Stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities on CT

High-attenuation pulmonary abnormalities are commonly seen on CT. These findings are increasingly encountered with the growing number of CT examinations and the wide availability of thin-slice images. The abnormalities include benign lesions, such as infectious granulomatous diseases and metabolic diseases, and malignant tumors, such as lung cancers and metastatic tumors. Due to the wide spectrum of diseases, the proper diagnosis of high-attenuation abnormalities can be challenging. The assessment of these abnormal findings requires scrutiny, and the treatment is imperative. Our proposed stepwise diagnostic algorithm consists of five steps. Step 1: Establish the presence or absence of metallic artifacts. Step 2: Identify associated nodular or mass-like soft tissue components. Step 3: Establish the presence of solitary or multiple lesions if identified in Step 2. Step 4: Ascertain the predominant distribution in the upper or lower lungs if not identified in Step 2. Step 5: Identify the morphological pattern, such as linear, consolidation, nodular, or micronodular if not identified in Step 4. These five steps to diagnosing high-attenuation abnormalities subdivide the lesions into nine categories. This stepwise radiologic diagnostic approach could help to narrow the differential diagnosis for various pulmonary high-attenuation abnormalities and to achieve a precise diagnosis.Critical relevance statement Our proposed stepwise diagnostic algorithm for high-attenuation pulmonary abnormalities may help to recognize a variety of those high-attenuation findings, to determine whether the associated diseases require further investigation, and to guide appropriate patient management. Key points • To provide a stepwise diagnostic approach to high-attenuation pulmonary abnormalities.• To familiarize radiologists with the varying cause of high-attenuation pulmonary abnormalities.• To recognize which high-attenuation abnormalities require scrutiny and prompt treatment.

Bilateral lung transplantation in a 9-year-old girl with bronchopulmonary dysplasia with pulmonary hypertension

BACKGROUND

Bronchopulmonary dysplasia (BPD) is a chronic respiratory disease that occurs in premature infants and the prognosis is variable depending on the comorbidities including fibrosis, emphysema, or pulmonary hypertension (PH). We present a case of a 9-year-old girl who developed PH associated with severe BPD (BPD-PH) and underwent bilateral lung transplantation (BLTx). Case description A 9-year-old girl was admitted to our department to undergo BLTx. She was born at 23 weeks and 4 days gestation with a weight of 507 g. She received ventilation for the first 2 months and required further respiratory care due to repetitive, severe respiratory infections. She was diagnosed with BPD-PH at 6 months of age and oral administration of pulmonary vasodilators were initiated. She was registered as a lung transplant candidate at 4 years of age after the life-threatening exacerbation. Chest computed tomography (CT) revealed severe lung conditions with ground-glass opacities and emphysematous low-density areas in the upper and lower lobes. BLTx from a brain-dead male donor was performed. The pathological findings of her resected lung revealed saccular, hypoplastic lung with alveolar repair/regeneration, and medial hypertrophy and muscularization of peripheral arteries. The postoperative course was mostly uneventful. She was free from oxygen administration and showed no signs of PH after 6 months of the surgery.

CONCLUSION

This is the first case report of BLTx in a pediatric, irreversible BPD-PH patient with detailed pathohistological findings and clinical examination. Lung transplantation is one of the treatment options for severe BPD-PH.

Radiographic features and poor prognostic factors of interstitial lung disease with nivolumab for non-small cell lung cancer

Nivolumab can cause interstitial lung disease (ILD), which may be fatal; however, mortality risk factors have not been identified. This postmarketing study evaluated the poor prognostic factors of ILD in nivolumab-treated patients with non-small cell lung cancer (NSCLC) in Japan. Clinical and chest imaging findings for each ILD case were assessed by an expert central review committee, and prognosis was evaluated by radiographic findings, including the presence/absence of peritumoral ground-glass opacity (peritumoral-GGO). Poor prognostic factors were identified by univariate and multivariate Cox regression analysis. Of the 238 patients with nivolumab-induced ILD, 37 died. The main radiographic patterns of ILD were cryptogenic organizing pneumonia/chronic eosinophilic pneumonia-like (53.4%), faint infiltration pattern/acute hypersensitivity pneumonia-like (20.2%), diffuse alveolar damage (DAD)-like (10.9%), and nonspecific interstitial pneumonia-like (6.3%). The main poor prognostic factors identified were DAD-like pattern (highest hazard ratio: 10.72), ≤60 days from the start of nivolumab treatment to the onset of ILD, pleural effusion before treatment, lesion distribution contralateral or bilateral to the tumor, and abnormal change in C-reactive protein (CRP) levels. Of the 37 deaths due to ILD, 17 had DAD-like radiographic pattern, three had peritumoral-GGO, and five had a change in radiographic pattern from non-DAD at the onset to DAD-like. Patients with NSCLC who develop ILD during nivolumab treatment should be managed carefully if they have poor prognostic factors such as DAD-like radiographic pattern, onset of ILD ≤60 days from nivolumab initiation, pleural effusion before nivolumab treatment, lesion distribution contralateral or bilateral to the tumor, and abnormal changes in CRP levels.

Treatment and relapse of interstitial lung disease in nivolumab-treated patients with non-small cell lung cancer

Nivolumab, a human monoclonal antibody against programmed death‐1, is approved for the treatment of non–small cell lung cancer (NSCLC). Although nivolumab is generally well tolerated, it can cause interstitial lung disease (ILD), a rare but potentially fatal immune‐related adverse event. Currently, there are limited data available on the treatment of nivolumab‐induced ILD and its outcome. This retrospective cohort study based on a post–marketing study described the treatment of nivolumab‐induced ILD and its outcome in NSCLC patients in Japan through the assessment of clinical and chest imaging findings by an expert central review committee. Treatment details for patients who experienced a relapse of ILD were also analyzed. Of the 238 patients identified as having nivolumab‐induced ILD, 37 patients died of ILD. Corticosteroids were used in 207 (87.0%) patients. Of those, 172 (83.1%) patients responded well and survived and 35 (16.9%) died (most died during corticosteroid treatment). A total of nine patients experienced a relapse; at the time of relapse, four patients were taking nivolumab. Of those who were receiving corticosteroids at the time of relapse, three of four patients were taking low doses or had nearly completed dose tapering. All patients (except one, whose treatment was unknown) received corticosteroids for the treatment of relapse, but one patient died. Patients with NSCLC who experience nivolumab‐induced ILD are treated effectively with corticosteroids, and providing extra care when ceasing or reducing the corticosteroid dose may prevent relapse of ILD.

Computed tomography findings of current nonspecific interstitial pneumonia based on the 2013 updated classification of idiopathic interstitial pneumonias: What is a characteristic of previously diagnosed nonspecific interstitial pneumonia excluded from the updated classification

PURPOSE

To evaluate computed tomography (CT) findings of nonspecific interstitial pneumonia (NSIP) based on the current classification of idiopathic interstitial pneumonias (IIPs) and elucidate a characteristic of previously diagnosed NSIP excluded from the current classification.

MATERIALS AND METHODS

The study included 74 patients with biopsy-proven NSIP (idiopathic NSIP [I-NSIP], 39 patients; NSIP associated with connective tissue disease [CTD-NSIP], 35 patients). Among patients who were compatible with the current classification of IIPs, 29 and 21 were categorized as having current I-NSIP and current CTD-NSIP, respectively. The remaining 24 patients were categorized as having previous I-NSIP or previous CTD-NSIP due to the primary pathologic diagnosis of cellular NSIP or associated findings of acute inflammatory changes. CT findings were evaluated and compared among the four groups.

RESULTS

Current I-NSIP was indicated by ground-glass attenuation and reticulation with traction bronchiectasis/bronchiolectasis in predominantly peribronchovascular areas of the lower lung zone. The previous I-NSIP group tended to show broader airspace consolidation than the current I-NSIP group (p = 0.068). The previous CTD-NSIP group showed significantly broader airspace consolidation than the current I-NSIP group (p = 0.035).

CONCLUSION

Broad airspace consolidation is a characteristic of previously diagnosed CTD-NSIP excluded from the current classification of IIPs.

Movement of the proximal segment after intraoral vertical ramus osteotomy versus short lingual osteotomy with physiological positioning strategy

PURPOSE

To clarify whether intraoral vertical ramus osteotomy (IVRO) or short lingual osteotomy (SLO) induces less proximal segmental movement after surgery without bone fixation.

METHODS

This study included patients who underwent IVRO or SLO without bone fixation. Cephalograms were taken before surgery (T1), immediately after surgery (T2), and >6 months after surgery (T3) to assess postoperative movement of the proximal segment and skeletal stability. The condylar angle was measured using computed tomography images taken at T1 and T3 to assess rotation.

RESULTS

Ninety patients were included (IVRO, n = 25; SLO, n = 65). The proximal segment swung laterally on the frontal cephalogram in the asymmetrical IVRO group at T3. The condylar head was rotated outwardly 6.52 ± 4.49° (p < 0.0001) in the symmetrical IVRO group and 8.06 ± 6.88° (p = 0.030) on the non-deviated side in the asymmetrical IVRO group at T3. The condyles were almost stable in the SLO group. Temporomandibular joint disorders were found in 2 of 22 IVRO patients and in 2 of 42 SLO patients with asymmetry at T3.

CONCLUSION

This study suggests that SLO with the physiological positioning strategy (PPS) should be preferred over IVRO with the PPS whenever possible.

Radiologic features of pneumonitis associated with nivolumab in non-small-cell lung cancer and malignant melanoma

Aim: To assess the clinical features/imaging characteristics of pneumonitis reported during nationwide nivolumab postmarketing surveillance in Japan. Patients & methods: Clinical and radiological data were collected from pneumonitis cases reported during/after nivolumab treatment for melanoma or non-small-cell lung cancer. The expert central review committee evaluated each case. Results: Among 144 cases analyzed, 91 (63.2%) had radiological patterns considered typical for drug-induced pneumonitis and 53 (36.8%) patients had previously unobserved patterns with one or more atypical features, including 23 cases (16.0%) with ground glass opacity confined to the area around the tumor (peritumoral infiltration). A higher proportion of patients with (vs without) peritumoral infiltration had an antitumor response to nivolumab. Conclusion: Images of nivolumab-induced pneumonitis showed previously unobserved radiological patterns.

Correlation between the native lung volume change and postoperative pulmonary function after single lung transplantation for lymphangioleiomyomatosis: Evaluation of lung volume by three-dimensional computed tomography volumetry

PURPOSE

Whereas native lung overinflation has been thought to happen in recipients of single lung transplantation for lymphangioleiomyomatosis because of its increased compliance, there is no study that has reported the details on the change of the native lung volume after single lung transplantation by three-dimensional computed tomography volumetry. The purpose of the present study was to evaluate the lung volume after single lung transplantation for lymphangioleiomyomatosis by three-dimensional computed tomography volumetry and investigate the correlation between the native lung volume change and postoperative pulmonary function.

METHODS

We retrospectively reviewed the data of 17 patients who underwent single lung transplantation for lymphangioleiomyomatosis. We defined the ratio of the native lung volume to total lung volume (N/T ratio) as an indicator of overinflation of the native lung. In order to assess changes in the N/T ratio over time, we calculated the rate of change in the N/T ratio which is standardized by the N/T ratio at 1 year after single lung transplantation: rate of change in N/T ratio (%) = {(N/T ratio at a certain year)/(N/T ratio at 1 year)- 1}× 100.

RESULTS

We investigated the correlations between the N/T ratio and the pulmonary function test parameters at 1 year and 5 years; however, there was no significant correlation between them. On the other hand, there was a significant negative correlation between the rate of change in the N/T ratio and that in forced expiratory volume in 1 second %predicted (%FEV1) at 5 years after single lung transplantation.

CONCLUSION

The single lung transplantation recipients for lymphangioleiomyomatosis showed increased rate of change in the N/T ratio in the long-time course after lung transplantation with the decrease of %FEV1. We expect that these cases will probably cause the overinflation of the native lung in the future.

Pathological features of explant lungs with fibrosis in autoimmune pulmonary alveolar proteinosis

Association of fibrosis with autoimmune pulmonary alveolar proteinosis (aPAP) is rare. However, prognoses of such cases are poor and the process of the formation of fibrosis is still unknown. In this study, we report a case of aPAP with progressive fibrosis occurring in a 46‐year‐old woman. She had undergone several repetitions of whole lung lavage (WLL) for 7 years and granulocyte‐macrophage colony‐stimulating factor (GM‐CSF) inhalation for 3 months; however, the progression of fibrosis was not hindered. Eventually, she was treated with bilateral lung transplantation. The computed tomography (CT) image suggested pulmonary fibrotic changes in her lung similar to usual interstitial pneumonia. However, the pathological analyses of explant lungs revealed that the fibrosis was not similar to ordinary interstitial pneumonias and suggested that the dysfunction of alveolar macrophage in removing the excess surfactant of alveolar spaces played an important role in the fibrogenesis in aPAP.

Nivolumab-induced interstitial lung disease (ILD) in Japanese patients with non-small cell lung cancer: A study on risk factors for fatal outcome

9077

Background: We investigated case reports of nivolumab-induced ILD in patients with non-small cell lung cancer to identify risk factors for poor prognosis of ILD. Methods: Among data obtained during post-marketing surveillance of nivolumab, case reports of ILD with detailed clinical course and chest imaging (CT) findings were assessed by the ILD Expert Review Committee, which consists of respiratory medicine specialists and expert chest radiologists. The imaging findings were examined and classified into those with typical or atypical patterns. Atypical patterns included shadows limited to surrounding tumors designated as “peritumoral infiltration”, relapse of radiation pneumonitis, worsening of underlying infection, and predominant shadow in diseased side. CT pattern was classified as DAD (diffuse alveolar damage) or non-DAD. Data were analyzed using a multivariate stepwise logistic regression analysis. Results: Among 160 reported cases of ILD, 140 cases were considered to be induced by nivolumab. Imaging findings showed typical patterns in 92 patients, and 23 (25.0%) died of ILD. Atypical patterns were noted in 48 patients, and 5 (10.4%) died of ILD. The following table summarizes the results of univariate and multivariate analyses of risk factors for poor prognosis of ILD. See table. DAD pattern was observed in 20, 14 (70%) among them showed fatal outcome, whereas non-DAD pattern showed it in 14/120 (11.7%). Male and pretreatment CRP level were significant risk factors for fatal outcome. Conclusions: Nivolumab-induced ILD may show some atypical pattern that was not seen in conventional chemotherapy or EGFR-TKI. Outcome of patients with atypical patterns was better than those with typical patterns. DAD pattern at CT, male, and pretreatment level of CRP were identified as risk factors of fatal outcome. [Table: see text]

Invasive pulmonary mucormycosis: rare presentation with pulmonary eosinophilia

BACKGROUND

Fungi can cause a variety of infectious diseases, including invasive mycosis and non-invasive mycosis, as well as allergic diseases. The different forms of mycosis usually have been described as mutually exclusive, independent entities, with few descriptions of overlapping cases. Here, we describe the first reported case of a patient with the complication of pulmonary eosinophilia in the course of invasive mucormycosis.

CASE PRESENTATION

A 74-year-old Japanese man with asthma-COPD overlap underwent emergency surgery for a ruptured abdominal aortic aneurysm. The surgery was successful, but fever and worsening dyspnea appeared and continued from postoperative day (POD) 10. A complete blood count showed leukocytosis with neutrophilia and eosinophilia, and the chest X-ray showed consolidation of the left upper lung at POD 15. We suspected nosocomial pneumonia together with an exacerbation of the asthma-COPD overlap, and both antibiotics and bronchodilator therapy were initiated. However, the symptoms, eosinophilia and imaging findings deteriorated. We then performed a bronchoscopy, and bronchoalveolar lavage (BAL) fluid analysis revealed an increased percentage of eosinophils (82% of whole cells) as well as filamentous fungi. We first suspected that this was a case of allergic bronchopulmonary mycosis (ABPM) caused by Aspergillus infection and began corticosteroid therapy with an intravenous administration of voriconazole at POD 27. However, the fungal culture examination of the BAL fluid revealed mucormycetes, which were later identified as Cunninghamella bertholletiae by PCR and DNA sequencing. We then switched the antifungal agent to liposomal amphotericin B for the treatment of the pulmonary mucormycosis at POD 29. Despite replacing voriconazole with liposomal amphotericin B, the patient developed septic shock and died at POD 39. The autopsy revealed that filamentous fungi had invaded the lung, heart, thyroid glands, kidneys, and spleen, suggesting that disseminated mucormycosis had occurred.

CONCLUSIONS

We describe the first reported case of pulmonary mucormycosis with pulmonary eosinophilia caused by Cunninghamella bertholletiae, which resulted in disseminated mucormycosis. Although it is a rather rare case, two important conclusions can be drawn: i) mycosis can simultaneously cause both invasive infection and a host allergic reaction, and ii) Cunninghamella bertholletiae rarely infects immunocompetent patients.

Instability and Spontaneous Reconstruction of Few-Monolayer Thick GaN Graphitic Structures

Two-dimensional (2D) semiconductors are a very hot topic in solid state science and technology. In addition to van der Waals solids that can be easily formed into 2D layers, it was argued that single layers of nominally 3D tetrahedrally bonded semiconductors, such as GaN or ZnO, also become flat in the monolayer limit; the planar structure was also proposed for few-layers of such materials. In this work, using first-principles calculations, we demonstrate that contrary to the existing consensus the graphitic structure of few-layer GaN is unstable and spontaneously reconstructs into a structure that remains hexagonal in plane but with covalent interlayer bonds that form alternating octagonal and square (8|4 Haeckelite) rings with pronounced in-plane anisotropy. Of special interest is the transformation of the band gap from indirect in planar GaN toward direct in the Haeckelite phase, making Haeckelite few-layer GaN an appealing material for flexible nano-optoelectronics.

A case of pulmonary adenocarcinoma harboring osteoclast-like giant cells: Its evaluation by immunohistochemical and genetic analyses

Tumors harboring osteoclast-like giant cells (OGCs) at extraosseous site are extremely rare. These rare tumors have been detected most frequently in the pancreas and few pulmonary tumors harboring OGCs have been previously reported. In addition, the genetic profiles of these tumors have remained virtually unknown. Therefore, we report a case of pulmonary adenocarcinoma harboring OGCs in which k-ras mutation and immunohistochemical study of proteins associated with OGCs were examined. The case was a 70-year-old man, who demonstrated a pulmonary mass associated with unusual radiological features. Histopathologically, three different cell types, mucinous adenocarcinoma cell, OGC and mononuclear cell were detected. OGCs were immunohistochemically negative for epithelial markers and positive for histiocytic markers but mononuclear cells were immunopositive for epithelial markers. In addition, both mononuclear and adenocarcinoma cells had the same k-ras mutation profiles and mononuclear cells were immunohistochemically positive for macrophage colony-stimulating factor (M-CSF), one of the factors associated with OGC differentiation. Therefore, mononuclear cells were considered to be derived from neoplastic epithelium and OGCs could represent non-neoplastic cells. In addition, M-CSF locally produced could promote the differentiation of OGCs.

Understanding Phase-Change Memory Alloys from a Chemical Perspective

Phase-change memories (PCM) are associated with reversible ultra-fast low-energy crystal-to-amorphous switching in GeTe-based alloys co-existing with the high stability of the two phases at ambient temperature, a unique property that has been recently explained by the high fragility of the glass-forming liquid phase, where the activation barrier for crystallisation drastically increases as the temperature decreases from the glass-transition to room temperature. At the same time the atomistic dynamics of the phase-change process and the associated changes in the nature of bonding have remained unknown. In this work we demonstrate that key to this behavior is the formation of transient three-center bonds in the excited state that is enabled due to the presence of lone-pair electrons. Our findings additionally reveal previously ignored fundamental similarities between the mechanisms of reversible photoinduced structural changes in chalcogenide glasses and phase-change alloys and offer new insights into the development of efficient PCM materials.

Immunohistochemical evidence for the association between attenuated mTOR signaling and diffuse alveolar damage, a fatal lung complication

Targeted anticancer therapies have been developed to interfere with specific target molecules including those of downstream pathways required for tumor growth and progression. Mammalian target of rapamycin (mTOR) has been considered as one of the target molecules of cancer growth, and its inhibitors have been reported to exert an anticancer effect in various malignant tumors. The pulmonary disorder is one of the major side effects of anticancer drugs including mTOR inhibitor (mTORi), and the diagnosis of lung injury induced by medication is difficult because of non-specific nature of the radiological findings. In this study, we present the detailed autopsy findings of a patient who developed diffuse alveolar damage (DAD) following mTORi treatment for metastatic renal cell carcinoma. We also studied 19 cases of DAD derived from other diseases and 9 cases with non-pathological lung. Of interest, pneumocytes of the patients with DAD, who received other anticancer drugs or contacted bacteria, demonstrated significantly lower mTOR activities than pneumocytes of those with non-pathological lung tissue, as judged by the immunohistochemical analysis. In contrast, both pneumocytes and T cells in DAD tissues of the patient treated with mTORi showed higher mTOR activities than those of patients with DAD of other causes, suggesting that the enhanced mTOR signaling may be involved in the development of DAD after mTORi treatment. This unexpected finding needs to be confirmed in other patients treated with mTORi. In conclusion, the attenuated mTOR signaling in pneumocytes may contribute to the pathogenesis of DAD in patients without mTORi treatment.

Study of band inversion in the PbxSn1-xTe class of topological crystalline insulators using x-ray absorption spectroscopy

Pb(x)Sn(1-x)Te and Pb(x)Sn(1-x)Se crystals belong to the class of topological crystalline insulators where topological protection is achieved due to crystal symmetry rather than time-reversal symmetry. In this work, we make use of selection rules in the x-ray absorption process to experimentally detect band inversion along the PbTe(Se)-SnTe(Se) tie-lines. The observed significant change in the ratio of intensities of L1 and L3 transitions along the tie-line demonstrates that x-ray absorption can be a useful tool to study band inversion in topological insulators.

Transport properties in a Sb-Te binary topological-insulator system

Sb-Te layers having various compositions between Sb2Te3 and Sb2Te are grown using molecular beam epitaxy. The structural and electrical properties of the layers change gradually with composition but exhibit a discontinuity involving a bistability. The holes in the layers are generated by Sb bilayers intercalated between Sb2Te3 quintuple layers and their mobility is governed by the scattering from the parent acceptors. Magnetoresistance for compositions around SbTe is linear, for which the reduction of the parabolic component due to low mobility is crucial. Density functional calculations predict Sb2Te3 and SbTe to be topological insulators (TIs) resembling Bi2Se3 and Bi2Te3, respectively. The prefactor of the weak antilocalization effect is α =- 1 regardless of the composition. The Sb-Te system is thus a family of TIs possessing undisturbed surface states for which the location of the Dirac point with respect to the bulk band gap is adjustable.

Interfacial phase-change memory

Phase-change memory technology relies on the electrical and optical properties of certain materials changing substantially when the atomic structure of the material is altered by heating or some other excitation process. For example, switching the composite Ge(2)Sb(2)Te(5) (GST) alloy from its covalently bonded amorphous phase to its resonantly bonded metastable cubic crystalline phase decreases the resistivity by three orders of magnitude, and also increases reflectivity across the visible spectrum. Moreover, phase-change memory based on GST is scalable, and is therefore a candidate to replace Flash memory for non-volatile data storage applications. The energy needed to switch between the two phases depends on the intrinsic properties of the phase-change material and the device architecture; this energy is usually supplied by laser or electrical pulses. The switching energy for GST can be reduced by limiting the movement of the atoms to a single dimension, thus substantially reducing the entropic losses associated with the phase-change process. In particular, aligning the c-axis of a hexagonal Sb(2)Te(3) layer and the 〈111〉 direction of a cubic GeTe layer in a superlattice structure creates a material in which Ge atoms can switch between octahedral sites and lower-coordination sites at the interface of the superlattice layers. Here we demonstrate GeTe/Sb(2)Te(3) interfacial phase-change memory (IPCM) data storage devices with reduced switching energies, improved write-erase cycle lifetimes and faster switching speeds.

Distortion-triggered loss of long-range order in solids with bonding energy hierarchy

An amorphous-to-crystal transition in phase-change materials like Ge-Sb-Te is widely used for data storage. The basic principle is to take advantage of the property contrast between the crystalline and amorphous states to encode information; amorphization is believed to be caused by melting the materials with an intense laser or electrical pulse and subsequently quenching the melt. Here, we demonstrate that distortions in the crystalline phase may trigger a collapse of long-range order, generating the amorphous phase without going through the liquid state. We further show that the principal change in optical properties occurs during the distortion of the still crystalline structure, upsetting yet another commonly held belief that attributes the change in properties to the loss of long-range order. Furthermore, our results suggest a way to lower energy consumption by condensing phase change inducing energy into shorter pulses or through the use of coherent phonon excitation.

Toward the ultimate limit of phase change in Ge(2)Sb(2)Te(5)

The limit to which the phase change memory material Ge(2)Sb(2)Te(5) can be scaled toward the smallest possible memory cell is investigated using structural and optical methodologies. The encapsulation material surrounding the Ge(2)Sb(2)Te(5) has an increasingly dominant effect on the material's ability to change phase, and a profound increase in the crystallization temperature is observed when the Ge(2)Sb(2)Te(5) layer is less than 6 nm thick. We have found that the increased crystallization temperature originates from compressive stress exerted from the encapsulation material. By minimizing the stress, we have maintained the bulk crystallization temperature in Ge(2)Sb(2)Te(5) films just 2 nm thick.

An in vivo 3D micro-CT evaluation of tooth movement after the application of different force magnitudes in rat molar

OBJECTIVE

To investigate the precise longitudinal change in the periodontal ligament (PDL) space width and three-dimensional tooth movement with continuous-force magnitudes in living rats.

MATERIALS AND METHODS

Using nickel-titanium closed-coil springs for 28 days, 10-, 25-, 50-, and 100-g mesial force was applied to the maxillary left first molars. Micro-CT was taken in the same rat at 0, 1, 2, 3, 10, 14, and 28 days. The width of the PDL was measured in the pressure and tension sides from 0 to 3 days. Angular and linear measurements were used to evaluate molar position at day 0, 10, 14, and 28. The finite element model (FEM) was constructed to evaluate the initial stress distribution, molar displacement, and center of rotation of the molar.

RESULTS

The initial evaluation of PDL width showed no statistical differences among different force magnitudes. Tooth movement was registered 1 hour after force application and gradually increased with time. From day 10, greater tooth movement was observed when 10 g of force was applied. The FEM showed that the center of rotation in the molar is located in the center of five roots at the apical third of the molar roots.

CONCLUSION

The rat's molar movement mainly consists of mesial tipping, extrusion of distal roots, intrusion of mesial root, palatal inclination, and mesial rotation. Although the initial tooth movement after the application of different force magnitudes until day 3 was not remarkably different, 10 g of force produced more tooth movement compared with heavier forces at day 28.

Initial structure memory of pressure-induced changes in the phase-change memory alloy Ge2Sb2Te5

We demonstrate that while the metastable face-centered cubic (fcc) phase of Ge2Sb2Te5 becomes amorphous under hydrostatic compression at about 15 GPa, the stable trigonal phase remains crystalline. Upon higher compression, a body-centered cubic phase is obtained in both cases around 30 GPa. Upon decompression, the amorphous phase is retained for the starting fcc phase while the initial structure is recovered for the starting trigonal phase. We argue that the presence of vacancies and associated subsequent large atomic displacements lead to nanoscale phase separation and loss of initial structure memory in the fcc staring phase of Ge2Sb2Te5.

MR imaging of medullary carcinoma of the breast

PURPOSE

To examine the magnetic resonance imaging (MRI) findings of medullary carcinoma of the breast and to correlate them with histopathologic features.

MATERIALS AND METHODS

Eight patients were retrospectively evaluated with pathologically confirmed medullary carcinoma of the breast. T1-weighted fat-saturated, T2-weighted fast spine echo, and gadolinium-enhanced fat-saturated fast spoiled gradient-echo images were obtained. Interpretation of the MRI findings was based on evaluation of the configuration, internal signal intensity, contrast enhancement, and type of the time-intensity curve.

RESULTS

Medullary carcinoma showed a lobular shape and a smooth margin, either homogenous or heterogeneous enhancement and delayed peripheral enhancement in the late phase on contrast-enhanced MRI, and either a plateau or washout type with rapid initial rise on the time-intensity curve of the dynamic study.

CONCLUSION

Although the MRI findings showed a close relationship with histopathologic features of medullary carcinoma, it was difficult to differentiate medullary carcinoma from other histologic types of invasive breast carcinomas.

Pressure-induced site-selective disordering of Ge2Sb2Te5: a new insight into phase-change optical recording

We demonstrate that , the material of choice in phase-change optical recording (such as DVD-RAM), can be rendered amorphous by the application of hydrostatic pressure. It is argued that this structural change is due to a very strong second-nearest-neighbor Te-Te interaction that determines the long-range order in the metastable cubic phase of and also to the presence of vacancies. This newly discovered phenomenon suggests that pressure is an important factor for the formation of the amorphous phase which opens new insight into the mechanism of phase-change optical recording.

Time-related Changes in Computed Tomographic Appearance and Pathologic Findings after Radiofrequency Ablation of the Rabbit Lung: Preliminary Experimental Study

PURPOSE

To evaluate correlations between computed tomographic (CT) appearance and pathologic findings after radiofrequency (RF) ablation of lungs and to determine whether CT appearance could predict the extent of the effective therapeutic area.

MATERIALS AND METHODS

The lungs of 14 rabbits were subjected to RF ablation and CT scans were obtained immediately and at various intervals thereafter. Four rabbits were killed immediately after the initial CT imaging (n = 4). The remaining 10 rabbits were killed after additional CT scans at intervals of 3 days (n = 2), 1 week (n = 4), 2 weeks (n = 2), and 3 weeks (n = 2) after RF ablation. Pathologic findings were correlated with CT appearance.

RESULTS

Immediately after RF ablation, a restricted area of central dense opacity enclosed by an extensive area of ground-glass opacity was noted in the ablated region on CT images. Pathologically, the former corresponded to destructive tissue and the latter corresponded to tissue with some degree of injury. After 1 week, the entire ablated region appeared as a well-demarcated homogeneous dense opacity on CT that corresponded to necrotic tissue and its surrounding rim of granulation tissue on histopathologic examination, indicating that the enclosing extensive area of ground-glass opacity on the initial CT scan represented an ongoing necrosis. Within 2-3 weeks, the ablated region gradually contracted on the CT images, representing a tissue repairing process in which the granulation tissue was encroaching on the inner necrotic tissue.

CONCLUSION

Ground-glass opacity of the ablated region on CT immediately after RF ablation represents an ongoing necrosis.

[Correlation between CT and pathological findings after radiofrequency ablation of rabbit lung: evaluation of therapeutic effective area]

The purpose of this study was to correlate the CT and pathologic findings after radiofrequency ablation (RFA) of rabbit lung and evaluate the therapeutically effective area. RFA was performed in eight rabbit lungs, and ablated regions were imaged immediately after RFA (n=8) and 1 week later (n=4). Immediately after RFA, the ablated regions showed ground-glass opacity. At one week, the ablated region showed very dense opacity, which corresponded to necrotic tissue. Ground-glass opacity signified the therapeutically effective area that would later turn into necrosis.

Thermal-induced optical properties of a PdOx mask layer in an optical data storage system with a superresolution near-field structure

Optical-thermal and thermal-optical properties of a PdOx mask layer in a system with a superresolution near-field structure are investigated with a Z-scan technique and a heating experiment. The high photothermal stability of the PdOx mask is shown, and the reversible limit of the PdOx mask layer and a weak switch effect are revealed. The PdOx decomposition, which results in a bubble with Pd particles, is confirmed, and the laser-induced physical and chemical mechanisms in the PdOx mask layer are clarified and discussed. Our microscopic studies and heating analysis are consistent with the Z-scan results. The PdOx mask sample is also compared briefly with a PtO2 mask layer that has the same structure.

Asymptomatic versus symptomatic infarcts from vasospasm in patients with subarachnoid hemorrhage: serial magnetic resonance imaging

OBJECTIVE

By use of serial magnetic resonance imaging (MRI), we prospectively investigated the incidence of and the risk factors associated with infarction caused by vasospasm with or without a delayed ischemic neurological deficit (DIND) in patients with subarachnoid hemorrhage (SAH).

METHODS

In 125 patients who underwent surgery for early aneurysms, postoperative MRI scans were obtained at four time points. We defined an infarct from vasospasm as a new lesion not present on the initial MRI within 3 days after SAH and therefore not attributable to primary brain damage or surgical complications.

RESULTS

Overall, symptoms of infarction (i.e., DIND) occurred in 38% of patients (48 of 125); DIND with a new infarct on MRI was evident in 34% (43 patients), whereas 4% (5 patients) showed no new lesion but had a DIND. However, 29 patients (23%) showed a new infarct but no DIND on MRI studies (asymptomatic infarction). Asymptomatic ischemic lesions due to vasospasm tended to involve noneloquent brain areas in the territory of intraparenchymal perforators. Multivariate analysis identified variables associated with symptomatic infarction to be of poor SAH grade, advanced age of the patient, angiographic findings of vasospasm, multiple cortical infarcts on MRI studies consistent with vasospasm, and chronic hydrocephalus.

CONCLUSION

Analysis of the data confirmed the occurrence of asymptomatic infarcts due to vasospasm. These infarcts often developed in noneloquent areas representing perforator territory. MRI investigation of vasospastic lesions referable to intraparenchymal vessels such as perforators complements the study of extraparenchymal major vessel vasospasm in patients with SAH by computed tomographic angiography.

MRimaging findings after ventricular puncture in patients with SAH

OBJECT

Using magnetic resonance (MR) imaging, we studied brain injury from ventricular puncture performed during craniotomy in the acute stage of subarachnoid hemorrhage (SAH).

METHODS

80 patients underwent craniotomy for aneurysm obliteration within 48 hr after SAH, ventricular puncture for drainage of cerebrospinal fluid (CSF) was performed to reduce intracranial pressure. MR imaging was performed within 3 days following surgery to measure the size of the lesion, and was repeated on postoperative days 14 and 30.

CONCLUSIONS

Of the 80 patients with ventricular puncture preceding craniotomy, 65 (81%) showed MR evidence of brain injury from the puncture. Overall, 149 lesions were detected. According to coronal images, cortical injuries (54 cases), penetrating injury to tracts along the ventricular tube (55 cases), caudate injury (25 cases), and corpus callosum injury (15 cases). Brain injuries from ventricular puncture did not correlate significantly to patient outcome. While ventricular puncture and drainage of CSF can readily be performed to decrease brain volume at the time of craniotomy in acute-stage SAH, neurosurgeons should be aware of a surprisingly high incidence of brain injury complicating puncture.

Superresolution optical disk with a thermoreversible organic thin film

Recording and retrieving small marks far beyond the optical diffraction limit in a high-speed rotating phase-change optical disk have been investigated by use of a thermoreversible organic thin film as a superresolution mask layer. The organic thin film exhibited significant thermoreversibility and rapid response on laser irradiation. Recorded marks as small as 120 nm in length could be detected by a dynamic disk tester with a laser wavelength of 635 nm and a numerical aperture of 0.6.

Efficacy of neuroendoscopic procedures in minimally invasive preferential management of pineal region tumors: a prospective study

OBJECT

This prospective study is based on a consecutive series of 20 patients with pineal region tumors who underwent minimally invasive preferential management. The purpose of this report is to discuss the role of neuroendoscopic procedures in the management of pineal region tumors.

METHODS

If the tumor markers alpha-fetoprotein and human chorionic gonadotropin were not detected in serum and there was significant ventricular dilation visualized on neuroimages, neuroendoscopic surgery was first applied for tumor debulking with tissue diagnosis and gross morphological analysis of the tumor and the intraventricular structures, followed by third ventriculostomy. Subsequent procedures were determined on the basis of verified individual tumors. For treatment of germinomas and pineoblastomas, if no tumor dissemination was confirmed by pre-, intra-, or postoperative findings, stereotactic radiotherapy or radiosurgery was performed after one course of chemotherapy with the ICE regimen (isofomid, cisplatin, and etoposide) and followed by two additional courses of chemotherapy. For treatment of malignant germ cell tumors, after extensive surgery, adjuvant chemotherapy with the ICE regimen was performed in three courses in all cases. Then radiotherapy was started using various methods, depending on the evidence of tumor dissemination. For treatment of teratomatous and neuroectodermal tumors other than pineoblastomas, extensive surgical removal was performed. As for adjuvant therapy, if the tumor was a low-grade glioma or if the patient was younger than 5 years of age, postoperative treatment did not include radiotherapy. If the tumor was a malignant teratoma or high-grade glioma, conventional focal radiotherapy was performed, followed by chemotherapy with ICE for 1 year. All but two treated patients had ventriculomegaly. Neuroendoscopic procedures were performed in six of 15 treated patients. Neuroendoscopic biopsy with tumor debulking offered enough material for tissue diagnosis, including immunohistochemical analysis and, in one case, revealed evidence of tumor dissemination undetectable on neuroimaging. With one exception, no shunt was required in any patient undergoing endoscopic third ventriculostomy. Stereotactic radiotherapy was performed in indicated cases. Favorable therapeutic outcomes were obtained in all cases of germinoma and pineoblastoma, with follow-up periods ranging from 24 months to 6.5 years.

CONCLUSIONS

Our minimally invasive preferential regimen clarified the precise indication for neuroendoscopic procedures, and the majority of our patients with dilated ventricles and no evidence of tumor markers were treated satisfactorily with effective neuroendoscopic procedures as the initial procedure, avoiding unnecessary craniotomy and radiotherapy and promising excellent therapeutic outcomes. The treatment for malignant pineal region tumors remains a subject for further study.

Delayed ischemic neurological deficit of short duration in patients with subarachnoid hemorrhage

We retrospectively examined the duration of delayed ischemic neurological deficits (DIND) attributed to vasospasm following subarachnoid hemorrhage (SAH) in order to delineate the nature and involved factors. Among 605 patients with SAH, 201 developed DIND, and 137 of these had undergone early aneurysmal obliteration. In these 137, duration of DIND was clearly determined in 67 cases. Hypervolemic therapy was instituted only after the onset of DIND. In the 67 patients, the mean duration of DIND was 5.2 days (ranging from 2 to 13 days); 22 patients had DIND lasting only 2 to 3 days, 26 patients had DIND lasting 4 to 6 days, and in 19, DIND lasted 7 to 13 days. Clinical factors associated with short DIND duration (2 to 3 days) as determined by multivariate analysis included internal carotid artery or middle cerebral artery aneurysm, age under 60, and a good World Federation of Neurological Surgeons grade on admission. No patients developed pulmonary edema from hypervolemic therapy, and the outcomes of all 67 patients were extremely favorable. In SAH patients developing DIND after early aneurysmal surgery, 16% (22 of 137) had a documented brief duration of DIND. We believe DIND rapidly improved and resolved with hypervolemic therapy because antecedent brain damage from SAH or surgical manipulation had been minimal.

Results of early surgical evacuation of packed intraventricular hemorrhage from aneurysm rupture in patients with poor-grade subarachnoid hemorrhage

OBJECT

The goal of this study was to evaluate the results of early surgical evacuation of "packed" intraventricular hemorrhage (IVH) in patients with poor-grade subarachnoid hemorrhage (SAH).

METHODS

The authors performed surgery within 24 hours after onset of SAH, identified on neuroimaging as a cast distending the ventricular system, in 74 patients with poor-grade SAH (World Federation of Neurosurgical Societies Grades IV and V) without intracerebral hemorrhage. Eighteen of these patients had packed IVH; in these patients the intraventricular clots were extensively evacuated via frontal corticotomy performed under microscopic view.

CONCLUSIONS

Overall, 42% of the 74 patients undergoing craniotomy in the acute stage had favorable outcomes, whereas 30% died. Using multivariate analysis, variables significantly associated with favorable outcome in patients with poor-grade SAH included absence of a packed intraventricular clot on computerized tomography scanning; absence of a history of cardiac disease; and a Glasgow Coma Scale score of 11 or 12. None of the 18 patients who had packed IVH had favorable outcomes and seven of these died. In six recently treated patients with packed IVH, which was examined using fluid-attenuated inversion recovery imaging, extensive periventricular brain damage was found both immediately after surgery and during the chronic stage. Accordingly, the authors believe that irreversible periventricular brain damage is already complete immediately after packed IVH occurs.

[Delayed ischemic neurological deficit that developed over 15 days after subarachnoid hemorrhage]

We retrospectively studied subarachnoid hemorrhage (SAH) patients with delayed ischemic neurological deficit (DIND), and analyzed the factors causing extremely late onset of deficits occurring over 15 days after onset of the SAH. Among 605 patients with SAH, 201 (33%) developed DIND. Among DIND patients, 137 had undergone early aneurysm surgery. In these 137 patients, onset date of DIND was definite in 131 patients. Six patients (5%) developed DIND over 15 days after SAH. All 6 had asymptomatic angiographical vasospasm and infections, most often meningitis, before the onset of DIND. Compared with cases in which there was ordinary onset of DIND, other statistically significant factors among these 6 patients were intracerebral hemorrhage, sepsis and meningitis. We suspect that DIND were manifested subclinically in the early period because of the associated hyperdynamic hemodynamics resulting from sepsis in these patients.