Non-ECG-gated cardiac CT angiography in acute stroke is feasible and detects sources of embolism.

BACKGROUND: A significant portion of cryptogenic stroke is hypothesized to be secondary to cardiac embolism. However, transthoracic echocardiogram is usually delayed after stroke, and more detailed cardiac imaging is not routinely done. AIMS: This study aimed to determine whether non-ECG-gated cardiac CT angiography (cCTA) during hyperacute stroke would provide diagnostic quality images and act as an adjunct modality of cardiac imaging to detect sources of emboli. METHODS: In this single-center prospective cohort study, modified Code Stroke imaging was implemented with a 64-slice CT scanner, where the longitudinal axis of CT angiography was extended from the carina to the diaphragm. The primary outcomes of image quality, recruitment feasibility, impact on hyperacute time metrics, and additional radiation dose were assessed. Secondary outcomes consisted of detection of high-risk cardiac sources of embolism, mediastinal or lung pathology, and impact on etiologic classification. RESULTS: One hundred and twenty eligible patients were enrolled, of which 105 (87.5%) had good/moderate quality images for motion artifact and 119 (99.2%) for contrast opacification. Total CT time, door-to-needle time, and door-to-groin puncture time were unchanged with the addition of cCTA. Eighty-nine patients received a final diagnosis of ischemic stroke, of which 12/89 (13.5%) had high-risk cardioembolic findings on cCTA. Incidental findings, such as pulmonary embolism (PE) (7/89, 7.9%) and malignancy (6/89, 6.7%), were observed. cCTA led to changes in management for 19/120 (15.8%) of all patients, and reclassification of stroke etiology for 8/89 (9%) of patients. CONCLUSIONS: Non-ECG-gated cCTA can be feasibly incorporated into Code Stroke and provide diagnostic quality images without delays in hyperacute time metrics. It can detect high-risk cardiac sources, and other findings impacting patient care. This may help reclassify a subset of cryptogenic stroke cases and improve secondary prevention.

Middle Mediastinal Mass Compressing the Pulmonary Trunk in a Patient With a History of Breast Cancer.

CASE PRESENTATION: A 61-year-old White woman, nonsmoker, was referred to Respirology for evaluation of small pulmonary nodules discovered incidentally on surveillance imaging 3 years after breast cancer treatment. She had a remote left breast ductal carcinoma in situ treated with lumpectomy followed by radiation therapy, and recurrent stage 1 breast cancer (estrogen receptor/progesterone receptor-positive, human epidermal growth factor receptor 2-negative) treated with mastectomy, axillary lymph node dissection, and reconstructive surgery, followed with adjuvant chemotherapy, radiation therapy, and letrozole maintenance. Her other medical conditions included compensated cirrhosis secondary to nonalcoholic fatty liver disease, type 2 diabetes, hypertension, OSA, restless legs syndrome, obesity, anxiety, and depression. She reported no dyspnea or constitutional symptoms.

Study protocol for DICE trial: Video-assisted thoracoscopic surgery decortication versus interventional radiology guided chest tube insertion for the management of empyema.

BACKGROUND: Empyema is a common thoracic surgery presentation, defined as pus in the pleural space. Despite the commonality of empyema, consensus on initial management remains ambiguous. Two standard of care treatment options include inserting a chest tube (thoracostomy) and the administration of intrapleural fibrinolytics, or an initial surgical approach, surgical decortication. Due to the complexity of this pleural space infection, often repeat interventions are required after initial management in order to achieve source control and resolution of clinical symptoms. This study aims to identify the most effective initial management option for empyema. STUDY DESIGN: We present a study protocol for a randomized control trial (RCT) comparing adult individuals with empyema to one of two standard of care initial management options. Participants will be randomized into either interventional radiology guided chest tube insertion with intrapleural fibrinolytics (Dornase 5 mg and Alteplase 10 mg intrapleural twice daily for three days) or video-assisted thoracoscopic surgery (VATS) decortication. METHODS: All adults with empyema meeting inclusion criteria will be invited to participate. They will be randomized into one of two intervention groups; interventional radiology guided chest tube insertion with fibrinolytics or initial VATS decortication. Each intervention will take place within 48 hours of randomization. The primary outcome will be the rate of re-intervention within 30 days. Re-intervention is defined as repeat chest tube insertion, VATS decortication, or decortication via thoracotomy. Secondary outcomes include a change in the size of empyema, length of stay, morbidity, as well as 30-day and 90-day mortality, as well as quality of life measurements. ANTICIPATED IMPACT: This study is aimed at identifying the most effective initial management option for individuals with empyema.

Diagnostic Yield for Cancer and Diagnostic Accuracy of Computed Tomography-guided Core Needle Biopsy of Subsolid Pulmonary Lesions.

PURPOSE: We aimed to determine the diagnostic yield for cancer and diagnostic accuracy of computed tomography-guided core needle biopsy (CTNB) in subsolid pulmonary lesions. MATERIALS AND METHODS: Fifty-two biopsies of 52 subsolid lesions in 51 patients were identified from a database of 912 lung biopsies and analyzed for the diagnostic yield for cancer and diagnostic accuracy of core CTNB diagnosis as well as complication rates. RESULTS: When indeterminate biopsy results were included in the analysis, the diagnostic yield for cancer was 80.8% and the diagnostic accuracy of core needle biopsy was 84.6% (n=52). It was 85.7% and 91.7%, respectively, when indeterminate results were excluded (n=48) and 82.4% and 82.4%, respectively, for biopsies with surgical confirmation (n=17). Attenuation was statistically significant for diagnostic yield for cancer (P=0.028) and diagnostic accuracy of core needle biopsy (P=0.001) when the indeterminate results were excluded (n=48). Attenuation and size were not statistically significant for diagnostic yield for cancer and diagnostic accuracy of needle biopsy (n=52), and size was not statistically significant for either when the indeterminate results were excluded. These results were achieved without any major complications as per the Society of Interventional Radiology Standards of Practice. CONCLUSIONS: CTNB offers a high yield in establishing a histopathologic diagnosis of subsolid pulmonary lesions, with both ground-glass and solid-predominance. The pure ground-glass category of lesions requires further research to determine the true diagnostic yield and diagnostic accuracy of core needle biopsies.

Rasamsonia argillacea pulmonary and aortic graft infection in an immune-competent patient.

Rasamsonia argillacea (formerly known as Geosmithia argillacea) is a fungus recently recognized as a pathogen of immunocompromised patients. Here we report the first case of Rasamsonia infection in an immunocompetent host, presenting as a pulmonary and aortic graft infection. Its morphological similarity to nonpathogenic Penicillium species delayed the diagnosis and initiation of appropriate treatment.

A significant reduction of the diaphragm in mdx:MyoD-/-(9th) embryos suggests a role for MyoD in the diaphragm development.

To further investigate the role of MyoD during skeletal myogenesis, we backcrossed mdx mutant mice (lacking dystrophin) with MyoD knock-out mice to obtain viable mice with MyoD allele on a pure mdx background. However, after nine generations of backcrossing, it was not possible to obtain a viable mdx:MyoD-/- phenotype (designated as: mdx:MyoD-/-(9th)). The compound-mutant embryos were examined just before birth. Essentially normal Myf5-dependent and most of the MyoD-dependent musculature was observed. By contrast, the skeletal muscle compartment of the diaphragm was significantly reduced. The mesenchymal compartment of the diaphragm was intact and no herniations were observed. Other examined organs (e.g., liver, kidney, brain, etc.) showed no histological abnormalities. Pulmonary hypoplasia was determined as the cause of neonatal death. Therefore, using a different approach, our new data supplement our previous findings and suggest an essential role for MyoD in development of skeletal muscle of the diaphragm. The failure of mdx:MyoD-/-(9th) diaphragm to develop normally is not caused by a reduced number of satellite cells, but from the inability of stem cells to progress through the myogenic program. Our data also suggest that functions of MyoD and Myf5 (and the respective muscle precursor cell sub-populations) are not entirely redundant by term, as previously suggested, since Myf5 is not capable of fully substituting for MyoD in the diaphragm development.