Interstitial lung abnormalities in the Queensland Lung Cancer Screening Study: prevalence and progression over 2 years of surveillance.

BACKGROUND: We report the prevalence and progression of incidentally detected interstitial lung abnormalities (ILA) in the Queensland Lung Cancer Screening Study cohort. METHODS: About 256 volunteers aged 60-74, with ≥30 pack years smoking history and forced expiratory volume in 1 s (FEV1) ≥50% predicted underwent low-dose computed tomography (CT) chest screening. Electronic search of baseline (T0) and 2-year follow-up (T2) CT reports identified candidate cases using Fleischner Society interstitial terminology. Candidate CT were reviewed in a randomised order by two experienced radiologists and a senior respiratory medicine trainee blinded to the existing reports. Scans were evaluated for the presence and extent of ILA using an in-house score, and graded for progression. RESULTS: ILA were detected in 20/256 baseline cases (7.8%) with no incident cases detected at T2 surveillance imaging. Of these 20 cases, 9 (45%) had reticulation, 18 (90%) had ground glass change, 1 had traction bronchiectasis and 1 had randomly distributed nodularity. Seven cases with ground glass changes also had areas of reticulation, and only two had reticulation alone. All ILA were graded as minor except for traction bronchiectasis, which was moderate. Only one case progressed on T2 imaging. ILA were associated with the presence of auscultatory crackles (50% vs 11.6%, P = 0.001) and a lesser degree of emphysema (mean % volumetric emphysema 6.7% vs 9.8%, P = 0.009). No relationship was observed between baseline and serial lung function parameters. CONCLUSION: ILA are frequent incidental findings in lung cancer screening. In the majority of cases these abnormalities do not appear to change significantly over a 2-year period of surveillance.

MRI measurements of the thoracic aorta and pulmonary artery.

INTRODUCTION: The purpose of this study was to obtain a range of normal measurements of the adult thoracic aorta and main pulmonary artery using cardiac MRI, and to assess agreement between measurements made on ECG-gated two-dimensional (2D) breath held steady-state-free precession (SSFP), and three-dimensional (3D) breath held SSFP image acquisitions. METHODS: Forty-nine normal volunteers underwent cardiac MRI using a 1.5T system. Two independent examiners measured the ascending aorta, aortic arch, descending thoracic aorta and main pulmonary artery in pre-defined locations. RESULTS: Overall, inter-observer agreement for all measurements was excellent. Close agreement was observed in aortic diameters obtained from the 2D and 3D SSFP methods in six of the nine aortic measurement sites. There was a tendency for the 3D measurements to be smaller than the 2D measurements but this was only significant at two sites, the aortic annulus, and the ascending aorta. There was a significance difference in aortic measurements between the left carotid artery (LC) and the left subclavian artery (LSC). CONCLUSION: Normal values for transverse diameters of the thoracic aorta and main pulmonary artery were established using 2D and 3D non-contrast MR sequences in healthy adults. Overall both inter-observer agreement, and agreement between 2D and 3D techniques was good. Mean diameter differences demonstrated at the aortic annulus, ascending aorta and aortic arch between LC and LSC although significant were less than one millimetre and unlikely to be important in clinical practice.

Screen-detected subsolid pulmonary nodules: long-term follow-up and application of the PanCan lung cancer risk prediction model.

OBJECTIVE: To report the long-term follow-up of subsolid nodules (SSNs) detected in participants of a prospective low-dose CT lung cancer screening cohort, and to investigate the utility of the PanCan model in stratifying risk in baseline SSNs. METHODS: Participants underwent a baseline scan, two annual incidence scans and further follow-up scans for the detected nodules. All SSNs underwent a minimum of 2 years of follow-up (unless resolved or resected). Risk of malignancy was estimated using the PanCan model; discrimination [area under the receiver-operating characteristic curve (AUC)] and calibration (Hosmer-Lemeshow goodness-of-fit test) were assessed. The Mann-Whitney U-Wilcoxon test was used to compare estimated risk between groups. RESULTS: 70 SSNs were detected in 41 (16.0%) out of 256 total participants. Median follow-up period was 25.5 months (range 2.0-74.0 months). 29 (41.4%) SSNs were transient. Five (7.1%) SSNs were resected, all found to be Stage I lung adenocarcinoma, including one SSN stable in size for 3.0 years before growth was detected. The PanCan model had good discrimination for the 52 baseline SSNs (AUC = 0.89; 95% confidence interval 0.76-1); the Hosmer-Lemeshow goodness-of-fit test was non-significant (p = 0.27). Estimated risk was significantly higher in the baseline SSNs found to be cancer vs those not found to be cancer after 2-6 years of follow-up (p < 0.01). CONCLUSION: Our findings support a long-term follow-up approach for screen-detected SSNs for 3 years or longer. The PanCan model appeared discriminatory and well calibrated in this cohort. ADVANCES IN KNOWLEDGE: The PanCan model may have utility in identifying low-risk SSNs which could be followed with less frequent CT scans.

Late gadolinium enhancement does occur in Tako-tsubo cardiomyopathy - A quantitative cardiac magnetic resonance and speckle tracking strain study.

BACKGROUND: Late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) has been recommended to distinguish Tako-tsubo cardiomyopathy (TTC) from either acute myocardial infarction or myocarditis. METHOD: 44 consecutive patients with confirmed Mayo Clinic criteria for TTC underwent CMR imaging at 1.5 Tesla during the acute phase. 10 patients who had CMRI to exclude scar related ventricular tachycardia, and had negative studies, were used as negative controls. LGE was quantitated at two signal intensity thresholds (CircleCVi software) at > 2 and > 5 standard-deviations (SD) above reference myocardium, and compared to biomarkers. FINDINGS: Mean door-to-CMR time was 57 hours. 18 patients (41%) had LGE > 2 SD localized to the area of abnormal wall motion, representing 28.9 ± 11.2% LV mass. In 16 of these 18 patients (89%) LGE signal intensity was > 5 SD above normal myocardium, representing 12.1 ± 10% LV mass. LGE signal intensity was significantly greater in TTC than in matched controls (p < 0.05) but lower than in STEMI patients (p < 0.05). Mean troponin was significantly higher in LGE positive patients (2.5 ± 1.8 vs 4.4 ± 6.9, p = 0.001). Mean ejection fraction (EF) by CMR was 45% ± 8.7 in LGE-negative, and 40% ± 7.1 in LGE-positive patients (p = 0.37). Recovery of segmental function was confirmed at follow-up, mean EF was 59% in both groups. CONCLUSION: LGE was present in 41% of cases of TTC, 89% of which had intense enhancement > 5 SD above normal myocardium. Presence of LGE was associated with worse myocardial injury in the acute setting, with no difference in recovery of function.

Enhancing Academic Success by Creating a Community of Learners.

OBJECTIVE: To enhance academic performance and student progression by creating a community of learners. DESIGN: Academic performance and student progression of students participating in the first 3 years of a second-year pharmacy learning community were compared with those of students in the 3 previous classes. Students participating in the learning community completed surveys at the end of each semester and at the end of the academic year. Peer mentors were surveyed at the end of the academic year. ASSESSMENT: After implementing the learning community, failures during the second year of the pharmacy program decreased. Students had increasingly positive perceptions of the experience over the 3 years. Peer mentors rated their overall experience highly. CONCLUSION: Implementation of a learning community resulted in improved progression through the program and was well received by students.

Coronary artery calcification on computed tomography correlates with mortality in chronic obstructive pulmonary disease.

OBJECTIVE: This cross-sectional study assessed the prognostic implications of computed tomography (CT) coronary artery calcification (CAC), independent of emphysema, in patients with chronic obstructive pulmonary disease (COPD). MATERIALS AND METHODS: Coronary artery calcification and emphysema were assessed on noncontrast, ungated chest CT scans of patients with COPD using the validated CAC ordinal visual scale (CAC OVS; range, 0-12) and visual CT emphysema index. RESULTS: A total of 200 CT images were analyzed. All-cause mortality was associated with CAC OVS greater than 4 (hazard ratio, 2.03; 95% confidence interval, 1.08-3.82; P = 0.028) and with moderate to severe CT emphysema index (hazard ratio, 4.34; 95% confidence interval, 1.53-12.33; P = 0.006). Increased emphysema severity, myocardial infarction, hypertension, and male sex independently correlated with CAC OVS greater than 4. CONCLUSIONS: Coronary artery calcification severity and emphysema severity on CT images are related and are strongly as well as independently associated with prognosis in patients with moderate to severe COPD. The potential to use CAC OVS on unenhanced nongated CT as a screening tool for coronary artery disease and as a prognostic marker in patients with COPD needs further investigation in prospective studies.

Pharmacokinetic behavior presents drug therapy challenges.

There are conditions that cause a substantial change in drug clearance to such a degree that how a specific drug is managed to optimize drug response and minimize drug toxicity presents a challenge. This review will focus on recent literature (within the past 5 years) that evaluates pathophysiologic and genetic conditions and drug interactions which can change drug clearance to the magnitude that response is affected. Situations discussed that cause an increase in drug clearance will include: augmented renal clearance in critically ill patients; ultrafast drug metabolism caused by gene duplication; and enzyme induction interactions caused by rifampin. Situations discussed that result in a reduction in clearance will include: multiple organ failure in critically ill, patients with non-functioning CYP2D6 and CYP2C8/9 alleles, and CYP3A4 drug interactions with erythromycin and clarithromycin. In each case evaluated clearance is changed to the magnitude such that managing drug therapy can be difficult.

RETRACTED: Right to left ventricular volume ratio: A novel marker of disease severity in chronic thromboembolic pulmonary hypertension.

[This retracts the article DOI: 10.1016/j.ijchv.2013.10.001.].

Radiology and pathology correlation in common infiltrative cardiomyopathies.

Infiltrative cardiomyopathies generally pose a diagnostic dilemma as current diagnostic tools are imprecise. Invasive endomyocardial biopsy is considered as the gold standard however it has some limitations. Recently cardiovascular magnetic resonance (CMR) is emerging as an excellent technique in diagnosing infiltrative cardiomyopathies and is increasingly being used. Characteristic pathologic and radiologic findings in most common infiltrative cardiomyopathies (amyloid, sarcoid and Fabry's) are discussed and correlated with relative CMR and histologic examples. There is fairly good correlation between the non-invasive radiologic and the invasive histologic findings in common infiltrative cardiomyopathies. Non-invasive CMR with its high sensitivity and specificity has an excellent role in establishing the diagnosis and improving the prognosis of common infiltrative cardiomyopathies.

Systemic thrombolysis for acute, severe Budd-Chiari syndrome.

Budd-Chiari syndrome (BCS) or hepatic venous outflow obstruction, is a rare and complex clinical entity, with diverse aetiology and a wide range of presentations. Its rarity and heterogeneity create significant challenges for evidence-based clinical decision-making, particularly in the even more infrequent setting of acute BCS presentation. Here we present the case of a young woman with acute, severe BCS, where treatment alternatives were limited due to a significant IVC thrombus burden. A clearly defined acute onset allowed the prompt use of systemic thrombolysis, conducted in consultation with a multi-disciplinary team of clinicians, with close monitoring for both treatment response and complications. Her treatment resulted in resolution of hepatic vein occlusion and prevention of the potentially significant clinical sequelae. We review the literature and discuss current opinion in the management of BCS.

CT angiography with cardiac MRI: non-invasive functional and anatomical assessment for the etiology in newly diagnosed heart failure.

Exclusion of ischemia is important in patients with newly diagnosed systolic heart failure (HF). We prospectively compared standard-of-care invasive catheter angiography (iCA) and echocardiography to a novel non-invasive strategy of both Coronary Computed Tomographic Angiography (CCTA) and Cardiovascular MRI (CMR) to determine the etiology of myocardial dysfunction Prospective data were collected from consecutive patients referred for iCA to investigate echocardiographically-confirmed new onset HF. CMR (1.5T GE) and dual source CCTA were performed within 2-7 days of iCA. Results were blinded and separately analyzed by expert readers. 426 coronary segments from 28 prospectively enrolled patients were analyzed by CCTA and quantitative iCA. The per-patient sensitivity and specificity of CCTA was 100% and 90%, respectively, negative predictive value (NPV) 100%, positive predictive value (PPV) 78%. Mean ejection fraction by CMR was 24%. Presence of ischemic-type LGE on CMR conferred a 67% sensitivity, 100% specificity, 90% NPV and 100% PPV. Combining CCTA with CMR conferred 100% specificity, 100% sensitivity, 100% PPV and 100% NPV for detection or exclusion of coronary disease. In patients with negative CCTA all invasive angiograms could have been avoided. In addition, two patients with no ischemic LGE by CMR had severe coronary disease on both CCTA and iCA, indicating global hibernation. This is a noteworthy finding in contrast to previous reports which suggested that absence of LGE rules out significant CAD. CCTA with CMR in newly-diagnosed HF enables non-invasive assessment of coronary artery disease, the severity and etiology of myocardial dysfunction and defines suitability for revascularization. Absence of ischemic-type LGE at CMR does not exclude CAD as a cause of LV dysfunction. A first-line strategy of functional and anatomic imaging with CMR and CCTA appears appropriate in newly diagnosed HF.

Prevalence of articles with honorary and ghost authors in three pharmacy journals.

PURPOSE: The prevalence of honorary and ghost authors in articles published in 2009 in three peer-reviewed pharmacy journals was studied. METHODS: A 20-question survey was e-mailed to corresponding authors of articles with two or more authors published in 2009 in the American Journal of Health-System Pharmacy, Annals of Pharmacotherapy, and Pharmacotherapy. The survey solicited the following information: demographic characteristics of the corresponding author, information about the published article, information to determine whether any of the authors did not meet the International Committee of Medical Journal Editors criteria for authorship, and information to determine if an individual contributed substantially to the research or writing of the article but was not listed as an author. RESULTS: Of the 491 corresponding authors to whom the survey was sent, 457 had a working e-mail address; 114 surveys were completed (24.9% response rate). Usable responses were provided by 112 authors. The prevalence of articles with honorary and ghost authors was 14.3% and 0.9%, respectively. Honorary authorship was more common in original research than review articles. Articles with honorary authors had longer bylines than articles without honorary authors (mean number of authors, 4.9 versus 3.7; p = 0.002). The proportion of articles with an honorary author was 1.9% for articles with fewer than 4 authors, 25% for articles with 4 or 5 authors, and 29.4% for articles with more than 5 authors (p = 0.001). CONCLUSION: A survey sent to the corresponding authors of articles published in 2009 in three peer-reviewed pharmacy journals revealed that a substantial percentage of articles demonstrated evidence of honorary or ghost authorship.

Angioembolisation of pulmonary artery pseudoaneurysm arising in H1N1 influenza viral pneumonia.

A 51 year-old Aboriginal woman was diagnosed with H1N1 influenza virus and methicillin-resistant Staphylococcus aureus. Contrasted CT of the pulmonary and bronchial vasculature undertaken for investigation for of haemoptysis revealed an 11 mm left upper lobe pulmonary artery pseudoaneurysm (PAP). The PAP was successfully treated with angioembolisation of the parent artery with two platinum coils. Pulmonary artery pseudoaneurysms are uncommon but potentially life-threatening and have not previously been reported in association with H1N1 influenza viral pneumonia, which has been prominent in recent times in both medical literature and popular press.

Percutaneous treatment of an occlusive left main pseudoaneurysm: a role for multimodality imaging.

A pseudoaneurysm with compression of the left main coronary artery causing significant ischaemia was successfully treated with a covered stent. We report this rare complication of cardiac surgery for infective endocarditis with a large root abscess. The patient developed a pseudoaneurysm arising from the body of the left main and causing compression of this vessel following his fourth redo aortic valve replacement for staphylococcal endocarditis. The endocarditis had been successfully managed and ongoing infection was excluded. The patient was then treated percutaneously with a covered stent that excluded the aneurysm and relieved the stenosis in the vessel.