Successful flow diversion treatment of ruptured infectious middle cerebral artery aneurysms with the use of Pipeline Flex with Shield technology.

BACKGROUND: Rupture of infectious intracranial aneurysms (IIAs) is associated with a high likelihood of mortality. Endovascular treatment of IIAs via parent artery sacrifice offers good efficacy and outcomes; however, depending on the lesion's location, neurologic deficit may result. CASE DESCRIPTION: We describe a pediatric patient with ruptured IIAs off the left middle cerebral artery (MCA) treated with coil embolization and endovascular flow diversion using the Pipeline Flex Embolization Device (PED) with Shield technology. We chose to place a flow diverter because 1) there was a second, more distal IIA not amenable to direct coil embolization, 2) there was significant potential for aneurysm regrowth and need for retreatment, and 3) we believed the diseased parent MCA needed to be reconstructed. CONCLUSIONS: In the setting of previous hemicraniectomy, PED-Shield gave us the option to discontinue dual antiplatelet therapy should the patient require further neurosurgical intervention. Our case supports a role for PED-Shield to address ruptured pseudoaneurysms.

Class I histone deacetylase inhibition promotes CD8 T cell activation in ovarian cancer.

OBJECTIVE: Patients with epithelial ovarian cancer (EOC) typically present with late-stage disease, posing a significant challenge to treatment. Although taxane and platinum-based chemotherapy plus surgical debulking are initially effective, EOC is marked by frequent recurrence with resistant disease. Immunotherapy represents an appealing treatment paradigm given the ability of immune cells to engage metastatic sites and impede recurrence; however, response rates to checkpoint blockade in ovarian cancer have been disappointing. Here, we tested whether class I HDAC inhibition can promote anti-tumor T cell responses in a spontaneous and nonspontaneous murine model of EOC. METHODS: We used the spontaneous Tg-MISIIR-Tag and nonspontaneous ID8 models of murine ovarian cancer to test this hypothesis. Whole tumor transcriptional changes were assessed using the nCounter PanCancer Mouse Immune Profiling Panel. Changes in select protein expression of regulatory and effector T cells were measured by flow cytometry. RESULTS: We found that treatment with the class I HDAC inhibitor entinostat upregulated pathways and genes associated with CD8 T cell cytotoxic function, while downregulating myeloid derived suppressor cell chemoattractants. Suppressive capacity of regulatory T cells within tumors and associated ascites was significantly reduced, reversing the CD8-Treg ratio. CONCLUSIONS: Our findings suggest class I HDAC inhibition can promote activation of intratumoral CD8 T cells, potentially by compromising suppressive networks within the EOC tumor microenvironment. In this manner, class I HDAC inhibition might render advanced-stage EOC susceptible to immunotherapeutic treatment modalities.

Early analysis of operative management of Chiari I malformation in pediatric cystic fibrosis patients.

INTRODUCTION: Chiari I malformation, defined as herniation of the cerebellar tonsils at least 5 mm below the foramen magnum, can result from congenital or acquired pathology. While the mechanism is not well understood, an association between Chiari I and cystic fibrosis has been described in the literature. The lifelong respiratory status management necessitated by cystic fibrosis creates a greater risk of Chiari symptomatology as well as post-operative CSF-related complications in the setting of duraplasty secondary to recurrent transient increases in intracranial pressure. We will review the literature, describe our experience with these patients, and propose bony decompression as an approach to treatment. METHODS: A retrospective review of pediatric patients treated at our institution with both cystic fibrosis and Chiari I was performed. Since our first case in 2016, our department has evaluated four patients carrying that dual diagnosis. All four underwent posterior fossa decompression surgery. Two patients had incidental pathology. Two symptomatic patients exhibited headaches and/or coordination difficulty. Half of the patients had associated syringomyelia. All patients were offered posterior fossa decompression utilizing intraoperative ultrasound. RESULTS: All four patients underwent posterior fossa decompression without duraplasty. Average operative time was 128 min. There were no complications post-operatively. Average hospital stay was 3.8 days. Average surgical length of stay was 2.3 days. Morbidity and mortality were 0%. The longest follow-up to date is 20 months. The two asymptomatic patients remained so post-operatively. The child with headaches and imbalance had complete resolution of his symptoms after surgery, as did the toddler with headaches. Both patients with syringomyelia demonstrated significant decrease in the size of their syrinxes on imaging performed at least 3 months post-operatively. CONCLUSION: Based on the literature and our experience, we recommend considering posterior fossa decompression without duraplasty as treatment for pediatric cystic fibrosis patients with Chiari I malformation. This approach can be effective for symptomatic and prophylactic cases in this particular patient demographic because their comorbidities predispose them to Chiari pathology and symptomatology as well as certain post-operative complications.

Routine isotropic computed tomography scanning of chest: value of coronal and sagittal reformations.

OBJECTIVE: We sought to evaluate the usefulness of coronal and sagittal reformations from isotropic chest computed tomography (CT) examinations. METHODS: A total of 30 chest CT examinations were reconstructed into 2 sets of axial source images: 0.9-mm slice width with 0.45-mm reconstruction interval (isotropic) and 4-mm slices with 3-mm reconstruction interval. The isotropic dataset was reformatted into coronal and sagittal stacks with 4-mm slices. Three readers reviewed the image sets with 4-mm slice widths. Coronal and sagittal reformations were compared at the same sitting to axial images for depiction of anatomy and disease in the aorta, pulmonary arteries, hilar regions, mediastinum, lung parenchyma, pleura, diaphragm, thoracic spine, ribs, and trachea. A 5-point scale was used to determine whether nonaxial reformations showed anatomy and disease significantly better, somewhat better, same, somewhat worse or significantly worse than equivalent thickness axial source images. A 3-point scale was used to score if nonaxial image sets showed no, some, or significant additional information compared with the axial plane regarding the main diagnosis. RESULTS: There was better visualization of the hilar regions, diaphragm, spine, and trachea on the coronal reformations compared with source axial images (P < 0.05). Sagittal reformations scored better than axial source images for aorta, pleura, diaphragm, spine, and ribs (P < 0.05). The coronal and sagittal series showed significant additional information in 11% and 9% of patients, respectively. CONCLUSION: Radiologists should consider the use of one or both of coronal and sagittal planes in addition to the axial series in routine interpretation of chest CT.

Radiology of community-acquired pneumonia.

This article reviews the radiographic appearance of common community-acquired pneumonia. Included are the common bacterial pneumonias, tuberculosis, fungal pneumonia, pneumocystis pneumonia, and viral pneumonias. The various radiographic appearances and the clues for differentiating the pneumonias are discussed. Images enhance the discussion.

Metastatic meningioma to the lungs.

Meningioma with extracranial metastases is a rare occurrence. However, the lungs are the most common site of extracranial metastases. We describe a case of a patient with recurrent intracranial meningioma and intrapulmonary metastases.

Changes in serum testosterone and estradiol concentrations following acute androstenedione ingestion in young women.

The effect of androstenedione intake on serum hormone concentrations in women is equivocal. Therefore, we examined the hormonal response to androstenedione intake in healthy young (22.1 +/- 0.4 y) women for 4 hours. On day 3 of the follicular phase, subjects ingested placebo, 100, or 300 mg androstenedione in a random, double-blind, cross-over manner. Blood samples were collected before and every 30 min for 240 min after intake. Serum androstenedione concentrations (means +/- SE) increased above basal (6.2 +/- 0.8 nmol/l) from 60-240 min for both 100 mg (22.6 +/- 1.0 nmol/l at 240 min) and 300 mg (28.1 +/- 1.3 nmol/l at 210 min). Androstenedione intake increased serum total testosterone concentrations above basal (1.2 +/- 0.2 nmol/l) from 120-240 min (5.5 +/- 0.9 nmol/l at 210 min) with 100 mg and from 60-240 with 300 mg (10.2 +/- 1.6 nmol/l at 210 min). Androstenedione intake also increased serum estradiol concentrations (basal 191 +/- 24 pmol/l) at 150 min with 100 mg (237 +/- 35 pmol/l) and from 150-240 min with 300 mg (reaching 260 +/- 32 pmol/l at 240 min). These data indicate that, in contrast to men, androstenedione intake in women increases serum testosterone concentrations.

A study of the feasibility of Internet administration of a computerized health survey: the headache impact test (HIT).

BACKGROUND: Headache impact test (HIT) is a precise, practical tool that quantifies the impact of headache on respondents' lives. It is the first widely-available dynamic health assessment (DynHA). Applications of this brief, precise survey include population based screening for disabling headaches, tracking of individual patient scores over time, disease management programs and others. We use data from Internet HIT assessments during the fall of 2000 to (1) evaluate characteristics of respondents and assessments, (2) assess the utility of joint administration of HIT and the SF-8 Health Survey (SF-8) to screen for migraine and depression, and (3) explore associations between HIT scores and subsequent healthcare-related attitudes and behaviors. METHODS: We analyzed Internet HIT surveys completed between 9/1 and 11/30/2000 (n = 19,195). Subsamples include respondents who also completed (1) a 12-item Internet survey assessing severity, frequency, cause and management of headaches; (2) an e-mail survey measuring healthcare-related behaviors; (3) the SF-8; or (4) the website registration process, providing age and gender data. We used analysis of variance (ANOVA) to evaluate HIT score differences associated with age, gender, headache severity or frequency, and healthcare-related behaviors and attitudes and chi2 tests to assess the prevalence and comorbidity of migraine and depression. RESULTS: Three-quarters of respondents achieved a precise HIT score in < or = 5 items. Most had moderate/severe headaches; 65% had headaches at least monthly. HIT scores were directly related to headache severity and frequency. Most respondents were females, with significantly higher HIT scores than males. Most HIT respondents were between ages 25 and 54 (HIT scores were higher for younger respondents). Sixty four percent screened positive for migraine; 20% for depression. Both conditions were more prevalent among females than males. Comorbid migraine and depression was 50% more prevalent among females and increased with age until age 50. Patients with worse headache impact were more likely to seek care, discuss headaches with their providers and find HIT useful. CONCLUSIONS: It is feasible to use Internet-based dynamic assessments to measure health status. These data complement previous results showing that HIT differentiates respondents according to headache characteristics (severity and frequency). HIT plus SF-8 yields a practical screen for migraine and depression in headache patients and may lead to more effective treatment for patients with these conditions. Preliminary findings suggest that the experience of taking HIT on the Internet may motivate headache patients to seek care and discuss headaches with their providers.

Imaging of intrathoracic metastases of nonseminomatous germ cell tumors.

Radiologic imaging is crucial in the evaluation of intrathoracic metastatic nonseminomatous germ cell tumors. Helical CT is the workhorse of radiologic staging and is sensitive in the detection of parenchymal nodules and mediastinal lymphadenopathy. CT may also demonstrate other less common sites of metastatic disease. Although, currently, no radiologic procedure is effective in distinguishing viable tumor or teratoma from residual fibrosis and necrosis, cross-sectional imaging remains essential in the presurgical evaluation of potential metastatic disease. FDG PET and CT-guided needle biopsy may be useful in select, high-risk patients.

Fat-containing lesions of the chest.

Although most lesions that occur in the chest have a nonspecific soft-tissue appearance, fat-containing lesions are occasionally encountered at cross-sectional computed tomography (CT) or magnetic resonance imaging. The various fat-containing lesions of the chest include parenchymal and endobronchial lesions such as hamartoma, lipoid pneumonia, and lipoma. Endobronchial hamartoma usually appears at CT as a lesion with a smooth edge, focal collections of fat, or fat collections that alternate with foci of calcification. Mediastinal fat-containing lesions include germ cell neoplasms, thymolipomas, lipomas, and liposarcomas. The most frequent CT manifestation of the germ cell neoplasm teratoma is a heterogeneous mass with soft-tissue, fluid, fat, and calcium attenuation. Cardiac lesions with fat content include lipomatous hypertrophy of the interatrial septum and arrhythmogenic right ventricular dysplasia. Diagnosis of the former is made with CT when a smooth, nonenhancing, well-marginated fat-containing lesion is identified in the interatrial septum. Finally, fat may herniate into the chest at several characteristic locations. When such a lesion is identified, the time required for differential diagnosis is significantly reduced, often allowing a definitive radiologic diagnosis. Sagittal and coronal reformatted images can add valuable information by showing diaphragmatic defects and hernia contents.

Volumetric growth rate of stage I lung cancer prior to treatment: serial CT scanning.

PURPOSE: To determine the range of growth rates of stage I lung cancers prior to treatment by using volumetric measurement at serial chest computed tomographic (CT) examinations. MATERIALS AND METHODS: The study population comprised 50 patients who underwent two CT examinations at 25-day or greater intervals. Tumor craniocaudal length and cross-sectional diameters and perimeters were used to volumetrically model each tumor in three ways (spherical, elliptical, perimeter). Volumes were compared by determining Pearson correlation coefficients. By using these volumes, tumor doubling time was determined for each patient. RESULTS: Volumes measured with all three methods were highly correlated. With the perimeter method, median doubling time was 181 days, with a very wide range. Eleven (22%) of 50 tumors had doubling times of 465 days or more. There was considerable overlap in doubling time between histologic subtypes. Assuming constant growth, only three (6%) of the 50 tumors would have been the size of a stage IA tumor for less than 1 year. CONCLUSION: Comparison of tumor volumes at serial CT examinations reveals a very wide range of growth rates. Some tumors grow so slowly that biopsy is required to prove they are malignant.

A non-enzymatic method for lens decapsulation which leaves the epithelial cells attached to the fibers.

We have developed a method to mechanically decapsulate the lens yet leave the epithelial cells attached to the fibers. This method uses divalent ion chelaters to loosen the capsule-epithelial interactions and bumetanide to control cell swelling. Light microscopy, scanning electron microscopy, and in-vitro fluorescence microscopy demonstrate that the capsule is removed and the epithelial cells remain adherent to the fibers when these procedures are used. Ion channel activity and epithelial gap junction communication remain following decapsulation. This decapsulated lens preparation should prove useful for many kinds of lens studies.

Acceptance of direct physician access to a computer-based patient record in a managed care setting.

Kaiser Permanente Mid-Atlantic States has developed a fully integrated outpatient information system which currently runs on an IBM ES9000 on a VM platform written in MUMPS. The applications include Lab, Radiology, Transcription, Appointments. Pharmacy, Encounter tracking, Hospitalizations, Referrals, Phone Advice, Pap tracking, Problem list, Immunization tracking, and Patient demographics. They are department specific and require input and output from a dumb terminal. We have developed a physician's work station to access this information using PC compatible computers running Microsoft Windows and a custom Microsoft Visual Basic 2.0 environment which draws from these 14 applications giving the physician a comprehensive view of all electronic medical records. Through rapid prototyping, voluntary participation, formal training and gradual implementation we have created an enthusiastic response. 95% of our physician PC users access the system each month. The use ranges from 0.2 to 3.0 screens of data viewed per patient visit. This response continues to drive the process toward still greater user acceptance and further practice enhancement.