Assessment of the Impact of Skeletonization on Pleuropulmonary Changes after Bilateral Internal Thoracic Artery Harvest for Coronary Artery Bypass Grafting.

BACKGROUND AND AIMS: Skeletonization has been proposed as a technique to minimize the risk of sternal devascularization during bilateral internal thoracic artery harvest for coronary artery bypass grafting. The impact of this strategy on late radiologic pleuropulmonary changes has not been addressed. MATERIAL AND METHODS: Post-operative chest radiographs from patients (n = 253 per group) undergoing bilateral internal thoracic artery harvest using skeletonized and non-skeletonized techniques were reviewed by blinded radiologists. The primary outcome was the incidence of atelectasis and pleural effusion. Multivariable linear regression models were derived to assess the relationship of radiologic pleuropulmonary outcomes to patients and operative variables. RESULTS AND CONCLUSION: Patients in the skeletonized group were older (p < 0.0001), had a lower preoperative hematocrit (p = 0.014), had higher prevalence of peripheral vascular disease (p = 0.001), were of female gender (p = 0.015), underwent off-pump surgery (p < 0.001), had urgent/emergent status (p = 0.024), and had chronic obstructive pulmonary disease (p = 0.019). There was no difference in the incidence of post-operative complications, ventilation time, or intensive care unit stay. There was no difference in the severity of post-operative atelectasis in both groups. More patients in the non-skeletonized group had a grade 2/3 left pleural effusion on the late post-operative chest X-ray (p = 0.007). The independent effect of skeletonization on the development of a late left pleural effusion was significant (odds ratio = 0.558, 95% confidence interval = 0.359-0.866, p = 0.009). Skeletonization results in a decreased incidence of late post-operative left pleural effusion with no difference in early or late atelectasis. Further studies are warranted to assess the mechanism of these pleuropulmonary changes and the impact of other factors such as pleural violation during surgery.

Transthoracic needle biopsy of the lung: results of early discharge in 506 outpatients.

PURPOSE: To determine the safety of early discharge (30 minutes) after transthoracic needle biopsy (TTNB) of the lung. MATERIALS AND METHODS: In a prospective study of 506 consecutive outpatients who underwent TTNB of the lung, 440 patients underwent fine-needle aspiration biopsy (FNAB) only, and 66 underwent FNAB and core biopsy. Patients were discharged after 30-minute postbiopsy chest radiography if there was no pneumothorax. Patients were discharged after 60-minute chest radiography if they had a stable asymptomatic pneumothorax. These patients were followed up 1 day and/or 1 week after biopsy to identify delayed complications. Patients with a symptomatic or enlarging pneumothorax were treated with an 8-F pigtail catheter attached to a Heimlich valve, discharged, and followed up 24 hours later for chest tube removal. RESULTS: The pneumothorax rate was 22.9% (116 patients). Eighty-one patients (16.0%) had an asymptomatic pneumothorax, and 33 (6.5%) had a pigtail catheter in place. Seven (1.4%) patients developed a symptomatic pneumothorax after discharge; two of them (0.4%) underwent large-bore chest tube insertion. The other five (1.0%) underwent delayed pigtail catheter insertion. There were no deaths or other major complications. CONCLUSION: Early discharge after outpatient TTNB of the lung is associated with little morbidity and no mortality.

Minimizing the risk of Q fever in the hospital setting.

Q fever is caused by a rickettsial microorganism (Coxiella burnetii) harboured in sheep. The highest concentration of organisms are found in birth products. It is a very contagious organism which humans can contract by inhaling aerosolized organisms. Most commonly it leads to an acute 'flu-like illness. Rarely, chronic disease with endocarditis is fatal. Infected patients should be treated with tetracyclines or chloramphenicol. A number of outbreaks have been reported in hospital and research settings. Because of the fear of patients and staff contracting Q fever, Hospital Research Review Boards have increasingly resisted the presence of sheep in medical facilities. The authors have reviewed the circumstances leading to these outbreaks and believe researchers can minimize the risk of Q fever. The most important precautions are to use sheep only from Q fever controlled flocks and, depending on the nature of the research, only male sheep.

The trachea: pathologic conditions and trauma.

A variety of common and uncommon conditions affect the trachea. Respiratory symptoms rarely occur until there is a 50% narrowing of the trachea. Chondromalacia, sometimes seen in conjunction with congenital tracheoesophageal fistula, can be identified with fluoroscopy. Patients with tracheal narrowing who undergo general anesthesia are at great risk for life-threatening acute airway obstruction after removal of the tube. Tracheal narrowing is associated with calcified mediastinal and hilar masses in fibrosing mediastinitis. Tracheal widening has been reported in 30% of patients with pulmonary fibrosis. Primary tracheal neoplasms are rare. In adults 90% of such lesions are malignant, but in children 90% are benign; these benign lesions include squamous cell papilloma and hemangioma. Malignant involvement of the trachea is usually secondary to invasion from adjacent lung, larynx, esophagus or thyroid tissue. Because misplaced tubes are associated with several complications, the radiologist must confirm the location of all tubes. Displacement of the endotracheal tube from full extension to flexion averages 2 cm. Therefore, the tube's tip should be at least this far above the carina to avoid insertion of the tube into the mainstem bronchus. Malpositioning of feeding tubes may cause pneumothorax. Tracheal trauma may be missed unless the radiologist is highly suspicious, as would occur for patients with unresponsive pneumothorax. Observation of the hyoid bone above the third cervical vertebra suggests transection of the cervical trachea.

The trachea: normal anatomic features, imaging and causes of displacement.

Radiologists have long regarded the trachea as one of their "blind spots," even though this structure can be visualized as well as, if not better than, any other intrathoracic component because of the excellent intrinsic contrast provided by air within the trachea and by the tracheal interfaces with the mediastinum and the lung. Despite this ease of visualization, radiologists may overlook tracheal abnormalities in their diligence in examining the pulmonary parenchyma and the heart. The trachea can be imaged by a variety of techniques, including plain radiography, computed tomography (CT) and magnetic resonance imaging. Important tracheal interfaces include the right and left paratracheal stripes and the tracheoesophageal stripe. The right posterolateral tracheal band is best seen with CT. The trachea is generally a midline structure displaced slightly to the right by the aortic arch. Various conditions, including mediastinal masses and vascular anomalies, may bow, displace or indent the trachea. Such appearances are most commonly seen in patients with thyroid masses or a right-sided aortic arch. Enlarged nodes do not usually narrow the trachea unless they are much harder than the cartilaginous rings, as occurs in nodular sclerosing Hodgkin's disease, or the rings are soft, as is the case in children.

Research in the clinical radiology department.

Researchers often feel tangled in a web of bureaucracy when attempting to conduct their research. However, it is vital that researchers get involved and develop review processes such as those described above, which facilitate animal research yet address the important ethical, legal, and other related issues raised by hospital administrators and the public. As we do so, it is vital that we communicate directly with the public. Without this participation, we will find more and more hospital radiology departments closing their doors to animal-based research.