Histoplasmosis is an endemic infection of the Ohio and Mississippi River valleys. Clinical presentation of infection in immunocompetent hosts ranges from asymptomatic to minor flu-like symptoms; however, disseminated infection can occur in immunocompromised patients. Esophageal involvement in the form of dysphagia secondary to mediastinal histoplasmosis is rarely reported in the literature. We present a young female who complained of dysphagia and was found to have an esophageal stricture on barium esophagogram. Endoscopy revealed a submucosal nodule stricture situated 29 cm from the incisors. She underwent thoracotomy for lymph node removal. Histologic findings of the removed lymph node showed caseating granuloma with macrophages. The clinical findings together with the laboratory evaluation and biopsy features were suggestive of mediastinal histoplasmosis as the cause of the dysphagia.

Histoplasmosis is an endemic infection of the Ohio and Mississippi River valleys. Clinical presentation of infection in immunocompetent hosts ranges from asymptomatic to minor flu-like symptoms; however, disseminated infection can occur in immunocompromised patients. Esophageal involvement in the form of dysphagia secondary to mediastinal histoplasmosis is rarely reported in the literature. We present a young female who complained of dysphagia and was found to have an esophageal stricture on barium esophagogram. Endoscopy revealed a submucosal nodule stricture situated 29 cm from the incisors. She underwent thoracotomy for lymph node removal. Histologic findings of the removed lymph node showed caseating granuloma with macrophages. The clinical findings together with the laboratory evaluation and biopsy features were suggestive of mediastinal histoplasmosis as the cause of the dysphagia.

Patients with an anterior mediastinal mass pose significant risk for cardiorespiratory compromise during surgical procedures and general anesthesia. Several techniques have been described to reverse airway obstruction in these patients. In extreme circumstances, patients may require cardiac bypass or extracorporeal membrane oxygenation (ECMO) until definitive treatment of the mass and patient stabilization is achieved. We present a case in which the RulTract (R) system was used for emergency sternal elevation as a bridge to ECMO in acute respiratory collapse in an 11-year-old female with a minimally symptomatic anterior mediastinal mass. (C) 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background- Mediastinal staging is the rate-limiting step prior to initiation of lung cancer treatment and is essential in identifying the most appropriate treatment for the patient. However, this process is often complex and involves multiple imaging modalities including invasive and non-invasive methods for the assessment of lymph nodes in the mediastinum which are error prone. The use of Artificial Intelligence may be able to provide more accurate and precise measurements and eliminate error associated with medical imaging. Methods-This thesis was conducted in three parts. In Part 1, we synthesized and critically appraised the methodological quality of existing studies that use Artificial Intelligence to diagnosis and stage lung cancer from thoracic imaging based on lymph node features. In Part 2, we determined the inter-rater reliability of segmentation of the ultrasonographic lymph node features performed by an experienced endoscopist (manually) compared to NeuralSeg (automatically). In Part 3, we developed and validated a deep neural network through a clinical prediction model to determine if NeuralSeg could learn and identify ultrasonographic lymph node features from endobronchial ultrasound images in patients undergoing lung cancer staging. Results- In Part 1, there were few studies in the Artificial Intelligence literature that provided a complete and detailed description of the design, Artificial Intelligence architecture, validation strategies and performance measures. In Part 2, NeuralSeg and the experienced endosonographer possessed excellent inter-rater correlation (Intraclass Correlation Coefficient = 0.76, 95% CI= 0.70 – 0.80, p<0.0001). In Part 3, NeuralSeg’s algorithm had an accuracy of 73.78% (95% CI: 68.40% to 78.68%), a sensitivity of 18.37% (95% CI: 8.76% to 32.02%) and specificity of 84.34% (95% CI: 79.22% to 88.62%). Conclusions- Analysis of staging modalities for lung cancer using Artificial Intelligence may be useful for when results are inconclusive or uninterpretable by a human reader. NeuralSeg’s high specificity may inform decision-making regarding biopsy if results are benign. Prospective external validation of algorithms and direct comparisons through cut-off thresholds are required to determine their true predictive capability. Future work with a larger dataset will be required to improve and refine the algorithm prior to trials in clinical practice. / Thesis / Master of Science (MSc) / Before deciding on treatment for patients with lung cancer, a critical step in the investigation is finding out whether the lymph nodes in the chest contain cancer cells. This is accomplished through medical imaging of the lymph nodes or taking a biopsy of the lymph node tissue using a needle attached to a scope that is entered through the airway wall. The purpose of these tests is to ensure that lung cancer patients receive the optimal treatment option. However, imaging of the lymph nodes is heavily reliant on human interpretation, which can be error prone. We aimed to critically analyze and investigate the use of Artificial Intelligence to enhance clinician performance for image interpretation. We performed a search of the medical literature for the use of Artificial Intelligence to diagnosis lung cancer from medical imaging. We also taught a computer program, known as NeuralSeg, to learn and identify cancerous lymph nodes from ultrasound imaging. This thesis provides a significant contribution to the Artificial Intelligence literature and provides recommendations for future research.

Mediastinal pancreatic pseudocyst (MPP) is a rare, but known, complication of both acute and chronic pancreatitis. Most pseudocysts are associated with alcoholic pancreatitis. Recent advances in endoscopic techniques have shown promising results, with reduced chances of infection and recurrence than with percutaneous drainage, but limited availability restricts widespread use. Left gastric artery pseudoaneurysm with mediastinal pseudocyst has not been described in the literature to date. We report a successful resolution of hemorrhagic MPP with embolization of pseudoaneurysm and percutaneous trans-hepatic pseudocyst drainage.

No description available.

Seit Beginn der 90er Jahre wurden minimal-invasive Operationsmethoden zur Therapie des Bronchialkarzinoms eingeführt, ohne vorher sicherzustellen, daß sie hinsichtlich der onkologischen Sicherheit und Radikalität der konventionellen Operationsmethode ebenbürtig sind. Die vorliegende Arbeit hat daher die Entwicklung einer onkologisch adäquaten thorakoskopischen Lobektomie zur Aufgabe. Die dazu notwendige wissenschaftliche Evaluation erfolgt in mehreren Schritten. Zunächst wird der aktuelle operative Standard der konventionellen Chirurgie beim Bronchialkarzinom in der Literatur dargestellt. Auf dieser Grundlage wird die thorakoskopische Resektion inklusive Lymphadenektomie beim Bronchialkarzinom definiert. Dieser Standard dient als Vorlage für die Entwicklung der minimal-invasiven Chirurgie im Tier- und Leichenmodell. Im ersten Schritt der Phase I wird anhand tierexperimenteller Arbeiten untersucht, ob und unter welchen technischen Voraussetzungen eine thorakoskopische Lobektomie vollständig minimal-invasiv durchführbar ist. Mit den anschließenden chirurgisch-anatomischen Untersuchungen soll festgestellt werden, inwieweit die erarbeitete thorakoskopische Technik den onkologischen Prinzipien, insbesondere der Lymphadenektomie, Rechnung trägt. Diese Phase stellt die Grundvoraussetzung für eine weitere Evaluierung der erarbeiteten Ergebnisse in der Phase II dar. Die Erprobung der erarbeiteten Technik in der Klinik dient der Überprüfung auf Morbidität und Mortalität im Vergleich zur konventionellen Operationsmethode und der Übertragung in randomisierte Studien zum Nachweis relevanter Unterschiede im Frühverlauf (Phase IIIa) und Spätverlauf (Phase IIIb). / Since the beginning of the 1990's, minimal invasive surgery has expanded to include extensive thoracic operations, especially the lobectomy. Implementation of this procedure has been described in numerous publications, however the development occurred unsystematically. So the oncologic radicality and safety of both thoracoscopic lobectomy and lymph node dissection is a debated topic in the literature. Therefore, previous results could not prove that minimal invasive resections by bronchial carcinoma are equivalent to conventional surgical methods with respect to oncological security and radical resectability. For this reason thoracoscopic lobectomy with lymphadenectomy is investigated for radicality and completeness according to the recommendations for scientific evaluation. In a first step the criterias of an oncologic lung resection - lobectomy and lymphadenectomy - are established. This definition is the basis for the following phase I, the animal study and the experimental-anatomic study in a human cadaver model. The task of the animal study is to examine if a lobectomy could be done by thoracoscopic technique completely and on which conditions. Than an experimental-anatomic study in a cadaver model is done to control the extent of the radical thoracoscopic lobectomy with lymphadenectomy by a following thoracotomy. This study is essential for a phase II-trial, the application of the acquired thoracoscopic technique in a pilot study for examination of morbidity and mortality. The comparison of the thoracoscopic and the conventional lobectomy in the pilot study also served to evaluate potential advantages of the minimal-invasive method. These advantages are a strong argument in favour of the introduction of the thoracoscopic method in to the clinic for prospective-randomized trials (phase III a and III B).

Background: The standard of care for mediastinal staging during endobronchial ultrasound (EBUS) is Systematic Sampling (SS) where a minimum of 3 lymph node (LN) stations are biopsied, even if they appear normal on imaging. When LNs appear normal on PET and CT, the Canada Lymph Node Score can also identify if they appear normal on EBUS. For these Triple Normal LNs, the pretest probability of malignancy is < 6%, and routine biopsy may not be required. This preliminary study introduced Selective Targeted Sampling (STS), which omits biopsy of Triple Normal LNs and compared it firsthand to SS. Methods: A prospective, feasibility RCT was conducted to determine whether the progression of a definitive trial was warranted. Primary outcomes and their progression criterium were recruitment rate (70% acceptable minimum); procedure length (no overlap between sampling methods’ 95%CIs); and missed nodal metastasis (overlap between sampling methods’ diagnostic accuracy 95%CIs and crossing of the null for the percent difference in diagnosis). cN0-N1 NSCLC patients undergoing EBUS were randomized to the STS or SS arm. Patients in the STS arm were then crossed over to the SS arm to receive standard of care. Wilson’s CI method and McNemar’s test of paired proportions were used for statistical comparison. Surgical pathology was the reference standard. Results: Thirty-eight patients met the eligibility criteria, and all were recruited (100%; 95%CI: 90.82 to 100.00%). The median procedure lengths, in minutes, for STS and SS were 3.07 (95%CI: 2.33 to 5.52) and 19.07 (95%CI: 15.34 to 20.05) respectively. STS had a diagnostic accuracy of 100% (95%CI: 74.65% to 100.00%), whereas SS was 93.75% (95%CI: 67.71% to 99.67%) with the inclusion of inconclusive results. Percent difference in diagnosis between sampling method was 5.35% (95%CI: -0.54% to 11.25%). Conclusion: With the progression criteria successfully met, a subsequent multicentered, non-inferiority crossover trial comparing STS to SS is warranted. / Thesis / Master of Science (MSc) / Before deciding on treatment for patients with lung cancer, a critical step in the investigations is finding out whether the lymph nodes in the chest contain cancer. This is best done with a needle that biopsies those lymph nodes through the walls of the airway, known as endobronchial ultrasound transbronchial needle aspiration. Guidelines require that every lymph node in the chest be biopsied through a process called Systematic Sampling. However, new research has suggested that some lymph nodes may not need a biopsy. These lymph nodes are ones with a very low chance of cancer, based on their imaging tests. In this study, Selective Targeted Sampling was introduced whereby lymph nodes that appeared normal were not initially biopsied. The study followed a feasibility design, which proved sufficient patient interest, adequate safety and possible benefits in pursuing a larger trial comparing Selective Targeted Sampling to Systematic Sampling.

La fibrillation auriculaire postopératoire (FAPO) est une complication fréquente de la chirurgie cardiaque et est associée à une morbidité et des coûts accrus. Bien que de nombreuses méthodes prophylactiques aient été évaluées, aucune n’est actuellement universellement employée compte tenu du risque de complications, de contre-indications et du manque de données probantes. Ce mémoire tente d’examiner la contribution du sang intra-péricardique à la genèse de fibrillation auriculaire après une chirurgie cardiaque et d’évaluer son potentiel en tant que cible prophylactique. Trois études furent réalisées dans le cadre de ce travail. Dans un premier temps, une revue de la littérature fut pilotée afin d’éclaircir les éléments pathophysiologiques et cliniques unissant l’accumulation de sang dans le sac péricardique à la FAPO. Ensuite, un projet rétrospectif avec analyse par score de propension et un essai clinique randomisés furent menés afin d’évaluer l’effet d’un protocole de drainage thoracique adoptant un dispositif de dégagement actif des drains [active tube clearance (ATC)], visant à prévenir la formation de caillots intraluminaux, sur l’incidence de FAPO. La première étude conclut que la présence de sang intra-péricardique, via l’activation de processus inflammatoire et oxydatif local, est un facteur périopératoire contribuant à la survenue de FAPO. La seconde étude identifia l’utilisation de l’ATC en tant que facteur protecteur indépendant contre la FAPO. Finalement, la dernière étude démontra une diminution non-significative du risque relatif de FAPO de 18% associée à l’ATC. En somme, un drainage efficace du péricarde pourrait réduire l’incidence de FAPO, or les modalités optimales demeurent à être spécifiées. / Postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery that is associated with increased morbidity and costs. Although numerous prophylactic measures have been evaluated, none have been universally implemented considering the risk of complications, contraindications and lack of evidence. The aim of this thesis is to examine the role of intrapericardial blood in the development of POAF after cardiac surgery and evaluate its potential as a target for prophylaxis. For this thesis, a total of three studies were carried out. To begin, a literature review was conducted to elucidate the pathophysiological and clinical elements connecting the accumulation of shed blood within the pericardial sac to POAF. Afterwards, both a retrospective study with propensity score analysis and a randomized controlled trial were carried out to evaluate the incidence of POAF after implementing a universal postoperative chest drainage protocol using an active tube clearance (ATC) device, designed to prevent intraluminal clogging and improve drainage. The first study concluded that the presence of intra-pericardial blood, through the activation of local and oxidative processes, is a perioperative factor triggering POAF in susceptible individuals. The second study identified the use of ATC as an independent protective factor against POAF. Finally, the last study demonstrated a 15% non-significant relative risk reduction of POAF associated with ATC. In conclusion, an efficient pericardial drainage could reduce the incidence of POAF after cardiac surgery. However, the optimal strategy has yet to be determined.

Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma. It is a molecular and prognostic heterogeneous disease. Three main genetic subtypes are called germinal center-like DLBCL (GC-like DLBCL), non-germinal center-like DLBCL (nonGC-like DLBCL) and primary mediastinal B-cell lymphoma (PMBL). These subtypes can be reliably distinguished only with usage of gene expression profiling (GEP). The GEP method can be applied only when fresh frozen tissue is available. The method is technically difficult and expensive. Thus, it is not used routinely. Since the DLBCL subtypes differ in prognosis, it is extremely important to be able to distinguish them. The presented thesis is focused on distinguishing of PMBL diagnosis in the group of DLBCL. Easily stored formalin-fixed, paraffin-embedded tissue (FFPE) and gene expression analysis using real-time quantitative polymerase chain reaction (RTqPCR) are used. In the first step, PMBL and DLBCL cases were distinguished with an internationally accepted clinical-pathological method. The agreement between clinical-pathological diagnosis and GEP is only 76%. In the presented text a genetic algorithm for PMBL/DLBCL distinguishing is suggested. It uses three carefully chosen genes and their expression is measured with RTqPCR. Both, the...