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Jonas F Ludvigsson,1 Johan Askling,1 Sven Cnattingius,1 Per Hall,1 Lars Klareskog,1 Olof Nyren,1 John A Baron,2 Henrik Toft Sørensen3 1Karolinska Institutet, Solna, Sweden; 2University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; 3Aarhus University, Aarhus, DenmarkCorrespondence: Jonas F Ludvigsson, Email jonasludvigsson@yahoo.com

Objectives: Computed tomography pulmonary angiography (CTPA) is the gold standard diagnostic method for patients with suspected pulmonary embolism (PE), but it has its drawbacks, including exposure to ionizing radiation and iodinated contrast agent. The present study aims to evaluate the diagnostic performance of our in-house developed non-contrast MRI protocol for PE diagnosis in reference to CTPA. Methods: 107 patients were included, all of whom underwent MRI immediately before or within 36 hours after CTPA. Additional cases examined only with MRI and a negative result were added to reach a PE prevalence of approximately 20%. The protocol was a non-contrast 2D steady-state free precession (SSFP) sequence under free-breathing, without respiratory or cardiac gating, and repeated five times to capture the vessels at different breathing/cardiac phases. The MRIs were blinded and read by two radiologists and the results were compared to CTPA. Results: Of the 243 patients included, 47 were positive for PE. Readers 1 and 2 demonstrated 89% and 87% sensitivity, 100% specificity, 98% accuracy and Cohen’s kappa of 0.88 on patient level. In the per embolus comparison, readers 1 and 2 detected, 60 and 59/61 (98, 97%) proximal, 101 and 94/113 (89, 83%) segmental, and 5 and 2/32 (16, 6%) subsegmental emboli, resulting in 81 and 75% sensitivity respectively. Conclusion: The repeated 2D SSFP can reliably be used for the diagnosis of acute PE at the proximal and segmental artery levels.

Abstract Background Common bile duct exploration (CBDE) is safe and effective for managing choledocholithiasis, but most US general surgeons have limited experience with CBDE and are uncomfortable performing this procedure in practice. Surgical trainee exposure to CBDE is limited, and their learning curve for achieving autonomous, practice-ready performance has not been previously described. This study tests the hypothesis that receipt of one or more prior CBDE operative performance assessments, combined with formative feedback, is associated with greater resident operative performance and autonomy. Methods Resident and attending assessments of resident operative performance and autonomy were obtained for 189 laparoscopic or open CBDEs performed at 28 institutions. Performance and autonomy were graded along validated ordinal scales. Cases in which the resident had one or more prior CBDE case evaluations (n = 48) were compared with cases in which the resident had no prior evaluations (n = 141). Results Compared with cases in which the resident had no prior CBDE case evaluations, cases with a prior evaluation had greater proportions of practice-ready or exceptional performance ratings according to both residents (27% vs. 11%, p = .009) and attendings (58% vs. 19%, p

Purpose: Severe COVID-19 is associated with inflammation, thromboembolic disease, and high mortality. We studied factors associated with fatal outcomes in consecutive COVID-19 patients examined by computed tomography pulmonary angiogram (CTPA).Methods: This retrospective, single-center cohort analysis included 130 PCR-positive patients hospitalized for COVID-19 [35 women and 95 men, median age 57 years (interquartile range 51–64)] with suspected pulmonary embolism based on clinical suspicion. The presence and extent of embolism and parenchymal abnormalities on CTPA were recorded. The severity of pulmonary parenchymal involvement was stratified by two experienced radiologists into two groups: lesions affecting ≤50% or >50% of the parenchyma. Patient characteristics, radiological aspects, laboratory parameters, and 60-day mortality data were collected.Results: Pulmonary embolism was present in 26% of the patients. Most emboli were small and peripheral. Patients with widespread parenchymal abnormalities, with or without pulmonary embolism, had increased main pulmonary artery diameter (p < 0.05) and higher C-reactive protein (p < 0.01), D-dimer (p < 0.01), and troponin T (p < 0.001) and lower hemoglobin (p < 0.001). A wider main pulmonary artery diameter correlated positively with C-reactive protein (r = 0.28, p = 0.001, and n = 130) and procalcitonin. In a multivariant analysis, D-dimer >7.2 mg/L [odds ratio (±95% confidence interval) 4.1 (1.4–12.0)] and ICU stay were significantly associated with embolism (p < 0.001). The highest 60-day mortality was found in patients with widespread parenchymal abnormalities combined with pulmonary embolism (36%), followed by patients with widespread parenchymal abnormalities without pulmonary embolism (26%). In multivariate analysis, high troponin T, D-dimer, and plasma creatinine and widespread parenchymal abnormalities on CT were associated with 60-day mortality.Conclusions: Pulmonary embolism combined with widespread parenchymal abnormalities contributed to mortality risk in COVID-19. Elevated C-reactive protein, D-dimer, troponin-T, P-creatinine, and enlarged pulmonary artery were associated with a worse outcome and may mirror a more severe systemic disease. A liberal approach to radiological investigation should be recommended at clinical deterioration, when the situation allows it. Computed tomography imaging, even without intravenous contrast to assess the severity of pulmonary infiltrates, are of value to predict outcome in COVID-19. Better radiological techniques with higher resolution could potentially improve the detection of microthromboses. This could influence anticoagulant treatment strategies, preventing clinical detoriation.

To demonstrate the feasibility and potential of using a second-generation prototype photon-counting computed tomography (CT) system to provide simultaneous high spatial resolution images and high spectral resolution material information across a range of routine imaging tasks using clinical patient exposure levels. The photon-counting system employs an innovative silicon-based photon-counting detector to provide a balanced approach to ultra-high-resolution spectral CT imaging. An initial cohort of volunteer subjects was imaged using the prototype photon-counting system. Acquisition technique parameters and radiation dose exposures were guided by routine clinical exposure levels used at the institution. Images were reconstructed in native slice thickness using an early version of a spectral CT reconstruction algorithm Samples of images across a range of clinical tasks were selected and presented for review. Clinical cases are presented across inner ear, carotid angiography, chest, and musculoskeletal imaging tasks. Initial reconstructed images illustrate ultra-high spatial resolution imaging. The fine detail of small structures and pathologies is clearly visualized, and structural boundaries are well delineated. The prototype system additionally provides concomitant spectral information with high spatial resolution. This initial study demonstrates that routine imaging at clinically appropriate patient exposure levels is feasible using a novel deep-silicon photon-counting detector CT system. Furthermore, a deep-silicon detector may provide a balanced approach to photon-counting CT, providing high spatial resolution imaging with simultaneous high-fidelity spectral information. [ABSTRACT FROM AUTHOR]

Background Rheumatoid arthritis (RA)-associated anticitrullinated protein/peptide antibodies (ACPA) might originate at mucosal sites such as the lungs. We aimed to examine the relationship between the ACPA repertoire and lung abnormalities on high-resolution CT (HRCT) in patients with earlyuntreated RA.Methods 106 patients with newly diagnosed untreated RA were examined with HRCT of the lungs. Blood samples were analysed for presence of rheumatoid factor (RF) and ACPA using either a CCP2 detection kit or an immunochip containing 10 different citrullinated peptides. Association between HRCT findings and the antibody repertoire was assessed by logistic regression analysis.Results The number (%) of patients with HRCT abnormalities was 58 (54.7%) for parenchymal abnormalities and 68 (64.2%) for airway abnormalities. CCP2 IgG, RF IgA and antibodies against citrullinated fibrinogen were associated with the presence of parenchymal lung abnormalities. Interestingly, a high number of ACPA fine specificities gave a high risk of having parenchymal lung abnormalities at the time of RA diagnosis. No significant signals were identified between ACPA specificities and risk for airway abnormalities.Conclusions The presence of RF and ACPAs (especially against citrullinated fibrinogen peptides) as well as high number of ACPAs fine specificities are associated with parenchymal lung abnormalities in patients with early, untreated RA. This provides further support for an important pathogenic link between the lung and systemic autoimmunity, contributing to RA development.

Intraoperative cholangiography may allow for earlier identification of common bile duct injury and choledocholithiasis. The role of intraoperative cholangiography in decreasing resource use related to biliary pathology remains unclear. This study tests the null hypothesis that there is no difference in resource use for patients undergoing laparoscopic cholecystectomy with versus without intraoperative cholangiography. This retrospective, longitudinal cohort study included 3,151 patients who underwent laparoscopic cholecystectomy at 3 university hospitals. To minimize differences in baseline characteristics while maintaining adequate statistical power, propensity scores were used to match 830 patients who underwent intraoperative cholangiography at surgeon discretion and 795 patients who underwent cholecystectomy without intraoperative cholangiography. Primary outcomes were the incidence of postoperative endoscopic retrograde cholangiography, the interval between surgery and endoscopic retrograde cholangiography, and total direct costs. In the propensity-matched analysis, the intraoperative cholangiography and no intraoperative cholangiography cohorts had similar age, comorbidities, American Society of Anesthesiologists Sequential Organ Failure Assessment scores, and total/direct bilirubin ratios. The intraoperative cholangiography cohort had a lower postoperative endoscopic retrograde cholangiography (2.4% vs 4.3%; P =.04), a shorter interval between cholecystectomy and endoscopic retrograde cholangiography (2.5 [1.0–17.8] vs 4.5 [2.0–9.5] days; P =.04), and shorter length of stay (0.3 [0.2–1.5] vs 1.4 [0.3–3.2] days; P <.001). Patients undergoing intraoperative cholangiography had lower total direct costs ($4.0K [3.6K–5.4K] vs $8.1K [4.9K–13.0K]; P <.001). There were no differences in 30-day or 1-year mortality among the cohorts. Compared with laparoscopic cholecystectomy without intraoperative cholangiography, cholecystectomy with intraoperative cholangiography was associated with decreased resource use, which was primarily attributable to decreased incidence and the earlier timing of postoperative endoscopic retrograde cholangiography. [ABSTRACT FROM AUTHOR]

Laparoscopic common bile duct exploration is safe and effective for managing choledocholithiasis, but laparoscopic common bile duct exploration is rarely performed, which threatens surgical trainee proficiency. This study tests the hypothesis that prior operative or simulation experience with laparoscopic common bile duct exploration is associated with greater resident operative performance and autonomy without adversely affecting patient outcomes. This longitudinal cohort study included 33 consecutive patients undergoing laparoscopic common bile duct exploration in cases involving postgraduate years 3, 4, and 5 general surgery residents at a single institution during the implementation of a laparoscopic common bile duct exploration simulation curriculum. For each of the 33 cases, resident performance and autonomy were rated by residents and attendings, the resident's prior operative and simulation experience were recorded, and patient outcomes were ascertained from electronic health records for comparison among 3 cohorts: prior operative experience, prior simulation experience, and no prior experience. Operative approach was similar among cohorts. Overall morbidity was 6.1% and similar across cohorts. The operative performance scores were higher in prior experience cohorts according to both residents (3.0 [2.8–3.0] vs 2.0 [2.0–3.0]; P =.01) and attendings (3.0 [3.0–4.0]; P <.001). The autonomy scores were higher in prior experience cohorts according to both residents (2.0 [2.0–3.0] vs 2.0 [2.0–2.0]; P =.005) and attendings (2.5 [2.0–3.0] vs 2.0 [1.0–2.0]; P =.001). Prior simulation and prior operative experience had similar associations with performance and autonomy. Simulation experience with laparoscopic common bile duct exploration was associated with greater resident operative performance and autonomy, with effects that mimic prior operative experience. This illustrates the potential for simulation-based training to improve resident operative performance and autonomy for laparoscopic common bile duct exploration. [ABSTRACT FROM AUTHOR]

Dual X-ray and Laser (DXL) adds a measure of the external thickness of the heel, measured by laser, to a conventional measurement of bone mineral density (BMD) of the calcaneus, using Dual energy X-ray Absorptiometry (DXA). The addition of heel thickness aims at a better separation of fatty tissue from bone than the standard method of DXA, which may mistake fatty tissue for bone and vice versa. The primary aim of this study was to evaluate whether DXL of the calcaneus can be used to assess the 10-year risk of fractures. Secondary aims were to compare the predictive ability of DXL with the two most established methods, Dual energy X-ray Absorptiometry (DXA) of the hip and spine and the WHO fracture risk assessment tool, FRAX. In 1999 a cohort of 388 elderly Swedish women (mean age 73.2 years) was examined with all three methods. Prospective fracture data was collected in 2010 from health care registers. One SD decrease in BMD of the heel resulted in an age-adjusted Hazard Ratio (HR) of 1.47 for a hip fracture (95% CI 1.09-1.98). Harrell's C is the Cox regression counterpart of the Area Under Curve (AUC) of the Receiver Operating Characteristic (ROC) as a measure of predictive accuracy. Harrell's C for BMD of the calcaneus was 0.65 for prediction of hip fractures. These results were not significantly different from those for BMD of the femoral neck or for FRAX. The HR for a hip fracture, for one SD decrease in BMD at the femoral neck, was 1.72 (95% CI 1.21-2.44. Harrell's C was 0.67 for BMD at the femoral neck and 0.59 for FRAX. We conclude that DXL of the calcaneus could be a useful tool for fracture risk assessments.

The strong male predominance in oesophageal adenocarcinoma (OAC) and Barrett's oesophagus (BO) continues to puzzle. Hormonal influence, e.g. oestrogen or oxytocin, might contribute.This genetic-epidemiological study pooled 14 studies from three continents, Australia, Europe, and North America. Polymorphisms in 3 key genes coding for the oestrogen pathway (receptor alpha (ESR1), receptor beta (ESR2), and aromatase (CYP19A1)), and 3 key genes of the oxytocin pathway (the oxytocin receptor (OXTR), oxytocin protein (OXT), and cyclic ADP ribose hydrolase glycoprotein (CD38)), were analysed using a gene-based approach, versatile gene-based test association study (VEGAS).Among 1508 OAC patients, 2383 BO patients, and 2170 controls, genetic variants within ESR1 were associated with BO in males (p = 0.0058) and an increased risk of OAC and BO combined in males (p = 0.0023). Genetic variants within OXTR were associated with an increased risk of BO in both sexes combined (p = 0.0035) and in males (p = 0.0012). We followed up these suggestive findings in a further smaller data set, but found no replication. There were no significant associations between the other 4 genes studied and risk of OAC, BO, separately on in combination, in males and females combined or in males only.Genetic variants in the oestrogen receptor alpha and the oxytocin receptor may be associated with an increased risk of BO or OAC, but replication in other large samples are needed.

Introduction: Migrant studies may provide valuable clues to the etiology of chronic diseases such as cancer. We conducted a migrant study to examine cancer incidence among Iranian immigrants in Sweden. Methods: A cohort of Iranian immigrants in Sweden in 1960-2004 was followed through record linkages with Swedish registers of cancer, death, and migration. We compared Age-Standardized Incidence Rates (ASRs) with corresponding ASRs in Tehran and Sweden and estimated Standard Rate Ratios with 95% confidence intervals (CI). In addition, ASRs were stratified by follow-up time. Results: In total 1,041 cancers occurred among 60,718 Iranian immigrants. The ASRs for all cancers combined were 182.3 and 175.5 per 100,000 person-years among men and women, respectively. For men, this rate was slightly and non-significantly higher than in Iran, while for women the excess (24%) was statistically significant. However, their ASRs were significantly lower than those for native Swedes: men had 37% (95% CI 27-47%) and women 35% (95% CI 33-37%) lower ASRs. Compared to male Iranians living in Tehran, ASRs of esophageal and gastric cancer were lower while ASRs of colorectal and prostate cancer were higher, and both of the latter increased with time since immigration. In women, the ASR of non-melanoma skin cancer was lower and that of breast cancer higher and increasing. Conclusion: In male first-generation immigrants, incidence rates of esophageal, gastric, colorectal, and prostate cancer change in the direction of prevailing rates in Sweden, likely due to changes in exposure to environmental risk factors. A similar adjustment occurs for breast and non-melanoma skin cancer among female immigrants.

This summary of the annual meeting of the New England Library Association presents highlights of presentations on federal aid futures, public relations and internal communications, building and maintaining a videocassette collection, online catalogs, and approval plans, as well as remarks by book award winners, another author, and a publisher. (RAA)

Surveys library construction during 1979 through statistical tables and photographs. Costs, volumes, and funding are listed by state for new buildings and additions/remodelings/renovations. Also represented in tables are public libraries in Canada, leased public library space, and a six-year cost summary. (SW)

Composed mostly of photographs and statistical tables, this survey report provides data about construction costs, book capacity, and seating capacity for academic libraries. New libraries, additions, addition/renovations, renovations only, and new law libraries are the subjects of the statistical presentation. (SW)

The purpose of the Voices of Brooklyn" project is to promote multicultural understanding and to involve the people of the various cultures in a common cultural undertaking. (Author/MM)

To develop appropriate bioenergy production systems to match site-specific situations, establishment and yield were evaluated for switchgrass (Panicum virgatum L.), intermediate wheatgrass [Thinopyrum intermedium (Host) Barkworth and D.R. Dewey], tall wheatgrass [Thinopyrum ponticum (Podp.) Z.-W. Liu and R.-C. Wang], and three binary mixtures at four sites in North Dakota from 2006 to 2011. One year after seeding in 2007, intermediate wheatgrass, tall wheatgrass, a binary mixture of tall wheatgrass and intermediate wheatgrass, and a binary mixture of tall wheatgrass with 'Sunburst' switchgrass (dominated by tall wheatgrass) stand canopy cover was above 85% at all four sites. Sunburst switchgrass and its binary mixture with big bluestem (Andropogon gerardii Vitman) stand canopy cover reached 100% at Carrington, the most eastern site; and below 35% at Williston, the most western site, 1 yr after seeding. Meanwhile, their stand canopy cover was more than 70% at Minot and Streeter, the north central and south central sites, respectively, 2 to 3 yr after seeding. Sunburst switchgrass produced the highest biomass at Carrington (10.6 ± 1.8 Mg ha-1), whereas intermediate wheatgrass was the highest at Williston (3.0 ± 1.0 Mg ha-1). The binary mixture of tall wheatgrass with Sunburst switchgrass had the highest yield at Minot (8.5 ± 2.5 Mg ha-1) and Streeter (6.7 ± 1.9 Mg ha-1). Yields of binary mixtures were at least comparable to and sometimes higher than those of their compositional component monocultures. Binary mixtures with carefully selected species could have potential for bioenergy production systems in North Dakota. [ABSTRACT FROM AUTHOR]