Healthcare Disparities in Interventional Radiology.

Racial, ethnic, and sex-based healthcare disparities have been documented for the past several decades. Nonetheless, disparities remain firmly entrenched in our care delivery systems, with multiple contributing factors, including patient interactions with care providers, systemic barriers to access, and socioeconomic determinants of health. Interventional radiology is also subject to these drivers of health inequity. In this review, documented disparities for the most common conditions being addressed by interventional radiologists are summarized; their magnitude is quantified where relevant, and underlying drivers are identified. Specific examples are provided to illustrate how medical, cultural, and socioeconomic factors interact to produce unequal outcomes. By outlining known disparities and common contributors, this review aims to motivate future efforts to mitigate them.

Bridging the Equity Gap.

OBJECTIVE. This article introduces key concepts of inequity as they apply to interventional radiology, from both the patient and the physician perspectives, to ultimately improve the health care of all patients. CONCLUSION. By directing society's efforts toward addressing health care disparities, our specialty may begin to establish trust and partnerships with populations that are disproportionately affected and those that have been historically exploited and disenfranchised by medicine in the name of innovation. Although we may look to close the equity gap by understanding health care disparities as they pertain to our patient populations, a closer examination of barriers of entry into medicine for underrepresented minorities reveals numerous disparities across race, sexual orientation, and socioeconomic status.

The resuscitative endovascular balloon occlusion of aorta (REBOA) device-what radiologists need to know.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a novel device approved by the Food and Drug administration (FDA) in 2017 as an alternative to resuscitative emergent thoracotomy (RET). Due to advancements in placement of REBOA, including newly validated placement using anatomic landmarks, REBOA is now widely used by interventional radiologists and emergency physicians in acute subdiaphragmatic hemorrhage. Increased use of REBOA necessitates that radiologists are familiar with verification of proper REBOA placement to minimize complications. This review describes the REBOA device, indications, placement, and complications, summarizing the current available literature.

Impacts of warming revealed by linking resource growth rates with consumer functional responses.

Warming global temperatures are driving changes in species distributions, growth and timing, but much uncertainty remains regarding how climate change will alter species interactions. Consumer-Resource interactions in particular can be strongly impacted by changes to the relative performance of interacting species. While consumers generally gain an advantage over their resources with increasing temperatures, nonlinearities can change this relation near temperature extremes. We use an experimental approach to determine how temperature changes between 5 and 30 °C will alter the growth of the algae Scenedesmus obliquus and the functional responses of the small-bodied Daphnia ambigua and the larger Daphnia pulicaria. The impact of warming generally followed expectations, making both Daphnia species more effective grazers, with the increase in feeding rates outpacing the increases in algal growth rate. At the extremes of our temperature range, however, warming resulted in a decrease in Daphnia grazing effectiveness. Between 25 and 30 °C, both species of Daphnia experienced a precipitous drop in feeding rates, while algal growth rates remained high, increasing the likelihood of algal blooms in warming summer temperatures. Daphnia pulicaria performed significantly better at cold temperatures than D. ambigua, but by 20 °C, there was no significant difference between the two species, and at 25 °C, D. ambigua outperformed D. pulicaria. Warming summer temperatures will favour the smaller D. ambigua, but only over a narrow temperature range, and warming beyond 25 °C could open D. ambigua to invasion from tropical species. By fitting our results to temperature-dependent functions, we develop a temperature- and density-dependent model, which produces a metric of grazing effectiveness, quantifying the grazer density necessary to halt algal growth. This approach should prove useful for tracking the transient dynamics of other density-dependent consumer-resource interactions, such as agricultural pests and biological-control agents.

Multimodality imaging to assess immediate response to irreversible electroporation in a rat liver tumor model.

PURPOSE: To compare changes on ultrasonographic (US), computed tomographic (CT), and magnetic resonance (MR) images after irreversible electroporation (IRE) ablation of liver and tumor tissues in a rodent hepatoma model. MATERIALS AND METHODS: Studies received approval from the institutional animal care and use committee. Forty-eight rats were used, and N1-S1 tumors were implanted in 24. Rats were divided into groups and allocated for studies with each modality. Imaging was performed in normal liver tissues and tumors before and after IRE. MR imaging was performed in one group before and after IRE after hepatic vessel ligation. US images were graded to determine echogenicity changes, CT attenuation was measured (in Hounsfield units), and MR imaging signal-to-noise ratio (SNR) was measured before and after IRE. Student t test was used to compare attenuation and SNR measurements before and after IRE (P < .05 indicated a significant difference). RESULTS: IRE ablation produced greater alterations to echogenicity in normal tissues than in tumors. Attenuation in ablated liver tissues was reduced compared with that in control tissues (P < .001), while small attenuation differences between ablated (42.11 HU ± 2.11) and control (45.14 HU ± 2.64) tumors trended toward significance (P = .052). SNR in ablated normal tissues was significantly altered after IRE (T1-weighted images: pre-IRE, 145.95 ± 24.32; post-IRE, 97.80 ± 18.03; P = .004; T2-weighted images, pre-IRE, 47.37 ± 18.31; post-IRE, 90.88 ± 37.15; P = .023). In tumors, SNR differences before and after IRE were not significant. No post-IRE signal changes were observed after hepatic vessel ligation. CONCLUSION: IRE induces rapid changes on gray-scale US, unenhanced CT, and MR images. These changes are readily visible and may assist a performing physician to delineate ablation zones from the unablated surrounding parenchyma.

Silencing of the inhibitor of DNA binding protein 4 (ID4) contributes to the pathogenesis of mouse and human CLL.

Inhibitor of DNA binding protein 4 (ID4) is a member of the dominant-negative basic helix-loop-helix transcription factor family that lacks DNA binding activity and has tumor suppressor function. ID4 promoter methylation has been reported in acute myeloid leukemia and chronic lymphocytic leukemia (CLL), although the expression, function, and clinical relevance of this gene have not been characterized in either disease. We demonstrate that the promoter of ID4 is consistently methylated to various degrees in CLL cells, and increased promoter methylation in a univariable analysis correlates with shortened patient survival. However, ID4 mRNA and protein expression is uniformly silenced in CLL cells irrespective of the degree of promoter methylation. The crossing of ID4(+/-) mice with Eµ-TCL1 mice triggers a more aggressive murine CLL as measured by lymphocyte count and inferior survival. Hemizygous loss of ID4 in nontransformed TCL1-positive B cells enhances cell proliferation triggered by CpG oligonucleotides and decreases sensitivity to dexamethasone-mediated apoptosis. Collectively, this study confirms the importance of the silencing of ID4 in murine and human CLL pathogenesis.

17-DMAG targets the nuclear factor-kappaB family of proteins to induce apoptosis in chronic lymphocytic leukemia: clinical implications of HSP90 inhibition.

The HSP90 client chaperone interaction stabilizes several important enzymes and antiapoptotic proteins, and pharmacologic inhibition of HSP90 results in rapid client protein degradation. Therefore, HSP90 inhibition is an attractive therapeutic approach when this protein is active, a phenotype commonly observed in transformed but not normal cells. However, preclinical studies with HSP90 inhibitors such as 17-AAG demonstrated depletion of only a subset of client proteins and very modest tumor cytotoxicity in chronic lymphocytic leukemia (CLL) cells. Herein, we describe another HSP90 inhibitor, 17-DMAG, which is cytotoxic to CLL but not normal lymphocytes. Treatment with 17-DMAG leads to depletion of the HSP90 client protein IKK, resulting in diminished NF-kappaB p50/p65 DNA binding, decreased NF-kappaB target gene transcription, and caspase-dependent apoptosis. Furthermore, treatment with 17-DMAG significantly decreased the white blood cell count and prolonged the survival in a TCL1-SCID transplant mouse model. The ability of 17-DMAG to function as an NF-kappaB inhibitor is of great interest clinically, as few currently available CLL drugs target this transcription factor. Therefore, the effect of 17-DMAG on NF-kappaB signaling pathways represents a novel therapy warranting further clinical pursuit in this and other B-cell lymphoproliferative disorders.

Management of Femoral Neck Fracture in Above Knee Amputee with Femoral Neck System: A Case Report.

Introduction: Femoral neck fractures in patients with a history of above knee amputation present as a strain for orthopedic surgeons due to the difficulty of positioning and handling of the limb for proper reduction. Surgical treatment options typically involve open reduction internal fixation versus arthroplasty depending on patient factors such as age, surgeon skill, and available equipment. Case Report: We present a case of a femoral neck fracture (OTA 31-B2) in a relatively active 89-year-old Caucasian male after a ground level fall that has been ambulating with a prosthesis since his teenage years. In this report, we describe the patient positioning, technique used to treat a femoral neck fracture (OTA 31-B2) using the femoral neck system, and the successful outcome of our patient 1 year from the injury. Conclusion: We conclude that using the femoral neck system (FNS) is a viable option for patients with a high above knee amputation where, due to the length of the limb and potentially the lack of appropriately sized implants, dislocating and reducing the hip for total hip arthroplasties and hemiarthroplasties provide a challenge.

Leveraging Social Media and Web Presence to Discuss and Promote Diversity, Equity, and Inclusion in Radiology.

PURPOSE: This article seeks to better understand how radiology residency programs leverage their social media presences during the 2020 National Residency Match Program (NRMP) application cycle to engage with students and promote diversity, equity, and inclusion to prospective residency applicants. METHODS: We used publicly available information to determine how broad a presence radiology programs have across specific platforms (Twitter [Twitter, Inc, San Francisco, California], Facebook [Facebook, Inc, Menlo Park, California], Instagram [Facebook, Inc], and website pages) as well as what strategies these programs use to promote diversity, equity, and inclusion. RESULTS: During the 2020 NRMP application cycle, radiology residency programs substantially increased their social media presence across the platforms we examined. We determined that 29.3% (39 of 133), 58.9% (43 of 73), and 29.55% (13 of 44) of programs used Twitter, Instagram, and Facebook, respectively; these accounts were established after an April 1, 2020, advisory statement from the NRMP. Program size and university affiliation were correlated with the degree of social media presence. Those programs using social media to promote diversity, equity, and inclusion used a broad but similar approach across programs and platforms. CONCLUSION: The events of 2020 expedited the growth of social media among radiology residency programs, which subsequently ushered in a new medium for conversations about representation in medicine. However, the effectiveness of this medium to promote meaningful expansion of diversity, equity, and inclusion in the field of radiology remains to be seen.

Impacts of Air Velocity Treatments under Summer Condition: Part I-Heavy Broiler's Surface Temperature Response.

Heavy broilers exposed to hot summer conditions experience fluctuations in surface temperatures due to heat stress, which leads to decreased performance. Maintaining a bird's homeostasis depends on several environmental factors (temperature, relative humidity, and air velocity). It is important to understand the responses of birds to environmental factors and the amount of heat loss to the surrounding environment to create thermal comfort for the heavy broilers for improved performances and welfare. This study investigates the variation in surface temperatures of heavy broilers under high and low air velocity treatments. Daytime, age and bird location's effect on the surface temperature variation was also examined. The experiment was carried out in the poultry engineering laboratory of North Carolina State University during summers of 2017, 2018, and 2019 as a part of a comprehensive study on the effectiveness of wind chill application to mitigate heat stress on heavy broilers. This live broiler heat stress experiment was conducted under two dynamic air velocity treatments (high and low) with three chambers per treatment and 44 birds per chamber. Surface temperatures of the birds were recorded periodically through the experimental treatment cycles (flocks, 35-61 d) with infrared thermography in the morning, noon, evening, and nighttime. The overall mean surface temperature of the broilers under two treatments was found to be 35.89 ± 2.37 °C. The variation in surface temperature happened due to air temperature, thermal index, air velocity, bird's age, daytime, and position of birds inside the experimental chambers. The surface temperatures were found lower under high air velocity treatment and higher under low air velocity treatment. During the afternoon time, the broilers' surface temperatures were higher than other times of the day. It was also found that the birds' surface temperature increased with age and temperature humidity indices. Based upon the experimental data of five flocks, a simple linear regression model was developed to predict surface temperature from the birds' age, thermal indices, and air velocity. It will help assess heavy broilers' thermal comfort under heat stress, which is essential to provide a comfortable environment for them.

A global experiment suggests climate warming will not accelerate litter decomposition in streams but might reduce carbon sequestration.

The decomposition of plant litter is one of the most important ecosystem processes in the biosphere and is particularly sensitive to climate warming. Aquatic ecosystems are well suited to studying warming effects on decomposition because the otherwise confounding influence of moisture is constant. By using a latitudinal temperature gradient in an unprecedented global experiment in streams, we found that climate warming will likely hasten microbial litter decomposition and produce an equivalent decline in detritivore-mediated decomposition rates. As a result, overall decomposition rates should remain unchanged. Nevertheless, the process would be profoundly altered, because the shift in importance from detritivores to microbes in warm climates would likely increase CO(2) production and decrease the generation and sequestration of recalcitrant organic particles. In view of recent estimates showing that inland waters are a significant component of the global carbon cycle, this implies consequences for global biogeochemistry and a possible positive climate feedback.

The novel plant-derived agent silvestrol has B-cell selective activity in chronic lymphocytic leukemia and acute lymphoblastic leukemia in vitro and in vivo.

Therapeutic options for advanced B-cell acute lymphoblastic leukemia (ALL) and chronic lymphocytic leukemia (CLL) are limited. Available treatments can also deplete T lymphocytes, leaving patients at risk of life-threatening infections. In the National Cancer Institute cell line screen, the structurally unique natural product silvestrol produces an unusual pattern of cytotoxicity that suggests activity in leukemia and selectivity for B cells. We investigated silvestrol efficacy using primary human B-leukemia cells, established B-leukemia cell lines, and animal models. In CLL cells, silvestrol LC(50) (concentration lethal to 50%) is 6.9 nM at 72 hours. At this concentration, there is no difference in sensitivity of cells from patients with or without the del(17p13.1) abnormality. In isolated cells and whole blood, silvestrol is more cytotoxic toward B cells than T cells. Silvestrol causes early reduction in Mcl-1 expression due to translational inhibition with subsequent mitochondrial damage, as evidenced by reactive oxygen species generation and membrane depolarization. In vivo, silvestrol causes significant B-cell reduction in Emu-Tcl-1 transgenic mice and significantly extends survival of 697 xenograft severe combined immunodeficient (SCID) mice without discernible toxicity. These data indicate silvestrol has efficacy against B cells in vitro and in vivo and identify translational inhibition as a potential therapeutic target in B-cell leukemias.

Meta-analysis of Intraprocedural Comparative Effectiveness of Vascular Plugs Vs Coils in Proximal Splenic Artery Embolization and Associated Patient Radiation Exposure.

PURPOSE: To compare vascular plugs to coil embolization of the proximal splenic artery and evaluate differences in radiation exposure to the patients. METHODS: An electronic literature search was performed for relevant studies from January 2000 to July 2018 that compared the efficacy of vascular plugs vs coils in splenic artery embolization. Only studies that investigated coil or vascular plug use, without combination with other embolic agents, were included. Meta-analysis was performed using a fixed effects model approach with the inverse variance-weighted average method to determine pooled differences in time to vessel occlusion, procedure time, fluoroscopy time, total number of devices used, and radiation exposure. Heterogeneity was assessed using the I square statistic. Pooled outcomes were compared, and quality assessments were evaluated using the Newcastle Ottawa Scale. RESULTS: Eight studies met inclusion criteria. 81 patients were embolized with vascular plugs and 52 patients with coils only. The most common indication for splenic artery embolization was trauma. Time to vessel occlusion was shorter in the vascular plug group by 7.11 minutes (P = 0.003). Fluoroscopy time was shorter by 13.82 minutes in the vascular plug cohort, and these patients received less radiation (-439 mGy) compared to the coil group (P = 0.006 and P = 0.02, respectively). The number of devices was significantly fewer in the vascular plug group (-3.54; P < 0.001). Procedure time was not statistically significant. CONCLUSION: Our data supports the vascular plug is superior to coils for embolization of the proximal splenic artery with respect to occlusion time, fluoroscopy time, patient radiation exposure, and number occlusive devices used.

Fortifying Our Teams to Best Serve Our Patients: A Report of the 2019 Summer Intersociety Meeting.

Continuing the thematic focus on fostering wellness and professional fulfillment in our workplace, the 2019 Radiology Intersociety Committee Conference focused on understanding and leading multigenerational workforces and developing high-functioning teams. To lead a multigenerational workforce and to understand and embrace traditional versus emerging cultures in our workplace, effective leaders should foster diversity of their teams. Sustaining such teams requires an understanding of different styles and preferences for bidirectional communication and clarity of information sharing and learning; active efforts may be needed to focus on practical approaches to succession planning, breaking down traditional hierarchies, clarifying role delineation, and managing authority gradients. An effective team requires attention to the well-being of team members and professional behavior in and out of the workplace. Conference participants unanimously endorsed multi-organizational support statements and activities assuring professional behavior of their members, along with the desire to explore codes of conduct and ethics.

A Road Map to Foster Wellness and Engagement in Our Workplace-A Report of the 2018 Summer Intersociety Meeting.

The 2018 radiology Intersociety Committee reviewed the current state of stress and burnout in our workplaces and identified approaches for fostering engagement, wellness, and job satisfaction. In addition to emphasizing the importance of personal wellness (the fourth aim of health care), the major focus of the meeting was to identify strategies and themes to mitigate the frequency, manifestations, and impact of stress. Strategies include reducing the stigma of burnout, minimizing isolation through community building and fostering connectivity, utilizing data and benchmarking to guide effectiveness of improvement efforts, resourcing and training "wellness" committees, acknowledging value contributions of team members, and improving efficiency in the workplace. Four themes were identified to prioritize organizational efforts: (1) collecting, analyzing, and benchmarking data; (2) developing effective leadership; (3) building high-functioning teams; and (4) amplifying our voice to increase our influence.

Endovascular treatment of intimomedial mucoid degeneration.

Intimomedial degeneration is a rare and poorly understood vascular disorder involving the circumferential deposition of large amounts of mucoid material within the intima and media of the arterial wall, causing weakening that results in aneurysm formation of the involved segment. The cause of the disease is unknown at this time. The authors describe the endovascular treatment of a large symptomatic superior gluteal artery aneurysm in a patient with multiple arterial aneurysms and the histologic diagnosis of intimomedial mucoid degeneration. In addition, they perform a review of the literature on this unusual vasculopathy.

Selection of PD1/PD-L1 X-Aptamers.

Specific, chemically modified aptamers (X-Aptamers) were identified against two immune checkpoint proteins, recombinant Programmed Death 1 (PD-1) and Programmed Death Ligand 1 (PD-L1). Selections were performed using a bead-based X-Aptamer (XA) library containing several different amino acid functional groups attached to dU at the 5-position. The binding affinities and specificities of the selected XA-PD1 and XA-PDL1 were validated by hPD-1 and hPD-L1 expression cells, as well as by binding to human pancreatic ductal adenocarcinoma tissue. The selected PD1 and PDL1 XAs can mimic antibody functions in in vitro assays.

Ethnic and Gender Diversity in Radiology Fellowships.

PURPOSE: The purpose of the study is to assess ethnic and gender diversity in US radiology fellowship programs from 2006 to 2013. MATERIALS AND METHODS: Data for this study was obtained from Journal of the American Medical Association supplements publications from 2005 to 2006 to 2012-2013 (Gonzalez-Moreno, Innov Manag Policy Pract. 15(2):149, 2013; Nivet, Acad Med. 86(12):1487-9, 2011; Reede, Health Aff. 22(4):91-3, 2003; Chapman et al., Radiology 270(1):232-40, 2014; Getto, 2005; Rivo and Satcher, JAMA 270(9):1074-8, 1993; Schwartz et al., Otolaryngol Head Neck Surg. 149(1):71-6, 2013; Simon, Clin Orthop Relat Res. 360:253-9, 1999) and the US census 2010. For each year, Fisher's exact test was used to compare the percentage of women and under-represented minorities in each Accreditation Council for Graduate Medical Education (ACGME)-certified radiology fellowship to the percentage of women and under-represented minorities in (1) all ACGME-certified radiology fellowships combined, (2) radiology residents, (3) ACGME-certified fellows in all of medicine combined, (4) ACGME-certified residents in all of medicine combined, and (5) graduating medical students. Chi-Squared test was used to compare the percentage of women and under-represented minorities and the 2010 US census. RESULTS: p < 0.05 was used as indicator of significance. Interventional radiology and neuroradiology demonstrated the highest levels of disparities, compared to every level of medical education. Abdominal and musculoskeletal radiology fellowships demonstrated disparity patterns consistent with lack of female and URM medical graduates entering into radiology residency. CONCLUSION: All radiology fellowships demonstrated variable levels of gender and ethnic disparities. Outreach efforts, pipeline programs, and mentoring may be helpful in addressing this issue.

Distribution of Iron Oxide Core-Titanium Dioxide Shell Nanoparticles in VX2 Tumor Bearing Rabbits Introduced by Two Different Delivery Modalities.

This work compares intravenous (IV) versus fluoroscopy-guided transarterial intra-catheter (IC) delivery of iron oxide core-titanium dioxide shell nanoparticles (NPs) in vivo in VX2 model of liver cancer in rabbits. NPs coated with glucose and decorated with a peptide sequence from cortactin were administered to animals with developed VX2 liver cancer. Two hours after NPs delivery tumors, normal liver, kidney, lung and spleen tissues were harvested and used for a series on histological and elemental analysis tests. Quantification of NPs in tissues was done both by bulk inductively coupled plasma mass spectrometry (ICP-MS) analysis and by hard X-ray fluorescence microscopy. Both IV and IC NPs injection are feasible modalities for delivering NPs to VX2 liver tumors with comparable tumor accumulation. It is possible that this is an outcome of the fact that VX2 tumors are highly vascularized and hemorrhagic, and therefore enhanced permeability and retention (EPR) plays the most significant role in accumulation of nanoparticles in tumor tissue. It is, however, interesting to note that IV delivery led to increased sequestration of NPs by spleen and normal liver tissue, while IC delivery lead to more NP positive Kupffer cells. This difference is most likely a direct outcome of blood flow dynamics. Armed with this knowledge about nanoparticle delivery, we plan to test them as radiosensitizers in the future.

Percutaneous ultrasound guided implantation of VX2 for creation of a rabbit hepatic tumor model.

Creation of a VX2 tumor model has traditionally required a laparotomy and surgical implantation of tumor fragments. Open surgical procedures are invasive and require long procedure times and recovery that can result in post-operative morbidity and mortality. The purpose of this study is to report the results of a percutaneous ultrasound guided method for creation of a VX2 model in rabbit livers. A total of 27 New Zealand white rabbits underwent a percutaneous ultrasound guided approach, where a VX2 tumor fragment was implanted in the liver. Magnetic resonance imaging was used to assess for tumor growth and necropsy was performed to determine rates of tract seeding and metastatic disease. Ultrasound guided tumor implantation was successful in all 27 rabbits. One rabbit died 2 days following the implantation procedure. Two rabbits had no tumors seen on follow-up imaging. Therefore, tumor development was seen in 24/26 (92%) rabbits. During the follow-up period, tract seeding was seen in 8% of rabbits and 38% had extra-hepatic metastatic disease. Therefore, percutaneous ultrasound guided tumor implantation safely provides reliable tumor growth for establishing hepatic VX2 tumors in a rabbit model with decreased rates of tract seeding, compared to previously reported methods.