Impact of thoracoabdominal imaging on diagnosis and management in patients with suspected infective endocarditis.

Embolic events (EEs) are a common complication of infective endocarditis (IE) and their presence can impact diagnosis and modify the therapeutic plan. The present study aimed to describe the role of thoracoabdominal imaging, either thoracoabdominal-pelvic Computed Tomography or <sup>18</sup> F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography, on diagnosis and management of patients with suspected IE. This study was conducted at a university hospital, from January 2014 to June 2022. EEs and IE were defined according to modified Duke criteria. Among 966 episodes with suspected IE and thoracoabdominal imaging, 528 (55%) patients were asymptomatic. At least one EE was found in 205 (21%) episodes. Based on thoracoabdominal imaging findings, the diagnosis was reclassified from rejected to possible or from possible to definite IE in 6 (1%) and 10 (1%) episodes, respectively. Among the 413 patients with IE, at least one EE was found on thoracoabdominal imaging in 143 (35%) episodes. Together with the presence of left-side valvular vegetation >10 mm, the results of thoracoabdominal imaging established a surgical indication (prevention of embolism) in 15 (4%) episodes, 7 of which were asymptomatic. Thoracoabdominal imaging performed in asymptomatic patients with suspected IE improved the diagnosis in only a small proportion of patients. Thoracoabdominal imaging led to a new surgical indication (in association with left-side valvular vegetation >10 mm) in only a small percentage of patients

Do quantitative and qualitative shear wave elastography have a role in evaluating musculoskeletal soft tissue masses?

Objectives: To determine if quantitative and qualitative shear wave elastography have roles in evaluating musculoskeletal masses. Methods: 105 consecutive patients, prospectively referred for biopsy within a specialist sarcoma centre, underwent B-mode, quantitative (m/s) and qualitative (colour map) shear wave elastography. Reference was histology from subsequent biopsy or excision where possible. Statistical modelling was performed to test elastography data and/or B-mode imaging in predicting malignancy. Results: Of 105 masses, 39 were malignant and 6 had no histology but benign characteristics at 12 months. Radiologist agreement for B-mode and elastography was moderate to excellent Kw 0.52-0.64; PABAKw 0.85-0.90). B-Mode imaging had 78.8% specificity, 76.9% sensitivity for malignancy. Quantitatively, adjusting for age, B-mode and lesion volume there was no statistically significant association between longitudinal velocity and malignancy (OR [95% CI] 0.40[0.10, 1.60], p=0.193), but some evidence that higher transverse velocity was associated with decreased odds of malignancy (0.28[0.06, 1.28], p=0.101). Qualitatively malignant masses tended to be towards the blue spectrum (lower velocities); 39.5% (17/43) of predominantly blue masses were malignant, compared to 14.3% (1/7) of red lesions. Conclusions: Quantitatively and qualitatively there is no statistically significant association between shear wave velocity and malignancy. There is no clear additional role to B-mode imaging currently. Key Points: • Correlation between shear wave velocity and soft tissue malignancy was statistically insignificant• B-mode ultrasound is 76.9 % sensitive and 78.8 % specific• Statistical models show elastography does not significantly add to lesion assessmen

The role of early defervescence in ruling out infective endocarditis: a cohort study.

To evaluate the role of defervescence within 4 days from antibiotic treatment initiation in ruling out infective endocarditis (IE) among patients suspected of such diagnosis. This study was conducted at the Lausanne University Hospital, Switzerland (January 2014 to May 2022). All patients with suspected IE being febrile upon presentation were included. IE was classified according to the modified Duke criteria proposed by the 2015 European Society of Cardiology guidelines, before or after applying the criterion 'resolution of symptoms suggesting IE within 4 days of the introduction of antibiotic therapy' based solely on early defervescence. Among 1022 episodes with suspected IE, 332 (37%) had IE according to Endocarditis-Team evaluation; 248 were classified by clinical Duke criteria as definite and 84 as possible IE. The rate of defervescence within 4 days from antibiotic treatment initiation was similar (p 0.547) among episodes without (606/690; 88%) and those with IE (287/332; 86%); among episodes classified as definite and possible IE by clinical Duke criteria, 211 of 248 (85%) and 76 of 84 (90%), respectively, defervesced within 4 days from antibiotic treatment initiation. By using early defervescence as a rejection criterion, the 76 episodes with final IE diagnosis classified as possible by clinical criteria could be reclassified as rejected. The majority of IE episodes defervesced within 4 days from antibiotic treatment initiation; thus, early defervescence should not be used to rule out the diagnosis of IE

Risk of embolic events before and after antibiotic treatment initiation among patients with left-side infective endocarditis.

Embolic events (EEs) are a common complication of left-side infective endocarditis (IE). The aim of the present study was to identify risk factors for the occurrence of EEs before or after antibiotic treatment instauration among patients with definite or possible IE. This retro-prospective study was conducted at the Lausanne University Hospital, Lausanne, Switzerland, from January 2014 to June 2022. EEs and IE were defined according to modified Duke criteria. A total of 441 left-side IE episodes were included (334: 76% were definite and 107; 24% possible IE). EE were diagnosed in 260 (59%) episodes; in 190 (43%) before antibiotic treatment initiation and 148 (34%) after. Central nervous system (184; 42%) was the most common site of EE. Multivariable analysis identified S. aureus (P 0.022), immunological phenomena (P < 0.001), sepsis (P 0.027), vegetation size ≥ 10 mm (P 0.003) and intracardiac abscess (P 0.022) as predictors of EEs before antibiotic treatment initiation. For EEs after antibiotic treatment initiation, multivariable analysis revealed vegetation size ≥ 10 mm (P < 0.001), intracardiac abscess (P 0.035) and prior EE (P 0.042), as independent predictors of EEs, while valve surgery (P < 0.001) was associated with lower risk for EEs. We reported a high percentage of EEs among patients with left-side IE; vegetation size, intracardiac abscess, S. aureus and sepsis were independently associated with the occurrence of EEs. In addition to antibiotic treatment, early surgery led to further decrease in EEs incidence

Role of Cerebral Imaging on Diagnosis and Management in Patients With Suspected Infective Endocarditis.

Cerebral embolic events (CEEs) are common complications of infective endocarditis (IE), and their presence can modify diagnosis and therapeutic plans. The aim of the present study was to assess the role of cerebral imaging (Cer-Im) on diagnosis and management of patients with suspected IE. This study was conducted at the Lausanne University Hospital, Lausanne, Switzerland, from January 2014 to June 2022. CEEs and IE were defined according to modified Duke criteria of the European Society of Cardiology (ESC) guidelines. Among 573 patients with IE suspicion and Cer-Im, 239 (42%) patients had neurological symptoms. At least 1 CEE was found in 254 (44%) episodes. Based on Cer-Im findings, episodes were reclassified from rejected to possible or from possible to definite IE in 3 (1%) and 25 (4%) patients, respectively (0% and 2% in asymptomatic patients, respectively). Among the 330 patients with possible or definite IE, at least 1 CEE was found in 187 (57%) episodes. A new surgical indication (in association with left-side vegetation >10 mm) was established in 74/330 (22%) IE patients and 30/155 (19%) asymptomatic IE patients, respectively. Cer-Im in asymptomatic patients with IE suspicion showed limited potential for improving the diagnosis of IE. In contrast, performing Cer-Im in asymptomatic patients with IE may be useful for decision making, because Cer-Im findings led to the establishment of new operative indication for valvular surgery in one fifth of patients according to ESC guidelines

TRANSLATIONAL REVIEW Immunotherapy for Malignant Pleural Mesothelioma Current Status and Future Prospects

Abstract Malignant pleural mesothelioma (MPM) is a rare malignancy of the pleura that is frequently resistant to conventional therapies. Immunotherapy is a promising investigational approach for MPM that has shown some evidence of clinical benefit in select patients. However, tumor-induced immunosuppression is likely a major impediment to achieving optimal clinical responses to immunotherapeutic intervention. MPM contains a variable degree of infiltrating T-regulatory cells and M2 macrophages, which are believed to facilitate tumor evasion from the host immune system. Additional immunosuppressive factors identified in other human tumor types, such as tumor-associated programmed death ligand-1 expression, may be relevant for investigation in MPM. Conventional cytoreductive therapies, such as radiation, chemotherapy, and surgery, may play a critical role in successful immunotherapeutic strategies by ablating intratumoral and/or systemic immunosuppressive factors, thus creating a host environment more amenable to immunotherapy. This article reviews the immunotherapeutic approaches being evaluated in patients with MPM and discusses how immunotherapy might be rationally combined with conventional tumor cytoreductive therapies for this disease

Immunotherapy for malignant pleural mesothelioma. Current status and future prospects.

Malignant pleural mesothelioma (MPM) is a rare malignancy of the pleura that is frequently resistant to conventional therapies. Immunotherapy is a promising investigational approach for MPM that has shown some evidence of clinical benefit in select patients. However, tumor-induced immunosuppression is likely a major impediment to achieving optimal clinical responses to immunotherapeutic intervention. MPM contains a variable degree of infiltrating T-regulatory cells and M2 macrophages, which are believed to facilitate tumor evasion from the host immune system. Additional immunosuppressive factors identified in other human tumor types, such as tumor-associated programmed death ligand-1 expression, may be relevant for investigation in MPM. Conventional cytoreductive therapies, such as radiation, chemotherapy, and surgery, may play a critical role in successful immunotherapeutic strategies by ablating intratumoral and/or systemic immunosuppressive factors, thus creating a host environment more amenable to immunotherapy. This article reviews the immunotherapeutic approaches being evaluated in patients with MPM and discusses how immunotherapy might be rationally combined with conventional tumor cytoreductive therapies for this disease

Immunotherapy for malignant pleural mesothelioma. Current status and future prospects.

Malignant pleural mesothelioma (MPM) is a rare malignancy of the pleura that is frequently resistant to conventional therapies. Immunotherapy is a promising investigational approach for MPM that has shown some evidence of clinical benefit in select patients. However, tumor-induced immunosuppression is likely a major impediment to achieving optimal clinical responses to immunotherapeutic intervention. MPM contains a variable degree of infiltrating T-regulatory cells and M2 macrophages, which are believed to facilitate tumor evasion from the host immune system. Additional immunosuppressive factors identified in other human tumor types, such as tumor-associated programmed death ligand-1 expression, may be relevant for investigation in MPM. Conventional cytoreductive therapies, such as radiation, chemotherapy, and surgery, may play a critical role in successful immunotherapeutic strategies by ablating intratumoral and/or systemic immunosuppressive factors, thus creating a host environment more amenable to immunotherapy. This article reviews the immunotherapeutic approaches being evaluated in patients with MPM and discusses how immunotherapy might be rationally combined with conventional tumor cytoreductive therapies for this disease