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The use of cryoablation, a minimally-invasive image-guided technique to target and kill cancer cells, continues to gain traction within the medical field and with patients. This includes the use of cryoablation for the treatment of small breast cancers and focal sites of metastatic disease. In comparison to open surgical approaches, length of hospital stay and recovery time are decreased with the use of cryoablation. Research studies have also found that cryoablation may actually enhance tumor susceptibility to immunotherapy agents. Immunotherapy enhances a person’s own immune system to identify and attack cancer cells. It is proposed that after cryoablation there is increased expression of tumor specific antigens which the body can recognize as foreign invaders and with the combination of immunotherapy, result in an even more robust and efficient attack on the cancer cells. In this review we aim to highlight some of the recent advances in cryoablation which support the potential for cryoablation to induce these tumor-specific immune responses and thus supporting the use of combining cryoablation and immunotherapy for the treatment of breast cancer.

ObjectivesTo compare interobserver variability (IOV), reader confidence, and sensitivity/specificity in detecting architectural distortion (AD) on digital mammography (DM) versus digital breast tomosynthesis (DBT).MethodsThis IRB-approved, HIPAA-compliant reader study used a counterbalanced experimental design. We searched radiology reports for AD on screening mammograms from 5 March 2012–27 November 2013. Cases were consensus-reviewed. Controls were selected from demographically matched non-AD examinations. Two radiologists and two fellows blinded to outcomes independently reviewed images from two patient groups in two sessions. Readers recorded presence/absence of AD and confidence level. Agreement and differences in confidence and sensitivity/specificity between DBT versus DM and attendings versus fellows were examined using weighted Kappa and generalised mixed modeling, respectively.ResultsThere were 59 AD patients and 59 controls for 1,888 observations (59 × 2 (cases and controls) × 2 breasts × 2 imaging techniques × 4 readers). For all readers, agreement improved with DBT versus DM (0.61 vs. 0.37). Confidence was higher with DBT, p = .001. DBT achieved higher sensitivity (.59 vs. .32), p < .001; specificity remained high (>.90). DBT achieved higher positive likelihood ratio values, smaller negative likelihood ratio values, and larger ROC values.ConclusionsDBT decreases IOV, increases confidence, and improves sensitivity while maintaining high specificity in detecting AD.Key points• Digital breast tomosynthesis decreases interobserver variability in the detection of architectural distortion.• Digital breast tomosynthesis increases reader confidence in the detection of architectural distortion.• Digital breast tomosynthesis improves sensitivity in the detection of architectural distortion.

Objective To examine whether incorrect AI results impact radiologist performance, and if so, whether human factors can be optimized to reduce error. Methods Multi-reader design, 6 radiologists interpreted 90 identical chest radiographs (follow-up CT needed: yes/no) on four occasions (09/20–01/22). No AI result was provided for session 1. Sham AI results were provided for sessions 2–4, and AI for 12 cases were manipulated to be incorrect (8 false positives (FP), 4 false negatives (FN)) (0.87 ROC-AUC). In the Delete AI (No Box) condition, radiologists were told AI results would not be saved for the evaluation. In Keep AI (No Box) and Keep AI (Box), radiologists were told results would be saved. In Keep AI (Box), the ostensible AI program visually outlined the region of suspicion. AI results were constant between conditions. Results Relative to the No AI condition (FN = 2.7%, FP = 51.4%), FN and FPs were higher in the Keep AI (No Box) (FN = 33.0%, FP = 86.0%), Delete AI (No Box) (FN = 26.7%, FP = 80.5%), and Keep AI (Box) (FN = to 20.7%, FP = 80.5%) conditions (all p s < 0.05). FNs were higher in the Keep AI (No Box) condition (33.0%) than in the Keep AI (Box) condition (20.7%) ( p  = 0.04). FPs were higher in the Keep AI (No Box) (86.0%) condition than in the Delete AI (No Box) condition (80.5%) ( p  = 0.03). Conclusion Incorrect AI causes radiologists to make incorrect follow-up decisions when they were correct without AI. This effect is mitigated when radiologists believe AI will be deleted from the patient’s file or a box is provided around the region of interest. Clinical relevance statement When AI is wrong, radiologists make more errors than they would have without AI. Based on human factors psychology, our manuscript provides evidence for two AI implementation strategies that reduce the deleterious effects of incorrect AI. Key Points • When AI provided incorrect results, false negative and false positive rates among the radiologists increased. • False positives decreased when AI results were deleted, versus kept, in the patient’s record. • False negatives and false positives decreased when AI visually outlined the region of suspicion.

The Watchman device (WD) is a commonly used alternative strategy to oral anticoagulation for stroke risk reduction in patients with atrial fibrillation who have an increased bleeding risk. There are rare case reports of WD-related infection. Currently, there is no formal study that has systematically evaluated the incidence and outcomes WD-related infections. The objective of this study was to evaluate the incidence, risk factors, and outcomes for WD-associated infections in a single-center cohort over a 14-year period. All patients who underwent WD implantation over a 14-year study period (July 2004 through December 2018) comprised our cohort. Baseline characteristics, procedural data, and postimplantation events were identified through a retrospective chart review. Primary study outcomes included WD-related infection, other cardiovascular device-related infection, bacteremia, and mortality. A total of 181 patients (119 males; 65.7%) with a mean age of 75 years at implantation were included in the analysis. A total of 534.7 patient years of follow-up was accrued, with an average of 2.9 years per patient. The most common indications for implantation included gastrointestinal bleeding (56 patients; 30.9%) and intracerebral bleeding (51 patients; 28.2%). During the follow-up period, 37 (20.4%) patients died. Six developed evidence of bacteremia. Only 1 developed an implantable cardioverter defibrillator infection that required a complete system extraction. None of the cohort developed a WD-related device infection during the study period. We concluded that there is a low risk of WD-related infection even in the setting of a blood stream infection.

2.Which one of this patient's risk factors would most strongly increase his risk of a perioperative cardiovascular event? a. Previous malignancy b. First-degree AV block c. Creatinine level of 1.2 mg/dL d. Diabetes mellitus treated with insulin e. Hemoglobin level of 10.3 g/dL A commonly used and well-validated perioperative cardiac risk model is the Revised Cardiac Risk Index outlined by Lee et al.2 In an analysis of 2893 consecutive patients undergoing noncardiac surgery, 6 independent risk factors were identified. The patient continued to deny any chest pain, palpitations, shortness of breath, orthopnea or other signs of ischemic cardiac disease or congestive heart failure. 3.Given the previously noted findings, which one of the following would you use to treat the newly found left apical thrombus? a. No acute treatment, follow up in 3 months b. Surgical thrombectomy c. Intravenous heparin bridging to warfarin d. Intravenous thrombolysis e. Low-dose aspirin and clopidogrel The main risk associated with an intracardiac thrombus is a cardioembolic event, primarily stroke. [...]the incidence of left ventricular thrombus has been reported to be as high as 1.3% of patients with stress-induced cardiomyopathy.12 The primary goal of treatment is prevention of cardioembolic phenomena, in particular, stroke. There are currently limited data regarding using direct oral anticoagulants in this scenario, and this may be a future area of research. [...]apical ballooning syndrome should be high on one's differential diagnosis, especially in the setting of an acute stressor.

Based on this patient's presentation, which one of the following diagnostic tests should be performed next? a. Magnetic resonance imaging (MRI) of the brain b. Electroencephalography c. Lumbar puncture (LP) d. Angiotensin-converting enzyme measurement e. Electromyography Magnetic resonance imaging of the brain is a good test to evaluate changes within the brain parenchyma and can also help in the diagnosis of herpes simplex virus (HSV) encephalitis. Given the overall presentation so far, which one of the following additional CSF tests would provide the highest diagnostic yield? a. Streptococcus pneumoniae PCR b. Neisseria meningitidis PCR c. Enterovirus PCR d. Coccidioidomycosis antigen test e. Cryptococcal antigen test Streptococcus pneumoniae and N meningitides are common pathogens in acute bacterial meningitis, which presents with fever, nuchal rigidity, and characteristic CSF findings of pleocytosis (cell count over 100), low glucose level, and high protein value.3 This scenario does not fit with our patient's subacute/chronic disease course nor with results of his CSF analysis. [...]his clinical course is consistent with subacute meningoencephalitis, characterized by a subacute headache and gradual mental status changes over 2 to 4 weeks, which is seen with cryptococcal meningitis (CM).5 Second, his initial CSF findings of mildly elevated nucleated cell count with a lymphocyte predominance, low glucose concentration, and high protein level are suggestive of a fungal or mycobacterial infection, the latter being less common. Flucytosine can also cause neutropenia, especially in patients with chronic kidney disease. [...]it is extremely important to monitor electrolyte levels and complete blood cell counts closely.

Idiopathic ventricular tachycardia (VT) is an important cause of morbidity and less commonly, mortality in patients with structurally normal hearts. Appropriate diagnosis and management are predicated on an understanding of the mechanism, relevant cardiac anatomy, and associated ECG signatures. Catheter ablation is a viable strategy to adequately treat and potentially provide a cure in patients that are intolerant to medications or when these are ineffective. In this review, we discuss special approaches and considerations for effective and safe ablation of VT arising from the right ventricular outflow tract, left ventricular outflow tract, left ventricular fascicles, papillary muscles, and moderator band.

Cryoablation is a promising, cost-effective option to de-escalate surgical breast cancer morbidity, but presently is only suggested for breast cancers < 1.5 cm, in select candidates. Breast cancer cryoablation is not a reliably covered procedure by insurance and is mainly guided by ultrasound (US), using a single cryoprobe. Yet, cryoablation is an accepted treatment option for various malignancies, including those of the kidney, liver and lung, utilizing a predominantly CT-guided, multi-probe approach using crucial cytotoxic isotherms for thorough tumor coverage. Cryoablation thus continues to find new clinical utility and is rapidly advancing on multiple fronts, similar to immunotherapy. Clinical concerns of expanding cryoablation to breast tumors > 1.5 cm is more related to the greater risk of metastatic spread to local lymph nodes and beyond. Combined adjuvant treatment, such as radiation and/or chemotherapy, are currently used for regional and systemic breast cancer control, but have significant associated morbidities. US/CT-guided multi-probe large-volume breast cryoablation is presented as a thorough local control option for select patients. Intratumoral chemotherapy by direct tumor injection has been shown to be safe and is currently being tested with immunotherapy drugs and exhibits much lower morbidity. Cryoablation combined with intratumoral immunotherapy is presented to show robust systemic immune response and the potential to provide additional protection from regional and/or metastatic disease spread while de-escalating the morbidities from current adjuvant treatments for larger breast cancers. While further clinical trials are needed, it is essential to pursue safe and effective breast cancer treatments that offer the potential for cost-efficiency and therapeutic de-escalation across a wide spectrum of breast cancer cases.