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Drug deposition in the peripheral airways has been reported to differ between pressurized metered dose inhalers (pMDIs) and dry powder inhalers (DPIs). This study was conducted to determine the drug deposition fraction from three inhaled corticosteroids/long-acting β2-agonists (ICS/LABA) combination products for inhalation in the peripheral airways. An airway deposition model was constructed using computed tomography (CT) images obtained in patients with asthma. Functional respiratory imaging was used to determine the airway deposition of Flutiform® (Kyorin Pharmaceutical), Symbicort® (AstraZeneca and Astellas Pharma), and Relvar® (GlaxoSmithKline K.K.) without actual drug inhalation based on airway images from CT and computational fluid dynamics using drug particle size. The mean drug deposition fractions and standard deviations (SDs) in the peripheral airways for Flutiform, Symbicort, and Relvar were 30.33% ± 1.89%, 18.95% ± 2.03%, and 6.58% ± 0.98% for ICS, and 29.17% ± 1.81%, 17.24% ± 1.87%, and 11.30% ± 1.42% for LABA, respectively, showing that significantly higher proportions of ICS and LABA were deposited to the peripheral airways from Flutiform than from Symbicort and Relvar (p

Purpose: To identify the normal performance of left ventricular (LV) regional contraction using cine MR imaging with presaturation myocardial tagging. Material and Methods: Sixteen normal volunteers were examined on a 1.5 T MR system with tagging cine sequences. Tags were applied at end-diastole as 2 parallel black lines on short-axis and 4-chamber sections, and the fractional shortenings were calculated at 7 LV locations. Results: The following results were obtained with significance: a transmural gradient of contractility in the short-axis section; prolonged late-systolic endocardial shortening and epicardial early termination in the free wall; initial delay of shortening in the anterior wall; apical predominance of contractility; predominance of circumferential shortening in the free wall and of meridional shortening in the septum. These findings could be associated with myocardial fiber architecture, presumed wall stress and temporal asynergy of excitation. Conclusion: Cine MR imaging with myocardial tagging proved to be useful in assessing the nonuniformity of LV contraction.

Purpose: The clinical usefulness of an advanced image-processing system called “dynamic range control processing” was investigated, with which selected parts of the dynamic range of digital chest images could be controlled. Material and Methods: A comparative study of 3 different post-processed formats of storage phosphor (SR) images was performed in 35 patients with abnormalities in the chest. The 3 formats were SR images with standard mode (SR-standard), SR images with strong edge-enhancement (SR-enhanced), and dynamic range controlled SR images (SR-controlled). Results: For lung abnormalities, there was no difference among the 3 SR image formats. For normal mediastinal structures and lung abnormalities covered by the heart or diaphragm, SR-controlled and SR-enhanced images were significantly superior to SR-standard images, while no difference was found between SR-controlled and SR-enhanced images except for the trachea and bony structures. Conclusion: Dynamic range control processing appears to be a useful method for displaying SR chest images with an extremely wide dynamic range.

Chondrosarcomas are the most frequently occurring primary malignant chest wall tumors. Furthermore, the lungs serve as the most frequent sites for metastases. Pulmonary metastases from sarcomas usually appear as round nodules of varying sizes on roentgenograms. Here, we report an unusual clinical and radiographic presentation of pulmonary metastasis from a costal chondrosarcoma. Bilateral pulmonary metastases developed soon after wide surgical resection. Thoracic computed tomography revealed unusual radiological findings: consolidation accompanied with ground-glass opacity. To confirm the metastasis, we recommend a transbronchial biopsy in cases where unusual pulmonary findings are detected.

The serial computed tomography findings and prognosis of the acute exacerbation of idiopathic pulmonary fibrosis (IPF) are not yet well defined in a larger number of cases.To evaluate the parenchymal abnormalities and prognosis using high-resolution computed tomography (HRCT) in acute exacerbation of IPF.The study consisted of clinical, laboratory, and HRCT data before and at the time of acute exacerbation in 64 episodes of 58 patients with IPF. A semiquantitative analysis of overall extent of parenchymal abnormalities, extent of alveolar opacity (ground-glass attenuation and consolidation), and extent of fibrotic opacity (reticulation and honeycombing) on CT was performed by two chest radiologists. The newly appeared parenchymal abnormalities were also classified into three patterns: peripheral, multifocal, and diffuse.In all patients, HRCT scans taken at the exacerbation showed typical signs of IPF and newly developing alveolar opacity. They included 34 patients of peripheral pattern, 8 of multifocal pattern, and 16 of diffuse pattern. Twenty-five patients died and 33 survived after the initial exacerbation. Worse survival was associated with patients with diffuse type compared with patients with multifocal and peripheral type. The CT patterns and overall CT extent were associated with an increased hazard of death after adjusting for age, sex, smoking, baseline diffusion capacity for carbon monoxide, baseline FVC, and disease extent on CT. On multivariate analysis, the strongest correlations were observed between CT patterns (combined diffuse and multifocal versus peripheral) and survival (odds ratio, 4.629; 95% confidence interval, 1.900-11.278; P = 0.001).HRCT extent and patterns are predictive of survival in acute exacerbation of IPF.

Nine patients with dural arteriovenous malformations (AVMs) in the region of the cavernous sinus were treated by means of external carotid artery (ECA) embolization using polyvinyl alcolhol. All AVMs received vascular supply from both the ECA and the internal carotid artery. Seven cases were clinically cured after embolization, while 2 cases with cortical venous drainage and high flow through the shunt were not completely cured. Venous thrombosis was observed in 5 cases before and in 9 after embolization. In 6 cases the drainage pattern changed owing to venous thrombosis. Complete thrombosis of the cavernous sinus was found on a follow-up angiography in 2 cases. Formation of venous thrombosis and occlusion of feeding arteries are crucial factors for success of ECA embolization. Dural AVMs with cortical venous drainage and high flow cannot be relieved by ECA embolization alone owing to difficulty in obtaining thrombosis of the veins.

OBJECTIVE--To assess the effect of the condition of the right heart after the Fontan operation on portal venous flow, and to determine whether the characteristics of portal venous flow were different when there was an atriopulmonary connection with atrial septal closure rather than an atriopulmonary or total cavopulmonary connection with intra-atrial routing. PATIENTS AND METHODS--After the Fontan operation six patients with an atriopulmonary connection (group 1), three patients with an atriosubpulmonary connection (group 2), four patients with intra-atrial routing and an atriopulmonary connection (group 3), and five patients with a total cavopulmonary connection (group 4) were studied by pulsed Doppler echocardiography. The flow signals were recorded for the pulmonary artery, hepatic vein, and intrahepatic portal vein in each patient. Postoperative cardiac catheterisation was performed in 16 of the 18 patients. The Doppler findings were compared with those of 14 controls. RESULTS--The portal flow was pulsatile in 13 patients and constant in five patients. Reversed flow was shown at or just after the QRS wave after hepatic venous regurgitation in two group 1 patients. The flow signal was interrupted in two group 1 patients and two group 2 patients. Decrease in velocity of flow was recorded in two group 1 patients, one group 2 patients, three group 3 patients, and one group 4 patient. Portal flow was constant in one group 3 patient and four group 4 patients. The pulsatility ratio ranged from -0.46 to 0.49 (mean (SD), 0.03 (0.32)) in the patients from group 1 and 2, from 0.41 to 0.76 (0.54 (0.15)) in group 3, and from 0.70 to 0.80 (0.75 (0.04)) in group 4. The ratio in the controls ranged from 0.29 to 0.83 (0.61 (0.13)). The ratio was significantly lower in groups 1 and 2 than in group 3 (p < 0.01), group 4 (p < 0.01), or the controls (p < 0.005). There was no significant difference in the ratio between group 3 and group 4 and no correlation between the pulsatility ratio and the cardiac index (r = 0.26), mean right atrial pressure (r = 0.25), or pulmonary vascular resistance (r = 0.17). CONCLUSION--The larger hepatic venous regurgitation caused by atrial contraction in patients with an atriopulmonary connection correlated with the higher portal pulsatility and a total cavopulmonary connection reduced portal pulsatility.

To establish clearly the pathologic basis for small low-intensity nodules seen on MR images of the cirrhotic liver, we obtained MR images in 26 patients with cirrhosis in whom partial hepatectomy for hepatoma (15 patients), laparoscopy for cirrhosis (10 patients), or autopsy (one patient) was subsequently performed. Small low-intensity nodules were seen on gradient-echo images with short TEs (10-13 msec) in 13 of the 26 patients. In 12 of these 13 patients, small low-intensity nodules appeared larger and clearer as the TE was prolonged (14-25 msec). On T2-weighted spin-echo images, small low-intensity nodules were seen in 12 of the 13 patients, but not seen as well as on gradient-echo images. Pathologic correlation in these 13 patients revealed that the nodules on the MR images corresponded to iron deposits in regenerating nodules. Small low-intensity nodules were observed only on T2-weighted spin-echo images in two of the remaining 13 patients, in whom microscopic examination of the liver revealed marked inflammatory cell infiltration in the fibrous septa and no iron deposition. We conclude that small low-intensity nodules observed on MR images are caused by iron deposits in regenerating nodules, and that gradient-echo images with short and prolonged TEs are useful to confirm the presence of iron deposits in regenerating nodules.

The article describes a new method for computed tomographic arteriography (CTA) of hepatocellular carcinoma (HCC) using a balloon occlusion catheter in 8 patients. Our dynamic study indicated that: 1) a bolus injection of contrast medium with our method of CTA (CTA-B) produced an attenuation difference between liver and tumor which was about double that obtained with standard methods for CTA, and 2) marked tumor-liver attenuation differences (above 20 HU) persisted for more than 60 s in CTA-B and for not more than 20 s with conventional methods for CTA. The results show that CTA-B is superior to standard methods in enabling multiple scans of the liver during greater and prolonged differential tumor enhancement after administration of a bolus of contrast medium. In conjunction with table incrementation, CTA-B allows scanning of the entire liver at the time of maximal contrast enhancement with two to three injections of contrast medium. Two patients complained of abdominal pain during balloon inflation. No other complications were observed.

To determine the most appropriate radiographic approach to parotid tumors, computed tomography (CT) was performed in 65 patients with 33 benign tumors, 19 malignant tumors, 3 abscesses and 10 other lesions with a clinical appearance of tumor. In 22 of the 65 cases CT-sialography and in 26 ultrasonography (US) were also performed. The mass was well recognized on CT without sialography in all patients, and the lesion was also well evaluated in all those examined with US. At CT-sialography the tumor was well shown, but this method made it difficult to differentiate a benign from a malignant lesion, because the character of the delineation and the border of the tumor were difficult to evaluate. It is concluded that US and CT without sialography are satisfactory for evaluating the parotid tumor, and the indication for CT-sialography is limited to those cases in which the tumor is demonstrated on US, but is unclear on conventional CT.

Single-photon emission CT (SPECT) was performed with technetium-99m autologous RBCs in 11 patients with chronic hepatitis and in 46 cirrhotic patients with portal hypertension to determine the value of the procedure for identifying portosystemic collateral blood flow. Twenty millicuries (740 MBq) of 99mTc-RBCs, labeled by an in vivo technique, were given IV, and tomographic imaging of the intraabdominal vascular blood pool was performed. Fourteen patients with cirrhosis also had arterial portography, and 37 had scintiphotosplenoportography. In 38 of 46 patients with cirrhosis, SPECT images showed portosystemic collaterals. The coronary vein was seen in 52% of the patients, the short gastric vein in 11%, the gastrorenal or splenorenal shunt in 24%, the umbilical vein in 11%, and the anterior abdominal wall vein in 17%. Portosystemic collaterals were not shown in any of the patients with chronic hepatitis. Collaterals were identified on SPECT images in 10 of 11 patients in whom collaterals were documented by arterial portography and in all 28 patients in whom collaterals were shown by scintiphotosplenoportography. Furthermore, SPECT clearly showed a patent portal vein in three patients and the coronary vein in two patients, when these veins were not identified by means of scintiphotosplenoportography. This experience suggests that SPECT is useful for the noninvasive identification of portosystemic collaterals in patients with portal hypertension.

The morphology of the common atrioventricular valve and its relation to the ventricles was assessed by cross sectional echocardiography in 17 patients with atrial isomerism--four with left isomerism and 13 with right isomerism. In 13 patients the atrioventricular valve consisted of four leaflets: a large anterosuperior leaflet, two lateral leaflets, and a posteroinferior leaflet. The remaining four patients had two anterosuperior leaflets. Five patients had hearts with a double inlet right ventricle and all of them had a rudimentary left ventricle. All the commissures were attached to the right ventricle. Five patients showed severe right ventricular dominance. The atrioventricular morphology in these five hearts differed from that in the patients with the usual atrial arrangement, concordant atrioventricular connection, and hypoplasia of the left ventricle. Only the anterosuperior leaflet bridged the rudimentary left ventricle, and the posteroinferior leaflet was tethered to the ventricular septal crest. Six patients had a biventricular atrioventricular connection and two of them showed mild right ventricular dominance. The atrioventricular morphology in these hearts was the same as that seen in the patients with usual atrial arrangement and a concordant atrioventricular connection. The remaining patient showed dominance of the left ventricle. Only the anterosuperior leaflet bridged the rudimentary right ventricle in this heart.

A patient with hemangioendothelioma is described, who developed a metastatic pulmonary nodule, subsequently a bullous lesion contiguous to the nodule, and finally spontaneous pneumothorax. In such cases, newly formed bullous lesions may conceal originally visible metastatic foci and can be a potential source of spontaneous pneumothorax.