Salary Equity in Academic Radiology Relative to Other Clinical Specialties.

BACKGROUND: Equity in faculty compensation in U.S. academic radiology physicians relative to other specialties is not well known. OBJECTIVE: The aim of this study is to assess salary equity in U.S. academic radiology physicians at different ranks relative to other clinical specialties. METHODS: The American Association of Medical Colleges (AAMC) Faculty Salary Survey was used to collect information for full-time faculty at U.S. medical schools. Financial compensation data were collected for 2023 for faculty with MD or equivalent degree in medical specialties, stratified by gender and rank. RESULTS: The AAMC Faculty Salary Survey data for 2023 included responses for 97,224 faculty members in clinical specialties, with 5847 faculty members in Radiology departments. In radiology, compared to men (n = 3839), the women faculty members (n = 1763) had a lower median faculty compensation by 6% at the rank of Assistant Professor, 3% for Associate Professors, 4% for Professors and 6% for Section Chief positions. Surgery had the highest difference in median compensation with 21%, 24%, 22% and 19% lower faculty compensation, respectively, for women faculty members at corresponding ranks. Pathology had the lowest percent difference (<1%) in median compensation for all professor ranks. Salary inequity in radiology was lower compared to most other specialties. From assistant to full professors, all other clinical specialties except Pathology and Psychiatry, had a greater salary inequity than Radiology. CONCLUSION: The salary inequity in academic radiology faculty is lower than most other specialties. Further efforts should be made to reduce salary inequities as broader efforts to provide a more diverse, equitable and inclusive environment. SUMMARY STATEMENT: Salary inequity in academic radiology faculty is lower than most other specialties.

Single-Cell Analysis Reveals a Subset of High IL-12p40-Secreting Dendritic Cells within Mouse Bone Marrow-Derived Macrophages Differentiated with M-CSF.

Macrophages and dendritic cells (DCs), although ontogenetically distinct, have overlapping functions and exhibit substantial cell-to-cell heterogeneity that can complicate their identification and obscure innate immune function. In this study, we report that M-CSF-differentiated murine bone marrow-derived macrophages (BMDMs) exhibit extreme heterogeneity in the production of IL-12, a key proinflammatory cytokine linking innate and adaptive immunity. A microwell secretion assay revealed that a small fraction of BMDMs stimulated with LPS secrete most IL-12p40, and we confirmed that this is due to extremely high expression of Il12b, the gene encoding IL-12p40, in a subset of cells. Using an Il12b-YFP reporter mouse, we isolated cells with high LPS-induced Il12b expression and found that this subset was enriched for genes associated with the DC lineage. Single-cell RNA sequencing data confirmed a DC-like subset that differentiates within BMDM cultures that is transcriptionally distinct but could not be isolated by surface marker expression. Although not readily apparent in the resting state, upon LPS stimulation, this subset exhibited a typical DC-associated activation program that is distinct from LPS-induced stochastic BMDM cell-to-cell heterogeneity. Overall, our findings underscore the difficulty in distinguishing macrophages and DCs even in widely used in vitro murine BMDM cultures and could affect the interpretation of some studies that use BMDMs to explore acute inflammatory responses.

Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery.

Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multidatabase literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, 4 of which were comparative in nature and included both closures by PS and SS. Of these 4, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in 2 of the 4 (50%) studies (P = 0.014, P < 0.001) and radiation in 3 of the 4 (75%) studies (P < 0.001, P < 0.01, P < 0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.

Predictors for large vessel recanalization before stroke thrombectomy: the HALT score.

BACKGROUND: Large vessel recanalization (LVR) before endovascular therapy (EVT) for acute large vessel ischemic strokes is a poorly understood phenomenon. Better understanding of predictors for LVR is important for optimizing stroke triage and patient selection for bridging thrombolysis. METHODS: In this retrospective cohort study, consecutive patients presenting to a comprehensive stroke center for EVT treatment were identified from 2018 to 2022. Demographic information, clinical characteristics, intravenous thrombolysis (IVT) use, and LVR before EVT were recorded. Factors independently associated with different rates of LVR were identified, and a prediction model for LVR was constructed. RESULTS: 640 patients were identified. 57 (8.9%) patients had LVR before EVT. A minority (36.4%) of LVR patients had significant improvements in National Institutes of Health Stroke Scale. Independent predictors for LVR were identified and used to construct the 8-point HALT score: hyperlipidemia (1 point), atrial fibrillation (1 point), location of vascular occlusion (internal carotid: 0 points, M1: 1 point, M2: 2 points, vertebral/basilar: 3 points), and thrombolysis at least 1.5 hours before angiography (3 points). The HALT score had an area under the receiver-operating curve (AUC) of 0.85 (95% CI 0.81 to 0.90, P<0.001) for predicting LVR. LVR before EVT occurred in only 1 of 302 patients (0.3%) with low (0-2) HALT scores. CONCLUSIONS: IVT at least 1.5 hours before angiography, site of vascular occlusion, atrial fibrillation, and hyperlipidemia are independent predictors for LVR. The 8-point HALT score proposed in this study may be a valuable tool for predicting LVR before EVT.

Analysis of Medical Malpractice Claims Involving Interventional Radiologists: A Comprehensive Analysis From Two National Legal Databases.

PURPOSE: The nature of lawsuits involving interventional radiologists (IRs) is not well understood. The purposes of this article are to provide an overview of the causes of action underlying medical malpractice lawsuits related to IRs and to characterize the associated factors and outcomes. METHODS: Two large legal databases were used to search for US legal cases in which there were jury awards and settlements involving IRs in the United States. Cases were screened to include only those cases in which the cause of action involved negligence on the part of IRs. RESULTS: A total of 389 published case summaries were identified, of which 93 were eligible to be included in the analysis. In 46% of the cases (43 of 93), medical malpractice was alleged against an individual IR, whereas in 43% (40 of 93), it was alleged against both an individual IR and a health care institution. Thirty-five percent of IR malpractice cases (33 of 93) involved the performance of a vascular procedure, most commonly embolization procedures (30% [n = 10]), stenting or angioplasty (21% [n = 7]), and diagnostic arteriography and angiography (18% [n = 6]). Twenty-six percent of cases (24 of 93) involved IR performance of a biopsy. Eighteen percent of cases (17 of 93) involved a failure to gain informed consent in addition to an allegation of medical negligence during treatment. Eleven percent of cases (10 of 93) were resolved by settlement, with an average settlement amount of $877,500 (range, $200,000-$2,700,000). Among the 72 cases that went to trial, 74% (53 of 72) resulted in judgments for the defendants, and 26% (19 of 72) resulted in judgements for the plaintiffs, with an average award of $2,012,243 (range, $101,667-$6,400,000). CONCLUSIONS: Vascular procedures and biopsies were the most frequent reasons for malpractice lawsuits involving IRs. Failure to gain informed consent in addition to an allegation of medical negligence during treatment was not infrequent. Although the majority of published medical malpractice claims involving IRs resulted in judgments in favor of the defendants, the average amount awarded to plaintiffs was higher compared with previous data reported for all physicians.

Dural arteriovenous fistula onyx embolization through a non-visible previously embolized pedicle.

Cerebral dural arteriovenous fistulas (dAVFs) are commonly treated with endovascular embolization, either through arterial or venous routes in single or multi-staged procedures. Treatment outcomes depend on multiple factors, including the patient's clinical status, the anatomy of the malformation, and the operator's experience, but technical success is also highly dependent on choice of neurovascular devices and embolic agents. When transvenous routes are not feasible and the most obvious transarterial routes do not appear safe, deep knowledge of the dynamic fluid properties of liquid embolics can be a valuable asset. We present a case(video 1) in which a complex skull-base dAVF was completely occluded through a non-visualized previously partially embolized arterial feeder. It is a unique case in which the embolization takes advantage of the peculiar fluid dynamic properties of non-adhesive embolic agents (Onyx-Medtronic, Minnesota, USA) 18 and 34.1-3neurintsurg;jnis-2023-020506v1/V1F1V1Video 1 Technical video presenting a dAVF completely cured through a non-visible previously embolized arterial pedicle.

Distribution and Disparities of Industry Payments to Radiologists (2016-2020).

BACKGROUND: The frequency, magnitude, and distribution of industry payments to radiologists are not well understood. RATIONALE AND OBJECTIVES: The aim of this study was to analyze the distribution of industry payments to physicians working in diagnostic radiology, interventional radiology, and radiation oncology, study the categories of payments and determine their correlation. MATERIALS AND METHODS: The Open Payments Database from the Centers for Medicare & Medicaid Services was accessed and analyzed for the period from January 1, 2016 to December 31, 2020. Payments were grouped into six categories: consulting fees, education, gifts, research, speaker fees, and royalties/ownership. The total amount and types of industry payments going to the top 5% group were determined overall and for each category of payment. RESULTS: From 2016 to 2020, a total of 513 020 payments, amounting to $370 782 608, were made to 28 739 radiologists suggesting that approximately 70% of the 41 000 radiologists in the US received at least one industry payment during the 5-year period. The median payment value was $27 (IQR: $15-$120) and the median number of payments per physician over the 5-year period was 4 (IQR: 1-13). Gifts were the most frequent payment type made (76.4%), but accounted for only 4.8% of payment value. The median total value of payments earned by members of the top 5% group over the 5-year period was $58 878 (IQR: $29 686-$162 425) ($11 776 per year) compared to $172 (IQR: $49-877) ($34 per year) in the bottom 95% group. Members of the top 5% group received a median of 67 (IQR: 26-147) individual payments (13 payments per year) while members of the bottom 95% group received a median of 3 (IQR: 1-11) (0.6 payments per year). CONCLUSION: Between 2016 and 2020, industry payments to radiologists were highly concentrated both in terms of number/frequency and value of payments.

National Trends of Cerebral Venous Sinus Stenting for the Treatment of Idiopathic Intracranial Hypertension.

OBJECTIVES: Cerebral venous sinus stenting (VSS) has emerged as a new surgical procedure for the treatment of severe idiopathic intracranial hypertension (IIH), and its popularity has been anecdotally on the rise. This study explores recent temporal trends of VSS and other surgical IIH treatments in the United States. METHODS: Adult patients with IIH were identified from the 2016-2020 National Inpatient Sample databases, and surgical procedures and hospital characteristics were recorded. Temporal trends of procedure numbers for VSS, CSF shunts, and optic nerve sheath fenestrations (ONSFs) were assessed and compared. RESULTS: A total of 46,065 (95% CI 44,710-47,420) patients with IIH were identified, of whom 7,535 patients (95% CI 6,982-8,088) received surgical IIH treatments. VSS procedures increased 80% (150 [95% CI 55-245] to 270 [95% CI 162-378] per year, p < 0.001). Concurrently, the number of CSF shunts decreased by 19% (1,365 [95% CI 1,126-1,604] to 1,105 [95% CI 900-1,310] per year, p < 0.001), and ONSF procedures decreased by 54% (65 [95% CI 20-110] to 30 [95% CI 6-54] per year, p < 0.001). DISCUSSION: Practice patterns for surgical IIH treatment in the United States are rapidly evolving, and VSS is becoming increasingly common. These findings highlight the urgency of randomized controlled trials to investigate the comparative effectiveness and safety of VSS, CSF shunts, ONSF, and standard medical treatments.

Cost-effectiveness of thrombectomy in patients with minor stroke and large vessel occlusion: effect of thrombus location on cost-effectiveness and outcomes.

BACKGROUND: To evaluate the cost-effectiveness of endovascular thrombectomy (EVT) to treat large vessel occlusion (LVO) in patients with acute, minor stroke (National Institute of Health Stroke Scale (NIHSS) <6) and impact of occlusion site. METHODS: A Markov decision-analytic model was constructed accounting for both costs and outcomes from a societal perspective. Two different management strategies were evaluated: EVT and medical management. Base case analysis was done for three different sites of occlusion: proximal M1, distal M1 and M2 occlusions. One-way, two-way and probabilistic sensitivity analyses were performed. RESULTS: Base-case calculation showed EVT to be the dominant strategy in 65-year-old patients with proximal M1 occlusion and NIHSS <6, with lower cost (US$37 229 per patient) and higher effectiveness (1.47 quality-adjusted life years (QALYs)), equivalent to 537 days in perfect health or 603 days in modified Rankin score (mRS) 0-2 health state. EVT is the cost-effective strategy in 92.7% of iterations for patients with proximal M1 occlusion using a willingness-to-pay threshold of US$100 000/QALY. EVT was cost-effective if it had better outcomes in 2%-3% more patients than intravenous thrombolysis (IVT) in absolute numbers (base case difference -16%). EVT was cost-effective when the proportion of M2 occlusions was less than 37.1%. CONCLUSIONS: EVT is cost-effective in patients with minor stroke and LVO in the long term (lifetime horizon), considering the poor outcomes and significant disability associated with non-reperfusion. Our study emphasizes the need for caution in interpreting previous observational studies which concluded similar results in EVT versus medical management in patients with minor stroke due to a high proportion of patients with M2 occlusions in the two strategies.

Excessive platelet inhibition following Pipeline embolization of intracranial aneurysms.

BACKGROUND: High levels of platelet inhibition have been associated with hemorrhagic complications following Pipeline embolization of intracranial aneurysms. We therefore titrate clopidogrel dosing to maintain a moderate level of platelet inhibition using the VerifyNow P2Y12 assay. However, many patients demonstrate dramatic increases in platelet inhibition following treatment despite being on a consistent antiplatelet regimen. We therefore elected to explore the incidence of this phenomenon and possible predisposing factors. METHODS: All successful Pipeline aneurysm treatments performed at our institution from 2011 to 2019 with moderate procedure-day platelet inhibition levels as indicated by a VerifyNow PRU of 60-235 were included. Patients who received glycoprotein IIb/IIIa inhibitors and those treated for ruptured/symptomatic lesions were excluded. The incidence of excessive platelet inhibition defined by a PRU<60 within 8 weeks of treatment was noted. Multivariable logistic regression was performed to determined independent predictors of the phenomenon. RESULTS: Some 190 treatments were performed in 178 qualifying patients. A post-procedure PRU <60 occurred following 79% of treatments, documented on average after 8.5 (range 1-47) days. A higher procedure day hematocrit level (P=0.003, OR 1.09, 95% CI 1.029 to 1.152) was an independent predictor of reaching a PRU <60, while intra-procedural midazolam exposure (P=0.044, OR 0.44, 95% CI 0.201 to 0.980) and a higher procedure-day PRU (P=0.047, OR 0.99, 95% CI 0.982 to 1.000) were associated with a reduced odds. Time-since-procedure and hematocrit levels were associated with excessive platelet inhibition when excluding patients who initially demonstrated hyperresponse. CONCLUSION: Elevations in platelet inhibition were frequently observed following flow diversion with Pipeline.

Cost-effectiveness of endovascular thrombectomy in patients with acute stroke and M2 occlusion.

BACKGROUND: The cost-effectiveness of endovascular thrombectomy (EVT) in patients with acute ischemic stroke due to M2 branch occlusion remains uncertain. OBJECTIVE: To evaluate the cost-effectiveness of EVT compared with medical management in patients with acute stroke presenting with M2 occlusion using a decision-analytic model. METHODS: A decision-analytic study was performed with Markov modeling to estimate the lifetime quality-adjusted life years and associated costs of EVT-treated patients compared with no-EVT/medical management. The study was performed over a lifetime horizon with a societal perspective in the Unites States setting. Base case, one-way, two-way, and probabilistic sensitivity analyses were performed. RESULTS: EVT was the long-term cost-effective strategy in 93.37% of the iterations in the probabilistic sensitivity analysis, and resulted in difference in health benefit of 1.66 QALYs in the 65-year-old age groups, equivalent to 606 days in perfect health. Varying the outcomes after both strategies shows that EVT was more cost-effective when the probability of good outcome after EVT was only 4-6% higher relative to medical management in clinically likely scenarios. EVT remained cost-effective even when its cost exceeded US$200 000 (threshold was US$209 111). EVT was even more cost-effective for 55-year-olds than for 65-year-old patients. CONCLUSION: Our study suggests that EVT is cost-effective for treatment of acute M2 branch occlusions. Faster and improved reperfusion techniques would increase the relative cost-effectiveness of EVT even further in these patients.

Implications of achieving TICI 2b vs TICI 3 reperfusion in patients with ischemic stroke: a cost-effectiveness analysis.

BACKGROUND: The benefit of endovascular thrombectomy (EVT) in stroke patients with large-vessel occlusion (LVO) depends on the degree of recanalization achieved. We aimed to determine the health outcomes and cost implications of achieving TICI 2b vs TICI 3 reperfusion in acute stroke patients with LVO. METHODS: A decision-analytic study was performed with Markov modeling to estimate the lifetime quality-adjusted life years (QALY) of EVT-treated patients, and costs based on the degree of reperfusion achieved. The study was performed with a societal perspective in the United States' setting. The base case calculations were performed in three age groups: 55-, 65-, and 75-year-old patients. RESULTS: Within 90 days, achieving TICI 3 resulted in a cost saving of $3676 per patient and health benefit of 11 days in perfect health as compared with TICI 2b. In the long term, for the three age groups, achieving TICI 3 resulted in cost savings of $46,498, $25,832, and $15 719 respectively, and health benefits of 2.14 QALYs, 1.71 QALYs, and 1.23 QALYs. Every 1% increase in TICI 3 in 55-year-old patients nationwide resulted in a cost saving of $3.4 million and a health benefit of 156 QALYs. Among 65-year-old patients, the corresponding cost savings and health benefit were $1.9 million and 125 QALYs. CONCLUSION: There are substantial cost and health implications in achieving complete vs incomplete reperfusion after EVT. Our study provides a framework to assess the cost-benefit analysis of emerging diagnostic and therapeutic techniques that might improve patient selection, and increase the chances of achieving complete reperfusion.

The therapeutic landscape for cells engineered with chimeric antigen receptors.

Despite the global rapid increase in the number of clinical trials employing chimeric antigen receptors (CARs), no comprehensive survey of their scope, targets and design exists. In this study, we present an interactive CAR clinical trial database, spanning 64 targets deployed in T cells (CAR-T), natural killer cells (CAR-NK) or mixtures (CAR-NK/T) from over 500 clinical trials in 20 countries, encompassing >20,000 patients. By combining these data with transcriptional and proteomic data, we create a 'targetable landscape' for CAR cell therapies based on 13,206 proteins and RNAs across 78 tissues, 124 cell types and 20 cancer types. These data suggest a landscape of over 100 single targets and over 100,000 target pairs using logical switches for CAR cell engineering. Our analysis of the CAR cellular therapeutic landscape may aid the design of future therapies, improve target-to-patient matching, and ultimately help inform our understanding of CAR therapy's safety and efficacy.

Epigenetic Modifications in Acute Myeloid Leukemia: Prognosis, Treatment, and Heterogeneity.

Leukemia, specifically acute myeloid leukemia (AML), is a common malignancy that can be differentiated into multiple subtypes based on leukemogenic history and etiology. Although genetic aberrations, particularly cytogenetic abnormalities and mutations in known oncogenes, play an integral role in AML development, epigenetic processes have been shown as a significant and sometimes independent dynamic in AML pathophysiology. Here, we summarize how tumors evolve and describe AML through an epigenetic lens, including discussions on recent discoveries that include prognostics from epialleles, changes in RNA function for hematopoietic stem cells and the epitranscriptome, and novel epigenetic treatment options. We further describe the limitations of treatment in the context of the high degree of heterogeneity that characterizes acute myeloid leukemia.