Number Of Imaging Studies Research Articles

Imaging Follow-Up of Nonsurgical Therapies for Lung Cancer: AJR Expert Panel Narrative Review.

Lung cancer continues to be the most common cause of cancer-related death worldwide. In the past decade, with the implementation of lung cancer screening programs and advances in surgical and nonsurgical therapies, the survival of patients with lung cancer has increased, as has the number of imaging studies that these patients undergo. However, most patients with lung cancer do not undergo surgical re-section, because they have comorbid disease or lung cancer in an advanced stage at diagnosis. Nonsurgical therapies have continued to evolve with a growing range of systemic and targeted therapies, and there has been an associated evolution in the imaging findings encountered at follow-up examinations after such therapies (e.g., with respect to posttreatment changes, treatment complications, and recurrent tumor). This AJR Expert Panel Narrative Review describes the current status of nonsurgical therapies for lung cancer and their expected and unexpected imaging manifestations. The goal is to provide guidance to radiologists regarding imaging assessment after such therapies, focusing mainly on non-small cell lung cancer. Covered therapies include systemic therapy (conventional chemotherapy, targeted therapy, and immunotherapy), radiotherapy, and thermal ablation.

Diagnosing pancreatic neuroendocrine tumors in patients with multiple endocrine neoplasia type 1 in daily practice.

BackgroundIn multiple endocrine neoplasia type 1 (MEN1), pancreatic neuroendocrine tumors (PanNETs) have a high prevalence and represent the main cause of death. This study aimed to assess the diagnostic accuracy of the currently used conventional pancreatic imaging techniques and the added value of fine needle aspirations (FNAs).MethodsPatients who had at least one imaging study were included from the population-based MEN1 database of the DutchMEN Study Group from 1990 to 2017. Magnetic resonance imaging (MRI), computed tomography (CT), endoscopic ultrasonography (EUS), FNA, and surgical resection specimens were obtained. The first MRI, CT, or EUS was considered as the index test. For a comparison of the diagnostic accuracy of MRI versus CT, patients with their index test taken between 2010 and 2017 were included. The reference standard consisted of surgical histopathology or radiological follow-up.ResultsA total of 413 patients (92.8% of the database) underwent 3,477 imaging studies. The number of imaging studies per patient increased, and a preference for MRI was observed in the last decade. Overall diagnostic accuracy was good with a positive (PPV) and negative predictive value (NPV) of 88.9% (95% confidence interval, 76.0–95.6) and 92.8% (89.4–95.1), respectively, for PanNET in the pancreatic head and 92.0% (85.3–96.0) and 85.3% (80.5–89.1), respectively, in the body/tail. For MRI, PPV and NPV for pancreatic head tumors were 100% (76.1–100) and 87.1% (76.3–93.6) and for CT, 60.0% (22.9–88.4) and 70.4% (51.3–84.3), respectively. For body/tail tumors, PPV and NPV were 91.3% (72.0–98.8) and 87.0% (75.3–93.9), respectively, for MRI and 100% (74.9–100) and 77.8% (54.3–91.5), respectively, for CT. Pathology confirmed a PanNET in 106 out of 110 (96.4%) resection specimens. FNA was performed on 34 lesions in 33 patients and was considered PanNET in 24 [all confirmed PanNET by histology (10) or follow-up (14)], normal/cyst/unrepresentative in 6 (all confirmed PanNET by follow-up), and adenocarcinoma in 4 (2 confirmed and 2 PanNET). Three patients, all older than 60 years, had a final diagnosis of pancreatic adenocarcinoma.ConclusionAs the accuracy for diagnosing MEN1-related PanNET of MRI was higher than that of CT, MRI should be the preferred (non-invasive) imaging modality for PanNET screening/surveillance. The high diagnostic accuracy of pancreatic imaging and the sporadic occurrence of pancreatic adenocarcinoma question the need for routine (EUS-guided) FNA.

Translator use not associated with longer time to pain medication in initial evaluation of low-severity geriatric trauma

ObjectivesDetermine whether geriatric victims of blunt trauma who preferred to communicate in a language other than English waited longer for pain medication or received more imaging studies than English-speaking patients with the same age and injuries. Secondary outcomes were the type of medication administered and number of imaging studies. MethodsWe conducted a retrospective analysis of all trauma activations to a single academic urban medical center from January 2019 to October 2019. We included all hemodynamically stable patients older than 65, with head or torso trauma after a low energy injury, and on at least one medication that was an anti-coagulant, anti-platelet, or chemotherapeutic. ResultsWe identified 1,153 unique patients (17, 379 radiologic studies) performed from January 2019 to October 2019, with a median of 5 (4–6) radiologic studies per patient. We excluded 419 patients for whom the language used was not reported (n = 7), no imaging was not reported (n = 16), or no medication was recorded as given (n = 409), leaving 734 patients for further analysis. Of those 734 patients, 460 preferred to communicate in English, 84 in Mandarin Chinese, 64 in Spanish, 37 in Cantonese Chinese, and 35 in Korean, and 29 in Russian. Across all languages patient age and Injury Severity Score (ISS) were comparable. Those who preferred to communicate in Spanish, Russian, or Korean were more likely to be female than those who preferred English, Mandarin, or Cantonese, but this tendency was not statistically significant (χ2-test; p = 0.051, 0.15 after Bonferroni correction). We did not find a statistically significant association between preferred language and time to medication, fraction of opioids used as first-line pain medication, or number of imaging studies performed. Across all patients, the most common medications administered were acetaminophen (524/734, 71%), any opioid (111/734, 15%), followed by local infiltration or nerve block with lidocaine (49/734, 6.7%). ConclusionsA retrospective analysis of patients with low-risk blunt trauma found no relationship between preferred language, time to pain medication, use of opioids or number of imaging studies.

Multi-Health System Comparison of Diagnostic Testing in Hospitalized Sepsis Patients

Abstract Introduction/Objective Comparisons of diagnostic testing across multiple health systems over multiple years are uncommon. Such comparisons would quantify variations in test use between health systems. Methods/Case Report Using the Vizient Clinical Database, we compared clinical laboratory and imaging utilization for hospitalized adult sepsis patients (N = 69,035) over three years (2017-2019) at 19 large academic-affiliated health systems across the United States. We used Medicare Severity Diagnosis Related Groups (MSDRG), employed by the US Centers for Medicare and Medicaid Services (CMS), and identified sepsis patients (MSDRG triplet 870/871/872). We stratified hospitalized sepsis patients by severity of illness (SOI) into high severity (MSDRG 870), moderate severity (MSDRG 871), and low severity (MSDRG 872) groups. SOI further categorizes patients within a diagnostic group, quantifying the extent of comorbid conditions and complications. We measured hospital length of stay (LOS), number of laboratory tests (CPT codes 80000-89999), and number of imaging studies (CPT codes 70000-79999). We divided the number of laboratory tests and radiology studies by mean hospital LOS (in days) to calculate laboratory tests and imaging studies per hospital day. Results (if a Case Study enter NA) Between health systems, lowest and highest values for laboratory and imaging utilization ranged from 50.1 to 141.3 tests per hospitalization and 1.4 to 7.2 studies per hospitalization, respectively. Differences in laboratory tests between health systems persisted after adjusting for SOI with low to high laboratory tests per hospitalization ranging from 127.8 to 405.7, 51.0 to 144.7, and 31.9 to 78.2, for high, moderate, and low SOI groups. Utilization ranges were smaller for imaging studies. After adjusting for hospital LOS, laboratory testing differences between health systems were more pronounced and with low and high laboratory test per day utilization of 6.5 to 24.3, 6.1 to 18.5, and 6.0 to 17.1, for high, moderate, and low SOI groups. Differences in radiology studies were not as pronounced after adjusting for LOS. Conclusion There is considerable variation among health systems in laboratory and radiology resource utilization for hospitalized sepsis patients. This variation persists, especially for laboratory testing, after adjusting for SOI and LOS.

Variation in management of pediatric post-traumatic urine leaks

High-grade pediatric renal trauma may be associated with a urine leak and appropriate management remains unclear. Data on patients with a traumatic renal injury were retrieved from the trauma registry and data warehouse of a pediatric level 1 trauma center over a 15-year period. Demographics, diagnoses, imaging, interventions performed, and follow-up information on patients with a urine leak were analyzed. 187 renal injuries were identified and 32 (17%) were high grade. There were 21 (11%) diagnoses of urine leak, comprising the study population. Leaks were identified 0-10day post-injury. All patients underwent initial computerized tomography (CT); however, 10 (48%) lacked excretory-phase imaging, leading to repeat CT. Ten patients (48%) did not undergo an intervention for their leak, and 11 (52%) underwent at least one, most commonly stent placement (10). Comparing non-intervention and intervention groups: Injury Severity Score (ISS) and initial Shock Index - Pediatric Adjusted (SIPA) were similar, but there was variation in antibiotic prophylaxis (60% vs 100%), average number of imaging studies performed (6.4 vs 8.1) and average length of hospital stay in days (7.7 vs 8.6). Traumatic urine leaks are unusual, and half require no intervention. Management is variable and the development of care guidelines could decrease variation. Given their infrequency a multi-institutional study is required to generate sufficient patient volume.

Clinical and Economic Outcomes of Patients Undergoing Guideline-Directed Management of Pancreatic Cysts.

Numerous guidelines exist for the management of pancreatic cysts. We sought to compare the guideline-directed management strategies for pancreatic cysts by comparing 2 approaches (2017 International Consensus Guidelines and 2015 American Gastroenterological Association Guidelines) that differ significantly in their thresholds for imaging, surveillance, and surgery. We developed a Monte Carlo model to evaluate the outcomes for a cohort of 10,000 patients managed per each guideline. The primary outcome was mortality related to pancreatic cyst management. Secondary outcomes included all-cause mortality, missed cancers, number of surgeries, number of imaging studies, cumulative cost, and quality-adjusted life years. Deaths because of pancreatic cyst management and quality-adjusted life years were similar in both guidelines at a significantly higher cost of $3.6 million per additional cancer detected in the Consensus Guidelines. Deaths from "unrelated" causes (1,422) vastly outnumbered deaths related to pancreatic cysts (125). Secondary outcomes included more missed cancers in the American Gastroenterological Association guideline (71 vs 49), more surgeries and imaging studies in the Consensus guideline (711 vs 163; 116,997 vs 68,912), and higher cost in the Consensus guideline ($168.3 million vs $89.4 million). As the rate of malignant transformation increases, a more-intensive guideline resulted in fewer deaths related to pancreatic cyst management. Our study demonstrates trade-offs between more- and less-intensive management strategies for pancreatic cysts. Although deaths related to pancreatic cyst management were similar in each strategy, fewer missed cancers in the more-intensive surveillance strategy is offset by a greater number of surgical deaths and higher cost. In conclusion, our study identifies that if the rate malignant transformation of pancreatic cysts is low (0.12% annually), a less-intensive guideline will result in similar deaths to a more-intensive guideline at a much lower cost.

IMAGING TECHNIQUES IN THE DIAGNOSIS OF PULMONARY HYPERTENSION

Introduction: Pulmonary hypertension is defined as being a haemodynamic state, wherein the mean pulmonary artery pressure measured during right heart catheterization is equal or greater than 25 mmHg. As a result, right ventricular heart failure develops and clinical symptoms such as dyspnea, fatigue, weakness, angina and fainting occur. The aim: To highlight the role of imaging techniques in diagnostic process for pulmonary hypertension. Review and Disscusion: The diagnosis of pulmonary hypertension is multistage and often requires a number of studies. Currently, imaging techniques play a significant role in the diagnostic algorithm for pulmonary hypertension due to the fact that they are non-invasive and readily available, and many of their parameters are closely related to pulmonary hemodynamics. Conclusions: The diagnosis of pulmonary hypertension requires a multistep approach and a number of imaging studies. The suspicion of the disease is based on medical history, clinical symptoms and chest radiogram. Echocardiography plays a crucial role in pulmonary hypertension detection. A computed tomography and cardiac magnetic resonance are valuable methods in determining the cause of suspected or confirmed pulmonary hypertension.

Survival Benefits from Antifungal Prophylaxis and a Dedicated Inpatient Malignant Hematology Service during Induction Chemotherapy for Acute Myeloid Leukemia

Introduction: Invasive fungal infections (IFIs) are a major cause of morbidity and mortality in patients undergoing induction chemotherapy for acute myeloid leukemia (AML). During induction chemotherapy for AML patients, antifungal prophylaxis (AP) has been associated with a decreased incidence of IFIs and increased survival. However, some centers do not use AP, as it is unclear whether it improves outcomes in settings where the incidence of IFIs is low (<8% of mold infections), as at our center. We retrospectively assessed the differences in clinical outcomes and resource utilization in patients undergoing induction chemotherapy for AML before and after implementation of an AP policy and a dedicated inpatient malignant hematology service at our institution. Methods: AML patients ≥18 years of age who underwent induction chemotherapy between 1/1/07 and 4/1/19 were identified by pharmacy records. Data was verified and extracted by two members of the research team. Primary endpoints were in-hospital mortality during induction chemotherapy and rates of fungal infections within 90-days after induction. Secondary endpoints were 30-day post induction and 90-day post-discharge survival, rates of proven/probable IFI by application of the Mycoses Study Group definitions, diagnostic resource utilization and tolerability. Categorical variables were compared with x2 or Fisher's exact tests and continuous variables with independent samples t-test or the non-parametric Mann-Whitney test as appropriate. Post-induction survival was also analyzed with Kaplan-Meier (KM) curves. Results: 108 adult AML patients were retrospectively reviewed. Fifty-six received AP during induction and 52 did not, without significant differences in demographic or leukemia-specific factors. AP was associated with numerically less fungal infections (9/56 (16%) vs. 14/52 (27%), P=0.169) and proven/probable IFIs (3/52 (6%) vs. 0/56, P=0.1). AP was also associated with lower in-hospital (11/52 (21%) vs. 4/56 (7%), P=0.035) mortality. Clinicians obtained more electrocardiograms (median 4 vs. 1.5, P<0.001) in the AP group; otherwise, there were no significant differences in the number of imaging studies, bronchoscopies, blood cultures, β-D-glucan and Aspergillus galactomannan tests, or adverse events, specifically clinically significant QT prolongation, nephrotoxicity or hepatotoxicity. Antifungals were more likely to be started in the non-prophylaxis group (36/52 (69%)) than changed in the prophylaxis group (23/56 (41%), P=0.003). Implementation of a dedicated inpatient malignant hematology service led to standardization of practices including AP (24/76 (32%) vs. 32/32 (100%), P<0.001) and was associated with significantly lower in-hospital (14/76 (18%) vs. 1/32 (3%), P=0.036) and 90-day post-discharge (16/71 (23%) vs. 1/29 (3%), P=0.021) mortality. Before implementation of this service, AP was associated with numerically lower in-hospital mortality during induction (3/24 (13%) vs. 11/52 (21%), P=0.366), and significantly improved 30-day post-induction survival (Fig. 1, log-rank P=0.042). Conclusions: In a setting where mold infections are rare, AP in patients undergoing induction chemotherapy for AML was associated with improved survival, empiric or targeted antifungal treatment, and a signal for decreased frequency of fungal infections, without substantial increases in utilization of diagnostic resources. This study is limited in its single-center retrospective study design, the overall small number of patients, and is confounded by simultaneous changes in practice, especially with the implementation of a dedicated malignant hematology service. Notably however there was improved 30-day mortality in patients on AP versus those not on AP prior to the implementation of the malignant hematology service. Our findings indicate that outcomes are optimized when adult patients with AML receive their care by a dedicated malignant hematology team, with implications for low-volume institutions and community practices, where AML inductions are not always performed under the care of malignant hematology specialists. Our results suggest that AP and admitting or transferring adult AML patients to a center with a dedicated malignant hematology service, when feasible, may lead to better outcomes. Figure 1 Disclosures Farmakiotis: Astellas: Research Funding; Viracor-Eurofins: Consultancy, Research Funding.

Neurophysiology of threat processing bias in combat-related post-traumatic stress disorder.

Post‐traumatic stress disorder (PTSD) is a debilitating condition that may develop after experiencing a traumatic event. Combat exposure increases an individual's chance of developing PTSD, making veterans especially susceptible to the disorder. PTSD is characterized by dysregulated emotional networks, memory deficits, and a hyperattentive response to perceived threatening stimuli. Recently, there have been a number of imaging studies that show structural and functional abnormalities associated with PTSD; however, there have been few studies utilizing electroencephalography (EEG). The goal of this study was to characterize **EEG brain dynamics in individuals with PTSD, in order to better understand the neurophysiological underpinnings of some of the salient features of PTSD, such as threat‐processing bias. Veterans of Operation Enduring Freedom/Iraqi Freedom completed an implicit visual threat semantic memory recognition task with stimuli that varied on both category (animals, items, nature, and people) and feature (threatening and nonthreatening) membership, including trauma‐related stimuli. Combat veterans with PTSD had slower reaction times for the threatening stimuli relative to the combat veterans without PTSD (VETC). There were trauma‐specific effects in frontal regions, with theta band EEG power reductions for the threatening combat scenes in the PTSD patients compared to the VETC group. Additionally, a moderate negative correlation was observed between trauma‐specific frontal theta power and hyperarousal symptoms as measured by clinically administered PTSD scale. These findings complement and extend current models of cortico‐limbic dysfunction in PTSD. The moderate negative correlation between frontal theta power and hyperarousal endorsements suggests the utility of these measures as therapeutic markers of symptomatology in PTSD patients.

Patients with acute cholecystitis should be admitted to a surgical service.

In bowel obstruction and biliary pancreatitis, patients receive more expedient surgical care when admitted to surgical compared with medical services. This has not been studied in acute cholecystitis. Retrospective analysis of clinical and cost data from July 2013 to September 2015 for patients with cholecystitis who underwent laparoscopic cholecystectomy in a tertiary care inpatient hospital. One hundred ninety lower-risk (Charlson-Deyo) patients were included. We assessed admitting service, length of stay (LOS), time from admission to surgery, time from surgery to discharge, number of imaging studies, and total cost. Patients admitted to surgical (n = 106) versus medical (n = 84) service had shorter mean LOS (1.4 days vs. 2.6 days), shorter time from admission to surgery (0.4 days vs. 0.8 days), and shorter time from surgery to discharge (0.8 days vs. 1.1 days). Surgical service patients had fewer CT (38% vs. 56%) and magnetic resonance imaging (MRI) (5% vs. 16%) studies. Cholangiography (30% vs. 25%) and endoscopic retrograde cholangiopancreatography (ERCP) (3 vs. 8%) rates were similar. Surgical service patients had 39% lower median total costs (US $7787 vs. US $12572). Nonsurgical admissions of patients with cholecystitis are common, even among lower-risk patients. Routine admission to the surgical service should decrease LOS, resource utilization and costs. Therapeutic/care management, level IV.

Exploring the Less Common Pathogens of Infectious Diarrhea

ABSTRACT Objective: Gastrointestinal (GI) panels have allowed for faster and accurate detection, treatment, and control of pathogens. Because of the large number of potential pathogens included in the panel the clinical significance and manifestations of some organisms, such as Enteroaggregative Escherichia coli (EAEC) and Enteropathogenic E. coli (EPEC), remains undetermined. Methodology: We performed a single-institution retrospective chart review for 222 patients with a stool sample tested on BioFire FilmArray Gastrointestinal Panel (GI Panel) between June 1, 2016 and March 9, 2017. Results: Of the 222 patients, four had EAEC and 17 and EPEC. Patients who tested positive for EAEC and EPEC were younger (26.3 years and 33.9 years, respectively) than patients that did not test positive for a GI pathogen (47.7 years). In cases where multiple organisms were detected, EPEC was present 56.3% of the time. Analysis of symptoms showed that EPEC patients had a high prevalence of abdominal pain (p=0.0425) and vomiting (p=0.0045), but not diarrhea, when compared to the presence of these symptoms in patients with no targets detected. With only four patients positive for EAEC in this study, the results of symptoms in EAEC patients were inconclusive. Cases involving EPEC and EAEC were treated similarly to other cases of diarrhea with no significant difference in the number of imaging studies and medication changes. Conclusions: While further studies are required to determine the specific clinical significance of EAEC or EPEC, it is evident that patients positive for EPEC often experience abdominal pain and diarrhea, suggesting EPEC may be more pathogenic than previously thought. J Microbiol Infect Dis 2019; 9(1):1-9.

HSR19-087: Intensity of Symptom Management After Palliative Care Referral Not Associated With Reduced Imaging Intensity for Cancer Patients During the End-of-Life Period

Purpose: For patients with advanced cancer, palliative care (PC) referral itself results in improved quality of life and lower total health care costs. While our earlier research suggests that PC referral alone does not appear to affect imaging utilization, the effect of the intensity of services for PC symptom management on utilization of imaging services is unknown. We sought to evaluate whether an association exists between the intensity of PC symptom management services and utilization of high-cost imaging at the end-of-life. Methods/Materials: Adult cancer patients who died between January 1, 2012–May 31, 2015 were identified. A PC symptom management intensity score was determined for each patient during the last year of life based upon the number of inpatient and outpatient PC service visits and the number of problems addressed within the 8 defined domains for palliative care. Frequency of utilization of nonemergent oncologic imaging was determined for the last 3 months and the last month of life. Using chi-square and Wilcoxon-rank sum tests, effects of low (<20th percentile) and high (>80th percentile) PC symptom management intensity score on the proportion of patients imaged and mean number of studies per patient (mean imaging intensity [MII]) were compared for the last 3 months and last month of life. Results: 3,772 decedents were included, with 3,523 (93.4%) never referred to PC and 249 (6.6%) referred to PC, largely before the last month of life (70.3%). Within the last 3 months and last month of life, the proportion of patients imaged was significantly greater (P<.001) in patients with high PC symptom management intensity scores when compared to those with low PC symptom management intensity scores. There was no significant difference in the mean number of imaging studies received by either group in the last 1 month or 3 months of life. (P>.05). Conclusions: The intensity of PC symptom management in end-of-life oncologic care was not associated with decreased use of nonemergent, high-cost cancer imaging in our cohort. This may suggest an opportunity for reduced high-cost imaging through further clarification of the goals of care with both patients and oncologists, although the role of imaging in the setting of PC during the end-of-life period warrants further study as well.

Chapter 17 - Cingulate-mediated approaches to treating chronic pain

Anterior midcingulate cortex (aMCC) has been shown to be involved in most of the functional imaging studies investigating acute pain. For 10-15 years, it has even been a main focus of interest for pain studies, considering that neurons in the aMCC could encode for pain intensity. This latter function is now presumed to occur in secondary somatosensory (SII) area and/or insular cortices, while anterior cingulate cortex (ACC) is supposed to sustain other functions such as pain-related attention, arousal, motor withdrawal reflex, pain modulations, and engagement of endogenous pain control system. The quantitative imaging studies have shown a rich density of opioid receptors in the ACC. Thus, the perigenual subdivision has been suggested to participate in top-down controls of pain, (including the placebo effects known to be opioid mediated), mainly (but not exclusively) through the connection between the orbitofrontal/subgenual ACC and the periaqueductal gray (PAG). From this rationale, this area may lead to neurosurgical targeting including electrical stimulation for intractable pain in the future. A number of imaging studies have also reported activity changes in the posterior cingulate cortex during pain and proposed its speculative involvement to modulate the conscious experience of pain according to elements from the context and awareness of the self and others.

A37 EFFICACY OF CTA IN DIAGNOSING NON-TRAUMATIC NON-VARICEAL GASTROINTESTINAL BLEEDING PRIOR TO TRANSARTERIAL EMBOLIZATION AFTER ENDOSCOPIC FAILURE IN MANAGING ACUTE GASTROINTESTINAL BLEEDING

AbstractBackgroundNon-variceal gastrointestinal bleeding (NVGIB) is associated with a high mortality and morbidity. 10–30% of these patients tend to fail endoscopy and receive transarterial embolization (TAE) as an alternative. Studies suggest that performing pre-angiography computed tomography angiography (CTA) increases the positive yield of visceral angiography.AimsOur objective was to determine (1) the accuracy of CTA in diagnosing NVGIB following failed endoscopy and (2) the impact of CTA pre-TAE on the angiographic technique.MethodsData was collected from 83 consecutive patients who presented to the emergency department with acute NVGIB and received TAE after endoscopy failed to manage their NVGIB. Of these 83 patients, 40 underwent pre-angiography CTA. These CTA examinations were retrospectively reviewed by 2 radiology residents and 2 staff radiologists. These findings were compared to angiography, or/and surgery. Inter-reader reliability was evaluated with kappa coefficient (κ).ResultsSensitivity, specificity, PPV, NPV, and accuracy of CTA in diagnosing NVGIB was 89%, 100%, 100%, 86%, and 93%, respectively. CTA was able to accurately diagnose the cause and source of NVGIB in 85% of the patients respectively. The inter-reader reliability coefficient for identifying the cause and source of NVGIB was κ=0.72 and κ=0.66 respectively. In 20 cases, in whom CTA localized NVGIB, no diagnostic catheter angiogram was required. In 6/20 cases, pre-TAE CTA enabled the identification of the bleeding site, which would not have been visualized on a routine diagnostic angiogram. When comparing patients that received CTA prior to their therapeutic embolization for NVGIB to the patients that did not receive a pre-embolization CTA, there was an overall reduction of 20 minutes of procedural time.ConclusionsCTA is an accurate diagnostic modality in detecting NVGIB. Performing abdomen and pelvis CTA before TAE improves the localization of gastrointestinal bleeding and facilitates embolization by reducing the overall procedural time. Impact of pre-angiography CTA on reducing the overall number of imaging studies, amount of contrast administered, and overall mortality and morbidity needs to be further investigated.Funding AgenciesNone

Multiple Neuroimaging Measures for Examining Exercise-induced Neuroplasticity in Older Adults: A Quasi-experimental Study.

Physical exercise can improve physical and mental health. A number of imaging studies have examined the role of neuroplasticity in improving cognition with physical exercise; however, such neuroplasticity changes are not consistent across the reports partly due to small sample sizes in some studies. We thought to explore the concept that identifying consistent findings across multi-modality imaging measures would provide relatively reliable results. We designed a 6-week quasi-experiment with Wii-fitness exercise program in 24 healthy adults older than 60, and then examined the changes on neuroimaging measures including brain volume, the amplitude of low-frequency oscillation function (ALFF), regional homogeneity (ReHo), seed-based functional connectivity (FC), and the global efficiency of nodal connectivity during resting state. We focused on whether there were common regions showing changes after exercise across these measures and which measure was closely correlated with cognitive improvement. After the six-week exercise program, participants demonstrated a significant improvement in memory and executive function on neuropsychological tests, and in memory recall on an emotional memory task. The common brain regions that showed significant changes across different measures were the right striatum and the posterior cingulate (PCC). After exercise, the PCC showed decreased ReHo and increased volume, and the striatum did not show volume loss as the control group did and increased its FC with the cingulate, temporal, parietal, and occipital regions. Moreover, the connectivity change between the striatum and the thalamus was correlated with the improvement of executive function. This result implicates the striatum and the PCC associated network in physical exercise. Our work highlights the effectiveness of multi-modality neuroimaging measures in investigating neuroplasticity.

Comparative Outcomes of Treated Sterile vsInfected Walled off Pancreatic Necrosis at a High-Volume Center

Introduction: Walled-off necrosis (WON) as sequelae of severe acute, necrotizing pancreatitis has been associated with high morbidity and mortality. Both sterile WON and infected WON can lead to multiorgan failure, with generally held opinions suggesting worse outcomes in infected WON. There is a dearth of studies specifically comparing outcomes between infected WON and sterile WON. Methods: All patients undergoing minimally invasive treatment for symptomatic or infected WON have been maintained in a prospectively collected institutional database since October 2007. We performed a retrospective analysis of this database including patients encountered between October 2007 and June 2015. Infected WON was strictly defined by either positive culture of fluid from the necrotic cavity or sepsis associated with positive blood culture. Patients were treated with either standard percutaneous drainage (SPD) or dual modality endoscopic and percutaneous drainage (DMD). Descriptive statistics were performed for infected and sterile groups, and appropriate univariate analyses were performed to compare the two groups. Results: Overall, 219 patients were included in the analysis. Of these, 111 (50.7%) were classified as infected WON and 108 (49.3%) were sterile WON. When compared to patients with sterile WON, those with infected WON tended to be older (mean age 57.2 vs 51.8; p=0.01). Sex, BMI, and etiologies of pancreatitis were similar in both groups. There were no significant differences in the number of imaging studies nor procedures performed in the two groups. There was no difference between the two groups with regards to type of intervention received (SPD vs DMD). However, the infected WON group had an overall longer length of stay (32 days vs 24 days; p=0.045), were more likely to require ICU-level care (60.3% vs 45.3%; p=0.01), and more likely to require multiple drains (37.8% vs 22.2%; p=0.01) when compared with the sterile WON group. The infected WON group was more likely to have fistulized to surrounding organs (OR 3.6; 95%CI 1.7-7.8; p < 0.001). Six patients in the infected group died during the course of therapy vs 1 patient in the sterile group (p=0.12). Conclusion: When comparing outcomes in patients with infected WON to those with sterile WON, patients with infected WON have a longer length of hospital stay, require ICU management more frequently, require multiple drains, and have more fistulas. Although not statistically significant, infected WON has a numerically higher mortality.

A Combined Ultrasonographic and Conventional Radiographic Assessment of Hemophilic Arthropathy.

Hemophilic arthropathy (HA) can be diagnosed by a number of imaging studies. However, it is difficult with conventional radiography to find soft tissue structures around joints, and ultrasonography has limited effectiveness in evaluating internal bony structures. We attempt to determine whether a combination of ultrasonography for soft tissue around joints and conventional radiography for bony structures can be used as a cost-effective imaging tool for evaluating HA and whether it reflects the functional status of hemophilic patients. Thirty-six males (median age 16.5years; severe 34, mild 2) with hemophilia were recruited. We evaluated the severity of HA using combined imaging score that consisted of modified Petterson X-ray score (mPXS) and the modified ultrasonographic score (mUS). Joint impairment was clinically assesses using the World Federation of Hemophilia-Physical Examination (WFH-PE) scale and the Hemophilic joint health score (HJHS). We assessed the Hemophilia activities list (HAL) for the functional level. We performed a comparative analysis between the combined imaging score and the joint impairment scores as well as the functional scores. The mean mUS was 4.97±3.99 points, and the mean mPXS was 2.85±2.91 points; the combined imaging score was 7.83±6.31 points. The combined imaging score was significantly correlated with the HJHS (p=0.006) and WFH-PE scores (p=0.019) as well as the HAL score (p=0.002). A combination of conventional radiological and ultrasongraphic study might ultimately impact the optimal evaluation of joint impairment and functional status in hemophilic patients.

Searching for the philosopher's stone: promising links between meditation and brain preservation.

In the context of an aging population and increased prevalence of dementia and other neurodegenerative diseases, developing strategies to decrease the negative effects of aging is imperative. The scientific study of meditation as a potential tool to downregulate processes implicated in brain aging is an emerging field, and a growing body of research suggests that mindfulness practices are beneficial for cerebral resilience. Adding further evidence to this notion, an increasing number of imaging studies report effects of meditation on brain structure that are consistent with our understanding of neuroprotection. Here, we review the published findings in this field of research addressing the question of whether meditation diminishes age-related brain degeneration. Altogether, although analyses are still sparse and based on cross-sectional data, study outcomes suggest that meditation might be beneficial for brain preservation-both with respect to gray and white matter-possibly by slowing down the natural (age-related) decrease of brain tissue. Nevertheless, it should also be recognized that, until robust longitudinal data become available, there is no evidence for causation between meditation and brain preservation. This review includes a comprehensive commentary on limitations of the existing research and concludes with implications and directions for future studies.

Reductions in Diagnostic Imaging With High Deductible Health Plans.

Diagnostic imaging utilization grew rapidly over the past 2 decades. It remains unclear whether patient cost-sharing is an effective policy lever to reduce imaging utilization and spending. Using 2010 commercial insurance claims data of >21 million individuals, we compared diagnostic imaging utilization and standardized payments between High Deductible Health Plan (HDHP) and non-HDHP enrollees. Negative binomial models were used to estimate associations between HDHP enrollment and utilization, and were repeated for standardized payments. A Hurdle model were used to estimate associations between HDHP enrollment and whether an enrollee had diagnostic imaging, and then the magnitude of associations for enrollees with imaging. Models with interaction terms were used to estimate associations between HDHP enrollment and imaging by risk score tercile. All models included controls for patient age, sex, geographic location, and health status. HDHP enrollment was associated with a 7.5% decrease in the number of imaging studies and a 10.2% decrease in standardized imaging payments. HDHP enrollees were 1.8% points less likely to use imaging; once an enrollee had at least 1 imaging study, differences in utilization and associated payments were small. Associations between HDHP and utilization were largest in the lowest (least sick) risk score tercile. Increased patient cost-sharing may contribute to reductions in diagnostic imaging utilization and spending. However, increased cost-sharing may not encourage patients to differentiate between high-value and low-value diagnostic imaging services; better patient awareness and education may be a crucial part of any reductions in diagnostic imaging utilization.

Anti-TNF Therapy Reduces Ionizing Radiation Exposure in Patients with Ulcerative Colitis

Background: Patients with ulcerative colitis (UC) may be exposed to ionizing radiation for evaluation of disease with inherent risks from protracted exposure. Meanwhile, evolving definitions of disease control with evolving treatment paradigms have led to earlier introduction of biological therapy. Our aim was to compare the effective radiation dose prior to and 1 and 3 years after initiating anti- TNF therapy or corticosteroid in patients with UC. Methods: We performed a retrospective review of UC patients treated with Infliximab or corticosteroids at our institution from 2005-2012. Results: We analysed 102 patients with ulcerative colitis (66 anti-TNF and 36 corticosteroid treated). Demographics and disease characteristics between the two groups were similar. The decrease in mean number of radiology studies between the year preceding and the year following initiation of therapy was significantly larger in the Infliximab group compared to the corticosteroid group (-2.5 vs. -0.6, CI=-3.3 to -0.4, p=0.009). Linear regression analysis suggested a statistically significant decrease in the number of imaging studies by 2 with the use of Infliximab compared to the corticosteroid group within a year of therapy. Differences between the two groups in the number imaging studies 3 years after therapy and in the cumulative effective radiation dose exposure 1 and 3 years after therapy did not reach statistical significance. Conclusion: Anti-TNF therapy is associated with a significant reduction in diagnostic imaging exposure at 1 year after therapy.