Precision and Test-Retest Repeatability of Stiffness Measurement with MR Elastography: A Multicenter Phantom Study.

Background MR elastography (MRE) has been shown to have excellent performance for noninvasive liver fibrosis staging. However, there is limited knowledge regarding the precision and test-retest repeatability of stiffness measurement with MRE in the multicenter setting. Purpose To determine the precision and test-retest repeatability of stiffness measurement with MRE across multiple centers using the same phantoms. Materials and Methods In this study, three cylindrical phantoms made of polyvinyl chloride gel mimicking different degrees of liver stiffness in humans (phantoms 1-3: soft, medium, and hard stiffness, respectively) were evaluated. Between January 2021 and January 2022, phantoms were circulated between five different centers and scanned with 10 MRE-equipped clinical 1.5-T and 3-T systems from three major vendors, using two-dimensional (2D) gradient-recalled echo (GRE) imaging and/or 2D spin-echo (SE) echo-planar imaging (EPI). Similar MRE acquisition parameters, hardware, and reconstruction algorithms were used at each center. Mean stiffness was measured by a single observer for each phantom and acquisition on a single section. Stiffness measurement precision and same-session test-retest repeatability were assessed using the coefficient of variation (CV) and the repeatability coefficient (RC), respectively. Results The mean precision represented by the CV was 5.8% (95% CI: 3.8, 7.7) for all phantoms and both sequences combined. For all phantoms, 2D GRE achieved a CV of 4.5% (95% CI: 3.3, 5.7) whereas 2D SE EPI achieved a CV of 7.8% (95% CI: 3.1, 12.6). The mean RC of stiffness measurement was 5.8% (95% CI: 3.7, 7.8) for all phantoms and both sequences combined, 4.9% (95% CI: 2.7, 7.0) for 2D GRE, and 7.0% (95% CI: 2.9, 11.2) for 2D SE EPI (all phantoms). Conclusion MRE had excellent in vitro precision and same-session test-retest repeatability in the multicenter setting when similar imaging protocols, hardware, and reconstruction algorithms were used. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Tang in this issue.

Short-acting opioid prescriptions and Workers' Compensation using the National Ambulatory Medical Care Survey.

BACKGROUND: Short-acting opioids have been utilized for pain management with little known about their use in patients on Workers' Compensation (WC) insurance. Our goal was to investigate this association in the ambulatory care setting. METHODS: Using the National Ambulatory Medical Care Survey, visits from patients aged 18-64 during the years 2010 until 2018 were evaluated (excluding 2017 due to data availability). Demographic and co-morbidity data from each visit was obtained along with the visit year. The first short-acting opioid medication prescribed in the database was considered. Survey-weighted frequencies were evaluated. Logistic regression estimated the crude and adjusted odds ratios (OR) with 95% confidence intervals for the use of short-acting opioid prescription. RESULTS: There were 155,947 included visits with 62.5% for female patients. Most patients were White with 11.7% identifying as Black, and 6% identifying as another race. Over 13% of the sample was of Hispanic descent. WC was the identified insurance type in 1.6% of the sample population. Of these patients, 25.6% were prescribed a short-acting opioid, compared with 10.1% of those with another identified insurance. On multivariable regression, Black patients had increased odds of being prescribed a short-acting opioid compared to white patients (OR: 1.22, 95% CI: 1.11-1.34). Those on WC had 1.7-fold higher odds of being prescribed short-acting opioids (95% CI: 1.46-2.06). CONCLUSION: Certain patient characteristics, including having WC insurance, increased the odds of a short-acting opioid prescription. Further work is needed to identify prescribing patterns in specific high-risk occupational groups, as well as to elicit potential associated health outcomes.

Cluster Analysis of World Trade Center Related Lower Airway Diseases.

ABSTRACT: Introduction: Cluster analysis can classify without a priori assumptions the heterogeneous chronic lower airway diseases found in former workers at the World Trade Center (WTC) disaster site. Methods: We selected the first available chest computed tomography scan with quantitative computed tomography measurements on 311 former WTC workers with complete clinical, and spirometric data from their closest surveillance visit. We performed a nonhierarchical iterative algorithm K-prototype cluster analysis, using gap measure. Results: A five-cluster solution was most satisfactory. Cluster 5 had the healthiest individuals. In cluster 4, smoking was most prevalent and intense but there was scant evidence of respiratory disease. Cluster 3 had symptomatic subjects with reduced forced vital capacity impairment (low FVC). Clusters 1 and 2 had less dyspneic subjects, but more functional and quantitative computed tomography evidence of chronic obstructive pulmonary disease (COPD) in cluster 1, or low FVC in cluster 2. Clusters 1 and 4 had the highest proportion of rapid first-second forced expiratory volume decliners. Conclusions: Cluster analysis confirms low FVC and COPD/pre-COPD as distinctive chronic lower airway disease phenotypes on long-term surveillance of the WTC workers.

Inflammatory marker levels in children with tobacco smoke exposure.

BACKGROUND: Tobacco smoke exposure (TSE) has inflammatory and immunosuppressive effects which may be associated with altered levels of inflammatory markers and pediatric illnesses. OBJECTIVE: The primary objective was to examine the associations of cotinine-confirmed and parent-reported child TSE patterns and discharge diagnoses with C-reactive protein (CRP), IL-8, and IL-10 in 0-11-year-old pediatric emergency department (PED) patients who lived with ≥ 1 smoker. METHODS: Saliva samples were obtained from 115 children with a mean (SD) age of 3.5 (3.1) years during the PED visit (T0). Saliva was analyzed for cotinine, CRP, IL-8, and IL-10. Parents self-reported their children's TSE patterns; children's medical records were reviewed to identify and categorize discharge diagnoses. Linear regression models were utilized to find T0 associations of cotinine-confirmed and parent-reported child TSE patterns, and PED diagnoses with each inflammatory marker. All models were adjusted for child race/ethnicity, child sex, annual household income, and housing type. The TSE models also adjusted for child discharge diagnosis. RESULTS: At T0, the geometric mean (GeoM) of cotinine was 4.1 ng/ml [95 %CI = 3.2-5.2]; the GeoMs of CRP, IL-8, and IL-10 were 3,326 pg/ml [95 %CI = 2,696-4,105], 474 pg/ml [95 %CI = 386-583], and 1.1 pg/ml [95 %CI = 0.9-1.3], respectively. Parent-reported child TSE patterns were positively associated with ln-transformed CRP levels, while adjusting for the covariates (ß^ = 0.012 [95 %CI:0.004-0.020], p = 0.037). In the parent-reported child TSE pattern model, there were significant positive associations between the covariate of child age with CRP and IL-8 levels (p = 0.028 and p < 0.001, respectively). Children with a bacterial diagnosis had higher IL-8 levels (p = 0.002) compared to the other diagnosis groups. CONCLUSIONS: Results indicate that parent-reported child TSE increases the expression of CRP in ill children and supports prior work demonstrating that IL-8 is higher in children with TSE who have bacterial infections. These findings should be examined in future research with ill children with and without TSE.

Postoperative CT surveillance in the evaluation of local recurrence after sub-lobar resection of neoplastic lesions of the lung.

OBJECTIVE: As indications for sub-lobar resections increase, it will become more important to identify risk factors for postsurgical recurrence. We investigated retrospectively the association between local recurrence after sub-lobar resection of neoplastic lung lesions and pre- and post-operative CT imaging and pathologic features. MATERIALS AND METHODS: We reviewed retrospectively neoplastic lung lesions with postoperative chest CT surveillance of sub-lobar resections in 2006-2016. We defined "suspicious" findings as nodularity ≥3 mm or soft tissue thickening ≥4 mm along the suture line and/or progression and explored their association with local recurrence. Primary lung cancer stage, tumoral invasion of lymphatics, visceral pleura or large vessels, bronchial and vascular margin distance were also assessed. RESULTS: Our study group included 45 cases of sub-lobar resection took for either primary (n = 37) or metastatic (n = 8) lung tumors. Local recurrence was observed in 16 of those patients. New nodularity ≥3 mm or soft tissue thickening ≥4 mm along the suture line on surveillance CT was significantly associated with local recurrence (p = 0.037). Additionally, solid nodule (p = 0.005), age at surgery ≤60 years (p = 0.006), two or more sites of invasion (p < 0.0001) and poor histologic differentiation (p = 0.0001) were also significantly associated with local tumor recurrence. Of 16 patients with surveillance post-surgical PET-CT, 15 had elevated FDG uptake. CONCLUSION: The postoperative changes along the suture line should follow a predictable time course demonstrating a pattern of stability, thinning or resolution on CT surveillance. New or increasing postoperative nodularity ≥3 mm or soft tissue thickening ≥4 mm along the suture line requires close diagnostic work-up. Surgical pathology characteristics added prognostic value on postoperative recurrence surveillance.

The diagnostic accuracy of perfusion-only scan in the diagnosis of pulmonary embolism in the era of COVID-19: A single-center study of 434 patients.

INTRODUCTION: There is a paucity of data in the literature regarding the diagnostic accuracy of perfusion (Q)-only studies in the absence of ventilation images. This study aims to assess the diagnostic accuracy of Q-only imaging in the pandemic era. METHODS: Patients who underwent Q-only imaging for pulmonary embolism between March 2020 and February 2021 were analyzed. Patients who underwent lung quantification analysis were excluded. Q-only test results were reported as per modified PIOPED II criteria and single positron emission tomography/computed tomography (SPECT/CT) imaging was performed as needed. Patients were considered concordant or discordant by correlating the Q-only results with CT angiogram (CTA) or clinical diagnosis made through chart review. The diagnostic accuracy was calculated after excluding intermediate probability and nondiagnostic studies. RESULTS: Four hundred and thirty-four patients were identified. One hundred and twenty-eight patients (29.4%) underwent ultrasound Doppler, 37 patients (8.5%) underwent CTA, and 16 patients (3.6%) underwent both. After excluding patients with intermediate probability or nondiagnostic studies and who did not have follow-up (a total of 87 patients [20%]), 347 patients were enrolled in the final analysis. The combined planar and SPECT/CT sensitivity and specificity were 85.4% (72.2%-93.9% confidence interval [CI]) and 98.7% (96.9%-98.6% CI), respectively. The positive predictive value (PPV) of the Q-only imaging was 89.1% (77.3%-95.1% CI) and the negative predictive value (NPV) was 98.2% (96.4%-99% CI). The sensitivity with SPECT/CT reached 100% (CI: 71.5%-100%) with a specificity of 92.3% (CI: 64%-99.8%). The PPV was 85.7% (CI: 62.1%-95.6%) and the NPV was 100%. CONCLUSION: Q-only imaging provides clinically acceptable results. The sensitivity of the Q-only scan is increased when coupled with SPECT/CT.

Assessment of HCC response to Yttrium-90 radioembolization with gadoxetate disodium MRI: correlation with histopathology.

BACKGROUND AND AIMS: Transarterial 90Y radioembolization (TARE) is increasingly being used for hepatocellular carcinoma (HCC) treatment. However, tumor response assessment after TARE may be challenging. We aimed to assess the diagnostic performance of gadoxetate disodium MRI for predicting complete pathologic necrosis (CPN) of HCC treated with TARE, using histopathology as the reference standard. METHODS: This retrospective study included 48 patients (M/F: 36/12, mean age: 62 years) with HCC treated by TARE followed by surgery with gadoxetate disodium MRI within 90 days of surgery. Two radiologists evaluated tumor response using RECIST1.1, mRECIST, EASL, and LI-RADS-TR criteria and evaluated the percentage of necrosis on subtraction during late arterial, portal venous, and hepatobiliary phases (AP/PVP/HBP). Statistical analysis included inter-reader agreement, correlation between radiologic and pathologic percentage of necrosis, and prediction of CPN using logistic regression and ROC analyses. RESULTS: Histopathology demonstrated 71 HCCs (2.8 ± 1.7 cm, range: 0.5-7.5 cm) including 42 with CPN, 22 with partial necrosis, and 7 without necrosis. EASL and percentage of tumor necrosis on subtraction at the AP/PVP were independent predictors of CPN (p = 0.02-0.03). Percentage of necrosis, mRECIST, EASL, and LI-RADS-TR had fair to good performance for diagnosing CPN (AUCs: 0.78 - 0.83), with a significant difference between subtraction and LI-RADS-TR for reader 2, and in specificity between subtraction and other criteria for both readers (p-range: 0.01-0.04). Radiologic percentage of necrosis was significantly correlated to histopathologic degree of tumor necrosis (r = 0.66 - 0.8, p < 0.001). CONCLUSIONS: Percentage of tumor necrosis on subtraction and EASL criteria were significant independent predictors of CPN in HCC treated with TARE. Image subtraction should be considered for assessing HCC response to TARE when using MRI. KEY POINTS: • Percentage of tumor necrosis on image subtraction and EASL criteria are significant independent predictors of complete pathologic necrosis in hepatocellular carcinoma treated with90Y radioembolization. • Subtraction, mRECIST, EASL, and LI-RADS-TR have fair to good performance for diagnosing complete pathologic necrosis in hepatocellular carcinoma treated with90Y radioembolization.

Prostate MRI using a rigid two-channel phased-array endorectal coil: comparison with phased array coil acquisition at 3 T.

BACKGROUND: To compare image quality, lesion detection and patient comfort of 3T prostate MRI using a combined rigid two-channel phased-array endorectal coil and an external phased-array coil (ERC-PAC) compared to external PAC acquisition in the same patients. METHODS: Thirty three men (mean age 65.3y) with suspected (n = 15) or biopsy-proven prostate cancer (PCa, n = 18) were prospectively enrolled in this exploratory study. 3T prostate MRI including T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI) was performed using an ERC-PAC versus PAC alone, in random order. Image quality, lesion detection and characterization (biparametric PI-RADSv2.1) were evaluated by 2 independent observers. Estimated signal-to-noise ratio (eSNR) was measured in identified lesions and the peripheral zone (PZ). Patient comfort was assessed using a questionnaire. Data were compared between sequences and acquisitions. Inter/intra-observer agreement for PI-RADS scores was evaluated. RESULTS: Twenty four prostate lesions (22 PCa) were identified in 20/33 men. Superior image quality was found for ERC-PAC compared to PAC for T2WI for one observer (Obs.1, p < 0.03) and high b-value DWI for both observers (p < 0.05). The sensitivity of PI-RADS for lesion detection for ERC-PAC and PAC acquisitions was 79.2 and 75% for Obs.1, and 79.1 and 66.7%, for Obs.2, without significant difference for each observer (McNemar p-values ≥0.08). Inter-/intra-observer agreement for PI-RADS scores was moderate-to-substantial (kappa = 0.52-0.84). Higher eSNR was observed for lesions and PZ for T2WI and PZ for DWI using ERC-PAC (p < 0.013). Most patients (21/33) reported discomfort at ERC insertion. CONCLUSION: Despite improved image quality and eSNR using the rigid ERC-PAC combination, no significant improvement in lesion detection was observed, therefore not supporting the routine use of ERC for prostate MRI.

Environmental exposures to pesticides, phthalates, phenols and trace elements are associated with neurodevelopment in the CHARGE study.

OBJECTIVE: To determine if higher exposures measured in early childhood to environmental phenols, phthalates, pesticides, and/or trace elements, are associated with increased odds of having a diagnosis of Autism Spectrum Disorder (ASD), Developmental Delay (DD), or Other Early Concerns (OEC) compared to typically developing children (TD). METHODS: This study included 627 children between the ages of 2-5 who participated in the Childhood Autism Risks from Genetics and Environment (CHARGE) study. Urine samples were collected at the same study visit where diagnostic assessments to confirm diagnosis indicated during the recruitment process were performed. Adjusted multinomial regression models of each chemical with diagnosis as the outcome were conducted. Additionally, two methods were used to analyze mixtures: repeated holdout multinomial weighted quantile sum (WQS) regression for each chemical class; and a total urinary mixture effect was assessed with repeated holdout random subset WQS. RESULTS: Many urinary chemicals were associated with increased odds of ASD, DD or OEC compared to TD; however, most did not remain significant after false discovery rate adjustment. Repeated holdout WQS indices provided evidence for associations of both a phenol/paraben mixture effect and a trace element mixture effect on DD independently. In analyses adjusted for confounders and other exposures, results suggested an association of a pesticide mixture effect with increased risk for ASD. Results also suggested associations of a total urinary mixture with greater odds of both ASD and DD separately. CONCLUSION: Higher concentrations of urinary biomarkers were associated with ASD, DD, and OEC compared to TD, with consistency of the results comparing single chemical analyses and mixture analyses. Given that the biospecimens used for chemical analysis were generally collected many months after diagnoses were made, the direction of any causal association is unknown. Hence findings may reflect higher exposures among children with non-typical development than TD children due to differences in behaviors, metabolism, or toxicokinetics.

Glycemic Changes and Weight Loss Precede Pancreatic Ductal Adenocarcinoma by up to 3 Years in a Diverse Population.

BACKGROUND & AIMS: Elevations in fasting blood glucose are observed prior to the development of pancreatic ductal adenocarcinoma (PDAC). Our aim was to describe glycemic and weight changes that occur prior to PDAC diagnosis in a diverse population. METHODS: We conducted a case-control study comparing patients with PDAC with matched controls between January 2011 and November 2019 at a tertiary care institution. Normally distributed variables were compared using t tests, and the Wilcoxon rank sum test was used for non-normally distributed variables; logistic regression was used to estimate odds of PDAC based on changes over time in hemoglobin A1c (HbA1c) and body mass index (BMI), controlling for appropriate confounders. RESULTS: A total of 4626 patients met inclusion criteria: 1542 cases and 3084 controls; the median age was 69.3 years, and 2487 (53.8%) were male; 751 cases (48.7%) were non-Hispanic white. In the 3 years prior to diagnosis, HbA1c was higher in patients with PDAC compared with controls (P ≤ .02 for all); a similar trend was seen for glucose values. BMI was greater for patients with PDAC for all study periods, except 0 to 6 months prior to cancer diagnosis when BMI was lower (P < .01 for all). The change in BMI (ΔBMI) of cases at 1 year and 6 months before diagnosis was -0.59 and -1.21 when compared with -0.08 and 0.03 for controls (P < .01 for both). Multivariable logistic regression demonstrated that HbA1c slope (adjusted odds ratio, 1.33; 95% confidence interval, 1.01-1.76) and BMI slope (adjusted odds ratio, 0.75; 95% confidence interval, 0.65-0.87) were predictors of PDAC. CONCLUSION: Glycemic elevations and weight loss predate PDAC diagnosis. These metabolic changes may suggest an underlying PDAC.

Alexithymia, Affective Lability, Impulsivity, and Childhood Adversity in Borderline Personality Disorder.

Long-standing theories of borderline personality disorder (BPD) suggest that symptoms develop at least in part from childhood adversity. Emotion dysregulation may meaningfully mediate these effects. The current study examined three factors related to emotion dysregulation-alexithymia, affective lability, and impulsivity-as potential mediators of the relation between childhood adversity and BPD diagnosis in 101 individuals with BPD and 95 healthy controls. Path analysis compared three distinct models informed by the literature. Results supported a complex mediation model wherein (a) alexithymia partially mediated the relation of childhood adversity to affective lability and impulsivity; (b) affective lability mediated the relation of childhood adversity to BPD diagnosis; and (c) affective lability and impulsivity mediated the relation of alexithymia to BPD diagnosis. Findings suggest that affective lability and alexithymia are key to understanding the relationship between childhood adversity and BPD. Interventions specifically targeting affective lability, impulsivity, and alexithymia may be particularly useful for this population.

Efficacy of Intravenous Immunoglobulin for Preventing Infections in Patients with Multiple Myeloma.

INTRODUCTION: Despite many recent advances in the treatment of multiple myeloma (MM), infection remains a major cause of morbidity and mortality. Prior studies have shown mixed results using intravenous immunoglobulin (IVIG) to prevent infections in MM and were conducted prior to most modern MM therapies. PATIENTS AND METHODS: We retrospectively reviewed all patients with MM treated with IVIG at our institution from 2010 to 2017. The primary endpoint was the incidence rate ratio (IRR) of infectious events (IEs) per patient-year during IVIG versus observation. RESULTS: A total of 68 patients were included; 151 IEs occurred during 918 months of IVIG treatment, whereas 446 IEs occurred during 2484 months of observation. Although the annual rate of IEs was substantially higher during periods of progressive disease (PD) compared with non-PD (4.9 vs. 1.8; P < .001), most IEs occurred during periods of non-PD (75% vs. 25% during PD). There was no overall difference in the annual rate of IEs per patient between IVIG and observation (1.97 vs. 2.16; IRR, 0.92; 95% confidence interval [CI], 0.76-1.10; P = .376). The subgroup of patients with hypogammaglobulinemia and whose myeloma was in a non-PD phase had a significant reduction in all-grade IEs (1.20 vs. 1.92; IRR, 0.63; 95% CI, 0.45-0.88; P = .009) and ≥ grade 3 IEs (0.25 vs. 0.56; IRR, 0.45; 95% CI, 0.22-0.94; P = .041) with IVIG compared with observation. CONCLUSION: Although treatment with IVIG did not show benefit in the overall population, there may be subgroups of patients that derive significant benefit. Additional observational studies are needed to confirm these findings and further refine patient selection.

Geriatric emergency department revisits after discharge with Potentially Inappropriate Medications: A retrospective cohort study.

OBJECTIVE: To determine whether Potentially Inappropriate Medications (PIMs) prescribed in an academic emergency department (ED) are associated with increased ED revisits in older adults. METHODS: A retrospective chart review of Medicare beneficiaries 65 years and older, discharged from an academic ED (January 2012 - November 2015) with any PIMs versus no PIMs. PIMs were defined using Category 1 of the 2015 Updated Beers criteria. Primary outcomes, obtained from a Medicare database linked to hospital ED subjects, were ED revisits 3 and 30 days from index ED discharge. Adjusted multiple logistic regression was used with entropy balance weighted covariates: Age in years, Gender, Race, Number of discharge medications, Charlson Comorbidity Index (CCI) score, Emergency Severity Index scores (ESI), Chief Complaint, Medicaid status, and prior 90 Day ED visits. RESULTS: Over the study period, there were a total of 7,591 Medicare beneficiaries 65+ discharged from the ED with a prescription; 1,383 (18%) received one or more PIMs. ED revisits in 30 days were fewer for the PIMs cohort (12% PIMs vs 16% no PIMs, OR 0.79, 95% CI 0.65 - 0.95, P value <0.005). Hospital admissions in 30 days were fewer for the PIMs cohort (4 PIMs vs 7% no PIMs, OR 0.75, 95% CI 0.56 - 1.00, P value <0.005). In addition to PIMs, covariate risk factors associated with ED revisits in 30 days included comorbidity severity, history of prior ED revisits, chief complaint, and Medicaid status. Risk factors associated with hospitalization in 30 days included those plus age and emergency severity index, but not race nor ethnicity. CONCLUSIONS: Patients discharged from the ED receiving potentially inappropriate medications as defined by Category 1 of the 2015 updated Beers criteria had lower odds of revisiting the ED within 30 days of index visit. Sociodemographic factors such as gender and race did not predict ED revisits or hospital admissions. Clinical characteristics predicted ED revisits and hospital admissions, the strongest risk being increasing Charlson Comorbidity Index score followed by triage acuity and chief complaint. Future studies are needed to delineate the implications of our findings.

The Prescription of Long-Acting Opioids for Working-Age Patients With Workers' Compensation or Chronic Illness Diagnoses in the United States: From the National Ambulatory Medical Care Survey (NAMCS), 2010 to 2016.

OBJECTIVE: To examine associations of workers' compensation, chronic conditions, age, sex, and race/ethnicity with primary prescription of long-acting opioids (LAO) among working-age patients in ambulatory care. METHODS: Using the National Ambulatory Medical Care Survey (2010 to 2016), we conducted descriptive, bivariate, and multivariate logistic regression analyses of patients aged 18 to 64 with an LAO as their primary medication. RESULTS: Those prescribed an LAO were more likely to be men (adjusted odds ratio [aOR] = 1.48, 95% CI 1.13, 1.91), have workers' compensation (aOR = 2.00, 95% CI 1.12, 3.57), or have diagnoses of lower back pain (aOR = 4.70, 95% CI 3.51, 6.29), arthritis (aOR = 1.53, 95% CI 1.11, 2.09), or depression (aOR = 1.69; 95% CI 1.24, 2.31). Hispanic ethnicity/race had a lower likelihood of LAO use compared with non-Hispanic White (aOR = 0.58; 95% CI 0.37, 0.90). CONCLUSIONS: Male sex, workers' compensation, and diagnoses of lower back pain, arthritis, or depression were independently associated with increased LAO prescription odds.

Outcomes and Prognosis Factors in Patients With Vena Cava Filters in a Quaternary Medical Center: A 5-Year Retrospective Analysis.

BACKGROUND: Indications for inferior vena cava filter (IVCF) placement are controversial. This study assesses the proportion of different indications for IVCF placement and the associated 30-day event rates and predictors for all-cause mortality, deep vein thrombosis (DVT), pulmonary embolism, and bleeding after IVCF placement. METHOD: In this 5-year retrospective cohort observational study in a quaternary care center, consecutive patients with IVCF placement were identified through cross-matching of 3 database sets and classified into 3 indication groups defined as "standard" in patients with venous thromboembolism (VTE) and contraindication to anticoagulants, "extended" in patients with VTE but no contraindication to anticoagulants, and "prophylactic" in patients without VTE. RESULTS: We identified 1248 IVCF placements, that is, 238 (19.1%) IVCF placements for standard indications, 583 (46.7%) IVCF placements for extended indications, and 427 (34.2%) IVCF placements for prophylactic indications. Deep vein thrombosis rates [95% confidence interval] were higher in the extended (8.06% [5.98-10.58]) and prophylactic (7.73% [5.38-10.68]) groups than in the standard group (3.36% [1.46-6.52]). Mortality rates were higher in the standard group (12.18% [8.31-17.03]) than in the extended group (7.55% [5.54-9.99]) and the prophylactic (5.85% [3.82-8.52]) group. Bleeding rates were higher in the standard group (4.62% [2.33-8.12]) than in the prophylactic group (2.11% [0.97-3.96]). Best predictors for VTE were acute medical conditions; best predictors for mortality were age, acute medical conditions, cancer, and Medicare health insurance. CONCLUSIONS: Prophylactic and extended indications account for the majority of IVCF placements. The standard indication is associated with the lowest VTE rate that may be explained by the competing risk of mortality higher in this group and related to the underlying medical conditions and bleeding risk. In the prophylactic group (no VTE at baseline), the exceedingly high DVT rate may be related to the IVCF placement.

Association of quantitative CT lung density measurements and lung function decline in World Trade Center workers.

BACKGROUND: Occupational exposures at the WTC site after 11 September 2001 have been associated with presumably inflammatory chronic lower airway diseases. AIMS: In this study, we describe the trajectories of expiratory air flow decline, identify subgroups with adverse progression, and investigate the association of those trajectories with quantitative computed tomography (QCT) imaging measurement of increased and decreased lung density. METHODS: We examined the trajectories of expiratory air flow decline in a group of 1,321 former WTC workers and volunteers with at least three periodic spirometries, and using QCT-measured low (LAV%, -950 HU) and high (HAV%, from -600 to -250 HU) attenuation volume percent. We calculated the individual regression line slopes for first-second forced expiratory volume (FEV1 slope), identified subjects with rapidly declining ("accelerated decliners") and increasing ("improved"), and compared them to subjects with "intermediate" (0 to -66.5 mL/year) FEV1 slope. We then used multinomial logistic regression to model those three trajectories, and the two lung attenuation metrics. RESULTS: The mean longitudinal FEV1 slopes for the entire study population, and its intermediate, decliner, and improved subgroups were, respectively, -40.4, -34.3, -106.5, and 37.6 mL/year. In unadjusted and adjusted analyses, LAV% and HAV% were both associated with "accelerated decliner" status (ORadj , 95% CI 2.37, 1.41-3.97, and 1.77, 1.08-2.89, respectively), compared to the intermediate decline. CONCLUSIONS: Longitudinal FEV1 decline in this cohort, known to be associated with QCT proximal airway inflammation metric, is also associated with QCT indicators of increased and decreased lung density. The improved FEV1 trajectory did not seem to be associated with lung density metrics.

Luminal Narrowing Alone Allows an Accurate Diagnosis of Crohn's Disease Small Bowel Strictures at Cross-Sectional Imaging.

BACKGROUND AND AIMS: Current consensus recommendations define small bowel strictures [SBS] in Crohn's disease [CD] on imaging as luminal narrowing with unequivocal upstream bowel dilation. The aim of this study was to [1] evaluate the performance of cross-sectional imaging for SBS diagnosis in CD using luminal narrowing with upstream SB dilation and luminal narrowing with or without upstream dilation, and [2] compare the diagnostic performance of computed tomography [CT] and magnetic resonance enterography [MRE] for SBS diagnosis. METHODS: In total, 111 CD patients [81 with pathologically confirmed SBS, 30 controls] who underwent CT and/or MRE were assessed. Two radiologists [R1, R2] blinded to pathology findings independently assessed the presence of luminal narrowing and upstream SB dilation. Statistical analysis was performed for [1] luminal narrowing with or without SB upstream dilation ['possible SBS'], and [2] luminal narrowing with upstream SB dilation ≥3 cm ['definite SBS']. RESULTS: Sensitivity for detecting SBS was significantly higher using 'possible SBS' [R1, 82.1%; R2, 77.9%] compared to 'definite SBS' [R1, 62.1%; R2, 65.3%; p < 0.0001] with equivalent specificity [R1, 96.7%; R2, 93.3%; p > 0.9]. Using the criterion 'possible SBS', sensitivity/specificity were equivalent between CT [R1, 87.3%/93.3%; R2, 83.6%/86.7%] and MRE [R1, 75.0%/100%; R2: 70.0%/100%]. Using the criterion 'definite SBS', CT showed significantly higher sensitivity [78.2%] compared to MRE [40.0%] for R1 but not R2 with similar specificities [CT, 86.7-93.3%; MRE, 100%]. CONCLUSION: SBS can be diagnosed using luminal narrowing alone without the need for upstream dilation. CT and MRE show similar diagnostic performance for SBS diagnosis using luminal narrowing with or without upstream dilation.

A new face of the HPV epidemic: Oropharyngeal cancer in the elderly.

OBJECTIVES: As the human papillomavirus (HPV) epidemic continues to grow, the number of elderly patients with oropharyngeal squamous cell carcinoma (OPSCC) is rapidly increasing. Despite this observation, this cohort remains understudied. We aimed to understand HPV prevalence and characteristics within this cohort as well as its impact on disease control in elderly patients. METHODS AND MATERIALS: We identified patients aged ≥70 with newly diagnosed, non-metastatic, OPSCC treated with curative intent at our institution from 2007 to 2018. Logistic regression and survival analyses were used for outcome-specific endpoints. RESULTS: In total, 88 patients were identified with a median age of 73 (interquartile range [IQR]: 71-78) and a median Charlson Comorbidity Index of 6 (IQR: 5-7). Eighty-two percent were ECOG 0 or 1 performance. Of note, 70% of the cohort had HPV+ tumors. Fifty-one percent of patients were AJCC 8th edition stage I/II and 49% were stage III/IV. Median follow-up time was 2.5 years (IQR: 0.9-4.7). Eight percent had surgery alone, 27% underwent adjuvant RT, and 64% received definitive RT. Sixty-four percent received concurrent chemotherapy. By both univariate and multivariable analyses, HPV+ status was significantly associated with improved locoregional control (LRC), overall survival (OS), and disease specific survival (DSS). CONCLUSIONS: In our cohort of elderly patients with OPSCC, the majority was HPV+, which was associated with improved clinical outcomes. There are many challenges when managing elderly patients with OPSCC, but as the population ages and the HPV epidemic evolves, these patients should be considered for elderly specific clinical trials.

Nonoperative Management of Hallux Limitus Using a Novel Forefoot Orthosis.

Hallux limitus is among the most common arthritides of the foot and ankle, with increasing incidence in the aging population. Despite its prevalence and disease burden, treatment of the condition remains poorly understood. Many patients will fail initial conservative management, whereas controversy exists surrounding indications for and outcomes of surgery. The present study sought to examine the impact of a novel forefoot orthosis on foot function, pain, and plantar pressure distributions in patients with symptomatic hallux limitus. Nineteen adult patients completed a questionnaire consisting of the 23-item Foot Function Index and a 10-point visual analogue scale measuring pain. Standing pedobarographic maps were generated using a foot scanning system. Participants were instructed to wear the orthosis in athletic shoes for 4 weeks. Eighteen participants (94.7%) experienced improvements in foot function and pain, with 12 (63.2%) reporting complete resolution of pain at the end of the 4-week trial. Mean Foot Function Index scores improved significantly from 43.0% at baseline to 11.0% with the orthosis (p < .001). Similarly, mean visual analogue scale pain scores decreased significantly from 4.87 to 1.18 (p < .001). Pedobarographic analysis while wearing the orthosis demonstrated increased ability of participants to bear weight on the arthritic hallux metatarsophalangeal joint and restoration of physiologic stance. Compared to existing products, the device was well tolerated and did not require footwear modifications or impede normal gait. Overall, the orthosis offers an appealing solution to patients dissatisfied with existing treatment options as well as those who may be averse to or ineligible for surgery.

Quantitative CT Evidence of Airway Inflammation in WTC Workers and Volunteers with Low FVC Spirometric Pattern.

BACKGROUND: The most common abnormal spirometric pattern reported in WTC worker and volunteer cohorts has consistently been that of a nonobstructive reduced forced vital capacity (low FVC). Low FVC is associated with obesity, which is highly prevalent in these cohorts. We used quantitative CT (QCT) to investigate proximal and distal airway inflammation and emphysema in participants with stable low FVC pattern. METHODS: We selected study participants with at least two available longitudinal surveillance spirometries, and a chest CT with QCT measurements of proximal airway inflammation (wall area percent, WAP), end-expiratory air trapping, suggestive of distal airway obstruction (expiratory to inspiratory mean lung attenuation ratio, MLAEI), and emphysema (percentage of lung volume with attenuation below - 950 HU, LAV%). The comparison groups in multinomial logistic regression models were participants with consistently normal spirometries, and participants with stable fixed obstruction (COPD). RESULTS: Compared to normal spirometry participants, and after adjusting for age, sex, race/ethnicity, BMI, smoking, and early arrival at the WTC disaster site, low FVC participants had higher WAP (ORadj 1.24, 95% CI 1.06, 1.45, per 5% unit), suggestive of proximal airway inflammation, but did not differ in MLAEI, or LAV%. COPD participants did not differ in WAP with the low FVC ones and were more likely to have higher MLAEI or LAV% than the other two subgroups. DISCUSSION: WTC workers with spirometric low FVC have higher QCT-measured WAP compared to those with normal spirometries, but did not differ in distal airway and emphysema measurements, independently of obesity, smoking, and other covariates.