Assessment of the comparative agreement between chest radiographs and CT scans in intensive care units.

PURPOSE: Chest radiographs in critically ill patients can be difficult to interpret due to technical and clinical factors. We sought to determine the agreement of chest radiographs and CT scans, and the inter-observer variation of chest radiograph interpretation, in intensive care units (ICUs). METHODS: Chest radiographs and corresponding thoracic computerised tomography (CT) scans (as reference standard) were collected from 45 ICU patients. All radiographs were analysed by 20 doctors (radiology consultants, radiology trainees, ICU consultants, ICU trainees) from 4 different centres, blinded to CT results. Specificity/sensitivity were determined for pleural effusion, lobar collapse and consolidation/atelectasis. Separately, Fleiss' kappa for multiple raters was used to determine inter-observer variation for chest radiographs. RESULTS: The median sensitivity and specificity of chest radiographs for detecting abnormalities seen on CTs scans were 43.2% and 85.9% respectively. Diagnostic sensitivity for pleural effusion was significantly higher among radiology consultants but no specialty/experience distinctions were observed for specificity. Median inter-observer kappa coefficient among assessors was 0.295 ("fair"). CONCLUSIONS: Chest radiographs commonly miss important radiological features in critically ill patients. Inter-observer agreement in chest radiograph interpretation is only "fair". Consultant radiologists are least likely to miss thoracic radiological abnormalities. The consequences of misdiagnosis by chest radiographs remain to be determined.

Immunoproteasome function maintains oncogenic gene expression in KMT2A-complex driven leukemia.

Pharmacologic targeting of chromatin-associated protein complexes has shown significant responses in KMT2A-rearranged (KMT2A-r) acute myeloid leukemia (AML) but resistance frequently develops to single agents. This points to a need for therapeutic combinations that target multiple mechanisms. To enhance our understanding of functional dependencies in KMT2A-r AML, we have used a proteomic approach to identify the catalytic immunoproteasome subunit PSMB8 as a specific vulnerability. Genetic and pharmacologic inactivation of PSMB8 results in impaired proliferation of murine and human leukemic cells while normal hematopoietic cells remain unaffected. Disruption of immunoproteasome function drives an increase in transcription factor BASP1 which in turn represses KMT2A-fusion protein target genes. Pharmacologic targeting of PSMB8 improves efficacy of Menin-inhibitors, synergistically reduces leukemia in human xenografts and shows preserved activity against Menin-inhibitor resistance mutations. This identifies and validates a cell-intrinsic mechanism whereby selective disruption of proteostasis results in altered transcription factor abundance and repression of oncogene-specific transcriptional networks. These data demonstrate that the immunoproteasome is a relevant therapeutic target in AML and that targeting the immunoproteasome in combination with Menin-inhibition could be a novel approach for treatment of KMT2A-r AML.

Histone demethylase KDM4C is a functional dependency in JAK2-mutated neoplasms.

Mutations of the JAK2 gene are frequent aberrations in the aging hematopoietic system and in myeloid neoplasms. While JAK-inhibitors efficiently reduce hyperinflammation induced by the constitutively active mutated JAK2 kinase, the malignant clone and abundance of mutated cells remains rather unaffected. Here, we sought to assess for genetic vulnerabilities of JAK2-mutated clones. We identified lysine-specific demethylase KDM4C as a selective genetic dependency that persists upon JAK-inhibitor treatment. Genetic inactivation of KDM4C in human and murine JAK2-mutated cells resulted in loss of cell competition and reduced proliferation. These findings led to reduced disease penetrance and improved survival in xenograft models of human JAK2-mutated cells. KDM4C deleted cells showed alterations in target histone residue methylation and target gene expression, resulting in induction of cellular senescence. In summary, these data establish KDM4C as a specific dependency and therapeutic target in JAK2-mutated cells that is essential for oncogenic signaling and prevents induction of senescence.

YBX1 mediates translation of oncogenic transcripts to control cell competition in AML.

Persistence of malignant clones is a major determinant of adverse outcome in patients with hematologic malignancies. Despite the fact that the majority of patients with acute myeloid leukemia (AML) achieve complete remission after chemotherapy, a large proportion of them relapse as a result of residual malignant cells. These persistent clones have a competitive advantage and can re-establish disease. Therefore, targeting strategies that specifically diminish cell competition of malignant cells while leaving normal cells unaffected are clearly warranted. Recently, our group identified YBX1 as a mediator of disease persistence in JAK2-mutated myeloproliferative neoplasms. The role of YBX1 in AML, however, remained so far elusive. Here, inactivation of YBX1 confirms its role as an essential driver of leukemia development and maintenance. We identify its ability to amplify the translation of oncogenic transcripts, including MYC, by recruitment to polysomal chains. Genetic inactivation of YBX1 disrupts this regulatory circuit and displaces oncogenic drivers from polysomes, with subsequent depletion of protein levels. As a consequence, leukemia cells show reduced proliferation and are out-competed in vitro and in vivo, while normal cells remain largely unaffected. Collectively, these data establish YBX1 as a specific dependency and therapeutic target in AML that is essential for oncogenic protein expression.

Immunoproteasome Function in Normal and Malignant Hematopoiesis.

The ubiquitin-proteasome system (UPS) is a central part of protein homeostasis, degrading not only misfolded or oxidized proteins but also proteins with essential functions. The fact that a healthy hematopoietic system relies on the regulation of protein homeostasis and that alterations in the UPS can lead to malignant transformation makes the UPS an attractive therapeutic target for the treatment of hematologic malignancies. Herein, inhibitors of the proteasome, the last and most important component of the UPS enzymatic cascade, have been approved for the treatment of these malignancies. However, their use has been associated with side effects, drug resistance, and relapse. Inhibitors of the immunoproteasome, a proteasomal variant constitutively expressed in the cells of hematopoietic origin, could potentially overcome the encountered problems of non-selective proteasome inhibition. Immunoproteasome inhibitors have demonstrated their efficacy and safety against inflammatory and autoimmune diseases, even though their development for the treatment of hematologic malignancies is still in the early phases. Various immunoproteasome inhibitors have shown promising preliminary results in pre-clinical studies, and one inhibitor is currently being investigated in clinical trials for the treatment of multiple myeloma. Here, we will review data on immunoproteasome function and inhibition in hematopoietic cells and hematologic cancers.

Sensitivity of SARS-CoV-2 RNA polymerase chain reaction using a clinical and radiological reference standard.

OBJECTIVES: Diagnostic tests for SARS-CoV-2 are important for epidemiology, clinical management, and infection control. Limitations of oro-nasopharyngeal real-time PCR sensitivity have been described based on comparisons of single tests with repeated sampling. We assessed SARS-CoV-2 PCR clinical sensitivity using a clinical and radiological reference standard. METHODS: Between March-May 2020, 2060 patients underwent thoracic imaging and SARS-CoV-2 PCR testing. Imaging was independently double- or triple-reported (if discordance) by blinded radiologists according to radiological criteria for COVID-19. We excluded asymptomatic patients and those with alternative diagnoses that could explain imaging findings. Associations with PCR-positivity were assessed with binomial logistic regression. RESULTS: 901 patients had possible/probable imaging features and clinical symptoms of COVID-19 and 429 patients met the clinical and radiological reference case definition. SARS-CoV-2 PCR sensitivity was 68% (95% confidence interval 64-73), was highest 7-8 days after symptom onset (78% (68-88)) and was lower among current smokers (adjusted odds ratio 0.23 (0.12-0.42) p < 0.001). CONCLUSIONS: In patients with clinical and imaging features of COVID-19, PCR test sensitivity was 68%, and was lower among smokers; a finding that could explain observations of lower disease incidence and that warrants further validation. PCR tests should be interpreted considering imaging, symptom duration and smoking status.

Differences in expression rather than methylation at placenta-specific imprinted loci is associated with intrauterine growth restriction.

BACKGROUND: Genome-wide studies have begun to link subtle variations in both allelic DNA methylation and parent-of-origin genetic effects with early development. Numerous reports have highlighted that the placenta plays a critical role in coordinating fetal growth, with many key functions regulated by genomic imprinting. With the recent description of wide-spread polymorphic placenta-specific imprinting, the molecular mechanisms leading to this curious polymorphic epigenetic phenomenon is unknown, as is their involvement in pregnancies complications. RESULTS: Profiling of 35 ubiquitous and 112 placenta-specific imprinted differentially methylated regions (DMRs) using high-density methylation arrays and pyrosequencing revealed isolated aberrant methylation at ubiquitous DMRs as well as abundant hypomethylation at placenta-specific DMRs. Analysis of the underlying chromatin state revealed that the polymorphic nature is not only evident at the level of allelic methylation, but DMRs can also adopt an unusual epigenetic signature where the underlying histones are biallelically enrichment of H3K4 methylation, a modification normally mutually exclusive with DNA methylation. Quantitative expression analysis in placenta identified two genes, GPR1-AS1 and ZDBF2, that were differentially expressed between IUGRs and control samples after adjusting for clinical factors, revealing coordinated deregulation at the chromosome 2q33 imprinted locus. CONCLUSIONS: DNA methylation is less stable at placenta-specific imprinted DMRs compared to ubiquitous DMRs and contributes to privileged state of the placenta epigenome. IUGR-associated expression differences were identified for several imprinted transcripts independent of allelic methylation. Further work is required to determine if these differences are the cause IUGR or reflect unique adaption by the placenta to developmental stresses.

The cell fate determinant Scribble is required for maintenance of hematopoietic stem cell function.

Cell fate determinants influence self-renewal potential of hematopoietic stem cells. Scribble and Llgl1 belong to the Scribble polarity complex and reveal tumor-suppressor function in drosophila. In hematopoietic cells, genetic inactivation of Llgl1 leads to expansion of the stem cell pool and increases self-renewal capacity without conferring malignant transformation. Here we show that genetic inactivation of its putative complex partner Scribble results in functional impairment of hematopoietic stem cells (HSC) over serial transplantation and during stress. Although loss of Scribble deregulates transcriptional downstream effectors involved in stem cell proliferation, cell signaling, and cell motility, these effectors do not overlap with transcriptional targets of Llgl1. Binding partner analysis of Scribble in hematopoietic cells using affinity purification followed by mass spectometry confirms its role in cell signaling and motility but not for binding to polarity modules described in drosophila. Finally, requirement of Scribble for self-renewal capacity also affects leukemia stem cell function. Thus, Scribble is a regulator of adult HSCs, essential for maintenance of HSCs during phases of cell stress.

[Azygos vein aneurysm forming a mediastinal mass]. / Aneurisma de la vena ácigos como masa mediastínica.

Aneurysm of the azygos vein is a rare cause of mediastinal mass that is normally detected radiologically in asymptomatic patients. In some cases a diagnosis is made by noninvasive methods, such as computed tomography and magnetic resonance. However, in the present case imaging revealed what appeared to be a solid mass. When the mass had been excised by thoracotomy, the histopathologic diagnosis was aneurysm of the azygos vein.

Aneurisma de la vena ácigos como masa mediastínica / Azygos vein aneurysm forming a mediastinal mass

El aneurisma de la vena ácigos es una causa muy infrecuente de masa mediastínica y habitualmente se trata de un hallazgo radiológico en pacientes asintomáticos. Aunque en algunas ocasiones se puede llegar al diagnóstico por métodos no invasivos, como la tomografía computarizada y la resonancia magnética, en nuestro caso la imagen obtenida se asemejaba a una masa sólida. Se intervino a la paciente mediante toracotomía y se procedió a la exéresis de la tumoración. El diagnóstico histopatológico fue de aneurisma de la vena ácigos

Aneurysm of the azygos vein is a rare cause of mediastinal mass that is normally detected radiologically in asymptomatic patients. In some cases a diagnosis is made by noninvasive methods, such as computed tomography and magnetic resonance. However, in the present case imaging revealed what appeared to be a solid mass. When the mass had been excised by thoracotomy, the histopathologic diagnosis was aneurysm of the azygos vein

MR angiographic evaluation of complications in surgically treated type A aortic dissection.

Thoracic aortic dissection is a life-threatening disease with a high mortality rate and an elevated incidence of early and long-term complications. Advances in surgical treatment of ascending (Stanford type A) aortic dissection have helped improve patient survival, but follow-up imaging is critically important for the identification of postsurgical complications. Gadolinium-enhanced three-dimensional (3D) magnetic resonance (MR) angiography, along with multisection computed tomography, is the technique of choice for this purpose. For accurate assessment of 3D MR angiograms, it is important to know what surgical procedure was performed and to be familiar with the appearance of the normal postsurgical anatomy. A thorough understanding of potential postsurgical complications also is essential. Some complications (eg, formation of a periprosthetic hematoma or pseudoaneurysm, stenosis in a graft anastomosis) may derive from the prosthesis. Complications also may occur in the remnant of the native aorta, where persistent dissection distal to the prosthesis is common and may result in false channel thrombosis or aneurysmatic dilatation with collapse of the true lumen. Residual dissection that involves the supra-aortic trunks or the visceral aortic branches may produce neurologic effects or renal and mesenteric ischemia, respectively.

Gestión de calidad y dosimetría en estudios de tomografía computarizada en la pancreatitis aguda / Quality control and dosimetry in CT studies in acute pancreatitis

Objetivo: Analizar los protocolos de tomografía computarizada (TC) para el estudio de la pancreatitis aguda utilizados en los distintos turnos de trabajo del Servicio de Radiodiagnóstico del Hospital Clínico San Carlos (HCSC), para valorar si existen diferencias significativas entre ellos y si éstas afectan a la calidad de los estudios y a las dosis impartidas a los pacientes. Material y métodos: Se revisaron retrospectivamente 120 estudios de TC en pacientes con pancreatitis aguda. Se obtuvieron los protocolos técnicos estándar usados en los siete turnos de trabajo y se compararon entre sí, lo que permitió agrupar los protocolos en dos grupos. Se escogieron 10 exploraciones de cada grupo para evaluar los criterios de calidad y las magnitudes dosimétricas (DLP, CTDIw y dosis efectiva), y se siguieron los criterios para las exploraciones de páncreas de la Guía Europea de Criterios de Calidad para la TC. Resultados: Entre los dos grupos finales existen diferencias en la intensidad de corriente de tubo y en el tiempo por cada rotación del tubo entre los protocolos (p < 0,05). No hay diferencias significativas entre los dos grupos en cuanto a la calidad de los estudios (p = 0,47) aunque sí las hubo en los valores de las magnitudes dosimétricas (p < 0,001). Conclusiones: Las diferencias encontradas entre los protocolos que se usaron en el estudio de TC para pancreatitis aguda en el HCSC afectan directamente a la dosis de radiación recibida por el paciente, pero no a la calidad de los estudios. Por tanto, debe establecerse un protocolo único que obtenga una calidad suficiente de imagen con la mínima dosis en el estudio de la pancreatitis aguda

Objective: To analyze the protocols for the use of computed tomography (CT) in the study of acute pancreatitis employed in different work shifts in our diagnostic imaging department in order to determine whether there are significant differences among them and whether these differences affect the quality of the examinations and the dose of radiation received by the patients. Material and methods: A total of 120 CT studies carried out in patients with acute pancreatitis were reviewed retrospectively. The standard technical protocols used in the seven work shifts were examined and compared with one another. The results allowed the protocols to be divided into two groups. Ten examinations from each group were selected to be evaluated with respect to dosimetric parameters (dose length product (DLP), weighted computed tomography dose index (CTDIw), and effective dose) and the quality criteria for CT examinations of the pancreas laid out in the «European Guidelines on Quality Criteria for Computed Tomography». Results: Significant differences (p < 0.05), de forma que existen dos grupos diferenciados claramente in tube current levels and tube rotation time were found between the two groups of protocols. No significant differences with respect to the quality of the studies were found between the two groups (p = 0.47), although there were significant differences (p < 0.001) in the dosimetric values. Conclusions: The differences found between the protocols used for CT examination in acute pancreatitis in our department directly affect the dose of radiation the patient receives but not the quality of the study. Therefore, a single protocol that ensures sufficient image quality using the minimum dose of radiation should be established for CT evaluation of acute pancreatitis