Waiting to exhale: salvaging the nondiagnostic CT pulmonary angiogram by using expiratory imaging to improve contrast dynamics.

We attempted to investigate whether computed tomography pulmonary angiography (CTPA) in the expiratory phase can improve contrast enhancement of the pulmonary arteries and mitigate the effect of inspiratory transient attenuation artifact, potentially salvaging nondiagnostic studies. Eighteen patients with indeterminate inspiratory CTPA, despite proper contrast bolus were studied. Patients were rescanned in expiration using the same contrast bolus and scanning parameters. The attenuation of each pulmonary arterial segment, superior and inferior vena cava, and atria and ventricles during the two phases of respiration was measured independently by three radiologists. All pulmonary segments were evaluated for filling defects during the two phases. In addition, the studies were graded for diagnostic quality of enhancement and probable impact on management. A statistically significant increase in pulmonary arterial enhancement was seen during expiration from the pulmonary trunk to the segmental pulmonary arteries (P < 0.001) and for the inferior vena cava, the right atrium, and the ventricle. The incidence of nondiagnostic inspiratory studies ranged from 89 to 100%, depending on the observer. All studies were upgraded to fully acceptable diagnostic quality with follow-up expiratory imaging (P < 0.0001). Expiratory phase imaging was observed to have diagnostic impact in 78 to 88% of cases, with overall good to moderate interobserver agreement. In one case, pulmonary embolism was detected on the expiratory scan, which was not seen on the inspiratory scan. Expiratory imaging for nondiagnostic CTPA improves pulmonary arterial enhancement and improves diagnostic quality of CTPA by eliminating transient attenuation artifact, thus facilitating more accurate diagnosis and providing earlier treatment of pulmonary embolism.

Political identity and the Third Way: some social-psychological implications of the current anti-ideological turn.

This paper considers recent large-scale changes in British politics from the standpoint of a detailed examination of the practical dilemmas, concerning political identity, faced by local politicians in their talk about politics. It seeks to examine the social-psychological significance of a shift which has meant that politics, while continuing to be characterized by formal division, has begun to extensively reflect the influence of an ideology of anti-ideology.

Preperitoneal herniation into a laparoscopic port site without a fascial defect.

BACKGROUND: Port site herniation is an uncommon event that usually occurs as a result of incomplete fascial closure. This allows the omentum or viscera to herniate through the incompletely closed defect. However, in laparoscopic surgery for morbid obesity, the omentum and viscera can herniate through the thick preperitoneal space even with a complete closure of the fascia. CASE REPORT: A 19-year-old female with BMI 55 underwent uneventful long limb laparoscopic Roux-en-Y gastric bypass. On postoperative day 1 the patient had limited pain, was ambulating well, and was tolerating slps of liquids. A limited upper GI series performed on postoperative day 2 revealed no leak or obstruction. Several hours later the patient developed abdominal pain associated with nausea, which progressed to vomiting. CT of the abdomen suggested a port site herniation into the left subcostal port. The cause of the obstruction appeared to be herniation through the left subcostal port site. At laparotomy, a segment of bowel just distal to the anastomosis was found herniated through the port site. The Richter's hernia was reduced. Careful inspection of the fascia revealed a complete fascial closure, with the strangulated portion of the bowel incarcerated in the preperitoneal space. Following repair of the preperitoneal defect, her subsequent recovery was unremarkable. CONCLUSION: Laparoscopic surgery for morbid obesity presents the possibility for preperitoneal herniation. Closure, using a fascial closure device, under laparoscopic control, may offer a solution by closing both the fascia and peritoneum all at once.