Strategies to Reduce the Use of Gadolinium-Based Contrast Agents for Abdominal MRI in Children.

OBJECTIVE. The objective of this article is to review strategies to reduce the use of gadolinium-based contrast agents for pediatric abdominal MRI. CONCLUSION. Alternative contrast agents that do not contain gadolinium and unenhanced pediatric abdominal MRI protocols have shown clinical utility. Sequences such as DWI and new multicontrast MRI pulse sequences offer promise for tissue characterization without IV contrast agents. Patients requiring repeat MRI to evaluate for change in focal disease can be monitored with unenhanced abdominal MRI.

MRI Techniques to Decrease Imaging Times in Children.

Long acquisition times can limit the use of MRI in pediatric patients, and the use of sedation or general anesthesia is frequently necessary to facilitate diagnostic examinations. The use of sedation or anesthesia has disadvantages including increased cost and imaging time and potential risks to the patient. Reductions in imaging time may decrease or eliminate the need for sedation or general anesthesia. Over the past decade, a number of imaging techniques that can decrease imaging time have become commercially available. These products have been used increasingly in clinical practice and include parallel imaging, simultaneous multisection imaging, radial k-space acquisition, compressed sensing MRI reconstruction, and automated protocol selection software. The underlying concepts, supporting data, current clinical applications, and available products for each of these strategies are reviewed in this article. In addition, emerging techniques that are still under investigation may provide further reductions in imaging time, including artificial intelligence-based reconstruction, gradient-controlled aliasing sampling and reconstruction, three-dimensional MR spectroscopy, and prospective motion correction. The preliminary results for these techniques are also discussed. ©RSNA, 2020 See discussion on this article by Greer and Vasanawala.

Collaborative Interventions Reduce Time-to-Thrombolysis for Acute Ischemic Stroke in a Public Safety Net Hospital.

BACKGROUND AND PURPOSE: Shorter time-to-thrombolysis in acute ischemic stroke (AIS) is associated with improved functional outcome and reduced morbidity. We evaluate the effect of several interventions to reduce time-to-thrombolysis at an urban, public safety net hospital. METHODS: All patients treated with tissue plasminogen activator for AIS at our institution between 2008 and 2015 were included in a retrospective analysis of door-to-needle (DTN) time and associated factors. Between 2011 and 2014, we implemented 11 distinct interventions to reduce DTN time. Here, we assess the relative impact of each intervention on DTN time. RESULTS: The median DTN time pre- and postintervention decreased from 87 (interquartile range: 68-109) minutes to 49 (interquartile range: 39-63) minutes. The reduction was comprised primarily of a decrease in median time from computed tomography scan order to interpretation. The goal DTN time of 60 minutes or less was achieved in 9% (95% confidence interval: 5%-22%) of cases preintervention, compared with 70% (58%-81%) postintervention. Interventions with the greatest impact on DTN time included the implementation of a stroke group paging system, dedicated emergency department stroke pharmacists, and the development of a stroke code supply box. CONCLUSIONS: Multidisciplinary, collaborative interventions are associated with a significant and substantial reduction in time-to-thrombolysis. Such targeted interventions are efficient and achievable in resource-limited settings, where they are most needed.

Impact of antimalarial treatment and chemoprevention on the drug sensitivity of malaria parasites isolated from ugandan children.

Changing treatment practices may be selecting for changes in the drug sensitivity of malaria parasites. We characterized ex vivo drug sensitivity and parasite polymorphisms associated with sensitivity in 459 Plasmodium falciparum samples obtained from subjects enrolled in two clinical trials in Tororo, Uganda, from 2010 to 2013. Sensitivities to chloroquine and monodesethylamodiaquine varied widely; sensitivities to quinine, dihydroartemisinin, lumefantrine, and piperaquine were generally good. Associations between ex vivo drug sensitivity and parasite polymorphisms included decreased chloroquine and monodesethylamodiaquine sensitivity and increased lumefantrine and piperaquine sensitivity with pfcrt 76T, as well as increased lumefantrine sensitivity with pfmdr1 86Y, Y184, and 1246Y. Over time, ex vivo sensitivity decreased for lumefantrine and piperaquine and increased for chloroquine, the prevalences of pfcrt K76 and pfmdr1 N86 and D1246 increased, and the prevalences of pfdhfr and pfdhps polymorphisms associated with antifolate resistance were unchanged. In recurrent infections, recent prior treatment with artemether-lumefantrine was associated with decreased ex vivo lumefantrine sensitivity and increased prevalence of pfcrt K76 and pfmdr1 N86, 184F, and D1246. In children assigned chemoprevention with monthly dihydroartemisinin-piperaquine with documented circulating piperaquine, breakthrough infections had increased the prevalence of pfmdr1 86Y and 1246Y compared to untreated controls. The noted impacts of therapy and chemoprevention on parasite polymorphisms remained significant in multivariate analysis correcting for calendar time. Overall, changes in parasite sensitivity were consistent with altered selective pressures due to changing treatment practices in Uganda. These changes may threaten the antimalarial treatment and preventive efficacies of artemether-lumefantrine and dihydroartemisinin-piperaquine, respectively.

Real-World Performance of Large Vessel Occlusion Artificial Intelligence-Based Computer-Aided Triage and Notification Algorithms-What the Stroke Team Needs to Know.

PURPOSE: To evaluate the real-world performance of two FDA-approved artificial intelligence (AI)-based computer-aided triage and notification (CADt) detection devices and compare them with the manufacturer-reported performance testing in the instructions for use. MATERIALS AND METHODS: Clinical performance of two FDA-cleared CADt large-vessel occlusion (LVO) devices was retrospectively evaluated at two separate stroke centers. Consecutive "code stroke" CT angiography examinations were included and assessed for patient demographics, scanner manufacturer, presence or absence of CADt result, CADt result, and LVO in the internal carotid artery (ICA), horizontal middle cerebral artery (MCA) segment (M1), Sylvian MCA segments after the bifurcation (M2), precommunicating part of cerebral artery, postcommunicating part of the cerebral artery, vertebral artery, basilar artery vessel segments. The original radiology report served as the reference standard, and a study radiologist extracted the above data elements from the imaging examination and radiology report. RESULTS: At hospital A, the CADt algorithm manufacturer reports assessment of intracranial ICA and MCA with sensitivity of 97% and specificity of 95.6%. Real-world performance of 704 cases included 79 in which no CADt result was available. Sensitivity and specificity in ICA and M1 segments were 85.3% and 91.9%. Sensitivity decreased to 68.5% when M2 segments were included and to 59.9% when all proximal vessel segments were included. At hospital B the CADt algorithm manufacturer reports sensitivity of 87.8% and specificity of 89.6%, without specifying the vessel segments. Real-world performance of 642 cases included 20 cases in which no CADt result was available. Sensitivity and specificity in ICA and M1 segments were 90.7% and 97.9%. Sensitivity decreased to 76.4% when M2 segments were included and to 59.4% when all proximal vessel segments are included. DISCUSSION: Real-world testing of two CADt LVO detection algorithms identified gaps in the detection and communication of potentially treatable LVOs when considering vessels beyond the intracranial ICA and M1 segments and in cases with absent and uninterpretable data.

Rosai-Dorfman Disease Isolated to the Thoracic Epidural Spine.

Rosai-Dorfman disease is a rare benign histiocytic disease that infrequently presents in the spine. We report a case of Rosai-Dorfman disease isolated to the epidural thoracic spine in a 26-year-old male. To our knowledge, this is the 15th reported case of isolated spinal disease and only the fourth case of isolated thoracic epidural disease. Given its rarity as well as non-specific symptoms and imaging findings, Rosai-Dorfman disease is often not considered and misdiagnosed on imaging studies. To help improve awareness of Rosai-Dorfman spinal disease, we review the literature and discuss the epidemiology, clinical presentation, imaging features, and treatment considerations for this condition.

Medical Student Usage of the American College of Radiology Appropriateness Criteria.

RATIONALE AND OBJECTIVES: Educating medical students on appropriate imaging utilization has been increasingly recognized as important for patient care. The American College of Radiology Appropriateness Criteria (ACR-AC) is designed to support evidence-based imaging examination selection. We sought to assess whether medical students order imaging studies independently, what resources they use for guidance, and whether they use the ACR-AC in clinical practice. A secondary aim was to determine whether increasing familiarity with the ACR-AC could impact student usage. MATERIALS AND METHODS: We surveyed third year medical students at a single institution on their imaging practices, familiarity with the ACR-AC, and preferences among available resources to guide proper examination selection. The survey was performed in person before a lecture. We also designed a brief intervention to improve familiarity with the ACR-AC and then reassessed students to determine any effect on utilization. RESULTS: The response rate for the initial survey was 103 of 109 (94%) and the response rate for the second survey was 99 of 109 (91%).Our initial survey found students initiated imaging orders independently (74 of 100, 74.8%) and consulted resources to assist in examination selection (50 of 74, 67.6%). Students expressed a preference for non-ACR-AC resources, notably Up to Date via its online mobile application.Few students (8 of 71, 11.3%) were familiar with the ACR-AC. After an intervention to increase familiarity with the ACR-AC, student awareness of the ACR-AC increased to 61 of 74 (82.4%). However, usage among those familiar with the resource remained low, 13 of 61(21.3%) versus 3 of 8 (37.5%). CONCLUSIONS: Use of the ACR-AC was low among third year medical students. After increasing students' familiarity with the ACR-AC, their usage in a clinical setting did not increase. The largest barrier to use may be the lack of a quick, easy to use online mobile application-based interface.

Katanin localization requires triplet microtubules in Chlamydomonas reinhardtii.

Centrioles and basal bodies are essential for a variety of cellular processes that include the recruitment of proteins to these structures for both centrosomal and ciliary function. This recruitment is compromised when centriole/basal body assembly is defective. Mutations that cause basal body assembly defects confer supersensitivity to Taxol. These include bld2, bld10, bld12, uni3, vfl1, vfl2, and vfl3. Flagellar motility mutants do not confer sensitivity with the exception of mutations in the p60 (pf19) and p80 (pf15) subunits of the microtubule severing protein katanin. We have identified additional pf15 and bld2 (ε-tubulin) alleles in screens for Taxol sensitivity. Null pf15 and bld2 alleles are viable and are not essential genes in Chlamydomonas. Analysis of double mutant strains with the pf15-3 and bld2-6 null alleles suggests that basal bodies in Chlamydomonas may recruit additional proteins beyond katanin that affect spindle microtubule stability. The bld2-5 allele is a hypomorphic allele and its phenotype is modulated by nutritional cues. Basal bodies in bld2-5 cells are missing proximal ends. The basal body mutants show aberrant localization of an epitope-tagged p80 subunit of katanin. Unlike IFT proteins, katanin p80 does not localize to the transition fibers of the basal bodies based on an analysis of the uni1 mutant as well as the lack of colocalization of katanin p80 with IFT74. We suggest that the triplet microtubules are likely to play a key role in katanin p80 recruitment to the basal body of Chlamydomonas rather than the transition fibers that are needed for IFT localization.