Evaluation of various patient-, lesion-, and procedure-related factors on the occurrence of pneumothorax as a complication of CT-guided percutaneous transthoracic needle biopsy

Purpose: To assess the influence of various patient-, lesion-, and procedure-related variables on the occurrence of pneumothorax as a complication of CT-guided percutaneous transthoracic needle biopsy. Material and methods: In a total of 208 patients, 215 lung/mediastinal lesions (seven patients were biopsied twice) were sampled under CT guidance using coaxial biopsy set via percutaneous transthoracic approach. Incidence of post procedure pneumothorax was seen and the influence of various patient-, lesion-, and procedure-related variables on the frequency of pneumothorax with special emphasis on procedural factors like dwell time and needle-pleural angle was analysed. Results: Pneumothorax occurred in 25.12% (54/215) of patients. Increased incidence of pneumothorax had a statistically significant correlation with age of the patient (p = 0.0020), size (p = 0.0044) and depth (p = 0.0001) of the lesion, and needle-pleural angle (p = 0.0200). Gender of the patient (p = 0.7761), emphysema (p = 0.2724), site of the lesion (p = 0.9320), needle gauge (p = 0.7250), patient position (p = 0.9839), and dwell time (p = 0.9330) had no significant impact on the pneumothorax rate. Conclusions: This study demonstrated a significant effect of the age of the patient, size and depth of the lesion, and needle-pleural angle on the incidence of post-procedural pneumothorax. Emphysema as such had no effect on pneumothorax rate, but once pneumothorax occurred, emphysematous patients were more likely to be symptomatic, necessitating chest tube placement. Gender of the patient, site of the lesion, patient position during the procedure, and dwell time had no statistically significant relation with the frequency of post-procedural pneumothorax. Surprisingly, needle gauge had no significant effect on pneumothorax frequency, but due to the small sample size, non-randomisation, and bias in needle size selection as per lesion size, further studies are required to fully elucidate the causal relationship between needle size and post-procedural pneumothorax rate. The needle should be as perpendicular as possible to the pleura (needle-pleural angle close to 90°), to minimise the possibility of pneumothorax after percutaneous transthoracic needle biopsy

The spectrum of imaging findings in pulmonary hydatid disease and the additive value of T2-weighted magnetic resonance imaging in its diagnosis

Purpose: To describe the spectrum of imaging findings in pulmonary echinococcosis and to study the additive value of T2-weighted magnetic resonance imaging (MRI) in the characterisation of pulmonary hydatid disease. Material and methods: This was a descriptive, prospective study conducted for a period of 3 years from December 2016 to November 2019. Patients suspected of having pulmonary echinococcosis (n = 110) on preliminary chest radiography were examined with chest computed tomography (CT). Among them 41 cases were additionally examined with T2-weighted MRI of thorax. Final diagnosis was based on surgery or histopathology. Results: Of the 110 patients enrolled for the study 15 were lost to attrition, and among the final cohort of 95 patients CT correctly diagnosed 68/84 (80.9%) as hydatid cyst, whereas 16/84 (19.1%) received an erroneous alternate diagnosis on CT. Based on the classical findings of hyperintense pulmonary cystic lesion with T2-weighted hypointense rim or detached internal T2-weighted hypointense membrane, a correct diagnosis of hydatid cyst was possible in 30 patients whereas a correct alternate diagnosis was made in 8 cases. T2-weighted MRI was found to have sensitivity of 96.7%, specificity of 80%, positive predictive value (PPV) of 93.7% and negative predictive value (NPV) of 88.9% with an overall diagnostic accuracy of 92.6%. Using the McNemar test, MRI was found to be diagnostically superior to CT (p = 0.019). Conclusions: Most of the pulmonary hydatid cysts can be diagnosed on CT; however, sometimes the findings may be indeterminate or atypical, leading to a diagnostic dilemma. MRI, owing to its ability to demonstrate hypointense endocyst, can act as a useful adjunct to correctly diagnose hydatid cyst or suggest an alternative diagnosis

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions. Funding: Bill & Melinda Gates Foundation

Pseudoaneurysm of mitral-aortic intervalvular fibrosa in a child: Demonstration by MDCT and MRI

Subaortic left ventricular outflow tract pseudoaneurysms are rare lesions that are associated with aortic valve diseases, infective endocarditis, trauma or surgery. We present dynamic multidetector computerized tomography and cine magnetic resonance imaging features of a case of subaortic aneurysm arising from interaortic-mitral valvular region in a child with past history of infective endocarditis

Role of Diffusion-Weighted and Chemical Shift Magnetic Resonance Imaging in Differentiation of Benign and Malignant Spinal Fractures

Atraumatic spinal compression fractures are common clinical problem. Differentiating benign osteoporotic fractures from pathological fractures due to malignant/metastatic lesions affects the management and prognoses in patients with known extraspinal malignancy.    The objective of the research was to assess the role of conventional magnetic resonance imaging sequences with diffusion-weighted imaging and chemical-shift imaging in differentiating benign and malignant acute spinal compression fractures. Materials and Methods. The study included 40 patients with acute spinal compression fractures. Patients were evaluated using magnetic resonance imaging with diffusion-weighted imaging and chemical-shift imaging to differentiate benign etiology from malignant one. The results obtained were compared with histopathological follow-up for 6 months for definite clinical diagnoses. Results. No significant difference was noted in signal characteristics of benign and malignant fractures on T1, T2 and short-tau inversion recovery. However, posterior element involvement, soft tissue component and post-contrast enhancement were seen more frequently in malignant fractures (p<0.05). On diffusion-weighted images, 77.8% of malignant fractures were hyperintense and 59.1% of benign fractures were hypointense (p<0.05). The mean apparent diffusion coefficient value was 0.81 ± 0.19 for malignant and 1.24 ± 0.24 for benign fractures (p<0.5). The mean signal intensity ratio for malignant fractures was 0.91 ± 0.125, whereas the signal intensity ratio for benign fractures was 0.64 ± 0.096 (p<0.001). Conclusions. Signal characteristics on T1, T2 and short-tau inversion recovery sequences do not differentiate benign from malignant fractures; however, posterior element involvement, soft tissue and post contrast enhancement help in differentiating the etiology. Diffusion-weighted imaging and apparent diffusion coefficient values, as well as using chemical shift imaging further improve the diagnostic accuracy of magnetic resonance imaging

High resolution B Mode ultrasound of common carotid artery in evaluation of atherosclerosis in patients of rheumatoid arthritis.

Research Question: Can atherosclerotic changes be detected using b mode ultrasound. (Carotid Doppler) Objectives: The aim of our study was 1) to confirm the presence of atherosclerosis in patients of rheumatoid arthritis; 2) Role of high resolution B mode ultrasound Doppler to assess the existence of atherosclerosis in RA patients, measuring the intima-medial thickness (IMT) of the common carotid arteries; and 3) Role of inflammation in development of atherosclerosis in absence of traditional risk factors. Study Design: Hospital based cross-sectional case control study. Methods: Carotid IMT was measured using high-resolution B-mode ultrasound in 40 patients with RA and 20 age- and sex-matched healthy controls. Serum total cholesterol, serum triglycerides, rheumatoid factor, body mass index (BMI) was determined. ESR, C-reactive protein (CRP) were used to measure systemic inflammation. DAS 28 was used to measure disease activity and x ray hands were used to determine erosions for bone damage. Results: Common carotid IMT were significantly higher (p=0.0000) in RA patients (0.61±0.02) compared with controls (0.45±0.07). In RA patients common carotid IMT significantly correlated with serum triglycerides (p=0.037), and ESR (p=0.034). No significant correlation was found with other clinical and laboratory parameters reflecting disease activity. Significant positive correlation was observed with use of non steroidal anti inflammatory drugs and use of ayurvedic drugs. Conclusions: Our results confirm an accelerated atherosclerosis, as shown by increased common carotid IMT, in patients with RA compared with controls even in the absence of traditional risk factors. There is definite role of inflammation in development of atherosclerosis in these patients. High-resolution B-mode ultrasound may be considered a promising, sensitive, non invasive, and cost effective tool for assessing the existence of atherosclerosis in RA patients

64-slice CT imaging in a case of total anomalous pulmonary venous circulation

For long, catheter angiography has been the investigation of choice for the diagnosis of congenital anomalies of the heart such as total anomalous pulmonary venous circulation (TAPVC). In the last few years, MRI and multislice CT scan have also been introduced for this purpose. We report a case where 64-slice CT scan was found very useful in the evaluation of TAPVC