Nasal High Flow at 25 L/min or Expiratory Resistive Load Do Not Improve Regional Lung Function in Patients With COPD: A Functional CT Imaging Study

Background

Nasal high flow (NHF) is a non-invasive breathing therapy that is based on the delivery via a large-caliber nasal cannula of heated and humidified air at flow rates that exceed peak inspiratory flow. It is thought that positive airway pressure generated by NHF can help reduce gas trapping and improve regional lung ventilation. There are no data to confirm this hypothesis at flow rates applicable in stable chronic obstructive pulmonary disease (COPD) patients.

Methods

In this study, we used non-rigid registration of computed tomography (CT) images acquired at maximal expiration and inspiration to compute regional lung attenuation changes (ΔHU), and lung displacement (LD), indices of regional lung ventilation. Parametric response maps (Galban et al., 2012) were also computed in each experimental condition. Eight COPD patients were assessed at baseline (BL) and after 5 min of NHF and expiratory resistive loading (ERL).

Results

ΔHU was: BL (median, IQR): 85 (67.2, 102.8); NHF: 90.7 (57.4, 97.6); ERL: 74.6 (46.4, 89.6) HU (p = 0.531); and LD: 27.8 (22.3, 39.3); 17.6 (15.4, 27.9); and 20.4 (16.6, 23.6) mm (p = 0.120) in the 3 conditions, respectively. No significant difference in trapping was observed. Respiratory rate significantly decreased with both treatments [BL: 17.3 (16.4, 18.9); NHF: 13.7; ERL: 11.4 (9.6, 13.2) bpm; and p < 0.001].

Conclusion

Neither NHF at 25 L/min nor ERL significantly improved the regional lung ventilation of stable COPD patients with gas trapping, based on functional lung CT imaging. Further study including more subjects is needed to assess the potential effect of NHF on regional lung function at higher flow rates.

Clinical Trial Registration

www.clinicaltrials.gov/under, identifier NCT03821311.

Treatment of metastatic placental site trophoblastic tumor with surgery, chemotherapy, immunotherapy and coil embolization of multiple pulmonary arteriovenous fistulate

•

Placental site trophoblastic tumor can be resistant to chemotherapy.

•

Multidisciplinary care is required for management of advanced disease.

•

Increased PD-L1 expression can help guide use of immunotherapies.

•

Complete responses are possible with aggressive multidisciplinary management.

Placental Site Trophoblastic Tumor (PSTT) is a rare malignancy that often presents with extensive disease and can be resistant to traditional treatments. We present the case of a woman with stage IV PSTT who was initially managed with neoadjuvant chemotherapy followed by tumor debulking. Adjuvant therapy was guided by further pathologic analysis that revealed high levels of staining for PD-L1 as well as the presence of tumor infiltrating lymphocytes (TILs). Subsequently, the patient was treated with traditional chemotherapy with the EP/EMA regimen with the addition of pembrolizumab. The patient’s treatment course was complicated by the development of pulmonary arteriovenous malformations, autoimmune thyroiditis thought to be secondary to immunotherapy, and significant tinnitus secondary to platinum agents. Currently the patient is in follow up and remains in a complete remission.

Development and Validation of a Deep Learning-Based Automated Detection Algorithm for Major Thoracic Diseases on Chest Radiographs

IMPORTANCE

Interpretation of chest radiographs is a challenging task prone to errors, requiring expert readers. An automated system that can accurately classify chest radiographs may help streamline the clinical workflow.

OBJECTIVES

To develop a deep learning-based algorithm that can classify normal and abnormal results from chest radiographs with major thoracic diseases including pulmonary malignant neoplasm, active tuberculosis, pneumonia, and pneumothorax and to validate the algorithm's performance using independent data sets.

DESIGN, SETTING, AND PARTICIPANTS

This diagnostic study developed a deep learning-based algorithm using single-center data collected between November 1, 2016, and January 31, 2017. The algorithm was externally validated with multicenter data collected between May 1 and July 31, 2018. A total of 54 221 chest radiographs with normal findings from 47 917 individuals (21 556 men and 26 361 women; mean [SD] age, 51 [16] years) and 35 613 chest radiographs with abnormal findings from 14 102 individuals (8373 men and 5729 women; mean [SD] age, 62 [15] years) were used to develop the algorithm. A total of 486 chest radiographs with normal results and 529 with abnormal results (1 from each participant; 628 men and 387 women; mean [SD] age, 53 [18] years) from 5 institutions were used for external validation. Fifteen physicians, including nonradiology physicians, board-certified radiologists, and thoracic radiologists, participated in observer performance testing. Data were analyzed in August 2018.

EXPOSURES

Deep learning-based algorithm.

MAIN OUTCOMES AND MEASURES

Image-wise classification performances measured by area under the receiver operating characteristic curve; lesion-wise localization performances measured by area under the alternative free-response receiver operating characteristic curve.

RESULTS

The algorithm demonstrated a median (range) area under the curve of 0.979 (0.973-1.000) for image-wise classification and 0.972 (0.923-0.985) for lesion-wise localization; the algorithm demonstrated significantly higher performance than all 3 physician groups in both image-wise classification (0.983 vs 0.814-0.932; all P < .005) and lesion-wise localization (0.985 vs 0.781-0.907; all P < .001). Significant improvements in both image-wise classification (0.814-0.932 to 0.904-0.958; all P < .005) and lesion-wise localization (0.781-0.907 to 0.873-0.938; all P < .001) were observed in all 3 physician groups with assistance of the algorithm.

CONCLUSIONS AND RELEVANCE

The algorithm consistently outperformed physicians, including thoracic radiologists, in the discrimination of chest radiographs with major thoracic diseases, demonstrating its potential to improve the quality and efficiency of clinical practice.

CT-texture analysis of subsolid nodules for differentiating invasive from in-situ and minimally invasive lung adenocarcinoma subtypes

PURPOSE

The purpose of this study was to evaluate the usefulness of computed tomography-texture analysis (CTTA) in differentiating between in-situ and minimally-invasive from invasive adenocarcinomas in subsolid lung nodules (SSLNs).

MATERIAL AND METHODS

Two radiologists retrospectively reviewed 49 SSLNs in 44 patients. There were 27 men and 17 women with a mean age of 63±7 (SD) years (range: 47-78years). For each SSLN, type (pure ground-glass or part-solid) was assessed by consensus and CTTA was conducted independently by each observer using a filtration-histogram technique. Different filters were used before histogram quantification: no filtration, fine, medium and coarse, followed by histogram quantification using mean intensity, standard deviation (SD), entropy, mean positive pixels (MPP), skewness and kurtosis.

RESULTS

We analyzed 13 pure ground-glass and 36 part-solid nodules corresponding to 16 adenocarcinomas in-situ (AIS), 5 minimally invasive adenocarcinomas (MIA) and 28 invasive adenocarcinomas (IVA). At uni- and multivariate analysis CTTA allowed discriminating between IVAs and AIS/MIA (P<0.05 and P=0.025, respectively) with the following histogram parameters: skewness using fine textures and kurtosis using coarse filtration for pure ground-glass nodules, and SD without filtration for part-solid nodules.

CONCLUSION

CTTA has the potential to differentiate AIS and MIA from IVA among SSLNs. However, our results require further validation on a larger cohort.

Abnormal mismatch repair and other clinicopathologic predictors of poor response to progestin treatment in young women with endometrial complex atypical hyperplasia and well-differentiated endometrial adenocarcinoma: a consecutive case series

OBJECTIVE

To report the response to progestin therapy in young women with endometrial complex atypical hyperplasia (CAH) or FIGO grade 1 endometrial adenocarcinoma (FIGO 1 EAC) based on clinicopathologic features, including abnormal DNA mismatch repair (MMR) by immunohistochemistry (IHC).

DESIGN

Consecutive case series.

SETTING

Olive View-UCLA Medical Center in Sylmar, CA, USA, and Cedars-Sinai Medical Center in Los Angeles, CA, USA.

POPULATION

Women ≤55 years old with CAH or FIGO 1 EAC.

METHODS

Response to progestin therapy in 84 consecutive patients was assessed based on clinicopathologic factors, including age, body mass index (BMI), initial histology, and IHC staining for MMR proteins.

MAIN OUTCOME MEASURES

Rates of abnormal MMR protein expression and response to progestin therapy were determined.

RESULTS

Six (7%) patients had abnormal IHC staining, of whom five (83%) had FIGO 1 EAC at initial diagnosis. Following progestin treatment, none of the endometrial lesions in patients with abnormal IHC for MMR proteins had resolution of hyperplasia or malignancy, in contrast to 41 (53%) with normal staining (P = 0.028). Age ≤40 years and initial lesion (CAH versus FIGO 1 EAC) were predictors of response to progestin; BMI was not.

CONCLUSIONS

In this cohort, 7% of women ≤55 years of age with CAH or FIGO 1 EAC had loss of MMR proteins by IHC. These patients had a higher incidence of invasive cancer and a lower incidence of resolution with progestin therapy.

TWEETABLE ABSTRACT

Abnormal MMR protein expression predicts poor response to progestins in young women with CAH or FIGO 1 EAC.

Lung adenocarcinomas: correlation of computed tomography and pathology findings

Adenocarcinoma is the most common histologic type of lung cancer. Recent lung adenocarcinoma classifications from the International Association for the Study of Lung cancer, the American Thoracic Society and the European Respiratory Society (IASLC/ETS/ERS, 2011) and World Health Organization (WHO, 2015) define a wide range of adenocarcinoma types and subtypes featuring different prognosis and management. This spectrum of lesions translates into various CT presentations and features, which generally show good correlation with histopathology, stressing the key role of the radiologist in the diagnosis and management of those patients. This review aims at helping radiologists to understand the basics of the up-to-date adenocarcinoma pathological classifications, radio-pathological correlations and how to use them in the clinical setting, as well as other imaging-related correlations (radiogenomics, quantitative analysis, PET-CT).

Serum potassium concentration predicts brain hypoxia on CT after avalanche-induced cardiac arrest

BACKGROUND

Brain anoxia after complete avalanche burial and cardiac arrest (CA) may occur despite adequate on-site triage.

PURPOSE

To investigate clinical and biological parameters associated with brain hypoxia in a cohort of avalanche victims with whole body computed tomographic (CT) scan.

METHODS

Retrospective study of patients with CA and whole body CT scan following complete avalanche burial admitted in a level-I trauma center.

MAIN FINDINGS

Out of 19 buried patients with whole body CT scan, eight patients had refractory CA and 11 patients had pre-hospital return of spontaneous circulation. Six patients survived at hospital discharge and only two had good neurologic outcome. Twelve patients had signs of brain hypoxia on initial CT scan, defined as brain edema, loss of gray/white matter differentiation and/or hypodensity of basal ganglia. No clinical pre-hospital parameter was associated with brain anoxia. Serum potassium concentration at admission was higher in patients with brain anoxia as compared to patients with normal CT scan: 5.5 (4.1-7.2) mmol/L versus 3.3 (3.0-4.2) mmol/L, respectively (P<.01). A threshold of 4.35 mmol/L serum potassium had 100% specificity to predict brain anoxia on brain CT scan.

CONCLUSIONS

Serum potassium concentration had good predictive value for brain anoxia after complete avalanche burial. This finding further supports the use of serum potassium concentration for extracorporeal life support insertion at hospital admission in this context.

Differentiating pre- and minimally invasive from invasive adenocarcinoma using CT-features in persistent pulmonary part-solid nodules in Caucasian patients

OBJECTIVE

To retrospectively investigate the diagnostic value of pre-operative CT-features between pre/minimally invasive and invasive lesions in part-solid persistent pulmonary ground glass nodules in a Caucasian population.

MATERIALS AND METHODS

Retrospective review of two pre-operative CTs for 31 nodules in 30 patients. There were 10 adenocarcinomas in situ, 1 minimally invasive adenocarcinoma, 20 invasive adenocarcinomas. We analyzed the correlation between histopathology and the following CT-features: maximal axial diameter, maximal orthogonal axial diameter, height, density, size of solid component, air bronchogram, pleural retraction, nodule mass, disappearance rate and their evolution during follow-up.

RESULTS

In univariate analysis, invasive adenocarcinomas had a higher maximal height, density, solid component size, mass, a lower disappearance rate and presented more often with pleural retraction (p<0.05). After logistic regression performed with the uncorrelated parameters using a method of selection of variables, only the size of solid component remained significant, with 100% sensitivity for invasive adenocarcinoma when larger than 5mm.

CONCLUSION

Preoperative CT-features can help differentiating in situ and minimally invasive adenocarcinomas from invasive adenocarcinomas in Caucasian patients. A solid component larger than 5mm in diameter had 100% sensitivity for the diagnosis of invasive adenocarcinoma.

RB1 genetic testing as a clinical service: a follow-up study

BACKGROUND

Genetic testing for inherited predisposition to diverse cancers has recently become available as a clinical service. We conducted a follow-up study of the initial series of US families who underwent RB1 genetic testing to evaluate long-term effects of the service.

PROCEDURE

We enrolled 52 of 71 eligible families who responded to a follow-up study questionnaire administered 3-10 years after receipt of their RB1 results. Each family had one proband with unilateral, non-familial retinoblastoma, which is associated with a 12% pre-test probability of hereditary retinoblastoma. RB1 testing identified germline RB1 mutations in five patients, lowered the carrier probability to 2% in 21 patients, and did not substantially modify the carrier probability in the remaining 26.

RESULTS

Diverse medical specialists offered and arranged for RB1 testing, and their recommendation was the most influential factor in the decision to be tested. Pre-test counseling was provided by ophthalmologists (30), oncologists (11), and geneticists and genetic counselors (11). Most respondents, regardless of test result, were satisfied and perceived gains from their genetic testing. Based on small numbers, families with reduced likelihood of hereditary retinoblastoma reported more positive outcomes. Parents of RB1 carriers were more likely to seek medical services, worry, and decide against having more children.

CONCLUSIONS

This study demonstrates the feasibility of follow-up studies of families who had genetic testing. Results from our small series suggest that genetic information and counseling are important components of RB1 clinical genetic testing, and long-term adverse effects of testing are uncommon.

Caltech Faint Galaxy Redshift Survey. XI. The Merger Rate to Redshift 1 from Kinematic Pairs

The rate of mass accumulation due to galaxy merging depends on the mass, density, and velocity distribution of galaxies in the near neighborhood of a host galaxy. The fractional luminosity in kinematic pairs combines all of these effects in a single estimator that is relatively insensitive to population evolution. Here we use a k-corrected and evolution-compensated volume-limited sample having an R-band absolute magnitude of Mk,eR</=-19.8+5logh mag drawing about 300 redshifts from the Caltech Faint Galaxy Redshift Survey and 3000 from the Canadian Network for Observational Cosmology field galaxy survey to measure the rate and redshift evolution of merging. The combined sample has an approximately constant comoving number and luminosity density from redshift 0.1 to 1.1 (OmegaM=0.2, OmegaLambda=0.8); hence, any merger evolution will be dominated by correlation and velocity evolution, not density evolution. We identify kinematic pairs with projected separations less than either 50 or 100 h-1 kpc and rest-frame velocity differences of less than 1000 km s-1. The fractional luminosity in pairs is modeled as fL&parl0;Deltav,rp,Mk,er&parr0;&parl0;1+z&parr0;mL, where &sqbl0;fL,mL&sqbr0; are &sqbl0;0.14+/-0.07,0+/-1.4&sqbr0; and &sqbl0;0.37+/-0.7,0.1+/-0.5&sqbr0; for rp</=50 and 100 h-1 kpc, respectively (OmegaM=0.2, OmegaLambda=0.8). The value of mL is about 0.6 larger if Lambda=0. To convert these redshift-space statistics to a merger rate, we use the data to derive a conversion factor to a physical space pair density, a merger probability, and a mean in-spiral time. The resulting mass accretion rate per galaxy (M1,M2>/=0.2M*) is 0.02+/-0.01&parl0;1+z&parr0;0.1+/-0.5M* Gyr-1. Present-day high-luminosity galaxies therefore have accreted approximately 0.15M* of their mass over the approximately 7 Gyr to redshift 1. Since merging is likely only weakly dependent on the host mass, the fractional effect, deltaM&solm0;M approximately 0.15M*&solm0;M, is dramatic for lower mass galaxies but is, on the average, effectively perturbative for galaxies above 1M*.

Rotations and Abundances of Blue Horizontal-Branch Stars in Globular Cluster M15

High-resolution optical spectra of 18 blue horizontal-branch stars in the globular cluster M15 indicate that their stellar rotation rates and photospheric compositions vary strongly as a function of effective temperature. Among the cooler stars in the sample, at Teff approximately 8500 K, metal abundances are in rough agreement with the canonical cluster metallicity, and the vsini rotations appear to have a bimodal distribution, with eight stars at vsini<15 km s-1 and two stars at vsini approximately 35 km s-1. Most of the stars at Teff>/=10,000 K, however, are slowly rotating, vsini<7 km s-1, and their iron and titanium are enhanced by a factor of 300 to solar abundance levels. Magnesium maintains a nearly constant abundance over the entire range of Teff, and helium is depleted by factors of 10-30 in three of the hotter stars. Diffusion effects in the stellar atmospheres are the most likely explanation for these large differences in composition. Our results are qualitatively very similar to those previously reported for M13 and NGC 6752, but with even larger enhancement amplitudes, presumably due to the increased efficiency of radiative levitation at lower intrinsic [Fe/H]. We also see evidence for faster stellar rotation explicitly preventing the onset of the diffusion mechanisms among a subset of the hotter stars.