Determining the impact of an artificial intelligence tool on the management of pulmonary nodules detected incidentally on CT (DOLCE) study protocol: a prospective, non-interventional multicentre UK study

INTRODUCTION

In a small percentage of patients, pulmonary nodules found on CT scans are early lung cancers. Lung cancer detected at an early stage has a much better prognosis. The British Thoracic Society guideline on managing pulmonary nodules recommends using multivariable malignancy risk prediction models to assist in management. While these guidelines seem to be effective in clinical practice, recent data suggest that artificial intelligence (AI)-based malignant-nodule prediction solutions might outperform existing models.

METHODS AND ANALYSIS

This study is a prospective, observational multicentre study to assess the clinical utility of an AI-assisted CT-based lung cancer prediction tool (LCP) for managing incidental solid and part solid pulmonary nodule patients vs standard care. Two thousand patients will be recruited from 12 different UK hospitals. The primary outcome is the difference between standard care and LCP-guided care in terms of the rate of benign nodules and patients with cancer discharged straight after the assessment of the baseline CT scan. Secondary outcomes investigate adherence to clinical guidelines, other measures of changes to clinical management, patient outcomes and cost-effectiveness.

ETHICS AND DISSEMINATION

This study has been reviewed and given a favourable opinion by the South Central-Oxford C Research Ethics Committee in UK (REC reference number: 22/SC/0142).Study results will be available publicly following peer-reviewed publication in open-access journals. A patient and public involvement group workshop is planned before the study results are available to discuss best methods to disseminate the results. Study results will also be fed back to participating organisations to inform training and procurement activities.

TRIAL REGISTRATION NUMBER

NCT05389774.

Barriers to the Use of Medicinal Mushrooms for Production of Metabolites : The Bjarmin Rushton Story

Traditionalists are reluctant to leave the technology they and their forefathers knew. To them the new technology based on the stirred tank bioreactor is too removed from the soil the mushroom comes from. On the other hand, there are examples of applications of a bioreactor which support the change from the old to the new technology. In this chapter Bjarmin Rushton, the creator of the well-known medicinal mushroom company Wellness, gives his view of the much talked about difficulties with cultivation in stirred tanks. These problems, are they real or figment of our imagination? Those who read will find out.

Extent of pulmonary thromboembolic disease in patients with COVID-19 on CT: relationship with pulmonary parenchymal disease

AIM

To report the severity and extent of pulmonary thromboembolic disease (PTD) in COVID-19 patients undergoing computed tomography pulmonary angiography (CTPA) in a tertiary centre.

MATERIALS AND METHODS

This is a retrospective analysis of COVID-19 patients undergoing CTPA over a period of 27 days. The presence, extent, and severity of PTD were documented. Two observers scored the pattern and extent of lung parenchymal disease including potential fibrotic features, as well as lymph node enlargement and pleural effusions. Consensus was achieved via a third observer. Interobserver agreement was assessed using kappa statistics. Student's t-test, chi-squared, and Mann-Whitney U-tests were used to compare imaging features between PTD and non-PTD sub-groups.

RESULTS

During the study period, 100 patients with confirmed COVID-19 underwent CTPA imaging. Ninety-three studies were analysed, excluding indeterminate CTPA examinations. Overall incidence of PTD was 41/93 (44%) with 28/93 patients showing small vessel PTD (30%). D-dimer was elevated in 90/93 (96.8%) cases. A high Wells' score did not differentiate between PTD and non-PTD groups (p=0.801). The interobserver agreement was fair (kappa=0.659) for parenchymal patterns and excellent (kappa=0.816) for severity. Thirty-four of the 93 cases (36.6%) had lymph node enlargement; 29/34 (85.3%) showed no additional source of infection. Sixteen of the 93 (17.2%) cases had potential fibrotic features.

CONCLUSION

There is a high incidence of PTD in COVID-19 patients undergoing CTPA and lack of a risk stratification tool. The present data indicates a higher suspicion of PTD is needed in severe COVID-19 patients. The concomitant presence of possible fibrotic features on CT indicates the need for follow-up.

Tuberculosis in the pituitary fossa: a common pathology in an uncommon site

Tuberculosis (TB) is an important cause of mortality and morbidity across the world. In 2–5% of all cases of systemic TB, the C is affected, with lesions reported in the meninges, cortex and ventricles. Intrasellar tuberculomas, however, are extremely rare. We report the interesting case of a young female patient who presented with secondary hypothyroidism and hyperprolactinaemia. She was treated successfully for pituitary TB. We also highlight and discuss some interesting (and hitherto unreported) endocrine issues. Radiological and histological features and treatment of pituitary TB are discussed using this case as an example.

Is hybrid imaging (SPECT/CT) a useful adjunct in the management of suspected facet joints arthropathy?

PURPOSE

The purpose of this study was to assess the value of SPECT/CT imaging in patients with chronic spinal pain.

METHODS

This was a retrospective consecutive study. Patients with chronic neck or back pain from outpatient spinal clinics with clinical features raising the possibility of a facetogenic pain generator and non-conclusive MRI/CT findings were included. Imaging was performed on a dual-headed, hybrid SPECT/CT γ-camera with a low-dose CT transmission scan acquired after the SPECT study. SPECT/CT studies were viewed in the coronal, axial, and sagittal planes and in 3-dimensional mode. Descriptive statistical analysis was performed.

RESULTS

Seventy-two patients were included (37 females, 35 males, mean age of 53.9 years). There were 25 cervical spine scans and 49 lumbar spine scans. In the cervical spine group, 13 (52 %) patients had scintigraphically active cervical facet joint arthropathy and ten (36 %) had other pathology identified. Two thirds of patients diagnosed with facet joint arthropathy received steroid guided injections following their scans. In the lumbar spine group 34 (69.4 %) patients had scintigraphically active lumbar facet joint arthropathy and eight had other pathology identified. Twenty patients (58.8 %) diagnosed with facet joint arthropathy subsequently received steroid guided injections.

CONCLUSIONS

Hybrid SPECT/CT imaging identified potential pain generators in 92 % of cervical spine scans and 86 % of lumbar spine scans. The scan precisely localised SPECT positive facet joint targets in 65 % of the referral population and a clinical decision to inject was made in 60 % of these cases.

Idiopathic pulmonary fibrosis and diffuse parenchymal lung disease: implications from initial experience with 18F-FDG PET/CT

The purpose of this study was to evaluate integrated (18)F-FDG PET/CT in patients with idiopathic pulmonary fibrosis (IPF) and diffuse parenchymal lung disease (DPLD).

METHODS

Thirty-six consecutive patients (31 men and 5 women; mean age +/- SD, 68.7 +/- 9.4 y) with IPF (n = 18) or other forms of DPLD (n = 18) were recruited for PET/CT and high-resolution CT (HRCT), acquired on the same instrument. The maximal pulmonary (18)F-FDG metabolism was measured as a standardized uptake value (SUV(max)). At this site, the predominant lung parenchyma HRCT pattern was defined for each patient: ground-glass or reticulation/honeycombing. Patients underwent a global health assessment and pulmonary function tests.

RESULTS

Raised pulmonary (18)F-FDG metabolism in 36 of 36 patients was observed. The parenchymal pattern on HRCT at the site of maximal (18)F-FDG metabolism was predominantly ground-glass (7/36), reticulation/honeycombing (26/36), and mixed (3/36). The mean SUV(max) in patients with ground-glass and mixed patterns was 2.0 +/- 0.4, and in reticulation/honeycombing it was 3.0 +/- 1.0 (Mann-Whitney U test, P = 0.007). The mean SUV(max) in patients with IPF was 2.9 +/- 1.1, and in other DPLD it was 2.7 +/- 0.9 (Mann-Whitney U test, P = 0.862). The mean mediastinal lymph node SUV(max) (2.7 +/- 1.3) correlated with pulmonary SUV(max) (r = 0.63, P < 0.001). Pulmonary (18)F-FDG uptake correlated with the global health score (r = 0.50, P = 0.004), forced vital capacity (r = 0.41, P = 0.014), and transfer factor (r = 0.37, P = 0.042).

CONCLUSION

Increased pulmonary (18)F-FDG metabolism in all patients with IPF and other forms of DPLD was observed. Pulmonary (18)F-FDG uptake predicts measurements of health and lung physiology in these patients. (18)F-FDG metabolism was higher when the site of maximal uptake corresponded to areas of reticulation/honeycomb on HRCT than to those with ground-glass patterns.

Biochemical engineering aspects of solid state bioprocessing

Despite centuries of use and renewed interest over the last 20 years in solid-state fermentation (SSF) technology, and despite its good potential for a range of products, there are currently relatively few large-scale commercial applications. This situation can be attributed to the complexity of the system: Macroscale and microscale heat and mass transfer limitations are intrinsic to the system, and it is only over the last decade or so that we have begun to understand them. This review presents the current state of understanding of biochemical engineering aspects of SSF processing, including not only the fermentation itself, but also the auxiliary steps of substrate and inoculum preparation and downstream processing and waste disposal. The fermentation step has received most research attention. Significant advances have been made over the last decade in understanding how the performance of SSF bioreactors can be controlled either by the intraparticle processes of enzyme and oxygen diffusion or by the macroscale heat transfer processes of conduction, convection, and evaporation. Mathematical modeling has played an important role in suggesting how SSF bioreactors should be designed and operated. However, these models have been developed on the basis of laboratory-scale data and there is an urgent need to test these models with data obtained in large-scale bioreactors.

Application of Convective Interaction Media (CIM) disk monolithic columns for fast separation and monitoring of organic acids

The separation of organic acids on the anion-exchange monolithic support, commercially available as Convective Interaction Media (CIM), is presented in this study. It is demonstrated that citric, isocitric, pyruvic, fumaric, malic, and alpha-ketoglutaric acid can be successfully separated using a CIM monolithic column of suitable user-adjustable length. The effect of the mobile phase composition on the separation is investigated. CIM monolithic columns of adjustable length from 3 to 18 mm are compared regarding the resolution and the back pressure. It is shown that the CIM monolithic column of 12 mm in length enables a good separation of all six organic acids within 3 min and exhibits a linear dependence of back pressure versus flow rate. The resolution and the dynamic binding capacity are found to be flow-unaffected. A filtrated sample of bioprocess supernatant is analyzed without previous pretreatment, which indicates the possibility of online monitoring of small molecules during the bioprocess using CIM monolithic columns.

Scale-up of citric acid fermentation by redox potential control

To obtain high citric acid productivity in Aspergillus niger fermentation on beet molasses substrate, a certain redox potential profile with two maxima (260 and 280 mV) and two minima (180 and 80 mV) must be maintained. The most effective regulation of redox potential is by regulation of aeration and agitation. It has been shown that control of redox potential by aeration and agitation is a most successful method for scale-up from 10-L laboratory scale to the 100- and 1000-L pilot-plant scale, even in geometrically dissimilar stirred-tank reactors. Copyright 1999 John Wiley & Sons, Inc.

Production of Aspergillus niger pectolytic enzymes by solid state bioprocessing of apple pomace

The aim of this work was to develop a low cost process for apple pomace utilisation. Accordingly this production of pectynolitic enzymes based on solid state bioprocessing of this actual waste, was developed. Production of pectolytic enzymes of Aspergillus niger, pectinesterase and polygalacturonase as well as the activity of pectolytic enzymatic complex by solid state bioprocessing were studied. The results of preliminary substrate optimization, on open trays in laboratory scale experiments, were transferred to 15 1 horizontal solid state stirred tank reactor (HSS STR). In situ sterilization of solid substrate with periodical mixing was used. Secondary raw material, apple pomace the waste from food and agriculture industry combined with soya flour, wheat bran and simple mineral salts was utilised. Various substrate moistures were studied. Process parameters such as inoculation, influence of mixing, aeration, temperature and moisture content on pectolytic enzymes production were studied. Maximal amounts of 15 g kg-1 of solid medium of polygalacturonase, 200 mg kg-1 pectinesterase at activity up to 900 AJDA U ml-1 of enzyme mixture was obtained on average.