Incidental findings in emergency imaging: frequency,recommendations, and compliance with consensus guidelines

The purpose of this study was to evaluate the frequency of incidental findings (IFs) in emergency department (ED) imaging reports and evaluate the adherence of imaging recommendations to consensus societal guidelines for IFs. A retrospective review of consecutive ED computed tomography (CT) and ultrasonography (US) reports from two university-affiliated EDs over a 2-month period was performed. Each imaging report was reviewed in its entirety, and incidental findings were documented along with recommendations for additional imaging. Imaging recommendations were compared to published societal guidelines from the American College of Radiology (ACR) and Fleischner Society. Three thousand one hundred thirty-one total cases consisting of 1967 CTs and 1164 US contained 514 incidental findings (16.4 %), with 329 CT IFs (64 %) and 185 US IFs (36 %). The ovary was the most common organ for an IF (n?=?214, 42 %). Of all IFs, 347 (67.5 %) recommendations were concordant with societal guidelines and 167 (32.5 %) were discordant. 39.8 % of CT recommendations were discordant, while 19.5 % of US recommendations were discordant (p?<?0.0001). Incidental findings are commonly encountered in the emergent setting. Variable adherence to societal guidelines is noted. Targeted radiologist education and technological solutions may decrease rates of discordance.     

Post-trauma “abrasive” right ventricular rupture without mediastinitis early post-CABG. Is the Robicsek closure technique necessary for all elderly patients?

INTRODUCTION

Right ventricular (RV) rupture with mediastinitis, is a very rare but extremely dangerous (even fatal) complication, following CABG surgery.

PRESENTATION OF CASE

In this paper, we present the case of a post-trauma (after fall) RV rupture (without mediastinitis) in a patient who had undergone cardiac surgery several days ago. The cause of the rupture proved to be a broken bone piece from the lower sternal edge.

DISCUSSION

RV rupture post-operatively caused by broken bone pieces or bone dislocation may occur through two mechanisms: either penetration of the RV, or through the “sandpaper effect”. In order to prevent the rupture, we should be able to recognize patients with aggravating factors (age, weight) and choose intra-operatively a suitable closure technique.

CONCLUSION

We propose that the technique that could prevent such ruptures is the Robicsek technique.     

Emerging growth factor receptor antagonists for the treatment of renal cell carcinoma

Introduction: The landscape of systemic treatment for metastatic renal cell carcinoma (RCC) has dramatically changed with the introduction of targeted agents including vascular endothelial growth factor (VEGF) inhibitors. Recently, multiple new agents including growth factor receptor antagonists and a checkpoint inhibitor were approved for the treatment of refractory metastatic RCC based on encouraging benefit shown in clinical trials.

Areas covered: The background and biological rationale of existing treatment options including a brief discussion of clinical trials which led to their approval, is presented. This is followed by reviewing the limitations of these therapeutic options, medical need to develop new treatments and major goals of ongoing research. We then discuss two recently approved growth factor receptor antagonists i.e. cabozantinib and lenvatinib, and a recently approved checkpoint inhibitor, nivolumab, and issues pertaining to drug development, and future directions in treatment of metastatic RCC.

Expert opinion: Recently approved growth factor receptor antagonists have shown encouraging survival benefit but associated drug toxicity is a major issue. Nivolumab, a programmed death 1 (PD-1) checkpoint inhibitor, has similarly shown survival benefit and is well tolerated. With multiple options now available in this patient population, the right sequence of these agents remains to be determined.     

Where do these cadavers come from?

Cadaveric surgical courses are highly useful in developing operative skills, however, the provenance of the cadavers themselves remains opaque. Trade in cadaveric parts is an important source of material for courses, and this has spawned the unique service of body brokerage. Body brokers, however, operate in an unregulated market and obtain bodies by exploiting family members' altruistic instincts and financial concerns. Unethical and illegal sale of body parts has been well-documented, while the use of cadavers for uses other than that consented by donors is also a key concern. Undoubtedly, cadaveric surgical courses would have used bodies sourced from brokers, and questions remain about the moral and ethical implications of this. We discuss this issue using an ethical and historical context as well as offering solutions to ensure the ethical sourcing of cadavers for surgical training.     

Melphalan-Based Reduced-Intensity Conditioning is Associated with Favorable Disease Control and Acceptable Toxicities in Patients Older Than 70 with Hematologic Malignancies Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

Allogeneic hematopoietic stem cell transplantation (alloHCT) is offered increasingly to elderly patients with hematologic malignancies. However, outcome data in those who are 70 years or older are limited, and no standard conditioning regimen has been established for this population. In this retrospective study we evaluated the outcome of 53 consecutive patients aged 70 years and older who underwent alloHCT with melphalan-based reduced-intensity conditioning (RIC) at City of Hope. Engraftment was prompt, with median time to neutrophil engraftment of 15 days. More than 95% of patients achieved complete donor chimerism within 6 weeks from HCT, consistent with the “semiablative” nature of this regimen. With a median follow-up of 31.1 months, the 2-year overall survival (OS), progression-free survival (PFS), and nonrelapse mortality (NRM) were 68.9%, 63.8%, and 17.0%, respectively. Cumulative incidence of relapse at 1 and 2 years was 17.0% and 19.3%, respectively. One hundred–day cumulative incidence of grades II to IV acute graft-versus-host disease was 37.7% (grades III to IV, 18.9%), and 2-year cumulative incidence of chronic graft-versus-host disease was 61.9% (extensive, 45.9%). The only significant predictor for poor OS was high/very high disease risk index. Transplant-related complications and morbidities observed here did not differ from the commonly expected in younger patients treated with RIC. In conclusion, alloHCT with a melphalan-based conditioning regimen is associated with acceptable toxicities and NRM, lower incidence of relapse, and favorable OS and PFS in patients aged 70 years or older.