Radiology of fibrosis. Part I: Thoracic organs.

Sustained injury from factors such as hypoxia, infection, or physical damage may provoke improper tissue repair and the anomalous deposition of connective tissue that causes fibrosis. This phenomenon may take place in any organ, ultimately leading to their dysfunction and eventual failure. Tissue fibrosis has also been found to be central in both the process of carcinogenesis and cancer progression. Thus, its prompt diagnosis and regular monitoring is necessary for implementing effective disease-modifying interventions aiming to reduce mortality and improve overall quality of life. While significant research has been conducted on these subjects, a comprehensive understanding of how their relationship manifests through modern imaging techniques remains to be established. This work intends to provide a comprehensive overview of imaging technologies relevant to the detection of fibrosis affecting thoracic organs as well as to explore potential future advancements in this field.

Radiology of fibrosis part II: abdominal organs.

Fibrosis is the aberrant process of connective tissue deposition from abnormal tissue repair in response to sustained tissue injury caused by hypoxia, infection, or physical damage. It can affect almost all organs in the body causing dysfunction and ultimate organ failure. Tissue fibrosis also plays a vital role in carcinogenesis and cancer progression. The early and accurate diagnosis of organ fibrosis along with adequate surveillance are helpful to implement early disease-modifying interventions, important to reduce mortality and improve quality of life. While extensive research has already been carried out on the topic, a thorough understanding of how this relationship reveals itself using modern imaging techniques has yet to be established. This work outlines the ways in which fibrosis shows up in abdominal organs and has listed the most relevant imaging technologies employed for its detection. New imaging technologies and developments are discussed along with their promising applications in the early detection of organ fibrosis.

Radiology of fibrosis part III: genitourinary system.

Fibrosis is a pathological process involving the abnormal deposition of connective tissue, resulting from improper tissue repair in response to sustained injury caused by hypoxia, infection, or physical damage. It can impact any organ, leading to their dysfunction and eventual failure. Additionally, tissue fibrosis plays an important role in carcinogenesis and the progression of cancer.Early and accurate diagnosis of organ fibrosis, coupled with regular surveillance, is essential for timely disease-modifying interventions, ultimately reducing mortality and enhancing quality of life. While extensive research has already been carried out on the topics of aberrant wound healing and fibrogenesis, we lack a thorough understanding of how their relationship reveals itself through modern imaging techniques.This paper focuses on fibrosis of the genito-urinary system, detailing relevant imaging technologies used for its detection and exploring future directions.

Automated Identification of Optimal Portal Venous Phase Timing with Convolutional Neural Networks.

OBJECTIVES: To develop a deep learning-based algorithm to automatically identify optimal portal venous phase timing (PVP-timing) so that image analysis techniques can be accurately performed on post contrast studies. METHODS: 681 CT-scans (training: 479 CT-scans; validation: 202 CT-scans) from a multicenter clinical trial in patients with liver metastases from colorectal cancer were retrospectively analyzed for algorithm development and validation. An additional external validation was performed on a cohort of 228 CT-scans from gastroenteropancreatic neuroendocrine cancer patients. Image acquisition was performed according to each centers' standard CT protocol for single portal venous phase, portal venous acquisition. The reference gold standard for the classification of PVP-timing as either optimal or nonoptimal was based on experienced radiologists' consensus opinion. The algorithm performed automated localization (on axial slices) of the portal vein and aorta upon which a novel dual input Convolutional Neural Network calculated a probability of the optimal PVP-timing. RESULTS: The algorithm automatically computed a PVP-timing score in 3 seconds and reached area under the curve of 0.837 (95% CI: 0.765, 0.890) in validation set and 0.844 (95% CI: 0.786, 0.889) in external validation set. CONCLUSION: A fully automated, deep-learning derived PVP-timing algorithm was developed to classify scans' contrast-enhancement timing and identify scans with optimal PVP-timing. The rapid identification of such scans will aid in the analysis of quantitative (radiomics) features used to characterize tumors and changes in enhancement with treatment in a multitude of settings including quantitative response criteria such as Choi and MASS which rely on reproducible measurement of enhancement.

Machine learning defined diagnostic criteria for differentiating pituitary metastasis from autoimmune hypophysitis in patients undergoing immune checkpoint blockade therapy.

PURPOSE: New-onset pituitary gland lesions are observed in up to 18% of cancer patients undergoing treatment with immune checkpoint blockers (ICB). We aimed to develop and validate an imaging-based decision-making algorithm for use by the clinician that helps differentiate pituitary metastasis (PM) from ICB-induced autoimmune hypophysitis (HP). MATERIALS AND METHODS: A systematic search was performed in the MEDLINE and EMBASE databases up to October 2018 to identify studies concerning PM and HP in patients treated with cytotoxic T-lymphocyte-associated protein 4 and programmed cell death (ligand) 1. The reference standard for diagnosis was confirmation by histology or response on follow-up imaging. Patients from included studies were randomly assigned to the training set or the validation set. Using machine learning (random forest tree algorithm) with the most-described six imaging and three clinical features, a multivariable prediction model (the signature) was developed and validated for diagnosing PM. Signature performance was evaluated using area under a receiver operating characteristic curves (AUCs). RESULTS: Out of 3174 screened articles, 65 were included totalising 122 patients (HP: 60 pts, PM: 62 pts). Complete radiological data were available in 82 pts (Training: 62 pts, Validation: 20 pts). The signature reached an AUC = 0.91 (0.82, 1.00), P < 10-8 in the training set and AUC = 0.94 (0.80, 1.00), P = 0.001 in the validation set. The signature predicted PM in lesions either ≥ 2 cm in size or < 2 cm if associated with heterogeneous contrast enhancement and cavernous extension. CONCLUSION: An image-based signature was developed with machine learning and validated for differentiating PM from HP. This tool could be used by clinicians for enhanced decision-making in cancer patients undergoing ICB treatment with new-onset, concerning lesions of the pituitary gland.

Detection of immune-related adverse events by medical imaging in patients treated with anti-programmed cell death 1.

BACKGROUND: Programmed death receptor-1 blocking antibodies (anti-PD1) are a new standard of care in many cancer types. Patients benefit from improved survival but have the risk of immune-related adverse events (irAE). We evaluated if medical imaging procedures, used for anti-tumour response assessment, can detect irAEs. MATERIALS AND METHODS: All consecutive patients treated with anti-PD1 and with a medical imaging acquisition performed within 2 weeks with irAEs ≥2 were retrospectively included. Data were gathered from June 2014 to February 2017, and a central review was performed. The primary and secondary end-points were i) to evaluate the overall detection rate of irAEs by medical imaging and ii) to provide a comprehensive radiological description of irAEs. RESULTS: Fifty-three patients (31 women, 22 men; average age: 61 years) were included. The primary tumour was melanoma (n = 32), lung cancer (n = 18) and other (n = 3). Patients were treated with nivolumab (n = 27) or pembrolizumab (n = 26). Of 74 medical imaging procedures analysed (ratio = 1.4 medical imaging per patient), 55 irAE were detected. The detection rate was overall: 74% (95 confidence interval: 63-84%), positron emission tomography with 18F-fludeoxyglucose integrated with computed tomography (18F-FDG PET/CT): 83% (n = 10/12), magnetic resonance imaging: 83% (n = 5/6), computed tomography scan: 79% (n = 19/24), ultrasonography: 70% (n = 19/27), standard X-rays: 40% (n = 2/5), lung/mediastinum: 100% (n = 7/7), enterocolitis: 100% (n = 8/8), hypophysitis: 100% (n = 3/3), thyroiditis: 75% (n = 15/20), hepatitis: 67% (n = 2/3), arthralgia or arthritis: 40% (n = 2/5) and pancreas: 28% (n = 2/7). CONCLUSION: Medical imaging detected 74% of irAE in patients treated with anti-PD1. Beyond response assessment, medical imaging can detect irAE and guide towards specific management. We described the most frequent sites and patterns of imaging findings.

Interobserver variability in tumor contouring affects the use of radiomics to predict mutational status.

Radiomic features characterize tumor imaging phenotype. Nonsmall cell lung cancer (NSCLC) tumors are known for their complexity in shape and wide range in density. We explored the effects of variable tumor contouring on the prediction of epidermal growth factor receptor (EGFR) mutation status by radiomics in NSCLC patients treated with a targeted therapy (Gefitinib). Forty-six early stage NSCLC patients (EGFR mutant:wildtype = 20:26) were included. Three experienced radiologists independently delineated the tumors using a semiautomated segmentation software on a noncontrast-enhanced baseline and three-week post-therapy CT scan images that were reconstructed using 1.25-mm slice thickness and lung kernel. Eighty-nine radiomic features were computed on both scans and their changes (radiomic delta-features) were calculated. The highest area under the curves (AUCs) were 0.87, 0.85, and 0.80 for the three radiologists and the number of significant features ([Formula: see text]) was 3, 5, and 0, respectively. The AUCs of a single feature significantly varied among radiologists (e.g., 0.88, 0.75, and 0.73 for run-length primitive length uniformity). We conclude that a three-week change in tumor imaging phenotype allows identifying the EGFR mutational status of NSCLC. However, interobserver variability in tumor contouring translates into a significant variability in radiomic metrics accuracy.

Impact of Variability in Portal Venous Phase Acquisition Timing in Tumor Density Measurement and Treatment Response Assessment: Metastatic Colorectal Cancer as a Paradigm.

PURPOSE: New response patterns to anticancer drugs have led tumor size-based response criteria to shift to also include density measurements. Choi criteria, for instance, categorize antiangiogenic therapy response as a decrease in tumor density > 15% at the portal venous phase (PVP). We studied the effect that PVP timing has on measurement of the density of liver metastases (LM) from colorectal cancer (CRC). METHODS: Pretreatment PVP computed tomography images from 291 patients with LM-CRC from the CRYSTAL trial (Cetuximab Combined With Irinotecan in First-Line Therapy for Metastatic Colorectal Cancer; ClinicalTrials.gov identifier: NCT00154102) were included. Four radiologists independently scored the scans' timing according to a three-point scoring system: early, optimal, late PVP. Using this, we developed, by machine learning, a proprietary computer-aided quality-control algorithm to grade PVP timing. The reference standard was a computer-refined consensus. For each patient, we contoured target liver lesions and calculated their mean density. RESULTS: Contrast-product administration data were not recorded in the digital imaging and communications in medicine headers for injection volume (94%), type (93%), and route (76%). The PVP timing was early, optimal, and late in 52, 194, and 45 patients, respectively. The mean (95% CI) accuracy of the radiologists for detection of optimal PVP timing was 81.7% (78.3 to 85.2) and was outperformed by the 88.6% (84.8 to 92.4) computer accuracy. The mean ± standard deviation of LM-CRC density was 68 ± 15 Hounsfield units (HU) overall and 59.5 ± 14.9 HU, 71.4 ± 14.1 HU, 62.4 ± 12.5 HU at early, optimal, and late PVP timing, respectively. LM-CRC density was thus decreased at nonoptimal PVP timing by 14.8%: 16.7% at early PVP ( P < .001) and 12.6% at late PVP ( P < .001). CONCLUSION: Nonoptimal PVP timing should be identified because it significantly decreased tumor density by 14.8%. Our computer-aided quality-control system outperformed the accuracy, reproducibility, and speed of radiologists' visual scoring. PVP-timing scoring could improve the extraction of tumor quantitative imaging biomarkers and the monitoring of anticancer therapy efficacy at the patient and clinical trial levels.

The myADHDportal.com Improvement Program: An innovative quality improvement intervention for improving the quality of ADHD care among community-based pediatricians.

Though the American Academy of Pediatrics has developed and disseminated clear evidence-based guidelines for ADHD care, community-based pediatricians often have difficulty implementing these guidelines. New strategies are needed to improve the quality of care received by children with ADHD and to improve utilization of the AAP consensus guidelines by pediatricians. An evidence-based quality improvement intervention has been developed that effectively improves the quality of ADHD care delivered by community-based pediatricians. In order to facilitative widespread dissemination of this intervention model, the entire intervention has been modified for online delivery. The intervention is called the myADHDportal.com Improvement Program. The full functionality of this online intervention is described including the collection of online ADHD rating scales from parents and teachers and online communication between parents, teachers, and physicians. In addition, the web portal integrates several innovative quality improvement features including an online wizard for mapping ADHD patient flow, an online report card for monitoring quality of care, and an online wizard for guiding practices through the Plan-Do-Study-Act (PDSA) cycle process. The combination of clinical utility and quality improvement tools facilitates delivery of quality ADHD care and reduces several of the obstacles to implementing AAP-recommended practice behaviors. Initial results with this intervention model are reviewed and goals for dissemination are described.

Use of an Internet portal to improve community-based pediatric ADHD care: a cluster randomized trial.

OBJECTIVE: To determine the effectiveness of a quality improvement program to improve pediatricians' adherence to existing, evidence-based, attention-deficit/hyperactivity disorder (ADHD) practice guidelines. METHODS: Forty-nine community-based pediatricians at 8 practices participated in a cluster-randomized trial. Practices were matched according to the numbers of pediatricians and the proportions of patients receiving Medicaid. The medical charts for a random sample of patients with ADHD for each of the participating pediatricians were examined at baseline and 6 months. All practices participated in 4 sessions of training, including didactic lectures and office flow modification workshops. Practices were then given access to an ADHD Internet portal that allowed parents, teachers, and pediatricians to input information (eg, rating scales) about patients, after which information was scored, interpreted, and formatted in a report style that was helpful for assessment and treatment of patients with ADHD. Physicians evaluated their practice behaviors quarterly and addressed underperforming areas. RESULTS: Pediatricians in the intervention group, compared with those in the control group, demonstrated significantly higher rates of many American Academy of Pediatrics-recommended ADHD care practices, including collection of parent (Cohen's d = 0.69) and teacher (d = 0.68) rating scales for assessment of children with ADHD, use of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria (d = 0.85), and use of teacher rating scales to monitor treatment responses (d = 1.01). CONCLUSION: A quality improvement intervention that can be widely disseminated by using Internet-based information technology significantly improved the quality of ADHD care in community-based pediatric settings.

Wounds measured from digital photographs using photodigital planimetry software: validation and rater reliability.

UNLABELLED:  Traditional wound tracing technique consists of tracing the perimeter of the wound on clear acetate with a fine-tip marker, then placing the tracing on graph paper and counting the grids to calculate the surface area. Standard wound measurement technique for calcu- lating wound surface area (wound tracing) was compared to a new wound measurement method using digital photo-planimetry software ([DPPS], PictZar® Digital Planimetry). METHODS: Two hundred wounds of varying etiologies were measured and traced by experienced exam- iners (raters). Simultaneously, digital photographs were also taken of each wound. The digital photographs were downloaded onto a PC, and using DPPS software, the wounds were measured and traced by the same examiners. Accuracy, intra- and interrater reliability of wound measurements obtained from tracings and from DPPS were studied and compared. Both accuracy and rater variability were directly related to wound size when wounds were measured and traced in the tradi- tional manner. RESULTS: In small (< 4 cm2), regularly shaped (round or oval) wounds, both accuracy and rater reliability was 98% and 95%, respectively. However, in larger, irregularly shaped wounds or wounds with epithelial islands, DPPS was more accurate than traditional mea- suring (3.9% vs. 16.2% [average error]). The mean inter-rater reliabil- ity score was 94% for DPPS and 84% for traditional measuring. The mean intrarater reliability score was 98.3% for DPPS and 89.3% for traditional measuring. In contrast to traditional measurements, DPPS may provide a more objective assessment since it can be done by a technician who is blinded to the treatment plan. Planimetry of digital photographs allows for a closer examination (zoom) of the wound and better visibility of advancing epithelium. CONCLUSION: Measurements of wounds performed on digital photographs using planimetry software were simple and convenient. It was more accurate, more objective, and resulted in better correlation within and between examiners. .

Attention-deficit/hyperactivity disorder outcomes for children treated in community-based pediatric settings.

OBJECTIVE: To determine if children treated by community physicians who participated in an attention-deficit/hyperactivity disorder (ADHD) quality improvement intervention demonstrate symptom and impairment improvements comparable with those achieved in university-based clinical trials. DESIGN: Case series. SETTING: Rural, suburban, and urban practices, with 28% of the 47 practices serving primarily (>50% of patients) Medicaid-receiving populations. PARTICIPANTS: A total of 785 children aged between 7 and 11 years were treated for ADHD by community physicians participating in the study. Intervention A total of 158 community physicians from 47 separate practices participated in a quality improvement intervention, the ADHD Collaborative, designed to improve physician adherence to evidence-based ADHD treatment guidelines. The intervention included mapping and redesign of practice office flow to facilitate adherence to American Academy of Pediatrics ADHD guidelines as well as didactic sessions related to diagnosis and treatment of ADHD. Medical record reviews were completed at the initial assessment and every 3 months for 1 year to evaluate treatment outcome. OUTCOME MEASURES: Improvement in parent- and teacher-rated ADHD symptoms and functional impairment. RESULTS: Children showed large improvements in parent- and teacher-rated ADHD symptoms, similar to some clinical trials, but made no significant improvements in functional impairment. CONCLUSIONS: Large improvements in ADHD symptoms can be achieved in primary care settings when physicians provide evidence-based ADHD care using medication. Because many children with ADHD continued to have significant functional impairment despite symptom improvement, collaboration with other mental health or educational services in additional to medication appears warranted.

Interventions to promote the evidence-based care of children with ADHD in primary-care settings.

Attention-deficit/hyperactivity disorder (ADHD) is a commonly occurring behavioral disorder among children. Community-based physicians are often the primary providers of services for children with ADHD. A set of consensus guidelines has been published by the American Academy of Pediatrics that provides best-practice diagnostic procedures for primary-care physicians. These recommendations emphasize the importance of using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria as the basis for making an ADHD diagnosis and conducting systematic follow-up, including the collection of parent and teacher ratings scales to quantitatively assess response to treatment. Although these recommendations have been widely disseminated and their adoption actively promoted, guideline adherence, in general, is known to be poor. Two types of intervention models, ancillary service and office systems modification, have been proposed to promote adoption of evidence-based ADHD practice in primary-care settings. The present article reviews the efficacy of these intervention models, and discusses the cost and sustainability of each model as related to feasibility of intervention dissemination.

Community-wide intervention to improve the attention-deficit/hyperactivity disorder assessment and treatment practices of community physicians.

OBJECTIVES: The goals were to implement and to test a quality-improvement intervention aimed at improving community-based primary care providers' adherence to the American Academy of Pediatrics, evidence-based diagnostic and treatment guidelines for attention-deficit/hyperactivity disorder. METHODS: Nineteen practices (with 84 primary care providers) from a large urban community were trained by using quality-improvement methods with some academic detailing. Pretraining and posttraining adherence to evidence-based practices was assessed through review of patient charts. RESULTS: Preintervention rates of guideline usage were uniformly low. After the intervention, primary care providers showed substantial improvement in their use of the guidelines for the assessment and treatment of elementary school-aged patients with newly diagnosed attention-deficit/hyperactivity disorder. Use of parent and teacher assessment rating scales increased from levels of 52% to 55% to levels of nearly 100%. Systematic monitoring of responses to medication improved from a baseline level of 9% to 40%. CONCLUSIONS: Quality-improvement interventions such as the one used in this study seem quite effective in improving primary care providers' practices at offices that express interest in improving the quality of care for attention-deficit/hyperactivity disorder. The design of the intervention, problems associated with improving and sustaining treatment monitoring, and issues related to generalizability of the intervention model are discussed.

A safety-net antibiotic prescription for otitis media: the effects of a PBRN study on patients and practitioners.

Pediatricians can decrease antibiotic use by treating acute otitis media (AOM) with a safety-net antibiotic prescription (SNAP). This study assessed whether the practitioners of the Practice-Based Research Network who participated in the study continued to use the SNAP and report a 60-day follow-up of the study patients. Charts were reviewed of study patients for 60 days following study enrollment. A survey on antibiotic use for AOM was mailed to the 17 study practitioners (SP) and 30 randomly selected community pediatricians (CP). Eight of the SP used the SNAP more than 20 times over the year following the study vs 1 of the CP. Sixty-two percent of patients never received antibiotics. The recurrence/relapse rate was greater in children younger than 2 years old compared to those older, 34% vs 10%. Practitioners who participate in a Practice-Based Research Network study are more likely to use a study intervention than others.

Implementing an evidence-based acute gastroenteritis guideline at a children's hospital.

BACKGROUND: Guidelines for preventing and treating acute gastroenteritis (AGE) have generally not been incorporated into medical practice. An evidence-based clinical practice guideline was adapted from national guidelines to meet the practice styles characterizing care in southwestern Ohio and implemented at the Children's Hospital Medical Center (Cincinnati). Its efficacy was assessed in terms of emergency department (ED) encounters and admissions, mean and total hospital costs, and mean length of hospitalization. METHODS: Comparisons were made between patients seen during peak gastroenteritis months (December-May) before (fiscal year [FYs] 1994-1997) and after (FYs 1998 and 1999) guideline implementation. Data were extracted from hospital charts, clinical databases, and billing records. RESULTS: Following implementation, mean yearly ED encounters for AGE decreased 22% and mean yearly admissions decreased 33%. The percentage of admitted children with minor illness decreased (p = 0.002). Mean length of stay decreased 21% for children with minor illness (p = 0.0001) and 5% for others. Hydration status was noted in only 15% of ED charts examined but increased to 63% in FY 1998 and 86% in FY 1999 (p < 0.001). The proportion of admitted patients who advanced to a regular diet by discharge increased from 4.9% (FY 1997) to 23% (FY 1998) and 76% (FY 1999; p < 0.0001). Total inpatient days/year decreased by 43%. Mean hospital costs did not change significantly. DISCUSSION: Following implementation, fewer patients with AGE were seen in the ED and fewer were admitted to the hospital for care. Hospital stays were shorter, and children were more likely to resume their diets before discharge.