Publications

PURPOSE: To report the safety and effectiveness of transjugular intrahepatic portosystemic shunt and mechanical thrombectomy (TIPS-thrombectomy) for symptomatic acute noncirrhotic portal vein thrombosis (NC-PVT).

MATERIALS AND METHODS: Patients with acute NC-PVT who underwent TIPS-thrombectomy between 2014 and 2021 at a single academic medical center were retrospectively reviewed. Thirty-two patients were included (men, 56%; median age, 51 years [range, 39-62 years]). The causes for PVT included idiopathic (n = 12), prothrombotic disorders (n = 11), postsurgical sequelae (n = 6), pancreatitis (n = 2), and Budd-Chiari syndrome (n = 1). The indications for TIPS-thrombectomy included refractory abdominal pain (n = 14), intestinal venous ischemia (n = 9), ascites (n = 4), high-risk varices (n = 3), and variceal bleeding (n = 2). Variables studied included patient, disease, and procedure characteristics. Patients were monitored over the course of 1-year follow-up.

RESULTS: Successful recanalization of occluded portal venous vessels occurred in all 32 patients (100%). Compared with pretreatment patency, recanalization with TIPS-thrombectomy resulted in an increase in patent veins (main portal vein [28% vs 97%, P < .001], superior mesenteric vein [13% vs 94%, P < .001], and splenic vein [66% vs 91%, P < .001]). Three procedure-related adverse events occurred (Society of Interventional Radiology grade 2 moderate). Hepatic encephalopathy developed in 1 (3%) of 32 patients after TIPS placement. At 1-year follow-up, return of symptoms occurred in 3 (9%) of 32 patients: (a) ascites (n = 1), (b) variceal bleeding (n = 1), and (c) intestinal venous ischemia (n = 1). The intention-to-treat 1-year portal vein and TIPS primary and secondary patency rates were 78% (25/32) and 100% (32/32), respectively. Seven patients required additional procedures, and the 1-year mortality rate was 3% (1/32).

CONCLUSIONS: TIPS-thrombectomy is a safe and effective method for treating patients with symptomatic acute NC-PVT.

PURPOSE: To evaluate the ability of hand motion analysis using conventional and new motion metrics to differentiate between operators of varying levels of experience for central venous access (CVA) and liver biopsy (LB).

MATERIALS AND METHODS: In the CVA task, 7 interventional radiologists (experts), 10 senior trainees, and 5 junior trainees performed ultrasound-guided CVA on a standardized manikin; 5 trainees were retested after 1 year. In the LB task, 4 radiologists (experts) and 7 trainees biopsied a lesion on a manikin. Conventional motion metrics (path length and task time), a refined metric (translational movements), and new metrics (rotational sum and rotational movements) were calculated.

RESULTS: In the CVA task, experts outperformed trainees on all metrics (P < .02). Senior trainees required fewer rotational movements (P = .02), translational movements (P = .045), and time (P = .001) than junior trainees. Similarly, on 1-year follow-up, trainees had fewer translational (P = .02) and rotational (P = .003) movements with less task time (P = .003). The path length and rotational sum were not different between junior and senior trainees or for trainees on follow-up. Rotational and translational movements had greater area under the curve values (0.91 and 0.86, respectively) than the rotational sum (0.73) and path length (0.61). In the LB task, experts performed the task with a shorter path length (P = .04), fewer translational (P = .04) and rotational (P = .02) movements, and less time (P < .001) relative to the trainees.

CONCLUSIONS: Hand motion analysis using translational and rotational movements was better at differentiating levels of experience and improvement with training than the conventional metric of path length.

BACKGROUND. A major cause of burnout is moral distress: when one knows the right course of action but institutional constraints make the right course impossible to pursue. OBJECTIVE. The purpose of this study was to assess the frequency and severity with which radiologists experience moral distress and to explore moral distress's root causes and countermeasures. METHODS. This study entailed a national survey that evaluated moral distress in radiology. The survey incorporated the validated Moral Distress Scale for Health Care Professionals, along with additional questions. After the scale was modified for applicability to radiology, respondents were asked to assess 16 clinical scenarios in terms of frequency and severity of moral distress. On May 10, 2022, the survey was sent by e-mail to 425 members of radiology practices included on a national radiology society's quality-and-safety LISTSERV. The Measure of Moral Distress for Health Care Professionals (MMD-HP) score was calculated for each respondent as a summary measure of distress across scenarios (maximum possible score, 256). RESULTS. After 12 surveys with incomplete data were excluded, the final analysis included 93 of 425 respondents (22%). A total of 91 of 93 respondents (98%) experienced at least some moral distress for at least one scenario. A total of 17 of 93 respondents (18%) had left a clinical position due to moral distress; 26 of 93 (28%) had considered leaving a clinical position due to moral distress but did not leave. The mean MMD-HP score was 73 ± 51 (SD) for those who had left, 89 ± 47 for those who had considered leaving but did not leave, and 39 ± 35 for those who had never considered leaving (p < .001). A total of 41 of 85 respondents (48%) thought that the COVID-19 pandemic had influenced their moral distress level. Across respondents, the three scenarios with highest moral distress were related to systemic causes (higher case volume than could be read safely, high case volume preventing teaching residents, and lack of administrative action or support). The countermeasure most commonly selected to alleviate moral distress was educating leadership about sources of moral distress (71%). CONCLUSION. Moral distress is prevalent in radiology, typically relates to systemic causes, and is a reported contributor to radiologists changing jobs. CLINICAL IMPACT. Urgent action by radiology practice leadership is required to address moral distress, as radiologists commonly practice in environments contradictory to their core values as physicians.

BACKGROUND. Distal pancreatitis is an atypical imaging subtype of acute pancreatitis involving only the pancreatic body and tail, the head being spared. If no cause is identified, suspicion of a small imaging-occult cancer may be warranted. OBJECTIVE. The purpose of this study was to determine the frequency of subsequently diagnosed pancreatic cancer in patients with unexplained acute distal pancreatitis and to compare this frequency to that found in patients with unexplained nondistal pancreatitis. METHODS. This retrospective study included patients who underwent contrast-enhanced CT between January 1, 2019, and December 31, 2020, that showed acute pancreatitis without identifiable explanation. Studies were classified as showing distal or nondistal acute pancreatitis on the basis of consensus. The Fisher exact test was used to compare the frequency of subsequent histologic diagnosis of pancreatic cancer between groups. Negative classification required 6 or more months of imaging follow-up and/or 12 or more months of clinical follow-up. Interreader agreement among seven readers of varying experience was assessed by Fleiss kappa. RESULTS. Among 215 patients with acute pancreatitis, 116 (54%) had no identifiable explanation and formed the study sample. A total of 100 of 116 (86%) patients (59 men, 41 women; mean age, 57 ± 18 [SD] years) had nondistal acute pancreatitis; 16 of 116 (14%) patients (10 men, six women; mean age, 66 ± 14 years) had distal acute pancreatitis. Among patients with nondistal pancreatitis, none were subsequently diagnosed with pancreatic cancer; 62 had sufficient follow-up (median, 2.5 years) to be classified as having negative follow-up for pancreatic cancer. Among patients with distal pancreatitis, nine were subsequently diagnosed with pancreatic cancer (median interval to suspected cancer on subsequent CT, 174 days); five had sufficient follow-up (median, 3.1 years) to be classified as having negative follow-up for pancreatic cancer. The frequency of pancreatic cancer was higher (p < .001) in patients with distal pancreatitis (9/14 [64%; 95% CI, 35-87%]) than in with those with nondistal pancreatitis (0/62 [0%; 95% CI, 0-6%]). Interreader agreement on classification of distal versus nondistal pancreatitis was almost perfect (κ = 0.81). CONCLUSION. Distal pancreatitis without identifiable cause on CT is an uncommon but unique imaging subtype of acute pancreatitis that is associated with a high frequency of pancreatic cancer. CLINICAL IMPACT. In patients with acute distal pancreatitis without identifiable cause, endoscopic ultrasound-guided biopsy should be considered to evaluate for an underlying small cancer.

BACKGROUND AND PURPOSE: Medical errors can result in significant morbidity and mortality. The goal of our study is to evaluate correlation between shift volume and errors made by attending neuroradiologists at an academic medical center, using a large data set.

MATERIALS AND METHODS: CT and MRI reports from our Neuroradiology Quality Assurance database (years 2014 - 2020) were searched for attending physician errors. Data were collected on shift volume, category of missed findings, error type, interpretation setting, exam type, clinical significance.

RESULTS: 654 reports contained diagnostic error. There was a significant difference between mean volume of interpreted studies on shifts when an error was made compared with shifts in which no error was documented (46.58 (SD=22.37) vs 34.09 (SD=18.60), p<0.00001); and between shifts when perceptual error was made compared with shifts when interpretive errors were made (49.50 (SD=21.9) vs 43.26 (SD=21.75), p=0.0094). 59.6% of errors occurred in the emergency/inpatient setting, 84% were perceptual and 91.1% clinically significant. Categorical distribution of errors was: vascular 25.8%, brain 23.4%, skull base 13.8%, spine 12.4%, head/neck 11.3%, fractures 10.2%, other 3.1%. Errors were detected most often on brain MRI (25.4%), head CT (18.7%), head/neck CTA (13.8%), spine MRI (13.7%).

CONCLUSION: Errors were associated with higher volume shifts, were primarily perceptual and clinically significant. We need National guidelines establishing a range of what is a safe number of interpreted cross-sectional studies per day.

Currently, many prostate cancer patients, detected through the prostate specific antigen test, harbor organ-confined indolent disease that cannot be differentiated from aggressive cancer according to clinically and pathologically known measures. Spermine has been considered as an endogenous inhibitor for prostate-confined cancer growth and its expression has shown correlation with prostate cancer growth rates. If established clinically, measurements of spermine bio-synthesis rates in prostates may predict prostate cancer growth and patient outcomes. Using rat models, we tested the feasibility of quantifying spermine bio-synthesis rates with 13 C NMR. Male Copenhagen rats (10 weeks, n = 6) were injected with uniformly 13 C-labeled L-ornithine HCl, and were sacrificed in pairs at 10, 30, and 60 min after injection. Another two rats were injected with saline and sacrificed at 30 min as controls. Prostates were harvested and extracted with perchloric acid and the neutralized solutions were examined by 13 C NMR at 600 MHz. 13 C NMR revealed measurable ornithine, as well as putrescine-spermidine-spermine syntheses in rat prostates, allowing polyamine bio-synthetic and ornithine bio-catabolic rates to be calculated. Our study demonstrated the feasibility of 13 C NMR for measuring bio-synthesis rates of ornithine to spermine enzymatic reactions in rat prostates. The current study established a foundation upon which future investigations of protocols that differentiate prostate cancer growth rates according to the measure of ornithine to spermine bio-synthetic rates may be developed.

Chiari malformation Type I (CMI) is known to have an altered biomechanical environment for the brainstem and cerebellum; however, it is unclear whether these altered biomechanics play a role in the development of CMI symptoms. We hypothesized that CMI subjects have a higher cardiac-induced strain in specific neurological tracts pertaining to balance, and postural control. We measured displacement over the cardiac cycle using displacement encoding with stimulated echoes magnetic resonance imaging in the cerebellum, brainstem, and spinal cord in 37 CMI subjects and 25 controls. Based on these measurements, we computed strain, translation, and rotation in tracts related to balance. The global strain on all tracts was small (<1%) for CMI subject and controls. Strain was found to be nearly doubled in three tracts for CMI subjects compared to controls (p < 0.03). The maximum translation and rotation were ∼150 μm and ∼1 deg, respectively and 1.5-2 times greater in CMI compared to controls in four tracts (p < 0.005). There was no significant difference between strain, translation, and rotation on the analyzed tracts in CMI subjects with imbalance compared to those without imbalance. A moderate correlation was found between cerebellar tonsillar position and strain on three tracts. The lack of statistically significant difference between strain in CMI subjects with and without imbalance could imply that the magnitude of the observed cardiac-induced strain was too small to cause substantial damage to the tissue (<1%). Activities such as coughing, or Valsalva may produce a greater strain.

Recurrent hormone receptor-positive (HR+) breast cancer kills more than 600,000 women annually. Although HR+ breast cancers typically respond well to therapies, approximately 30% of patients relapse. At this stage, the tumors are usually metastatic and incurable. Resistance to therapy, particularly endocrine therapy is typically thought to be tumor intrinsic (e.g., estrogen receptor mutations). However, tumor-extrinsic factors also contribute to resistance. For example, stromal cells, such as cancer-associated fibroblasts (CAFs), residing in the tumor microenvironment, are known to stimulate resistance and disease recurrence. Recurrence in HR+ disease has been difficult to study due to the prolonged clinical course, complex nature of resistance, and lack of appropriate model systems. Existing HR+ models are limited to HR+ cell lines, a few HR+ organoid models, and xenograft models that all lack components of the human stroma. Therefore, there is an urgent need for more clinically relevant models to study the complex nature of recurrent HR+ breast cancer, and the factors contributing to treatment relapse. Here, we present an optimized protocol that allows a high take-rate, and simultaneous propagation of patient-derived organoids (PDOs) and matching CAFs, from primary and metastatic HR+ breast cancers. Our protocol allows for long-term culturing of HR+ PDOs that retain estrogen receptor expression and show responsiveness to hormone therapy. We further show the functional utility of this system by identifying CAF-secreted cytokines, such as growth-regulated oncogene α , as stroma-derived resistance drivers to endocrine therapy in HR+ PDOs.

OBJECTIVES: To determine the factors that affect successful ultrasound-guided biopsy of liver lesions and build a model predicting feasibility of US-guided liver biopsy.

METHODS: This is IRB-approved HIPAA-compliant retrospective review of consecutive ultrasound-guided targeted liver biopsies performed or attempted between 1/2018 and 9/2020 at a single tertiary academic institution with a total of 501 patients included. Mann-Whitney and chi-square tests were used to compare continuous and categorical variables, respectively. Logistic regression model was built to predict feasibility of successful ultrasound-guided biopsy.

RESULTS: Liver lesion biopsy was successfully performed with US guidance in 429/501 (86%) patients. Lesions not amenable for US biopsy were smaller (median size 1.6 cm vs 3.3 cm, p < 0.0001) and deeper within the liver (median depth 9.0 cm vs 5.8 cm, p < 0.0001). The technical success rate was lowest for lesions in segment II (40/53, 75%), while lesions in segment IVb (87/91, 96%) had highest success rate (p < 0.003). US targeting in patients with 1 or 2 lesions was less feasible than in patients with 3 or more lesions, 126/180 (70%) vs. 303/321 (94%), (p < 0.0001). Model including lesion size, depth, location, and number of lesions predicts feasibility of US-guided biopsy with Area under the ROC curve (AUC) = 0.92.

CONCLUSIONS: Linear logistic regression model that includes lesion size, depth and location, and number of lesions is highly successful in predicting feasibility of ultrasound-guided biopsy for liver lesions. Smaller lesions, deeper lesions, and lesions in segment II and VIII in patients with less than 3 lesions were less feasible for ultrasound-guided biopsy of liver lesions.