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Arthroscopic findings associated with roof impingement of an anterior cruciate ligament graft.

Nineteen patients with roof impingement of an anterior cruciate ligament graft had their grafts inspected during second-look arthroscopy. The diagnosis of roof impingement was suspected from the clinical findings of an effusion, extension deficit, recurrent instability, or anterior knee pain. The diagnosis was confirmed when a portion of the tibial tunnel was anterior to the tibial intersection of the slope of the intercondylar roof on a lateral roentgenogram of the fully extended knee. During second-look arthroscopy the impinged anterior cruciate ligament graft had one or more of the following features: fractured bundles, guillotined remnants at the tibial insertion, parallel fragmentation of an uninterrupted graft, fibrous nodule, or an extrusion of graft material at the outlet of the notch. We hypothesize that these changes in the integrity of the anterior cruciate ligament graft are caused by mechanical injury from roof impingement. CLINICAL RELEVANCE. One should suspect that a patient with an effusion, extension deficit, recurrent instability, or anterior knee pain after an anterior cruciate ligament reconstruction may have roof impingement. A lateral roentgenogram in full extension is diagnostic if the tibial tunnel is anterior to the intercondylar roof. The surgeon should be aware that impinged grafts can have a variety of arthroscopic appearances in addition to the previously reported fibrous nodule or Cyclops lesion.

Adult↗

A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes.

BACKGROUND: In order to determine the type and incidence of pulmonary complications associated with the placement of narrow-bore enteral feeding tubes we conducted a prospective, descriptive study in the multidisciplinary intensive care unit (ICU) of a university hospital. All patients that had narrow-bore enteral feeding tubes inserted over a 2-year period (1993-1995) were included. The study required no clinical interventions. RESULTS: Seven hundred and forty feeding tubes were inserted during the study period. In 14 cases (2%), the feeding tube was inserted into the tracheopulmonary system. Five patients (0.7%) suffered a major complication, including two (0.3%) who died from complications directly related to the feeding tube placement. All patients had altered consciousness and 13 of the 14 had endotracheal tubes in place. Malposition of the feeding tube was not predictable from clinical signs and auscultation, but was detectable by chest roentgenogram. CONCLUSIONS: Inadvertent insertion of enteral feeding tubes into the tracheopulmonary system during placement is associated with significant morbidity and mortality. Clinical signs at the time of insertion are not useful in identifying feeding tubes which are malpositioned. In the ICU patient, a chest roentgenogram is required after all feeding tube insertions prior to the initiation of enteral feeding. In the high-risk patient, alternatives to blind feeding tube insertion should be considered.

Journal Article↗

Pathogenesis and prophylaxis of postlaminectomy deformity of the spine after multiple level laminectomy: difference between children and adults.

The pathogenesis of postlaminectomy spinal deformity and instability in children was evaluated by reviewing appropriate roentgenographic findings. First, we reviewed spine roentgenograms of patients below 40 years of age who underwent spinal fusion for deformity and instability of the spine developing after a multiple level laminectomy. Two types of deformity were recognized on the roentgenograms: increased mobility between the vertebral bodies and wedging deformity of the ventral aspect of the vertebral bodies. Second, we did a follow-up study of another group of patients who had undergone laminectomy. We found the same two types of deformity in children, but not in adult patients. The incidence of deformity was higher after laminectomies of the cervical or cervicothoracic region than after lumbar laminectomies. Our data suggest that postlaminectomy spinal deformity can develop in children without irradiation or facet injury. The deformity is due to a wedging change in the cartilaginous portion of the vertebral body and to the viscoelasticity of ligaments in children. When treatment of this complication becomes necessary, anterior fusion may be effective in arresting progression. Prophylactic measures against the development of deformity are discussed. Our hypothesis concerning the mechanism of development of this complication supports the rationale of osteoplastic laminar resection and reconstruction instead of laminectomy, particularly in the management of children.

Adolescent↗

Primary cardiac sarcoma: two case reports.

Two case reports of primary cardiac sarcoma, which is uncommon, are presented. The first case, a 38-year-old male, complained of chest tightness. Chest roentgenograms showed enlargement of the cardiac shadow and left pleural effusion. Transthoracic echocardiography and chest magnetic resonance imaging showed a tumor in the right atrium, and pericardial effusion. The tumor involved the right atrial wall and interatrial septum, and was partially resected. Pathohistological examination revealed angiosarcoma. He died 1 month later. The second case, a 19-year-old male complained of dyspnea and orthopnea. Chest roentgenograms showed pulmonary congestion. Transthoracic echocardiography showed a large mobile mass in the left atrium. An emergency operation was performed and the tumor was totally resected. Pathohistological examination demonstrated leiomyosarcoma. The postoperative course was uneventful, but the tumor rapidly recurred. Second and third operations were performed at intervals of 2 months. After the third operation, he was treated with radiotherapy. Local recurrence was not found but multiple distant metastases were found 2 months after completion of radiation therapy.

Adult↗

The value of flexible bronchoscopy in childhood pulmonary tuberculosis.

The value of 121 flexible bronchoscopy (FB) procedures was evaluated in 54 children, aged three months to 14 years, suspected of having pulmonary tuberculosis. Specimens from FB were culture-positive for Mycobacterium tuberculosis in seven of the 13 bacteriologically confirmed cases. Bronchial abnormalities consistent with the diagnosis were found in 31 of 54 cases. Separate or coexistent findings at initial FB included airway compression (20 cases), granulation tissue (ten cases), and obstructive caseum (four cases). Chest roentgenograms underestimated bronchial involvement in 14 children. Further FB monitoring documented disease evolution. The FB was important in the management of patients, as it (1) guided the use of prednisone therapy, especially in the children with a chest roentgenogram not suggestive of bronchial involvement; (2) indicated a need for resection of granulation tissue by rigid bronchoscopy (three cases); and (3) guided the surgical decision (two children with persistent bronchial obstruction). Thus, FB is a safe and valuable procedure in the management of childhood pulmonary tuberculosis.

Adolescent↗

Atelectatic lung escaping radiation pneumonitis.

An 80-year-old man was admitted to our division because of hemosputum, cough, and chest pain for three months. A chest roentgenogram, chest CT scanning, and bronchoscopic examinations revealed adenocarcinoma of the lung with atelectasis of the right upper lobe. The patient developed radiation pneumonitis after receiving radiation therapy (5,100 cGy) for lung cancer. At the same time, the right upper lobe atelectasis improved and movement of infiltrates consistent with radiation pneumonitis to the middle lung fields occurred. A chest roentgenogram taken when the atelectasis had improved revealed the absence of pneumonitis shadows in the right upper lobe, suggesting that the atelectatic lung escaped radiation pneumonitis.

Aged↗

Long-term outcome of pediatric sarcoidosis with emphasis on pulmonary status.

Sixty-one pediatric and adolescent patients (age < or = 16 years) with sarcoidosis proved by biopsy specimen were identified during the period 1957 to 1976; 19 patients with elapsed time from diagnosis of 8 to 35 years (mean, 21 years) were reexamined in 1985. Age at onset of disease ranged from 4 to 16 years (mean, 12.5 years). Sex distribution was equal; 68 percent of individuals were black. At follow-up, clinical evaluation, chest roentgenograms, pulmonary function tests, electrocardiograms (ECGs), echocardiograms (ECHO), and angiotensin-converting enzyme (ACE) activity were performed on each subject. In addition, complete blood cell counts, erythrocyte sedimentation rates, serum calcium, immunoglobulin levels, B- and T-cell enumerations, and intradermal skin tests for delayed hypersensitivity were also obtained. Although all initial pediatric chest roentgenograms were abnormal, at follow-up only 37 percent were abnormal. Pulmonary function test results were available for ten children, and 90 percent were decreased. In 1985, 68 percent of the adults had abnormal lung function; furthermore, eight patients had reduced diffusing capacities, one had hypoxemia, and two had elevated ACE activity. Specific abnormalities were noted on two ECGs and 12 ECHOs. One individual had an elevated sedimentation rate, while another had an increased serum calcium level. Six patients had elevated IgA values, two had elevated IgM values, and two had depressed IgM values; IgG values were normal in all subjects. B- and T-cell percentages were unremarkable in all patients tested. Four individuals were anergic to skin test antigens. Long-term pulmonary morbidity was observed in four patients; in addition, one of these and four others suffered nonpulmonary sequelae. These results are in agreement with those of other investigators, but insufficient data still exist on the long-term effects of sarcoidosis on the pediatric host.

Adolescent↗

Lung cancer in young adults.

OBJECTIVE: To define the basis for the conflicting reports on the prognosis of lung cancer in young adults. DESIGN: Retrospective review of lung cancer patients between 1977 and 1988. SETTING: Medical centers in Chicago (Northwestern Memorial Hospital), northern Israel (Rambam Medical Center), and northern Italy (S. Anna and U. of Pavia Hospitals). PATIENTS: Patients were < or = 45 years of age with a diagnosis of primary lung cancer identified from tumor registry records, pathology reports, and hospital charts, plus a sample of patients > 45 years of age. MEASUREMENTS AND MAIN RESULTS: In Chicago, younger patients had a higher incidence of chest pain, fever, and neurologic symptoms at presentation than the older patients, and fewer were asymptomatic. They also had more lower lobe lesions on chest roentgenogram, a higher incidence of adenocarcinoma, more advanced disease, an increased likelihood of receiving chemotherapy, and reduced survival (p < 0.03). The poorer prognosis was due to more advanced disease at presentation. In Israel, younger patients more frequently presented with stage I disease than the older patients and they had a higher incidence of adenocarcinoma, an increased likelihood of receiving treatment especially surgery, and better survival (p < 0.02). There were no differences between the two age groups for symptoms, symptom duration, and chest roentgenogram findings. Compared with the younger patients in Chicago and Israel, those from northern Italy had more squamous cell cancers and fewer adenocarcinomas, more commonly presented with stage I or II disease, received radiation therapy less frequently, and were given supportive care more often. Survival was low and comparable to that reported from Chicago. CONCLUSION: Differences exist in the clinical characteristics, pathologic findings, and prognosis of younger and older patients with lung cancer from the same region and of younger patients from different regions. The difference in prognosis is related in part to the stage of disease at presentation and the ability to undergo resectional surgery.

Adenocarcinoma↗

Radiologic abnormalities of the sternum in Turner's syndrome.

Various skeletal abnormalities, including chest deformity, have been reported with Turner's syndrome. We report radiologic findings of the sternum on lateral chest roentgenograms in 15 children and adolescents with Turner's syndrome, whose ages ranged between 2 weeks and 20 years. Eight had associated congenital heart disease (CHD). Twelve patients (80 percent) had various sternal abnormalities; 5 had short sternum, 3 had premature fusion of the manubrio-sternal junction, and 4 had premature fusion of the mesosternum. Five had decreased ratio of sternal body to manubrium. Three patients had two ossification centers of the manubrium. Four patients had bowing of the mesosternum; three of these had mild pectus excavatum also. In this series, children with and without CHD had similar sternal abnormalities. Although not pathognomonic, sternal abnormalities on a lateral chest roentgenogram are common skeletal abnormalities associated with Turner's syndrome and are independent of associated CHD. In our series of 15 patients, 10 had monosomy (45,X) on blood karyotype; 7 of them had associated CHD. This is the first systematic analysis of radiologic abnormalities of the sternum in Turner's syndrome and includes findings not previously reported.

Adolescent↗

Pleural plaques and risk for bronchial carcinoma and mesothelioma. A prospective study.

From the general population in the county of Uppsala, Sweden, 1,596 men with pleural plaques fulfilling strict radiologic criteria were identified from 1963 until June 1985. The men have been followed prospectively for 16,369 person-years. The number of mesotheliomas and bronchial carcinomas was compared with the age- and year-specific expected incidence from the official cancer registry of Sweden. Fifty bronchial carcinomas occurred, while 32.1 were expected after correction for smoking habits, a difference which was statistically significant. Patients with radiologic asbestosis were overrepresented among those with bronchial carcinoma. The risk for patients with pleural plaques without asbestosis was increased 1.4 times, which was statistically significant. There were 9 mesotheliomas, while only 0.8 were expected. The mean latency time from first exposure to diagnosis of bronchial cancer was 44.1 years and for mesothelioma was 48.1 years. Thus, pleural plaques on the chest roentgenogram indicate significant exposure to asbestos, with an increased risk for mesothelioma and possibly also for bronchial carcinoma. Any person found to have plaques on chest roentgenogram should be informed of them and should be persuaded to stop smoking.

Adolescent↗

Hypersensitivity studies in popple (Aspen tree) peelers.

In the course of investigation of the relationship between hypersensitivity pneumonitis and the wood industry 45 popple peelers were studied. Four roentgenograms consistent with diffuse lung disease were found. All cases were in examinees who were also dairy farmers. Questionnaires revealed no instance of clinical symptoms of hypersensitivity pneumonitis. Gel immunodiffusion studies were positive to various antigens in eight cases, but no correlation could be made with pulmonary function or chest roentgenogram abnormalities in relation to occupation. Cultures of the wood and the surrounding environment yielded thermophilic fungi as well as other known antigenic material. It is concluded that the occupation of popple peeling does not represent an increased risk of development of hypersensitivity pneumonitis.

Actinomyces↗

Clinical course of 91 consecutive near-drowning victims.

Hospital records of 91 consecutive near-drowning victims were studied retrospectively. Eight-one (89 percent) of these patients survived. Patients who were alert on arrival at the emergency room survived, but those who were comatose and had fixed dilated pupils died. Other states of consciousness were unreliable predictors of survival. All patients with a normal chest roentgenogram on admission survived; however, values for arterial oxygen tension (PaO2) did not necessarily correlate with the chest roentgenograms. Values for arterial blood gas tensions and pH varied widely, as follows; PaO2, 25 to 465 mm Hg; arterial carbon dioxide tension (PaCO2), 17 to 100 mm Hg; pH, 6.77 to 7.50; and arterial bicarbonate level, 6.6 to 29.7 mEq/L. The ratio of PaO2 to the fractional concentration of oxygen in the inspired gas (FIo2), which was calculated to standardize PaO2 data for varying concentrations of inspired oxygen, ranged from 30 to 585 mm Hg. Only one patient with a ratio of PaO2/FIo2 greater than 150 mm Hg on admission subsequently died; this was a neurologic rather than a pulmonary death. Serum electrolytic concentrations and values for hemoglobin level and hematocrit reading neither predicted survival nor indicated that a threat to life existed. Steroid and prophylactic antibiotic therapy did not appear to increase the chance of survival. Observations on these patients are discussed in light of previous experiments in animals, and an approach to therapy is suggested.

Adolescent↗

Pulmonary manifestations in patients with malignant melanoma during BCG immunotherapy. A preliminary report.

Ten patients with malignant melanoma who were treated with bacillus Calmette-Guérin (BCG) were studied with chest roentgenograms, scintiscans with radioactive 67gallium citrate, and the single-breath diffusing capacity of carbon monoxide (Dsb). Three patients (stage 1B) with normal findings had no evidence of progression of disease. Seven patients had abnormal findings on at least one test. Two patients (stage 3B and stage 4B) with focal uptake in the lungs on the scintiscan had metastatic melanoma. Three patients (stage 3B) with diffuse uptake on the scintiscan and a reduced Dsb had no evidence of progression of disease. One patient (stage 1B) with an abnormal chest roentgenogram had a benign pleural effusion, and one patient (stage 4B) with a reduced Dsb was free of melanoma. A diffuse increase in the uptake of radioactive 67gallium in the lungs and a low Dsb may not indicate progression of melanoma. On the other hand, a focal uptake of 67gallium in the lungs is highly suggestive of metastatic disease.

Administration, Oral↗

Necrotizing sarcoid granulomatosis.

Twelve cases of necrotizing sarcoid granulomatosis are presented as a retrospective study. The population of patients consisted of ten women and two men, with an average age of 50 years. Nine patients initially had a variety of pulmonary and nonpulmonary complaints, while three were asymptomatic. Chest roentgenograms demonstrated bilateral nodules in seven patients, solitary nodules in four, and a miliary pattern progressing to nodules in one. Enlarged hilar nodes were found in six. Histologically, all biopsies showed a combination of individual granulomas, confluent masses of granulomas which formed the nodular masses seen on the roentgenograms, a variable amount of necrosis of tissue and hyalinization, and a granulomatous vasculitis. Follow-up periods ranged from four months to 11 years. Eleven patients are alive and asymptomatic. The sole death occurred in a patient treated with an immunosuppressive agent (cyclophosphamide). We conclude that the clinical behavior of necrotizing sarcoid granulomatosis is not similar to that of the other angiocentric granulomatoses and that most patients with this disease can be left untreated or be treated with steroids alone. We suggest the possibility that necrotizing sarcoid granulomatosis may be the histologic counterpart of so-called nodular sarcoid.

Adult↗

Sarcoidosis in Japanese and American children.

A study of sarcoidosis among Japanese and American children suggests that there are more than the previously suspected number of children with asymptomatic sarcoidosis. The annual chest roentgenogram in Japanese school children detected the majority of these cases, while in the United States, where the annual chest roentgenogram is not required, the majority of children had sarcoidosis diagnosed through symptomatic complaints.

Adolescent↗

Hematogenous staphylococcal pneumonia secondary to soft tissue infection.

Staphylococcal pneumonia is rare, has a high mortality and morbidity rate, and occurs commonly during influenza epidemics (airborne) or during the course of right sided bacterial endocarditis in drug addicts (blood borne). In recent years, much emphasis has been given to the staphylococcal infections in intravenous drug abusers. This report describes ten patients with staphylococcal pneumonia resulting from soft tissue infection who were previously healthy and had no history of drug abuse. They were 12 to 45 years old. Eight were male patients. Soft tissue infection was community-acquired in nine and was most commonly located in the lower extremities. Three patients had diabetes. All presented with a clinical picture of acute pneumonia. Hemoptysis occurred in three. Chest roentgenogram showed multiple large or small round discrete densities in most of the patients. Lobar involvement was notably absent. Eight developed cavitary lesions in their lungs. The average length of hospital stay was 40 days. One patient died and six developed complications. Staphylococcal etiology should be suspected in patients with acute pneumonia who have soft tissue infection or have characteristic chest roentgenogram findings; antistaphylococcal agents should be included in the therapeutic regimens of such patients until the results of the cultures are known.

Adolescent↗

Chronic lung damage caused by adenovirus type 7: a ten-year follow-up study.

Twenty-seven children aged 0.6 to 7.0 (mean 2.1) years were admitted to the hospital in 1967 and 1968 with type 7 adenoviral pneumonia. All ran a prolonged course. Type 7 adenovirus was isolated from 14 children, and in the other 13, the rise in the titer of complement-fixing antibodies to adenovirus was fourfold or greater. The outcome of the disease in these 27 children was reassessed in 1979, 9.6 to 12.1 (mean 10.7) years after the adenovirus type 7 pneumonia. Twenty-two were examined clinically and roentgenographically and all had lung function tests. Twelve had abnormal chest roentgenograms, and of these, six had bronchiectasis. Six of the ten children with normal chest x-ray films and ten of the 12 with abnormal chest roentgenograms had abnormal pulmonary function tests. Of the six patients with bronchiectasis, four showed no discernible cause of bronchiectasis other than the antecedent type 7 adenoviral infection. The other two patients had bronchial asthma, which can be a risk factor for bronchiectasis.

Acute Disease↗

Management of spontaneous pneumothorax with small lumen catheter manual aspiration.

We reviewed the case histories and roentgenograms of 50 patients with spontaneous pneumothorax who underwent small lumen catheter aspiration. The results were analyzed with regard to the presence or absence of preexisting lung disease. Patients with no history of previous lung disease and no roentgenogram abnormality other than the pneumothorax had a 66 percent chance of successful reinflation using the technique of manual aspiration described here. Patients with evidence of tension pneumothorax, bullae, pleural adhesions, and active tuberculosis were treated unsuccessfully. None of the patients experienced any complication from this procedure. Our results indicate that many patients with spontaneous pneumothorax may be quickly and successfully treated with small lumen catheter manual aspiration.

Adolescent↗