Virtual monochromatic images of dual-energy CT as an alternative to single-energy CT: performance comparison using a detectability index for different acquisition techniques.

OBJECTIVES: To investigate the performance of virtual monochromatic (VM) images with the same dose and iodine contrast as those for single-energy (SE) images using five dual-energy (DE) scanners with DE techniques: two generations of fast kV switching (FKS), two generations of dual source (DS), and one split filter (SF). METHODS: A water-bath phantom with a diameter of 300 mm, which contains one rod-shaped phantom made of a material equivalent to soft-tissue and two rod-shaped phantoms made of diluted iodine (2 and 12 mg/mL), was scanned using both SE (120, 100, and 80 kV) and DE techniques with the same CT dose index in each scanner. The VM energy at which the CT number of the iodine rod is closest to that of each SE tube voltage was determined as the equivalent energy (Eeq). A detectability index (d') was calculated from the noise power spectrum, the task transfer functions, and a task function corresponding to each rod. The percentage of the d' value of the VM image to that of the corresponding SE image was calculated for performance comparison. RESULTS: The average percentages of d' of FKS1, FKS2, DS1, DS2, and SF were 84.6%, 96.2%, 94.3%, 107%, and 104% for 120 kV-Eeq; 75.9%, 91.2%, 88.2%, 99.2%, and 82.6% for 100 kV-Eeq; 71.6%, 88.9%, 82.6%, 85.2%, and 62.3% for 80 kV-Eeq, respectively. CONCLUSION: The performance of VM images was on the whole inferior to that of SE images especially at low equivalent energy levels, depending on the DE techniques and their generations. KEY POINTS: • This study evaluated the performance of VM images with the same dose and iodine contrast as those for SE images using five DE scanners. • The performance of VM images varied with the DE techniques and their generations and was mostly inferior at low equivalent energy levels. • The results highlight the importance of distribution of available dose over the two energy levels and spectral separation for the performance improvement of VM images.

Mortality After Hip and Spine Fractures in Patients With End-Stage Kidney Disease: A Systematic Review and Meta-Analysis.

Fractures represent a major cause of disability in the elderly, and patients with fractures exhibit a higher mortality rate than those without. Fractures are also an important health problem among patients with end-stage kidney disease (ESKD) requiring hemodialysis, peritoneal dialysis, or kidney transplantation. To the best of our knowledge, no study in the literature has yet quantitatively summarized the mortality rates, and a summary of evidence on post-hip and spine fracture mortality in patients with ESKD is lacking. The purpose of this study is to quantitatively evaluate the mortality rate, one-year mortality rate, and five-year mortality rate after hip and spine fractures in patients with ESKD receiving kidney replacement therapy. The MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and ClinicalTrials.gov databases were comprehensively searched for reports on mortality rate and time-period mortality in patients with ESKD after hip or spine fractures up to June 2022. Prospective and retrospective cohort studies, as well as case series involving four or more patients, were included. Pooled mortality rate, one-year rate, and five-year mortality rate with 95% confidence intervals (CIs) were examined using a random-effects model. The risk of bias was assessed using the Joanna Briggs Institute (JBI) Prevalence Critical Appraisal Tool. Additionally, heterogeneity between studies was evaluated. A total of 26 studies were included in this meta-analysis. The one-year and five-year mortality rates after hip and spine fractures were 215.35-774.0 per 1,000 person-year and 148-194.1 per 1,000 person-year, respectively. After hip fractures, the one-year mortality rate was 27% (95% CI: 18-38%, I2 = 98%), whereas the five-year mortality rate was 56% (95% CI: 41-71%, I2 = 99%). After spine fractures, the one-year mortality rate was 10% (95% CI: 4-17%, I2 = 70%), whereas the five-year mortality rate was 48.3%. The post-fracture mortality rate was high in patients with ESKD, particularly within one year after the occurrence of fractures. Additionally, the five-year mortality rate after hip femoral or spine fractures was high at approximately 50%.

Ventricular septal rupture with right hypochondrial pain mimicking acute cholecystitis.

A 67-year-old man was admitted for anterior acute ST elevation myocardial infarction (STEMI) management. He developed a severe acute right subcostal pain with normal cardiac tests. On day 5 of hospitalization, cholecystectomy was performed for suspected acute cholecystitis, but the pain intensified with hemodynamical instability. Transthoracic echocardiography revealed ventricular septal rupture (VSR). After emergency operation was performed, the pain diminished with improved hemodynamics. Right subcostal pain associated with heart disease can be referred from STEMI or liver congestion with right heart failure. VSR and right heart failure may be considered as a cause of right subcostal pain of uncertain etiology. .

A Comparison Between the Efficacy and Safety of Endovascular Arteriovenous Fistula Creation and Surgical Fistula Creation: A Systematic Review and Meta-Analysis.

An endovascular arteriovenous fistula is a recent technological advancement in hemodialysis vascular access. This systematic review and meta-analysis aimed to investigate the efficacy and safety of endovascular arteriovenous fistula (eAVF) creation compared with surgical arteriovenous fistula (sAVF) creation among patients with chronic kidney disease. We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Clinical Trials.gov, and the WHO International Clinical Trials Registry Platform until May 2021 to perform meta-analyses using random-effects models. Pre-specified primary outcomes were fistula maturation, procedure-related complications, and patient satisfaction. Secondary outcomes were procedural technical success, procedure time, all adverse events, and medical expenditure. The risk of bias in non-randomized studies of the interventions assessment tool, and the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach were used to assess the quality of individual studies and the body of evidence, respectively. In seven studies including 860 patients, endovascular arteriovenous fistula creation had little to no effect on fistula maturation (odds ratio, 0.58; 95% confidence intervals, 0.05 to 6.91). Meta-analysis could not be performed for procedure-related complications and patient satisfaction due to insufficient data. For secondary outcomes, endovascular arteriovenous fistula resulted in a slight to no difference in procedural technical success (odds ratio, 0.69: 95% confidence intervals, 0.04 to 11.98) and all adverse events (odds ratio, 6.31; 95% confidence intervals, 0.64 to 62.22). Endovascular fistula creation incurred less medical expenditure than sAVF (mean difference, USD 12760; 95% confidence intervals, -19710 to -5820). Meta-analysis for procedure time was not performed because one of the studies had a critical risk of bias. All of these outcomes were of low certainty of evidence or very low certainty of evidence. There was limited evidence for supporting endovascular arteriovenous fistula creation over conventional surgical arteriovenous fistula creation for patients with chronic kidney disease. Multicenter randomized controlled trials are needed to confirm the efficacy and safety of eAVFs in selected populations.

The Effect of Changing Arterial Transducer Position on Stroke Volume Measurements Using FloTrac System Version 4.0: A Pilot Experimental Study.

OBJECTIVES: We conducted a pilot study using an experimental study protocol to evaluate the measurement error of arterial pulse contour analysis-derived stroke volume due to improper transducer leveling during the passive leg raising test and the impact of such error on the determination of fluid responsiveness. DESIGN: Prospective observational study. SETTING: A medical-surgical ICU at a tertiary referral center in Kobe, Japan. PATIENTS: Consecutive critically ill adult patients using the FloTrac system Version 4.0 (Edwards Lifesciences, Irvine, CA) for hemodynamic monitoring between September 1, 2018, and November 31, 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using 20 patients, we estimated the change in the zero-reference level of an arterial transducer during head-down tilting as the vertical distance between the zero-reference levels of the transducer in the 45° semi-recumbent and supine positions. Using the FloTrac system Version 4.0, we recorded the hemodynamic variables every 20 seconds for 180 seconds at each of the following three points: 1) baseline, 2) after the transducer was elevated by the predetermined distance, and 3) after the transducer had returned to baseline. With respect to the predetermined change in the transducer level, a mean value of 18 ± 3 cm resulted in an increase in stroke volume measurement (mean value, 11 mL/beat; 95% CI, 10-13). This value corresponded to 20% (95% CI, 18-23%) of the baseline value 20 seconds after changing the transducer level. A significant correlation was observed between the predetermined change in the transducer level and the increase in the measured stroke volume (r 2 = 0.58; p < 0.001). CONCLUSIONS: When using the FloTrac system Version 4.0, a rapid increase in stroke volume was observed after elevating the arterial transducer. Clinicians and researchers are advised that proper leveling of the arterial transducer is necessary in order to accurately assess the change in arterial pulse contour analysis-derived stroke volume during the passive leg raising test.

Clinical characteristics and outcomes of critically ill patients with COVID-19 in Kobe, Japan: a single-center, retrospective, observational study.

PURPOSE: Coronavirus disease 2019 (COVID-19) has placed a great burden on critical care services worldwide. Data regarding critically ill COVID-19 patients and their demand of critical care services outside of initial COVID-19 epicenters are lacking. This study described clinical characteristics and outcomes of critically ill COVID-19 patients and the capacity of a COVID-19-dedicated intensive care unit (ICU) in Kobe, Japan. METHODS: This retrospective observational study included critically ill COVID-19 patients admitted to a 14-bed COVID-19-dedicated ICU in Kobe between March 3, 2020 and June 21, 2020. Clinical and daily ICU occupancy data were obtained from electrical medical records. The last follow-up day was June 28, 2020. RESULTS: Of 32 patients included, the median hospital follow-up period was 27 (interquartile range 19-50) days. The median age was 68 (57-76) years; 23 (72%) were men and 25 (78%) had at least one comorbidity. Nineteen (59%) patients received invasive mechanical ventilation for a median duration of 14 (8-27) days. Until all patients were discharged from the ICU on June 5, 2020, the median daily ICU occupancy was 50% (36-71%). As of June 28, 2020, six (19%) died during hospitalization. Of 26 (81%) survivors, 23 (72%) were discharged from the hospital and three (9%) remained in the hospital. CONCLUSION: During the first months of the outbreak in Kobe, most critically ill patients were men aged ≥ 60 years with at least one comorbidity and on mechanical ventilation; the ICU capacity was not strained, and the case-fatality rate was 19%.

Performance of clinically available deep learning image reconstruction in computed tomography: a phantom study.

Purpose: To assess the physical performance of deep learning image reconstruction (DLIR) compared with those of filtered back projection (FBP) and iterative reconstruction (IR) and to estimate the dose reduction potential of the technique. Approach: A cylindrical water bath phantom with a diameter of 300 mm including two rods composed of acrylic and soft tissue-equivalent material was scanned using a clinical computed tomography (CT) scanner at four dose levels (CT dose index of 20, 15, 10, and 5 mGy). Phantom images were reconstructed using FBP, DLIR, and IR. The in-plane and z axis task transfer functions (TTFs) and in-plane noise power spectrum (NPS) were measured. The dose reduction potential was estimated by evaluating the system performance function calculated from TTF and NPS. The visibilities of a bar pattern phantom placed in the same water bath phantom were compared. Results: The use of DLIR resulted in a notable decrease in noise magnitude. The shift in peak NPS frequency was reduced compared with IR. Preservation of in-plane TTF was superior using DLIR than using IR. The estimated dose reduction potentials of DLIR and IR were 39% to 54% and 19% to 29%, respectively. However, the z axis resolution was decreased with DLIR by 6% to 21% compared with FBP. The bar pattern visibilities were approximately consistent with the TTF results in both planes. Conclusions: The in-plane edge-preserving noise reduction performance of DLIR is superior to that of IR. Moreover, DLIR enables approximately half-dose acquisitions with no deterioration in noise texture in cases that permit some z axis resolution reduction.

Longer term hemodialysis-dependent chronic renal failure increases the risk of post-cardiac surgery vasoplegic syndrome.

PURPOSE: We evaluated whether longer term hemodialysis (HD) is associated with a higher incidence of vasoplegic syndrome (VS) after cardiac surgery. METHODS: This retrospective, single-center cohort study included 562 consecutive patients who underwent cardiac surgery in a tertiary hospital from January 2015 to December 2016. We assessed VS occurrence and its relationship with HD duration and other risk factors. To assess the effect of the HD duration on VS occurrence, we constructed ordinal variables: HD = 0 (non-HD), 0 < HD ≤ 5 (HD ≤ 5 years), 5 < HD ≤ 10, and 10 < HD. RESULTS: The overall mean (± standard deviation) age of patients was (73 ± 11) years, and there were 60.9% men. Forty-one patients (7.3%) were HD dependent. Cardiac surgeries included all coronary artery bypass graft procedures, all valvular procedures, and aortic surgery involving cardiopulmonary bypass (CPB). Sixty-six patients (10%) developed VS. Most preoperative patient characteristics were comparable between the VS and no-VS groups; a chronic HD status and a total CPB time of > 180 min were significantly more common in the VS group (P < 0.0001 and P = 0.02, respectively). Longer term HD significantly correlated with VS incidence (P < 0.0001). Ordinal variables for the HD duration and age and known risk factors for VS (preoperative use of angiotensin-converting enzyme inhibitors and beta-blockers, low left-ventricular ejection fraction, and CPB time > 180 min) were subjected to multivariate regression analysis. Long-term HD was identified as an independent predictor of VS (odds ratio, 2.29, 95% confidence interval, 1.66-3.18). CONCLUSIONS: Longer term HD may be associated with a higher VS incidence after cardiac surgery. VS should be given attention after cardiac surgery in chronic HD-dependent patients.

Airway Obstruction Caused by Mucinous Material Adherent to the Epiglottis in a Patient with a Progressive Neurological Disorder: An Unusual Case of a Condition Mimicking Acquired Laryngomalacia.

We herein report the successful management of a condition mimicking acquired laryngomalacia using conservative methods in an elderly man with a progressive neurological disorder. The patient developed stridor and was transferred to the intensive-care unit. Flexible laryngoscopy revealed a collapsed epiglottis during inspiration, as seen in acquired laryngomalacia, with mucinous material firmly adhered to the epiglottis. The stridor resolved after the removal of this material. Pathology revealed keratinized material, suggesting a collection of sputum or epithelial tissue. Thus, flexible laryngoscopy can differentiate the cause of airway obstruction and avoid unnecessary endotracheal intubation in patients with neurological disorders.

Interaction between warfarin and short-term intravenous amiodarone in intensive care unit patients after cardiac surgery.

BACKGROUND: Amiodarone and warfarin are sometimes administered immediately after cardiac surgery. Although the interaction between long-term oral amiodarone and warfarin has been reported, the interaction between warfarin and short-term intravenous amiodarone has not been reported. In this study, we investigated the effect of short-term intravenous amiodarone on the anticoagulant effect of warfarin in patients who underwent cardiac surgery. METHODS: We retrospectively reviewed the medical records of 11 patients who received oral warfarin before and after cardiac surgery, and loading doses of 125-150 mg or a 750 mg continuous infusion of amiodarone, or both in the intensive care unit (ICU) within 5 days after the surgery between July 2011 and January 2017. The prothrombin time-international normalized ratio (PT-INR)/daily warfarin dose (PT-INR/dose) was used as an indicator of anticoagulant effect. The values before surgery were considered as the baseline. RESULTS: The PT-INR and PT-INR/dose values were elevated in 7 and 10 patients, respectively, after amiodarone administration. The mean PT-INR values were not significantly different before and after amiodarone administration (2.13 ± 0.58 vs 2.29 ± 0.50, respectively, p = 0.643). In contrast, the mean PT-INR/dose values were significantly elevated after the administration of amiodarone (0.93 ± 0.46 vs 1.54 ± 0.63, respectively, p = 0.002). CONCLUSIONS: Short-term intravenous amiodarone enhanced the anticoagulant effect of warfarin in patients admitted to the ICU after cardiac surgery. We suggest that the dose of warfarin should be carefully adjusted for a few days after cardiac surgery if intravenous amiodarone is coadministered.

Epstein-Barr virus-associated early gastric carcinoma with lymphoid stroma, accompanied with lymph node metastasis.

The present case report presents a rare case of Epstein-Barr virus (EBV)-associated early gastric carcinoma with lymphoid stroma, accompanied by lymph node metastasis. A 61-year-old woman was referred to our hospital following observation of a gastric mass lesion that was initially diagnosed at a medical check-up. Esophagogastroduodenoscopy revealed a slightly elevated lesion with a central irregular depression in the middle third of the stomach. Endoscopic ultrasonography revealed a well-circumscribed hypoechoic mass located predominantly within the submucosa and the mucosa. Biopsy specimens of the lesion indicated the possibility of carcinoma with lymphoid stroma with a lymphoepithelial lesion. Abdominal contrast-enhanced computed tomography (CT) revealed a well-defined mass with homogeneous enhancement approximately 1.2 cm in diameter in the middle part of the stomach, demonstrating lymphadenopathy in the perigastric area at a maximum size of 1.4 cm in diameter. The patient underwent laparoscopic distal gastrectomy with regional lymphadenectomy due to suspicion of a gastric carcinoma with lymphoid stroma. Histopathological and immunohistochemical findings verified the diagnosis of carcinoma with lymphoid stroma, which were positive for EBV-encoded RNA (EBER-ISH) by in situ hybridization. There was one lymph node metastasis, which was in line with the CT imaging. Marked infiltration of lymphoid cells was observed in the tumor stroma, which were negative for EBER-ISH. The present case is informative of the pathological characteristics of this condition, and clinicians should recognize the features of this disease to make an accurate diagnosis and select the appropriate treatment.

Successful recovery without any neurological complication after intraoperative cardiopulmonary resuscitation for an extended period of time in the lateral position: a case report.

No successful resuscitation has ever been reported about intraoperative cardiopulmonary resuscitation (CPR) for an extended period of time in the lateral position. Here we report a case of successful resuscitation without any neurological complication after cardiac arrest due to massive hemorrhage and 25 min of CPR in the lateral position. The patient was a 65-year-old man. During open hemostasis for the postoperative hemorrhage, the patient's rhythm changed sinus to ventricular fibrillation (VF), followed by asystole. We started CPR immediately with the patient in the left lateral position. Chest compression was performed by two practitioners, one pressing patient's sternum and the other pressing simultaneously patient's mid-thoracic spine from his back. During CPR, though the value of end-tidal CO2 (EtCO2) was significantly low (around 5-20 mmHg), the value of systolic arterial pressure was kept about 35-50 mmHg, and diastolic pressure about 20-30 mmHg. After the 25 min of lateral CPR, he achieved the return of spontaneous circulation (ROSC). He was hemodynamically stable after ROSC. He regained his consciousness at the next postoperative day. He was discharged from our hospital on the 60th day of operation without any cardiac and neurological complication. Successful neurological outcome suggests that we may expect satisfactory neurological outcome even in the case of lateral position and prolonged CPR if we perform effective CPR with the feedback of arterial blood pressure and EtCO2 and with the immediate intervention to culprit injuries.

Erythropoietin-producing tubercle granuloma in a hemodialysis patient.

BACKGROUND: We describe a case of a fever of unknown etiology that was caused by a caseating tubercle granuloma which produced erythropoietin. To our knowledge, this is the first report of an erythropoietin- producing granuloma. CASE PRESENTATION: A 48-year-old Japanese man with a 5-year history of maintenance hemodialysis for diabetic nephropathy presented with an intermittent fever over a few months. During febrile periods he developed erythema nodosum on his legs. Computed tomography showed axillary lymph node enlargement and this was further corroborated by a gallium scan that revealed high gallium uptake in these nodes. A Mantoux test was positive and an interferongamma release assay for tuberculosis diagnosis was also positive. Lymph node tuberculosis was suspected and the patient underwent lymphadenectomy. Histological analysis of the lymph nodes revealed a caseating granuloma that showed positive results on an acid-fast bacteria stain and a Mycobacterium tuberculosis polymerase chain reaction test. After lymphadenectomy, however, the patient's hemoglobin levels rapidly decreased from 144 to 105 g/L, and this was further compounded by a decrease in serum erythropoietin from 223 mIU/mL to 10.7 mIU/mL by postoperative day 21. We suspected the tubercle to be a source of the erythropoietin and this was further confirmed by in situ hybridization. CONCLUSIONS: We report for the first time ectopic erythropoietin production by a tuberculous lymph node. Our observations are substantiated by a postoperative decline in his erythropoietin level and a clinical requirement for erythropoietin treatment.

Primary gastric small cell carcinoma: report of a case and review of the literature.

A 52-year-old man suffering from a pure-type primary gastric small cell carcinoma was treated with surgery and combination chemotherapy. The small cell carcinoma, approximately 6.5 cm in diameter, was situated in the posterior wall of the antrum and there were no distant metastases. Total gastrectomy and regional lymph node dissection was carried out. Histological examination revealed a solid pattern of proliferation of small cells with hyperchromatic, round nuclei and scant cytoplasm. Neoplastic cells infiltrated into the subserosal layer with severe lymphatic and vascular invasion. Regional lymph node cells were mostly replaced by tumor cells that stained positive for Grimelius, neuron-specific enolase (NSE), and synaptophysin. Accumulations of electron-dense core granules in the small neoplastic cells were seen by electron microscopy. Following surgery, the patient was treated with adjuvant chemotherapy consisting of cisplatin and etoposide. The patient is alive and recurrence free 3 years after surgical operation. We review 107 published cases of primary gastric small cell carcinoma, an extremely rare disease first reported in 1976. Small cell carcinoma is an aggressive, malignant tumor. Intensive chemotherapy is essential for patient survival even when curative surgical resection is carried out.