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Fernandez-Bussy S, Yu Lee-Mateus A, Reisenauer J, Balasubramanian P, Barrios-Ruiz A, Garza-Salas A, Chandra NC, Koratala A, Nadrous A, Edell ES, Bowman AW, Grage RA, Reisenauer CJ, Kurup AN, Patel NM, Chadha R, Hazelett BN, Abia-Trujillo D. Shape-Sensing Robotic-Assisted Bronchoscopy versus Computed Tomography-Guided Transthoracic Biopsy for the Evaluation of Subsolid Pulmonary Nodules. Respiration 2024; 103:280-288. [PMID: 38471496 DOI: 10.1159/000538132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
INTRODUCTION Lung cancer remains the leading cause of cancer death worldwide. Subsolid nodules (SSN), including ground-glass nodules (GGNs) and part-solid nodules (PSNs), are slow-growing but have a higher risk for malignancy. Therefore, timely diagnosis is imperative. Shape-sensing robotic-assisted bronchoscopy (ssRAB) has emerged as reliable diagnostic procedure, but data on SSN and how ssRAB compares to other diagnostic interventions such as CT-guided transthoracic biopsy (CTTB) are scarce. In this study, we compared diagnostic yield of ssRAB versus CTTB for evaluating SSN. METHODS A retrospective study of consecutive patients who underwent either ssRAB or CTTB for evaluating GGN and PSN with a solid component less than 6 mm from February 2020 to April 2023 at Mayo Clinic Florida and Rochester. Clinicodemographic information, nodule characteristics, diagnostic yield, and complications were compared between ssRAB and CTTB. RESULTS A total of 66 nodules from 65 patients were evaluated: 37 PSN and 29 GGN. Median size of PSN solid component was 5 mm (IQR: 4.5, 6). Patients were divided into two groups: 27 in the ssRAB group and 38 in the CTTB group. Diagnostic yield was 85.7% for ssRAB and 89.5% for CTTB (p = 0.646). Sensitivity for malignancy was similar between ssRAB and CTTB (86.4% vs. 88.5%; p = 0.828), with no statistical difference. Complications were more frequent in CTTB with no significant difference (8 vs. 2; p = 0.135). CONCLUSION Diagnostic yield for SSN was similarly high for ssRAB and CTTB, with ssRAB presenting less complications and allowing mediastinal staging within the same procedure.
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Affiliation(s)
| | | | - Janani Reisenauer
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Alanna Barrios-Ruiz
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Ana Garza-Salas
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Nikitha C Chandra
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Anoop Koratala
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Anthony Nadrous
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Eric S Edell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew W Bowman
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Rolf A Grage
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Anil N Kurup
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Neal M Patel
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan Chadha
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Britney N Hazelett
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Bowman AW. Editorial Comment: When Will Coronary Artery Stent Imaging Be Ready for Prime Time? AJR Am J Roentgenol 2023; 221:610. [PMID: 37404087 DOI: 10.2214/ajr.23.29857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
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Bolan CW, Stauffer J, LeGout JD, Caserta M, Lockwood A, Bowman AW. A narrative review of imaging for pancreas adenocarcinoma: staging, surgical considerations, and surveillance. J Gastrointest Oncol 2023; 14:2260-2272. [PMID: 37969828 PMCID: PMC10643588 DOI: 10.21037/jgo-22-1044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 08/30/2023] [Indexed: 11/17/2023] Open
Abstract
Background and Objective Pancreas adenocarcinoma is a disease with dire prognosis. Imaging is pivotal to the diagnosis, staging, reassessment, surgical planning, and surveillance of pancreas cancer. The purpose of this paper is to provide the reader an overview of current imaging practices for pancreas adenocarcinoma. Methods A literature search of original papers and reviews through 2022 was performed using the PubMed database. The most current American College of Radiology Appropriateness Criteria and National Comprehensive Cancer Network guidelines on pancreas cancer imaging were also included. Key Content and Findings Multidisciplinary team care at a high-volume institution is instrumental to optimal patient management and outcomes. It is therefore important for all team members to be aware of imaging modality options, strengths, and challenges. Additionally, a high-level understanding of imaging findings is useful clinically. This manuscript provides a current overview of imaging modalities used in the identification and assessment of pancreas adenocarcinoma, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography. Imaging findings, including the expected and unexpected, are reviewed to give the novice imager a better understanding. Conclusions This review provides a current overview of imaging for pancreas adenocarcinoma, including strengths and weakness of various imaging modalities; therefore, providing the reader with a robust resource when considering imaging in the management of this disease.
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Affiliation(s)
| | - John Stauffer
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Amy Lockwood
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
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Elboraey MA, Overfield C, Taylor SR, Bowen SN, Bhatt S, Garner HW, Bowman AW, Bhatt AA. Preference Signaling for the Diagnostic Radiology Match: A Single Institution Experience. Curr Probl Diagn Radiol 2023; 52:334-335. [PMID: 37142486 DOI: 10.1067/j.cpradiol.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/13/2023] [Accepted: 04/13/2023] [Indexed: 05/06/2023]
Abstract
The Association of American Medical Colleges announced the addition of preference signaling to the 2022-2023 residency match cycle for Diagnostic and Interventional Radiology. This new offering provided applicants the option to indicate their specific interest in up to 6 residency programs during initial application submission. Our institutional diagnostic radiology residency program received a total of 1294 applications. One hundred and eight applicants signaled the program. Interview invitations were sent to 104 applicants, 23 of which signaled the program. Out of the top 10 ranked applicants, 6 applicants signaled the program. Out of the 5 matched applicants, 80% used the program signal, and 100% did the geographic preference. Opting to signal programs during the initial application submission may be beneficial for both the applicants and the programs in finding the optimal match.
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Affiliation(s)
| | | | | | | | - Shweta Bhatt
- Department of Radiology, Mayo Clinic, Jacksonville, FL
| | | | | | - Alok A Bhatt
- Department of Radiology, Mayo Clinic, Jacksonville, FL.
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Alexander LF, McComb BL, Bowman AW, Bonnett SL, Ghazanfari SM, Caserta MP. Ultrasound Simulation Training for Radiology Residents-Curriculum Design and Implementation. J Ultrasound Med 2023; 42:777-790. [PMID: 36106721 DOI: 10.1002/jum.16098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/16/2022] [Accepted: 08/21/2022] [Indexed: 06/15/2023]
Abstract
Medical simulation training can be used to improve clinician performance, teach communication and professionalism skills, and enhance team training. Radiology residents can benefit from simulation training in diagnostic ultrasound, procedural ultrasound, and communication skills prior to direct patient care experiences. This paper details a weeklong ultrasound simulation training curriculum for radiology residents during the PGY-1 clinical internship. The organization of established teaching methods into a dedicated course early in radiology residency training with the benefit of a multi-disciplinary approach makes this method unique. This framework can be adapted to fit learners at different skill levels or with specific procedural needs.
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Affiliation(s)
- Lauren F Alexander
- Department of Radiology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Barbara L McComb
- Department of Radiology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Andrew W Bowman
- Division Chair of Hospital & Emergency Imaging | Department of Radiology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | | | | | - Melanie P Caserta
- Division Chair of Sonography | Department of Radiology, Mayo Clinic Florida, Jacksonville, Florida, USA
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Yu Lee-Mateus A, Reisenauer J, Garcia-Saucedo JC, Abia-Trujillo D, Buckarma EH, Edell ES, Grage RA, Bowman AW, Labarca G, Johnson MM, Patel NM, Fernandez-Bussy S. Robotic-assisted bronchoscopy versus CT-guided transthoracic biopsy for diagnosis of pulmonary nodules. Respirology 2023; 28:66-73. [PMID: 36104312 DOI: 10.1111/resp.14368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/18/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVE Currently, computed tomography-guided transthoracic biopsy (CTTB) is the most accurate diagnostic approach for pulmonary nodules suspected of malignancy. Traditional bronchoscopy has shown suboptimal diagnostic sensitivity, but the emergence of robotic-assisted bronchoscopy (RAB) has the potential to improve diagnostic accuracy, maximize diagnostic yield and complete mediastinal and hilar staging in a single procedure. We aim to assess the efficacy and diagnostic performance of RAB compared to CTTB for diagnosing pulmonary nodules suspected of lung cancer. METHODS A multicenter retrospective review of consecutive patients who underwent RAB and CTTB for evaluating pulmonary nodules from January 2019 to March 2021 at Mayo Clinic Florida and Mayo Clinic Rochester, United States. Clinical and demographic information, nodule characteristics, outcomes and complications were compared between RAB and CTTB. RESULTS A total of 225 patients were included: 113 in the RAB group and 112 in the CTTB group. Overall diagnostic yield was 87.6% for RAB and 88.4% for CTTB. For malignant disease, RAB had a sensitivity of 82.1% and a specificity of 100%, CTTB had a sensitivity of 88.5% and a specificity of 100%. Complication rate was significantly higher for CTTB compared to RAB (17% vs. 4.4%; p = 0.002). CONCLUSION RAB, when available, can be as accurate as CTTB for sampling pulmonary nodules with similar or reduced complications and should be considered as a means for nodule biopsy, particularly when mediastinal staging is also clinically warranted.
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Affiliation(s)
| | - Janani Reisenauer
- Department of Pulmonary Medicine and Thoracic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan C Garcia-Saucedo
- Internal Medicine Resident, Department of Internal Medicine, Morristown Medical Center, Morristown, New Jersey, USA
| | - David Abia-Trujillo
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Eric S Edell
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rolf A Grage
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Andrew W Bowman
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Gonzalo Labarca
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret M Johnson
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Neal M Patel
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Ramírez Pedraza N, Pérez Segovia AH, Garay Mora JA, Techawatanaset K, Bowman AW, Cruz Marmolejo MA, Chapa Ibargüengoitia M, Arizaga Ramírez S, Arizaga Ramírez MR. Perianal Fistula and Abscess: An Imaging Guide for Beginners. Radiographics 2022; 42:E208-E209. [PMID: 36083806 DOI: 10.1148/rg.210142] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Natalia Ramírez Pedraza
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico 14080 (N.R.P., A.H.P.S., J.A.G.M., M.C.I., S.A.R., M.R.A.R.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (K.T.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (A.W.B.); and Department of Radiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.A.C.M.)
| | - Aarón Horeb Pérez Segovia
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico 14080 (N.R.P., A.H.P.S., J.A.G.M., M.C.I., S.A.R., M.R.A.R.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (K.T.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (A.W.B.); and Department of Radiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.A.C.M.)
| | - Juan Alberto Garay Mora
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico 14080 (N.R.P., A.H.P.S., J.A.G.M., M.C.I., S.A.R., M.R.A.R.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (K.T.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (A.W.B.); and Department of Radiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.A.C.M.)
| | - Kurt Techawatanaset
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico 14080 (N.R.P., A.H.P.S., J.A.G.M., M.C.I., S.A.R., M.R.A.R.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (K.T.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (A.W.B.); and Department of Radiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.A.C.M.)
| | - Andrew W Bowman
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico 14080 (N.R.P., A.H.P.S., J.A.G.M., M.C.I., S.A.R., M.R.A.R.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (K.T.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (A.W.B.); and Department of Radiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.A.C.M.)
| | - Miguel Angel Cruz Marmolejo
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico 14080 (N.R.P., A.H.P.S., J.A.G.M., M.C.I., S.A.R., M.R.A.R.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (K.T.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (A.W.B.); and Department of Radiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.A.C.M.)
| | - Mónica Chapa Ibargüengoitia
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico 14080 (N.R.P., A.H.P.S., J.A.G.M., M.C.I., S.A.R., M.R.A.R.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (K.T.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (A.W.B.); and Department of Radiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.A.C.M.)
| | - Sofía Arizaga Ramírez
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico 14080 (N.R.P., A.H.P.S., J.A.G.M., M.C.I., S.A.R., M.R.A.R.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (K.T.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (A.W.B.); and Department of Radiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.A.C.M.)
| | - María Rebeca Arizaga Ramírez
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico 14080 (N.R.P., A.H.P.S., J.A.G.M., M.C.I., S.A.R., M.R.A.R.); Department of Radiology, Medical College of Wisconsin, Milwaukee, Wis (K.T.); Department of Radiology, Mayo Clinic, Jacksonville, Fla (A.W.B.); and Department of Radiology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico (M.A.C.M.)
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Wildman-Tobriner B, Ho LM, Bowman AW. Needle types used in abdominal cross-sectional interventional radiology: a survey of the Society of Abdominal Radiology emerging technology commission. Abdom Radiol (NY) 2022; 47:2623-2631. [PMID: 34128102 DOI: 10.1007/s00261-021-03145-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/11/2021] [Accepted: 05/22/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE To identify commonly used needle types in cross-sectional interventional radiology (CSIR) and to review features and safety profiles of those needles. METHODS Members of the Society of Abdominal Radiology (SAR) emerging technologies commission (ETC) on CSIR were sent a 13-question survey about what needles they use for common CSIR procedures: random and targeted solid organ biopsy, ultrasound-guided paracentesis, and ultrasound-guided thyroid fine needle aspiration (FNA). Results were compiled with descriptive statistics, and features of the most commonly used needles were reviewed. RESULTS 19 surveys were completed (response rate 57.6%, 19/33) from 16 institutions. For solid organ biopsies, the majority of respondents reported using an 18-gauge needle with an automatic firing mechanism and a variable throw length option. The most commonly used needle for both random and targeted biopsies was the Argon BioPince (26.3%, 5/19) The three most commonly used needles for solid organ biopsies all featured automatic firing, variable throw length options, and 18-gauge size. A 5 French Cook Yueh needle was most the most commonly used paracentesis needle (36.8%, 7/19). For thyroid FNA, all respondents used spinal needles, and 25-gauge was the most common size (72.2%, 13/18). CONCLUSION Abdominal radiologists use a variety of needles when performing common interventional procedures. Members of the SAR CSIR ETC commonly use automatic, 18-gauge, variable throw length needles for solid organ biopsies, 5 French catheter style needles for paracentesis, and 25-gauge spinal needles for thyroid FNA.
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Affiliation(s)
| | - Lisa M Ho
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
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Cortés P, Ghoz HM, Stancampiano F, Omer M, Malviya B, Bowman AW, Palmer WC. Incidentalomas are associated with an increase in liver transplantation in patients with cirrhosis: a single-center retrospective study. BMC Gastroenterol 2022; 22:336. [PMID: 35818022 PMCID: PMC9275240 DOI: 10.1186/s12876-022-02379-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 06/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background Incidentalomas, defined as incidental findings on imaging, are a growing concern. Our aim was to determine the impact and outcomes of extrahepatic incidentalomas on liver transplantation.
Methods Patients at a large liver transplant center, who had an initial MRI for hepatocellular carcinoma screening between January 2004 and March 2020 were identified. Clinical data were collected retrospectively. Survival analysis, utilizing Kaplan Meier estimates and Cox proportional hazards regression analysis, was utilized to determine factors associated with liver transplantation. Results 720 patients were included. NASH (24.9%), HCV (22.1%) and alcohol (20.6%) were the most common causes of cirrhosis. 79.7% of patients had an extrahepatic incidentaloma. Older age and having received a liver transplant by the end of the study were associated with an incidentaloma. MELD was not associated with the presence of an incidentaloma. On univariate Cox proportional hazards regression, male sex, history of moderate alcohol use, smoking history, MELD, and incidentalomas were predictors of liver transplantation. On multivariate analysis, only MELD and the presence of an incidentaloma were found to be significant. Discovery of an incidentaloma was associated with a 30% increase in the risk of liver transplantation. Median time to transplantation did not differ based on the presence on an incidentaloma. Patients with cirrhosis from alcohol or HCV had a significantly shorter median time to transplantation than those with NASH. Renal and pancreatic lesions comprised 91% of all incidentalomas. Conclusions In this single-center retrospective study, extrahepatic incidentalomas were common in patients with cirrhosis. The finding of an incidentaloma was associated with a higher risk of liver transplantation despite a similar median time to transplantation if no incidentaloma was discovered.
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Affiliation(s)
- Pedro Cortés
- Division of Community Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, 32224, USA
| | - Hassan M Ghoz
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Fernando Stancampiano
- Division of Community Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, 32224, USA
| | - Mohamed Omer
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Balkishan Malviya
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Andrew W Bowman
- Division of Hospital and Emergency Radiology, Mayo Clinic Florida, Jacksonville, FL, 32224, USA
| | - William C Palmer
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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LeGout JD, Bolan CW, Bowman AW, Caserta MP, Chen FK, Cox KL, Sanyal R, Toskich BB, Lewis JT, Alexander LF. Focal Nodular Hyperplasia and Focal Nodular Hyperplasia-like Lesions. Radiographics 2022; 42:1043-1061. [PMID: 35687520 DOI: 10.1148/rg.210156] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Focal nodular hyperplasia (FNH) is a benign lesion occurring in a background of normal liver. FNH is seen most commonly in young women and can often be accurately diagnosed at imaging, including CT, MRI, or contrast-enhanced US. In the normal liver, FNH frequently must be differentiated from hepatocellular adenoma, which although benign, is managed differently because of the risks of hemorrhage and malignant transformation. When lesions that are histologically identical to FNH occur in a background of abnormal liver, they are termed FNH-like lesions. These lesions can be a source of diagnostic confusion and must be differentiated from malignancies. Radiologists' familiarity with the imaging appearance of FNH-like lesions and knowledge of the conditions that predispose a patient to their formation are critical to minimizing the risks of unnecessary intervention for these lesions, which are rarely symptomatic and carry no risk for malignant transformation. FNH is thought to form secondary to an underlying vascular disturbance, a theory supported by the predilection for formation of FNH-like lesions in patients with a variety of hepatic vascular abnormalities. These include abnormalities of hepatic outflow such as Budd-Chiari syndrome, abnormalities of hepatic inflow such as congenital absence of the portal vein, and hepatic microvascular disturbances, such as those that occur after exposure to certain chemotherapeutic agents. Familiarity with the imaging appearances of these varied conditions and knowledge of their association with formation of FNH-like lesions allow radiologists to identify with confidence these benign lesions that require no intervention. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Jordan D LeGout
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Candice W Bolan
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Andrew W Bowman
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Melanie P Caserta
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Frank K Chen
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Kelly L Cox
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Rupan Sanyal
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Beau B Toskich
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Jason T Lewis
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Lauren F Alexander
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
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Flug JA, Stellmaker JA, Sharpe RE, Jokerst CE, Tollefson CD, Bowman AW, Nordland M, Hannafin CL, Froemming AT. Kaizen Process Improvement in Radiology: Primer for Creating a Culture of Continuous Quality Improvement. Radiographics 2022; 42:919-928. [PMID: 35333633 DOI: 10.1148/rg.210086] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Kaizen process improvement is an element of lean production that is an approach to creating continuous improvement. Kaizen is based on the idea that small ongoing positive changes in workflow and elimination of waste can yield major improvements over time. A focused Kaizen event, or rapid process improvement event, can lead to sustainable process improvement in health care settings that are resistant to change. This approach has been proven to be successful in health care. These events are led by a trained facilitator and coach who provides appropriate team education and engagement. To ensure success, the team must embrace the Kaizen culture, which emphasizes the development of a "learning organization" that is focused on relentless pursuit of perfection. The culture empowers all staff to improve the work they perform, with an emphasis on the process and not the individual. Respect for individual people is key in Kaizen. In radiology, this method has been successful in empowering frontline staff to improve their individual workflows. A 5-day Kaizen event has been successful in increasing on-time starts, decreasing lead time, increasing patient and staff satisfaction, and ensuring sustainability. Sustainable success can occur when the team stays true to lean principles, engages leaders, and empowers team members with the use of timely data to drive decision making. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Jonathan A Flug
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Jessica A Stellmaker
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Richard E Sharpe
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Clinton E Jokerst
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Chris D Tollefson
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Andrew W Bowman
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Michelle Nordland
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Cathy L Hannafin
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
| | - Adam T Froemming
- From the Departments of Radiology of Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054 (J.A.F., R.E.S., C.E.J., C.D.T., C.L.H.); Mayo Clinic Rochester, Rochester, Minn (J.A.S., M.N., A.T.F.); and Mayo Clinic Florida, Jacksonville, Fla (A.W.B.)
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12
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Bowman AW, Tan N, Adamo DA, Chen F, Venkatesh SK, Baumgarten DA. Implementation of peer learning conferences throughout a multi-site abdominal radiology practice. Abdom Radiol (NY) 2021; 46:5489-5499. [PMID: 33999282 DOI: 10.1007/s00261-021-03114-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/25/2021] [Accepted: 04/30/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To initiate a peer learning conference for our abdominal radiology division across multiple geographically separated sites and different time zones, and to determine radiologist preference for peer learning versus traditional score-based peer review. METHODS We implemented a monthly peer learning videoconference for our abdominal radiology division. Surveys regarding radiologist opinion regarding traditional peer review and the new peer learning conferences were conducted before and after 6 months of conferences. RESULTS Peer learning conferences were well attended across our multiple sites, with an average of 43 participants per conference. Radiologist opinion regarding peer review was poor, with survey radiologists responding positively to only 1 out of 12 process questions. Opinion regarding peer learning was extremely favorable, with radiologists responding positively to 12 out of the same 12 process questions. After 6 months of peer learning conferences, 87.9% of surveyed radiologists wished to continue them in some fashion, and no one preferred to return to score-based peer review alone. CONCLUSION We successfully implemented a peer learning conference for our abdominal radiology division spread out over multiple geographic sites. Our radiologists strongly preferred peer learning conferences over our traditional peer review system for quality control.
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Affiliation(s)
- Andrew W Bowman
- Department of Radiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
| | - Nelly Tan
- Department of Radiology, Mayo Clinic, 5777 Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Daniel A Adamo
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Frederick Chen
- Department of Radiology, Mayo Clinic, 5777 Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Sudhakar K Venkatesh
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Deborah A Baumgarten
- Department of Radiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
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13
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Bhatt AA, Garner HW, Bowman AW, Bhatt S. Resident Scholarly Activity for Diagnostic Radiology Residency - A Point System Approach. Curr Probl Diagn Radiol 2021; 51:301-303. [PMID: 34865959 DOI: 10.1067/j.cpradiol.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/19/2021] [Accepted: 09/19/2021] [Indexed: 11/22/2022]
Abstract
Scholarly activity is an important aspect of diagnostic radiology residency training, however, there is no clear standard for what is expected and deemed appropriate for scholarly activity. This article discusses the rationale and development of a point system approach for resident scholarly activity at our diagnostic radiology residency program.
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Affiliation(s)
- Alok A Bhatt
- Department of Radiology, Mayo Clinic, Jacksonville, FL.
| | | | | | - Shweta Bhatt
- Department of Radiology, Mayo Clinic, Jacksonville, FL
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14
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Bowman AW, DiSantis DJ, Frey RT. Esophagopericardial Fistula Causing Pyopneumopericardium. Radiol Cardiothorac Imaging 2020; 2:e200417. [PMID: 33778644 DOI: 10.1148/ryct.2020200417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/23/2020] [Accepted: 10/22/2020] [Indexed: 11/11/2022]
Abstract
An esophagopericardial fistula is a rare complication of esophageal malignancy, trauma, or surgery. Imaging is a cornerstone of diagnosis, with detection of pneumopericardium or hydropneumopericardium at imaging raising suspicion for pyopneumopericardium and prompting immediate search for the causative pathologic process. Given the high associated mortality rate of over 50% for patients with esophagopericardial fistulas, early diagnosis and intervention are vital. Supplemental material is available for this article. © RSNA, 2020.
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Affiliation(s)
- Andrew W Bowman
- Department of Radiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - David J DiSantis
- Department of Radiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - R Terrell Frey
- Department of Radiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224
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15
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LeGout JD, Bailey RE, Bolan CW, Bowman AW, Chen F, Cernigliaro JG, Alexander LF. Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion. Radiographics 2020; 40:2098-2116. [PMID: 33064623 DOI: 10.1148/rg.2020200047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A broad range of abdominal and pelvic tumors can manifest with or develop intraluminal venous invasion. Imaging features at cross-sectional modalities and contrast-enhanced US that allow differentiation of tumor extension within veins from bland thrombus include the expansile nature of tumor thrombus and attenuation and enhancement similar to those of the primary tumor. Venous invasion is a distinctive feature of hepatocellular carcinoma and renal cell carcinoma with known prognostic and treatment implications; however, this finding remains an underrecognized characteristic of multiple other malignancies-including cholangiocarcinoma, adrenocortical carcinoma, pancreatic neuroendocrine tumor, and primary venous leiomyosarcoma-and can be a feature of benign tumors such as renal angiomyolipoma and uterine leiomyomatosis. Recognition of tumor venous invasion at imaging has clinical significance and management implications for a range of abdominal and pelvic tumors. For example, portal vein invasion is a strong negative prognostic indicator in patients with hepatocellular carcinoma. In patients with rectal cancer, diagnosis of extramural venous invasion helps predict local and distant recurrence and is associated with worse survival. The authors present venous invasion by vascular distribution and organ of primary tumor origin with review of typical imaging features. Common pitfalls and mimics of neoplastic thrombus, including artifacts and anatomic variants, are described to help differentiate these findings from tumor in vein. By accurately diagnosing tumor venous invasion, especially in tumors where its presence may not be a typical feature, radiologists can help referring clinicians develop the best treatment strategies for their patients. ©RSNA, 2020.
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Affiliation(s)
- Jordan D LeGout
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Ryan E Bailey
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Candice W Bolan
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Andrew W Bowman
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Frank Chen
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Joseph G Cernigliaro
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Lauren F Alexander
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
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16
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Caserta MP, Bonnett SL, La Valley MC, De Meo S, Bowman AW. Ultrasound Practice Redesign to Improve Image Quality: Implementation of a Quality Control Sonographer. J Am Coll Radiol 2020; 17:1644-1652. [PMID: 32771494 DOI: 10.1016/j.jacr.2020.07.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/09/2020] [Accepted: 07/11/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE The aim of this study was to systematically improve ultrasound image quality via the implementation of a quality control (QC) sonographer. METHODS The position of a QC sonographer was created, whose responsibility was to preview ultrasound examinations performed by other sonographers and audit ultrasound examinations for image quality and protocol adherence. Retrospective audits of examinations performed before and after the implementation of the QC sonographer position were performed. Examinations from 17 sonographers were audited (16 examinations per sonographer), with a sample size of 272 examinations per audit. The QC sonographer graded the following imaging quality parameters (IQPs) as acceptable or needing improvement: gain, depth, color Doppler, spectral Doppler, and protocol adherence. Statistical comparisons were performed by a biostatistician using a χ2 test, with P < .05 used as the threshold for significance. RESULTS The baseline audit (September 1, 2015 to November 30, 2015) revealed 439 instances of IQPs that required improvement. A second audit after establishing the QC sonographer role (August 1, 2016 to October 31, 2016) found 176 instances of IQPs that required improvement. A third, follow-up audit (May 1, 2018 to September 30, 2018) found 172 instances of IQPs that required improvement. CONCLUSIONS Removing a sonographer from the clinical line to work as a QC sonographer resulted in a 60% decrease in parameter errors that was maintained over time. Another benefit of the QC sonographer role is improved sonographer education.
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Affiliation(s)
- Melanie P Caserta
- Division Chair of Ultrasonography, Mayo Clinic, Jacksonville, Florida.
| | | | | | | | - Andrew W Bowman
- Division Chair of Hospital and Emergency Radiology, Mayo Clinic, Jacksonville, Florida
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17
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Lewis JI, Patel NJ, Williams EA, Bowman AW. Prophylactic Intravenous Access: Is It Necessary for Renal Transplant Biopsies? Curr Probl Diagn Radiol 2019; 50:156-158. [PMID: 31611010 DOI: 10.1067/j.cpradiol.2019.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Percutaneous renal transplant biopsies have long been a safe and effective procedure with bleeding being the most common significant complication. Only a few studies, however, have addressed the need for intravenous access prior to the procedure. OBJECTIVES We postulate that the number of patients requiring intravenous resuscitation after a routine renal transplant biopsy is sufficiently low enough to prove that eliminating pre-procedural peripheral IV placement will have no negative impact on patient safety and could improve departmental efficiency. METHODS This is a retrospective analysis of complications that occurred in patients who underwent routine percutaneous renal transplant biopsies at an academic center. Patients were divided into two groups: the IV cohort that had peripheral IV access placed before the procedure (n=1318) and the no-IV cohort that did not (n=492). RESULTS This is a retrospective analysis of complications that occurred in patients who underwent routine percutaneous renal transplant biopsies at an academic center. Patients were divided into two groups: the IV cohort that had peripheral IV access placed before the procedure (n=1318) and the no-IV cohort that did not (n=492). CONCLUSIONS Placement of prophylactic peripheral IV access in patients undergoing routine renal transplant biopsies does not significantly impact the rate of biopsy complications.
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Affiliation(s)
- Jacob I Lewis
- Department of Radiology, Mayo Clinic, Jacksonville, FL
| | - Neema J Patel
- Department of Radiology, Mayo Clinic, Jacksonville, FL
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18
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Holliday RM, Jain MK, Accurso JM, Sharma A, Harrison SR, Aloszka DL, Bowman AW. Buffering the Suffering of Breast Lymphoscintigraphy. J Nucl Med Technol 2019; 48:51-53. [PMID: 31182657 DOI: 10.2967/jnmt.119.230011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 06/03/2019] [Indexed: 11/16/2022] Open
Abstract
Breast lymphoscintigraphy with 99mTc-sulfur colloid is frequently performed before breast-conserving surgery to delineate drainage to a sentinel node. Tracer injection for lymphoscintigraphy can be painful. Our aims were to determine whether administering a solution of buffered lidocaine immediately before lymphoscintigraphy injection could both reduce the patients' pain and increase nuclear medicine technologists' satisfaction with performing the procedure. Methods: A pain scale survey was obtained from patients undergoing breast lymphoscintigraphy with or without buffered lidocaine. Our nuclear medicine technologists were also surveyed for their satisfaction with the procedure, both with and without the addition of buffered lidocaine. Results: The patients' reported pain decreased by 86% with the addition of buffered lidocaine. Technologist satisfaction with performing the procedure increased by 36%. Conclusion: Lidocaine buffered with sodium bicarbonate injected before lymphoscintigraphy significantly reduces pain experienced by the patient and improves nuclear medicine technologist satisfaction in performing the procedure.
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Affiliation(s)
- Rex M Holliday
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, Florida; and
| | - Manoj K Jain
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, Florida; and
| | - Joseph M Accurso
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, Florida; and
| | - Akash Sharma
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, Florida; and
| | - Sara R Harrison
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, Florida; and
| | - Debora L Aloszka
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, Florida; and
| | - Andrew W Bowman
- Division of Hospital Radiology, Mayo Clinic, Jacksonville, Florida
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19
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Abstract
Although the small intestine accounts for over 90% of the surface area of the alimentary tract, tumors of the small intestine represent less than 5% of all gastrointestinal tract neoplasms. Common small bowel tumors typically are well evaluated with cross-sectional imaging modalities such as CT and MR, but accurate identification and differentiation can be challenging. Differentiating normal bowel from abnormal tumor depends on imaging modality and the particular technique. While endoscopic evaluation is typically more sensitive for the detection of intraluminal tumors that can be reached, CT and MR, as well as select nuclear medicine studies, remain superior for evaluating extraluminal neoplasms. Understanding the imaging characteristics of typical benign and malignant small bowel tumors is critical, because of overlapping features and associated secondary complications.
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Affiliation(s)
- Eric A Williams
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Andrew W Bowman
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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20
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Ghoz HM, Kröner PT, Stancampiano FF, Bowman AW, Vishnu P, Heckman MG, Diehl NN, McLeod E, Nikpour N, Palmer WC. Hepatic iron overload identified by magnetic resonance imaging-based T2* is a predictor of non-diagnostic elastography. Quant Imaging Med Surg 2019; 9:921-927. [PMID: 31367546 DOI: 10.21037/qims.2019.05.13] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Magnetic resonance elastography (MRE) is a non-invasive test used to assess liver stiffness and fibrosis in chronic liver disease, which includes systemic iron overload. However, iron deposition by itself is associated with technical failure of MRE of the liver which necessitates the use of invasive liver biopsy as an alternative monitoring method for these patients. T2*-weighted magnetic resonance imaging (T2*) is a reliable modality to asses for hepatic as well as total body iron overload. Therefore, we aimed to determine a cutoff value on the T2* reading at which MRE would no longer provide accurate stiffness measurements in patients with iron overload. Methods Ninety-five patients with iron overload who underwent MRE at our institution, between 2010 and 2017 were reviewed retrospectively. We compared T2* values between patients with adequate elastography (N=63) versus those with non-diagnostic elastography (N=32). We additionally examined the ability of T2* to predict the likelihood of non-diagnostic elastography by estimating area under the ROC curve (AUC). Results T2* was significantly different between patients with and without an adequate elastography (P<0.0001) and predicted occurrence of non-diagnostic elastography with an AUC of 0.95. All patients with a non-diagnostic elastography had a T2* value below 20 milliseconds (ms), and correspondingly 55% of the patients with a T2* value below 20 ms had a non-diagnostic elastography. The subgroups of patients with a T2* value ≤10, ≤8, and ≤6 ms, had a higher likelihood of non-diagnostic elastography (87%, 92%, and 95%, respectively). Conclusions T2* can be used to accurately predict which patients are most likely to have a non-diagnostic elastography reading. T2* of 20 ms or lower reflects a higher likelihood of non-diagnostic elastography.
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Affiliation(s)
- Hassan M Ghoz
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Paul T Kröner
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Prakash Vishnu
- Department of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Ethan McLeod
- Clinical Research Internship Study Program (CRISP), Mayo Clinic, Jacksonville, FL, USA
| | - Naveed Nikpour
- Clinical Research Internship Study Program (CRISP), Mayo Clinic, Jacksonville, FL, USA
| | - William C Palmer
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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Abstract
The radiologist's role in the evaluation of pancreatic ductal adenocarcinoma remains critical in the management of this deadly disease. Imaging plays a vital role in the diagnosis and staging of pancreatic cancer. Although CT is more commonly used for staging pancreatic cancer, MR is increasingly playing an important role in this regard. In our institution, all pancreatic malignancies undergo staging with MRI. In this pictoral essay, we illustrate the MR imaging features of pancreatic ductal adenocarcinoma and its mimics, and we also discuss pearls and pitfalls in MR staging of pancreatic carcinoma.
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Affiliation(s)
- Andrew W Bowman
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
| | - Candice W Bolan
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
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22
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McLean MI, Evers L, Bowman AW, Bonte M, Jones WR. Statistical modelling of groundwater contamination monitoring data: A comparison of spatial and spatiotemporal methods. Sci Total Environ 2019; 652:1339-1346. [PMID: 30586819 DOI: 10.1016/j.scitotenv.2018.10.231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/28/2018] [Accepted: 10/16/2018] [Indexed: 06/09/2023]
Abstract
Field monitoring of groundwater contamination plumes is an important component of managing risks for downgradient receptors and remedial strategies that rely on monitored natural attenuation. Collection of groundwater quality data can however take a considerable effort and be associated with high cost. Here, we investigated the relative merits of analyzing groundwater quality data using spatial compared to spatiotemporal statistical modelling and assessed the accuracy of both methods and implications for data collection requirements. The aim of this was to determine whether the quantity of data collected can be reduced, while retaining the same level of estimation accuracy, by analyzing groundwater contamination data using a spatiotemporal model which "borrows strength" across time, rather than a spatial model for individual sampling events. To capture the variability encountered under field conditions, we used three hypothetical groundwater contamination plumes with increasing complexity, and site data for a large groundwater gasoline additive plume. The results show that spatiotemporal methods can increase efficiency markedly so that, in comparison with repeated spatial analysis, spatiotemporal methods can achieve the same level of performance but with smaller sample sizes.
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Affiliation(s)
- M I McLean
- University of Glasgow, School of Mathematics and Statistics, University Place, Glasgow G12 8QQ, United Kingdom of Great Britain and Northern Ireland.
| | - L Evers
- University of Glasgow, School of Mathematics and Statistics, University Place, Glasgow G12 8QQ, United Kingdom of Great Britain and Northern Ireland
| | - A W Bowman
- University of Glasgow, School of Mathematics and Statistics, University Place, Glasgow G12 8QQ, United Kingdom of Great Britain and Northern Ireland
| | - M Bonte
- Shell Global Solutions International B.V., Kessler Park 1, Rijswijk 2288GS, the Netherlands
| | - W R Jones
- Shell Global Solutions, 40 Bank Street, Canary Wharf, London E14 5NR, United Kingdom of Great Britain and Northern Ireland
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23
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Palmer WC, Vishnu P, Sanchez W, Aqel B, Riegert-Johnson D, Seaman LAK, Bowman AW, Rivera CE. Diagnosis and Management of Genetic Iron Overload Disorders. J Gen Intern Med 2018; 33:2230-2236. [PMID: 30225768 PMCID: PMC6258594 DOI: 10.1007/s11606-018-4669-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 05/23/2018] [Accepted: 09/07/2018] [Indexed: 12/12/2022]
Abstract
Iron overload disorders lead to excess iron deposition in the body, which can occur as a result of genetic or secondary causes. Genetic iron overload, referred to as hereditary hemochromatosis, may present as a common autosomal recessive mutation or as one of several uncommon mutations. Secondary iron overload may result from frequent blood transfusions, exogenous iron intake, or certain hematological diseases such as dyserythropoietic syndrome or chronic hemolytic anemia. Iron overload may be asymptomatic, or may present with significant diseases of the liver, heart, endocrine glands, joints, or other organs. If treated appropriately prior to end-organ damage, life expectancy has been shown to be similar compared to matched populations. Alongside clinical assessment, diagnostic studies involve blood tests, imaging, and in some cases liver biopsy. The mainstay of therapy is periodic phlebotomy, although oral chelation is an option for selected patients.
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Affiliation(s)
- William C Palmer
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA.
| | - Prakash Vishnu
- Department of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - William Sanchez
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Bashar Aqel
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Doug Riegert-Johnson
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Candido E Rivera
- Department of Hematology/Oncology, Mayo Clinic, Jacksonville, FL, USA
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Vittert L, Katina S, Ayoub A, Khambay B, Bowman AW. Assessing the outcome of orthognathic surgery by three-dimensional soft tissue analysis. Int J Oral Maxillofac Surg 2018; 47:1587-1595. [PMID: 29933911 PMCID: PMC6234045 DOI: 10.1016/j.ijom.2018.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 04/26/2018] [Accepted: 05/30/2018] [Indexed: 11/28/2022]
Abstract
Studies of orthognathic surgery often focus on pre-surgical versus post-surgical changes in facial shape. In contrast, this study provides an innovative comparison between post-surgical and control shape. Forty orthognathic surgery patients were included, who underwent three different types of surgical correction: Le Fort I maxillary advancement, bilateral sagittal split mandibular advancement, and bimaxillary advancement surgery. Control facial images were captured from volunteers from local communities in Glasgow, with patterns of age, sex, and ethnic background that matched those of the surgical patients. Facial models were fitted and Procrustes registration and principal components analysis used to allow quantitative analysis, including the comparison of group mean shape and mean asymmetry. The primary characteristic of the difference in shape was found to be residual mandibular prognathism in the group of female patients who underwent Le Fort I maxillary advancement. Individual cases were assessed against this type of shape difference, using a quantitative scale to aid clinical audit. Analysis of the combined surgical groups provided strong evidence that surgery reduces asymmetry in some parts of the face such as the upper lip region. No evidence was found that mean asymmetry in post-surgical patients is greater than that in controls.
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Affiliation(s)
- L Vittert
- School of Mathematics and Statistics, The University of Glasgow, Glasgow, UK
| | - S Katina
- Institute of Mathematics and Statistics, Masaryk University, Brno, Czech Republic
| | - A Ayoub
- Glasgow Dental Hospital and School, The University of Glasgow, Glasgow, UK
| | - B Khambay
- School of Dentistry, University of Birmingham, Birmingham, UK
| | - A W Bowman
- School of Mathematics and Statistics, The University of Glasgow, Glasgow, UK.
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Affiliation(s)
- Neema J Patel
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Andrew W Bowman
- Department of Radiology, Mayo Clinic, Jacksonville, Florida.
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Abstract
Despite the increasing use of computed tomography pulmonary angiography to evaluate for pulmonary embolism (PE), ventilation/perfusion (V/Q) scintigraphy is still a fairly common examination. A rare finding on V/Q scintigraphy is whole-lung mismatched perfusion defect. Although this finding can occur with PE, it has an important, limited differential diagnosis. In this pictorial essay, we describe different causes of acquired whole-lung mismatched perfusion defect.
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Affiliation(s)
- Andrew W Bowman
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Brittany K Albers
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Manoj K Jain
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
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Sanchez-Alvarez C, Bowman AW, Menke DM, Wang B. IgG4 Isolated Retroperitoneal Fibrosis and Aneurysmal Periaortitis. Am J Med 2017; 130:e521-e524. [PMID: 28882661 DOI: 10.1016/j.amjmed.2017.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/16/2017] [Accepted: 08/23/2017] [Indexed: 12/30/2022]
Affiliation(s)
| | | | - David M Menke
- Department of Pathology, Mayo Clinic, Jacksonville, Fla
| | - Benjamin Wang
- Department of Rheumatology, Mayo Clinic, Jacksonville, Fla
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Ibrahim ESH, Bowman AW. Characterization of myocardial iron overload by dual-energy computed tomography compared to T2∗ MRI. A phantom study. Annu Int Conf IEEE Eng Med Biol Soc 2016; 2014:5133-6. [PMID: 25571148 DOI: 10.1109/embc.2014.6944780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Iron toxicity plays a key role in tissue damage in patients with iron overload, with induced heart failure being the main cause of death. T2*-weighted magnetic resonance imaging (MRI) has been established for evaluating myocardial iron overload with strong correlation with biopsy. The recently introduced dual-energy computed tomography (DECT) has the potential for evaluating iron overload without energy-dependent CT attenuation or tissue fat effects. This study investigates the performance of DECT for evaluating myocardial iron overload (based on images acquired at four different diagnostic imaging energies of 80, 100, 120, and 140 kVp) and compare the results to MRI T2* measurements based on DECT and MRI experiments on phantoms with calibrated iron concentrations. DECT showed high accuracy for evaluating iron overload compared to MRI T2* imaging, which might help in patient staging based on the degree of iron overload and independent of the implemented imaging energy.
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Miller C, Magdalina A, Willows RI, Bowman AW, Scott EM, Lee D, Burgess C, Pope L, Pannullo F, Haggarty R. Spatiotemporal statistical modelling of long-term change in river nutrient concentrations in England & Wales. Sci Total Environ 2014; 466-467:914-23. [PMID: 23988742 DOI: 10.1016/j.scitotenv.2013.07.113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 07/25/2013] [Accepted: 07/28/2013] [Indexed: 05/21/2023]
Abstract
Concentrations of nutrient nitrogen (N) and phosphorus (P) are elevated in rivers across large areas of Europe (European Nitrogen Assessment (ENA), Sutton et al., 2011). Environmental policies have been implemented over the past 20 years with the aim of reducing nitrogen inputs to surface waters. However, environmental and ecological status is still below set targets (ENA, Sutton et al., 2011). Identification of patterns in long-term change for nutrient trends in hydrological catchments in England & Wales is required to assess impacts of nutrient management policy and provide better evidence for future policy. Such information could provide essential evidence for supporting policy by combining information from the wider catchment, rather than relying on the analysis of data from individual sites. Surface water quality is subject to considerable spatial and short-period temporal variability, reflecting variability in loading and dilution. This makes it difficult to determine temporal trends at individual monitoring sites with relatively sparse sampling. Here we apply spatiotemporal statistical additive models for both nitrogen and phosphorus in river networks across England & Wales to investigate the overall pattern of nutrient concentrations in these river surface waters over the past 20-40 years. Concentrations of Orthophosphate (OP) have generally decreased over time for many of the Large Hydrological Areas with a seasonal pattern highlighting one peak in the summer months. Over the past ten years, Total Oxidised Nitrogen (Nitrate+Nitrite, TON) concentrations have generally been slowly decreasing or fairly constant. However, prior to 2000, concentrations were generally on an upward trend. The seasonal pattern highlights one trough in the summer months. The highest levels for OP and TON broadly occur in the same general areas across England & Wales. On average, over time, the lowest values are evident in the north-west and south-west (particularly for OP) and highest values are evident in the Midlands, Anglian and Southern regions.
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Affiliation(s)
- C Miller
- School of Mathematics and Statistics, University of Glasgow, UK.
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31
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Bowman AW. Markedly elevated plasma D-dimer and the prevalence of acute pulmonary embolus. Acta Med Acad 2011. [DOI: 10.5644/ama2006-124.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Hosey MT, Asbury AJ, Bowman AW, Millar K, Martin K, Musiello T, Welbury R. The effect of transmucosal 0.2 mg/kg midazolam premedication on dental anxiety, anaesthetic induction and psychological morbidity in children undergoing general anaesthesia for tooth extraction. Br Dent J 2009; 207:E2; discussion 32-3. [PMID: 19574992 DOI: 10.1038/sj.bdj.2009.570] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2008] [Indexed: 11/09/2022]
Abstract
BACKGROUND The project aims were to evaluate the benefit of transmucosal midazolam 0.2 mg/kg pre-medication on anxiety, induction behaviour and psychological morbidity in children undergoing general anaesthesia (GA) extractions. METHOD One hundred and seventy-nine children aged 5-10 years (mean 6.53 years) participated in this randomised, double blind, placebo-controlled trial. Ninety children had midazolam placed in the buccal pouch. Dental anxiety was recorded preoperatively and 48 hours later using a child reported MCDAS-FIS scale. Behaviour at anaesthetic induction was recorded and psychological morbidity was scored by the parent using the Rutter Scale preoperatively and again one week later. Subsequent dental attendance was recorded at one, three and six months after GA. RESULTS While levels of dental anxiety did not reduce overall, the most anxious patients demonstrated a reduction in anxiety after receiving midazolam premedication (p = 0.01). Neither induction behaviour nor psychological morbidity improved. Irrespective of group, parents reported less hyperactive (p = 0.002) and more pro-social behaviour (p = 0.002) after the procedure; older children improved most (p = 0.048). Post-GA dental attendance was poor and unaffected by premedication. CONCLUSION 0.2 mg/kg buccal midazolam provided some evidence for reducing anxiety in the most dentally anxious patients. However, induction behaviour, psychological morbidity and subsequent dental attendance were not found to alter.
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Affiliation(s)
- M T Hosey
- Paediatric Dentistry, Kings College London Dental Institute, London, UK.
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Bowman AW, Kantor B, Gerber TC. Coronary computed tomographic angiography: current role in the diagnosis and management of coronary artery disease. Pol Arch Intern Med 2009; 119:381-390. [PMID: 19694220 PMCID: PMC2735894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Advances in computed tomography (CT) technology allow images to be obtained with high spatial and temporal resolution. These features now permit noninvasive coronary CT angiography (CCTA). Many studies addressing proof of concept, feasibility, and clinical robustness have been published since CCTA was first described. More recently, the scientific evaluation of CCTA has rightly focused less on technical aspects and more on multicenter trials of the diagnostic value of CCTA and on head-to-head comparisons with other noninvasive modalities for the detection of coronary artery disease (CAD), such as stress myocardial perfusion imaging (MPI) with radionuclides. Recent peer-reviewed publications that compare CCTA to invasive, selective coronary angiography (SCA) or MPI, or that address radiation protection issues related to CCTA, were reviewed and summarized. Overall, there is high agreement between CCTA and both SCA and MPI for the presence of CAD. However, CCTA can over- or underestimate the severity of CAD compared to SCA as a reference standard. Initial studies that compared CCTA to MPI found their accuracies for determining the presence of high-grade luminal obstructions comparable. Limitations of CCTA include inability to reliably assess the coronary artery lumen dimensions in patients with large amounts of coronary artery calcium, artifacts caused by coronary and respiratory motion, and the need for ionizing radiation and intravenous administration of iodinated contrast material. Various dose reduction methods for CCTA now exist that may substantially lower patient dose to levels less than those of SCA or MPI. Although current expert consensus does not call for CCTA to be a first-line test for CAD, particularly for screening in asymptomatic individuals, current data suggest a promising role in the evaluation of symptomatic patients for possible CAD.
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Affiliation(s)
- Andrew W. Bowman
- Department of Radiology, Mayo Clinic, Jacksonville, FL, United States
| | - Birgit Kantor
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Thomas C. Gerber
- Department of Radiology, Mayo Clinic, Jacksonville, FL, United States
- Division of Cardiovascular Diseases, Mayo Clinic, Jacksonville, FL, United States
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Bowman AW, Kantor B, Gerber TC. Coronary computed tomographic angiography: current role in the diagnosis and management of coronary artery disease. Pol Arch Intern Med 2009. [DOI: 10.20452/pamw.715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Millar K, Asbury AJ, Bowman AW, Hosey MT, Martin K, Musiello T, Welbury RR. A randomised placebo-controlled trial of the effects of midazolam premedication on children's postoperative cognition. Anaesthesia 2007; 62:923-30. [PMID: 17697220 DOI: 10.1111/j.1365-2044.2007.05148.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This randomised, placebo-controlled study assessed the effects of midazolam premedication on children's postoperative cognition and physical morbidity. In all, 179 children aged 5-10 years were randomly assigned to receive buccal midazolam (0.2 mg x kg(-1)) or placebo before sevoflurane-nitrous oxide anaesthesia for multiple dental extractions. They performed tests of choice reaction time, attention, psychomotor co-ordination and memory pre-operatively (baseline), before discharge and at 48 h. The reaction time of both groups was significantly slower before discharge compared to baseline, with the midazolam group being significantly slower than placebo. Psychomotor co-ordination was also significantly impaired postoperatively after midazolam. Performance on both tests had recovered to baseline by 48 h. Midazolam was also associated with significant anterograde amnesia, both postoperatively and at 48 h, for information presented in the interval between premedication and surgery. The results show significant short-term impairment of children's cognitive function and amnesia enduring for 48 h after low-dose midazolam premedication.
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Affiliation(s)
- K Millar
- University of Glasgow, Section of Psychological Medicine, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G12 0XH, UK.
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Millar K, Asbury AJ, Bowman AW, Hosey MT, Musiello T, Welbury RR. The effects of brief sevoflurane-nitrous oxide anaesthesia upon children's postoperative cognition and behaviour. Anaesthesia 2006; 61:541-7. [PMID: 16704587 DOI: 10.1111/j.1365-2044.2006.04662.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This study assessed the effects of brief sevoflurane-nitrous oxide anaesthesia on children's postoperative cognition, behaviour and physical morbidity. Forty-eight children aged 5-10 years undergoing anaesthesia without premedication for multiple dental extractions, and 48 control children, performed tests of choice reaction time, attention, psychomotor co-ordination and memory pre-operatively (baseline), prior to discharge and at 48 h (anaesthesia group only). Physical and psychological morbidity were recorded at 1 week. Mean choice reaction time and psychomotor co-ordination were significantly impaired postoperatively but had recovered at 48 h. However, measures of performance variability suggested the presence of residual impairment. Profound retrograde amnesia affected postoperative and 48-h recall of pictorial stimuli presented prior to anaesthesia, but recognition memory was unimpaired. Attention-seeking, tantrums, crying and nightmares were occurring more frequently in some 8-20% of children 1 week after the procedure.
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Affiliation(s)
- K Millar
- University Section of Psychological Medicine, Gartnavel Royal Hospital, Glasgow, UK.
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Abstract
Accurately estimating left atrial (LA) volume with Doppler echocardiography remains challenging. Using angiography for validation, Marino et al. (Marino P, Prioli AM, Destro G, LoSchiavo I, Golia G, and Zardini P. Am Heart J 127: 886–898, 1994) determined LA volume throughout the cardiac cycle by integrating the velocity-time integrals of Doppler transmitral and pulmonary venous flow, assuming constant mitral valve and pulmonary vein areas. However, this LA volume determination method has never been compared with three-dimensional LA volume data from cardiac MRI, the gold standard for cardiac chamber volume measurement. Previously, we determined that the effective mitral valve area is not constant but varies as a function of time. Therefore, we sought to determine whether the effective pulmonary vein area (EPVA) might be time varying as well and also assessed Marino's method for estimating LA volume. We imaged 10 normal subjects using cardiac MRI and concomitant transthoracic Doppler echocardiography. LA and left ventricular (LV) volumes were measured by MRI, transmitral and pulmonary vein flows were measured by Doppler echocardiography, and time dependence was synchronized via the electrocardiogram. LA volume, estimated using Marino's method, was compared with the MRI measurements. Differences were observed, and the discrepancy between the echocardiographic and MRI methods was used to predict EPVA as a function of time. EPVA was also directly measured from short-axis MRI images and was found to be time varying in concordance with predicted values. We conclude that because EPVA and LA volume time dependence are in phase, LA filling in systole and LV filling in diastole are both facilitated. Application to subjects in select pathophysiological states is in progress.
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Affiliation(s)
- Andrew W Bowman
- Cardiovascular Biophysics Laboratory, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO 63110, USA
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Waters EA, Bowman AW, Kovács SJ. MRI-determined left ventricular "crescent effect": a consequence of the slight deviation of contents of the pericardial sack from the constant-volume state. Am J Physiol Heart Circ Physiol 2004; 288:H848-53. [PMID: 15486032 DOI: 10.1152/ajpheart.00744.2004] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
During one cardiac cycle, the volume encompassed by the pericardial sack in healthy subjects remains nearly constant, with a transient +/-5% decrease in volume at end systole. This "constant-volume" attribute defines a constraint that the longitudinal versus radial pericardial contour dimension relationship must obey. Using cardiac MRI, we determined the extent to which the constant-volume attribute is valid from four-chamber slices (two-dimensional) compared with three-dimensional volumetric data. We also compared the relative percentage of longitudinal versus radial (short-axis) change in cross-sectional area (dimension) of the pericardial contour, thereby assessing the fate of the +/-5% end-systolic volume decrease. We analyzed images from 10 normal volunteers and 1 subject with congenital absence of the pericardium, obtained using a 1.5-T MR scanner. Short-axis cine loop stacks covering the entire heart were acquired, as were single four-chamber cine loops. In the short-axis and four-chamber slices, relative to midventricular end-diastolic location, end-systolic pericardial (left ventricular epicardial) displacement was observed to be radial and maximized at end systole. Longitudinal (apex to mediastinum) pericardial contour dimension change and pericardial area change on the four-chamber slice were negligible throughout the cardiac cycle. We conclude that the +/-5% end-systolic decrease in the volume encompassed by the pericardial sack is primarily accounted for by a "crescent effect" on short-axis views, manifesting as a nonisotropic radial diminution of the pericardial/epicardial contour of the left ventricle. This systolic drop in cardiac volume occurs primarily at the ventricular level and is made up during the subsequent diastole when blood crosses the pericardium in the pulmonary venous Doppler D wave during early rapid left ventricular filling.
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Affiliation(s)
- Emily A Waters
- Department of Biomedical Engineering, Washington University School of Medicine, St. Louis, Missouri, USA
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Bowman AW, Frihauf PA, Kovács SJ. Time-varying effective mitral valve area: prediction and validation using cardiac MRI and Doppler echocardiography in normal subjects. Am J Physiol Heart Circ Physiol 2004; 287:H1650-7. [PMID: 15155259 DOI: 10.1152/ajpheart.00269.2004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Precise knowledge of the volume and rate of early rapid left ventricular (LV) filling elucidates kinematic aspects of diastolic physiology. The Doppler E wave velocity-time integral (VTI) is conventionally used as the estimate of early, rapid-filling volume; however, this implicitly requires the assumption of a constant effective mitral valve area (EMVA). We sought to evaluate whether the EMVA is truly constant throughout early, rapid filling in 10 normal subjects using cardiac magnetic resonance imaging (MRI) and contemporaneous Doppler echocardiography, which were synchronized via ECG. LV volume measurements as a function of time were obtained via MRI, and transmitral flow values were measured via Doppler echocardiography. The synchronized data were used to predict EMVA as a function of time during early diastole. Validation involved EMVA determination using 1) the short-axis echocardiographic images near the mitral valve leaflet tips, 2) the distance between leaflet tips in the echocardiographic parasternal long-axis view, and 3) the distance between leaflet tips from the MRI LV outflow tract view. Predicted EMVA values varied substantially during early rapid filling, and observed EMVA values agreed well with predictions. We conclude that the EMVA is not constant, and its variation causes LV volume to increase faster than is reflected by the VTI. These results reveal the mechanism of early rapid volumetric increase and directly affect the significance and physiological interpretation of the VTI of the Doppler E wave. Application to subjects in selected pathophysiological subsets is in progress.
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Affiliation(s)
- Andrew W Bowman
- Cardiovascular Biophysics Laboratory, School of Medicine, Washington University Medical Center, Box 8086, 660 S. Euclid Ave., St. Louis, MO 63110, USA
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Bowman AW, Kovács SJ. Left atrial conduit volume is generated by deviation from the constant-volume state of the left heart: a combined MRI-echocardiographic study. Am J Physiol Heart Circ Physiol 2004; 286:H2416-24. [PMID: 14751859 DOI: 10.1152/ajpheart.00969.2003] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Although modeling the four-chambered heart as a constant-volume pump successfully predicts causal physiological relationships between cardiac indexes previously deemed unrelated, the real four-chambered heart slightly deviates from the constant-volume state by ventricular end systole. This deviation has consequences that affect chamber function, specifically, left atrial (LA) function. LA attributes have been characterized as booster pump, reservoir, and conduit functions, yet characterization of their temporal occurrence or their causal relationship to global heart function has been lacking. We investigated LA function in the context of the constant-volume attribute of the left heart in 10 normal subjects using cardiac magnetic resonance imaging (MRI) and contemporaneous Doppler echocardiography synchronized via ECG. Left ventricular (LV) and LA volumes as a function of time were determined via MRI. Transmitral flow, pulmonary vein (PV) flow, and lateral mitral annular velocity were recorded via echocardiography. The relationship between the MRI-determined diastolic LA conduit-volume (LACV) filling rate and systolic LA filling rate correlate well with the relationship between the echocardiographically determined average flow rate during the early portion of the PV D wave and the average flow rate during the PV S wave (r = 0.76). We conclude that the end-systolic deviation from constant volume for the left heart requires the generation of the LACV during diastole. Because early rapid filling of the left ventricle is the driving force for LACV generation while the left atrium remains passive, it may be more appropriate to consider LACV to be a property of ventricular diastolic rather than atrial function.
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Affiliation(s)
- Andrew W Bowman
- Cardiovascular Biophysics Laboratory, Washington University Medical Center, Box 8086, 660 South Euclid Avenue, St. Louis, MO 63110, USA
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41
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Abstract
The constant-volume hypothesis regarding the four-chambered heart states that total pericardial volume remains invariant throughout the cardiac cycle. Previous canine studies have indicated that the pericardial volume remains constant within 5%; however, this hypothesis has not been validated in humans using state-of-the-art technology. The constant-volume hypothesis has several predictable functional consequences, including a relationship between atrial ejection fraction and chamber equilibrium volumes. Using cardiac magnetic resonance (MR) imaging (MRI), we measured the extent to which the constant-volume attribute of the heart is valid, and we tested the accuracy of the predicted relationship between atrial ejection fraction and chamber equilibrium volumes. Eleven normal volunteers and one volunteer with congenital absence of the pericardium were imaged using a 1.5-T MR scanner. A short-axis cine-loop stack covering the entire heart was acquired. The cardiac cycle was divided into 20 intervals. For each slice and interval, pericardial volumes were measured. The slices were stacked and summed, and total pericardial volume as a function of time was determined for each subject. In the normal subjects, chamber volumes at ventricular end diastole, end systole, and diastasis were measured. Pericardial volume remained invariant within 5 +/- 1% in normal subjects; maximum variation occurred near end systole. In the subject with congenital absence of the pericardium, total heart volume, defined by the epicardial surface, varied by 12%. The predictions of the relationship between atrial ejection fraction and chamber equilibrium volumes were well fit by MRI data. In normal subjects, the four-chambered heart is a constant-volume pump within 5 +/- 1%, and constant-volume-based modeling accurately predicts previously unreported physiological relationships.
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Affiliation(s)
- Andrew W Bowman
- Cardiovascular Biophysics Laboratory, Barnes-Jewish Hospital, Washington University Medical Center, Box 8086, 660 S. Euclid Avenue, St. Louis, MO 63110, USA
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Dent CL, Bowman AW, Scott MJ, Allen JS, Lisauskas JB, Janif M, Wickline SA, Kovács SJ. Echocardiographic characterization of fundamental mechanisms of abnormal diastolic filling in diabetic rats with a parameterized diastolic filling formalism. J Am Soc Echocardiogr 2001; 14:1166-72. [PMID: 11734783 DOI: 10.1067/mje.2001.115124] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Abnormalities of diastolic function (DF) precede systolic dysfunction in diabetic cardiomyopathy. Transmitral Doppler flow analysis is the primary method for noninvasively assessing DF. We used model-based Doppler E-wave analysis to evaluate diastolic function differences between normal and diabetic rat hearts. Control rats and those with diabetes underwent echocardiography with analysis by traditional Doppler indexes and by the parameterized diastolic filling (PDF) formalism, generating 3 parameters, x0, c, and k, that uniquely characterize each E-wave. Significant intergroup differences in the E/A ratios (P <.01), isovolumic relaxation times (P <.01), and the modeling parameter c (P <.05) were found. There were no significant differences in shortening fraction, deceleration time, myocardial collagen content, or the parameters x0 and k between diabetic and control rats. These results indicate that differences in diastolic function may be noninvasively quantified and that diabetic hearts may exhibit defects in uncoupling of the contractile apparatus without concomitant increases in chamber stiffness.
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Affiliation(s)
- C L Dent
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo 63110, USA
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Lisauskas JB, Singh J, Bowman AW, Kovács SJ. Chamber properties from transmitral flow: prediction of average and passive left ventricular diastolic stiffness. J Appl Physiol (1985) 2001; 91:154-62. [PMID: 11408426 DOI: 10.1152/jappl.2001.91.1.154] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
A chamber stiffness (K(LV))-transmitral flow (E-wave) deceleration time relation has been invasively validated in dogs with the use of average stiffness [(DeltaP/DeltaV)(avg)]. K(LV) is equivalent to k(E), the (E-wave) stiffness of the parameterized diastolic filling model. Prediction and validation of 1) (DeltaP/DeltaV)(avg) in terms of k(E), 2) early rapid-filling stiffness [(DeltaP/DeltaV)(E)] in terms of k(E), and 3) passive (postdiastasis) chamber stiffness [(DeltaP/DeltaV)(PD)] from A waves in terms of the stiffness parameter for the Doppler A wave (k(A)) have not been achieved. Simultaneous micromanometric left ventricular (LV) pressure (LVP) and transmitral flow from 131 subjects were analyzed. (DeltaP)(avg) and (DeltaV)(avg) utilized the minimum LVP-LV end-diastolic pressure interval. (DeltaP/DeltaV)(E) utilized DeltaP and DeltaV from minimum LVP to E-wave termination. (DeltaP/DeltaV)(PD) utilized atrial systolic DeltaP and DeltaV. E- and A-wave analysis generated k(E) and k(A). For all subjects, noninvasive-invasive relations yielded the following equations: k(E) = 1,401. (DeltaP/DeltaV)(avg) + 59.2 (r = 0.84) and k(E) = 229.0. (DeltaP/DeltaV)(E) + 112 (r = 0.80). For subjects with diastasis (n = 113), k(A) = 1,640. (DeltaP/DeltaV)(PD) - 8.40 (r = 0.89). As predicted, k(A) showed excellent correlation with (DeltaP/DeltaV)(PD); k(E) correlated highly with (DeltaP/DeltaV)(avg). In vivo validation of average, early, and passive chamber stiffness facilitates quantitative, noninvasive diastolic function assessment from transmitral flow.
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Affiliation(s)
- J B Lisauskas
- Cardiovascular Biophysics Laboratory, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Abstract
The variogram is a standard tool in the analysis of spatial data, and its shape provides useful information on the form of spatial correlation that may be present. However, it is also useful to be able to assess the evidence for the presence of any spatial correlation. A method of doing this, based on an assessment of whether the true function underlying the variogram is constant, is proposed. Nonparametric smoothing of the squared differences of the observed variables, on a suitably transformed scale, is used to estimate variogram shape. A statistic based on a ratio of quadratic forms is proposed and the test is constructed by investigating the distributional properties of this statistic under the assumption of an independent Gaussian process. The power of the test is investigated. Reference bands are proposed as a graphical follow-up. An example is discussed.
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Affiliation(s)
- A Diblasi
- Facultad de Ciencias Economicas, Universidad Nacional de Cuyo, Mendoza, Argentina
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Abstract
Kaplan-Meier curves provide an effective means of presenting the distributional pattern in a sample of survival data. However, in order to assess the effect of a covariate, a standard scatterplot is often difficult to interpret because of the presence of censored observations. Several authors have proposed a running median as an effective way of indicating the effect of a covariate. This article proposes a form of kernel estimation, employing double smoothing, that can be applied in a simple and efficient manner to construct an estimator of a percentile of the survival distribution as a function of one or two covariates. Permutations and bootstrap samples can be used to construct reference bands that help identify whether particular features of the estimates indicate real features of the underlying curve or whether this may be due simply to random variation. The techniques are illustrated on data from a study of kidney transplant patients.
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Affiliation(s)
- A W Bowman
- Department of Statistics, University of Glasgow, UK.
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Woo YM, Jardine AG, Clark AF, MacGregor MS, Bowman AW, Macpherson SG, Briggs JD, Junor BJ, McMillan MA, Rodger RS. Early graft function and patient survival following cadaveric renal transplantation. Kidney Int 1999; 55:692-9. [PMID: 9987094 DOI: 10.1046/j.1523-1755.1999.00294.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The influence of events that occur early following renal transplantation such as delayed graft function (DGF) and acute rejection on long-term graft survival has been widely reported, but its association with patient survival has received less attention. METHODS We studied 589 patients who received their first cadaveric transplants between 1984 and 1993, all of whom received cyclosporine-based immunosuppression and who had a median follow-up of seven years. The following factors were identified, and both univariate and multivariate analyses were used to determine their association with long-term patient and graft survival: age, sex, duration of pretransplant dialysis, primary renal disease, immediate graft function (IGF), DGF, primary nonfunction (PNF), acute rejection, and serum creatinine at 3, 6, and 12 months. RESULTS Patients with PNF had a poorer survival than those with DGF and IGF (P = 0.01), but there was no difference in survival between DGF and IGF (P = 0.54). Good graft function (serum creatinine of less than 200 mumol/liter) at three months was predictive of better long-term patient survival (P = 0.03). Other factors associated with poor patient outcome were older age, diabetes, adult polycystic kidney disease, male gender, and acute rejection. Cardiovascular disease was the most common cause of death (51.8%). Good graft function at three months (P < 0.001) and an absence of rejection episodes (P = 0.01) were associated with better graft survival. CONCLUSION Patients with poor levels of early graft function (but not DGF) and those with either acute rejection episodes or early graft loss are at an increased risk of early death. These high-risk groups should be targeted for interventional studies in an attempt to improve patient survival.
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Affiliation(s)
- Y M Woo
- Renal Unit, University of Glasgow, United Kingdom
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Macklon NS, Greer IA, Bowman AW. An ultrasound study of gestational and postural changes in the deep venous system of the leg in pregnancy. Br J Obstet Gynaecol 1997; 104:191-7. [PMID: 9070137 DOI: 10.1111/j.1471-0528.1997.tb11043.x] [Citation(s) in RCA: 155] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate gestational and postural changes in diameter and blood flow in the proximal deep leg veins during pregnancy. DESIGN A longitudinal, prospective observational study. SETTING The ultrasound department of a teaching maternity hospital. POPULATION Twenty-four healthy women with uncomplicated singleton pregnancies. METHODS Real-time and duplex Doppler ultrasound assessments of the vessel diameter, flow velocity and respiratory flow fluctuation in the proximal deep leg veins of women serially measured from the first trimester of pregnancy to six weeks postnatally. MAIN OUTCOME MEASURES The effects of increasing gestation and the adoption of the left lateral position on the above parameters. RESULTS An increase in vessel diameter and a fall in flow velocity with increasing gestation was observed. However, no change in venous flow variation was observed. Delivery had reverse effects. Flow velocity was slower in the left than right legs, but on adoption of the left lateral position an increase in flow velocity and venous flow variation was observed in both legs during pregnancy. CONCLUSIONS These data are consistent with the observed increase in incidence and pattern of deep venous thrombosis in pregnancy and may aid interpretation of duplex Doppler ultrasound examinations for deep venous thrombosis in pregnancy. Postural changes should be part of this evaluation. The gravid uterus may not be the sole cause for postural changes in deep venous flow velocity.
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Affiliation(s)
- N S Macklon
- Department of Obstetrics and Gynaecology, University of Glasgow, UK
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Krebs C, Macara LM, Leiser R, Bowman AW, Greer IA, Kingdom JC. Intrauterine growth restriction with absent end-diastolic flow velocity in the umbilical artery is associated with maldevelopment of the placental terminal villous tree. Am J Obstet Gynecol 1996; 175:1534-42. [PMID: 8987938 DOI: 10.1016/s0002-9378(96)70103-5] [Citation(s) in RCA: 254] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Our purpose was to evaluate the structure of placental terminal villi and their capillaries in pregnancies complicated by intrauterine growth restriction with absent end-diastolic flow velocity in the umbilical artery. STUDY DESIGN Glutaraldehyde-perfusion-fixed villous tissue and a plastic cast of the vessels in at least two cotyledons were prepared from 10 cases with intrauterine growth restriction and 9 gestational age-matched control placentas. The structure and dimensions of 20 terminal capillary loops per cast were determined by scanning electron microscopic examination, and their appearances were correlated with the peripheral villi of the perfusion-fixed villous tissue. RESULTS Capillary loops in the growth-restricted cases were sparse in number and significantly longer than in the control cases (218 microns [72] vs 137 microns [30], mean and SD, p < 0.05). They exhibited fewer branches (4.0 [1.9] per loop vs 6.1 [2.2], p < 0.05) and a majority of loops were uncoiled (79% vs 18%, p < 0.05). The villous tissues from the growth-restricted cases demonstrated elongated villi, consistent with the cast findings. The trophoblast surface was wrinkled and in some areas covered by fibrin plaques. CONCLUSIONS The terminal villous compartment of the placenta appears to be maldeveloped in preterm intrauterine growth restriction pregnancies where absent end-diastolic flow velocity is demonstrated in the umbilical artery before delivery. These findings are consistent with an increase in fetoplacental vascular impedance at the capillary level and may account for the impaired gas and nutrient transfer in this disorder.
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Affiliation(s)
- C Krebs
- Department of Veterinary Anatomy, Justus Liebig University, Giessen, Germany
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Macara L, Kingdom JC, Kohnen G, Bowman AW, Greer IA, Kaufmann P. Elaboration of stem villous vessels in growth restricted pregnancies with abnormal umbilical artery Doppler waveforms. Br J Obstet Gynaecol 1995; 102:807-12. [PMID: 7547738 DOI: 10.1111/j.1471-0528.1995.tb10847.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To assess the elaboration of placental stem villous vessels from pregnancies complicated by intrauterine growth restriction (IUGR) with absent end-diastolic flow velocity detected prior to delivery in the umbilical artery. DESIGN Comparison between IUGR and control groups of the distribution, in 15 microns increments of 600 randomly chosen stem vessel profiles (post-fixation diameter 10-160 microns) identified by immunohistochemical localisation of alpha-smooth muscle actin in the vessel media. SETTING Clinical teaching hospital and university anatomy department. SUBJECTS Paraffin-fixed blocks obtained from placentas of eight pregnancies complicated by IUGR and eight gestational age-matched controls. RESULTS The distribution of the stem villous vessels in the IUGR placentas, as assessed by the mean vessel diameter in each case, did not differ from the controls (mean vessel diameter 31.8 microns [SD 2.4] vs 29.6 microns [2.3]; P = 0.13). In five IUGR cases alpha-smooth muscle actin positive cells (myofibroblasts) were identified within the stroma of nonmuscularised peripheral (mature intermediate and terminal) villi, but in none of the controls. CONCLUSIONS Our data do not support the theory that IUGR with absent end-diastolic flow velocity in the umbilical artery is due to a selective loss of small stem villous vessels. The increased impedance in this condition may be conferred more distally within the nonmuscularised capillaries of the peripheral villi.
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Affiliation(s)
- L Macara
- Department of Obstetrics and Gynaecology, University of Glasgow, UK
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Kingdom JC, Ryan G, Whittle MJ, McNay MB, Bowman AW, Doyle J, Connell JM. Atrial natriuretic peptide: a vasodilator of the fetoplacental circulation? Am J Obstet Gynecol 1991; 165:791-800. [PMID: 1835300 DOI: 10.1016/0002-9378(91)90419-r] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Paired maternal and fetal atrial natriuretic peptide concentrations were measured in 62 percutaneous umbilical blood samplings performed principally for the assessment and treatment of rhesus isoimmunization. Pretransfusion fetal atrial natriuretic peptide levels were significantly higher than maternal atrial natriuretic peptide levels (median 117 pg/ml vs median 32 pg/ml; p less than 0.001); paired pretransfusion fetal and maternal atrial natriuretic peptide samples showed a weak correlation with each other (R2 = 17%; p = 0.002). Fetal atrial natriuretic peptide levels correlated inversely with hematocrit (R2 = 14%; p = 0.003), but not with albumin or gestational age. Paired pretransfusion and posttransfusion (median = 134 pg/ml) fetal atrial natriuretic peptide levels (n = 38) showed a significant rise after transfusion (p less than 0.001); this rise was related to the percentage of fetoplacental blood volume transfused (R2 = 33%; p = 0.035). In a subgroup of 26 procedures, change in fetal atrial natriuretic peptide levels was weakly correlated with transient reductions in the Doppler systolic/diastolic ratio of the umbilical artery (R2 = 14%; p = 0.07). These data support work in animals that indicate a role for atrial natriuretic peptide in the human fetus, but these data do not confirm that atrial natriuretic peptide modulates fetoplacental vascular impedance in the human fetus.
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Affiliation(s)
- J C Kingdom
- Department of Midwifery, Queen Mother's Hospital, Glasgow, Scotland
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