Low-dose CT screening among never-smokers with or without a family history of lung cancer in Taiwan: a prospective cohort study.

BACKGROUND: In Taiwan, lung cancers occur predominantly in never-smokers, of whom nearly 60% have stage IV disease at diagnosis. We aimed to assess the efficacy of low-dose CT (LDCT) screening among never-smokers, who had other risk factors for lung cancer. METHODS: The Taiwan Lung Cancer Screening in Never-Smoker Trial (TALENT) was a nationwide, multicentre, prospective cohort study done at 17 tertiary medical centres in Taiwan. Eligible individuals had negative chest radiography, were aged 55-75 years, had never smoked or had smoked fewer than 10 pack-years and stopped smoking for more than 15 years (self-report), and had one of the following risk factors: a family history of lung cancer; passive smoke exposure; a history of pulmonary tuberculosis or chronic obstructive pulmonary disorders; a cooking index of 110 or higher; or cooking without using ventilation. Eligible participants underwent LDCT at baseline, then annually for 2 years, and then every 2 years up to 6 years thereafter, with follow-up assessments at each LDCT scan (ie, total follow-up of 8 years). A positive scan was defined as a solid or part-solid nodule larger than 6 mm in mean diameter or a pure ground-glass nodule larger than 5 mm in mean diameter. Lung cancer was diagnosed through invasive procedures, such as image-guided aspiration or biopsy or surgery. Here, we report the results of 1-year follow-up after LDCT screening at baseline. The primary outcome was lung cancer detection rate. The p value for detection rates was estimated by the χ2 test. Univariate and multivariable logistic regression analyses were used to assess the association between lung cancer incidence and each risk factor. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of LDCT screening were also assessed. This study is registered with ClinicalTrials.gov, NCT02611570, and is ongoing. FINDINGS: Between Dec 1, 2015, and July 31, 2019, 12 011 participants (8868 females) were enrolled, of whom 6009 had a family history of lung cancer. Among 12 011 LDCT scans done at baseline, 2094 (17·4%) were positive. Lung cancer was diagnosed in 318 (2·6%) of 12 011 participants (257 [2·1%] participants had invasive lung cancer and 61 [0·5%] had adenocarcinomas in situ). 317 of 318 participants had adenocarcinoma and 246 (77·4%) of 318 had stage I disease. The prevalence of invasive lung cancer was higher among participants with a family history of lung cancer (161 [2·7%] of 6009 participants) than in those without (96 [1·6%] of 6002 participants). In participants with a family history of lung cancer, the detection rate of invasive lung cancer increased significantly with age, whereas the detection rate of adenocarcinoma in situ remained stable. In multivariable analysis, female sex, a family history of lung cancer, and age older than 60 years were associated with an increased risk of lung cancer and invasive lung cancer; passive smoke exposure, cumulative exposure to cooking, cooking without ventilation, and a previous history of chronic lung diseases were not associated with lung cancer, even after stratification by family history of lung cancer. In participants with a family history of lung cancer, the higher the number of first-degree relatives affected, the higher the risk of lung cancer; participants whose mother or sibling had lung cancer were also at an increased risk. A positive LDCT scan had 92·1% sensitivity, 84·6% specificity, a PPV of 14·0%, and a NPV of 99·7% for lung cancer diagnosis. INTERPRETATION: TALENT had a high invasive lung cancer detection rate at 1 year after baseline LDCT scan. Overdiagnosis could have occurred, especially in participants diagnosed with adenocarcinoma in situ. In individuals who do not smoke, our findings suggest that a family history of lung cancer among first-degree relatives significantly increases the risk of lung cancer as well as the rate of invasive lung cancer with increasing age. Further research on risk factors for lung cancer in this population is needed, particularly for those without a family history of lung cancer. FUNDING: Ministry of Health and Welfare of Taiwan.

Prone Positioning May Improve the Treatment of Diffuse Alveolar Hemorrhage and Severe Acute Respiratory Distress Syndrome (ARDS) Secondary to ANCA Associated Vasculitis: A Case Report.

Diffuse alveolar hemorrhage (DAH) secondary to anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis is rare in clinical practice and may present as severe acute respiratory distress syndrome (ARDS) with high mortality. Extracorporeal membrane oxygenation (ECMO) has been reported to be a salvage treatment providing the time necessary for immunosuppressive treatment in cases accompanied by severe ARDS. Prone positioning (PP) has been proven to reduce the mortality in patients with severe ARDS. However, there is no consensus about choosing PP or ECMO in severe ARDS due to DAH secondary to ANCA-associated vasculitis. We reported a case of microscopic polyangiitis (MPA)-related DAH and severe ARDS treated with PP successfully providing the time necessary for early glucocorticoids and plasma exchange to control the underlying disease. Since anticoagulation therapy is not necessary in PP, it does not increase the risk of bleeding tendency unlike ECMO. PP has a life-saving role in the management of patients with severe ARDS due to ANCA-associated pulmonary vasculitis.

Combination Therapy with Rituximab, Tofacitinib and Pirfenidone in a Patient with Rapid Progressive Interstitial Lung Disease (RP-ILD) Due to MDA5 Antibody-Associated Dermatomyositis: A Case Report.

Anti-melanoma differentiation-associated protein 5 (MDA5)-positive rapidly progressive interstitial lung disease (RP-ILD) is associated with poor prognosis, and the most effective therapeutic intervention has not been established. Herein we report a case of a 45-year-old female patient who presented with myalgia, Gottron's papules with ulceration, and dyspnea on exertion which became aggravated within weeks. Laboratory examination and electromyography confirmed myopathy changes, and a survey of myositis-specific antibodies was strongly positive for anti-MDA5 antibody. High-resolution chest tomography suggested organizing pneumonia with rapidly progressive changes within the first month after diagnosis of the disease. Anti-MDA5-associated dermatomyositis with RP-ILD was diagnosed. Following combination therapy with rituximab, tofacitinib and pirfenidone, clinical symptoms, including cutaneous manifestation, respiratory conditions and radiographic changes, showed significant and sustainable improvement. To our knowledge, this is the first reported case of anti-MDA5-associated dermatomyositis with RP-ILD successfully treated with the combination of rituximab, tofacitinib, and pirfenidone.

GAP Score and CA-153 Associated with One-Year Mortality in Anti-MDA-5 Antibody-Positive Patients: A Real-World Experience.

BACKGROUND: Anti-melanoma differentiation-associated gene 5 (MDA-5) antibody is associated with respiratory failure and death in patients with idiopathic inflammatory myositis (IIM) and interstitial lung disease (ILD). This study aimed to investigate clinical parameters associated with mortality in anti-MDA-5 antibody-positive patients. METHODS: We retrospectively reviewed the clinical and laboratory data, and pulmonary function test results in 55 anti-MDA-5 antibody-positive patients. A comparison was made between the survivors and non-survivors at the 12-month follow-up. RESULTS: A total of 13 patients (23.6%) died within 12 months. Non-survivors had higher GAP scores (gender, age, and physiology score for idiopathic pulmonary fibrosis) (1 vs. 6, p < 0.01) and CA-153 (16.4 vs. 72.9, p < 0.01). In addition, rapid progressive ILD, fever, peak ferritin, leukocyte count, lactate dehydrogenase, CT score, intravenous immunoglobulin, mycophenolic acid, CMV infections, pneumocystis pneumonia, and pneumothorax were significantly associated with increased risks of 1-year mortality, while forced vital capacity, forced expiratory volume in one second, and diffusion capacity for carbon monoxide were correlated with decreased risk of 1-year mortality. CONCLUSIONS: Our study results suggest that GAP scores and CA-153 could be prognostic factors for 1-year mortality in anti-MDA-5 antibody-positive patients. A prompt pulmonary function test and CA-153 are essential for these patients to guide further management.

The diagnostic and prognostic effectiveness of F-18 sodium fluoride PET-CT in detecting bone metastases for hepatocellular carcinoma patients.

BACKGROUND: The aim of this prospective study is to evaluate the diagnostic and prognostic usefulness of F-18 sodium fluoride (NaF) positron emission tomography-computed tomography (PET-CT) relative to Tc-99m methylene diphosphonate (MDP) planar bone scintigraphy with no CT (BS) for hepatocellular carcinoma (HCC) patients with suspicious bone metastasis. METHODS: Both Tc-99m MDP BS and F-18 NaF PET-CT were performed for 34 consecutive Taiwanese HCC patients (five female and 29 male; mean age, 61.0+/-12.0 years) within a time span of 1 month (mean: 11.3+/-10.4 days). The accuracies of BS and PET-CT were determined by comparing their results with the finalized clinical data in a lesion-by-lesion manner. RESULTS: According to the pathological and/or follow-up results, the accuracy for detecting metastatic bone lesions by Tc-99m MDP BS is 75.4% and that by F-18 NaF PET-CT is 95.7%, respectively. F-18 NaF PET-CT is significantly more accurate than Tc-99m MDP BS (P=0.0001). Furthermore, there is a significant correlation between the presence of F-18 NaF PET-CT-positive bone lesions and the survival time of HCC patients. On the other hand, the diagnostic results from BS are not correlated with the survival time of these HCC patients. CONCLUSION: F-18 NaF using PET-CT system has significantly better sensitivity and specificity than conventional Tc-99m MDP BS in detecting metastatic HCC bone lesions that are predominantly osteolytic. The diagnostic result of PET-CT also serves as a more effective prognostic indictor for HCC patients.

Endovascular therapy in pediatric intracranial carotid artery dissection.

Intracranial carotid dissection is an underrecognized cause of childhood stroke, and, in the face of limited therapeutic experience, its management is controversial. Reported here is the case of a 12-year-old girl who experienced an intracranial carotid artery dissection with progressive and symptomatic occlusion of the middle cerebral artery. Endovascular treatment with intra-arterial thrombolysis and stent reconstruction was successfully performed to recanalize the occluded arterial segment. Current management of intracranial carotid dissection in children is reviewed, with discussion of the reasons for aggressive endovascular intervention.

Combined transarterial, transvenous, and direct puncture of the cavernous sinus to cure a traumatic carotid cavernous fistula.

Direct carotid cavernous fistulas (CCF) are generally well managed by simple endovascular treatment. We report an 8-year-old boy who required subsequent direct puncture of the cavernous sinus to completely obliterate the residual fistula after both transarterial and transvenous embolization had been performed. He presented with a mild right frontal headache, congestion of the right conjunctiva, blurred vision, and photophobia. Cerebral angiography demonstrated a right direct CCF. The patient underwent transarterial and transvenous embolization of the cavernous sinus (CS) with Gugliemi detached coils (GDCs), but a residual shunt persisted. Two days later, another session of embolization by direct puncture of the CS with GDCs was performed after failure to navigate through the superior ophthalmic vein which was partially occupied by previously deployed coils. Immediate control angiography showed complete obliteration of the fistula and the patient's symptoms rapidly resolved. This is the first report of a patient with a CCF who required three combined approaches - transarterial, transvenous, and direct puncture of the CS - to achieve complete closure of the complexed shunt.

CT of two hearts beating in one chest.

OBJECTIVE: Because of the improvements in cardiac transplantation technology, pharmacology, and diagnostic imaging, the survival rate of patients who have undergone heterotopic heart transplantation has significantly increased, which makes postoperative evaluation of these patients increasingly important. Monitoring patients who have undergone heterotopic heart transplantation is technically more demanding than those who have undergone orthotopic heart transplantation because it is more difficult to monitor two hearts beating in one chest. In this article, we describe and evaluate cardiac and vascular anatomy and the status of the lungs in patients who have undergone heterotopic heart transplantation. CONCLUSION: ECG-gated cardiac CT has proven to be particularly important in evaluating the complex anatomy and anastomoses of the donor and recipient hearts as well as the postoperative follow-up status of the two hearts, the cardiac arteries and great vessels, and the lungs, ultimately contributing to the prolonged survival of heterotopic heart transplantation patients.

Radiosurgery for vestibular schwannomas.

BACKGROUND: Radiosurgery has been established as an important alternative to microsurgery. We report our experience with radiosurgery for tumor control and the complications of unilateral vestibular schwannomas. METHODS: We reviewed our early experience regarding clinical presentation, management and outcomes in 45 patients with acoustic schwannomas who underwent gamma knife stereotactic radiosurgery. The median follow-up period was 25 months (range, 6-48 months). Thirteen patients had undergone 1 or more previous resections before radiosurgery; 32 underwent radiosurgery as the first procedure. Median tumor volume was 4.5 mL (range, 0.5-30.0), and median radiotherapy dose was 11.5 Gy (range, 10.5-14.0 Gy). RESULTS: Tumor control was achieved in 43 patients (95.6%). Loss of central contrast enhancement was a characteristic change and was noted in 29 patients (64.4%). Reduction in tumor size was shown in 15 patients (33.3%). Thirteen patients (28.9%) had good or serviceable hearing preoperatively, and in all of these, the preoperative status was retained immediately after radiosurgery. At follow-up, however, 10 patients (76.9%) had preserved hearing and 3 (23.1%) had reduced hearing on the treated side. Hearing in 1 patient that was not serviceable preoperatively later improved to a serviceable level. No patients had delayed facial palsy or lower cranial nerve dysfunction, but one had delayed trigeminal sensory loss. CONCLUSION: Radiosurgery achieved a high tumor control rate and a relatively low post-radiosurgical complication rate for acoustic neuromas.

Interstitial deletion of chromosome 14q in a Taiwanese infant with microcephaly.

Deletion (14)(q11.2q13.1) is a rare cytogenetic abnormality associated with severe neurological deficit, microcephaly and psychomotor retardation. We report a case of de novo interstitial deletion of chromosome (14)(q11.2q13.1) in an 8-month-old girl, who presented with marked microcephaly, a nearly closed anterior fontanelle, dysmorphic facies, severe neurological deficits, and delayed developmental milestones. Three-dimensional computed tomography of the brain showed premature closure of the coronal suture and magnetic resonance imaging of the brain showed frontal atrophy and hypoplastic corpus callosum.

Spinal epidural hematoma following tissue plasminogen activator and heparinization for acute myocardial infarction.

The case of a 43-year-old Taiwanese man who presented with spinal epidural hematoma following intravenous administration of recombinant tissue plasminogen activator (rTPA) and heparin therapy for acute myocardial infarction (AMI) is reported. Upper back pain and progressive neurological dysfunction ensued, secondary to spinal epidural hematoma with spinal cord compression. The patient did not recover neurologic function postsurgically, possibly because the operation was delayed. In conclusion, cardiologists should be alert to this rare, severe complication of rTPA and should perform early laminectomy (in < or = 36 hours for those with complete deficit and in < or = 48 hours for those with incomplete deficit) if possible.

Surgical improvement of brain edema related to hypertensive intracerebral hemorrhage.

BACKGROUND: Patients with hypertensive intracerebral hemorrhage (ICH) are at risk for delayed neurological deterioration, especially during the second week after onset. Mass effect due to vasogenic edema caused by ICH has been shown to cause later deterioration. Control of brain edema and increased intracranial pressure (ICP) are related events that determine outcome. In this study, we compared the effects of three different treatments on brain edema caused by ICH. METHODS: Thirty-nine patients with ICH were involved in this study. Of these patients, 11 had medical therapy (group A), 15 were treated with stereotactic aspiration plus local administration of urokinase (group B), and 13 underwent conventional craniotomy and hematoma removal (group C). The intracerebral hematoma volume on admission was measured on the the brain computed tomographs (CTs), and the cerebral edema volumes surrounding the hematoma were assessed with CT scans every 5 to 7 days after symptom onset. RESULTS: The median intracerebral hematoma volumes were 23, 50 and 51 ml in groups A, B and C, respectively. Peak edema volume surrounding the hematoma was observed 5 to 15 days after symptom onset. A significant correlation (p < 0.05) was noted between peak edema and hematoma volumes in all groups. The ratio of median peak edema volume to median hematoma volume was 3.280 in group A, which was significantly higher than those in group B (0.745) and group C (0.863) (p < 0.05). CONCLUSIONS: The study revealed that brain edema induced by hypertensive ICH could be significantly ameliorated by surgical management. Stereotactic aspiration with local administration of urokinase was as effective as conventional craniotomy in reduction of brain edema volume caused by ICH and was characterized by its minimal invasiveness, easy performance, and safety.