Guiding Attention via a Cognitive Aid During a Simulated In-Hospital Cardiac Arrest Scenario: A Salience Effort Expectancy Value Model Analysis

OBJECTIVE

To investigate the effect of a cognitive aid on the visual attention distribution of the operator using the Salience Effort Expectancy Value (SEEV) model.

BACKGROUND

Cognitive aids aim to support an operator during the execution of a task. The effect of cognitive aids on performance is frequently evaluated but whether a cognitive aid improved, for example, attention distribution has not been considered.

METHOD

We built the Expectancy Value (EV) model version which can be considered to indicate optimal attention distribution for a given event. We analyzed the eye tracking data of emergency physicians while using a cognitive aid application versus no application during a simulated in-hospital cardiac arrest scenario.

RESULTS

The EV model could fit the attention distribution in such a simulated emergency situation. Partially supporting our hypothesis, the cognitive aid application group showed a significantly better EV model fit than the no application group in the first phases of the event, but a worse fit in the last phase.

CONCLUSION

We demonstrated that a cognitive aid affected attention distribution and that the SEEV model provides the means of capturing these effects. We suggest that the aid supported and improved visual attention distribution in the stressful first phases of a cardiopulmonary resuscitation but may have focused attention on objects that are relevant for lower priority goals in the last phase.

APPLICATION

The SEEV model can provide insights into expected and unexpected effects of cognitive aids on visual attention distribution and may help to design better artifacts.

Change in Splenic Volume as a Surrogate Marker for Immunotherapy Response in Patients with Advanced Urothelial and Renal Cell Carcinoma-Evaluation of a Novel Approach of Fully Automated Artificial Intelligence Based Splenic Segmentation

BACKGROUND

In the treatment of advanced urothelial (aUC) and renal cell carcinoma (aRCC), biomarkers such as PD-1 and PD-L1 are not robust prognostic markers for immunotherapy (IO) response. Previously, a significant association between IO and a change in splenic volume (SV) was described for several tumour entities. To the best of our knowledge, this study presents the first correlation of SV to IO in aUC and aRCC.

METHODS

All patients with aUC (05/2017-10/2021) and aRCC (01/2012-05/2022) treated with IO at our academic centre were included. SV was measured at baseline, 3 and 9 months after initiation of IO using an in-house developed convolutional neural network-based spleen segmentation method. Uni- and multivariate Cox regression models for overall survival (OS) and progression-free survival (PFS) were used.

RESULTS

In total, 35 patients with aUC and 30 patients with aRCC were included in the analysis. Lower SV at the three-month follow-up was significantly associated with improved OS in the aRCC group.

CONCLUSIONS

We describe a new, innovative artificial intelligence-based approach of a radiological surrogate marker for IO response in aUC and aRCC which presents a promising new predictive imaging marker. The data presented implicate improved OS with lower follow-up SV in patients with aRCC.

Portal hypertension in patients with hepatocellular carcinoma and immunotherapy: prognostic relevance of CT-morphologic estimates

BACKGROUND

Clinically significant portal hypertension (CSPH) has been identified as an important prognostic factor in patients with hepatocellular carcinoma (HCC) undergoing curative treatment. This study aimed to assess PH estimates as prognostic factors in patients with HCC treated with immunotherapy.

METHODS

All patients with HCC treated with an immunotherapeutic agent in first or subsequent lines at our tertiary care center between 2016 and 2021 were included (n = 50). CSPH was diagnosed using the established PH score for non-invasive PH estimation in pre-treatment CT data (cut-off ≥ 4). Influence of PH on overall survival (OS) and progression-free survival (PFS) was assessed in uni- and multivariable analyses.

RESULTS

Based on the PH score, 26 patients (52.0%) were considered to have CSPH. After treatment initiation, patients with CSPH had a significantly impaired median OS (4.1 vs 33.3 months, p < 0.001) and a significantly impaired median PFS (2.7 vs 5.3 months, p = 0.02). In multivariable Cox regression, CSPH remained significantly associated with survival (HR 2.9, p = 0.015) when adjusted for established risk factors.

CONCLUSIONS

Non-invasive assessment of CSPH using routine CT data yielded an independent prognostic factor in patients with HCC and immunotherapy. Therefore, it might function as an additional imaging biomarker to detect high-risk patients with poor survival and possibly for treatment decision making.

Radiomics-Based Prediction of Future Portal Vein Tumor Infiltration in Patients with HCC-A Proof-of-Concept Study

Portal vein infiltration (PVI) is a typical complication of HCC. Once diagnosed, it leads to classification as BCLC C with an enormous impact on patient management, as systemic therapies are henceforth recommended. Our aim was to investigate whether radiomics analysis using imaging at initial diagnosis can predict the occurrence of PVI in the course of disease. Between 2008 and 2018, we retrospectively identified 44 patients with HCC and an in-house, multiphase CT scan at initial diagnosis who presented without CT-detectable PVI but developed it in the course of disease. Accounting for size and number of lesions, growth type, arterial enhancement pattern, Child-Pugh stage, AFP levels, and subsequent therapy, we matched 44 patients with HCC who did not develop PVI to those developing PVI in the course of disease (follow-up ended December 2021). After segmentation of the tumor at initial diagnosis and texture analysis, we used LASSO regression to find radiomics features suitable for PVI detection in this matched set. Using an 80:20 split between training and holdout validation dataset, 17 radiomics features remained in the fitted model. Applying the model to the holdout validation dataset, sensitivity to detect occurrence of PVI was 0.78 and specificity was 0.78. Radiomics feature extraction had the ability to detect aggressive HCC morphology likely to result in future PVI. An additional radiomics evaluation at initial diagnosis might be a useful tool to identify patients with HCC at risk for PVI during follow-up benefiting from a closer surveillance.

Photon-counting detector CT improves quality of arterial phase abdominal scans: A head-to-head comparison with energy-integrating CT

PURPOSE

Photon-counting detector (PCD)-CT is expected to have a substantial impact on oncologic abdominal imaging. We compared subjective and objective image quality between PCD-CT and conventional energy-integrating detector (EID-)CT arterial phase abdominal scans.

METHODS

This study included 84 patients undergoing both types of abdominal CT. EID-CT scans were acquired with a tube voltage of 100 kVp. With PCD-CT, acquired with 120-kVp, we reconstructed polychromatic T3D images and virtual monoenergetic images (VMIs) in 10-keV intervals from 40 to 90 keV. Quantitative image analysis included noise and contrast-to-noise ratio (CNR) of hepatic vessels, kidney cortex, and hypervascular liver lesions to liver parenchyma. Three raters used a 5-point Likert scale for qualitative image analysis of image noise and contrast, lesion conspicuity, and overall image quality. Radiation dose exposure (CT dose index) was compared between the two CT types.

RESULTS

Mean CT dose index and effective dose were respectively 18 % and 26 % lower with PCD-CT versus EID-CT. Compared with EID-CT, CNRs of kidney cortex and vessel to liver parenchyma were significantly higher in PCD-CT VMIs at energies ≤ 60 keV and in polychromatic T3D images (p < 0.004). Overall image quality of PCD-CT VMIs at 50 and 60 keV was rated as significantly better (p < 0.01) than the EID-CT images (inter-reader agreement alpha = 0.80). Lesion conspicuity was significantly better in low-keV VMIs (p < 0.03) and worse in > 70-keV VMIs.

CONCLUSIONS

With low-keV VMI, PCD-CT yields significantly improved objective and subjective quality of arterial phase oncological imaging compared with EID-CT. This advantage may translate into higher diagnostic confidence and lower radiation dose protocols.

Qualitative evaluation of postdoctoral trainee and faculty advisor experiences within a research-intensive school of pharmacy

BACKGROUND

Postdoctoral trainees play a vital role in securing grant funding, building alliances, and mentoring graduate students under the guidance of a mentor who can help develop their intellectual independence. However, the experiences of postdoctoral trainees, particularly within health professions schools, is largely unexplored. The purpose of this study was to investigate the experiences of postdoctoral trainees and faculty advisors at a public four-year school of pharmacy and identify areas of opportunity to improve postdoctoral training.

METHODS

Focus groups and interviews were conducted to elicit participants' experiences, perceptions, and suggestions for improvement. Stakeholder groups included postdoctoral trainees and faculty who serve as postdoctoral advisors. Thematic coding was used to identify semantic themes, and summaries of participant perceptions were generated. Results were mapped to the identity-trajectory framework.

RESULTS

Participants described various experiences related to intellectual growth, networking opportunities, and institutional support. In addition, participant agency was critical for developing career goals and navigating transitions. COVID-19 introduced unique challenges associated with transitioning to remote work and managing goals/motivation. Areas of opportunity were identified, such as improving infrastructure, enhancing mentoring, and enhancing communication.

CONCLUSION

Postdoctoral trainees play a critical role in the success of academic institutions. Scholarly endeavors that explore postdoctoral experiences, specifically those utilizing qualitative methods, can help pharmacy education better understand and meet the needs of postdoctoral trainees and faculty advisors. This study provides insight into the experiences of postdoctoral scholars and provides evidence for improving these training programs in schools of pharmacy.

The prognostic role of early tumor shrinkage in patients with hepatocellular carcinoma undergoing immunotherapy

Background

Early tumor shrinkage (ETS) has been identified as a promising imaging biomarker for patients undergoing immunotherapy for several cancer entities. This study aimed to validate the potential of ETS as an imaging biomarker for patients undergoing immunotherapy for hepatocellular carcinoma (HCC).

Methods

We screened all patients with HCC that received immunotherapy as the first or subsequent line of treatment at our tertiary care center between 2016 and 2021. ETS was defined as the reduction in the sum of the sizes of target lesions, between the initial imaging and the first follow-up. The ETS was compared to the radiologic response, according to the modified response evaluation criteria in solid tumors (mRECIST). Furthermore, we evaluated the influence of ETS on overall survival (OS), progression-free survival (PFS), and the alpha-fetoprotein (AFP) response.

Results

The final analysis included 39 patients with available cross-sectional imaging acquired at the initiation of immunotherapy (baseline) and after 8–14 weeks. The median ETS was 5.4%. ETS was significantly correlated with the response according to mRECIST and with the AFP response. Patients with an ETS ≥10% had significantly longer survival times after the first follow-up, compared to patients with < 10% ETS (15.1 months vs. 4.0 months, p = 0.008). Additionally, patients with both an ETS ≥10% and disease control, according to mRECIST, also had significantly prolonged PFS times after the initial follow-up (23.6 months vs. 2.4 months, p < 0.001).

Conclusion

ETS was strongly associated with survival outcomes in patients with HCC undergoing immunotherapy. Thus, ETS is a readily assessable imaging biomarker that showed potential for facilitating a timely identification of patients with HCC that might benefit from immunotherapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40644-022-00487-x.

Baseline Splenic Volume Outweighs Immuno-Modulated Size Changes with Regard to Survival Outcome in Patients with Hepatocellular Carcinoma under Immunotherapy

Simple Summary

Splenic volume (SV) has been identified as a highly predictive parameter for prognosis in patients with hepatocellular carcinoma (HCC). Moreover, an association between immunotherapy and an increase in SV has been described for various types of cancer. In our cohort of patients with HCC under immunotherapy, SV was a highly predictive factor for overall survival at baseline and initial follow-up. Although a large proportion of patients (76%) showed an SV increase after the initiation of immunotherapy, this additional immuno-modulated SV change was negligible compared to long-standing changes in the splanchnic circulation in our patient cohort.

Abstract

Background: An association between immunotherapy and an increase in splenic volume (SV) has been described for various types of cancer. SV is also highly predictive of overall survival (OS) in patients with hepatocellular carcinoma (HCC). We evaluated SV and its changes with regard to their prognostic influence in patients with HCC undergoing immunotherapy. Methods: All patients with HCC who received immunotherapy in first or subsequent lines at our tertiary care center between 2016 and 2021 were screened for eligibility. SV was assessed at baseline and follow-up using an AI-based tool for spleen segmentation. Patients were dichotomized into high and low SV based on the median value. Results: Fifty patients were included in the analysis. The median SV prior to treatment was 532 mL. The median OS of patients with high and low SV was 5.1 months and 18.1 months, respectively (p = 0.01). An increase in SV between treatment initiation and the first follow-up was observed in 28/37 (75.7%) patients with follow-up imaging available. This increase in itself was not prognostic for median OS (7.0 vs. 8.5 months, p = 0.73). However, patients with high absolute SV at the first follow-up continued to have impaired survival (4.0 months vs. 30.7 months, p = 0.004). Conclusion: High SV prior to and during treatment was a significant prognostic factor for impaired outcome. Although a large proportion of patients showed an SV increase after the initiation of immunotherapy, this additional immuno-modulated SV change was negligible compared to long-standing changes in the splanchnic circulation in patients with HCC.

Tumor Burden in Patients With Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization: Head-to-Head Comparison of Current Scoring Systems

Objectives

Recently, several scoring systems for prognosis prediction based on tumor burden have been promoted for patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). This multicenter study aimed to perform the first head-to-head comparison of three scoring systems.

Methods

We retrospectively enrolled 849 treatment-naïve patients with HCC undergoing TACE at six tertiary care centers between 2010 and 2020. The tumor burden score (TBS), the Six-and-Twelve score (SAT), and the Seven-Eleven criteria (SEC) were calculated based on the maximum lesion size and the number of tumor nodes. All scores were compared in univariate and multivariate regression analyses, adjusted for established risk factors.

Results

The median overall survival (OS) times were 33.0, 18.3, and 12.8 months for patients with low, medium, and high TBS, respectively (p<0.001). The median OS times were 30.0, 16.9, and 10.2 months for patients with low, medium, and high SAT, respectively (p<0.001). The median OS times were 27.0, 16.7, and 10.5 for patients with low, medium, and high SEC, respectively (p<0.001). In a multivariate analysis, only the SAT remained an independent prognostic factor. The C-Indexes were 0.54 for the TBS, 0.59 for the SAT, and 0.58 for the SEC.

Conclusion

In a direct head-to-head comparison, the SAT was superior to the TBS and SEC in survival stratification and predictive ability. Therefore, the SAT can be considered when estimating the tumor burden. However, all three scores showed only moderate predictive power. Therefore, tumor burden should only be one component among many in treatment decision making.

Quantitative washout in patients with hepatocellular carcinoma undergoing TACE: an imaging biomarker for predicting prognosis?

BACKGROUND

The delayed percentage attenuation ratio (DPAR) was recently identified as a novel predictor of an early complete response in patients with hepatocellular carcinoma (HCC) undergoing transarterial chemoembolization (TACE). In this study, we aimed to validate the role of DPAR as a predictive biomarker for short-, mid-, and long-term outcomes after TACE.

METHODS

We retrospectively reviewed laboratory and imaging data for 103 treatment-naïve patients undergoing initial TACE treatment at our tertiary care center between January 2016 and November 2020. DPAR and other washin and washout indices were quantified in the triphasic computed tomography performed before the initial TACE. The correlation of DPAR and radiologic response was investigated. Furthermore, the influence of DPAR on the 6-, 12-, 18-, and 24-month survival rates and the median overall survival (OS) was compared to other established washout indices and estimates of tumor burden and remnant liver function.

RESULTS

The DPAR was significantly of the target lesions (TLs) with objective response to TACE after the initial TACE session was significantly higher compared to patients with stable disease (SD) or progressive disease (PD) (125 (IQR 118-134) vs 110 (IQR 103-116), p < 0.001). Furthermore, the DPAR was significantly higher in patients who survived the first 6 months after TACE (122 vs. 115, p = 0.04). In addition, the number of patients with a DPAR > 120 was significantly higher in this group (n = 38 vs. n = 8; p = 0.03). However, no significant differences were observed in the 12-, 18-, and 24-month survival rates after the initial TACE. Regarding the median OS, no significant difference was observed for patients with a high DPAR compared to those with a low DPAR (18.7 months vs. 12.7 months, p = 0.260).

CONCLUSIONS

Our results confirm DPAR as the most relevant washout index for predicting the short-term outcome of patients with HCC undergoing TACE. However, DPAR and the other washout indices were not predictive of mid- and long-term outcomes.

Fully automated AI-based splenic segmentation for predicting survival and estimating the risk of hepatic decompensation in TACE patients with HCC

OBJECTIVES

Splenic volume (SV) was proposed as a relevant prognostic factor for patients with hepatocellular carcinoma (HCC). We trained a deep-learning algorithm to fully automatically assess SV based on computed tomography (CT) scans. Then, we investigated SV as a prognostic factor for patients with HCC undergoing transarterial chemoembolization (TACE).

METHODS

This retrospective study included 327 treatment-naïve patients with HCC undergoing initial TACE at our tertiary care center between 2010 and 2020. A convolutional neural network was trained and validated on the first 100 consecutive cases for spleen segmentation. Then, we used the algorithm to evaluate SV in all 327 patients. Subsequently, we evaluated correlations between SV and survival as well as the risk of hepatic decompensation during TACE.

RESULTS

The algorithm showed Sørensen Dice Scores of 0.96 during both training and validation. In the remaining 227 patients assessed with the algorithm, spleen segmentation was visually approved in 223 patients (98.2%) and failed in four patients (1.8%), which required manual re-assessments. Mean SV was 551 ml. Survival was significantly lower in patients with high SV (10.9 months), compared to low SV (22.0 months, p = 0.001). In contrast, overall survival was not significantly predicted by axial and craniocaudal spleen diameter. Furthermore, patients with a hepatic decompensation after TACE had significantly higher SV (p < 0.001).

CONCLUSION

Automated SV assessments showed superior survival predictions in patients with HCC undergoing TACE compared to two-dimensional spleen size estimates and identified patients at risk of hepatic decompensation. Thus, SV could serve as an automatically available, currently underappreciated imaging biomarker.

KEY POINTS

• Splenic volume is a relevant prognostic factor for prediction of survival in patients with HCC undergoing TACE, and should be preferred over two-dimensional surrogates for splenic size. • Besides overall survival, progression-free survival and hepatic decompensation were significantly associated with splenic volume, making splenic volume a currently underappreciated prognostic factor prior to TACE. • Splenic volume can be fully automatically assessed using deep-learning methods; thus, it is a promising imaging biomarker easily integrable into daily radiological routine.

Natural language processing of radiology reports to investigate the effects of the COVID-19 pandemic on the incidence and age distribution of fractures

OBJECTIVE

During the COVID-19 pandemic, the number of patients presenting in hospitals because of emergency conditions decreased. Radiology is thus confronted with the effects of the pandemic. The aim of this study was to use natural language processing (NLP) to automatically analyze the number and distribution of fractures during the pandemic and in the 5 years before the pandemic.

MATERIALS AND METHODS

We used a pre-trained commercially available NLP engine to automatically categorize 5397 radiological reports of radiographs (hand/wrist, elbow, shoulder, ankle, knee, pelvis/hip) within a 6-week period from March to April in 2015-2020 into "fracture affirmed" or "fracture not affirmed." The NLP engine achieved an F₁ score of 0.81 compared to human annotators.

RESULTS

In 2020, we found a significant decrease of fractures in general (p < 0.001); the average number of fractures in 2015-2019 was 295, whereas it was 233 in 2020. In children and adolescents (p < 0.001), and in adults up to 65 years (p = 0.006), significantly fewer fractures were reported in 2020. The number of fractures in the elderly did not change (p = 0.15). The number of hand/wrist fractures (p < 0.001) and fractures of the elbow (p < 0.001) was significantly lower in 2020 compared with the average in the years 2015-2019.

CONCLUSION

NLP can be used to identify relevant changes in the number of pathologies as shown here for the use case fracture detection. This may trigger root cause analysis and enable automated real-time monitoring in radiology.

Prevalence and clinical significance of clinically evident portal hypertension in patients with hepatocellular carcinoma undergoing transarterial chemoembolization

Background

Clinically evident portal hypertension (CEPH) was previously identified as a prognostic factor for patients with hepatocellular carcinoma (HCC). However, little is known about the prognostic influence of CEPH on the long‐term outcome of patients with HCC undergoing transarterial chemoembolization (TACE), particularly in Western populations.

Objectives

This study investigated the prevalence and prognostic influence of CEPH in a Western population of patients with HCC undergoing TACE.

Methods

This retrospective study included 349 treatment‐naïve patients that received initial TACE treatment at our tertiary care center between January 2010 and November 2020. CEPH was defined as a combination of ascites, esophageal/gastric varices, splenomegaly and a low platelet count. We assessed the influence of CEPH and its defining factors on median overall survival (OS) in HCC patients. We compared the effects of CEPH to those of well‐known prognostic factors.

Results

Of the 349 patients included, 304 (87.1%) patients had liver cirrhosis. CEPH was present in 241 (69.1%) patients. The median OS times were 10.6 months for patients with CEPH and 17.1 months for patients without CEPH (log rank p = 0.036). Median OS without a present surrogate was 17.1 months, while patients with one respectively more than two present CEPH surrogates had a median OS of 10.8 and 9.4 months (log rank p = 0.053). In multivariate analysis, CEPH was no significant risk factor for OS (p = 0.190). Of the CEPH‐defining factors, only ascites reached significance in a univariate analysis.

Conclusion

CEPH was present in more than two thirds of the patients with HCC undergoing TACE in our cohort of Western patients. Patients with CEPH had a significantly impaired survival in univariate analysis. However, no significance was reached in multivariate analysis. Thus, when TACE treatment is deemed oncologically reasonable, patients should not be excluded from TACE treatment due to the presence of surrogates of portal hypertension alone.

Online teaching in radiology as a pilot model for modernizing medical education: results of an international study in cooperation with the ESR

BACKGROUND

Due to the outbreak of the coronavirus disease 2019 (COVID-19), it proved necessary to rapidly change medical education from on-site to online teaching. Thus, medical educators were forced to rethink the purpose of teaching and the best form of transmission of knowledge. In cooperation with the European Society of Radiology (ESR), we investigated the attitudes of radiologists in Europe and North America toward innovative online teaching concepts.

METHODS

In total, 224 radiologists from 31 different countries participated in our cross-sectional, web-based survey study. On a 7-point Likert scale, participants had to answer 27 questions about the online teaching situation before/during the pandemic, technical and social aspects of online teaching and the future role of online teaching in radiology.

RESULTS

An overwhelming majority stated that radiology is particularly well-suited for online teaching (91%), that online teaching should play a more prominent role after the pandemic (73%) and that lecturers should be familiar with online teaching techniques (89%). Difficulties include a higher workload in preparing online courses (59%), issues with motivating students to follow online courses (56%) and the risk of social isolation (71%). Before the pandemic, only 12% of teaching was provided online; for the future, our participants deemed a proportion of approximately 50% online teaching appropriate.

CONCLUSION

Our participants are open-minded about online teaching in radiology. As the best way of transferring knowledge in medical education is still unclear, online teaching offers potential for innovation in radiology education. To support online teaching development, a structured, framework-based "online curriculum" should be established.

Immunonutritive Scoring for Patients with Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization: Evaluation of the CALLY Index

The novel CRP-albumin-lymphocyte (CALLY) index is an improved immunonutritive scoring system, based on serum C-reactive protein (CRP), serum albumin, and the lymphocyte count. It has shown promise as a prognostic index for patients with hepatocellular carcinoma (HCC) undergoing resections. This study evaluated the prognostic ability of the CALLY index for patients with HCC undergoing transarterial chemoembolization (TACE). We retrospectively identified 280 treatment-naïve patients with HCC that underwent an initial TACE at our institution, between 2010 and 2020. We compared the CALLY index to established risk factors in univariate and multivariate regression analyses for associations with median overall survival (OS). A low CALLY score was associated with low median OS (low vs. high CALLY: 9.0 vs. 24.0 months, p < 0.001). In the multivariate analysis, the CALLY index remained an independent prognostic predictor (p = 0.008). Furthermore, all factors of the CALLY index reached significance in univariate and in-depth multivariate analyses. However, the concordance index (C-index) of the CALLY index (0.60) was similar to the C-indices of established immunonutritive and inflammation scoring systems (range: 0.54 to 0.63). In conclusion, the CALLY index showed promise as a stratification tool for patients with HCC undergoing TACE. Notably, the CALLY index was not superior to other immunonutritive and inflammation scoring systems in predicting the median OS. Thus, future studies should re-evaluate the mathematical calculation of the index, particularly the contributions of individual parameters.

Structured reporting of CT scans of patients with trauma leads to faster, more detailed diagnoses: An experimental study

PURPOSE

This study aimed to determine whether structured reports (SRs) reduce reporting time and/or increase the level of detail for trauma CT scans compared to free-text reports (FTRs).

METHOD

Eight radiology residents used SRs and FTRs to describe 14 whole-body CT scans of patients with polytrauma in a simulated emergency room setting. Each resident created both a brief report and a detailed report for each case using one of the two formats. We measured the time to complete the detailed reports and established a scoring system to objectively measure report completeness and the level of detail. Scoring sheets divided the CT findings into main and secondary criteria. Finally, the radiological residents completed a questionnaire on their opinions of the SRs and FTRs.

RESULTS

The detailed SRs were completed significantly faster than the detailed FTRs (mean 19 min vs. 25 min; p < 0.001). The maximum allowance of 25 min was used for 25% of SRs and 59% of FTRs. For brief reports, the SRs contained more secondary criteria than the FTRs (p = 0.001), but no significant differences were detected in main criteria. Study participants rated their own SRs as significantly more time-efficient, concise, and clearly structured compared to the FTRs. However, SRs and FTRs were rated similarly for quality, accuracy, and completeness.

CONCLUSION

We found that SRs for whole-body trauma CT add clinical value compared to FTRs because SRs reduce reporting time and increase the level of detail for trauma CT scans.

Search for Lepton Number and Flavor Violation in K^{+} and π^{0} Decays

Searches for the lepton number violating K^{+}→π^{-}μ^{+}e^{+} decay and the lepton flavor violating K^{+}→π^{+}μ^{-}e^{+} and π^{0}→μ^{-}e^{+} decays are reported using data collected by the NA62 experiment at CERN in 2017-2018. No evidence for these decays is found and upper limits of the branching ratios are obtained at 90% confidence level: B(K^{+}→π^{-}μ^{+}e^{+})<4.2×10^{-11}, B(K^{+}→π^{+}μ^{-}e^{+})<6.6×10^{-11} and B(π^{0}→μ^{-}e^{+})<3.2×10^{-10}. These results improve by 1 order of magnitude over previous results for these decay modes.

How COVID-19 kick-started online learning in medical education-The DigiMed study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic led to far-reaching restrictions of social and professional life, affecting societies all over the world. To contain the virus, medical schools had to restructure their curriculum by switching to online learning. However, only few medical schools had implemented such novel learning concepts. We aimed to evaluate students' attitudes to online learning to provide a broad scientific basis to guide future development of medical education.

METHODS

Overall, 3286 medical students from 12 different countries participated in this cross-sectional, web-based study investigating various aspects of online learning in medical education. On a 7-point Likert scale, participants rated the online learning situation during the pandemic at their medical schools, technical and social aspects, and the current and future role of online learning in medical education.

RESULTS

The majority of medical schools managed the rapid switch to online learning (78%) and most students were satisfied with the quantity (67%) and quality (62%) of the courses. Online learning provided greater flexibility (84%) and led to unchanged or even higher attendance of courses (70%). Possible downsides included motivational problems (42%), insufficient possibilities for interaction with fellow students (67%) and thus the risk of social isolation (64%). The vast majority felt comfortable using the software solutions (80%). Most were convinced that medical education lags behind current capabilities regarding online learning (78%) and estimated the proportion of online learning before the pandemic at only 14%. In order to improve the current curriculum, they wish for a more balanced ratio with at least 40% of online teaching compared to on-site teaching.

CONCLUSION

This study demonstrates the positive attitude of medical students towards online learning. Furthermore, it reveals a considerable discrepancy between what students demand and what the curriculum offers. Thus, the COVID-19 pandemic might be the long-awaited catalyst for a new "online era" in medical education.

The use of a cognitive aid app supports guideline-conforming cardiopulmonary resuscitations: A randomized study in a high-fidelity simulation

Aim

Cardiac arrests require fast, well-timed, and well-coordinated interventions delivered by several staff members. We evaluated a cognitive aid that works as an attentional aid to support specifically the timing and coordination of these interventions. We report the results of an experimental, simulation-based evaluation of the tablet-based cognitive aid in performing guideline-conforming cardiopulmonary resuscitation.

Methods

In a parallel group design, emergency teams (one qualified emergency physician as team leader and one qualified nurse) were randomly assigned to the cognitive aid application (CA App) group or the no application (No App) group and then participated in a simulated scenario of a cardiac arrest. The primary outcome was a cardiopulmonary resuscitation performance score ranging from zero to two for each team based on the videotaped scenarios in relation to twelve performance variables derived from the European Resuscitation Guidelines. As a secondary outcome, we measured the participants’ subjective workload.

Results

A total of 67 teams participated. The CA App group (n = 32 teams) showed significantly better cardiopulmonary resuscitation performance than the No App group (n = 31 teams; mean difference = 0.23, 95 %CI = 0.08 to 0.38, p = 0.002, d = 0.83). The CA App group team leaders indicated significantly less mental and physical demand and less effort to achieve their performance compared to the No App group team leaders.

Conclusions

Among well-trained in-hospital emergency teams, the cognitive aid could improve cardiopulmonary resuscitation coordination performance and decrease mental workload.

Pneumatosis intestinalis and porto-mesenteric venous gas: a multicenter study

BACKGROUND

Estimating the prognosis of patients with pneumatosis intestinalis (PI) and porto-mesenteric venous gas (PMVG) can be challenging. The purpose of this study was to refine prognostication to improve decision making in daily clinical routine.

METHODS

A total of 290 patients with confirmed PI were included in the final analysis. The presence of PMVG and mortality (90d follow-up) were evaluated with regard to the influence of possible risk factors. Furthermore, a linear estimation model was devised combining significant parameters to calculate accuracies for predicting death in patients undergoing surgery by means of a defined operation point (ROC-analysis).

RESULTS

Overall, 90d mortality was 55.2% (160/290). In patients with PI only, mortality was 46.5% (78/168) and increased significantly to 67.2% (82/122) in combination with PMVG (median survival: PI: 58d vs. PI and PMVG: 41d; p < 0.001). In the entire patient group, 53.5% (155/290) were treated surgically with a 90d mortality of 58.8% (91/155) in this latter group, while 90d mortality was 51.1% (69/135) in patients treated conservatively. In the patients who survived > 90d treated conservatively (24.9% of the entire collective; 72/290) PMVG/PI was defined as "benign"/reversible. PMVG, COPD, sepsis and a low platelet count were found to correlate with a worse prognosis helping to identify patients who might not profit from surgery, in this context our calculation model reaches accuracies of 97% specificity, 20% sensitivity, 90% PPV and 45% NPV.

CONCLUSION

Although PI is associated with high morbidity and mortality, "benign causes" are common. However, in concomitant PMVG, mortality rates increase significantly. Our mathematical model could serve as a decision support tool to identify patients who are least likely to benefit from surgery, and to potentially reduce overtreatment in this subset of patients.

Liver Resection for Intrahepatic Cholangiocarcinoma-Single-Center Experience with 286 Patients Undergoing Surgical Exploration over a Thirteen Year Period

Background: Intrahepatic cholangiocarcinoma (iCCA) accounts for about 10% of primary liver cancer. Surgery is the only potentially curative treatment. We report on our current series of 229 consecutive hepatic resections for iCCA, which is one of the largest Western single-center series published so far. Methods: Between January 2008 to December 2020, a total of 286 patients underwent 307 surgical explorations for intended liver resection of iCCA at our department. Data were analyzed with regard to (1) preoperative treatment of tumor, (2) operative details, (3) perioperative morbidity and mortality, (4) histopathology, (5) outcome measured by tumor recurrence, treatment of recurrence and survival and (6) prognostic factors for overall and disease-free survival. Results: the resectability rate was 74.6% (229/307). In total, 202 primary liver resections, 21 repeated, 5 re-repeated, and 1 re-re-repeated liver resections were performed. In primary liver resections there were 77% (155/202) major hepatectomies. In 39/202 (20%) of patients additional hepatic wedge resections and in 87/202 (43%) patients additional 119 other surgical procedures were performed next to hepatectomy. Surgical radicality in first liver resections was 166 R0-, 33 R1- and 1 R2-resection. Following the first liver resection, the calculated 1-, 3- and 5-year-survival is 80%, 39%, and 22% with a median survival of 25.8 months. Until the completion of data acquisition, tumors recurred in 123/202 (60.9%) patients after a median of 7.5 months (range 1–87.2 months) after resection. A multivariate cox regression revealed tumor size (p < 0.001), T stage (p < 0.001) and N stage (p = 0.003) as independent predictors for overall survival. N stage (p = 0.040), preoperative therapy (p = 0.005), T stage (p = 0.004), tumor size (p = 0.002) and M stage (p = 0.001) were independent predictors for recurrence-free survival. Conclusions: For complete surgical removal, often extended liver resection in combination with complex vascular or biliary reconstruction is required. However, despite aggressive surgery, tumor recurrence is frequent and long-term oncological results are poor. This indicated that surgery alone is unlikely to make great strides in improving prognosis of patients with iCCA, instead clearly suggesting that liver resection should be incorporated in multimodal treatment concepts.

Refining Prognosis in Chemoembolization for Hepatocellular Carcinoma: Immunonutrition and Liver Function

A combination of albumin-bilirubin (ALBI) grading and the Prognostic Nutritional Index (PNI) was identified recently as a highly predictive tool for patients with hepatocellular carcinoma (HCC) undergoing tumor ablation. The present study evaluated this combination in patients undergoing transarterial chemoembolization (TACE). Between 2010 and 2020, 280 treatment-naïve patients were retrospectively identified. The influence of ALBI grade, PNI and the novel ALBI-PNI on the median overall survival (OS) was assessed. In the next step, the prognostic ability of the combined approach was compared to established scoring systems. Both ALBI grade 2-3 and a low PNI were highly predictive for median OS (ALBI grade 1-3: 39.0 vs. 16.3 vs. 5.4 months, p < 0.001; high vs. low PNI: 21.4 vs. 7.5, p < 0.001). The combination of both resulted in a median OS of 39.0, 20.1, 10.3, and 5.4 months (p < 0.001). With a Concordance Index (C-Index) of 0.69, ALBI-PNI outperformed each individual score (ALBI 0.65, PNI 0.64) and was also better than BCLC, HAP, mHAP-II, and the Six-and-Twelve score (C-Indices 0.66, 0.60, 0.59, and 0.55). Thus, the easy-to-calculate ALBI-PNI may be a promising stratification tool for patients with HCC undergoing TACE, reflecting both immunonutritive status and liver function.

Immunonutritive Scoring in Patients With Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization: Prognostic Nutritional Index or Controlling Nutritional Status Score?

OBJECTIVES

The Prognostic Nutritional Index (PNI) and Controlling Nutritional Status (CONUT) score are immunonutritive scoring systems with proven predictive ability in various cancer entities, including hepatocellular carcinoma (HCC). We performed the first evaluation of the CONUT score for patients undergoing transarterial chemoembolization (TACE) and compared CONUT and PNI in the ability to predict median overall survival (OS).

METHODS

Between 2010 and 2020, we retrospectively identified 237 treatment-naïve patients with HCC who underwent initial TACE at our institution. Both scores include the albumin level and total lymphocyte count. The CONUT additionally includes the cholesterol level. Both scores were compared in univariate and multivariate regression analyses taking into account established risk factors. In a second step, a subgroup analysis was performed on BCLC stage B patients, for whom TACE is the recommended first-line treatment.

RESULTS

A high CONUT score and low PNI were associated with impaired median OS (8.7 vs. 22.3 months, p<0.001 and 6.8 vs. 20.1 months, p<0.001, respectively). In multivariate analysis, only the PNI remained an independent prognostic predictor (p=0.003), whereas the CONUT score lost its predictive ability (p=0.201). In the subgroup of recommended TACE candidates, both CONUT and PNI were able to stratify patients according to their median OS (6.6 vs. 17.9 months, p<0.001 and 10.3 vs. 22.0 months, p<0.001, respectively). Again, in the multivariate analysis, only the PNI remained an independent prognostic factor (p=0.012).

CONCLUSION

Both scores were able to stratify patients according to their median OS, but only the PNI remained an independent prognostic factor. Therefore, PNI should be preferred when evaluating the nutritional status of patients undergoing TACE.

Intrahepatic cholangiocarcinoma: Introducing the preoperative prediction score based on preoperative imaging

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) still has a poor long-term outcome, even after complete resection. We investigated different parameters gathered in preoperative imaging and analyzed their influence on resectability, recurrence, and survival.

METHODS

All patients who underwent exploration due to ICC between January 2008 and June 2018 were analyzed retrospectively. Kaplan-Meier model, log-rank test and Cox regression were used.

RESULTS

Out of 184 patients, 135 (73.4%) underwent curative intended resection. Median overall survival (OS) was 22.2 months with a consecutive 1-, 3- and 5-year OS of 73%, 29%, and 17%. Median recurrence-free survival (RFS) was 9.3 months with a consecutive 1-, 3- and 5-year RFS of 36%, 15%, and 11%. Site of tumor, parenchymal localization, tumor configuration/dissemination, and estimated tumor volume had significant influence on resectability. Univariate analyses showed that site of tumor, tumor configuration/dissemination, number of nodules, and estimated tumor volume had predictive values for OS and RFS. Together with tumor size the preoperative prediction (POP) score was created showing significance for OS and RFS (all P < 0.001). In multivariate analysis, POP score (HR = 1.779; 95% CI: 1.268-2.495; P = 0.001), T stage (HR = 1.255; 95% CI: 1.040-1.514; P = 0.018) and N stage (HR = 1.334; 95% CI: 1.081-1.645; P = 0.007) were the independent predictors for OS. For RFS, POP score (HR = 1.733; 95% CI: 1.300-2.311; P < 0.001) and M stage (HR = 3.036; 95% CI: 1.376-6.697; P = 0.006) were the independent predictors.

CONCLUSIONS

The POP score showed to have a highly significant influence on OS and RFS. The score is easy to assess through preoperative imaging. For patients in the high risk group at least staging laparoscopy or preoperative chemotherapy should be evaluated, because they showed equal outcome compared to the irresectable group.

Attitudes Toward Artificial Intelligence Among Radiologists, IT Specialists, and Industry

OBJECTIVES

We investigated the attitudes of radiologists, information technology (IT) specialists, and industry representatives on artificial intelligence (AI) and its future impact on radiological work.

MATERIALS AND METHODS

During a national meeting for AI, eHealth, and IT infrastructure in 2019, we conducted a survey to obtain participants' attitudes. A total of 123 participants completed 28 items exploring AI usage in medicine. The Kruskal-Wallis test was used to identify differences between radiologists, IT specialists, and industry representatives.

RESULTS

The strongest agreement between all respondents occurred with the following: plausibility checks are important to understand the decisions of the AI (93% agreement), validation of AI algorithms is mandatory (91%), and medicine becomes more efficient in the age of AI (86%). In contrast, only 25% of the respondents had confidence in the AI results, and only 17% believed that medicine will become more human through the use of AI. The answers were significantly different between the three professions for four items: relevance for protocol selection in cross-sectional imaging (p = 0.034), medical societies should be involved in validation (p = 0.028), patients should be informed about the use of AI (p = 0.047), and AI should be part of medical education (p = 0.026).

CONCLUSION

Currently, a discrepancy exists between high expectations for the future role of AI and low confidence in the results. This attitude was similar across all three groups. The demand for plausibility checks and the need to prove the usefulness in randomized controlled studies indicate what is needed in future research.

Hepatic vein tumor thrombosis in patients with hepatocellular carcinoma: Prevalence and clinical significance

BACKGROUND

There is strong evidence that portal vein tumor thrombosis (PVTT) is associated with poor survival in patients with hepatocellular carcinoma (HCC). However, data regarding the clinical significance of hepatic vein tumor thrombosis (HVTT) is rare, particularly in Western patients.

OBJECTIVE

To determine the HVTT prevalence in a Western patient population and its impact on survival.

METHODS

We included 1310 patients with HCC treated in our tertiary referral center between January 2005 and December 2016. HVTT and PVTT were diagnosed with contrast-enhanced cross-sectional imaging. Overall survival (OS) was calculated starting from the initial HCC diagnosis, and in a second step, starting from the first appearance of vascular invasion.

RESULTS

We observed macrovascular invasion (MVI) in 519 patients who suffered from either isolated HVTT (n = 40), isolated PVTT (n = 352), or both combined (HVTT + PVTT) (n = 127). Calculated from the initial HCC diagnosis, the median OS for patients with isolated HVTT was significantly shorter than that of patients without MVI (13.3 vs. 32.5 months, p < 0.001). Calculated from the first appearance of MVI, the median OS was similar among patients with isolated HVTT (6.5 months), isolated PVTT (5 months), and HVTT + PVTT (5 months). Multivariate analysis confirmed HVTT as an independent risk factor for poor survival.

CONCLUSIONS

HVTT may be more common than typically reported. In most patients, it was accompanied by PVTT. Isolated HVTT occurred less frequently and later than isolated PVTT; however, once developed, it had the same deleterious impact on survival. Therefore, patients with HVTT should be classified as advanced stage of HCC.

Refining prediction of survival after TIPS with the novel Freiburg index of post-TIPS survival

BACKGROUND & AIMS

Transjugular intrahepatic portosystemic shunt (TIPS) implantation is an effective and safe treatment for complications of portal hypertension. Survival prediction is important in these patients as they constitute a high-risk population. Therefore, the aim of our study was to develop an alternative prognostic model for accurate survival prediction after planned TIPS implantation.

METHODS

A total of 1,871 patients with de novo TIPS implantation for ascites or secondary prophylaxis of variceal bleeding were recruited retrospectively. The study cohort was divided into a training set (80% of study patients; n = 1,496) and a validation set (20% of study patients; n = 375). Further, patients with early (preemptive) TIPS implantation due to variceal bleeding were included as another validation cohort (n = 290). Medical data and overall survival (OS) were assessed. A Cox regression model was used to create an alternative prediction model, which includes significant prognostic factors.

RESULTS

Age, bilirubin, albumin and creatinine were the most important prognostic factors. These parameters were included in a new score named the Freiburg index of post-TIPS survival (FIPS). The FIPS score was able to identify high-risk patients with a significantly reduced median survival of 5.0 (3.1-6.9) months after TIPS implantation in the training set. These results were confirmed in the validation set (median survival of 3.1 [0.9-5.3] months). The FIPS score showed better prognostic discrimination compared to the Child-Pugh, MELD, MELD-Na score and the bilirubin-platelet model. However, the FIPS score showed insufficient prognostic discrimination in patients with early TIPS implantation.

CONCLUSIONS

The FIPS score is superior to established scoring systems for the identification of high-risk patients with a worse prognosis following elective TIPS implantation.

LAY SUMMARY

Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a safe and effective treatment for patients with cirrhosis and clinically significant portal hypertension. However, risk stratification is a major challenge in these patients as currently available scoring systems have major drawbacks. Age, bilirubin, albumin and creatinine were included in a new risk score which was named the Freiburg index of post-TIPS survival (FIPS). The FIPS score can identify patients at high risk and may guide clinical decision making.

Current Strategies to Identify Patients That Will Benefit from TACE Treatment and Future Directions a Practical Step-by-Step Guide

Treatment of hepatocellular carcinoma (HCC) depends on the stage of disease. In the Western Hemisphere, the Barcelona Clinic Liver Cancer classification (BCLC) is the preferred staging system. Approximately one-third of patients initially present with intermediate-stage disease. For these patients, transarterial chemoembolization (TACE) is the treatment of choice. However, the intermediate-stage comprises a heterogeneous subgroup of patients with considerable differences in tumor burden and liver function. In addition, differences in individual factors that are not captured by the BCLC framework, such as the tumor growth pattern, degree of hypervascularity, and vascular supply, complicate further evaluation of these patients. Due to these differences, not all patients benefit equally from TACE. Several tools and scoring systems have been devised to provide decision-making support. All of these have shown promising initial results but failed external evaluation and have not been translated to the clinic. Nevertheless, criteria for objectifying treatment decisions in daily clinical practice are needed in all stages of disease. Therefore, this review provides a concise practical step-by-step guide on current strategies for patient selection and decision-making, with a focus on TACE, to critically evaluate the existing decision-support tools and provide a summary of the latest updates in the field.

The impact of portal vein tumor thrombosis on survival in patients with hepatocellular carcinoma treated with different therapies: A cohort study

Background

Portal vein tumor thrombosis (PVTT) is a frequent complication of hepatocellular carcinoma (HCC), which leads to classification as advanced stage disease (regardless of the degree of PVTT) according to the Barcelona Clinic Liver Cancer Classification. For such patients, systemic therapy is the standard of care. However, in clinical reality, many patients with PVTT undergo different treatments, such as resection, transarterial chemoembolization (TACE), selective internal radiation therapy (SIRT), or best supportive care (BSC). Here we examined whether patients benefited from such alternative therapies, according to the extent of PVTT.

Methods

This analysis included therapy-naïve patients with HCC and PVTT treated between January 2005 and December 2016. PVTT was classified according to the Liver Cancer study group of Japan as follows: Vp1 = segmental PV invasion; Vp2 = right anterior or posterior PV; Vp3 = right or left PV; Vp4 = main trunk. Overall survival (OS) was analyzed for each treatment subgroup considering the extent of PVTT. We performed Cox regression analysis with adjustment for possible confounders. To further attenuate selection bias, we applied propensity score weighting using the inverse probability of treatment weights.

Results

A total of 278 treatment-naïve patients with HCC and PVTT were included for analysis. The median observed OS in months for each treatment modality (resection, TACE/SIRT, sorafenib, BSC, respectively) was 32.4, 8.1, N/A, and 1.7 for Vp1; 10.7, 6.9, 5.5, and 1.2 for Vp2; 6.6, 7.5, 2.9, and 0.6 for Vp3; and 8.0, 3.6, 5.3, and 0.7 for Vp4. Thus, the median OS in the resection group in case of segmental PVTT (Vp1) was significantly longer compared to any other treatment group (all p values <0.01).

Conclusions

Treatment strategy for HCC with PVTT should not be limited to systemic therapy in general. The extent of PVTT should be considered when deciding on treatment alternatives. In patients with segmental PVTT (Vp1), resection should be evaluated.

T1 and T2 mapping to detect chronic inflammation in cardiac magnetic resonance imaging in heart failure with reduced ejection fraction

Aims

The purpose of this retrospective single‐centre study was to evaluate the non‐invasive detection of endomyocardial biopsy (EMB)‐established chronic myocardial inflammation in patients with heart failure with reduced ejection fraction (HFrEF) using T1 and T2 mapping.

Methods and results

The study population consisted of 52 retrospectively identified HFrEF patients who underwent EMB and cardiac magnetic resonance imaging at 3 Tesla. EMB was defined according to the position statement of the European Society of Cardiology and served as reference to identify inflammation in all patients. A control group of healthy volunteers with prior cardiac magnetic resonance imaging studies (n = 58) was also identified. Global and segmental T1 and T2 values as well as septal measurements and tissue heterogeneity parameters were calculated.

Out of the 52 patients with HFrEF, 33 patients had myocardial inflammation detected by EMB, while 19 patients were EMB negative for inflammation. Mean left ventricular ejection fraction was 31% in both groups (P = 0.97). Global T1 and T2 values in HFrEF patients were significantly higher compared with healthy controls (T1 1275 ± 69 ms vs. 1,175 ± 44 ms, P < 0.001; T2 40.0 ± 3.4 ms vs. 37.9 ± 1.6 ms, P < 0.001). The distribution of T1 and T2 values between patients with and without EMB‐proven chronic myocardial inflammation was not statistically different when regarding global (T1 1292 ± 71 ms vs. 1266 ± 67 ms, P = 0.26; T2 40.0 ± 2.6 ms vs. 40.0 ± 3.9 ms, P = 1.0), septal (T1 1299 ± 63 ms vs. 1289 ± 76 ms, P = 0.76; T2 40.1 ± 3.5 ms vs 40.0 ± 6.4 ms, P = 0.49) or maximum segmental values (T1 1414 ± 111 ms vs. 1363 ± 88 ms, P = 0.15; T2 47.3 ± 5.2 ms vs. 48.8 ± 11.8 ms, P = 0.53). Mean absolute deviation of segmental T1 and T2 values and log‐transformed pixel‐wise standard deviation as parameters of tissue heterogeneity did not reveal statistical significant differences between inflammation‐positive and inflammation‐negative HFrEF patients (all P > 0.4).

Conclusions

Conventionally performed quantitative T1 and T2 mapping values significantly correlated with prevalence of HFrEF but did not discriminate HFrEF patients with or without chronic myocardial inflammation in our cohort. This suggests that EMB is the preferred method to detect chronic myocardial inflammation in HFrEF.

Relevance of suspicious lymph nodes in preoperative imaging for resectability, recurrence and survival of intrahepatic cholangiocarcinoma

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is often diagnosed at an advanced stage resulting in a low resectability rate. Even after potentially curative resection the risk for tumor recurrence is high. Although the extent and value of lymphadenectomy is part of ongoing discussion, the role of preoperative imaging for assessment of suspicious lymph nodes (suspLN) has only been studied modestly. Aim of this study is to demonstrate the influence of suspicious lymph nodes in preoperative imaging on resectability, recurrence, and long-term outcome.

METHODS

All patients who underwent exploration for ICC between January 2008 and June 2018 were included. Preoperative imaging (CT or MRI) was analysed with focus on suspLN at the hepatoduodenal ligament, lesser curvature, interaortocaval, and superior to the diaphragm; suspLN were classified according to the universally accepted RECIST 1.1 criteria; histopathology served as gold standard.

RESULTS

Out of 187 patients resection was performed in 137 (73.3%), in 50 patients the procedure was terminated after exploration. Overall, suspLN were found preoperatively in 73/187 patients (39%). Comparing patients who underwent resection and exploration only, suspLN were significantly more common in the exploration group (p = 0.011). Regarding lymph node stations, significant differences could be shown regarding resectability: All tumors with suspLN superior to the diaphragm were irresectable. Preoperative imaging assessment showed a strong correlation with final histopathology, especially of suspLN of the hepatoduodenal ligament and the lesser curvature. Sensitivity of suspLN was 71.1%, specificity 90.8%. Appearance of tumor recurrence was not affected by suspLN (p = 0.289). Using a short-axis cut-off of <> 1 cm, suspLN had significant influence on recurrence-free survival (RFS, p = 0.009) with consecutive 1-, 3-, and 5-year RFS of 41, 21, and 15% versus 29, 0, and 0%, respectively. Similarly, 1-, 3- and 5-year overall survival (OS) was 75, 30, and 18% versus 59, 18, and 6%, respectively (p = 0.040).

CONCLUSION

Suspicious lymph nodes in preoperative imaging are predictor for unresectability and worse survival. Explorative laparoscopy should be considered, if distant suspicious lymph nodes are detected in preoperative imaging. Nevertheless, given a sensitivity of only 71.1%, detection of suspicious lymph nodes in the preoperative imaging alone is not sufficient to allow for a clear-cut decision against a surgical approach.

Survival prediction for patients with non-resectable intrahepatic cholangiocarcinoma undergoing chemotherapy: a retrospective analysis comparing the tumor marker CA 19-9 with cross-sectional imaging

Purpose

Carbohydrate antigen (CA) 19-9 has been established as the main serum marker for patients with intrahepatic cholangiocarcinoma (ICC). The aim of this study was to compare the prognostic value of CA 19-9 changes versus response determined by imaging in patients with ICC undergoing chemotherapy.

Methods

Between 2003 and 2018, 151 patients with histopathologically confirmed ICC underwent chemotherapy at our tertiary care center for non-resectable or recurrent ICC, of whom 121 were included in this study. Serum CA 19-9 levels and imaging were retrospectively evaluated during chemotherapy. Log-rank testing and optimal stratification were used to classify patients into risk groups.

Results

Prior to chemotherapy, baseline serum CA 19-9 levels above the previously published cut-off of 37 U/ml were associated with poor survival (median OS 8.7 vs. 12.4 months, p = 0.003). After the beginning of chemotherapy, an increase in CA 19-9 of more than 40 U/ml resulted in impaired residual survival (median OS 5.0 vs. 12.1 months, p < 0.001). However, progressive disease at the first follow-up imaging proved the strongest predictor for poor outcome (median OS 4.6 vs. 15.5 months, p < 0.001). In contrast to prior studies, our data did not show statistically relevant differences in survival time with respect to absolute or relative decreases in serum CA 19-9 levels.

Conclusion

In our study, the disease control rate—that is, the absence of progressive disease—was the strongest predictor of prolonged residual OS. To this end, both CA 19-9 changes and progressive disease on initial follow-up showed remarkable discriminatory power, with the latter slightly outperforming the former. Therefore, imaging should remain the mainstay of patient evaluation during follow-up.

Electronic supplementary material

The online version of this article (10.1007/s00432-020-03200-2) contains supplementary material, which is available to authorized users.

Predicting survival after transarterial chemoembolization for hepatocellular carcinoma using a neural network: A Pilot Study

BACKGROUND AND AIMS

Deciding when to repeat and when to stop transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) can be difficult even for experienced investigators. Our aim was to develop a survival prediction model for such patients undergoing TACE using novel machine learning algorithms and to compare it to conventional prediction scores, ART, ABCR and SNACOR.

METHODS

For this retrospective analysis, 282 patients who underwent TACE for HCC at our tertiary referral centre between January 2005 and December 2017 were included in the final analysis. We built an artificial neural network (ANN) including all parameters used by the aforementioned risk scores and other clinically meaningful parameters. Following an 80:20 split, the first 225 patients were used for training; the more recently treated 20% were used for validation.

RESULTS

The ANN had a promising performance at predicting 1-year survival, with an area under the ROC curve (AUC) of 0.77 ± 0.13. Internal validation yielded an AUC of 0.83 ± 0.06, a positive predictive value of 87.5% and a negative predictive value of 68.0%. The sensitivity was 77.8% and specificity 81.0%. In a head-to-head comparison, the ANN outperformed the aforementioned scoring systems, which yielded lower AUCs (SNACOR 0.73 ± 0.07, ABCR 0.70 ± 0.07 and ART 0.54 ± 0.08). This difference reached significance for ART (P < .001); for ABCR and SNACOR significance was not reached (P = .143 and P = .201).

CONCLUSIONS

Artificial neural networks could be better at predicting patient survival after TACE for HCC than traditional scoring systems. Once established, such prediction models could easily be deployed in clinical routine and help determine optimal patient care.

Risk prediction in intrahepatic cholangiocarcinoma: Direct comparison of the MEGNA score and the 8th edition of the UICC/AJCC Cancer staging system

BACKGROUND

External validation of prognostic risk models is essential before they are implemented in clinical practice. This study evaluated the recently developed MEGNA score for survival prediction after resection of intrahepatic cholangiocarcinoma (ICC), with a focus on the direct comparison of its prognostic value to that of the current International Union Against Cancer (UICC)/American Joint Committee on Cancer (AJCC) Cancer staging system.

MATERIAL AND METHODS

Between 1997 and 2018, 417 consecutive patients with ICC were referred to our tertiary care centre and were retrospectively identified out of a dedicated clinical database. Of this group, 203 patients underwent surgical resection and met the inclusion criteria. Multivariate analysis was performed to assess the predictors of the recently proposed MEGNA score regarding overall survival (OS). Concordance indices (C-indices) and integrated Brier scores (IBS) were calculated to assess the ability of both the MEGNA score and the current (8th) edition of the UICC/AJCC Cancer staging system to predict individual patient outcome.

RESULTS

Stratification according to the MEGNA score resulted in a median OS of 34.5 months, 26.1 months, 21.5 months, and 16.6 months for MEGNA scores 0, 1, 2, and ≥3, respectively (log rank p < 0.001). However, of the five factors that contribute to the MEGNA score, age > 60 years was not a predictor for poor OS in our cohort. The C-index for the MEGNA score was 0.58, the IBS was 0.193. The 8th edition of the UICC/AJCC system performed slightly better, with a C-index of 0.61 and an IBS of 0.186.

CONCLUSION

The ability of the MEGNA score to predict individual patient outcome was only moderate in this external validation. Its prognostic value did not reach that of the more widely known and used UICC/AJCC system. However, neither scoring system performed well enough to support clear-cut clinical decisions.

Growth characteristics and therapeutic decision markers in von Hippel-Lindau disease patients with renal cell carcinoma

Background

Von Hippel-Lindau (VHL) disease is a multi-systemic hereditary disease associated with several benign and malignant tumor entities, including clear cell renal cell carcinoma (ccRCC). Since ccRCCs grow slowly, nephron sparing surgery is typically performed at a tumor diameter of 3–4 cm before the tumor metastasizes. However, in the case of recurrent disease, repeated surgical intervention can impair renal function. Therefore, it is crucial to optimize the timing for surgical interventions through a better understanding of the growth kinetics of ccRCCs in VHL. We investigated tumor growth kinetics and modern volumetric assessment to guide future therapeutic decisions.

Results

The prevalence of ccRCC was 28% in a cohort of 510 VHL patients. Of 144 patients with ccRCC, 41 were followed with serial imaging which identified 102 renal tumors, which exhibited heterogeneous growth kinetics. ccRCCs grew at an average absolute growth rate of 0.287 cm/year, an average relative growth rate [(lnV₁-lnV₀)/(t₁-t₀)] of 0.42% and an average volume doubling time of 27.15 months. Women had a faster relative growth rate than men. Age and specific mutations did not influence tumor growth. Because of the tumor heterogeneity, we developed an additional cut-off volume of 40 cm³ for surgical intervention.

Conclusions

Tumor heterogeneity and differences in growth kinetics is suggestive of a state of transient tumor dormancy in ccRCCs of VHL patients. The relative growth rate has not been previously described in other studies. Volumetric assessment as an additional parameter for surgical intervention could be a useful clinical tool and needs further investigation.

The role of sarcopenia in patients with intrahepatic cholangiocarcinoma: Prognostic marker or hyped parameter?

BACKGROUND & AIMS

Sarcopenia has emerged as a prognostic parameter in numerous cancer entities. Current research favours its role as a determining factor for overall survival (OS) in patients with intrahepatic cholangiocarcinoma (ICC); however, it is unclear whether sarcopenia is a truly independent survival predictor if combined with established prognostic factors.

METHODS

Between 1997-2018, 417 patients with histopathologically confirmed ICC were referred to our centre, of whom 293 were included in this study. Cross-sectional imaging, laboratory examinations and histopathological reports were retrospectively analysed. Psoas muscle index (PMI) as easy-to-measure marker of sarcopenia was calculated. Using optimal stratification, sex-specific PMI cut-offs were calculated and tested in hazard regression models against previously published risk factors-for the entire cohort, and within resected and non-resected subgroups.

RESULTS

Median OS for patients with low respectively high PMI was 23.5 and 34.5 months in the resected subgroup (P = 0.008) and 5.1 and 7.8 months (P = 0.01) in the non-resected subgroup. In multivariate hazard regression models for the entire cohort, low PMI exhibited independent predictive value (P = 0.01) as did translobar tumour spread (P = 0.005), extrahepatic extension (P = 0.03), tumour boundary type (P < 0.001), carbohydrate antigen 19-9 (CA 19-9) levels (P = 0.001), alkaline phosphatase levels (P = 0.001) and distant metastasis (P < 0.001). In subgroup analyses, low PMI remained predictive among non-resected patients (P = 0.03), but lost its predictive value among resected patients (P = 0.15).

CONCLUSIONS

Psoas muscle index strongly predicted OS in univariate analysis. However, addition of established risk factors eliminated its predictive value among resected patients. Thus, when resection is deemed oncologically reasonable, patients should not be excluded from surgery because of sarcopenia alone.

NA62 and NA48/2 results on search for Heavy Neutral Leptons

In this paper we present new results on upper limits for the search of Heavy Neutral Leptons (HNL) with data collected by NA48/2 (2003-2004), NA62-RK (2007) and NA62 (2015) CERN experiments. The data collected with different trigger configuration allow to search for both long and short living heavy neutrinos in the mass range below the kaon mass. In addition the status of the search for K+ → π+vv with the NA62 detector will be briefly presented.

Circulating tumor DNA as a predictor for response to treatment in BRAF V600E mutant malignant melanoma

9564

Background: Available biomarkers LDH and S100B possess limited sensitivity and specificity to predict outcome in melanoma. In this pilot study we evaluated the use of circulating tumor (ct)DNA harboring BRAF and NRAS mutations as a predictive biomarker for treatment response and progression-free survival (PFS) in patients with locally advanced or metastatic melanoma. Methods: We analyzed 89 retrospective plasma samples from 32 unselected pts, and 158 samples from 12 pts included in a prospective trial (DRKS00009507). We included stage III disease with planned resection or stage IV disease before initiation or change of medical treatment. Blood samples were taken at baseline at d +8, d +28, and thereafter at 3 months intervals for up to two years. We developed a hydrolysis probe based, Locked Nucleic Acid assay to detect BRAF V600E and wild type ctDNA by droplet digital PCR. Results were correlated with LDH, S100B and PFS. Results: Sensitivity of BRAF V600E specific assay was 0.01% with a limit of Blank of 0.28 copies/well. Of 31 stage IV pts with retrospective samples, 23 were positive for BRAF V600E ctDNA at least once (74%). Positive pts had a mean of 9 (range: 1-17) and 483 (range: 0.1-16,388) BRAF V600E copies/mL for stage III and stage IV respectively. The presence of ctDNA at baseline predicted poor PFS (hazard ratio [HR] 1.487, 95% CI 0.34-6.45). A negative slope in BRAF V600E ctDNA was a favorable prognostic factor for PFS (hazard ratio [HR] 0.230, 95% CI 0.04-1.20) with a median PFS of 3.42 vs. 2.56 months (Range 1.87-8.9 vs. 0.89-5.02). Residual ctDNA at the first time point after initiation or change of treatment was related to a shorter PFS (hazard ratio [HR] 2.02, 95% CI 0.39-10.53). Based on 144 measurement pairs, BRAF ctDNA strongly correlated with S100 (r = 0.73) and LDH (r = 0.52). Conclusions: Residual ctDNA early after change or institution of treatment predicted tumor progression at first clinical response assessment. A positive to negative conversion or a decrease indicated a more favorable course. These data support the use of ctDNA as an early predictive marker for treatment response. We will examine whether two or more detected mutations indicate clonal heterogeneity and confer adverse prognosis. Clinical trial information: DRKS00009507.

Risk Factors for Local Recurrence of Large, Flat Colorectal Polyps after Endoscopic Mucosal Resection

AIMS

Removal of large, flat colorectal polyps by endoscopic mucosal resection (EMR) is effective, but local recurrences occur regularly. This study investigated risk factors for local recurrence.

METHOD

Cases of EMR of flat colorectal polyps ≥20 mm at an academic center from 2004 to 2011 were retrospectively analyzed for polyp features, resection technique, complications and local recurrences. Behavioral risk factors were retrospectively determined by self-administered questionnaires.

RESULTS

Data were collected for 129 patients (57.3% male, mean age at time of EMR: 65.0 years). Mean polyp size was 37.2 mm. Polyps were mostly adenoma with low-grade dysplasia (58.1%) and predominantly located in the right colon (62%). En bloc resection was performed in 31.8%. The median follow-up time was 40 months. Local recurrence occurred in 26.3% of patients, with 87% being recurrence-free after 1 year (95% CI 81-93%). A history of smoking was reported by 51.6% of patients and 88.4% reported regular alcohol consumption. Univariate analysis showed that polyp size and piecemeal resection were associated with risk of local recurrence. In multivariate analysis, only polyp size was predictive for local recurrence. No association was found for behavioral risk factors.

CONCLUSION

Polyp size is the main predictor of local recurrence after EMR of large, flat colorectal polyps.

Frequent co-occurrence of high-grade dysplasia in large flat colonic polyps (>20 mm) and synchronous polyps

Background

Large colonic polyps are associated with advanced dysplasia, but prevalence and characteristics of synchronous polyps in patients with large flat colonic polyps are poorly investigated. This study aims to characterize clinicopathological features of large flat colonic polyps and their impact on occurrence and characteristics of synchronous polyps.

Methods

A total of 802 patients that underwent endoscopic mucosal resection (EMR) of flat colonic polyps >20 mm from 2003 to 2014 in an academic endoscopy unit were retrospectively analyzed for size, location and histology of large polyps and synchronous polyps.

Results

Average size of large polyps was 34.1 mm (range 20–150 mm, standard deviation 16.1 mm). Histology included 52.5 % adenomas with low-grade dysplasia (LGD), 26.7 % with high-grade dysplasia (HGD), 9.6 % serrated polyps and 11.2 % adenocarcinomas. The majority of large polyps were localized in the proximal colon (61 %). 72.2 % of adenocarcinomas were found in the distal colon, while 80.5 % of all serrated polyps were detected in the proximal colon. Increase in polyp size, advanced age and location in the distal colon were associated with presence of HGD/adenocarcinoma in large polyps, as identified by multivariate analysis. Synchronous polyps were detected in 67.2 % of patients undergoing complete colonoscopy during EMR. Presence of HGD/adenocarcinoma in the large polyp, localization of any synchronous polyp in the rectosigmoid colon and occurrence of multiple synchronous polyps were associated with presence of HGD/adenocarcinoma in synchronous polyps.

Conclusions

Synchronous polyps are frequently found in patients with large flat colonic polyps. The prevalence of synchronous polyps with high grade dysplasia is highest in patients with large flat polyps containing HGD/adenocarcinoma.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0312-4) contains supplementary material, which is available to authorized users.

The differential production cross section of the [Formula: see text](1020) meson in [Formula: see text] = 7 TeV [Formula: see text] collisions measured with the ATLAS detector

A measurement is presented of the [Formula: see text] production cross section at [Formula: see text] = 7 TeV using [Formula: see text] collision data corresponding to an integrated luminosity of 383 [Formula: see text], collected with the ATLAS experiment at the LHC. Selection of [Formula: see text](1020) mesons is based on the identification of charged kaons by their energy loss in the pixel detector. The differential cross section is measured as a function of the transverse momentum, [Formula: see text], and rapidity, [Formula: see text], of the [Formula: see text](1020) meson in the fiducial region 500 [Formula: see text] 1200 MeV, [Formula: see text] 0.8, kaon [Formula: see text] 230 MeV and kaon momentum [Formula: see text] 800 MeV. The integrated [Formula: see text]-meson production cross section in this fiducial range is measured to be [Formula: see text] = 570 [Formula: see text] 8 (stat) [Formula: see text] 66 (syst) [Formula: see text] 20 (lumi) [Formula: see text].

Behaviour of Bimetallic Pt-Pd Carbon-Supported Catalysts in Methanol Electrooxidation

Carbon powder supported bimetallic 8w%Pt+8w%Pd/C,8w%Pt+6w%Pd/C, 8w%Pt+4w%Pd/C, 8w%Pt+2w%Pd/C, 8w%Pt/C and 8w%Pd/C samples were prepared, characterised and tested for the electrooxidation of methanol. The particle sizes were found to depend greatly on the composition and the metal content. With pure palladium and samples rich in palladium, the diameter of the bimetallic particles was around 150 nm, but with pure Pt and samples poor in Pd it was much smaller, below 5 nm. The electrocatalytic activity of these catalysts was determined by cyclic voltammetry and polarization curves. Compounds with 33 and 43 at%Pd were the most active catalysts for the methanol oxidation reaction. A good correlation was obtained between electrochemistry and in situ infrared reflectance spectroscopy results.

Improved luminosity determination in pp collisions at [Formula: see text] using the ATLAS detector at the LHC

The luminosity calibration for the ATLAS detector at the LHC during pp collisions at [Formula: see text] in 2010 and 2011 is presented. Evaluation of the luminosity scale is performed using several luminosity-sensitive detectors, and comparisons are made of the long-term stability and accuracy of this calibration applied to the pp collisions at [Formula: see text]. A luminosity uncertainty of [Formula: see text] is obtained for the 47 pb-1 of data delivered to ATLAS in 2010, and an uncertainty of [Formula: see text] is obtained for the 5.5 fb-1 delivered in 2011.

Measurement of the inclusive jet cross-section in pp collisions at [Formula: see text] and comparison to the inclusive jet cross-section at [Formula: see text] using the ATLAS detector

The inclusive jet cross-section has been measured in proton-proton collisions at [Formula: see text] in a dataset corresponding to an integrated luminosity of [Formula: see text] collected with the ATLAS detector at the Large Hadron Collider in 2011. Jets are identified using the anti-kt algorithm with two radius parameters of 0.4 and 0.6. The inclusive jet double-differential cross-section is presented as a function of the jet transverse momentum pT and jet rapidity y, covering a range of 20≤pT<430 GeV and |y|<4.4. The ratio of the cross-section to the inclusive jet cross-section measurement at [Formula: see text], published by the ATLAS Collaboration, is calculated as a function of both transverse momentum and the dimensionless quantity [Formula: see text], in bins of jet rapidity. The systematic uncertainties on the ratios are significantly reduced due to the cancellation of correlated uncertainties in the two measurements. Results are compared to the prediction from next-to-leading order perturbative QCD calculations corrected for non-perturbative effects, and next-to-leading order Monte Carlo simulation. Furthermore, the ATLAS jet cross-section measurements at [Formula: see text] and [Formula: see text] are analysed within a framework of next-to-leading order perturbative QCD calculations to determine parton distribution functions of the proton, taking into account the correlations between the measurements.

Search for a light charged Higgs boson in the decay channel [Formula: see text] in [Formula: see text] events using pp collisions at [Formula: see text] with the ATLAS detector

A search for a charged Higgs boson (H+) in [Formula: see text] decays is presented, where one of the top quarks decays via t→H+b, followed by H+→ two jets ([Formula: see text]). The other top quark decays to Wb, where the W boson then decays into a lepton (e/μ) and a neutrino. The data were recorded in pp collisions at [Formula: see text] by the ATLAS detector at the LHC in 2011, and correspond to an integrated luminosity of 4.7 fb-1. With no observation of a signal, 95 % confidence level (CL) upper limits are set on the decay branching ratio of top quarks to charged Higgs bosons varying between 5 % and 1 % for H+ masses between 90 GeV and 150 GeV, assuming [Formula: see text].

Multi-channel search for squarks and gluinos in [Formula: see text]pp collisions with the ATLAS detector at the LHC

A search for supersymmetric particles in final states with zero, one, and two leptons, with and without jets identified as originating from b-quarks, in 4.7 fb-1 of [Formula: see text]pp collisions produced by the Large Hadron Collider and recorded by the ATLAS detector is presented. The search uses a set of variables carrying information on the event kinematics transverse and parallel to the beam line that are sensitive to several topologies expected in supersymmetry. Mutually exclusive final states are defined, allowing a combination of all channels to increase the search sensitivity. No deviation from the Standard Model expectation is observed. Upper limits at 95 % confidence level on visible cross-sections for the production of new particles are extracted. Results are interpreted in the context of the constrained minimal supersymmetric extension to the Standard Model and in supersymmetry-inspired models with diverse, high-multiplicity final states.