Impostor phenomenon: Prevalence among 1st year medical students and strategies for mitigation

Impostor phenomenon (IP) is described as a pattern typified by doubting one's accomplishments and a persistent fear of being exposed as a fraud. These feelings of self-doubt are pervasive along the medical education continuum, beginning with medical students where IP has been associated with emotional stress, physical exhaustion, depression, and anxiety. We, therefore, conducted an interactive workshop with first-year medical students to educate them about the manifesting patterns and risk factors of IP and strategies to mitigate these feelings. The 60-min workshop began with participants voluntarily completing the Young Imposter Scale (YIS) followed by an interactive presentation that reviewed the literature related to IP and its prevalence in medicine. Participants were then assigned to small groups where they discussed three cases of IP in academia and the medical profession. Medical school faculty acted as facilitators and utilized pre-designed prompt questions to stimulate discussion. Students re-convened for a large group report out, where each group shared main discussion points. The session ended with facilitators discussing IP mitigation strategies that can be implemented at the individual, peer, and institutional levels. Participants were also invited to complete a post-workshop evaluation. Fifty first-year medical students participated in the session. A total of 49 (96 %) completed the YIS and post-workshop evaluation. Nineteen (40 %) participants obtained scores on the YIS to indicate a positive finding of IP. The percentage of female medical students meeting the threshold for IP was significantly higher (84 %, n = 41 vs 16 %, n = 7) than male medical students. The workshop was effective at identifying IP and associated risk factors and providing mitigation strategies, with 95.8 % of participants agreeing or strongly agreeing. In qualitative feedback, participants reported that the workshop was "very interactive", "provided strategies to manage impostor syndrome" and "helped me become more vulnerable with my peers." This workshop provided a novel interactive and effective method to increase medical students' awareness about IP which can be employed as a strategy to enhance student's wellness.

Effect of comorbidity and multimorbidity on adherence to follow-up recommendations among long-term breast cancer survivors

OBJECTIVES

To study the impact of comorbidities, multimorbidity, and multimorbidity clusters on adherence to recommended follow-up guidelines among long-term breast cancer survivors.

STUDY DESIGN

Retrospective cohort study based on 2078 women diagnosed with breast cancer from 2000 to 2006 and followed up from 2012 to 2016.

MAIN OUTCOME MEASURES

Adherence to breast cancer follow-up recommendations (annual medical visit and imaging) was determined. Comorbidities were classified as acute/chronic. Multimorbidity was defined as the presence of two or more chronic comorbidities aside from breast cancer. Five multimorbidity clusters were considered. Multivariate logistic regression models were fitted to determine the relationship between adherence to recommendations and the presence of comorbidities and multimorbidity, considering both sociodemographic and clinical characteristics.

RESULTS

Overall adherence to recommendations was 79.5 %. Adherence was lower among long-term breast cancer survivors with no comorbidities (75.8 %). Among multimorbidity clusters, adherence was highest in the anxiety and fractures cluster (84.3 %) and was lowest in the musculoskeletal and cardiovascular cluster (76.4 %). In adjusted multivariate models, multimorbidity was associated with higher levels of adherence (OR = 1.52 95 %CI 1.16-1.99), and adherence was highest in the metabolic and degenerative cluster (OR = 2.2 95 %CI 1.4-3.5).

CONCLUSION

Adherence to follow-up recommendations was higher among long-term breast cancer survivors with multimorbidity than among those without. Adherence also differed by multimorbidity cluster. These results suggest suboptimal adherence to the current follow-up recommendations in certain groups, suggesting the need to adapt clinical practice guidelines to reflect patients' comorbidities and different characteristics.

Hybrid Magnetic Resonance Positron Emission Tomography Is Associated With Cardiac-Related Outcomes in Cardiac Sarcoidosis

BACKGROUND

Imaging with late gadolinium enhancement (LGE) magnetic resonance (MR) and 18F-fluorodeoxyglucose (18F-FDG) PET allows complementary assessment of myocardial injury and disease activity and has shown promise for improved characterization of active cardiac sarcoidosis (CS) based on the combined positive imaging outcome, MR(+)PET(+).

OBJECTIVES

This study aims to evaluate qualitative and quantitative assessments of hybrid MR/PET imaging in CS and to evaluate its association with cardiac-related outcomes.

METHODS

A total of 148 patients with suspected CS underwent hybrid MR/PET imaging. Patients were classified based on the presence/absence of LGE (MR+/MR-), presence/absence of 18F-FDG (PET+/PET-), and pattern of 18F-FDG uptake (focal/diffuse) into the following categories: MR(+)PET(+)FOCAL, MR(+)PET(+)DIFFUSE, MR(+)PET(-), MR(-)PET(+)FOCAL, MR(-)PET(+)DIFFUSE, MR(-)PET(-). Further analysis classified MR positivity based on %LGE exceeding 5.7% as MR(+/-)5.7%. Quantitative values of standard uptake value, target-to-background ratio, target-to-normal-myocardium ratio (TNMRmax), and T2 were measured. The primary clinical endpoint was met by the occurrence of cardiac arrest, ventricular tachycardia, or secondary prevention implantable cardioverter-defibrillator (ICD) before the end of the study. The secondary endpoint was met by any of the primary endpoint criteria plus heart failure or heart block. MR/PET imaging results were compared between those meeting or not meeting the clinical endpoints.

RESULTS

Patients designated MR(+)5.7%PET(+)FOCAL had increased odds of meeting the primary clinical endpoint compared to those with all other imaging classifications (unadjusted OR: 9.2 [95% CI: 3.0-28.7]; P = 0.0001), which was higher than the odds based on MR or PET alone. TNMRmax achieved an area under the receiver-operating characteristic curve of 0.90 for separating MR(+)PET(+)FOCAL from non-MR(+)PET(+)FOCAL, and 0.77 for separating those reaching the clinical endpoint from those not reaching the clinical endpoint.

CONCLUSIONS

Hybrid MR/PET image-based classification of CS was statistically associated with clinical outcomes in CS. TNMRmax had modest sensitivity and specificity for quantifying the imaging-based classification MR(+)PET(+)FOCAL and was associated with outcomes. Use of combined MR and PET image-based classification may have use in prognostication and treatment management in CS.

Improving the Access of Highly Sensitized Patients to Kidney Transplantation From Deceased Donors: The Spanish PATHI Program With Allocation Based on the Virtual Crossmatch

BACKGROUND

In 2015, the Spanish National Transplant Organization developed a prioritization system (Program for Access to Transplantation for Highly Sensitized Patients [PATHI]) to increase transplant options for patients with calculated panel-reactive antibodies (cPRAs) ≥98%, based on virtual crossmatch. We describe the experience with the implementation of PATHI and assess its efficacy.

METHODS

PATHI registry was used to collect characteristics of donors and patients between June 15, 2015, and March 1, 2018. One-year graft and patient survival and acute rejection were also measured. A Cox model was used to identify factors related to patient death and graft loss and logistical regression for those associated with rejection.

RESULTS

One thousand eighty-nine patients were included, and 272 (25%) were transplanted. Transplant rate by cPRA was 54.9%, 40.5%, and 12.8% in patients with cPRA98%, cPRA99%, and cPRA100%, respectively. One-year patient survival was 92.5%. Recipient age ≥60, time under dialysis >7 y, and delayed graft function were mortality risk factors. One-year graft survival was 88.7%. The factor related to graft loss was delayed graft function. The rejection rate was 22%. Factors related to rejection were sex, older recipients, and posttransplant donor-specific antibodies.

CONCLUSIONS

A prioritization approach increases transplant options for highly sensitized patients with appropriate short-term postransplant outcomes. Along with other programs, PATHI may inspire other countries to adopt strategies to meet transplant needs of these patients.

Establishing quantitative radiographic criteria for the diagnosis of pleuroparenchymal fibroelastosis

PURPOSE

Pleuroparenchymal Fibroelastosis (PPFE) is a type of pulmonary fibrosis most commonly occurring at the apices. Patients with PPFE have an increased risk of adverse effects from lung biopsy and in the post-surgical setting. Here, we investigated simple and reproducible measurements on chest CT to evaluate their predictive value in diagnosing PPFE.

METHODS

We analyzed a cohort of patients with histologically-proven PPFE and compared them to a cohort of patients diagnosed with "biapical scarring" (BAS) on chest CT. We measured plueuroparenchymal thickness using several independent parameters on chest CT. We also assessed other radiologic and clinical characteristics to identify if any were predictive of PPFF.

RESULTS

Our analysis demonstrated the average greatest apical thickness with a cut off of 4.5 mm yielded a sensitivity of 94.4% and a specificity of 88.9%, and an area under the curve of 97.2%. Single greatest apical thickness with a cut off of 7.5 mm had a sensitivity of 100% and a specificity of 88.9%, with the area under the curve of 97.8%. Average greatest upper lobe thickness with a cut off of 8.0 mm had a sensitivity of 88.9% and a specificity of 100%, with an area under the curve of 98.2%. Single greatest upper lobe thickness with a cut off of 8.5 yielded both a sensitivity and specificity of 94.4% and an area under the curve of 94.3%.

CONCLUSION

Measurements described above are highly sensitive and specific for the diagnosis of PPFE and warrant investigation with a larger cohort of patients.

Influence of thoracic radiology training on classification of interstitial lung diseases

INTRODUCTION

Interpretation of high-resolution CT images plays an important role in the diagnosis and management of interstitial lung diseases. However, interreader variation may exist due to varying levels of training and expertise. This study aims to evaluate interreader variation and the role of thoracic radiology training in classifying interstitial lung disease (ILD).

METHODS

This is a retrospective study where seven physicians (radiologists, thoracic radiologists, and a pulmonologist) classified the subtypes of ILD of 128 patients from a tertiary referral center, all selected from the Interstitial Lung Disease Registry which consists of patients from November 2014 to January 2021. Each patient was diagnosed with a subtype of interstitial lung disease by a consensus diagnosis from pathology, radiology, and pulmonology. Each reader was provided with only clinical history, only CT images, or both. Reader sensitivity and specificity and interreader agreements using Cohen's κ were calculated.

RESULTS

Interreader agreement based only on clinical history, only on radiologic information, or combination of both was most consistent amongst readers with thoracic radiology training, ranging from fair (Cohen's κ: 0.2-0.46), moderate to almost perfect (Cohen's κ: 0.55-0.92), and moderate to almost perfect (Cohen's κ: 0.53-0.91) respectively. Radiologists with any thoracic training showed both increased sensitivity and specificity for NSIP as compared to other radiologists and the pulmonologist when using only clinical history, only CT information, or combination of both (p < 0.05).

CONCLUSIONS

Readers with thoracic radiology training showed the least interreader variation and were more sensitive and specific at classifying certain subtypes of ILD.

SUMMARY SENTENCE

Thoracic radiology training may improve sensitivity and specificity in classifying ILD based on HRCT images and clinical history.

Interstitial lung disease diagnosis and prognosis using an AI system integrating longitudinal data

For accurate diagnosis of interstitial lung disease (ILD), a consensus of radiologic, pathological, and clinical findings is vital. Management of ILD also requires thorough follow-up with computed tomography (CT) studies and lung function tests to assess disease progression, severity, and response to treatment. However, accurate classification of ILD subtypes can be challenging, especially for those not accustomed to reading chest CTs regularly. Dynamic models to predict patient survival rates based on longitudinal data are challenging to create due to disease complexity, variation, and irregular visit intervals. Here, we utilize RadImageNet pretrained models to diagnose five types of ILD with multimodal data and a transformer model to determine a patient's 3-year survival rate. When clinical history and associated CT scans are available, the proposed deep learning system can help clinicians diagnose and classify ILD patients and, importantly, dynamically predict disease progression and prognosis.

Idiopathic pulmonary fibrosis and lung cancer: future directions and challenges

Idiopathic pulmonary fibrosis (IPF) is a progressive disease of pulmonary scarring. New treatments slow disease progression and allow pulmonary fibrosis patients to live longer. Persistent pulmonary fibrosis increases a patient's risk of developing lung cancer. Lung cancer in patients with IPF differs from cancers that develop in the non-fibrotic lung. Peripherally located adenocarcinoma is the most frequent cell type in smokers who develop lung cancer, while squamous cell carcinoma is the most frequent in pulmonary fibrosis. Increased fibroblast foci in IPF are associated with more aggressive cancer behaviour and shorter doubling times. Treatment of lung cancer in fibrosis is challenging because of the risk of inducing an exacerbation of fibrosis. In order to improve patient outcomes, modifications of current lung cancer screening guidelines in patients with pulmonary fibrosis will be necessary to avoid delays in treatment. 2-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) computed tomography (CT) imaging can help identify cancer earlier and more reliably than CT alone. Increased use of wedge resections, proton therapy and immunotherapy may increase survival by decreasing the risk of exacerbation, but further research will be necessary.

Coronary computed tomography angiography improves coronary risk prediction in general population

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Carlos III Health Institute and the European Regional Development FundAgency for Management of University and Research Grants

Introduction

In the next decades, it is expected an increasing incidence of acute coronary syndrome in the Spanish population. Identify high-risk patients could be the most cost-effective way to reduce its incidence and morbi-mortality burden. We studied the effect of adding coronary artery calcification (CAC) and the extent of atherosclerotic disease (SIS score) to classical cardiovascular (CV) risk factors in coronary risk prediction.

Methods

This was a prospective cohort study of 325 asymptomatic patients recruited between 2013-2017. Demographic characteristics and CV risk factors were obtained and all participants underwent a coronary computed tomography angiography exam in which CAC and SIS were determined. The cohort was followed-up (median= 4 years) for a composite endpoint that included CV death, myocardial infarction, coronary angiography and/or revascularization. Improvement in discrimination and in reclassification by the inclusion of CAC/SIS in the Framingham-REGICOR function were examined with the Sommer's D index and with the Net reclassification index (NRI) (categorical and continuous), respectively.

Results

Nine of the 251 individuals included in the study had an event in the follow-up. Of the included participants, 94 had a CAC = 0 and 85 a SIS = 0. These participants had no events. The addition of SIS or of SIS and CAC scores to the Framigham-REGICOR risk function increased significantly the discrimination capacity from 0.71 to 0.88 (Table 1). Reclassification measured by the continuous NRI also improved significantly from 69.5 to 112.4/115.5 when SIS or both scores were included (Table 2).

Conclusions

CAC and SIS scores were associated to 4-year CV event incidence, independently of coronary risk estimation. Discrimination and reclassification of the Framigham-REGICOR coronary function were significantly improved by both indexes, but SIS overrode the effect of CAC.

The Role of Radiology in Progressive Fibrosing Interstitial Lung Disease

In this article, we describe the role of radiology for diagnosis and follow-up of progressive fibrosing interstitial lung disease (PF-ILD). Patients with PF-ILD are at increased risk for early death without treatment. Clinical diagnosis of PF-ILD has been described in the literature. This manuscript reviews the radiographic diagnosis of PF-ILD and the unique CT characteristics associated with specific types of fibrosis. Ultimately, we believe that radiology has the potential to recognize progression early and thus make an important contribution to the multidisciplinary discussion for this important diagnosis.

Hypersensitivity pneumonitis: Airway-centered pulmonary fibrosis on chest CT

BACKGROUND

To evaluate the chest CT appearance of patients with a clinicopathologic diagnosis of hypersensitivity pneumonia.

METHODS

IRB approval was obtained for a retrospective review of patients with a preoperative CT scan, a surgical pathology report from a transbronchial biopsy or wedge resection consistent with hypersensitivity pneumonitis, and a pulmonary consultation, which also supported the diagnosis. The pathology report was evaluated for granulomas, airway-centered fibrosis, microscopic honeycombing, and fibroblast foci. The medical records were reviewed for any known antigen exposure. Patients were separated into two groups; those with and without a known antigen exposure. The CT scans were assessed for distribution of fibrosis: upper lobe or lower lobe predominance, airway-centered versus peripheral distribution, three-density pattern, and honeycombing.

RESULTS

264 pathology reports included the term chronic hypersensitivity pneumonitis (CHP). Thirty-eight of the patients had a pulmonologist who gave the patient a working diagnosis of CHP. The average age of these patients was 64 years, and 21/38 were women. Seventeen of the 38 patients had at least one antigen exposure described in the medical records. All the patients had fibrosis along the airways on chest CT. Both known antigen exposure and no known antigen patients had upper and lower lung-predominant fibrosis. There were more patients with hiatal hernias in the unknown antigen group. Honeycombing was an uncommon finding.

CONCLUSION

Airway-centered fibrosis was present on chest CT in all 38 patients with CHP (100%), with or without known antigen exposure.

Pulmonary Artery 18F-Fluorodeoxyglucose Uptake by PET/CMR as a Marker of Pulmonary Hypertension in Sarcoidosis

OBJECTIVES

This study investigated whether pulmonary artery (PA) ¹⁸F-FDG uptake is associated with hypertension, and if it correlates to elevated pulmonary pressures.

BACKGROUND

¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) combined with computed tomography or cardiac magnetic resonance (CMR) has been used to assess inflammation mostly in large arteries of the systemic circulation. Much less is known about inflammation of the vasculature of the pulmonary system and its relationship to pulmonary hypertension (PH).

METHODS

In a single-center cohort of 175 patients with suspected cardiac sarcoidosis, who underwent hybrid thoracic PET/CMR, ¹⁸F-FDG uptake in the PA was quantified according to maximum standardized uptake value (SUVmax) and target-to-background ratio (TBR) and compared with available results from right heart catheterization (RHC) or transthoracic echocardiography (TTE).

RESULTS

Thirty-three subjects demonstrated clear ¹⁸F-FDG uptake in the PA wall. In the subgroup of patients who underwent RHC (n = 10), the mean PA pressure was significantly higher in the group with PA ¹⁸F-FDG uptake compared with the group without uptake (34.4 ± 7.2 mm Hg vs 25.6 ± 9.3 mm Hg; P = 0.003), and 9 (90%) patients with PA ¹⁸F-FDG uptake had PH when a mean PA pressure cutoff of 25 mm Hg was used compared with 18 (45%) in the nonuptake group (P < 0.05). In the subgroup that underwent TTE, signs of PH were present in a significantly higher number of patients with PA ¹⁸F-FDG uptake (14 [51.9%] vs 37 [29.8%]; P < 0.05). Qualitative assessment of ¹⁸F-FDG uptake in the PA wall showed a sensitivity of 33% and specificity of 96% for separating patients with PH based on RHC-derived PA pressures. SUVmax and TBR in the PA wall correlated with PA pressure derived from RHC and/or TTE.

CONCLUSIONS

We demonstrate that ¹⁸F-FDG uptake by PET/CMR in the PA is associated with PH and that its intensity correlates with PA pressure.

Effects of nintedanib by inclusion criteria for progression of interstitial lung disease

Background

The INBUILD trial investigated nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs). We investigated the decline in forced vital capacity (FVC) in subgroups based on the inclusion criteria for ILD progression.

Methods

Subjects had a fibrosing ILD other than idiopathic pulmonary fibrosis and met the following criteria for ILD progression within the 24 months before screening despite management deemed appropriate in clinical practice: Group A, relative decline in FVC ≥10% predicted; Group B, relative decline in FVC ≥5–<10% predicted with worsened respiratory symptoms and/or increased extent of fibrosis on high-resolution computed tomography (HRCT); Group C, worsened respiratory symptoms and increased extent of fibrosis on HRCT only.

Results

In the placebo group, the rates of FVC decline over 52 weeks in Groups A, B and C, respectively, were −241.9, −133.1 and −115.3 mL per year in the overall population (p=0.0002 for subgroup-by-time interaction) and −288.9, −156.2 and −100.1 mL per year among subjects with a usual interstitial pneumonia (UIP)-like fibrotic pattern on HRCT (p=0.0005 for subgroup-by-time interaction). Nintedanib had a greater absolute effect on reducing the rate of FVC decline in Group A than in Group B or C. However, the relative effect of nintedanib versus placebo was consistent across the subgroups (p>0.05 for heterogeneity).

Conclusions

The inclusion criteria used in the INBUILD trial, based on FVC decline or worsening of symptoms and extent of fibrosis on HRCT, were effective at identifying patients with progressive fibrosing ILDs. Nintedanib reduced the rate of decline in FVC across the subgroups based on the inclusion criteria related to ILD progression.

In the INBUILD trial in patients with fibrosing ILDs, the relative effect of nintedanib versus placebo on reducing the rate of FVC decline was consistent across subgroups based on the criteria regarding ILD progression that patients fulfilled on trial entryhttps://bit.ly/35jpOiE

Quantifying normal lung in pulmonary fibrosis: CT analysis and correlation with %DLCO

BACKGROUND

Chest CT scans are routinely obtained to monitor disease progression in pulmonary fibrosis. However, radiologists do not employ a standardized system for quantitative description of the severity of the disease. Development and validation of a grading system offers potential for enhancing the information that radiologists provide clinicians.

STUDY DESIGN AND METHODS

Our retrospective review analyzed 100 sequential patients with usual interstitial pneumonitis (UIP) on HRCT scans from 2018 and 2019. A radiologic scoring system evaluated the percent of normal lung on the basis of a 0-5 point scale per lobe (findings for the right middle lobe were included in the right upper lobe score), yielding an overall additive numerical score on a scale of 20 (completely normal lung) to 0 (no normal lung). Two radiologists quantified the percentage of normal lung by consensus agreement. Percent DLCO as well as demographic data were obtained from the medical record. Statistical analysis was performed using Spearman correlation to assess correlation between grade and percent DLCO.

RESULTS

96 patients met the inclusion criteria; average age was 71, 68% were male. Score on CT scan ranged from 18 to 4; average 10.9, SD 3.58. The single-breath diffusing capacity (percent DLCO) ranged from 88% to 17%; mean 44.5%, SD 14.3%. Spearman's correlation for CT score and percent DLCO was 0.622, P < 0.001.

CONCLUSION

This scoring system quantifying the amount of normal lung on chest CT of patients with UIP correlated significantly with percent DLCO (P < 0.001) and appears to offer a promising quantitative measure to assess severity of disease.

The right upper lobe bronchus angle: A tool for differentiating fibrotic and non-fibrotic sarcoidosis

Purpose:

To evaluate the Right Upper Lobe Bronchus Angle (RUL-BA) on chest CT in patients with Stage 4 sarcoidosis and compare to others with non-fibrotic sarcoidosis.

Methods:

IRB approval was obtained for review of all chest CT scans performed from January 2015 through December 2017 that contained the word sarcoidosis using the computer program Montage. The most recent CT scans of 633 people were reviewed. The patients’ age and sex at the time of their most recent CT scan were recorded. The radiographic diagnosis and the Right Upper Lobe Bronchus Angle (RUL-BA) were determined by a chest radiologist with 20 years of experience.

Results:

The RUL-BA increased with Stage 4 sarcoidosis, measuring on average 104 degrees, compared to the average angle of 88 degrees for those without fibrotic sarcoid. More often men’s CT scans exhibited the earlier stages of sarcoidosis, and a higher number of women’s scans showed fibrotic sarcoidosis. As would be expected, scans with advanced disease were typically from older patients; however, there was no correlation between age and degree of fibrosis as measured by increasing RUL-BA.

Conclusion:

The RUL-BA assists radiologists in differentiating fibrotic sarcoidosis from non-fibrotic sarcoidosis. Further research will determine if the RUL-BA measurement can help differentiate fibrotic sarcoid from other fibrotic lung diseases and if the angle can be used to follow disease progression. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (2): 99-103)

Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Shared and Tissue-Specific Expression Signatures between Bone Marrow from Primary Myelofibrosis and Essential Thrombocythemia

Megakaryocytes have been implicated in the micro-environmental abnormalities associated with fibrosis and hematopoietic failure in the bone marrow (BM) of primary myelofibrosis (PMF) patients, the Philadelphia-negative myeloproliferative neoplasm (MPN) associated with the poorest prognosis. To identify possible therapeutic targets for restoring BM functions in PMF, we compared the expression profiling of PMF BM with that of BM from essential thrombocytopenia (ET), a fibrosis-free MPN also associated with BM megakaryocyte hyperplasia. The signature of PMF BM was also compared with published signatures associated with liver and lung fibrosis. Gene set enrichment analysis (GSEA) identified distinctive differences between the expression profiles of PMF and ET. Notch, K-Ras, IL-8, and apoptosis pathways were altered the most in PMF as compared with controls. By contrast, cholesterol homeostasis, unfolded protein response, and hypoxia were the pathways found altered to the greatest degree in ET compared with control specimens. BM from PMF expressed a noncanonical transforming growth factor β (TGF-β) signature, which included activation of ID1, JUN, GADD45b, and genes with binding motifs for the JUN transcriptional complex AP1. By contrast, the expression of ID1 and GADD45b was not altered and there was a modest signal for JUN activation in ET. The similarities among PMF, liver fibrosis, and lung fibrosis were modest and included activation of integrin-α9 and tropomyosin-α1 between PMF and liver fibrosis, and of ectoderm-neural cortex protein 1 and FRAS1-related extracellular matrix protein 1 between PMF and lung fibrosis, but not TGF-β. These data identify TGF-β as a potential target for micro-environmental therapy in PMF.

Interstitial Lung Abnormalities and Lung Cancer Risk in the National Lung Screening Trial

BACKGROUND

Some interstitial lung diseases are associated with lung cancer. However, it is unclear whether asymptomatic interstitial lung abnormalities convey an independent risk.

OBJECTIVES

The goal of this study was to assess whether interstitial lung abnormalities are associated with an increased risk of lung cancer.

METHODS

Data from all participants in the National Lung Cancer Trial were analyzed, except for subjects with preexisting interstitial lung disease or prevalent lung cancers. The primary analysis included those who underwent low-dose CT imaging; those undergoing chest radiography were included in a confirmatory analysis. Participants with evidence of reticular/reticulonodular opacities, honeycombing, fibrosis, or scarring were classified as having interstitial lung abnormalities. Lung cancer incidence and mortality in participants with and without interstitial lung abnormalities were compared by using Poisson and Cox regression, respectively.

RESULTS

Of the 25,041 participants undergoing low-dose CT imaging included in the primary analysis, 20.2% had interstitial lung abnormalities. Participants with interstitial lung abnormalities had a higher incidence of lung cancer (incidence rate ratio, 1.61; 95% CI, 1.30-1.99). Interstitial lung abnormalities were associated with higher lung cancer incidence on adjusted analyses (incidence rate ratio, 1.33; 95% CI, 1.07-1.65). Lung cancer-specific mortality was also greater in participants with interstitial lung abnormalities. Similar findings were obtained in the analysis of participants undergoing chest radiography.

CONCLUSIONS

Asymptomatic interstitial lung abnormalities are an independent risk factor for lung cancer that can be incorporated into risk score models.

Progression of probable UIP and UIP on HRCT

PURPOSE

To determine patterns of progression of probable Usual Interstitial Pneumonitis (UIP).

METHODS

This HIPPA compliant, IRB-approved study draws patients from our Fibrosis Registry. All patients with a consensus diagnosis of Idiopathic Pulmonary Fibrosis (IPF) were included. Most recent CT scans and all earlier CT scans were reviewed to determine the fibrosis grade in each lobe based on probable UIP (pUIP) findings of ground glass opacities, traction bronchiolectasis and reticulations or UIP findings of subpleural basilar predominant fibrosis with honeycombing (HC) and absence of features that would suggest an alternative diagnosis.

RESULTS

103 patients with a working diagnosis of IPF are the focus of this report. Among the 68 with pUIP on the initial CT, 32 (47%) progressed; median time to progression was 51 months. The risk of HC progression, adjusted for gender, of patients with emphysema was 2.53 times higher than patients without emphysema (HR = 2.53, 95% CI: 1.06-6.02). Among the 35 with HC on the initial CT scan, 20 (57%) progressed to more advanced HC; median time to progression was 31 months. Increased pulmonary artery size was significantly associated with an elevated risk for more advanced HC progression (HR = 1.16, 95% CI: 1.04-1.31).

CONCLUSION

Ground glass opacities, traction bronchiolectasis and reticulations, a "Probable UIP Pattern" by ATS criteria progressed to UIP in 47% of patients on follow-up imaging.

Correction of respiratory and cardiac motion in cardiac PET/MR using MR-based motion modeling

Cardiac positron emission tomography (PET) imaging suffers from image blurring due to the constant motion of the heart that can impact interpretation. Hybrid PET/magnetic resonance (MR) has the potential to use radiation-free MR imaging to correct for the effects of cardio-respiratory motion in the PET data, improving qualitative and quantitative PET imaging in the heart. The purpose of this study was (i) to implement a MR image-based motion-corrected PET/MR method and (ii) to perform a proof-of-concept study of quantitative myocardial PET data in patients. The proposed method takes reconstructions of respiratory and cardiac gated PET data and applies spatial transformations to a single reference frame before averaging to form a single motion-corrected PET (MC-PET) image. Motion vector fields (MVFs) describing the transformations were derived from affine or non-rigid registration of respiratory and cardiac gated MR data. Eight patients with suspected cardiac sarcoidosis underwent cardiac PET/MR imaging after injection of 5 MBq kg^-1 of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG). Myocardial regions affected by motion were identified by expert readers within which target-to-background ratios (TBR) and contrast-to-noise ratios (CNR) were measured on non-MC-non-gated, MC-PET, and double respiratory and cardiac gated PET images. Paired t-tests were used to determine statistical differences in quantitative uptake-measures between the different types of PET images. MC-PET images showed less blurring compared to non-MC-non-gated PET and tracer activity qualitatively aligned better with the underlying myocardial anatomy when fused with MR. TBR and CNR were significantly greater for MC-PET (2.8  ±  0.9; 21  ±  22) compared to non-MC-non-gated PET (2.4  ±  0.9, p  =  0.0001; 15  ±  13, p  =  0.02), while TBR was lower and CNR greater compared to double-gated PET (3.2  ±  0.9, p  =  0.04; 6  ±  3, p  =  0.004). This study demonstrated in a patient cohort that motion-corrected (MC) cardiac PET/MR is feasible using a retrospective MR image-based method and that improvement in TBR and CNR are achievable. MC PET/MR holds promise for improving interpretation and quantification in cardiac PET imaging.

Hybrid Magnetic Resonance Imaging and Positron Emission Tomography With Fluorodeoxyglucose to Diagnose Active Cardiac Sarcoidosis

OBJECTIVES

The purpose of this study was to explore the diagnostic usefulness of hybrid cardiac magnetic resonance (CMR) and positron emission tomography (PET) using 18F-fluorodeoxyglucose (FDG) for active cardiac sarcoidosis.

BACKGROUND

Active cardiac sarcoidosis (aCS) is underdiagnosed and has a high mortality.

METHODS

Patients with clinical suspicion of aCS underwent hybrid CMR/PET with late gadolinium enhancement (LGE) and FDG to assess the pattern of injury and disease activity, respectively. Patients were categorized visually as magnetic resonance (MR)+PET+ (characteristic LGE aligning exactly with increased FDG uptake), MR+PET- (characteristic LGE but no increased FDG), MR-PET- (neither characteristic LGE nor increased FDG), and MR-PET+ (increased FDG uptake in absence of characteristic LGE) and further characterized as aCS+ (MR+PET+) or aCS- (MR+PET-, MR-PET-, MR-PET+). FDG uptake was quantified using maximum target-to-normal-myocardium ratio and the net uptake rate (Ki) from dynamic Patlak analysis. Receiver-operating characteristic methods were used to identify imaging biomarkers for aCS. FDG PET was assessed using computed tomography/PET in 19 control subjects with healthy myocardium.

RESULTS

A total of 25 patients (12 males; 54.9 ± 9.8 years of age) were recruited prospectively; 8 were MR+PET+, suggestive of aCS; 1 was MR+PET-, consistent with inactive cardiac sarcoidosis; and 8 were MR-PET-, with no imaging evidence of cardiac sarcoidosis. Eight patients were MR-PET+ (6 with global myocardial FDG uptake, 2 with focal-on-diffuse uptake); they demonstrated distinct Ki values and hyperintense maximum standardized uptake value compared with MR+PET+ patients. Similar hyperintense patterns of global (n = 9) and focal-on-diffuse (n = 2) FDG uptake were also observed in control patients, suggesting physiological myocardial uptake. Maximum target-to-normal-myocardium ratio values were higher in the aCS+ group (p < 0.001), demonstrating an area under the curve of 0.98 on receiver-operating characteristic analysis for the detection of aCS, with an optimal maximum target-to-normal myocardium ratio threshold of 1.2 (Youden index: 0.94).

CONCLUSIONS

CMR/PET imaging holds major promise for the diagnosis of aCS, providing incremental information about both the pattern of injury and disease activity in a single scan. (In Vivo Molecular Imaging [MRI] of Atherothrombotic Lesions; NCT01418313).

Dual-sensitivity profilometry with defocused projection of binary fringes

A dual-sensitivity profilometry technique based on defocused projection of binary fringes is presented. Here, two sets of fringe patterns with a sinusoidal profile are produced by applying the same analog low-pass filter (projector defocusing) to binary fringes with a high- and low-frequency spatial carrier. The high-frequency fringes have a binary square-wave profile, while the low-frequency binary fringes are produced with error-diffusion dithering. The binary nature of the binary fringes removes the need for calibration of the projector's nonlinear gamma. Working with high-frequency carrier fringes, we obtain a high-quality wrapped phase. On the other hand, working with low-frequency carrier fringes we found a lower-quality, nonwrapped phase map. The nonwrapped estimation is used as stepping stone for dual-sensitivity temporal phase unwrapping, extending the applicability of the technique to discontinuous (piecewise continuous) surfaces. We are proposing a single defocusing level for faster high- and low-frequency fringe data acquisition. The proposed technique is validated with experimental results.

Osteophyte induced lung fibrosis prevalence and osteophyte qualities predicting disease

OBJECTIVE

To determine the prevalence of osteophyte induced lung fibrosis (OIF) and its relationship to osteophyte size, location, and surrounding fat.

METHODS

94 CT scans of the chest were reviewed, size of the largest osteophyte and the presence of fibrosis were recorded.

RESULTS

Presence of fibrosis was higher among patient with large (>10 mm) osteophytes compared to those with small (1-10mm) osteophytes. Age and presence of periosteophyte fat were significantly associated with presence of fibrosis.

CONCLUSIONS

As the size of an osteophyte increases, there is a greater likelihood of lung fibrosis. Subpleural fat protects the lung from OIF.

Analysing the effect of crystal size and structure in highly efficient CH3NH3PbI3 perovskite solar cells by spatially resolved photo- and electroluminescence imaging

CH3NH3PbI3 perovskite solar cells with a mesoporous TiO2 layer and spiro-MeOTAD as a hole transport layer (HTL) with three different CH3NH3I concentrations (0.032 M, 0.044 M and 0.063 M) were investigated. Strong variations in crystal size and morphology resulting in diversified cell efficiencies (9.2%, 16.9% and 12.3%, respectively) were observed. The physical origin of this behaviour was analysed by detailed characterization combining current-voltage curves with photo- and electroluminescence (PL and EL) imaging as well as light beam induced current measurements (LBIC). It was found that the most efficient cell shows the highest luminescence and the least efficient cell is most strongly limited by non-radiative recombination. Crystal size, morphology and distribution in the capping layer and in the porous scaffold strongly affect the non-radiative recombination. Moreover, the very non-uniform crystal structure with multiple facets, as evidenced by SEM images of the 0.032 M device, suggests the creation of a large number of grain boundaries and crystal dislocations. These defects give rise to increased trap-assisted non-radiative recombination as is confirmed by high-resolution μ-PL images. The different imaging techniques used in this study prove to be well-suited to spatially investigate and thus correlate the crystal morphology of the perovskite layer with the electrical and radiative properties of the solar cells and thus with their performance.

Honoring Roots in Multiple Worlds

Purpose. To obtain contextualized insights from professionals regarding factors that contribute to or inhibit the healthy development of Latino youth. Method. A community-engaged study in which semistructured in-depth interviews were conducted with 30 professionals who work extensively with Latino youth in urban clinics, schools, and other community-based settings. Results. Every key informant expressed opinions regarding factors that contribute to healthy development of Latino youth, ranging from cultural identity and a sense of belonging to family connectedness and adult role models. Contributing and inhibiting factors were characterized by being either intrinsic to the individual (e.g., sense of belonging, hope) or extrinsic (e.g., family support and love, community support). Conclusion. Recognition of and appreciation for the importance of cultural influences in the lives of Latino youth is a critical starting point on which professionals must build to respectfully and successfully encourage healthy youth development. Factors that contribute to the healthy development of Latino youth range from cultural identity and cultural pride to family connectedness, adult role models, and a sense of belonging. In working with Latino young people, professionals must recognize and appreciate cultural influences as foundational to this population’s health and well-being.

Idiopathic pulmonary fibrosis: the role of pathobiology in making a definitive diagnosis

Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease of unknown etiology characterized by fibrosis of the interstitium, resulting in progressive respiratory insufficiency and shortened lifespan. Treatment focus tends to shift from disease-centered to symptom-centered as the disease progresses. Over the years, a number of pharmacologic strategies have been used to treat IPF, albeit without solid evidence demonstrating a beneficial impact on the disease course. The previously held theory that inflammation was the predominant underlying feature of IPF led to the use of corticosteroids and immunosuppressive therapy as the standard of care. However, a greater understanding of the pathogenesis of IPF has evolved and guidelines were developed using evidence-based criteria. Guided by the data, treatment guidelines developed in 2011 stated that no pharmacologic therapy showed a proven benefit for patients with IPF and issued recommendations against the use of most treatments. The treatment landscape changed in October 2014, when the FDA approved pirfenidone and nintedanib for the treatment of IPF. For the first time, clinicians have therapeutic options with demonstrated clinical efficacy to treat patients with IPF. To provide effective high-value care for patients with IPF, healthcare professionals require thorough knowledge and awareness about these medications, including their safety concerns.

Bosentan for sarcoidosis-associated pulmonary hypertension: a double-blind placebo controlled randomized trial

BACKGROUND

Sarcoidosis-associated pulmonary hypertension (SAPH) is a common problem in patients with persistent dyspneic sarcoidosis. The objective of this study was to determine the effect of bosentan therapy on pulmonary arterial hemodynamics in patients with SAPH.

METHODS

This 16-week study was a double-blind, placebo-controlled trial of either bosentan or placebo in patients with SAPH confirmed by right-sided heart catheterization. Patients were enrolled from multiple academic centers specializing in sarcoidosis care. They were stable on sarcoidosis therapy and were receiving no therapy for pulmonary hypertension. The cohort was randomized two to one to receive bosentan at a maximal dose of 125 mg or placebo bid for 16 weeks. Pulmonary function studies, 6-min walk test, and right-sided heart hemodynamics, including pulmonary artery mean pressure and pulmonary vascular resistance (PVR), were performed before and after 16 weeks of therapy.

RESULTS

Thirty-five patients completed 16 weeks of therapy (23 treated with bosentan, 12 with placebo). For those treated with bosentan, repeat hemodynamic studies at 16 weeks demonstrated a significant mean±SD fall in PA mean pressure (-4±6.6 mm Hg, P=.0105) and PVR (-1.7±2.75 Wood units, P=.0104). For the patients treated with placebo, there was no significant change in either PA mean pressure (1±3.7 mm Hg, P>.05) or PVR (0.1±1.42 Wood units, P>.05). There was no significant change in 6-min walk distance for either group. Two patients treated with bosentan required an increase of supplemental oxygen by >2 L after 16 weeks of therapy.

CONCLUSIONS

This study demonstrated that bosentan significantly improved pulmonary hemodynamics in patients with SAPH.

TRIAL REGISTRY

ClinicalTrials.gov; No: NCT00581607; URL: www.clinicaltrials.gov.

Barriers to optimal palliative care of lung transplant candidates

BACKGROUND

The provision of effective palliative care is of great importance to patients awaiting lung transplantation. Although the prospect of lung transplantation provides hope to patients and their families, these patients are usually very symptomatic from their underlying disease.

METHODS

An e-mail questionnaire was sent to members of the American College of Chest Physicians' Transplant NetWork and the Pulmonary Council of the International Society for Heart and Lung Transplantation (ISHLT). The survey included questions about barriers to providing palliative care, the availability of palliative care services, and recommended strategies to improve palliative care for lung transplant candidates.

RESULTS

The 158 respondents represented approximately 65% of transplant programs in the ISHLT registry. Respondents were in practice a mean of 11.3 (± 9) years, 70% were pulmonologists, 17% were surgeons, and 13% were other care providers. Barriers were classified into domains including patient factors, family factors, physician factors, and institutional/transplant program/lung allocation system factors. Significant patient/family barriers included unrealistic patient/family expectations about survival, unwillingness to plan end-of-life care, concerns about abandonment or inappropriate care after enrollment in a palliative care program, and family disagreements about care goals. For institutional/program/allocation system barriers, only the requirement for weight loss or gain to meet program-specific BMI requirements was identified. Significant physician barriers included competing time demands and the seemingly contradictory goals of transplant vs palliative care. Strategies recommended to improve palliative care included routine advance care planning for patients awaiting transplantation, access to palliative care specialists, training of transplant physicians in symptom management, and regular meetings among transplant physicians, nurses, patients, and families.

CONCLUSIONS

Physicians providing care to lung transplant candidates reported considerable barriers to the delivery and acceptance of palliative care and identified specific strategies to improve palliative care for lung transplant candidates.

Measurement of the semileptonic charge asymmetry using B(s)(0) → D(s)μX decays

We present a measurement of the time-integrated flavor-specific semileptonic charge asymmetry in the decays of B(s)(0) mesons that have undergone flavor mixing, a(sl)(s), using B(s)(0)(B(s)(0)) → D(s)(-/+) μ(±) X decays, with D(s)(-/+) → [symbol: see text]π(-/+) and [symbol: see text]→ K(+) K(-), using 10.4 fb(-1) of proton-antiproton collisions collected by the D0 detector during Run II at the Fermilab Tevatron Collider. A fit to the difference between the time-integrated D(s)(-) and D(s)(+) mass distributions of the B(s)(0) and B(s)(0) candidates yields the flavor-specific asymmetry a(sl)(s) = [-1.12 ± 0.74(stat) ± 0.17(syst)]%, which is the most precise measurement and in agreement with the standard model prediction.

Search for the standard model Higgs boson in associated WH production in 9.7 fb(-1) of pp collisions with the D0 detector

We present a search for the standard model Higgs boson in final states with a charged lepton (electron or muon), missing transverse energy, and two or three jets, at least one of which is identified as a b-quark jet. The search is primarily sensitive to WH→ℓνbb production and uses data corresponding to 9.7 fb(-1) of integrated luminosity collected with the D0 detector at the Fermilab Tevatron pp Collider at √s = 1.96 TeV. We observe agreement between the data and the expected background. For a Higgs boson mass of 125 GeV, we set a 95% C.L. upper limit on the production of a standard model Higgs boson of 5.2 × σ(SM), where σ(SM) is the standard model Higgs boson production cross section, while the expected limit is 4.7 × σ(SM).

Combined search for the standard model Higgs boson decaying to bb using the D0 run II data set

We present the results of the combination of searches for the standard model Higgs boson produced in association with a W or Z boson and decaying into bb using the data sample collected with the D0 detector in pp collisions at √s = 1.96 TeV at the Fermilab Tevatron Collider. We derive 95% C.L. upper limits on the Higgs boson cross section relative to the standard model prediction in the mass range 100 GeV ≤ M(H) ≤ 150 GeV, and we exclude Higgs bosons with masses smaller than 102 GeV at the 95% C.L. In the mass range 120 GeV ≤ M(H) ≤145 GeV, the data exhibit an excess above the background prediction with a global significance of 1.5 standard deviations, consistent with the expectation in the presence of a standard model Higgs boson.

Search for the standard model Higgs boson in ZH→ℓ(+)ℓ(-)bb production with the D0 detector in 9.7 fb(-1) of pp collisions at √s = 1.96 TeV

We present a search for the standard model (SM) Higgs boson produced in association with a Z boson in 9.7 fb(-1) of pp collisions collected with the D0 detector at the Fermilab Tevatron Collider at √s = 1.96 TeV. Selected events contain one reconstructed Z→e(+)e(-) or Z→μ(+)μ(-) candidate and at least two jets, including at least one jet identified as likely to contain a b quark. To validate the search procedure, we also measure the cross section for ZZ production in the same final state. It is found to be consistent with its SM prediction. We set upper limits on the ZH production cross section times branching ratio for H→bb at the 95% C.L. for Higgs boson masses 90 ≤ M(H) ≤ 150 GeV. The observed (expected) limit for M(H) = 125 GeV is 7.1 (5.1) times the SM cross section.

Evidence for a particle produced in association with weak bosons and decaying to a bottom-antibottom quark pair in higgs boson searches at the tevatron

We combine searches by the CDF and D0 Collaborations for the associated production of a Higgs boson with a W or Z boson and subsequent decay of the Higgs boson to a bottom-antibottom quark pair. The data, originating from Fermilab Tevatron pp collisions at √s = 1.96 TeV, correspond to integrated luminosities of up to 9.7 fb(-1). The searches are conducted for a Higgs boson with mass in the range 100-150 GeV/c(2). We observe an excess of events in the data compared with the background predictions, which is most significant in the mass range between 120 and 135 GeV/c(2). The largest local significance is 3.3 standard deviations, corresponding to a global significance of 3.1 standard deviations. We interpret this as evidence for the presence of a new particle consistent with the standard model Higgs boson, which is produced in association with a weak vector boson and decays to a bottom-antibottom quark pair.

Search for violation of Lorentz invariance in top quark pair production and decay

Using data collected with the D0 detector at the Fermilab Tevatron Collider, corresponding to 5.3 fb(-1) of integrated luminosity, we search for violation of Lorentz invariance by examining the tt[over ¯] production cross section in lepton+jets final states. We quantify this violation using the standard-model extension framework, which predicts a dependence of the tt[over ¯] production cross section on sidereal time as the orientation of the detector changes with the rotation of the Earth. Within this framework, we measure components of the matrices (c(Q))(μν33) and (c(U))(μν33) containing coefficients used to parametrize violation of Lorentz invariance in the top quark sector. Within uncertainties, these coefficients are found to be consistent with zero.

Measurements of WW and WZ production in W + jets final states in pp collisions

We study WW and WZ production with ℓνqq (ℓ=e,μ) final states using data collected by the D0 detector at the Fermilab Tevatron Collider corresponding to 4.3  fb(-1) of integrated luminosity from pp collisions at sqrt[s]=1.96  TeV. Assuming the ratio between the production cross sections σ(WW) and σ(WZ) as predicted by the standard model, we measure the total WV (V=W,Z) cross section to be σ(WV)=19.6(-3.0)(+3.2)  pb and reject the background-only hypothesis at a level of 7.9 standard deviations. We also use b-jet discrimination to separate the WZ component from the dominant WW component. Simultaneously fitting WW and WZ contributions, we measure σ(WW)=15.9(-3.2)(+3.7)  pb and σ(WZ)=3.3(-3.3)(+4.1)  pb, which is consistent with the standard model predictions.