Cardiac Incidental Findings on Abdominopelvic Computed Tomography: Prevalence and Association with Subsequent Cardiovascular Events

PURPOSE

The aim of this study was to assess the prevalence of reportable cardiac findings detected on abdominopelvic CTs and the association with subsequent cardiovascular events.

MATERIALS AND METHODS

We performed a retrospective search of electronic medical record of patients who underwent abdominopelvic CT between November 2006 and November 2011 with a clinical history of upper abdominal pain. A radiologist blinded to the original CT report reviewed all 222 cases for the presence of pertinent reportable cardiac findings. The original CT report was also evaluated for documentation of pertinent reportable cardiac findings. The following findings were recorded on all CTs: presence of coronary calcification, fatty metaplasia, ventricle wall thinning and thickening, valve calcification or prosthesis, heart/chamber enlargement, aneurysm, mass, thrombus, device, air within ventricles, abnormal pericardium, prior sternotomy, and adhesions if prior sternotomy. Medical records were reviewed to identify cardiovascular events on follow-up in patients with the presence or absence of cardiac findings. We compared the distribution findings in patients with and without cardiac events using the Wilcoxon test (for continuous variables) and the Pearson's chi-squared test (for categorical variables).

RESULTS

Eighty-five of 222 (38.3%) patients (52.7% females, median age 52.5 years) had at least one pertinent reportable cardiac finding on the abdominopelvic CT, with a total of 140 findings in this group. From the total 140 findings, 100 (71.4%) were not reported. The most common findings seen on abdominal CTs were: coronary artery calcification (66 patients), heart or chamber enlargement (25), valve abnormality (19), sternotomy and surgery signs (9), LV wall thickening (7), device (5), LV wall thinning (2), pericardial effusion (5), and others (3). After a mean follow-up of 43.9 months, 19 cardiovascular events were found in the cohort (transient ischemic attack, cerebrovascular accident, myocardial infarction, cardiac arrest, acute arrhythmia, palpitation, syncope and acute chest pain). Only 1 event occurred in the group of patients with no incidental pertinent reportable cardiac findings (1/137 = 0.73%). All other 18 events occurred in patients with incidental pertinent reportable cardiac findings (18/85 = 21.2%), which was significantly different (p < 0.0001). One out of the total 19 events in the overall group (5.24%) occurred in a patient with no incidental pertinent reportable cardiac findings while 18 of 19 total events (94.74%) occurred with patients with incidental pertinent reportable cardiac findings, which was also significantly different (p < 0.001). Fifteen of the total events (79%) occurred in patients in whom the incidental pertinent reportable cardiac findings were not reported, which was significantly different (p < 0.001) from the four events that occurred in patients in whom the incidental pertinent reportable cardiac findings were reported or had no findings.

CONCLUSIONS

Incidental pertinent reportable cardiac findings are common on abdominal CTs and are frequently not reported by radiologists. These findings are of clinical relevance since patients with pertinent reportable cardiac findings have a significantly higher incidence of cardiovascular events on follow-up.

Can AI distinguish a bone radiograph from photos of flowers or cars? Evaluation of bone age deep learning model on inappropriate data inputs

OBJECTIVE

To evaluate the behavior of a publicly available deep convolutional neural network (DCNN) bone age algorithm when presented with inappropriate data inputs in both radiological and non-radiological domains.

METHODS

We evaluated a publicly available DCNN-based bone age application. The DCNN was trained on 12,612 pediatric hand radiographs and won the 2017 RSNA Pediatric Bone Age Challenge (concordance of 0.991 with radiologist ground-truth). We used the application to analyze 50 left-hand radiographs (appropriate data inputs) and seven classes of inappropriate data inputs in radiological (i.e., chest radiographs) and non-radiological (i.e., image of street numbers) domains. For each image, we noted if (1) the application distinguished between appropriate and inappropriate data inputs and (2) inference time per image. Mean inference times were compared using ANOVA.

RESULTS

The 16Bit Bone Age application calculated bone age for all pediatric hand radiographs with mean inference time of 1.1 s. The application did not distinguish between pediatric hand radiographs and inappropriate image types, including radiological and non-radiological domains. The application inappropriately calculated bone age for all inappropriate image types, with mean inference time of 1.1 s for all categories (p = 1).

CONCLUSION

A publicly available DCNN-based bone age application failed to distinguish between appropriate and inappropriate data inputs and calculated bone age for inappropriate images. The awareness of inappropriate outputs based on inappropriate DCNN input is important if tasks such as bone age determination are automated, emphasizing the need for appropriate oversight at the data input and verification stage to avoid unrecognized erroneous results.

Clinics in diagnostic imaging (191). Multiple system atrophy-cerebellar type (MSA-C)

A 49-year-old Chinese man was evaluated for progressive uncoordinated movements, dysphagia and urinary symptoms. Magnetic resonance imaging demonstrated a cruciform pattern of T2-weighted hyperintensity within the pons and selective atrophy of the cerebellar hemispheres and pons. The clinical history and radiological findings were consistent with a diagnosis of multiple system atrophy-cerebellar type. This article discussed the background, proposed mechanisms, diagnosis, radiological characteristics, prognosis and management of multiple system atrophy-cerebellar type.

Clinics in diagnostic imaging (190). Subacute combined degeneration of the spinal cord (SCD)

A 54-year-old man presented with progressive onset of lower limb paraesthesias, sensory ataxia, gait instability and lower limb weakness. Laboratory findings revealed low serum B12 levels. Magnetic resonance imaging showed long-segment symmetrically increased T2 signal within the dorsal columns of the spinal cord in the lower thoracic spine. The conglomeration of findings was consistent with a diagnosis of subacute combined degeneration of the spinal cord (SCD). Aside from mild residual paraesthesias, the patient's symptoms largely resolved after treatment with intramuscular injections of vitamin B12. The clinical presentation, pathophysiology, clinical and radiologic differential diagnosis, and management of SCD were described.

Clinics in diagnostic imaging (188). Transient global amnesia (TGA)

A 60-year-old woman was travelling on a plane with her spouse when she suddenly developed acute-onset disorientation to time and space. According to her husband, she repetitively questioned her whereabouts and complained of a minor headache. Upon landing, she was immediately brought to the emergency room and subsequent magnetic resonance imaging was performed, which showed multiple punctate 2-3 mm regions of diffusion-weighted imaging hyperintensity in the medial aspects of both temporal lobes. The conglomeration of clinical history and radiological findings was most suggestive of transient global amnesia. This article discussed the background, proposed mechanisms, diagnosis, radiological characteristics and management of transient global amnesia.

Current Applications and Future Impact of Machine Learning in Radiology

Recent advances and future perspectives of machine learning techniques offer promising applications in medical imaging. Machine learning has the potential to improve different steps of the radiology workflow including order scheduling and triage, clinical decision support systems, detection and interpretation of findings, postprocessing and dose estimation, examination quality control, and radiology reporting. In this article, the authors review examples of current applications of machine learning and artificial intelligence techniques in diagnostic radiology. In addition, the future impact and natural extension of these techniques in radiology practice are discussed.

Implementation of Digital Awareness Strategies to Engage Patients and Providers in a Lung Cancer Screening Program: Retrospective Study

Background

Lung cancer is the leading cause of cancer-related deaths in the United States. Despite mandated insurance coverage for eligible patients, lung cancer screening rates remain low. Digital platforms, including social media, provide a potentially valuable tool to enhance health promotion and patient engagement related to lung cancer screening (LCS).

Objective

The aim was to assess the effectiveness of LCS digital awareness campaigns on utilization of low-dose computed tomography (LDCT) and visits to institutional online educational content.

Methods

A pay-per-click campaign utilizing Google and Facebook targeted adults aged 55 years and older and caregivers aged 18 years and older (eg, spouses, adult children) with LCS content during a 20-week intervention period from May to September 2016. A concurrent pay-per-click campaign using LinkedIn and Twitter targeted health care providers with LCS content. Geographic target radius was within 60 miles of an academic medical center. Social media data included aggregate demographics and click-through rates (CTRs). Primary outcome measures were visits to institutional Web pages and scheduled LDCT exams. Study period was 20 weeks before, during, and after the digital awareness campaigns.

Results

Weekly visits to the institutional LCS Web pages were significantly higher during the digital awareness campaigns compared to the 20-week period prior to implementation (mean 823.9, SD 905.8 vs mean 51, SD 22.3, P=.001). The patient digital awareness campaign surpassed industry standard CTRs on Google (5.85%, 1108/18,955 vs 1.8%) and Facebook (2.59%, 47,750/1,846,070 vs 0.8%). The provider digital awareness campaign surpassed industry standard CTR on LinkedIn (1.1%, 630/57,079 vs 0.3%) but not Twitter (0.19%, 1139/587,133 vs 0.25%). Mean scheduled LDCT exam volumes per week before, during, and after the digital awareness campaigns were 17.4 (SD 7.5), 20.4 (SD 5.4), and 26.2 (SD 6.4), respectively, with the difference between the mean number of scheduled exams after the digital awareness campaigns and the number of exams scheduled before and after the digital awareness campaigns being statistically significant (P<.001).

Conclusions

Implementation of the LCS digital awareness campaigns was associated with increased visits to institutional educational Web pages and scheduled LDCT exams. Digital platforms are an important tool to enhance health promotion activities and engagement with patients and providers.

Optimizing the Use of Electronic Health Records to Identify High-Risk Psychosocial Determinants of Health

BACKGROUND

Care coordination programs have traditionally focused on medically complex patients, identifying patients that qualify by analyzing formatted clinical data and claims data. However, not all clinically relevant data reside in claims and formatted data. Recently, there has been increasing interest in including patients with complex psychosocial determinants of health in care coordination programs. Psychosocial risk factors, including social determinants of health, mental health disorders, and substance abuse disorders, are less amenable to rapid and systematic data analyses, as these data are often not collected or stored as formatted data, and due to US Health Insurance Portability and Accountability Act (HIPAA) regulations are often not available as claims data.

OBJECTIVE

The objective of our study was to develop a systematic approach using word recognition software to identifying psychosocial risk factors within any part of a patient's electronic health record (EHR).

METHODS

We used QPID (Queriable Patient Inference Dossier), an ontology-driven word recognition software, to scan adult patients' EHRs to identify terms predicting a high-risk patient suitable to be followed in a care coordination program in Massachusetts, USA. Search terms identified high-risk conditions in patients known to be enrolled in a care coordination program, and were then tested against control patients. We calculated precision, recall, and balanced F-measure for the search terms.

RESULTS

We identified 22 EHR-available search terms to define psychosocial high-risk status; the presence of 9 or more of these terms predicted that a patient would meet inclusion criteria for a care coordination program. Precision was .80, recall .98, and balanced F-measure .88 for the identified terms. For adult patients insured by Medicaid and enrolled in the program, a mean of 14 terms (interquartile range [IQR] 11-18) were present as identified by the search tool, ranging from 2 to 22 terms. For patients enrolled in the program but not insured by Medicaid, a mean of 6 terms (IQR 3-8) were present as identified by the search tool, ranging from 1 to 21.

CONCLUSIONS

Selected informatics tools such as word recognition software can be leveraged to improve health care delivery, such as an EHR-based protocol that identifies psychosocially complex patients eligible for enrollment in a care coordination program.

Fully Automated Deep Learning System for Bone Age Assessment

Skeletal maturity progresses through discrete phases, a fact that is used routinely in pediatrics where bone age assessments (BAAs) are compared to chronological age in the evaluation of endocrine and metabolic disorders. While central to many disease evaluations, little has changed to improve the tedious process since its introduction in 1950. In this study, we propose a fully automated deep learning pipeline to segment a region of interest, standardize and preprocess input radiographs, and perform BAA. Our models use an ImageNet pretrained, fine-tuned convolutional neural network (CNN) to achieve 57.32 and 61.40% accuracies for the female and male cohorts on our held-out test images. Female test radiographs were assigned a BAA within 1 year 90.39% and within 2 years 98.11% of the time. Male test radiographs were assigned 94.18% within 1 year and 99.00% within 2 years. Using the input occlusion method, attention maps were created which reveal what features the trained model uses to perform BAA. These correspond to what human experts look at when manually performing BAA. Finally, the fully automated BAA system was deployed in the clinical environment as a decision supporting system for more accurate and efficient BAAs at much faster interpretation time (<2 s) than the conventional method.

Effectiveness of second-opinion radiology consultations to reassess the cervical spine CT scans: a study on trauma patients referred to a tertiary-care hospital

PURPOSE

A second opinion is a valuable resource in confirming proper medical diagnosis and treatment. This study evaluates the effectiveness of second-opinion radiology consultations to reassess the cervical spine computed tomography (CT) scans of the trauma patients referred to our hospital.

METHODS

Cervical spine CT scans of 301 consecutive adult trauma patients, who were referred to our hospital from outside institutions, were analyzed. The emergency radiologists at our institution completed the over-read reports on the CT images obtained at the outside facilities. A single radiologist compared the outside- and over-read reports and determined the discrepancy of the radiologic reports.

RESULTS

Based on the outside reports, 31% of the CT scans had cervical traumatic injury. In 92% of patients, the first-read and the over-read reports had consistent radiologic findings. About 90% of the positive, and 93% of the negative radiologic findings, were reported consistently in the over-read reports. Our analysis showed that the over-read reporting resulted in reassurance of negative findings in 63%; confirmation of positive findings in 29%; clearing a false diagnosis in 3%; and detection of a missed diagnosis in 5%. A rescan was done in 80% of patients with inconsistent and 20% of patients with consistent findings (P < 0.05). The most common missed radiologic findings in the first-reports were transverse and spinous process fractures and the most common misdiagnoses were dens fractures.

CONCLUSION

For a service offering second-opinion consultations on cervical spine trauma, review of outside CT studies improves diagnosis and benefits patient care.

Abstract P2-09-20: Evaluation on the mutation screening by next-generation sequencing in hereditary breast and ovarian cancer: Implementation of recurrent mutation panel

Background: Hereditary disposition accounts for 10-15% in breast cancers and 20-25% in ovarian cancers, in which 5-10% of women have genomic alteration in breast cancer predisposition genes, BRCA1 and BRCA2, while the rest are likely due to less penetrant genes. In specific ethnicities such as Ashkenazi Jewish, three founder mutations have been identified which covers 95 % of all the BRCA mutations identified in this race. These genes are screened prior to the gold standard Sanger Sequencing in order to reduce cost. Sanger Sequencing, however, still has the limitation on the necessity of laborious processing and results interpretation. Moreover, it limits the number of genes that can be analyzed in one setting. With the use of next-generation sequencing (NGS), identification of hereditary breast and ovarian cancer (HBOC) syndrome associated genes, other than BRCA, can be sequenced at the same time but yet a faster turnover time. This allows more timely targeted risk-reducing strategies and interventions to be implemented for mutation positive carriers and their family members.

Methods: In this study cohort, 948 high-risk breast/ovarian patients who met the HBOC selection criteria were recruited for mutation screening by our NGS pipeline. With the inclusion of 90 Sanger-validated known mutation cases, the performance of the NGS pipeline were proven to be comparable to Sanger sequencing. PTEN and TP53, other than BRCA1 and BRCA2, a 4 gene sequencing panel were included in the mutation screening for high-risk patients.

Results: The prevalence of BRCA1/BRCA2 germline mutations was 7.28% in our Chinese cohort and 47.8% of the mutation were recurrent mutations. Based on this finding, we further adopted a new workflow by screening the recurrent mutations including founder mutations from Chinese cohort prior to NGS for those who tested negative. In a testing cohort of 343 cases, the recurrent mutation pick-up rate was 3.5%, this implicated a more cost-effective method for mutation screening in the clinical setting. Moreover, the frequencies of PTEN and TP53 were 0.21% and 0.53% respectively in our population with breast and ovarian cases.

Conclusion: Taken together, our data demonstrated a strategic upfront screening for recurrent mutations in Chinese population which is highly applicable in most of the diagnostic laboratories. Multi-gene sequencing using the NGS technology will be the upcoming strategies for mutation screening for HBOC patients.

Citation Format: Kwong A, Shin VY, Au CH, Law FB, Ho DN, Ip BK, Wong AT, Lau SS, To RM, Choy G, Ford JM, Ma ES, Chan TL. Evaluation on the mutation screening by next-generation sequencing in hereditary breast and ovarian cancer: Implementation of recurrent mutation panel. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-09-20.

Hospital Evaluations by Social Media: A Comparative Analysis of Facebook Ratings among Performance Outliers

BACKGROUND

An increasing number of hospitals and health systems utilize social media to allow users to provide feedback and ratings. The correlation between ratings on social media and more conventional hospital quality metrics remains largely unclear, raising concern that healthcare consumers may make decisions on inaccurate or inappropriate information regarding quality.

OBJECTIVES

The purpose of this study was to examine the extent to which hospitals utilize social media and whether user-generated metrics on Facebook(®) correlate with a Hospital Compare(®) metric, specifically 30-day all cause unplanned hospital readmission rates.

DESIGN AND PARTICIPANTS

This was a retrospective cross-sectional study conducted among all U.S. hospitals performing outside the confidence interval for the national average on 30-day hospital readmission rates as reported on Hospital Compare. Participants were 315 hospitals performing better than U.S. national rate on 30-day readmissions and 364 hospitals performing worse than the U.S. national rate.

MAIN MEASURES

The study analyzed ratings of hospitals on Facebook's five-star rating scale, 30-day readmission rates, and hospital characteristics including beds, teaching status, urban vs. rural location, and ownership type.

KEY RESULTS

Hospitals performing better than the national average on 30-day readmissions were more likely to use Facebook than lower-performing hospitals (93.3 % vs. 83.5 %; p < 0.01). The average rating for hospitals with low readmission rates (4.15 ± 0.31) was higher than that for hospitals with higher readmission rates (4.05 ± 0.41, p < 0.01). Major teaching hospitals were 14.3 times more likely to be in the high readmission rate group. A one-star increase in Facebook rating was associated with increased odds of the hospital belonging to the low readmission rate group by a factor of 5.0 (CI: 2.6-10.3, p <  0.01), when controlling for hospital characteristics and Facebook-related variables.

CONCLUSIONS

Hospitals with lower rates of 30-day hospital-wide unplanned readmissions have higher ratings on Facebook than hospitals with higher readmission rates. These findings add strength to the concept that aggregate measures of patient satisfaction on social media correlate with more traditionally accepted measures of hospital quality.

Appendectomy and Pregnancy: Gestational Age Does Not Affect the Position of the Incision

The position of the base of the appendix during advancing gestational age is based on inadequate data. Therefore, the proper location for an appendectomy incision during pregnancy is highly unclear. This study investigated the location of the appendix during pregnancy to determine the optimal location for an incision in pregnant patients with appendicitis relative to McBurney's point. Magnetic resonance images (MRIs) were reviewed independently by two fellowship-trained abdominal MRI radiologists blinded to the imaging report. The distance of the appendix from anatomic landmarks was measured in a total of 114 pregnant women with an abdominal or pelvic MRI who were admitted between 2001 and 2011 at a Level I trauma center. Patients with a history of appendectomy were excluded. The distance from the base of the appendix to McBurney's point changed over the course of the gestation by only 1.2 cm and which did not amount to a clinically or statistically significant change in position. Our data provide evidence that there is minimal upward or lateral displacement of the appendix during pregnancy, and therefore its distance from the McBurney's point remains essentially unchanged. These findings justify the use of the McBurney's incision for appendectomy during pregnancy regardless of the trimester.

Appendectomy and pregnancy: gestational age does not affect the position of the incision

The position of the base of the appendix during advancing gestational age is based on inadequate data. Therefore, the proper location for an appendectomy incision during pregnancy is highly unclear. This study investigated the location of the appendix during pregnancy to determine the optimal location for an incision in pregnant patients with appendicitis relative to McBurney's point. Magnetic resonance images (MRIs) were reviewed independently by two fellowship-trained abdominal MRI radiologists blinded to the imaging report. The distance of the appendix from anatomic landmarks was measured in a total of 114 pregnant women with an abdominal or pelvic MRI who were admitted between 2001 and 2011 at a Level I trauma center. Patients with a history of appendectomy were excluded. The distance from the base of the appendix to McBurney's point changed over the course of the gestation by only 1.2 cm and which did not amount to a clinically or statistically significant change in position. Our data provide evidence that there is minimal upward or lateral displacement of the appendix during pregnancy, and therefore its distance from the McBurney's point remains essentially unchanged. These findings justify the use of the McBurney's incision for appendectomy during pregnancy regardless of the trimester.

Image sharing: evolving solutions in the age of interoperability

Interoperability is a major focus of the quickly evolving world of Health IT. Easy, yet secure and confidential exchange of imaging exams and the associated reports must be a part of the solutions that are implemented. The availability of historical exams is essential in providing a quality interpretation and reducing inappropriate utilization of imaging services. Today, the exchange of imaging exams is most often achieved via a compact disc. We describe the virtues of this solution as well as challenges that have surfaced. Internet- and cloud-based technologies employed for many consumer services can provide a better solution. Vendors are making these solutions available. Standards for Internet-based exchange are emerging. Just as radiology converged on DICOM as a standard to store and view images, we need a common exchange standard. We will review the existing standards and how they are organized into useful workflows through Integrating the Healthcare Enterprise profiles. Integrating the Healthcare Enterprise and standards development processes are discussed. Health care and the domain of radiology must stay current with quickly evolving Internet standards. The successful use of the "cloud" will depend on both the technologies and the policies put into place around them, both of which we discuss. The radiology community must lead the way and provide a solution that works for radiologists and clinicians with use of the electronic medical record. We describe features we believe radiologists should consider when adding Internet-based exchange solutions to their practice.

Ultra-low dose abdominal MDCT: using a knowledge-based Iterative Model Reconstruction technique for substantial dose reduction in a prospective clinical study

PURPOSE

To assess lesion detection and image quality parameters of a knowledge-based Iterative Model Reconstruction (IMR) in reduced dose (RD) abdominal CT examinations.

MATERIALS AND METHODS

This IRB-approved prospective study included 82 abdominal CT examinations performed for 41 consecutive patients (mean age, 62 ± 12 years; F:M 28:13) who underwent a RD CT (SSDE, 1.5 mGy ± 0.4 [∼ 0.9 mSv] at 120 kV with 17-20 mAs/slice) immediately after their standard dose (SD) CT exam (10 mGy ± 3 [∼ 6 mSv] at 120 kV with automatic exposure control) on 256 MDCT (iCT, Philips Healthcare). SD data were reconstructed using filtered back projection (FBP). RD data were reconstructed with FBP and IMR. Four radiologists used a five-point scale (1=image quality better than SD CT to 5=image quality unacceptable) to assess both subjective image quality and artifacts. Lesions were first detected on RD FBP images. RD IMR and RD FBP images were then compared side-by-side to SD-FBP images in an independent, randomized and blinded fashion. Friedman's test and intraclass correlation coefficient were used for data analysis. Objective measurements included image noise and attenuation as well as noise spectral density (NSD) curves to assess the noise in frequency domain were obtained. In addition, a low-contrast phantom study was performed.

RESULTS

All true lesions (ranging from 32 to 55) on SD FBP images were detected on RD IMR images across all patients. RD FBP images were unacceptable for subjective image quality. Subjective ratings showed acceptable image quality for IMR for organ margins, soft-tissue structures, and retroperitoneal lymphadenopathy, compared to RD FBP in patients with a BMI ≤ 25 kg/m(2) (median-range, 2-3). Irrespective of patient BMI, subjective ratings for hepatic/renal cysts, stones and colonic diverticula were significantly better with RD IMR images (P<0.01). Objective image noise for RD FBP was 57-66% higher, and for RD IMR was 8-56% lower than that for SD-FBP (P<0.01). NSD showed significantly lower noise in the frequency domain with IMR in all patients compared to FBP.

CONCLUSION

IMR considerably improved both objective and subjective image quality parameters of RD abdominal CT images compared to FBP in patients with BMI less than or equal to 25 kg/m(2).

Oxygen saturation can predict pediatric pneumonia in a resource-limited setting

BACKGROUND

The World Health Organization (WHO) recommends using age-specific respiratory rates for diagnosing pneumonia in children. Past studies have evaluated the WHO criteria with mixed results.

OBJECTIVE

We examined the accuracy of clinical and laboratory factors for diagnosing pediatric pneumonia in resource-limited settings.

METHODS

We conducted a retrospective chart review of children under 5 years of age presenting with respiratory complaints to three rural hospitals in Rwanda who had received a chest radiograph. Data were collected on the presence or absence of 31 historical, clinical, and laboratory signs. Chest radiographs were interpreted by pediatric radiologists as the gold standard for diagnosing pneumonia. Overall correlation and test characteristics were calculated for each categorical variable as compared to the gold standard. For continuous variables, we created receiver operating characteristic (ROC) curves to determine their accuracy for predicting pneumonia.

RESULTS

Between May 2011 and April 2012, data were collected from 147 charts of children with respiratory complaints. Approximately 58% of our sample had radiologist-diagnosed pneumonia. Of the categorical variables, a negative blood smear for malaria (χ(2) = 6.21, p = 0.013) and the absence of history of asthma (χ(2) = 4.48, p = 0.034) were statistically associated with pneumonia. Of the continuous variables, only oxygen saturation had a statistically significant area under the ROC curve (AUC) of 0.675 (95% confidence interval [CI] 0.581-0.769 and p = 0.001). Respiratory rate had an AUC of 0.528 (95% CI 0.428-0.627 and p = 0.588).

CONCLUSION

Oxygen saturation was the best clinical predictor for pediatric pneumonia and should be further studied in a prospective sample of children with respiratory symptoms in a resource-limited setting.

SGI-110: DNA Methyltransferase Inhibitor Oncolytic

SGI-110 is a second-generation hypomethylating prodrug whose active metabolite is the well-characterized drug decitabine. This novel compound is an oligonucleotide consisting of decitabine linked through a phosphodiester bond to the endogenous nucleoside deoxyguanosine. The dinucleotide configuration provides protection from drug clearance by deamination, while maintaining at least equivalent effects on gene-specific and global hypomethylation both in vitro and in animal model systems. This agent is currently being tested in phase I and II clinical trials in humans and has been demonstrated to be safe and well tolerated as a single agent, with evidence of promising activity in heavily pretreated (including currently FDA approved hypomethylating drugs) myelodysplastic syndrome and acute myeloid leukemia patients. Ongoing trials are also open in platinum-resistant ovarian cancer and hepatocellular carcinoma.

Pertinent reportable incidental cardiac findings on chest CT without electrocardiography gating: review of 268 consecutive cases

BACKGROUND

Pertinent reportable cardiac findings on non-electrocardiography (ECG)-gated chest CT examinations have become easier to detect given recent advancements in multidetector CT technology. However, those findings are easily overlooked on routine chest CT without ECG gating given residual inherent cardiac motion artifact and non-cardiac indications.

PURPOSE

To describe and quantify the types of pertinent reportable cardiac findings that can be detected on chest CT examinations without ECG gating and evaluate how often they were reported.

MATERIAL AND METHODS

Two radiologists retrospectively reviewed (blinded to the original interpretation) 268 consecutive routine adult chest CT examinations without ECG gating for the presence of pertinent reportable cardiac findings. Retrospective interpretations were then compared with the original radiological reports.

RESULTS

One hundred and sixty-three patients (61%) had pertinent reportable cardiac findings. The findings encountered included: coronary artery disease (n = 131; 80.0%), coronary artery bypass grafts (n = 10; 6.1%), left ventricular aneurysm (n = 1; 0.6%), valve calcification (n = 131; 80.0%), valve repair/replacement (n = 5; 3.1%), pericardial effusion (n = 33; 20.2%), left atrial appendage thrombus (n = 1; 0.6%), cardiac mass (n = 1; 0.6%), and cardiac chamber enlargement (n = 29; 17.8%). On the original radiological reports 22.3% of the pertinent reportable cardiac findings, detected by the two radiologists retrospectively, were not reported.

CONCLUSION

Detection of pertinent reportable cardiac findings on routine chest CT examinations without ECG gating is possible. The high volume of chest CT examinations without ECG gating represents an opportunity for radiologists to comment on the presence or absence of cardiac disease which may influence future clinical decisions.

Targeting PIM kinase enhances the activity of sunitinib in renal cell carcinoma

Background:

Upregulation of PIM kinase expression has been reported in many malignancies, suggesting that inhibition of PIM kinase activity may be an attractive therapeutic strategy. We hypothesised that inhibition of PIM kinase activity with SGI-1776, a novel small molecule inhibitor of PIM kinase activity, would reduce the viability of renal cell carcinoma (RCC) cells and enhance the activity of sunitinib.

Methods:

Immunoblotting, qRT–PCR, and gene expression arrays were carried out to identify genes modulated by SGI-1776 treatment. The anticancer activity of SGI-1776 and sunitinib was determined by viability and apoptosis assays and in tumour xenografts in vivo.

Results:

Treatment with SGI-1776 led to a decrease in phosphorylated and total c-Myc levels, which resulted in the modulation of c-Myc target genes. SGI-1776 in combination with sunitinib induced a further reduction in c-Myc levels, which was associated with enhanced anticancer activity. siRNA-mediated knockdown of c-Myc demonstrated that its expression has a key role in regulating the sensitivity to the combination of SGI-1776 and sunitinib. Importantly, the combination significantly reduced tumour burden in two RCC xenograft models compared with single-agent therapy and was very well tolerated.

Conclusion:

These data indicate that targeting PIM kinase signalling is a promising treatment strategy for RCC.

[Prevalence and clinical significance of incidental cardiac findings in non-ECG-gated chest CT scans]

BACKGROUND

The purpose of this study was to evaluate the prevalence and clinical significance of incidental cardiac findings in non-ECG-gated chest CT.

PATIENTS AND METHODS

Non-ECG-gated chest CT examinations of 300 patients were retrospectively analyzed for incidental cardiac findings. Subsequently, these findings were evaluated for their clinical relevance by a cardiologist.

RESULTS

A total of 107 out of 300 examined patients had 174 incidental cardiac findings including coronary calcification (90), aortic/mitral valve calcification (42), iatrogenic changes (23), pericardial effusion (6), dilatation of the heart (4), myocardial changes (3), thrombus in the left ventricle (2), constrictive pericarditis (2) and atrial myxoma (1). Of the cardiac findings 51% were described in the written report and in 53 out of the 107 patients the cardiac findings were unknown. Newly detected incidental findings from 8 patients were rated as clinically significant: pericardial effusion (4), constrictive pericarditis (1), thrombus in the left ventricle (1), atrial myxoma (1) and dilatation of the heart (1).

CONCLUSION

Incidental cardiac findings are frequent in non-ECG-gated chest CT and may have a high clinical relevance.

Usefulness of comprehensive cardiothoracic computed tomography in the evaluation of acute undifferentiated chest discomfort in the emergency department (CAPTURE)

Newer cardiac computed tomographic (CT) technology has permitted comprehensive cardiothoracic evaluations for coronary artery disease, pulmonary embolism, and aortic dissection within a single breath hold, independent of the heart rate. We conducted a randomized diagnostic trial to compare the efficiency of a comprehensive cardiothoracic CT examination in the evaluation of patients presenting to the emergency department with undifferentiated acute chest discomfort or dyspnea. We randomized the emergency department patients clinically scheduled to undergo a dedicated CT protocol to assess coronary artery disease, pulmonary embolism, or aortic dissection to either the planned dedicated CT protocol or a comprehensive cardiothoracic CT protocol. All CT examinations were performed using a 64-slice dual source CT scanner. The CT results were immediately communicated to the emergency department providers, who directed further management at their discretion. The subjects were then followed for the remainder of their hospitalization and for 30 days after hospitalization. Overall, 59 patients (mean age 51.2 ± 11.4 years, 72.9% men) were randomized to either dedicated (n = 30) or comprehensive (n = 29) CT scanning. No significant difference was found in the median length of stay (7.6 vs 8.2 hours, p = 0.79), rate of hospital discharge without additional imaging (70% vs 69%, p = 0.99), median interval to exclusion of an acute event (5.2 vs 6.5 hours, p = 0.64), costs of care (p = 0.16), or the number of revisits (p = 0.13) between the dedicated and comprehensive arms, respectively. In addition, radiation exposure (11.3 mSv vs 12.8 mSv, p = 0.16) and the frequency of incidental findings requiring follow-up (24.1% vs 33.3%, p = 0.57) were similar between the 2 arms. Comprehensive cardiothoracic CT scanning was feasible, with a similar diagnostic yield to dedicated protocols. However, it did not reduce the length of stay, rate of subsequent testing, or costs. In conclusion, although this "triple rule out" protocol might be helpful in the evaluation of select patients, these findings suggest that it should not be used routinely with the expectation that it will improve efficiency or reduce resource use.

Differentiation of malignant thrombus from bland thrombus of the portal vein in patients with hepatocellular carcinoma: application of diffusion-weighted MR imaging

PURPOSE

To investigate the utility of diffusion-weighted (DW) imaging in distinguishing bland thrombus from neoplastic thrombus in the portal vein in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

In this retrospective institutional review board-approved HIPAA-complaint study, the imaging results in 25 patients (16 men [average age, 62.3 years; range, 35-75 years] and nine women [average age, 58.4 years; range, 32-69 years]; overall average age, 60.1 years; range, 32-75 years) with HCC and portal vein thrombosis who were examined with both contrast material-enhanced computed tomography (CT) and 1.5-T magnetic resonance (MR) imaging were reviewed. Axial echo-planar two-dimensional DW imaging was performed by using b values of 50, 400, and 800 sec/mm(2). A thrombus was considered neoplastic if it expanded the vessel or enhanced on the dynamic CT and MR images; otherwise it was considered bland. The signal intensity (SI) of the thrombus and HCC lesions in the same patients was compared on DW images. The results were evaluated by using the Fisher exact test. The apparent diffusion coefficients (ADCs) of HCC and thrombus were used to compute the ratio of the ADC of the thrombus to the ADC of the tumor.

RESULTS

On DW images, 15 of 19 neoplastic thrombi demonstrated same SI and four showed lower SI than the primary HCC. Each of the six bland thrombi had lower SI than the primary HCC (P < .001). The mean ADC of HCC and thrombus in the neoplastic thrombus group was 0.87 x 10(-3) mm(2)/sec and 0.88 x 10(-3) mm(2)/sec, respectively (P = .45). The ADC of the bland thrombus was 2.89 x 10(-3) mm(2)/sec, significantly higher than the ADC of the HCC (1.0 x 10(-3) mm(2)/sec, P < .0003). The ratio of the ADC of the thrombus to the ADC of the tumor in the bland thrombus group was 2.9 compared with 0.998 in the neoplastic group (P = .0003).

CONCLUSION

DW imaging enables discrimination between bland and neoplastic portal vein thrombi when the ratio of the ADC of the thrombus to the ADC of HCC was lower than 2 and when the thrombi showed similar SI as the primary HCC when qualitative analysis was performed.

ACR Appropriateness Criteria on acute pelvic pain in the reproductive age group

Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation.

A phase Ib dose-escalation study of orally administered MP-470, a multi-kinase inhibitor and supressor of Rad51, in combination with carboplatin doublet containing regimens shows activity in highly refractory solid tumor patients

e13511

Background: MP-470 (MP) is an oral multi-targeted tyrosine kinase inhibitor which inhibits a number of validated tumor targets including c-kit, flt3, and PDGFα. MP470 targets cancer cells by disrupting DNA repair, an important survival pathway in many human cancers. Results presented herein are from two arms of a phase-Ib five arm trial of MP combined with standard of care (SOC) anti- cancer therapies. Methods: MP is administered in combination with SOC in a 21-day cycle. Adults with ECOG PS of 0–2 and malignant disease appropriate for SOC regimens consisting of paclitaxel/carboplatin (PC), carboplatin/etoposide (CE), topotecan, docetaxel, and erlotinib were enrolled. Each arm follows a 3+3 design where MP is escalated based on the modified Fibonacci sequence until the MTD of MP in combination with SOC agents is reached. RECIST and CTCAE are utilized to assess response and safety, respectively. The primary objectives of the study are to determine the MTD, DLTs, and quantify the effects of MP on the PK of SOC agents. Results: Between Dec 2007 and Aug 2008, 26 subjects were enrolled in the PC and CE arms and received a total of 70 cycles (median 2; range, 0–8) of MP at 4 dose levels (100–500 mg/day). Median number of prior therapies was 2 (range, 0–19). Male/Female: 14/12. Median age, 56 years (range, 24–76). Subjects completing ≥ 6 and ≥ 4 cycles were 5 and 7, respectively. Six PRs (2 neuroendocrine, 2 SCLC, 1 NSCLC, 1 small cell of anal canal) and 3 SDs (≥ 4 cycles) was observed. The MTDs have not been reached and DLTs have not been identified. Adverse events occurring in ≥ 15% of patients were myelosuppression, diarrhea, constipation, nausea, reflux, fatigue, alopecia, rash, neuropathy, anorexia, hypokalemia, dyspnea, and myalgias. MP470 did not alter the kinetics of SOC agents. Dose escalation in the PC and CE arms is ongoing. Conclusions: MP470 combined with carboplatin-containing regimens may promote tumor regression and may also sensitize/resensitize tumors to the anticancer effects of such agents. An amendment will be issued to collect tumor tissue biopsy at baseline and during treatment to adequately evaluate DNA damage in tumor tissue.

[Table: see text]

A pharmacokinetic comparison of the Marqibo 3 and 5 vial injection kits in metatastic melanoma patients

8575

Background: In nonclinical and clinical studies, liposomal encapsulation of vincristine sulfate (VCR) increased the circulation time and accumulation of VCR at the tumor site, and thus improved antitumor efficacy in comparison to VCR. Marqibo (vincristine sulfate liposomes injection) may be administered safely at doses exceeding that typically employed by VCR, with a manageable pattern of clinical toxicities consistent with VCR. Methods: We conducted a phase I, single-center, open-label, randomized, 2-arm crossover study designed to compare the pharmacokinetics (PK) of Marqibo utilizing the 3- and 5-vial kits administered 2 mg/m2 IV infusion once every 2 weeks in histologically confirmed, surgically nonresectable Stage III or IV metastatic cutaneous, mucosal, or choroidal melanoma patients. Patients randomized to receive the 3-vial kit at Cycle 1 were crossed over to receive the 5-vial kit at Cycle 2 or vice versa. The 3-vial kit was used for all patients at all cycles from Cycle 3 to end of treatment. Antitumor activity was assessed by CT scan every 4 cycles. Blood samples for PK analysis was collected at pretreatment, during infusion, end of infusion, and at various time points within 96 hours post end of infusion at Cycles 1 and 2. Total VCR concentration and released vincristine concentration was measured using HPLC-MS/MS method. Results: Fifteen patients were enrolled and treated; 11 were evaluable for the PK analysis. Median number of cycles received was 4 (1- 24). Objective response was observed in 13% (1 CR, 1 PR) or stable disease (20%, 3 SD) as their best response. The 90% CI (0.83–1.12) on the ratio of the means of the AUC0-inf of the 3- and 5-vial kits was within the interval of 0.80–1.25 confirming the bioequivalence of the two kits. Seventy-three percent discontinued treatment due to disease progression and 13% discontinued due to adverse events. Adverse events included hypoesthesia or paresthesia, constipation, numbness, weakness, fatigue, nausea, vomiting. Conclusions: Single agent Marqibo demonstrated moderate activity in advanced Stage IV melanoma patients and was generally well tolerated with similar adverse event profile to VCR. The 3- and 5-vial kits produced similar bioequivalent PK profiles.

No significant financial relationships to disclose.

Dynamic Contrast-Enhanced Magnetic Resonance Imaging in the Assessment of Early Response to Tumor Necrosis Factor Alpha in a Colon Carcinoma Model

OBJECTIVE

We describe the effects of tumor necrosis factor alpha (TNFalpha) on tumor microvasculature in a murine colon carcinoma model using serial dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI).

MATERIAL AND METHODS

Mice with subcutaneous murine colon carcinomas (MC-38) were imaged at 4.7 T after administration of 0.2 mmol/kg gadolinium-DTPA. Both treated and control mice (each group, n = 4), were scanned at baseline and 2, 4, 6, and 96 hours. A 2-compartment pharmacokinetic model generated parameters such as K, kep, and initial area under the gadolinium concentration curve (IAUC).

RESULTS

The treatment group revealed significant differences in K at all time points after TNFalpha. kep and IAUC were significantly reduced at 2, 6, and 96 hours. The coefficient of variation in control animals ranged from 0.13 for IAUC to 0.30 for K. Mild histologic changes were observed at 2 to 6 hours, but considerable central necrosis with a vascular tumor rim was seen at 96 hours.

CONCLUSION

DCE MRI can be used to detect early effects of TNFalpha. Serial DCE MRI is a promising tool in assessing the early effects of antivascular therapies.

Comparison of noninvasive fluorescent and bioluminescent small animal optical imaging

Optical imaging is a modality that is cost-effective, rapid, easy to use, and can be readily applied to studying disease processes and biology in vivo. For this study, we used a green fluorescent protein (GFP)- and luciferase-expressing mouse tumor model to compare and contrast the quantitative and qualitative capabilities of a fluorescent reporter gene (GFP) and a bioluminescent reporter gene (luciferase). We describe the relationship between tumor volume, tumor mass, and bioluminescent/fluorescent intensity for both GFP and luciferase. Bioluminescent luciferase imaging was shown to be more sensitive than fluorescent GFP imaging. Luciferase-expressing tumors were detected as early as 1 day after tumor cell inoculation, whereas GFP-expressing tumors were not detected until 7 days later. Both bioluminescent and fluorescent intensity correlated significantly and linearly with tumor volume and tumor weight, as measured by caliper. Compared to bioluminescent imaging, fluorescent imaging does not require the injection of a substrate and may be appropriate for applications where sensitivity is not as critical. Knowing the relative strengths of each imaging modality will be important in guiding the decision to use fluorescence or bioluminescence.