Aluminosis pneumoconiosis presenting as hyperdense lung nodules.

We present the case of a 66-year-old man who presented with new incidentally found hyperdense pulmonary nodules. Further workup with a PET/CT revealed that the nodules were FDG-avid and that there was associated hypermetabolic lymphadenopathy. Due to his history of aluminum toxicity from welding, aluminosis pneumoconiosis was suspected. Biopsy of one of the nodules was done which reinforced this diagnosis. Aluminosis pneumoconiosis is a rare occupational lung disease mostly associated with industrial workers with prolonged unprotected exposure to fine aluminum dust. Prognosis depends on the duration and intensity of exposure, and there is no definitive treatment other than eliminating further exposure.

Enhancing the identification of rheumatoid arthritis-associated interstitial lung disease through text mining of chest computerized tomography reports.

OBJECTIVES: Algorithms have been developed to identify rheumatoid arthritis-interstitial lung disease (RA-ILD) in administrative data with positive predictive values (PPVs) between 70 and 80%. We hypothesized that including ILD-related terms identified within chest computed tomography (CT) reports through text mining would improve the PPV of these algorithms in this cross-sectional study. METHODS: We identified a derivation cohort of possible RA-ILD cases (n = 114) using electronic health record data from a large academic medical center and performed medical record review to validate diagnoses (reference standard). ILD-related terms (e.g., ground glass, honeycomb) were identified in chest CT reports by natural language processing. Administrative algorithms including diagnostic and procedural codes as well as specialty were applied to the cohort both with and without the requirement for ILD-related terms from CT reports. We subsequently analyzed similar algorithms in an external validation cohort of 536 participants with RA. RESULTS: The addition of ILD-related terms to RA-ILD administrative algorithms increased the PPV in both the derivation (improvement ranging from 3.6 to 11.7%) and validation cohorts (improvement 6.0 to 21.1%). This increase was greatest for less stringent algorithms. Administrative algorithms including ILD-related terms from CT reports exceeded a PPV of 90% (maximum 94.6% derivation cohort). Increases in PPV were accompanied by a decline in sensitivity (validation cohort -3.9 to -19.5%). CONCLUSIONS: The addition of ILD-related terms identified by text mining from chest CT reports led to improvements in the PPV of RA-ILD algorithms. With high PPVs, use of these algorithms in large data sets could facilitate epidemiologic and comparative effectiveness research in RA-ILD.

Head Lice Infestation: An Unusual Cause of Iron Deficiency Anemia in a 13-Year-Old Female.

Pediculosis is a parasitic infestation of the human head and body by Pediculus humanus. This is a benign condition commonly seen in children and capable of causing severe pruritus. The parasite thrives on human blood and in some cases, the volume of blood loss over time could be large enough to precipitate anemic symptoms in the patient. We describe the case of a 13-year-old girl who presented with shortness of breath on exertion, palpitations, and easy fatigability. An incidental finding of Pediculus humanus capitis infestation was made during physical examination. Complete laboratory investigations did not reveal other possible causes of anemia, leading to a diagnosis of iron deficiency anemia (IDA) secondary to severe chronic pediculosis. This case highlights a rare and unusual cause of IDA in children caused by pediculosis, and the need for a thorough investigation, close follow-up, and treatment.

Endovascular Repair of Blunt Thoracic Aortic Trauma is Associated With Increased Left Ventricular Mass, Hypertension, and Off-target Aortic Remodeling.

BACKGROUND: Aortic elasticity creates a cushion that protects the heart from pressure injury, and a recoil that helps perfuse the coronary arteries. TEVAR has become first-line therapy for many aortic pathologies including trauma, but stent-grafts stiffen the aorta and likely increase LV afterload. OBJECTIVE: Test the hypothesis that trauma TEVAR is associated with LV mass increase and adverse off-target aortic remodeling. METHODS: Computed Tomography Angiography (CTA) scans of 20 trauma TEVAR patients (17 M/3 F) at baseline [age 34.9 ±â€Š18.5 (11.4-71.5) years] and 5.1 ±â€Š3.1 (1.1-12.3) years after repair were used to measure changes in LV mass, LV mass index, and diameters and lengths of the ascending thoracic aorta (ATA). Measurements were compared with similarly-aged control patients without aortic repair (21 M/21 F) evaluated at similar follow-ups. RESULTS: LV mass and LV mass index of TEVAR patients increased from 138.5 ±â€Š39.6 g and 72.35 ±â€Š15.17 g/m2 to 173.5 ±â€Š50.1 g and 85.48 ±â€Š18.34 g/m2 at the rate of 10.03 ±â€Š12.79 g/yr and 6.25 ±â€Š10.28 g/m2/yr, whereas in control patients LV characteristics did not change. ATA diameters of TEVAR patients increased at a rate of 0.60 ±â€Š0.80 mm/yr, which was 2.4-fold faster than in controls. ATA length in both TEVAR and control patients increased at 0.58 mm/yr. Half of TEVAR patients had hypertension at follow-up compared to only 5% at baseline. CONCLUSIONS: TEVAR is associated with LV mass increase, development of hypertension, and accelerated expansile remodeling of the ascending aorta. Although younger trauma patients may adapt to these effects, these changes may be even more important in older patients with other aortic pathologies and diminished baseline cardiac function.

Imaging appearance of cystic and solid mesothelioma of the tunica vaginalis.

We present the case of a 32-year-old male who presented with a growing scrotal mass initially diagnosed as benign adenomatoid tumor on ultrasound 6 years prior. Repeat ultrasound showed an abnormal extra-testicular mass with nodular and cystic components and internal vascularity. A computed tomography scan of the abdomen and pelvis confirmed a right extra-testicular scrotal mass with cystic and solid enhancing components. The patient underwent radical orchiectomy and postoperative pathology diagnosed mesothelioma of the tunica vaginalis of the testis. Mesothelioma of the tunica vaginalis of the testis is an exceptionally rare disease. We discuss the risk factors, imaging features, and treatment strategies of the disease.

Infliximab Treatment of Refractory Cardiac Sarcoidosis.

Treatment of cardiac sarcoidosis is challenging, as the disease can be refractory to traditional treatment with steroids. Infliximab, a tumor necrosis factor-α inhibitor, has been reportedly used in cardiac sarcoidosis, but published evidence is limited. The potential cardiotoxicity of infliximab and the Food and Drug Administration black-box warning for patients with heart failure have hindered the use of this agent in cardiac sarcoidosis. Here, we report a case of refractory cardiac sarcoidosis successfully treated with infliximab and discuss the important role of fluorine-18-fluorodeoxyglucose positron emission tomography in prognostication and guidance of therapy. (Level of Difficulty: Intermediate.).

Impact of Enlarged Nonhypermetabolic Lymph Nodes on Outcomes After Stereotactic Body Radiotherapy for Early-Stage Non-Small-Cell Lung Cancer.

BACKGROUND: Up to 15% of patients undergoing positron emission tomography (PET)/computed tomography (CT) before stereotactic body radiotherapy (SBRT) harbor occult nodal disease. In the absence of invasive mediastinal staging, the clinical significance of enlarged nonhypermetabolic lymph nodes (LNs) remains unclear. We performed what is to our knowledge the first study to address whether enlarged nonhypermetabolic LNs were associated with higher post-SBRT failure rates. PATIENTS AND METHODS: Two academic centers assessed 157 consecutive patients treated with SBRT for cT1-2aN0M0 non-small-cell lung cancer who underwent PET/CT without pathologic nodal staging. The cutoff of an enlarged node was ≥ 1.0 cm, although a 7 mm threshold was also evaluated. Local recurrence-free survival (RFS), regional RFS, distant metastasis-free survival, RFS, and overall survival (OS) were calculated by Kaplan-Meier methodology. Multivariate Cox modeling addressed factors associated with RFS and OS. RESULTS: There were 120 patients (76%) with LNs < 1 cm and 37 (24%) with nodes ≥ 1 cm. Most patients had peripheral and/or T1 tumors. Median follow-up was 25.5 months. There were no differences between cohorts in actuarial local RFS, regional RFS, distant metastasis-free survival, RFS, or OS (P > .05 for all). Thirteen percent of patients experienced any nodal relapse, 15% of which occurred in the same station as that of the largest pre-SBRT LN. Stratification by largest LN location in an N1 versus N2 station showed no differences in RFS or OS (P > .05 for both). A 7 mm cutoff also showed no differences in outcomes (P > .05 for all). LN size was not correlated with RFS/OS on multivariable analysis (P > .05 for both). CONCLUSION: The presence of enlarged nonhypermetabolic LNs on PET/CT is not associated with increased post-SBRT failure rates.

Comprehensive Health Care Economics Curriculum and Training in Radiology Residency.

PURPOSE: To investigate the ability to successfully develop and institute a comprehensive health care economics skills curriculum in radiology residency training utilizing didactic lectures, case scenario exercises, and residency miniretreats. METHODS: A comprehensive health care economics skills curriculum was developed to significantly expand upon the basic ACGME radiology residency milestone System-Based Practice, SBP2: Health Care Economics requirements and include additional education in business and contract negotiation, radiology sales and marketing, and governmental and private payers' influence in the practice of radiology. RESULTS: A health care economics curriculum for radiology residents incorporating three phases of education was developed and implemented. Phase 1 of the curriculum constituted basic education through didactic lectures covering System-Based Practice, SBP2: Health Care Economics requirements. Phase 2 constituted further, more advanced didactic lectures on radiology sales and marketing techniques as well as government and private insurers' role in the business of radiology. Phase 3 applied knowledge attained from the initial two phases to real-life case scenario exercises and radiology department business miniretreats with the remainder of the radiology department. CONCLUSION: A health care economics skills curriculum in radiology residency is attainable and essential in the education of future radiology residents in the ever-changing climate of health care economics. Institution of more comprehensive programs will likely maximize the long-term success of radiology as a specialty by identifying and educating future leaders in the field of radiology.

Model for prioritization of Graduate Medical Education funding at a university setting - Engagement of GME committee with the Clinical Enterprise.

BACKGROUND: Funding for graduate medical education (GME) is becoming scarce and is likely to worsen. There is a higher degree of accountability and return on investment demanded from public funds dedicated to GME. Academic centers (AC) partnered with clinical enterprises (CE) are finding it increasingly difficult to retain sustainable funding streams for GME activities. METHODS: To develop and implement a novel algorithmic funding model at one AC in symbiotic partnership with the CE for all 50 GME programs with nearly 500 residents. RESULTS: A new GME Finance and Workforce Committee was convened which was tasked with developing the novel algorithmic financial model to prioritize GME funding. Early outcomes measures that were monitored consisted of: satisfaction of all stakeholders and financial savings. CONCLUSIONS: The model was presented to all the stakeholders and was well received and approved. Early signs, demonstrated AC and CE satisfaction with the model, financial savings and increased efficiency. This GME funding model may serve as a template for other academic centers with tailored modifications to suit their local needs, demands and constraints.

Name It! Store It! Protect It!: A Systems Approach to Managing Data in Research Core Facilities.

As the capabilities of technology increase, so do the production of data and the need for data management. The need for data storage at many academic institutions is increasing exponentially. Technology is expanding rapidly, and institutions are recognizing the need to incorporate data management that can be available for future data sharing as a critical component of institutional services. The establishment of a process to manage the surge in data storage is complex and often hindered by not having a plan. Simple file naming-nomenclature-is also becoming ever more important to leave an established understanding of the contents in a file. This is especially the case as research experiences turnover from research projects and personnel. The indexing of files consistently also helps to identify past work. Finally, the protection of the data contents is becoming increasing challenging. As the genomic field expands, and medicine becomes more personalized, the identification of methods to protect the contents of data in both short- and long-term storage needs to be established so as not to risk the potential of revealing identifiable information. This is often something we do not consider in a nonclinical research environment. The need for establishing basic guidelines for institutions is critical, as individual research laboratories are unable to handle the scope of data storage required for their own research. In addition to the immediate needs for establishing guidelines on data storage and file naming and how to protect information, the recognition of the need for specialized support for data management supporting research cores and laboratories at academic institutions is becoming a critical component of institutional services. Here, we outline some case studies and methods that you may be able to adopt at your own institution.

R-Type Ca2+ channels couple to inhibitory neurotransmission to the longitudinal muscle in the guinea-pig ileum.

NEW FINDINGS: What is the central question of this study? Subtypes of enteric neurons are coded by the neurotransmitters they synthesize, but it is not known whether enteric neuron subtypes might also be coded by other proteins, including calcium channel subtypes controlling neurotransmitter release. What is the main finding and its importance? Our data indicate that guinea-pig ileum myenteric neuron subtypes may be coded by calcium channel subtypes. We found that R-type calcium channels are expressed by inhibitory but not excitatory longitudinal muscle motoneurons. R-Type calcium channels are also not expressed by circular muscle inhibitory motoneurons. Calcium channel subtype-selective antagonists could be used to target subtypes of neurons to treat gastrointestinal motility disorders. There is evidence that R-type Ca2+ channels contribute to synaptic transmission in the myenteric plexus. It is unknown whether R-type Ca2+ channels contribute to neuromuscular transmission. We measured the effects of the nitric oxide synthase inhibitor nitro-l-arginine (NLA), Ca2+ channel blockers and apamin (SK channel blocker) on neurogenic relaxations and contractions of the guinea-pig ileum longitudinal muscle-myenteric plexus (LMMP) in vitro. We used intracellular recordings to measure inhibitory junction potentials. Immunohistochemical techniques localized R-type Ca2+ channel protein in the LMMP and circular muscle. Cadmium chloride (pan-Ca2+ channel blocker) blocked and NLA and NiCl2 (R-type Ca2+ channel blocker) reduced neurogenic relaxations in a non-additive manner. Nickel chloride did not alter neurogenic cholinergic contractions, but it potentiated neurogenic non-cholinergic contractions. Relaxations were inhibited by apamin, NiCl2 and NLA and were blocked by combined application of these drugs. Relaxations were reduced by NiCl2 or ω-conotoxin (N-type Ca2+ channel blocker) and were blocked by combined application of these drugs. Longitudinal muscle inhibitory junction potentials were inhibited by NiCl2 but not MRS 2179 (P2Y1 receptor antagonist). Circular muscle inhibitory junction potentials were blocked by apamin, MRS 2179, ω-conotoxin and CdCl2 but not NiCl2 . We conclude that neuronal R-type Ca2+ channels contribute to inhibitory neurotransmission to longitudinal muscle but less so or not all in the circular muscle of the guinea-pig ileum.

On-call resident outside study overreads: Our department's experience streamlining workflow and improving resident supervision while providing a new source of revenue.

Handling the interpretation of outside studies or "curbside" consults can be a daily problem for many radiology departments. In this article, we describe the efforts of a resident quality improvement project to create a more streamlined workflow for the interpretation of outside studies. The principle goal of this project was to ensure that at our teaching hospital, any outside study presented to a resident on call also received a final staff interpretation. An additional goal of this project was to use the digital tools available in our department to streamline the workflow for providing these outside interpretations. The result is an integrated workflow that allows for increased resident supervision as well as a potential new source of revenue in being able to generate billable interpretations.

Deletion of P2X2 and P2X3 receptor subunits does not alter motility of the mouse colon.

Purinergic P2X receptors contribute to neurotransmission in the gut. P2X receptors are ligand-gated cation channels that mediate synaptic excitation in subsets of enteric neurons. The present study evaluated colonic motility in vitro and in vivo in wild type (WT) and P2X2 and P2X3 subunit knockout (KO) mice. The muscarinic receptor agonist, bethanechol (0.3-3 muM), caused similar contractions of the longitudinal muscle in colon segments from WT, P2X2 and P2X3 subunit KO mice. Nicotine (1-300 muM), acting at neuronal nicotinic receptors, caused similar longitudinal muscle relaxations in colonic segments from WT and P2X2 and P2X3 subunit KO mice. Nicotine-induced relaxations were inhibited by nitro-l-arginine (NLA, 100 muM) and apamin (0.1 muM) which block inhibitory neuromuscular transmission. ATP (1-1000 muM) caused contractions only in the presence of NLA and apamin. ATP-induced contractions were similar in colon segments from WT, P2X2 and P2X3 KO mice. The mouse colon generates spontaneous migrating motor complexes (MMCs) in vitro. The MMC frequency was higher in P2X2 KO compared to WT tissues; other parameters of the MMC were similar in colon segments from WT, P2X2 and P2X3 KO mice. 5-Hydroxytryptophan-induced fecal output was similar in WT, P2X2 and P2X3 KO mice. These data indicate that nicotinic receptors are located predominately on inhibitory motor neurons supplying the longitudinal muscle in the mouse colon. P2X2 or P2X3 subunit containing receptors are not localized to motor neurons supplying the longitudinal muscle. Synaptic transmission mediated by P2X2 or P2X3 subunit containing receptors is not required for propulsive motility in the mouse colon.

P2X2 subunits contribute to fast synaptic excitation in myenteric neurons of the mouse small intestine.

P2X receptors are ATP-gated cation channels composed of one or more of seven different subunits. ATP acts at P2X receptors to contribute to fast excitatory postsynaptic potentials (fEPSPs) in myenteric neurons but the subunit composition of enteric P2X receptors is unknown. These studies used tissues from P2X2 wild-type (P2X2+/+) and P2X2 gene knockout (P2X2-/-) mice to investigate the role of this subunit in enteric neurotransmission. Intracellular electrophysiological methods were used to record synaptic and drug-induced responses from ileal myenteric neurons in vitro. Drug-induced longitudinal muscle contractions and peristaltic contractions of ileal segments were also studied in vitro. Gastrointestinal transit was measured as the progression in 30 min of a liquid radioactive marker administered by gavage to fasted mice. RT-PCR analysis of mRNA from intestinal tissues and data from immunohistochemical studies verified P2X2 gene deletion. The fEPSPs recorded from S neurons in tissues from P2X2+/+ mice were reduced by mecamylamine (nicotinic cholinergic receptor antagonist) and PPADS (P2X receptor antagonist). The fEPSPs recorded from S neurons from P2X2-/- mice were unaffected by PPADS but were blocked by mecamylamine. ATP depolarized S and AH neurons from P2X2+/+ mice. ATP depolarized AH but not S neurons from P2X2-/- mice. alpha,beta-Methylene ATP (alpha,beta-mATP)(an agonist at P2X3 subunit-containing receptors) did not depolarize S neurons but it did depolarize AH neurons in P2X2+/+ and P2X2-/- mice. Peristalsis was inhibited in ileal segments from P2X2-/- mice but longitudinal muscle contractions caused by nicotine and bethanechol were similar in segments from P2X2+/+ and P2X2-/- mice. Gastrointestinal transit was similar in P2X2+/+ and P2X2-/- mice. It is concluded that P2X2 homomeric receptors contribute to fEPSPs in neural pathways underlying peristalsis studied in vitro.

Peristalsis is impaired in the small intestine of mice lacking the P2X3 subunit.

P2X receptors are ATP-gated cation channels composed of one or more of seven different subunits. P2X receptors participate in intestinal neurotransmission but the subunit composition of enteric P2X receptors is unknown. In this study, we used tissues from P2X3 wild-type (P2X3+/+) mice and mice in which the P2X3 subunit gene had been deleted (P2X3-/-) to investigate the role of this subunit in neurotransmission in the intestine. RT-PCR analysis of mRNA from intestinal tissues verified P2X3 gene deletion. Intracellular electrophysiological methods were used to record synaptic and drug-induced responses from myenteric neurons in vitro. Drug-induced longitudinal muscle contractions were studied in vitro. Intraluminal pressure-induced reflex contractions (peristalsis) of ileal segments were studied in vitro using a modified Trendelenburg preparation. Gastrointestinal transit was measured as the progression in 30 min of a liquid radioactive marker administered by gavage to fasted mice. Fast excitatory postsynaptic potentials recorded from S neurons (motoneurons and interneurons) were similar in tissues from P2X3+/+ and P2X3-/- mice. S neurons from P2X3+/+ and P2X3-/- mice were depolarized by application of ATP but not alpha,beta-methylene ATP, an agonist of P2X3 subunit-containing receptors. ATP and alpha,beta-methylene ATP induced depolarization of AH (sensory) neurons from P2X3+/+ mice. ATP, but not alpha,beta-methylene ATP, caused depolarization of AH neurons from P2X3-/- mice. Peristalsis was inhibited in ileal segments from P2X3-/- mice but longitudinal muscle contractions caused by nicotine and bethanechol were similar in segments from P2X3+/+ and P2X3-/- mice. Gastrointestinal transit was similar in P2X3+/+ and P2X3-/- mice. It is concluded that P2X3 subunit-containing receptors participate in neural pathways underlying peristalsis in the mouse intestine in vitro. P2X3 subunits are localized to AH (sensory) but not S neurons. P2X3 receptors may contribute to detection of distention or intraluminal pressure increases and initiation of reflex contractions.