma (OR, 2.474; CI, 1.018-6.010), chest radiograph abnormality (OR, 2.902; CI, 1.289-6.532), and bronchoscopy abnormality (OR, 3.654; CI, 1.813-7.365) were associated with on-site decline, although lung allocation policy era was unassociated (P = .22). ConclusionsWe found that nearly 8% of accepted lungs are declined on site. Several donor factors were associated with on-site decline, although lung allocation policy change did not have a consistent impact on on-site decline.

Radiographic airway abnormalities in untreated early rheumatoid arthritis are associated with peripheral neutrophil activation

BackgroundThe role of the lung for the initiation and progression of rheumatoid arthritis (RA) is still unclear. Up to 10% of RA patients develop interstitial lung disease which remains a clinical challenge. Understanding early disease mechanisms is of great importance. The objective of this study was to determine whether there is an association between peripheral neutrophil phenotypes and presence of pulmonary abnormalities (PA) on chest high-resolution computed tomography (HRCT) in untreated early RA (ueRA).MethodsClinical data and blood were collected, and HRCT performed at diagnosis on 30 consecutive anti-citrullinated protein antibody (ACPA) and/or rheumatoid factor (RF) positive ueRA patients. HRCTs were evaluated for the presence of RA-associated parenchymal, airway and/or pleural abnormalities. Expression of phenotype markers on neutrophils were determined by flow cytometry. Levels of calprotectin, ACPA and RF were measured using immunoassays.ResultsThe frequency of having any PA was 60%. Airway abnormalities were present in 50%, parenchymal nodules in 43% and interstitial lung abnormalities (ILA) in 10%. Unsupervised multivariate data analysis showed clustering of any PA with neutrophil activation, parameters of inflammation and RF titres. In univariate analysis, the patients with PA displayed significantly increased CD11b and decreased CD62L expression on neutrophils (1.2-fold, p = 0.014; 0.8-fold, p = 0.012) indicating activation and significantly increased RF IgM titre and CRP (5.7-fold, p = 0.0025; 2.3-fold, p = 0.0035) as compared to no PA. Titres of RF, but not ACPA, correlated with expression of the neutrophil activation marker CD11b. A stratified analysis demonstrated that airway involvement was the PA subtype with the strongest association with neutrophil activation.ConclusionWe report a strong association between radiographic airway findings and activation of circulating neutrophils in early RA supporting a role of innate immunity and the lung at disease onset. Our results also indicate different contributions of RF and ACPA in the RA pathogenesis.

Location Fusion and Data Augmentation for Thoracic Abnormalites Detection in Chest X-Ray Images

The application of deep learning in medical image diagnosis has been widely studied recently. Unlike general objects, thoracic abnormalities in chest X-ray radiographs are much harder to label consistently by domain experts. Theproblem’s difficulty and inconsistency in data labeling lead to the downgraded performance of the robust deep learning models. This paper presents two methods to improve the accuracy of thoracic abnormalities detection in chest X-ray images. The first method is to fuse the locations of the same abnormality marked differently by radiologists. The second method is applying mosaic data augmentation in the training process to enrich the training data. Experiments on the VinDr-CXR chest X-ray data show that combining the two methods helps improve the predictive performance by up to 8% for F1-score and 9% for the mean average precision (MAP) score.

Designing an Intelligent Lesion Detection System Using Deep Architecture Neural Networks in the Lower Limb X-Ray Images

Purpose: Diagnosis of musculoskeletal abnormalities is critical because of the large number of people affected by these disorders worldwide. The recent advances in deep learning techniques show that convolutional neural networks can be a useful tool for the computer-aided detection of radiographic abnormalities. This study focuses on diagnosing musculoskeletal abnormalities in the lower extremities using X-Ray images by deep architecture neural networks.&#x0D; Materials and Methods: The dataset contains 61,098 musculoskeletal radiographic images, including 42,658 normal and 18,440 abnormal images. Each image belongs to a single type of lower extremity radiography, including the toe, foot, ankle, leg, knee, femur, and hip joints, which were prepared with standard projection without artifacts and with high quality. A novel deep neural network architecture is proposed with two different scenarios that perform the lower extremity lesion diagnosis functions with high accuracy. The foundation of the proposed method is a deep learning framework based on the Mask Regional Convolutional Neural Network (R-CNN) and Convolutional Neural Network (CNN). The model with the best results incorporated the Mask R-CNN algorithm to produce the bounding box, followed by the CNN algorithm to detect the class based on that.&#x0D; Results: The proposed model can identify different types of lower limb lesions by an Area Under the Curve (AUC) of the Receiver Operating Characteristics (ROC) curve 0.925 with an operating point of 0.859 of sensitivity and a specificity of 0.893.&#x0D; Conclusion: The results indicated that the consecutive implementation of Mask R-CNN and CNN has a higher efficiency than Mask R-CNN and CNN separately in lesion detection of lower limb X-ray images.

Role of magnetic resonance imaging features in diagnosing and localization of disc rupture related to cervical spinal cord injury without radiographic abnormalities.

A retrospective study. Traumatic cervical spinal cord injury (TSCI) is often associated with disc rupture. It was reported that high signal of disc and anterior longitudinal ligament (ALL) rupture on magnetic resonance imaging (MRI) were the typical signs of ruptured disc. However, for TSCI with no fracture or dislocation, there is still difficult to diagnose disc rupture. The purpose of this study was to investigate the diagnostic efficiency and localization method of different MRI features for cervical disc rupture in patient with TSCI but no any signs of fracture or dislocation. Affiliated hospital of University in Nanchang, China. Patients who had TSCI and underwent anterior cervical surgery between June 2016 and December 2021 in our hospital were included. All patients received X-ray, CT scan, and MRI examinations before surgery. MRI findings such as prevertebral hematoma, high-signal SCI, high-signal posterior ligamentous complex (PLC), were recorded. The correlation between preoperative MRI features and intraoperative findings was analyzed. Also, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these MRI features in diagnosing the disc rupture were calculated. A total of 140 consecutive patients, 120 males and 20 females with an average age of 53 years were included in this study. Of these patients, 98 (134 cervical discs) were intraoperatively confirmed with cervical disc rupture, but 59.1% (58 patients) of them had no definite evidence of an injured disc on preoperative MRI (high-signal disc or ALL rupture signal). For these patients, the high-signal PLC on preoperative MRI had the highest diagnostic rate for disc rupture based on intraoperative findings, with a sensitivity of 97%, specificity of 72%, PPV of 84% and NPV of 93%. Combined high-signal SCI with high-signal PLC had higher specificity (97%) and PPV (98%), and a lower FPR (3%) and FNR (9%) for the diagnosis of disc rupture. And combination of three MRI features (prevertebral hematoma, high-signal SCI and PLC) had the highest accuracy in diagnosing traumatic disc rupture. For the localization of the ruptured disc, the level of the high-signal SCI had the highest consistency with the segment of the ruptured disc. MRI features, such as prevertebral hematoma, high-signal SCI and PLC, demonstrated high sensitivities for diagnosing cervical disc rupture. High-signal SCI on preoperative MRI could be used to locate the segment of ruptured disc.

A marmoset model for Mycobacterium avium complex pulmonary disease.

Mycobacterium avium complex, is the most common nontuberculous mycobacterial respiratory pathogen in humans. Disease mechanisms are poorly understood due to the absence of a reliable animal model for M. avium complex pulmonary disease. The objectives of this study were to assess the susceptibility, immunologic and histopathologic responses of the common marmoset (Callithrix jacchus) to M. avium complex pulmonary infection. 7 adult female marmosets underwent endobronchial inoculation with 108 colony-forming units of M. intracellulare and were monitored for 30 or 60 days. Chest radiograph was assessed at baseline (prior to infection) and at the time of sacrifice (30 days for 3 animals and 60 days for 4 animals), and bronchoalveolar lavage cytokines, histopathology and cultures of the bronchoalveolar lavage, lungs, liver and kidney were assessed at time of sacrifice. Serum cytokines were monitored at baseline and weekly for 30 days for all animals and at 60 days for those alive. Group differences in serum cytokine measurements between those that tested positive versus negative for the M. intracellulare infection were assessed using a series of linear mixed models. Five of seven animals (two at 30 days and three at 60 days of infection) had positive lung cultures for M. intracellulare. Extra-pulmonary cultures were positive in three animals. All animals appeared healthy throughout the study. All five animals with positive lung cultures had radiographic changes consistent with pneumonitis. At 30 days, those with M. intracellulare lung infection showed granulomatous inflammation, while at 60 days there were fewer inflammatory changes but bronchiectasis was noted. The cytokine response in the bronchoalveolar lavage fluid was uniformly greater in the animals with positive M. intracellulare cultures than those without a productive infection, with greater levels at 30-days compared to 60-days. Similarly, serum cytokines were more elevated in the animals that had positive M. intracellulare cultures compared to those without a productive infection, peaking 14-21 days after inoculation. Endobronchial instillation of M. intracellulare resulted in pulmonary mycobacterial infection in marmosets with a differential immune response, radiographic and histopathologic abnormalities, and an indolent course consistent with M. avium complex lung infection in humans.

Autonomous Chest Radiograph Reporting Using AI: Estimation of Clinical Impact.

Background Automated interpretation of normal chest radiographs could alleviate the workload of radiologists. However, the performance of such an artificial intelligence (AI) tool compared with clinical radiology reports has not been established. Purpose To perform an external evaluation of a commercially available AI tool for (a) the number of chest radiographs autonomously reported, (b) the sensitivity for AI detection of abnormal chest radiographs, and (c) the performance of AI compared with that of the clinical radiology reports. Materials and Methods In this retrospective study, consecutive posteroanterior chest radiographs from adult patients in four hospitals in the capital region of Denmark were obtained in January 2020, including images from emergency department patients, in-hospital patients, and outpatients. Three thoracic radiologists labeled chest radiographs in a reference standard based on chest radiograph findings into the following categories: critical, other remarkable, unremarkable, or normal (no abnormalities). AI classified chest radiographs as high confidence normal (normal) or not high confidence normal (abnormal). Results A total of 1529 patients were included for analysis (median age, 69 years [IQR, 55-69 years]; 776 women), with 1100 (72%) classified by the reference standard as having abnormal radiographs, 617 (40%) as having critical abnormal radiographs, and 429 (28%) as having normal radiographs. For comparison, clinical radiology reports were classified based on the text and insufficient reports excluded (n = 22). The sensitivity of AI was 99.1% (95% CI: 98.3, 99.6; 1090 of 1100 patients) for abnormal radiographs and 99.8% (95% CI: 99.1, 99.9; 616 of 617 patients) for critical radiographs. Corresponding sensitivities for radiologist reports were 72.3% (95% CI: 69.5, 74.9; 779 of 1078 patients) and 93.5% (95% CI: 91.2, 95.3; 558 of 597 patients), respectively. Specificity of AI, and hence the potential autonomous reporting rate, was 28.0% of all normal posteroanterior chest radiographs (95% CI: 23.8, 32.5; 120 of 429 patients), or 7.8% (120 of 1529 patients) of all posteroanterior chest radiographs. Conclusion Of all normal posteroanterior chest radiographs, 28% were autonomously reported by AI with a sensitivity for any abnormalities higher than 99%. This corresponded to 7.8% of the entire posteroanterior chest radiograph production. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Park in this issue.

Cardiovascular abnormalities in chest radiographs of children with pneumonia, Uganda.

To describe chest radiograph findings among children hospitalized with clinically diagnosed severe pneumonia and hypoxaemia at three tertiary facilities in Uganda. The study involved clinical and radiograph data on a random sample of 375 children aged 28days to 12years enrolled in the Children's Oxygen Administration Strategies Trial in 2017. Children were hospitalized with a history of respiratory illness and respiratory distress complicated by hypoxaemia, defined as a peripheral oxygen saturation (SpO2) < 92%. Radiologists blinded to clinical findings interpreted chest radiographs using standardized World Health Organization method for paediatric chest radiograph reporting. We report clinical and chest radiograph findings using descriptive statistics. Overall, 45.9% (172/375) of children had radiological pneumonia, 36.3% (136/375) had a normal chest radiograph and 32.8% (123/375) had other radiograph abnormalities, with or without pneumonia. In addition, 28.3% (106/375) had a cardiovascular abnormality, including 14.9% (56/375) with both pneumonia and another abnormality. There was no significant difference in the prevalence of radiological pneumonia or of cardiovascular abnormalities or in 28-day mortality between children with severe hypoxaemia (SpO2: < 80%) and those with mild hypoxaemia (SpO2:80 to < 92%). Cardiovascular abnormalities were relatively common among children hospitalized with severe pneumonia in Uganda. The standard clinical criteria used to identify pneumonia among children in resource-poor settings were sensitive but lacked specificity. Chest radiographs should be performed routinely for all children with clinical signs of severe pneumonia because it provides useful information on both cardiovascular and respiratory systems.

Radiographic Sigmoid Sinus Wall Abnormalities and Pulsatile Tinnitus: A Case-Control Study.

Compare incidence of sigmoid sinus wall abnormalities (SSWAs) and other radiographic abnormalities in patients with pulsatile tinnitus (PT) versus controls. Retrospective case-control. Tertiary referral center. Adults with PT and high-resolution computed tomography imaging were compared with adults undergoing cochlear implant workup including high-resolution computed tomography imaging. Incidence of SSWA in PT cohort (n = 141) compared with control (n = 149, n = 298 ears). Secondary outcome measures included differences in demographics and in other radiographic abnormalities between cohorts. Patients with PT had a higher incidence of SSWA (34% versus 9%, p < 0.001) and superior canal dehiscence (23% versus 12%, p = 0.017) than controls. Spearman product component correlations demonstrated that ipsilateral PT was weakly associated with SSWA ( r = 0.354, p < 0.001). When SSWA was present in the PT cohort (n = 48 patients, n = 59 ears), in 31 cases (64.6%), the SSWA correlated with PT laterality (e.g., left SSWA, left PT); in 12 (25.0%), SSWA partially correlated with PT laterality (e.g., bilateral SSWA, right PT); and in 5 (10.4%), the SSWA did not correlate with PT laterality (e.g., right SSWA, left PT). For our patients with both PT and SSWA, the SSWA is likely a contributing factor in approximately 65% of cases. For a third of patients with PT and concomitant SSWA, the association between the two is either not causative or not solely causative. Surgeons counseling patients with PT and SSWA may be optimistic overall regarding sigmoid resurfacing procedures but must appreciate the possibility of treatment failure, likely because of untreated comorbid conditions.

Hypercapnia alters stroma-derived Wnt production to limit β-catenin signaling and proliferation in AT2 cells.

Persistent symptoms and radiographic abnormalities suggestive of failed lung repair are among the most common symptoms in patients with COVID-19 after hospital discharge. In mechanically ventilated patients with acute respiratory distress syndrome (ARDS) secondary to SARS-CoV-2 pneumonia, low tidal volumes to reduce ventilator-induced lung injury necessarily elevate blood CO2 levels, often leading to hypercapnia. The role of hypercapnia on lung repair after injury is not completely understood. Here - using a mouse model of hypercapnia exposure, cell lineage tracing, spatial transcriptomics, and 3D cultures - we show that hypercapnia limits β-catenin signaling in alveolar type II (AT2) cells, leading to their reduced proliferative capacity. Hypercapnia alters expression of major Wnts in PDGFRα+ fibroblasts from those maintaining AT2 progenitor activity toward those that antagonize β-catenin signaling, thereby limiting progenitor function. Constitutive activation of β-catenin signaling in AT2 cells or treatment of organoid cultures with recombinant WNT3A protein bypasses the inhibitory effects of hypercapnia. Inhibition of AT2 proliferation in patients with hypercapnia may contribute to impaired lung repair after injury, preventing sealing of the epithelial barrier and increasing lung flooding, ventilator dependency, and mortality.

Spinal cord injuries in the absence of post-traumatic radiographic anomalies (SCIWORA): the traumatic moment between patient anterior state and efficient/concurrent causes of injury.

Spinal Cord Injury without Radiographic Abnormality (SCIWORA) represents acute traumatic myelopathy in the absence of instrumental evidence of fractures and/or dislocations of the cervical vertebrae. In this article we present 4 cases of SCIWORA that came to our observation and the medico-legal implications associated with them. In defining the compensation in the context of a private accident policy for traumatic pathologies of the spinal cord, an in-depth medical-legal assessment is essential, based on an accurate examination of the health documentation including the instrumental investigations performed, the anamnesis and an accurate evaluation of the trauma dynamic. The paraphysiological deterioration of organ-tissue structures, identifiable in the concept of "natural variability of biological risk", should be included in the same definition of insured risk by age group, with the consequence that physical conditions that fall within the physiological or paraphysiological definitions, although potentially contributing to injury, do not necessarily exclude compensation.A different concept dominates the variability of the compensation according to a paraphysiological pre-existing condition. The two arguments therefore call for thorough consideration of both the paraphysiological contributing causes of injury and/or impairment as necessarily subject to a preliminary study, which through the clinical and instrumental investigation method, will define the perimeter of functionality.

A Comparison of Spinopelvic Alignment and Quality of Life between Farmers and Non-Farmers: A Cross-Sectional Population-Based Study in a Japanese Rural Area

It may be difficult to define what would constitute an abnormal spinal sagittal alignment. The same degree of malalignment may be found both in patients with pain and disability and in asymptomatic individuals. This study focuses on elderly farmers who characteristically have a kyphotic spine, in addition to local residents. It questions whether these patients experience cervical and lower back symptoms, respectively, more often than elderly people who never worked on a farm and do not have a kyphotic deformity. Previous research could have been biased by sampling patients who came to a spine clinic for treatment, whereas this study sampled asymptomatic elderly who may or may not have had kyphosis. We studied 100 local residents at their annual health checkup (22 farmers and 78 non-farmers) with a median age of 71 years (range 65-84 years). Spinal radiographs were used to measure sagittal vertical axis, lumbar lordosis, thoracic kyphosis and other measurements of sagittal malalignment. Back symptoms were measured using Oswestry Disability Index (ODI) and Neck Disability Index (NDI). The association between alignment measures and back symptoms were calculated by bivariate comparison between patient groups and by Pearson's correlation. About 55% of farmers and 35% of non-farmers had abnormal radiographs (i.e., vertebral fracture). Farmers had higher measurements of sagittal vertical axis (SVA), compared to non-farmers, when measured from C7 (median 24.4 mm vs. 9.15 mm, p = 0.04) and from C2 (47.65 vs. 25.3, p = 0.03). Lumbar lordosis (LL) and thoracic kyphosis (TK) were significantly decreased in farmers vs. non-farmers (37.5 vs. 43.5, p = 0.04 and 32.5 vs. 39, p = 0.02, respectively). The ODI was likely to be higher among farmers compared to non-farmers while NDI scores showed no significant difference between farmers and non-farmers (median 11.7 vs. 6.0, p = 0.06 and median 13 vs. 12, p = 0.82, respectively). In terms of correlation among spinal parameters, LL had a higher correlation with SVA, but TK had less correlation with SVA among farmers compared to non-farmers. There was no significant correlation between disability scores and measurements of sagittal alignment. Farmers had higher measurements of sagittal malalignment, characterized by loss of LL, decreased TK and an increased forward translation of cervical vertebrae relative to sacrum. ODI was likely to higher in farmers compared to non-farmers although the association did not reach a significant level. These results probably indicate that the gradual development of spinal malalignment in agricultural workers does not result in excess morbidity compared to controls.

Reversible Neurotoxicity Due To Excessive Use of Ethyl Chloride

BackgroundEthyl chloride is commercially available as a DVD/VCR cleaner, and can be found as a gasoline additive and topical anesthetic. There is an emerging trend of recreational huffing to enhance sexual relations. Neurotoxicity from repeated abuse is uncommon. Case ReportA 36-year-old man with a history of intermittent ethyl chloride use for 15 years presented to the Emergency Department with an inability to walk for 4 days after frequent use for 1 week. The patient reported a rapid titration of inhalation from zero to eight cans of 4.6 oz ethyl chloride aerosol per day over a 1-week period. Initial vital signs were heart rate 88 beats/min, blood pressure 147/60 mm Hg, temperature 37.2°C (99°F), and respiratory rate 16 breaths/min. Physical examination was notable for slurred speech, ptosis, a wide-based and ataxic gait with short strides, inability to stand without support, loss of toe/finger proprioception, horizontal and vertical nystagmus, and dysmetria on coordination testing. Strength and sensation were preserved. His work-up included computed tomography and magnetic resonance imaging of the brain, cervical, thoracic, and lumbar spine that demonstrated no acute abnormalities. On hospital day 9, the patient was able to ambulate with mild difficulty. Why Should an Emergeny Physician Be Aware of This?Toxicity from excessive ethyl chloride huffing has been rarely reported. The toxicity was characterized with cerebellar findings, no attributable laboratory abnormalities, and no radiographic abnormalities on computed tomography/magnetic resonance imaging. The neurotoxicity resolved with supportive care.This case of excessive huffing of ethyl chloride presenting with neurotoxicity and ataxia further characterizes a rare complication of ethyl chloride toxicity that is gaining popularity.