Development and External Validation of an Artificial Intelligence Model for Identifying Radiology Reports Containing Recommendations for Additional Imaging

BACKGROUND. Reported rates of recommendations for additional imaging (RAIs) in radiology reports are low. Bidirectional encoder representations from transformers (BERT), a deep learning model pretrained to understand language context and ambiguity, has potential for identifying RAIs and thereby assisting large-scale quality improvement efforts. OBJECTIVE. The purpose of this study was to develop and externally validate an artificial intelligence (AI)-based model for identifying radiology reports containing RAIs. METHODS. This retrospective study was performed at a multisite health center. A total of 6300 radiology reports generated at one site from January 1, 2015, to June 30, 2021, were randomly selected and split by 4:1 ratio to create training (n = 5040) and test (n = 1260) sets. A total of 1260 reports generated at the center's other sites (including academic and community hospitals) from April 1 to April 30, 2022, were randomly selected as an external validation group. Referring practitioners and radiologists of varying sub-specialties manually reviewed report impressions for presence of RAIs. A BERT-based technique for identifying RAIs was developed by use of the training set. Performance of the BERT-based model and a previously developed traditional machine learning (TML) model was assessed in the test set. Finally, performance was assessed in the external validation set. The code for the BERT-based RAI model is publicly available. RESULTS. Among a total of 7419 unique patients (4133 women, 3286 men; mean age, 58.8 years), 10.0% of 7560 reports contained RAI. In the test set, the BERT-based model had 94.4% precision, 98.5% recall, and an F1 score of 96.4%. In the test set, the TML model had 69.0% precision, 65.4% recall, and an F1 score of 67.2%. In the test set, accuracy was greater for the BERT-based than for the TML model (99.2% vs 93.1%, p < .001). In the external validation set, the BERT-based model had 99.2% precision, 91.6% recall, an F1 score of 95.2%, and 99.0% accuracy. CONCLUSION. The BERT-based AI model accurately identified reports with RAIs, outperforming the TML model. High performance in the external validation set suggests the potential for other health systems to adapt the model without requiring institution-specific training. CLINICAL IMPACT. The model could potentially be used for real-time EHR monitoring for RAIs and other improvement initiatives to help ensure timely performance of clinically necessary recommended follow-up.

3D Visual Guide to Lines and Stripes in Chest Radiography

Chest radiography continues to be the first-line imaging modality for evaluation of the chest. Interpretation is based on the understanding of complex three-dimensional (3D) structural relationships, which are translated into a two-dimensional (2D) plane. These 2D projections form multiple "lines and stripes" on chest radiographs, representing the interfaces between the pulmonary parenchyma, pleura, and normal mediastinal structures. Given the subtlety of overlying tissue and the need to mentally synthesize planar images into three dimensions, structural relationships may be difficult to appreciate. An understanding of these relationships forms the basis of recognizing pathologic conditions and providing an accurate differential diagnosis, which can assist in targeted appropriate further workup. On a 2D radiograph, this means recognizing the normal lines and stripes as well as their appearance when effaced or displaced. Once this abnormality is identified, a focused differential diagnosis can be generated, which can be further narrowed on the basis of other factors, such as patient history or ancillary findings. Three-dimensional cinematic rendering is an innovative tool that can help radiologists grasp these anatomic relationships and discern subtle findings at radiography. This technique allows improved visualization of structures such as the pleura that are difficult to appreciate with traditional imaging modalities. The authors provide an updated review of lines and stripes on chest radiographs, using 3D cinematic rendering as a teaching tool. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Naloxone administration by law enforcement officers in New York State (2015-2020)

BACKGROUND

The COVID-19 pandemic has amplified the need for wide deployment of effective harm reduction strategies in preventing opioid overdose mortality. Placing naloxone in the hands of key responders, including law enforcement officers who are often first on the scene of a suspected overdose, is one such strategy. New York State (NYS) was one of the first states to implement a statewide law enforcement naloxone administration program. This article provides an overview of the law enforcement administration of naloxone in NYS between 2015 and 2020 and highlights key characteristics of over 9000 opioid overdose reversal events.

METHODS

Data in naloxone usage report forms completed by police officers were compiled and analyzed. Data included 9133 naloxone administration reports by 5835 unique officers located in 60 counties across NYS. Descriptive statistics were used to examine attributes of the aided individuals, including differences between fatal and non-fatal incidents. Additional descriptive analyses were conducted for incidents in which law enforcement officers arrived first at the scene of suspected overdose. Comparisons were made to examine year-over-year trends in administration as naloxone formulations were changed. Quantitative analysis was supplemented by content analysis of officers' notes (n = 2192).

RESULTS

In 85.9% of cases, law enforcement officers arrived at the scene of a suspected overdose prior to emergency medical services (EMS) personnel. These officers assessed the likelihood of an opioid overdose having occurred based on the aided person's breathing status and other information obtained on the scene. They administered an average of 2 doses of naloxone to aided individuals. In 36.8% of cases, they reported additional administration of naloxone by other responders including EMS, fire departments, and laypersons. Data indicated the aided survived the suspected overdose in 87.4% of cases.

CONCLUSIONS

With appropriate training, law enforcement personnel were able to recognize opioid overdoses and prevent fatalities by administering naloxone and carrying out time-sensitive medical interventions. These officers provided life-saving services to aided individuals alongside other responders including EMS, fire departments, and bystanders. Further expansion of law enforcement naloxone administration nationally and internationally could help decrease opioid overdose mortality.

Fat content quantification using dual-energy CT for differentiation of anterior mediastinal lesions from normal or hyperplastic thymus

BACKGROUND

Detection of fat content in thymic lesions is crucial to differentiate thymic hyperplasia from thymic tumors or other anterior mediastinal pathologies.

PURPOSE

To assess the feasibility of dual-energy CT (DECT) fat content quantification for the differentiation of anterior mediastinal lesions from benign thymic lesions and the normal spectrum of the thymus.

MATERIALS AND METHODS

Chest DECT images of 465 patients (median 61 years, 63% female) were visually evaluated by two radiologists and semiquantitatively scored based on the degree of fatty degeneration ranging from completely fatty (score 0) to predominantly soft-tissue (score 3), and anterior mediastinal mass (score 4). A subset of scans (n =134 including all cases with scores 2-4 and 20 randomly-selected cases from scores 0 and 1) underwent quantitative DECT analysis (fat fraction, iodine density, and conventional CT value). DECT values were compared across the semiquantitative scores.

RESULTS

Results of visual evaluation included 35 with predominantly solid thymus (score 3) and 15 with anterior mediastinal mass (score 4). The most common clinical diagnoses of the 15 masses (including 8 with pathologic confirmation) were metastases (n = 10) and lymphoma (n = 4). CT values in the abnormal thymus were significantly higher than those in score 3 (median: 69.7 HU versus 19.9 HU, P <0.001). There was no significant difference in iodine density values (median: 1.7 mg/ml versus 1 mg/ml, P = 0.09). However, the fat fraction value was significantly lower in the abnormal thymus (score 4) than in the predominantly soft-tissue attenuation thymuses (score 3) (median: 12.8% versus 38.7%, P <0.001). ROC curve analysis showed that fat fraction had an AUC of 0.96 (P <0.001), with a cutoff of <39.2% fat fraction yielding 100% sensitivity and 85% specificity.

CONCLUSION

DECT fat fraction measurements of the thymus may provide additional value in distinguishing anterior mediastinal lesions from benign thymus. Use of DECT may reduce the need for subsequent imaging evaluation.

Inverted V-shaped extracapsular stabilisation technique and arthroscopic findings in six dogs with medial shoulder instability

OBJECTIVES

The aim of this case series was to report arthroscopic findings and to evaluate clinical outcomes of dogs treated with an inverted V-shaped extracapsular stabilisation technique without additional external coaptation for medial shoulder instability.

MATERIAL AND METHODS

Medical records of dogs with medial shoulder instability that underwent arthroscopy and an inverted V-shaped extracapsular stabilisation technique were retrospectively reviewed. Extracapsular stabilisation was performed in all dogs using screws and spiked washers as anchor points for the coated polyester prosthetic ligament. No additional external coaptation was used in any dog. A minimum 18-month follow-up period was required for study inclusion. Complications and long-term outcomes were recorded.

RESULTS

The subscapularis tendon and medial glenohumeral ligament were the structures most commonly affected. All dogs had pathological cartilage fibrillations. Implants were successfully placed in all dogs. Implant loosening was recorded in two out of six dogs on recheck but no revision surgery was performed. Function at the time of last clinical follow-up (median, 28 months, range 18 to 33 months) was full in four out of six and acceptable in two out of six dogs.

CLINICAL SIGNIFICANCE

Surgical treatment of medial shoulder instability using the novel inverted V-shaped extracapsular stabilisation technique was successful. Potential complications such as implant loosening may occur. Despite the limited number of cases, the present study suggests that additional postoperative external coaptation may not be necessary for successful management of dogs with medial shoulder instability.

Radiologist Variation in the Rates of Follow-up Imaging Recommendations Made for Pulmonary Nodules

OBJECTIVE

Determine whether differences exist in rates of follow-up recommendations made for pulmonary nodules after accounting for multiple patient and radiologist factors.

METHODS

This Institutional Review Board-approved, retrospective study was performed at an urban academic quaternary care hospital. We analyzed 142,001 chest and abdominal CT reports from January 1, 2016, to December 31, 2018, from abdominal, thoracic, and emergency radiology subspecialty divisions. A previously validated natural language processing (NLP) tool identified 24,512 reports documenting pulmonary nodule(s), excluding reports NLP-positive for lung cancer. A second validated NLP tool identified reports with follow-up recommendations specifically for pulmonary nodules. Multivariable logistic regression was used to determine the likelihood of pulmonary nodule follow-up recommendation. Interradiologist variability was quantified within subspecialty divisions.

RESULTS

NLP classified 4,939 of 24,512 (20.1%) reports as having a follow-up recommendation for pulmonary nodule. Male patients comprised 45.3% (11,097) of the patient cohort; average patient age was 61.4 years (±14.1 years). The majority of reports were from outpatient studies (62.7%, 15,376 of 24,512), were chest CTs (75.9%, 18,615 of 24,512), and were interpreted by thoracic radiologists (63.7%, 15,614 of 24,512). In multivariable analysis, studies for male patients (odds ratio [OR]: 0.9 [0.8-0.9]) and abdominal CTs (OR: 0.6 [0.6-0.7] compared with chest CT) were less likely to have a pulmonary nodule follow-up recommendation. Older patients had higher rates of follow-up recommendation (OR: 1.01 for each additional year). Division-level analysis showed up to 4.3-fold difference between radiologists in the probability of making a follow-up recommendation for a pulmonary nodule.

DISCUSSION

Significant differences exist in the probability of making a follow-up recommendation for pulmonary nodules among radiologists within the same subspecialty division.

Enterokolitis als Ursache eines akuten unerwarteten Todes eines Orang-Utans in Zoohaltung

Es wird von einem 13 Jahre alt gewordenen weiblichen Orang-Utan berichtet, der 4 Tage vor dem Tod an einer akuten Enterokolitis erkrankte. Die tierärztliche Ultraschalluntersuchung einen Tag vor dem Tod erbrachte den Nachweis von vermehrter Flüssigkeit im Zäkum und einer abschnittsweise verdickten Kolonwand. Nach dem für die Veterinärmediziner und die Zoomitarbeiter unerwarteten Todeseintritt erfolgte eine Obduktion durch Rechtsmediziner der Universitätsmedizin Rostock mit Unterstützung von Ärzten weiterer Fachrichtungen. Dabei wurde als Todesursache eine akute Escherichia-coli-Enterokolitis mit massiver Blutung in den Darm festgestellt. Begünstigend oder ursächlich für die letale Enterokolitis dürften wahrscheinlich zahlreiche rezidivierende Durchfallerkrankungen in der Anamnese des Orang-Utans als Folge eines Verweigerns des Stillens durch die Mutter nach der Geburt gewesen sein.

Simple quantitative chest CT for pulmonary edema

•

Quantitative CT is a highly accurate but underutilized method for identifying pulmonary edema on CT.

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There is a moderatelystrong correlation between CT HUs and CXR pulmonary edema grade in every lobe with correlation coefficients ranging from 0.585−0.685.

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CT Hounsfield unit measurement yields excellent accuracy in differentiating no edema from mild to severe edema, with AUCs up to 0.995 in the LUL.

•

Qualitative CT with a % versus 84 % and specificity 95 % versus 78 Qualitative CT with a HU cut-off of -825 in the LUL is more sensitive (100% vs 84%) and specific (95% vs 78%) than qualitative CT.

Purpose

To determine the accuracy of quantitative CT to diagnose pulmonary edema compared to qualitative CT and CXR and to determine a threshold Hounsfield unit (HU) measurement for pulmonary edema on CT examinations.

Method

Electronic medical records were searched for patients with a billing diagnosis of heart failure and a Chest CT and CXR performed within three hours between 1/1/2016 to 10/1/2016, yielding 100 patients. CXR and CT examinations were scored for the presence and severity of edema, using a 0–5 scale, and CT HU measurements were obtained in each lobe. Polyserial correlation coefficients evaluated the association between CT HUs and CXR scores, and receiver operating characteristic (ROC) curve analysis determined a cutoff CT HU value for identification of pulmonary edema.

Results

Correlation between CT HU and CXR score was moderately strong (r = 0.585−0.685) with CT HU measurements demonstrating good to excellent accuracy in differentiating between no edema (grade 0) and mild to severe edema (grades 1–5) in every lobe, with AUCs ranging between 0.869 and 0.995. The left upper lobe demonstrated the highest accuracy, using a cutoff value of -825 HU (AUC of 0.995, sensitivity = 100 % and specificity = 95.1 %). Additionally, qualitative CT evaluation was less sensitive (84 %) than portable CXR in identifying pulmonary edema. However, quantitative CT evaluation was as sensitive as portable CXR (100 %) and highly specific (95 %).

Conclusions

Quantitative CT enables the identification of pulmonary edema with high accuracy and demonstrates a greater sensitivity than qualitative CT in assessment of pulmonary edema.

Comparison of algorithms to suppress artifacts from the natural lens in fluorescence lifetime imaging ophthalmoscopy (FLIO)

Fluorescence lifetime imaging ophthalmoscopy (FLIO) has developed as a new diagnostic tool in ophthalmology. FLIO measurements are taken from 30° retinal fields in two spectral channels (short spectral channel (SSC): 498-560 nm, long spectral channel (LSC): 560-720 nm). Because of the layered structure of the eye, the detected signal is an interaction of the fluorescence decay of the anterior part and of the fundus. By comparing FLIO measurements before and after cataract surgery, the impact of the natural lens was proven, despite the application of a confocal laser scanning (cSLO) technique. The goal of this work was to determine the best algorithmic solution to isolate the sole fundus fluorescence lifetime from the measured signal, suppressing artifacts from the natural lens. Three principles based on a tri-exponential model were investigated: a tailfit, a layer-based approach with a temporally shifted component, and the inclusion of a separately measured fluorescence decay of the natural lens. The mean fluorescence lifetime τ_m,12 is calculated using only the shortest and the intermediate exponential component. τ_m,all is calculated using all three exponential components. The results of tri-exponential tailfit after cataract surgery were considered as a reference, because the implanted artificial lens can be assumed as non-fluorescent. In SSC, the best accordance of τ_m,all of the reference was determined with τ_m,12 of the tailfit before surgery. If high-quality natural lens measurements are available, the correspondence of τ_m,12 is best with τ_m,all of the reference. In LSC, there is a good accordance for all models between τ_m,12 before and after surgery. To study the pure fundus fluorescence decay in eyes with natural lenses, we advise to utilize fluorescence lifetime τ_m,12 of a triple-exponential tailfit, as it corresponds well with the mean fluorescence lifetime τ_m,all of eyes with fluorescence-less artificial intraocular lenses.

Paragangliomas Throughout the Body: Hereditary Syndromes and Imaging Features Including 3D Cinematic Rendering

Paragangliomas are highly vascular neuroendocrine tumors that arise from embryonic neural crest cells. They may either be hormonally active (sympathetic) or silent (parasympathetic). Approximately one-third are hereditary, and patients may develop multiple paragangliomas. Presurgical planning involves medical management as well as interventional and/or surgical techniques that must address vascular supply. Contrast-enhanced CT is the best initial anatomical study and shows the hypervascularity and feeding vessels. 3D cinematic rendering using multiplanar light sources can highlight spatial relationships of a mass to adjacent structures and help in surgical planning. This article will review the clinical presentation of paragangliomas, genetic syndromes, presurgical management, and tumor behavior and imaging appearance by location with a particular emphasis on 3D cinematic rendering.

Glycemic variability in patients with gastrointestinal cancer: An integrative review

PURPOSE

Glycemic variability is associated with risks for adverse events in patients with cancer. Several studies have evaluated the presence and impact of hyperglycemia and/or hypoglycemia in patients with cancer; however, few studies have evaluated glycemic variability. The purpose of this integrative review of studies in patients with gastrointestinal cancers was to investigate the presence and methods of reporting glycemic variability during and following treatments.

METHODS

A comprehensive review of the literature was conducted. PubMed, CINAHL, EMBASE, and Cochrane databases were searched for publications between 1/1/1969 and 7/24/2019. Studies of patients with gastrointestinal cancer following surgery, during treatment, and <5 years following treatment were included and evaluated by cancer type and method of glucose and glycemic variability measurement.

RESULTS

Among 1526 patients with gastrointestinal cancer across 19 studies, gastric and pancreatic cancers were most prevalent. Timing of glucose testing and methods of analyzing glycemic variability varied. Most analyses used the standard deviation or interquartile range. Glycemic variability was more prevalent among patients with Type 2 Diabetes and among those with pancreatic cancer. In some patients glycemic variability remained notable > one year following surgery despite improvements in glycemic control.

CONCLUSION

Patients with gastrointestinal cancer experience glycemic variability during and up to one year following treatment. There was heterogeneity in methods related to timing of testing and reporting glycemic variability among the 19 studies in this review. Future investigations need to identify the presence and define the methods of measuring glycemic variability in patients with gastrointestinal cancer.

A comparison of postoperative respiratory complications associated with the use of desflurane and sevoflurane: a single-centre cohort study

Sevoflurane and desflurane are the most commonly used volatile anaesthetics for maintenance of anaesthesia. In this study, we aimed to evaluate the relationship between choice of volatile anaesthetic and early postoperative respiratory complications, and to address a critical knowledge gap in safety outcomes between these two commonly used agents. We performed a retrospective analysis of adult (non-cardiac surgery) patients who received sevoflurane or desflurane for the maintenance of general anaesthesia at our institution between 2005 and 2018. We evaluated the association between desflurane exposure (when compared with sevoflurane) and the primary outcome of postoperative respiratory complications, defined by early post-extubation desaturation (S_p O₂  < 90%) or re-intubation within 7 days postoperatively. Multivariable regression analyses were performed and adjusted for confounding factors, including patient, anaesthetic and surgical factors. Propensity matched, interaction and sub-group analyses were performed to assess outcomes in high-risk groups: morbidly obese (BMI > 35 kg.m^-2 ); elderly (age > 65 years); and high risk of respiratory complications as well as the primary outcome at 24 h. Desflurane was used for 23,830 patients and sevoflurane for 84,608 patients. Patients exposed to desflurane did not demonstrate a reduced risk of postoperative respiratory complications when compared with sevoflurane (adjusted odds ratio 0.99, 95%CI 0.94-1.04, p = 0.598). These findings were consistent across all sub-groups of high-risk patients and in the propensity score matched cohort. In summary, desflurane use was not associated with reduced postoperative respiratory complications when compared with sevoflurane. In the context of environmental and cost concerns with volatile anaesthetic agents, our study provides important data to support organisational decisions regarding the use of desflurane.

A pictorial review of lung torsion using 3D CT cinematic rendering

Lung torsion is the abnormal rotation of a lobe or lung around its bronchovascular pedicle. It most commonly occurs in the setting of pulmonary resection, though it has also been described after large-volume thoracentesis and video-assisted thoracic surgery, as well as spontaneously. Resulting ischemia can lead to infarction, making this an emergent diagnosis. As findings are often nonspecific, a high index of suspicion is required, especially in the postsurgical setting. 2D CT angiography findings are subtle and include direct signs of pedicle rotation on CT as well as indirect findings including loss of normal parenchymal enhancement, atelectasis of torsed lobe/lung, and abnormal fissure position. These direct and indirect findings are often appreciated on different window presets and upon review of images in multiple planes, with need to collate the information subsequently. 3D cinematic rendering (CR) using multi-planar light sources can readily highlight spatial relationships of vasculature in the chest and may be able to assist in the confident diagnosis of this sometimes subtle but life-threatening pathology. We have provided the first characterization of common lung torsion findings on 3D CR.

THU0478 IS NEUROPATHIC PAIN IN INFLAMMATORY RHEUMATIC DISORDERS AN UNDERESTIMATED PROBLEM? RESULTS FROM THE GERMAN PAINDETECT DATABASE

Background:

The aim of the study was to investigate the impact and relevance of neuropathic pain in inflammatory rheumatic disorders (IRD) and osteoarthritis (OA).

Objectives:

Pain is one of the main symptoms in patients with IRD and OA. To enhance a mechanistic based treatment of pain the differentiation between nociceptive and neuropathic pain via screening tools (e.g. painDETECT questionaire) might possibly be helpful. The goal of the study was to investigate (1) if neuropathic pain is a significant burden for patients with IRD and (2) if pain patterns differs from degenerative joint diseases such as OA in over 9.000 patients in each group.

Methods:

painDETECT is a questionnaire that has been evaluated and used in numerous clinical trials to detect neuropathic pain in various diseases. The collected data is centrally managed and evaluated. In total (end of 2019) 395.984 patients have been documented. Out of the painDETECT database 9256 patients with IRD and 9436 patients with OA were extracted, analyzed and compared on their neuropathic pain pattern (screening was performed using the painDETECT-questionaire., PDQ). Secondary parameters were: intensity of pain, functional status, depression, chronicity and sleep disorder. Patients had been recruited from general practitioners (GPs), Rheumatologists, Orthopedics and Neurologists from 862 office-based physicians into the painDETECT-database. This project is an open label registry study in Germany.

Results:

The median PDQ-score of patients with inflammatory rheumatic disorders adds up to 14,2 (1-38) and of OA patients to 13,8. 28.7% of inflammatory rheumatic disorders and 27.2% of OA-patients showed signs for neuropathic pain by positive PDQ. The difference was according to this high patient numbers statistically significant (P=0.0015). VAS-Score, Depressions-Score, Chronicity -Score and Functional -Score showed no clinically relevant differences between these two groups.

Conclusion:

Nearly one third of patients with IRD as well as patients with OA showed neuropathic pain components by using PDQ. Despite increasingly better disease control through more effective therapies, pain still remains a major burden for many patients and has a profound impact on their quality of life. The present data indicate a surprisingly high symptoms of neuropathic pain even in IRD patients and should be considered in the management of our patients. A new documentation system for Rheumatologists (RheumaAssist) could help to address these questions.

Percentage of PDQ-categories (negative/unclear/positive) for patients with inflammatory rheumatic disorders (IRD) or Arthrosis (OA)

Acknowledgments:

This investigation was supported within a grant of Pfizer Deutschland GmbH.

Disclosure of Interests: :

Philipp Sewerin Grant/research support from: AbbVie Deutschland GmbH & Co. KG

Bristol-Myers Squibb Celgene GmbH

Lilly Deutschland GmbH

Novartis Pharma GmbH Pfizer Deutschland GmbH

Rheumazentrum Rhein-Ruhr, Consultant of: AMGEN GmbH AbbVie Deutschland GmbH & Co. KG Biogen GmbHBristol-Myers Squibb Celgene GmbH Chugai Pharma arketing Ltd. / Chugai Europe GmbHHexal Pharma Janssen-CilagGmbH Johnson & Johnson Deutschland GmbHLilly Deutschland GmbH / Lilly Europe / Lilly Global Novartis Pharma GmbH Pfizer Deutschland GmbH Roche Pharma Rheumazentrum Rhein-Ruhr Sanofi-Genzyme Deutschland GmbH Swedish Orphan Biovitrum GmbH UCB Pharma GmbH, Speakers bureau: AMGEN GmbH AbbVie Deutschland GmbH & Co. KG Biogen GmbHBristol-Myers Squibb Celgene GmbH Chugai Pharma arketing Ltd. / Chugai Europe GmbHHexal Pharma Janssen-CilagGmbH Johnson & Johnson Deutschland GmbHLilly Deutschland GmbH / Lilly Europe / Lilly Global Novartis Pharma GmbH Pfizer Deutschland GmbH Roche Pharma Rheumazentrum Rhein-Ruhr Sanofi-Genzyme Deutschland GmbH Swedish Orphan Biovitrum GmbH UCB Pharma GmbH, Rainer Freynhagen Consultant of: AOP Orphan Pharma, Grünenthal, Lilly, Merck, Mitsubishi Tanabe Pharma, Pfizer, Scilex Pharmaceutics

, Speakers bureau: AOP Orphan Pharma, Grünenthal, Lilly, Merck, Mitsubishi Tanabe Pharma, Pfizer, Scilex Pharmaceutics

, Thomas Tölle Consultant of: AOP Orphan, Almiral Hermal, Bionest Partners, Benkitt Renkiser, Grünenthal, Hexal, Indivior, Kaia Health, Lilly, Medscape Mundipharma, MSD, Novartis, Pfizer, Recordati Pharma, Sanofi-Aventis, and TAD Pharma, Speakers bureau: AOP Orphan, Almiral Hermal, Bionest Partners, Benkitt Renkiser, Grünenthal, Hexal, Indivior, Kaia Health, Lilly, Medscape Mundipharma, MSD, Novartis, Pfizer, Recordati Pharma, Sanofi-Aventis, and TAD Pharma, Michael Hammer Consultant of: Abbvie, Pfizer, Medac and Janssen, Speakers bureau: Abbvie, Pfizer, Medac and Janssen, Christoph Baerwald Consultant of: CGB received speaker or consulting fees from AbbVie, Paid instructor for: CGB received speaker or consulting fees from AbbVie, Speakers bureau: CGB received speaker or consulting fees from AbbVie, Jochen Walter Consultant of: Pfizer, Speakers bureau: AbbVie, Frauenhofer Institut, Gilead, Janssen-Cilag, Medac, Novartis, Pfizer, Ralf Schröder Shareholder of: Pfizer Pharma GmbH, Employee of: Pfizer Pharma GmbH, Matthias Schneider Grant/research support from: GSK, UCB, Abbvie, Consultant of: Abbvie, Alexion, Astra Zeneca, BMS, Boehringer Ingelheim, Gilead, Lilly, Sanofi, UCB, Speakers bureau: Abbvie, Astra Zeneca, BMS, Chugai, GSK, Lilly, Pfizer, Sanofi, Ralf Baron Consultant of: RB received speaker or consulting fees from AbbVie, Paid instructor for: RB received speaker or consulting fees from AbbVie, Speakers bureau: RB received speaker or consulting fees from AbbVie

Radiologic Pseudoprogression during Anti-PD-1 Therapy for Advanced Non-Small Cell Lung Cancer

INTRODUCTION

Anti-programmed cell death protein 1 (PD-1) therapy can lead to unconventional tumor responses, including radiologic pseudoprogression. Here we have determined the real-world incidence of radiologic pseudoprogression in advanced NSCLC and compared radiologic response criteria for assessment of disease response.

METHODS

The electronic medical records of all patients with NSCLC who were receiving anti-PD-1 therapy at our institution over a 3-year period were retrospectively reviewed, and patients with clinically suspected radiologic pseudoprogression were identified. Patients without available follow-up imaging or clinical data were excluded. Imaging examinations were then analyzed to determine whether progression was confirmed on subsequent reimaging. Assessments of tumor response by the Response Evaluation Criteria in Solid Tumors (RECIST), version 1.1 (RECIST 1.1), the unidimensional immune-related response criteria (iRRC), and the iRECIST criteria for all patients were performed and compared.

RESULTS

A total of 228 consecutive patients began receiving anti-PD-1 therapy over a 3-year period. Of the 166 of these patients who were evaluable, most (80%) received nivolumab. Fifteen patients (9%) were clinically suspected of having radiologic pseudoprogression on account of tumor enlargement and/or development of new lesions on computed tomography images during the first 4 to 6 weeks of therapy, and they continued receiving anti-PD-1 therapy. Three of these patients (2%) demonstrated evidence of radiologic pseudoprogression at first reimaging. The iRRC and immune RECIST criteria were more accurate in classifying radiologic pseudoprogression as nonprogression; none of the three cases were deemed progression by the iRRC or immune RECIST, whereas all three cases were determined to be progression according to the Response Evaluation Criteria in Solid Tumors, version 1.1.

CONCLUSIONS

Radiologic pseudoprogression is a clinical challenge but an uncommon occurrence in patients with NSCLC who are receiving anti-PD-1 therapy.

Thoracic Imaging of Non-Small Cell Lung Cancer Treated With Anti-programmed Death Receptor-1 Therapy

PURPOSE

Treatment with anti-programmed death receptor-1 (PD-1) therapeutics can lead to unconventional responses and side effect profiles due to their potentiating effects on the immune system. Here we evaluate the radiologic manifestations of anti-PD-1 therapy in the chest in patients with non-small cell lung cancer (NSCLC) receiving anti-PD-1 therapy.

MATERIALS AND METHODS

A retrospective review of real-world clinical practice was conducted of all the patients with NSCLC receiving anti-PD-1 therapy at our institution between 2013 and 2016. All patients without adequate clinical or radiologic follow-up data in the electronic medical records were excluded. Imaging examinations for all patients deemed by their thoracic oncologists to have radiologic pseudoprogression or therapy-associated pneumonitis were reviewed by experienced thoracic radiologists.

RESULTS

A total of 166 patients with NSCLC had available clinical and imaging data for retrospective review. Of these patients, 4 (2%) were considered to have radiologic pseudoprogression, 3 of which manifested as increased tumor size and 1 of which manifested with new lesions. A total of 5 patients (3%) were clinically deemed to have pneumonitis attributable to anti-PD-1 therapy, 4 of which had radiologic manifestations on computed tomography.

CONCLUSION

Radiologic pseudoprogression and drug-induced pneumonitis are uncommon but important manifestations of anti-PD-1 therapy on thoracic imaging.

[Intra-articular injection of cortisone]

Intra-articular injections with glucocorticoids are standard procedures according to therapy guidelines in many rheumatic conditions. There is increasing evidence from clinical trials on the treatment of rheumatoid arthritis that more patients will attain the target of remission using a combination of systemic medication and intra-articular injections with glucocorticoids compared to systemic medication alone. Intra-articular injections with glucocorticoids play an important role in the therapeutic management of pediatric rheumatic diseases. In many countries competency in performing intra-articular injections is among the important skills necessary for certification as a specialist in rheumatology.

Effects of mono-2-ethylhexyl phthalate on the respiratory tract in BALB/c mice

Airborne mono-2-ethylhexyl phthalate (MEHP) was studied for acute airway effects using a bioassay with BALB/c mice. Concentration-and time-dependent effects were obtained by continuous monitoring of the breathing pattern during exposure to 0.3-43.6 mg/m3 MEHP for 60 min. Additionally, inflammatory effects of MEHP were studied from bronchoalveolar lavage (BAL) fluid. MEHP showed no upper airway irritating effect. Lower airway irritation was apparent from a concentration-dependent decrease in tidal volume (shallow respiration) with a no-observed effect level (NOEL) of 0.3 mg/m3. The respiratory rate reached a maximum at about 8 mg/m3, demonstrating a rapid shallow breathing pattern. At concentrations above 4.9 mg/m3, the time of pause, another marker of lung irritation, increased concentration-dependently, resulting in a decrease in respiratory rate at high exposure levels. BAL fluid obtained from 0 to 72 hours after a 60 min exposure to 30 mg/m3 MEHP showed that the number of macrophage reached maximum about 16 hours after exposure. The NOEL was 1.7 mg/m3. BAL content of neutrophils, lymphocytes, eosinophils and epithelial cells was normal after exposure to 30 or 1.7 mg/m3 MEHP. Based on worst case inhalation scenario in the general population, no airway irritation is expected from non-occupational levels of MEHP originating from DEHP.

A Resident Perspective on Adding Value as Radiologists

During the annual 46th annual American Alliance of Academic Chief Residents in Radiology (A(3)CR(2)) meeting in New Orleans, chief residents discussed the role of residents within American College of Radiology 3.0 campaign. Our discussion was directed toward the evolving role of fourth-year radiology residents and how we might improve their training to better prepare them to add value as both leaders and radiologists. The ideas resulting from our Problem Solving session were divided into three categories: clinical presence in the wards and subspecialty clinics; visibility to clinicians and patients; and the education of medical students, residents, and advanced practice clinicians to aid in realizing the long-term goals of Imaging 3.0.

The symptom phenotype of oncology outpatients remains relatively stable from prior to through 1 week following chemotherapy

Some oncology outpatients experience a higher number of and more severe symptoms during chemotherapy (CTX). However, little is known about whether this high risk phenotype persists over time. Latent transition analysis (LTA) was used to examine the probability that patients remained in the same symptom class when assessed prior to the administration of and following their next dose of CTX. For the patients whose class membership remained consistent, differences in demographic and clinical characteristics, and quality of life (QOL) were evaluated. The Memorial Symptom Assessment Scale (MSAS) was used to evaluate symptom burden. LTA was used to identify subgroups of patients with distinct symptom experiences based on the occurrence of the MSAS symptoms. Of the 906 patients evaluated, 83.9% were classified in the same symptom occurrence class at both assessments. Of these 760 patients, 25.0% were classified as Low-Low, 44.1% as Moderate-Moderate and 30.9% as High-High. Compared to the Low-Low class, the other two classes were younger, more likely to be women and to report child care responsibilities, and had a lower functional status and a higher comorbidity scores. The two higher classes reported lower QOL scores. The use of LTA could assist clinicians to identify higher risk patients and initiate more aggressive interventions.

Assessment of the diagnostic value of dual-energy CT and MRI in the detection of iatrogenically induced injuries of anterior cruciate ligament in a porcine model

INTRODUCTION

Magnetic resonance imaging (MRI) is the standard of reference for the non-invasive evaluation of ligament injuries of the knee. The development of dual-energy CT (DE-CT) made it possible to differentiate between tissues of different density by two simultaneous CT measurements with different tube voltages. This approach enables DE-CT to discriminate ligament structures without intra-articular contrast media injection. The aims of this study were on the one hand to determine the delineation of the anterior cruciate ligament (ACL) and on the other hand to assess the diagnostic value of DE-CT and MRI in the detection of iatrogenically induced injury of the ACL in a porcine knee joint model.

MATERIALS AND METHODS

Twenty porcine hind legs, which were placed in a preformed cast in order to achieve a standardized position, were scanned using DE-CT. Thereafter, a 1.5-T MRI using a standard protocol was performed. The imaging procedures were repeated with the same parameters after inducing defined lesions (total or partial incision) on the ACL arthroscopically. After post-processing, two radiologists and two orthopedic surgeons first analyzed the delineation of the ACL and then, using a consensus approach, the iatrogenically induced lesions. The result of the arthrotomy was defined as the standard of reference.

RESULTS

The ACL could be visualized both on DE-CT and MRI in 100% of the cases. As for the MRI, the sensitivity and specificity of detecting the cruciate ligament lesion respectively compared with the defined arthrotomy was 66.7% and 78.6% for intact cruciate ligaments, 100% and 75% in the case of a complete lesion, 33.3% and 78.6% for lesions of the anteromedial bundle, and 0% and 100% for lesions of the posterolateral bundle. In comparison, DE-CT demonstrated a sensitivity and specificity of 66.7% and 71.4% in the case of intact cruciate ligaments, 75% and 68.8% in the case of completely discontinued ACLs, 0% and 92.9% in the case of lesions of the anteromedial bundle, and 25% and 87.5% in the case of lesions of the posterolateral bundle.

CONCLUSIONS

The present ex vivo experiment shows that both study modalities (DE-CT and MRI) are equal with regard to the delineation of the ACL, while MRI achieved higher sensitivity and specificity regarding iatrogenically induced complete ACL lesions. DE-CT could be a possible alternative to MRI for certain indications in the diagnosis of a knee ligament injury.

Perineuromal stimulation in the treatment of occipital neuralgia: a case study

This case study is presented to exemplify the application of a perineuromal approach in the treatment of recalcitrant occipital neuralgia. The patient was a 49-year-old female with severe and disabling occipital neuralgia. The pain persisted despite several surgical procedures, injections in the affected area, and medications. Threading the electrode into the cervical epidural space and attempts at peripheral stimulation using the Weiner and Reed approach were unsuccessful. Immediate benefit was derived when the electrode was advanced subcutaneously and positioned underneath the neuroma apparently created by a C2 nerve transection. A Medtronic Octad (model #3898) was utilized. The patient was contacted at seven and nine months post implantation. She reported 90% improvement in her pain. The improvements were also noted in numerical pain ratings, Beck Depression Inventory, and Oswestry Disability Scale. These improvements were corroborated by her husband. The Minnesota Multiphasic Personality Inventory (MMPI) remained relatively unchanged. This case illustrates the possible utilization of perineuromal stimulation in the treatment of occipital neuralgia. The specific mechanism of action remains unclear. Replication and controlled studies are required to determine the general applicability of this approach.

Dissolution and pharmacokinetics of a novel micronized aspirin formulation

Aspirin (acetylsalicylic acid, ASA) has been used as an analgesic, antipyretic and antiinflammatory drug for many years. A new 500 mg aspirin tablet formulation containing micronized active ingredient and an effervescent component has been developed for potential improvement in the onset of action for acute pain treatment. This paper describes the dissolution and the pharmacokinetics of the new formulation in comparison with regular aspirin tablets, aspirin granules and aspirin effervescent tablets. Micronized aspirin tablets dissolve significantly faster over a pH range from 1.2 to 6.8 compared to regular 500 mg aspirin tablets. Plasma concentration time curve comparison to regular 500 mg aspirin tablets showed a substantial improvement in the time to maximum plasma concentrations (T(max)) (ASA 17.5 min vs. 45 min) and an increase in maximum plasma concentration (C(max)) (ASA 13.8 μg/ml vs. 4.4 μg/ml) while the overall extent of exposure (AUC) remains almost unchanged. The data suggest a potential improvement for onset of action in treating acute pain with the new micronized aspirin formulation.

Patient-reported outcomes are superior in patients with Type 2 diabetes treated with liraglutide as compared with exenatide, when added to metformin, sulphonylurea or both: results from a randomized, open-label study

AIMS

The Liraglutide Effect and Action in Diabetes 6 trial was an open-label trial comparing liraglutide with exenatide as an 'add-on' to metformin and/or sulphonylurea.

METHODS

Patients with Type 2 diabetes were randomized to liraglutide 1.8 mg once daily or exenatide 10 μg twice daily for 26 weeks. This was followed by a 14-week extension phase, in which all patients received liraglutide 1.8 mg once daily.

RESULTS

Patient-reported outcomes were measured in 379 patients using Diabetes Treatment Satisfaction Questionnaire status (DTSQs) and DTSQ change (DTSQc). The change in overall treatment satisfaction (DTSQs score) from baseline at week 26 with liraglutide was 4.71 and with exentaide was 1.66 [difference between groups 3.04 (95% CI 1.73-4.35), P<0.0001]. Five of the six items on the DTSQs improved significantly more with liraglutide than with exenatide (differences: current treatment 0.37, P=0.0093; convenience 0.68, P<0.0001; flexibility 0.57, P=0.0002; recommend 0.49, P=0.0003; continue 0.66, P=0.0001). Patients perceived a greater reduction in hypoglycaemia at week 26 with liraglutide than with exenatide [difference in DTSQc score 0.48 (0.08-0.89), P=0.0193] and a greater reduction in perceived hyperglycaemia [difference 0.74 (0.31-1.17), P=0.0007]. During the extension phase, when all patients received liraglutide, DTSQs scores remained stable in patients who continued on liraglutide and increased significantly (P=0.0026) in those switching from exenatide.

CONCLUSIONS

These results demonstrate significant improvements in patients' treatment satisfaction with liraglutide compared with exenatide.