Learning Curve for Flow Diversion of Posterior Circulation Aneurysms: A Long-Term International Multicenter Cohort Study.

BACKGROUND AND PURPOSE: Flow diversion has gradually become a standard treatment for intracranial aneurysms of the anterior circulation. Recently, the off-label use of the flow diverters to treat posterior circulation aneurysms has also increased despite initial concerns of rupture and the suboptimal results. This study aimed to explore the change in complication rates and treatment outcomes across time for posterior circulation aneurysms treated using flow diversion and to further evaluate the mechanisms and variables that could potentially explain the change and outcomes. MATERIALS AND METHODS: A retrospective review using a standardized data set at multiple international academic institutions was performed to identify patients with ruptured and unruptured posterior circulation aneurysms treated with flow diversion during a decade spanning January 2011 to January 2020. This period was then categorized into 4 intervals. RESULTS: A total of 378 procedures were performed during the study period. Across time, there was an increasing tendency to treat more vertebral artery and fewer large vertebrobasilar aneurysms (P = .05). Moreover, interventionalists have been increasingly using fewer overlapping flow diverters per aneurysm (P = .07). There was a trend toward a decrease in the rate of thromboembolic complications from 15.8% in 2011-13 to 8.9% in 2018-19 (P = .34). CONCLUSIONS: This multicenter experience revealed a trend toward treating fewer basilar aneurysms, smaller aneurysms, and increased usage of a single flow diverter, leading to a decrease in the rate of thromboembolic and hemorrhagic complications.

In and around the pineal gland: a neuroimaging review.

Lesions arising in or around the pineal gland comprise a heterogeneous group of pathologies ranging from benign non-neoplastic cysts to highly malignant neoplasms. Pineal cysts are frequently encountered as an incidental finding in daily radiology practice but there is no universal agreement on the criteria for, frequency of, and duration of follow-up imaging. Solid pineal neoplasms pose a diagnostic challenge owing to considerable overlap in their imaging characteristics, although a combination of radiological appearances, clinical findings, and tumour markers allows for narrowing of the differential diagnosis. In this review, we describe the radiological anatomy of the pineal region, clinical symptoms, imaging appearances, and differential diagnosis of lesions arising in this area, and highlight the clinical management of these conditions.

A Deep Learning-Based Approach to Reduce Rescan and Recall Rates in Clinical MRI Examinations.

BACKGROUND AND PURPOSE: MR imaging rescans and recalls can create large hospital revenue loss. The purpose of this study was to develop a fast, automated method for assessing rescan need in motion-corrupted brain series. MATERIALS AND METHODS: A deep learning-based approach was developed, outputting a probability for a series to be clinically useful. Comparison of this per-series probability with a threshold, which can depend on scan indication and reading radiologist, determines whether a series needs to be rescanned. The deep learning classification performance was compared with that of 4 technologists and 5 radiologists in 49 test series with low and moderate motion artifacts. These series were assumed to be scanned for 2 scan indications: screening for multiple sclerosis and stroke. RESULTS: The image-quality rating was found to be scan indication- and reading radiologist-dependent. Of the 49 test datasets, technologists created a mean ratio of rescans/recalls of (4.7 ± 5.1)/(9.5 ± 6.8) for MS and (8.6 ± 7.7)/(1.6 ± 1.9) for stroke. With thresholds adapted for scan indication and reading radiologist, deep learning created a rescan/recall ratio of (7.3 ± 2.2)/(3.2 ± 2.5) for MS, and (3.6 ± 1.5)/(2.8 ± 1.6) for stroke. Due to the large variability in the technologists' assessments, it was only the decrease in the recall rate for MS, for which the deep learning algorithm was trained, that was statistically significant (P = .03). CONCLUSIONS: Fast, automated deep learning-based image-quality rating can decrease rescan and recall rates, while rendering them technologist-independent. It was estimated that decreasing rescans and recalls from the technologists' values to the values of deep learning could save hospitals $24,000/scanner/year.

Use of optical coherence tomography for the diagnosis of preclinical lesions of circumscribed palmar hypokeratosis.

Circumscribed hypokeratosis of palms and soles is a rare dermatosis, usually affecting women. Diagnosis is mainly based on the clinical characteristics, including the clinical appearance and anatomical site of the skin lesions and on the demographic features of the affected patients, usually middle-aged to elderly women. Skin biopsy may be performed to confirm clinical diagnosis. Optical coherence tomography (OCT) is a technique that has been undergone substantial development in dermatology in recent years, and its use in clinical practice has been growing progressively. Several dermatological conditions have been studied with this tool, but to our knowledge, it has not been used to investigate this form of hypokeratosis. We report a case of circumscribed palmar hypokeratosis for which diagnosis was confirmed by OCT, which was performed as the patient was reluctant to undergo skin biopsy because of its invasiveness. We highlight the potential use of OCT in obtaining a virtual skin biopsy to confirm clinical diagnosis and identify preclinical skin lesions amenable to early treatment.

3D element imaging using NSECT for the detection of renal cancer: a simulation study in MCNP.

This work describes a simulation study investigating the application of neutron stimulated emission computed tomography (NSECT) for noninvasive 3D imaging of renal cancer in vivo. Using MCNP5 simulations, we describe a method of diagnosing renal cancer in the body by mapping the 3D distribution of elements present in tumors using the NSECT technique. A human phantom containing the kidneys and other major organs was modeled in MCNP5. The element composition of each organ was based on values reported in literature. The two kidneys were modeled to contain elements reported in renal cell carcinoma (RCC) and healthy kidney tissue. Simulated NSECT scans were executed to determine the 3D element distribution of the phantom body. Elements specific to RCC and healthy kidney tissue were then analyzed to identify the locations of the diseased and healthy kidneys and generate tomographic images of the tumor. The extent of the RCC lesion inside the kidney was determined using 3D volume rendering. A similar procedure was used to generate images of each individual organ in the body. Six isotopes were studied in this work - (32)S, (12)C, (23)Na, (14)N, (31)P and (39)K. The results demonstrated that through a single NSECT scan performed in vivo, it is possible to identify the location of the kidneys and other organs within the body, determine the extent of the tumor within the organ, and to quantify the differences between cancer and healthy tissue-related isotopes with p ≤ 0.05. All of the images demonstrated appropriate concentration changes between the organs, with some discrepancy observed in (31)P, (39)K and (23)Na. The discrepancies were likely due to the low concentration of the elements in the tissue that were below the current detection sensitivity of the NSECT technique.

Lifelong physical activity in maintaining bone strength in older men and women of the Age, Gene/Environment Susceptibility-Reykjavik Study.

UNLABELLED: We examined if lifelong physical activity is important for maintaining bone strength in the elderly. Associations of quantitative computerized tomography-acquired bone measures (vertebral and femoral) and self-reported physical activity in mid-life (mean age, 50 years), in old age (≥65 years), and throughout life (recalled during old age) were investigated in 2,110 men and 2,682 women in the AGES-Reykjavik Study. Results conclude lifelong physical activity with continuation into old age (≥65 years) best maintains better bone health later in life. INTRODUCTION: Skeletal loading is thought to modulate the loss of bone in later life, and physical activity is a chief means of affecting bone strength by skeletal loading. Despite much discussion regarding lifelong versus early adulthood physical activity for preventing bone loss later in life, inconsistency still exists regarding how to maintain bone mass later in life (≥65 years). METHODS: We examined if lifelong physical activity is important for maintaining bone strength in the elderly. RESULTS: The associations of quantitative computerized tomography-acquired vertebral and femoral bone measures and self-reported physical activity in mid-life (mean age, 50 years), in old age (≥65 years), and throughout life (recalled during old age) were investigated in 2,110 men and 2,682 women in the AGES-Reykjavik Study. CONCLUSION: Our findings conclude that lifelong physical activity with continuation into old age (≥65 years) best maintains better bone health in the elderly.

Sensitivity analysis for liver iron measurement through neutron stimulated emission computed tomography: a Monte Carlo study in GEANT4.

Neutron stimulated emission computed tomography (NSECT) is being developed as a non-invasive imaging modality to detect and quantify iron overload in the human liver. NSECT uses gamma photons emitted by the inelastic interaction between monochromatic fast neutrons and iron nuclei in the body to detect and quantify the disease. Previous simulated and physical experiments with phantoms have shown that NSECT has the potential to accurately diagnose iron overload with reasonable levels of radiation dose. In this work, we describe the results of a simulation study conducted to determine the sensitivity of the NSECT system for hepatic iron quantification in patients of different sizes. A GEANT4 simulation of the NSECT system was developed with a human liver and two torso sizes corresponding to small and large patients. The iron concentration in the liver ranged between 0.5 and 20 mg g(-1), corresponding to clinically reported iron levels in iron-overloaded patients. High-purity germanium gamma detectors were simulated to detect the emitted gamma spectra, which were background corrected using suitable water phantoms and analyzed to determine the minimum detectable level (MDL) of iron and the sensitivity of the NSECT system. These analyses indicate that for a small patient (torso major axis = 30 cm) the MDL is 0.5 mg g(-1) and sensitivity is ∼13 ± 2 Fe counts/mg/mSv and for a large patient (torso major axis = 40 cm) the values are 1 mg g(-1) and ∼5 ± 1 Fe counts/mg/mSv, respectively. The results demonstrate that the MDL for both patient sizes lies within the clinically significant range for human iron overload.

SU-E-T-108: 3D Measurement of Neutron Dose from a Novel Neutron Imaging Technique.

PURPOSE: We have been developing a fast-neutron spectroscopic technique to quantitatively image the distribution of elements in the body using quasi-monochromatic neutron beams. Previously, we demonstrated the ability of the technique to quantify specific elements in the liver and breast while limiting radiation dose to clinically acceptable levels. Here we present the results of a physical dose measurement performed through neutron irradiation of 3D PRESAGE dosimetry phantoms. METHODS: Two PRESAGE optical-CT dosimeters were placed inside a physical phantom of the human torso and irradiated with 8 MeV neutrons produced via the 2H(d,n) reaction using a tandem Van-de-Graaff accelerator. The dosimeters, measuring 10 cm and 4 cm in diameter, were located in regions corresponding to the liver (10 cm), and the kidney (4 cm). Irradiation was performed with the neutron beam incident directly on the larger dosimeter. Cumulative neutron fluence incident upon each dosimeter was determined using an aluminum-foil activation technique. Following irradiation, the change in optical density in both dosimeters was measured to determine the relative irradiation and dose distribution in each volume. RESULTS: Both PRESAGE dosimeters exhibited detectable changes in optical density corresponding to the dose deposited in the volume. The two dosimeters registered doses of 8.5 Gy (direct incidence, 4.5 hour irradiation) and 0.25 Gy (off-axis, 20 hour irradiation), respectively. The larger dosimeter showed highest intensity at the entry point of the beam with exponential drop-off along the beam direction. The smaller dosimeter registered a more uniform change in intensity, consistent with the higher incidence of scattered neutrons at this location. CONCLUSION: The results demonstrate the utility of PRESAGE dosimeters in measuring dose from neutron irradiation and highlight the difference in relative doses between primary and proximal organs when exposed to neutron beams. This work was supported by the United States Department of Energy, Office of Nuclear Physics under Grant No. DE-FG02-97ER41033, the National Cancer Institute under grant R01CA100835, and by the Department of Defense under award W81XWH-09-1-0066.

SU-E-I-77: X-Ray Coherent Scatter Diffraction Pattern Modeling in GEANT4.

PURPOSE: To model X-ray coherent scatter diffraction patterns in GEANT4 for simulating experiments involving material detection through diffraction pattern measurement. Although coherent scatter cross-sections are modeled accurately in GEANT4, diffraction patterns for crystalline materials are not yet included. Here we describe our modeling of crystalline diffraction patterns in GEANT4 for specific materials and the validation of the results against experimentally measured data. METHODS: Coherent scatter in GEANT4 is currently based on Hubbell's non-relativistic form factor tabulations from EPDL97. We modified the form-factors by introducing an interference function that accounts for the angular dependence between the Rayleigh-scattered photons and the photon wavelength. The modified form factors were used to replace the inherent form-factors in GEANT4. The simulation was tested using monochromatic and polychromatic x-ray beams (separately) incident on objects containing one or more elements with modified form-factors. The simulation results were compared against the experimentally measured diffraction images of corresponding objects using an in-house x-ray diffraction imager for validation. The comparison was made using the following metrics: number of diffraction rings, radial distance, absolute intensity, and relative intensity. RESULTS: Sharp diffraction pattern rings were observed in the monochromatic simulations at locations consistent with the angular dependence of the photon wavelength. In the polychromatic simulations, the diffraction patterns exhibited a radial blur consistent with the energy spread of the polychromatic spectrum. The simulated and experimentally measured patterns showed identical numbers of rings with close agreement in radial distance, absolute and relative intensities (barring statistical fluctuations). No significant change was observed in the execution time of the simulations. CONCLUSIONS: This work demonstrates the ability to model coherent scatter diffraction in GEANT4 in an accurate and efficient manner without compromising the accuracy or runtime of the simulation. This work was supported by the Department of Homeland Security under grant DHS (BAA 10-01 F075), and by the Department of Defense under award W81XWH-09-1-0066.

Postinfectious glomerulonephritis: Is there a role for steroids?

The role of steroids in treatment of postinfectious glomerulonephritis (PIGN) has been controversial. The reason for such controversy is the risk of infection relapse associated with steroid therapy. Steroids may have a place in the treatment of resistant cases where renal function does not improve despite aggressive antibiotic therapy as well as in patients with crescentic form of PIGN. We report a case of a 39 year-old Caucasian man who was diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia resulting in acute IgA dominant PIGN that failed to respond to antibiotic treatment alone, but responded significantly to steroids in addition to antibiotics. This anecdotal experience suggests that steroids could be considered in conjunction with antibiotic therapy for the treatment of refractory cases of PIGN or crescentic form of PIGN. More studies with long-term follow-up of patients treated with steroids in addition to antimicrobial agents are required to quantify the risk of infection relapse with steroid therapy.

Review: molecular pathogenesis of blood-brain barrier breakdown in acute brain injury.

Historically, the blood-brain barrier (BBB) was considered to be at the level of cerebral endothelium. Currently, the interaction of endothelium with other components of the vessel wall and with neurones and glial cells is considered to constitute a functional unit, termed the neurovascular unit that maintains cerebral homeostasis in steady states and brain injury. The emphasis of this review is on cerebral endothelium, the best-studied component of the neurovascular unit, and its permeability mechanisms in health and acute brain injury. Major advances have been made in unravelling the molecular structure of caveolae and tight junctions, both of which are components of the structural barrier to the entry of plasma proteins into brain. Time course studies suggest that caveolar changes precede junctional changes in acute brain injury. Additional factors modulating BBB permeability in acute brain injury are matrix metalloproteinases-2 and 9 and angiogenic factors, the most notable being vascular endothelial growth factor-A and angiopoietins (Ang) 1 and 2. Vascular endothelial growth factor-A and Ang2 have emerged as potent inducers of BBB breakdown while Ang1 is a potent anti-leakage factor. These factors have the potential to modulate permeability in acute brain injury and this is an area of ongoing research. Overall, a combination of haemodynamic, structural and molecular alterations affecting brain endothelium results in BBB breakdown in acute brain injury.

Evaluating a New Risk Marker's Predictive Contribution in Survival Models.

Although the area under the receiver operating characteristic (ROC) curve (AUC) is the most popular measure of the performance of prediction models, it has limitations, especially when it is used to evaluate the added discrimination of a new risk marker in an existing risk model. Pencina et al. (2008) proposed two indices, the net reclassification improvement (NRI) and integrated discrimination improvement (IDI), to supplement the improvement in the AUC (IAUC). Their NRI and IDI are based on binary outcomes in case-control settings, which do not involve time-to-event outcome. However, many disease outcomes are time-dependent and the onset time can be censored. Measuring discrimination potential of a prognostic marker without considering time to event can lead to biased estimates. In this paper, we extended the NRI and IDI to time-to-event settings and derived the corresponding sample estimators and asymptotic tests. Simulation studies showed that the time-dependent NRI and IDI have better performance than Pencina's NRI and IDI for measuring the improved discriminatory power of a new risk marker in prognostic survival models.

Experimental detection of iron overload in liver through neutron stimulated emission spectroscopy.

Iron overload disorders have been the focus of several quantification studies involving non-invasive imaging modalities. Neutron spectroscopic techniques have demonstrated great potential in detecting iron concentrations within biological tissue. We are developing a neutron spectroscopic technique called neutron stimulated emission computed tomography (NSECT), which has the potential to diagnose iron overload in the liver at clinically acceptable patient dose levels through a non-invasive scan. The technique uses inelastic scatter interactions between atomic nuclei in the sample and incoming fast neutrons to non-invasively determine the concentration of elements in the sample. This paper discusses a non-tomographic application of NSECT investigating the feasibility of detecting elevated iron concentrations in the liver. A model of iron overload in the human body was created using bovine liver tissue housed inside a human torso phantom and was scanned with a 5 MeV pulsed beam using single-position spectroscopy. Spectra were reconstructed and analyzed with algorithms designed specifically for NSECT. Results from spectroscopic quantification indicate that NSECT can currently detect liver iron concentrations of 6 mg g(-1) or higher and has the potential to detect lower concentrations by optimizing the acquisition geometry to scan a larger volume of tissue. The experiment described in this paper has two important outcomes: (i) it demonstrates that NSECT has the potential to detect clinically relevant concentrations of iron in the human body through a non-invasive scan and (ii) it provides a comparative standard to guide the design of iron overload phantoms for future NSECT liver iron quantification studies.

Neutron stimulated emission computed tomography: a Monte Carlo simulation approach.

A Monte Carlo simulation has been developed for neutron stimulated emission computed tomography (NSECT) using the GEANT4 toolkit. NSECT is a new approach to biomedical imaging that allows spectral analysis of the elements present within the sample. In NSECT, a beam of high-energy neutrons interrogates a sample and the nuclei in the sample are stimulated to an excited state by inelastic scattering of the neutrons. The characteristic gammas emitted by the excited nuclei are captured in a spectrometer to form multi-energy spectra. Currently, a tomographic image is formed using a collimated neutron beam to define the line integral paths for the tomographic projections. These projection data are reconstructed to form a representation of the distribution of individual elements in the sample. To facilitate the development of this technique, a Monte Carlo simulation model has been constructed from the GEANT4 toolkit. This simulation includes modeling of the neutron beam source and collimation, the samples, the neutron interactions within the samples, the emission of characteristic gammas, and the detection of these gammas in a Germanium crystal. In addition, the model allows the absorbed radiation dose to be calculated for internal components of the sample. NSECT presents challenges not typically addressed in Monte Carlo modeling of high-energy physics applications. In order to address issues critical to the clinical development of NSECT, this paper will describe the GEANT4 simulation environment and three separate simulations performed to accomplish three specific aims. First, comparison of a simulation to a tomographic experiment will verify the accuracy of both the gamma energy spectra produced and the positioning of the beam relative to the sample. Second, parametric analysis of simulations performed with different user-defined variables will determine the best way to effectively model low energy neutrons in tissue, which is a concern with the high hydrogen content in biological tissue. Third, determination of the energy absorbed in tissue during neutron interrogation in order to estimate the dose. Results from these three simulation experiments demonstrate that GEANT4 is an effective simulation platform that can be used to facilitate the future development and optimization of NSECT.

Factors associated with the awareness and practice of evidence-based obstetric care in an African setting.

OBJECTIVE: To identify the factors associated with important (> or =50%) variation in awareness and practice of evidence-based obstetric interventions in an African setting where we have previously reported poor awareness and use of evidence-based reproductive interventions. DESIGN: Cross-sectional analysis of data from our Reproductive Health Interventions Study. SETTING: North-west province, Cameroon, Africa. POPULATION: Health workers including obstetricians, other physicians, midwives, nurses and other staff providing reproductive care. MAIN OUTCOME MEASURES: Prevalence ratios (PR) of uniform awareness and practice of four key evidence-based obstetric interventions from the World Health Organization Reproductive Health Library (WHO RHL): antiretrovirals to prevent mother-to-child transmission of HIV/AIDS, antenatal corticosteroids for prematurity, uterotonics to prevent postpartum haemorrhage and magnesium sulphate for seizure prophylaxis. METHODS: Comparisons of descriptive covariates, applying logistic regression to estimate independent relationships with awareness and use of evidence-based interventions. RESULTS: A total of 15.5% (50/322) of health workers were aware of all the four interventions while only 3.8% (12/312) reported optimal practice. Evidence-based awareness was strongly associated with practice (PR = 15.4; 96% CI: 4.3-55.0). Factors significantly associated with awareness were: attending continuing education, access to the WHO RHL, employment as an obstetrician/gynaecologist and working in autonomous military or National Insurance Fund facilities. Controlling for potential confounding, working as an obstetrician was associated with increased awareness (adjusted prevalence odds ratio [aPOR] = 8.3; 95% CI: 1.3-53.8) as was median work experience of 5-15 years (aPOR = 2.0; 95% CI: 1.0-3.8). Internet access was associated with increased practice (aPOR = 3.4; 95% CI: 1.0-11.8). Other potentially important variations were observed, although they did not attain statistical significance. CONCLUSIONS: Several factors including obstetric training and continuous education positively influence evidence-based awareness and practice of key obstetric interventions. Confirmation and application of this information may enhance the effectiveness of programmes to improve maternal and perinatal outcomes.

Study of perceived norms, beliefs and intended sexual behaviour among higher secondary school students in India.

The objective of this paper is to understand the intended sexual and condom behaviour patterns among teenage higher secondary school students in India. To achieve this, variables including perceived norms, perceived peer group norms, risk behaviour patterns, perceived chances of getting AIDS and relevant sociodemographic variables were regressed on intended sexual behaviour. Regression of actual sexual behaviour was carried out with perceived norms, perceived peer group norms and intended sexual behaviour as the independent variables. In this paper a conceptual model has been framed based on the theory of reasoned action, health belief model and self-efficacy theory. Cumulative scores are computed for perceived norms, perceived peer group norms, risk behaviour patterns, opinion on handling condoms and perceived chances of getting AIDS. Along with these variables, possible confounding variables such as age, gender, type of family, mother's education and father's education were considered for their effect on intended sexual and condom behaviour. The results revealed that perceived norms and perceived peer group norms showed significant association with intended sexual behaviour and actual sexual behaviour and that children of more highly educated parents are less likely to engage in sexual activities in their adolescent years.