Inter-reader variability when applying the 2013 Fleischner guidelines for potential solitary subsolid lung nodules.

BACKGROUND: In 2013, the Fleischner Society published recommendations for managing subsolid pulmonary nodules. Inter-reader variability has not yet been defined and has potential implications for the ease and reproducibility of applying the guidelines to clinical practice. PURPOSE: To evaluate inter-reader variability when applying the 2013 Fleischner guidelines for potential solitary subsolid lung nodules. MATERIAL AND METHODS: Potential nodules were identified through a systematic retrospective review of CT studies that reported a ground-glass lesion. Three radiologists decided whether these lesions fit criteria of a subsolid nodule and thus merit application of the Fleischner Society guidelines, determined if a solid component was present, and measured each component in two dimensions. Final management recommendations were based on these intermediate decisions. Inter-reader variability for management was calculated and Fleiss' kappa was used to determine significance. Logistic regression and Fisher's exact test determined whether management was contingent on each intermediate decision. RESULTS: Forty-four nodules with mean diameter of 9.4 mm were evaluated by three radiologists. Final management recommendations were in agreement for 93 out of 132 cases (70.4%, kappa = 0.56). Inter-reader variability in management recommendation was contingent on disagreement over whether a pulmonary lesion fit criteria of a subsolid nodule for 24 cases (P < 0.01), whether there was a solid component for 10 cases (P = 0.01), and whether the measurement met the threshold of 5 mm for five cases (P = 0.12). CONCLUSION: There is moderate inter-reader variability when applying the 2013 Fleischner Society management recommendations. Significant contributors of variability include whether the potential lesions fit subsolid nodule criteria and whether a solid component is present. Measurement variability does not significantly affect the final management decisions.

Suppression of TLR9 immunostimulatory motifs in the genome of a gammaherpesvirus.

Multiple receptors within the innate immune system have evolved to recognize nucleic acids as signatures of viral infection. It is believed that this specificity is essential for viral detection, as viruses often lack other invariant features that can serve as suitable targets for innate receptors. One such innate receptor, TLR9, has been implicated in the detection of many dsDNA viruses. In this study, we investigate the detection of murine gammaherpesvirus 68 (MHV68) by TLR9. We find that the genomic DNA of the murine CMV, a very potent inducer of innate responses. Genome-wide analysis of the number of stimulatory versus nonstimulatory CpG motifs present in the genome of each virus reveals that the MHV68 genome contains only a fraction of the number of immunostimulatory motifs present in murine CMV. Notably, MHV68 appears to have selectively suppressed the number of stimulatory motifs through cytosine to thymine conversion. These data suggest that certain viruses may have evolved and modified their genomic content to avoid recognition by nucleic acid-sensing receptors of the innate immune system.

Hypothermia-treated neonates with hypoxic-ischemic encephalopathy: Optimal timing of quantitative ADC measurement to predict disease severity.

To determine the optimal time window for MR imaging with quantitative ADC measurement in neonatal HIE after hypothermia treatment, a retrospective review was performed on consecutive hypothermia-treated term neonates with HIE, with an initial and follow-up MR imaging within the first two weeks of life. Three neuroradiologists categorized each set of MR imaging as normal, mild, moderate or severe HIE based on a consensus review of the serial imaging. The lowest ADC values from the white matter, corpus callosum, and basal ganglia/thalamus were measured. The ADC values between mild-moderate and severe HIE were compared using a Student's t-test over a range of different time windows. A total of 33 MR imaging examinations were performed on 16 neonates that included three normal, four mild, five moderate, and four severe HIE. The time window of 3-10 days showed a statistically significant decrease in ADC value in severe HIE compared to mild-moderate HIE in all three locations, respectively: white matter 0.5 ± 0.22 versus 0.83 ± 0.27 ( p value 0.01), corpus callosum 0.69 ± 0.19 versus 0.91 ± 0.17 ( p value 0.01), and basal ganglia/thalamus 0.63 ± 0.16 versus 0.98 ± 0.06 ( p value <0.01). The range of 3-10 days is the optimal time window for MR imaging with quantitative ADC after hypothermia treatment.

Demographics and frequency of the intermittently upturned omentum at CT.

OBJECTIVES: To describe the demographics and frequency of the intermittently upturned omentum at CT. METHODS: We retrospectively reviewed abdominal CT scans of 336 consecutive patients (189 men and 147 women) who were imaged between June 1 and June 17, 2010 and who had prior comparison scans. Readers recorded the presence or absence of an intermittently upturned omentum, defined as a thick rind of fat interposed between the liver and the anterior abdominal wall seen on one but not the other scan. At chart review, we recorded patient demographics and other clinical characteristics (prior surgical history, presence of cirrhosis). RESULTS: An intermittently upturned omentum was found in 10 of 336 (3.0%) patients. An intermittently upturned omentum was seen more commonly in men than in women (9 of 189 men, or 4.8% versus 1 of 147 women, or 0.7%, p=0.047) and in cirrhotics (4 of 37 cirrhotics, or 10.8% versus 6 of 299 non-cirrhotics, or 2.0%, p=0.023). In a sub-analysis of patients without prior abdominal surgery, this finding was again seen more commonly in men than women (7 of 163 men, or 4.3% versus 0 of 134 women, or 0%, p=0.018) and in cirrhotics (3 of 33 cirrhotics, or 9.1% versus 4 of 264 non-cirrhotics, or 1.5%, p=0.032). CONCLUSIONS: An intermittently upturned omentum is not uncommon and is more frequently seen in men and in patients with cirrhosis who may have a larger anterior hepatic space.

The Autodigestion Hypothesis in Shock and Multi-Organ Failure: Degrading Protease Activity.

Shock and multi-organ failure have one of the highest levels of inflammatory markers, morbidities and mortality. The underlying mechanisms are currently unknown and no effective intervention exists. We present evidence for a previously untested mechanism due to autodigestion by the digestive enzymes synthesized in the pancreas and transported in the lumen of the intestine as normal part of food digestion. We summarize experimental evidence in support of the autodigestion hypothesis and a new approach for possible intervention against multi-organ failure that is currently entering clinical trials.