Primary Hepatic Lymphoma: A Rare Form of Diffuse Large B-Cell Lymphoma of the Liver.

Background: Primary hepatic lymphoma is a rare, malignant lymphoma of the liver unlike the predominant lymph nodal or splenic involvement associated with other types of lymphoma. It is commonly associated with nonspecific symptoms and usually detected incidentally on imaging examination. Case Presentation: An 84-year-old man was evaluated for upper back pain. Chest computed tomography showed multiple large lesions in the liver, leading to the diagnosis of primary diffuse large B-cell lymphoma of the liver. Within 2 weeks of detecting his liver mass, the patient developed hypercalcemia and hyperuricemia that led to rapid deterioration and admission for treatment. Further diagnostic testing was performed, and he was initiated on appropriate chemotherapy. Conclusions: Primary hepatic lymphoma, a form of diffuse large B-cell lymphoma of the liver is a rare disease without specific clinical manifestations, biochemical indicators, or radiologic features except for space-occupying liver lesions. However, patients' conditions can deteriorate rapidly at an advanced stage as demonstrated in this case, which highlights the importance of a high level of suspicion for early diagnosis and treatment.

Faster sorting algorithms discovered using deep reinforcement learning.

Fundamental algorithms such as sorting or hashing are used trillions of times on any given day1. As demand for computation grows, it has become critical for these algorithms to be as performant as possible. Whereas remarkable progress has been achieved in the past2, making further improvements on the efficiency of these routines has proved challenging for both human scientists and computational approaches. Here we show how artificial intelligence can go beyond the current state of the art by discovering hitherto unknown routines. To realize this, we formulated the task of finding a better sorting routine as a single-player game. We then trained a new deep reinforcement learning agent, AlphaDev, to play this game. AlphaDev discovered small sorting algorithms from scratch that outperformed previously known human benchmarks. These algorithms have been integrated into the LLVM standard C++ sort library3. This change to this part of the sort library represents the replacement of a component with an algorithm that has been automatically discovered using reinforcement learning. We also present results in extra domains, showcasing the generality of the approach.

Thromboelastography after Cardiopulmonary Bypass: Does it Save Blood Products?

INTRODUCTION: This study aimed to determine if thromboelastography (TEG) is associated with reduced blood product use and surgical reintervention following cardiopulmonary bypass (CPB) compared to traditional coagulation tests. METHODS: A retrospective review was conducted of 698 patients who underwent CPB at a tertiary-care, community-based, university-affiliated hospital from February 16, 2014 to February 16, 2015 (Period I) and from May 16, 2015 to May 16, 2016 (Period II). Traditional coagulation tests guided transfusion during Period I and TEG guided transfusion during Period II. Intraoperative and postoperative administration of blood products (red blood cells, fresh frozen plasma, platelets, and cryoprecipitate), reoperation for hemorrhage or graft occlusion, duration of mechanical ventilation, hospital length of stay, and mortality were recorded. RESULTS: Use of a TEG-directed algorithm was associated with a 13.5% absolute reduction in percentage of patients requiring blood products intraoperatively (48.2% vs. 34.7%, p < 0.001). TEG resulted in a 64.3% and 43.1% reduction in proportion of patients receiving fresh frozen plasma (FFP) and platelets, respectively, with a 50% reduction in volume of FFP administered (0.3 vs. 0.6 units, p < 0.001). Use of TEG was not observed to decrease postoperative blood product usage or mortality significantly. The median length of hospital stay was reduced by one day after TEG guided transfusion was implemented (nine days vs. eight days, p = 0.01). CONCLUSIONS: Use of TEG-directed transfusion of blood products following CPB appeared to decrease the need for intraoperative transfusions, but the effect on clinical outcomes has yet to be clearly determined.

Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric operation performed. However, it is not without its drawbacks and patients may develop gastroesophageal reflux (GERD) after LSG. There are limited data available to guide treatment choice for patients suffering these sequelae. OBJECTIVE: This study was undertaken to evaluate the success of conversion to Roux-en-Y gastric bypass (RYGB) in treating GERD symptoms after LSG. SETTING: Single bariatric center, United States. METHODS: Analysis of a prospectively maintained clinical database was performed. Outcomes studied included heartburn-related quality of life score (GERD-HRQL), anti-secretory usage, and body mass index (BMI). RESULTS: A total of 54 patients met inclusion criteria during the review period. Of these, 41 patients (76%) underwent conversion for indication including GERD. Mean BMI at conversion was 33.8 ± 5.61 and was found to be significantly reduced at 12 months after conversion (n = 26; 63%; P < .001) and at long-term follow-up (n = 37; 90%) (P ≤ .001; mean follow-up period: 33.3 mo). Mean GERD-HRQL at time of conversion was 31.5 ± 11.4. Conversion to RYGB produced a significant reduction of HRQL at 6 months after conversion (n = 30; 73%) (mean: 5.6, P < .001) and long-term follow-up (n = 38; 93%) (mean: 7.3, P < .001. mean follow-up period: 15.1 mo). Prior to conversion, 32 patients (78%) required antisecretory therapy for GERD and after conversion, 12 of these patients (38%) required antisecretory therapy (P < .001). These 12 patients were found to exhibit a significantly (P = .005) smaller decrease in GERD-HRQL after revision compared with their peers who were liberated from antisecretory therapy. Preoperative symptoms were compared between these 2 groups. Delayed onset of GERD symptoms after LSG (>3 mo) was found to be a significant risk factor for continued antisecretory dependence after conversion to RYGB. CONCLUSION: Conversion of LSG to RYGB quantitatively reduces GERD symptoms, and results in a modest but significant amount of weight loss. While there was a significant improvement in HRQL after revision, a subgroup of patients continued to be antisecretory-dependent and showed a limited improvement in HRQL. This limited response was predicted by a gradual onset of GERD symptoms prior to revision. An interval of 3 months or greater between LSG and onset of symptoms was found to be a significant risk factor for limited response to conversion.

Enhancing wound healing dressing development through interdisciplinary collaboration.

The process of wound healing includes four phases: Hemostasis, inflammation, proliferation, and remodeling. Many wound dressings and technologies have been developed to enhance the body's ability to close wounds and restore the function of damaged tissues. Several advancements in wound healing technology have resulted from innovative experiments by individual scientists or physicians working independently. The interplay between the medical and scientific research fields is vital to translating new discoveries in the lab to treatments at the bedside. Tracing the history of wound dressing development reveals that there is an opportunity for deeper collaboration between multiple disciplines to accelerate the advancement of novel wound healing technologies. In this review, we explore the different types of wound dressings and biomaterials used to treat wounds, and we investigate the role of multidisciplinary collaboration in the development of various wound management technologies to illustrate the benefit of direct collaboration between physicians and scientists.

Incidental Findings of Malignancy of the Chest by Single Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT-CT MPI): One Year Follow-Up Report.

INTRODUCTION: We recently reported six cases of pulmonary/hilar malignancies as the result of incidental findings (IF) on CT attenuation correction (CTAC) during Single Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT-CT MPI). In this study, clinical features, diagnostic procedures, and clinical outcomes were examined on all patients who had malignancies or significant IF that required further follow-up. METHODS: Of 1,098 consecutive patients who underwent cardiac SPECT-CT MPI from September 1, 2017 to August 31, 2018, their MPI and CTAC were reviewed contemporaneously. Patients with known history of prior pulmonary or chest malignancy were excluded. RESULTS: A total of 79 (7.2%) patients were identified to have significant IF on CTAC. After diagnostic CT, 47 patients had significant findings that warranted further follow-up and included in this study. Eight of 1,098 patients (0.73%) and 8/79 patients (10.1%) were found to have malignancy of the chest because of IF on the CTAC. There were no statistically significant differences in baseline characteristics and cancer risk factors among patients who had cancer versus those without. At the time of diagnosis, four patients had cancer at an advanced stage, resulting in death within 12 months. Three others had early stage lung cancer and one had mantle cell lymphoma; they were alive at a mean follow-up of 17.5+/-2.1 months. Biopsy for tissue diagnosis was performed safely with needle biopsy. Major complication occurred in one patient (1/9 or 11.1%) with needle biopsy; none with surgical biopsy. CONCLUSION: This study underscored the importance of reviewing CTAC images obtained during cardiac SPECT-CT MPI to detect clinically important IF.

Incidental Findings of Pulmonary and Hilar Malignancy by Low-Resolution Computed Tomography Used in Myocardial Perfusion Imaging.

BACKGROUND: Low dose, low-resolution computed tomography (CT) is used for attenuation correction to improve the quality of single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). Because of its low resolution, these CT images are considered non-diagnostic and are not routinely or uniformly reviewed or interpreted by a cardiologist. On the other hand, low-dose CT has been used for lung cancer screening to reduce lung cancer mortality and is recommended for annual screening of high-risk patients by the US Preventive Services Task Force. METHODS: Siemens Symbia Intevo Excel SPECT/CT scanners, used primarily for cardiac MPI, were used in the study. The study was intended to report incidental findings of pulmonary and hilar malignancy detected by these CT images during cardiac evaluation. It included 1,098 consecutive patients who had SPECT MPI from September 1, 2017 to August 31, 2018. When suspicious pulmonary nodules or abnormalities were identified, primary care providers were notified of the findings and recommendations for further evaluation. RESULTS: Five patients were found to have lung cancer (all male with substantial smoking history, aged 64-75 years), 1 had mantle cell lymphoma. Six of 1,098 (0.55%) patients were found to have incidental pulmonary/hilar malignancy, which is comparable to the yield (0.65%/year) of detecting lung cancer using low-dose CT for screening in The National Lung Screening Trial. CONCLUSIONS: Routine review and report of incidental findings on low-resolution CT during cardiac MPI by physicians skilled in CT interpretation is necessary to identify incidental but clinically important findings, including malignancies.

The amount of surgical correction of the main thoracic curve is the best predictor of postoperative clinical shoulder balance in patients with Adolescent Idiopathic Scoliosis.

PURPOSE: This study sought to analyze factors that predict postoperative shoulder balance based on clinical photography. METHODS: Based on inclusion criteria, 132 AIS patients were selected. Age, sex, and BMI of each patient were recorded. The following parameters were recorded from radiographs: clavicle angle, T1 tilt, the upper instrumented vertebra (UIV), lowest instrumented vertebra (LIV) thoracic kyphosis, lumbar modifier, preoperative and postoperative proximal thoracic Cobb angle, preoperative and postoperative main thoracic Cobb angle, and preoperative and postoperative thoracolumbar Cobb angle, if applicable. Two spine surgeons independently assigned the photographs shoulder balance grades based on the WRVAS (1-2 = Acceptable, 3-5 = Unacceptable). Surgeons were blinded as to whether the photographs were taken preoperatively or postoperatively. The shoulders were also graded as right high, left high, or balanced. RESULTS: Of all variables analyzed, only main thoracic Cobb angle correction (MTCAC) showed a statistically significant relationship with postoperative shoulder balance (p = 0.01). Odds of having unacceptable shoulder balance increase by 21% for every 5° increase in MTCAC (Adjusted OR = 1.21, 95% CI 1.015-1.452). The odds of unbalanced shoulders are 4.7 times higher for patients whose MTCAC is 40° or more (p = 0.001). Inter-rater reliability was excellent (k =0 .7). Intra rater reliability was perfect for Surgeon 1 (kappa = 1.0) and showed substantial agreement for Surgeon 2 (kappa = 0.8) CONCLUSIONS: Greater correction of main thoracic Cobb angle predicts unacceptable postoperative shoulder balance with 40° of correction signifying a major dichotomy between acceptable and unacceptable.

Continued vertebral body growth in patients with juvenile idiopathic scoliosis following vertebral body stapling.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To quantitatively measure the rate of growth of vertebral bodies in juvenile idiopathic scoliosis (JIS) treated with vertebral body stapling (VBS). VBS has been suggested to be a safe and effective method for modulating the growth of the young scoliotic spine, but few long-term studies have examined its efficacy. METHODS: Seven patients with JIS 11 years of age or younger underwent VBS with a minimum 6-year follow-up. Vertebral body height on the unstapled and stapled aspects of the curve was measured from initial and final postoperative radiographs and converted into rate of growth per year. Known staple dimensions were used to standardize the measurements between radiographs. Interstaple distance was measured to demonstrate continued growth of the spine. Adjacent vertebral bodies without instrumentation served as an internal control of growth. Each vertebral body (n = 35) was analyzed as an individual experimental unit. RESULTS: The average rate of growth was 0.86 mm/year (standard deviation [SD] 0.44, 95% confidence interval [CI] 0.71-1.0) per vertebral body on the stapled side and 0.83 mm/year (SD 0.46, 95% CI 0.67-0.98) per vertebral body on the unstapled side of the vertebral body. The adjacent vertebral body segments grew at a rate of 0.91 mm/year (SD 0.42, 95% CI 0.66-1.15) on the stapled side and 0.99 mm/year (SD 0.66, 95% CI 0.61-1.37) on the unstapled side, p < 0.01. The distance between staples increased significantly from 3.0 mm (SD 2.0, 95% CI 2.3-3.6) to 8.4 mm (SD 2.4, 95% CI 7.7-9.3). CONCLUSIONS: Vertebral body growth in the presence of VBS occurred at a similar rate on the stapled and unstapled sides of the curve. The high standard deviation of instrumented segment growth further supports the conclusion that VBS is not a reliable method of growth modulation in the young scoliotic spine. LEVEL OF EVIDENCE: IV.

Significance of New, Isolated T-wave Inversion in Multiple Electrocardiogram Leads with Regadenoson Injection in Patients with Normal Myocardial Perfusion Imaging: An Observational Report of 5 Consecutive Cases.

INTRODUCTION: The pharmacologic (regadenoson) stress myocardial perfusion imaging (MPI) is used widely in patients who cannot exercise for detecting coronary artery disease (CAD). The interpretation of these studies depends primarily on the imaging results because the sensitivity of electrocardiograms (ECG) in this setting is poor. Prior study showed that effects of regadenoson on ST-segment occurred infrequently and had low sensitivity for detecting CAD. The significance of T-wave inversion in multiple ECG leads without ST-segment depression with regadenoson injection in patients with normal MPI is described and reported. METHODS: ECGs were reviewed retrospectively in 64 patients who had regadenoson MPI and coronary angiography for evaluation of CAD from June 1, 2016 to August 31, 2018. Five cases were identified with new, isolated T-wave inversion in multiple ECG leads. RESULTS: All five cases had new and isolated T-wave inversion in multiple leads without ST segment depression with regadenoson injection and normal MPI. At coronary angiography, three of the five cases showed obstructive coronary artery disease who received coronary percutaneous intervention. One case had nonobstructive coronary artery disease and one had a normal coronary artery. CONCLUSIONS: Despite nonspecific ST-T changes on baseline ECGs and normal MPI in all patients, three of five cases had obstructive CAD by coronary angiography. New, isolated T-wave inversion in multiple ECG leads with regadenoson injection were observed in our patients with normal MPI. These ECG findings may be associated with false negative MPI. Therefore, careful observation and scrutiny of all ECG changes, especially new, isolated T-wave inversion in multiple ECG leads during regadenoson MPI is advisable to identify potential obstructive CAD despite normal MPI findings.

Do Heavier Patients With Adolescent Idiopathic Scoliosis Have More Preserved Thoracic Kyphosis and Pulmonary Function?

STUDY DESIGN: Retrospective. OBJECTIVES: We aimed to determine if heavier patients with adolescent idiopathic scoliosis (AIS) had more preserved thoracic kyphosis (TK), and as a result, more preserved pulmonary function. SUMMARY OF BACKGROUND DATA: Some believe that childhood weight is predictive of adult sagittal plane parameters, with heavier children having greater TK as adults. Generally, thoracic scoliosis is coupled with loss of TK, which is associated with worsening pulmonary function. METHODS: A total of 142 patients with AIS and a structural main thoracic curve were analyzed. We excluded patients with structural proximal thoracic curves (Lenke 2 and 4). Standing preoperative radiographs, pulmonary function tests, and preoperative body mass indices (BMIs) were reviewed. The main thoracic Cobb angle, T2-T12 TK, percentage predicted forced vital capacity (FVC) and BMI were recorded. Spearman correlation was determined. Linear regression analysis used FVC as the primary outcome and BMI, TK, and Cobb angle as the independent variables. BMI categories were overweight/obese (BMI ≥25) and normal (BMI <25). Wilcoxon rank-sum tests were performed to detect a difference in TK and BMI between the 2 groups. The Cobb angles between the two groups were analyzed by t tests. RESULTS: Demonstrated correlations included BMI and FVC (0.37, p ≤.01), FVC and TK (0.26, p <.01), BMI and TK (0.23, p = .01), and FVC and Cobb angle (-0.23, p = .01). Linear regression revealed that Cobb angle (p ≤.01), TK (p <.01), and BMI (p <.01) remained statistically significant predictors of FVC. Wilcoxon rank-sum tests revealed a statistically significant difference between TK (p = .03) and FVC (p <.01) in the overweight/obese group and the normal group, with the overweight/obese group having greater values for both TK and FVC. The Cobb angles between the overweight/obese and normal group were not significantly different (p = .72). CONCLUSIONS: Heavier AIS patients have greater values of TK and percentage predicted FVC. LEVEL OF EVIDENCE: Level III.