A cost-free approach to evaluating vertebral body bone density and height loss in lung transplant recipients using routine chest CT.

BACKGROUND: To assess changes in bone density and vertebral body height of patients undergoing lung transplant surgery using computed tomography (CT). METHODS: This institutional review board (IRB) approved retrospective observational study enrolled patients with a history of lung transplant who had at least two chest CT scans. Vertebral body bone density (superior, middle, and inferior sections) and height (anterior, middle, and posterior sections) were measured at T1-T12 at baseline and follow up CT scans. Changes in the mean bone density, mean vertebral height, vertebral compression ratio (VBCR), percentage of anterior height compression (PAHC), and percentage of middle height compression (PMHC) were calculated and analyzed. RESULTS: A total of 93 participants with mean age of 58 ± 12.3 years were enrolled. The most common underlying disease that led to lung transplants was interstitial lung diseases (57 %). The inter-scan interval was 34.06 ± 24.8 months. There were significant changes (p-value < 0.05) in bone density at all levels from T3 to T12, with the greatest decline at the T10 level from 163.06 HU to 141.84 HU (p-value < 0.05). The average VBCR decreased from 96.91 to 96.15 (p-value < 0.05). CONCLUSION: Routine chest CT scans demonstrate a gradual decrease in vertebral body bone density over time in lung transplant recipients, along with evident anatomic changes such as vertebral body bone compression. This study shows that utilizing routine chest CT for lung transplant recipients can be regarded as a cost-free tool for assessing the vertebral body bone changes in these patients and potentially aiding in the prevention of complications related to osteoporosis.

How AI Responds to Common Lung Cancer Questions: ChatGPT vs Google Bard.

Background The recent release of large language models (LLMs) for public use, such as ChatGPT and Google Bard, has opened up a multitude of potential benefits as well as challenges. Purpose To evaluate and compare the accuracy and consistency of responses generated by publicly available ChatGPT-3.5 and Google Bard to non-expert questions related to lung cancer prevention, screening, and terminology commonly used in radiology reports based on the recommendation of Lung Imaging Reporting and Data System (Lung-RADS) v2022 from American College of Radiology and Fleischner society. Materials and Methods Forty of the exact same questions were created and presented to ChatGPT-3.5 and Google Bard experimental version as well as Bing and Google search engines by three different authors of this paper. Each answer was reviewed by two radiologists for accuracy. Responses were scored as correct, partially correct, incorrect, or unanswered. Consistency was also evaluated among the answers. Here, consistency was defined as the agreement between the three answers provided by ChatGPT-3.5, Google Bard experimental version, Bing, and Google search engines regardless of whether the concept conveyed was correct or incorrect. The accuracy among different tools were evaluated using Stata. Results ChatGPT-3.5 answered 120 questions with 85 (70.8%) correct, 14 (11.7%) partially correct, and 21 (17.5%) incorrect. Google Bard did not answer 23 (19.1%) questions. Among the 97 questions answered by Google Bard, 62 (51.7%) were correct, 11 (9.2%) were partially correct, and 24 (20%) were incorrect. Bing answered 120 questions with 74 (61.7%) correct, 13 (10.8%) partially correct, and 33 (27.5%) incorrect. Google search engine answered 120 questions with 66 (55%) correct, 27 (22.5%) partially correct, and 27 (22.5%) incorrect. The ChatGPT-3.5 is more likely to provide correct or partially answer than Google Bard, approximately by 1.5 folds (OR = 1.55, P = 0.004). ChatGPT-3.5 and Google search engine were more likely to be consistent than Google Bard by approximately 7 and 29 folds (OR = 6.65, P = 0.002 for ChatGPT and OR = 28.83, P = 0.002 for Google search engine, respectively). Conclusion Although ChatGPT-3.5 had a higher accuracy in comparison with the other tools, neither ChatGPT nor Google Bard, Bing and Google search engines answered all questions correctly and with 100% consistency.

Pulmonary vein and left atrial posterior wall isolation for the treatment of atrial fibrillation: Comparable outcomes for adults with congenital heart disease.

INTRODUCTION: Optimal treatment strategies for ACHD with AF are unknown. This study sought to assess outcomes of pulmonary vein isolation (PVI) ± left atrial (LA), posterior wall isolation (PWI) for adults with congenital heart disease (ACHD), and atrial fibrillation (AF). METHODS: A retrospective review of all cryoballoon (CB) PVI ± PWI procedures at a single center over a 3-year period were performed. Clinical characteristics and outcomes for patients with and without ACHD were compared. The primary outcome was the occurrence of atrial tachyarrhythmia at 12-months postablation after a 90-day blanking period. RESULTS: Three-hundred and sixteen patients (mean: 63 ± 12 years, [63% male]) underwent CB PVI ± PWI during the study, including 31 (10%) ACHD (simple 35%, moderate 39% complex 26%; nonparoxysmal AF in 52%). ACHD was younger (51 vs. 64 years; p < .001) with a lower CHADS2 DS2 -VASc score (1.2 vs. 2.1; p = .001) but had a greater LA diameter (4.9 vs. 4.0 cm; p < .001) and a number of prior cardioversions (0.9 vs. 0.4; p < .001) versus controls. 12-month freedom from recurrent AF was similar for ACHD and controls (76% vs. 80%; p = .6) and remained nonsignificant in multivariate analysis (hazard ratio: 1.8, 95% confidence interval: 0.7-5.1; p = .22). At 12-months postablation, 75% of ACHD versus 93% of control patients were off antiarrhythmic drug therapy (p = .07). CONCLUSION: This study demonstrates younger age and lower conventional stroke risk, yet clinically advanced AF for ACHD relative to controls. CB PVI ± PWI was an effective strategy for the treatment of AF among all forms of ACHD with similar 12-month outcomes as compared to controls.

Case 286: Sarcoidlike Granulomatosis and Lymphadenopathy-Thoracic Manifestations of Nivolumab Drug Toxicity.

History A 70-year-old man had a posterior left thigh lesion confirmed to be biopsy-proven melanoma. The patient underwent wide excision and sentinel node biopsy, which showed absence of residual melanoma. Two years later, the patient noticed a subcentimeter subcutaneous lump in his thigh. Repeat excisional biopsy showed involvement of the surrounding soft tissue, consistent with a satellite lesion. Follow-up combined PET/CT revealed satellite nodules around the primary lesion, enabling confirmation of subcutaneous metastatic disease. The patient was subsequently started on nivolumab, an anti-programmed cell death 1 (PD-1) immune checkpoint inhibitor that blocks PD-1 and is approved as a first-line treatment in patients with advanced metastatic melanoma. On the baseline scan prior to starting nivolumab, there were no CT findings that suggested metastatic disease, nor were there enlarged mediastinal or hilar lymph nodes. Five months after initiation of nivolumab treatment, the first follow-up chest CT scan was performed and showed new findings in the mediastinum and bilateral lungs. The patient remained asymptomatic during the treatment period. Furthermore, the subcutaneous metastatic disease remained stable during the treatment period, and no other site of metastatic disease was noted on follow-up CT scans obtained during the first 5 months of treatment. The patient had no prior history of infectious or occupational exposures. During the nivolumab treatment cycle, his pertinent laboratory values and physical examination findings were unremarkable.

Case 286.

History A 70-year-old man had a posterior left thigh lesion confirmed to be biopsy-proven melanoma. The patient underwent wide excision and sentinel node biopsy, which showed absence of residual melanoma. Two years later, the patient noticed a subcentimeter subcutaneous lump in his thigh. Repeat excisional biopsy showed involvement of the surrounding soft tissue, consistent with a satellite lesion. Follow-up combined PET/CT revealed satellite nodules around the primary lesion, enabling confirmation of subcutaneous metastatic disease. The patient was subsequently started on nivolumab, an anti-programmed cell death 1 (PD-1) immune checkpoint inhibitor that blocks PD-1 and is approved as a first-line treatment in patients with advanced metastatic melanoma. On the baseline scan prior to starting nivolumab, there were no CT findings that suggested metastatic disease, nor were there enlarged mediastinal or hilar lymph nodes. Five months after initiation of nivolumab treatment, the first follow-up chest CT scan was performed and showed new findings in the mediastinum (Fig 1) and bilateral lungs (Figs 2, 3). The patient remained asymptomatic during the treatment period. Furthermore, the subcutaneous metastatic disease remained stable during the treatment period, and no other site of metastatic disease was noted on follow-up CT scans obtained during the first 5 months of treatment. The patient had no prior history of infectious or occupational exposures. During the nivolumab treatment cycle, his pertinent laboratory values and physical examination findings were unremarkable.

Recent Innovations in Renal Vascular Imaging.

Noninvasive imaging of the vascular renal system is a common request in diagnostic radiology. Typical indications include suspected renovascular hypertension, vasculitis, neoplasm, vascular malformation, and structural diseases of the kidney. Profound knowledge of the renal anatomy, including vascular supply and variants, is mandatory for radiologists and allows for optimized protocolling and interpretation of imaging studies. Besides renal ultrasound, computed tomography and MR imaging are commonly requested cross-sectional studies for renal and renal vascular imaging. This article discusses basic renal vascular anatomy, common imaging findings, and current and potential future imaging protocols for various renovascular pathologic conditions.

Tracheobronchial Tumors: Radiologic-Pathologic Correlation of Tumors and Mimics.

Tracheobronchial masses encompass a broad spectrum of entities, ranging from benign and malignant neoplasms to infectious and inflammatory processes. This article reviews the cross-sectional findings of tracheal tumors and tumor-like entities, correlates imaging findings with histologic pathology, and discusses pearls and pitfalls in accurately diagnosing and classifying tracheal tumors and mimics.

A Private Investigation: Radiologic-Pathologic Correlation of Testicular Tumors.

To review the classification of testicular tumors, describe the sonographic and pathologic features of each tumor type, and discuss the mimics, diagnostic pitfalls, and management of testicular tumors. Method consists of pictorial review. We review sonographic and pathologic findings of several testicular tumors and tumorlike entities. Although ultrasound is the first-line imaging modality to differentiate between intratesticular and extratesticular location of an intrascrotal mass, it is not specific for intratesticular lesion characterization. Therefore, correlation with histology sampling is often necessary.

Breast: Sezary Syndrome: A Unique Presentation.

Sezary syndrome is a subtype of cutaneous T cell lymphoma which usually presents as generalized skin disease with erytheroderma. Distal organ involvement is rare and is usually a late finding in the course of the disease. Breast involvement is extremely rare. Herein, we present a case report of a patient whose initial presentation involved an intramammary lymph node prior to the onset of more characteristic skin disease. Sezary syndrome was confirmed by cythopathologic findings.

Computed tomography and echocardiography in patients with acute pulmonary embolism: part 2: prognostic value.

PURPOSE: The aim of the study was to compare the prognostic value of right ventricular (RV) dysfunction detected on computed tomography pulmonary angiography (CTPA) and transthoracic echocardiography (TTE) in patients with acute pulmonary embolism (PE). MATERIALS AND METHODS: From all consecutive CTPAs performed between August 2003 and May 2010 that were positive for acute PE (n=1744), those with TTE performed within 48 hours of CTPA (n=785) were selected as the study cohort. Multivariate logistic regression analysis was performed to assess the association of CTPA RV/left ventricular (LV) diameter ratio and TTE RV strain with PE-related 30-day mortality, including other associated factors as covariates. The predictive ability (area under the curve) was compared between the model including the CT RV/LV diameter ratio and that including TTE RV strain. Test characteristics of the 2 modalities were calculated. RESULTS: Both CT RV/LV diameter ratio and TTE RV strain were independently associated with PE-related 30-day mortality (adjusted odds ratio=1.14, P=0.023 for 0.1 increment of the CT RV/LV diameter ratio; and odds ratio=2.13, P=0.041 for TTE RV strain). History of congestive heart failure and malignancy were independent predictors of PE-related mortality, while there was significantly lower mortality associated with anticoagulation use. The model including TTE RV strain and that including CT RV/LV had similar predictive ability (area under the curve=0.80 vs. 0.81, P=0.50). The sensitivity, specificity, and positive and negative predictive values of TTE RV strain and CT RV/LV diameter ratio at a cutoff of ≥1.0 were similar for PE-related 30-day mortality. CONCLUSIONS: Both RV strain on TTE and an increased CT RV/LV diameter ratio are predictors of PE-related 30-day mortality with similar prognostic significance.

Malignancy and acute pulmonary embolism: risk stratification including the right to left ventricle diameter ratio in 1596 subjects.

PURPOSE: To test the hypothesis that subjects with a known malignancy at the time of acute pulmonary embolism (PE) have different clinical characteristics and predictors of 30-day all-cause mortality when compared with subjects with no known malignancy. MATERIALS AND METHODS: A retrospective (August 2003 to March 2010) cohort of 1596 consecutive positive (for acute PE) computed tomography pulmonary angiograms (CTPAs) performed at a single, large, urban teaching hospital was separated into those from subjects with (n=835) and those from subjects without (n=761) a known malignancy. Clinical characteristics were compared between groups, and a logistic regression model determined predictors of 30-day all-cause mortality for each group. RESULTS: Subjects with malignancy were older (60.8±13.9 vs. 54.5±18.8 y, P<0.001), had fewer risk factors for PE, and had a higher 30-day all-cause mortality (19.6% vs. 3.2%, P<0.001). The malignancy group had fewer predictors of death compared with the nonmalignancy group; advanced age, presence of coronary artery disease, history of stroke, and chronic obstructive lung disease were significantly more predictive of death in the nonmalignancy population. An enlarged right ventricle on CTPA (right to left ventricular diameter ratio >1.0) had a higher risk of 30-day death only among subjects with no known malignancy at the time of the CTPA (odds ratio=4.08, 95% confidence interval: 1.67-9.96). CONCLUSIONS: Among subjects who present with acute PE, those with a malignancy had different clinical characteristics and predictors of mortality when compared with the cohort of subjects with no known malignancy. A computed tomography-derived right to left ventricular diameter ratio predicts 30-day all-cause mortality only for those subjects who do not have a malignancy.

Comparison of coronary plaque subtypes in male and female patients using 320-row MDCTA.

OBJECTIVE: Determine plaque subtype and volume difference in male and female patients with obstructive and non-obstructive CAD using 320-row MDCTA. MATERIALS AND METHODS: 128 patients with suspected CAD underwent MDCTA. All studies were divided into two groups based on disease severity. 0-70% stenosis (non-obstructive CAD) & >70% (obstructive). All were compared for plaque quantity and subtypes by gender. Main arteries, RCA, LM, LAD and LCX were analyzed using Vitrea 5.2 software to quantify fatty, fibrous and calcified plaque. Thresholds for coronary plaque quantification (volume in mm(3)) were preset at 35 ± 12 HU for fatty, 90 ± 24 HU for fibrous and >130 HU for calcified/mixed plaque and analyzed using STATA software. RESULTS: Total plaque burden in 118 patients [65M: 53F] was significantly higher in all arteries in males compared to females with non-obstructive disease. Total plaque volume for males vs. females was: RCA: 10.10 ± 5.02 mm(3) vs. 6.89 ± 2.75 mm(3), respectively, p = 0.001; LAD: 7.21 ± 3.38 mm(3) vs. 5.89 ± 1.93 mm(3), respectively, p = 0.04; LCX: 9.13 ± 3.27 mm(3) vs. 7.16 ± 1.73 mm(3), respectively, p = 0.002; LM 15.13 ± 4.51 mm(3) vs. 11.85 ± 4.03 mm(3), respectively, p = 0.001. In sub-analyses, males had significantly more fibrous and fatty plaque in LM, LAD & LCX than females. However in the RCA, only fibrous plaque was significantly greater in males. Calcified plaque volume was not significantly different in both genders. Only 8% of patients had obstructive CAD (>70% stenosis); there was no significant difference in plaque volume or subtypes. CONCLUSION: In patients with non-obstructive CAD, males were found to have significantly higher total coronary plaque volume with predominance of fibrous and fatty subtypes compared to females of the same age and BMI. There was no significant difference in plaque subtype or volume in patients with obstructive disease.

Statistical methods for predicting mortality in patients diagnosed with acute pulmonary embolism.

RATIONALE AND OBJECTIVES: Risk stratification in pulmonary embolism (PE) guides patient management. The purpose of this study was to develop and test novel mortality risk prediction models for subjects with acute PE diagnosed using computed tomographic pulmonary angiography in a large cohort with comprehensive clinical data. MATERIALS AND METHODS: Retrospective analyses of 1596 consecutive subjects diagnosed with acute PE from a single, large, urban teaching hospital included two modern statistical methods to predict survival in patients with acute PE. Landmark analysis was used for 90-day mortality. Adaptive least absolute shrinkage and selection operator (aLASSO), a penalization method, was used to select variables important for prediction and to estimate model coefficients. Receiver-operating characteristic analysis was used to evaluate the resulting prediction rules. RESULTS: Using 30-day all-cause mortality outcome, three of the 16 clinical risk factors (the presence of a known malignancy, coronary artery disease, and increased age) were associated with high risk, while subjects treated with anticoagulation had lower risk. For 90-day landmark mortality, subjects with recent operations had a lower risk for death. Both prediction rules developed using aLASSO performed well compared to standard logistic regression. CONCLUSIONS: The aLASSO regression approach combined with landmark analysis provides a novel tool for large patient populations and can be applied for clinical risk stratification among subjects diagnosed with acute PE. After positive results on computed tomographic pulmonary angiography, the presence of a known malignancy, coronary artery disease, and advanced age increase 30-day mortality. Additional risk stratification can be simplified with these methods, and future work will place imaging-based prediction of mortality in perspective with other clinical data.

Histopathologic and clinical findings of congenital nephrotic syndrome in Iranian children: a study of two centers.

INTRODUCTION: Congenital nephrotic syndrome (CNS), an uncommon form of kidney disease, presents during the first year of life and is a diagnostic and therapeutic challenge for the pediatricians as well as pediatric nephrologists. Our study is the first study of Iranian children with CNS in two pediatric nephrology centers in Tehran, Iran. MATERIALS AND METHODS: We reviewed medical charts of 30 infants diagnosed with CNS from 1990 to 2005. RESULTS: There were 15 boys and 15 girls with CNS (mean age, 1.7 months). The presentation of the disease was nephrotic syndrome in 96.6% of the patients. Eighty percent of the patients presented within 3 months of life and 16 in the neonatal period. The Finnish type of CNS was seen in 43.3% and diffuse mesangial sclerosis in 50%. Preterm labor and low birth weight was seen in 20%. A family history of nephrotic syndrome in infancy was noted for 8 children (26.7%). Numerous complications of nephrotic syndrome occurred in 73.3%. Seventy percent of the patients had 27 episodes of infections. Sepsis was seen in 43.3% of the children, of which 61.5% were caused by gram-negative bacteria and 38.6% were caused by Staphylococcus aureus. Thrombotic complications and hypertension developed in 6.6% and 23.3% of the patients, respectively. The mortality rate of patients was 86.6%. CONCLUSIONS: Diffuse mesangial sclerosis is an important cause of CNS. The outcome of our patients was poor and most of our patients died before reaching the age of 5 years old.

Urine macrophage migration inhibitory factor (MIF) in children with urinary tract infection: a possible predictor of acute pyelonephritis.

Macrophage migration inhibitory factor (MIF) is an important pro-inflammatory cytokine expressed at sites of inflammation. We have assessed this factor (MIF) in urinary tract infections with the aim of determining a non-invasive and sensitive method to differentiate upper and lower renal involvement. Thirty-three pediatric patients with urinary track infection (25 with acute pyelonephritis, eight with acute cystitis) and 40 healthy subjects were recruited for this prospective case-control study. Pyelonephritis was differentiated from cystitis by dimercaptosuccinic acid (DMSA) scan. Urinary MIF concentration was determined using an enzyme-linked immunosorbent assay method. The urine MIF/creatinine (Cr) ratio was significantly higher in pyelonephritis patients than in those with acute cystitis and the control group (P < 0.001). The optimal cut-point of 4.90 pg/micromol Cr for the urine MIF/Cr ratio has the potential to be a biomarker for distinguishing patients with acute pyelonephritis from those with acute cystitis. Determination of the urinary MIF was also useful in selecting the patients at risk of permanent renal damage. Of those patients with pyelonephritis, based on the DMSA scan at the time of infection, scarring on follow-up DMSA scan 9-12 months later occurred in patients with the highest urinary MIF/Cr ratios. We conclude that the urine MIF/Cr ratio is a sensitive test for differentiating acute pyelonephritis from acute cystitis and also for detecting children with acute pyelonephritis who are at a higher risk for permanent renal scars in the future.