Development of a Medical Social Media Ethics Scale and Assessment of #IRad, #CardioTwitter, and #MedTwitter Posts: Mixed Methods Study.

BACKGROUND: Social media posts by clinicians are not bound by the same rules as peer-reviewed publications, raising ethical concerns that have not been extensively characterized or quantified. OBJECTIVE: We aim to develop a scale to assess ethical issues on medical social media (SoMe) and use it to determine the prevalence of these issues among posts with 3 different hashtags: #MedTwitter, #IRad, and #CardioTwitter. METHODS: A scale was developed based on previous descriptions of professionalism and validated via semistructured cognitive interviewing with a sample of 11 clinicians and trainees, interrater agreement, and correlation of 100 posts. The final scale assessed social media posts in 6 domains. This was used to analyze 1500 Twitter posts, 500 each from the 3 hashtags. Analysis of posts was limited to original Twitter posts in English made by health care professionals in North America. The prevalence of potential issues was determined using descriptive statistics and compared across hashtags using the Fisher exact and χ2 tests with Yates correction. RESULTS: The final scale was considered reflective of potential ethical issues of SoMe by participants. There was good interrater agreement (Cohen κ=0.620, P<.01) and moderate to strong positive interrater correlation (=0.602, P<.001). The 6 scale domains showed minimal to no interrelation (Cronbach α=0.206). Ethical concerns across all hashtags had a prevalence of 1.5% or less except the conflict of interest concerns on #IRad, which had a prevalence of 3.6% (n=18). Compared to #MedTwitter, posts with specialty-specific hashtags had more patient privacy and conflict of interest concerns. CONCLUSIONS: The SoMe professionalism scale we developed reliably reflects potential ethical issues. Ethical issues on SoMe are rare but important and vary in prevalence across medical communities.

Pulmonary interstitial lymphography: A prospective trial with potential impact on stereotactic ablative radiotherapy planning for early-stage lung cancer.

This prospective feasibility trial investigated pulmonary interstitial lymphography to identify thoracic primary nodal drainage (PND). A post-hoc analysis of nodal recurrences was compared with PND for patients with early-stage lung cancer; larger studies are needed to establish correlation. Exploratory PND-inclusive stereotactic ablative radiotherapy plans were assessed for dosimetric feasibility.

From Acceptable to Superlative: Scaling a Technologist Coaching Intervention to Improve Image Quality.

OBJECTIVE: To explore factors influencing the expansion of the peer-based technologist Coaching Model Program (CMP) from its origins in mammography and ultrasound to all imaging modalities at a single tertiary academic medical center. METHODS: After success in mammography and ultrasound, efforts to expand the CMP across all Stanford Radiology modalities commenced in September 2020. From February to April 2021 as lead coaches piloted the program in these novel modalities, an implementation science team designed and conducted semistructured stakeholder interviews and took observational notes at learning collaborative meetings. Data were analyzed using inductive-deductive approaches informed by two implementation science frameworks. RESULTS: Twenty-seven interviews were collected across modalities with radiologists (n = 5), managers (n = 6), coaches (n = 11), and technologists (n = 5) and analyzed with observational notes from six learning meetings with 25 to 40 recurrent participants. The number of technologists, the complexity of examinations, or the existence of standardized auditing criteria for each modality influenced CMP adaptations. Facilitators underlying program expansion included cross-modality learning collaborative, thoughtful pairing of coach and technologist, flexibility in feedback frequency and format, radiologist engagement, and staged rollout. Barriers included lack of protected coaching time, lack of pre-existing audit criteria for some modalities, and the need for privacy of auditing and feedback data. DISCUSSION: Adaptations to each radiology modality and communication of these learnings were key to disseminating the existing CMP to new modalities across the entire department. An intermodality learning collaborative can facilitate the dissemination of evidence-based practices across modalities.

Current State of Peer Learning in Radiology: A Survey of ACR Members.

PURPOSE: Peer learning (PL) programs seek to improve upon the limitations of score-based peer review and incorporate modern approaches to improve patient care. The aim of this study was to further understand the landscape of PL among members of the ACR in the first quarter of 2022. METHODS: Members of the ACR were surveyed to evaluate the incidence, current practices, perceptions, and outcomes of PL in radiology practice. The survey was administered via e-mail to 20,850 ACR members. The demographic and practice characteristics of the 1,153 respondents (6%) were similar to those of the ACR radiologist membership and correspond to a normal distribution of the population of radiologists and can therefore be described as representative of that population. Therefore, the error range for the results from this survey is ±2.9% at a 95% confidence level. RESULTS: Among the total sample, 610 respondents (53%) currently use PL, and 334 (29%) do not. Users of PL are younger (mode age ranges, 45-54 years for users and 55-64 years for nonusers; P < .01), more likely to be female (29% vs 23%, P < .05), and more likely to practice in urban settings (52% vs 40%, P = .0002). Users of PL feel that it supports an improved culture of safety and wellness (543 of 610 [89%]) and fosters continuous improvement initiatives (523 of 610 [86%]). Users of PL are more likely than nonusers to identify learning opportunities from routine clinical practice (83% vs 50%, P < .00001), engage in programming inclusive of more team members, and implement more practice improvement projects (P < .00001). PL users' net promoter score of 65% strongly suggests that users of PL are highly likely to recommend the program to colleagues. CONCLUSIONS: Radiologists across a breadth of radiology practices are engaged in PL activities, which are perceived to align with emerging principles of improving health care and enhance culture, quality, and engagement.

Monitoring Sarcoma Response to Immune Checkpoint Inhibition and Local Cryotherapy with Circulating Tumor DNA Analysis.

PURPOSE: Immune checkpoint inhibition has led to promising responses in soft tissue sarcomas (STS), but the majority of patients do not respond and biomarkers of response will be crucial. Local ablative therapies may augment systemic responses to immunotherapy. We evaluated circulating tumor DNA (ctDNA) as a biomarker of response in patients treated on a trial combining immunotherapy with local cryotherapy for advanced STS. PATIENTS AND METHODS: We enrolled 30 patients with unresectable or metastatic STS to a phase II clinical trial. Patients received ipilimumab and nivolumab for four doses followed by nivolumab alone with cryoablation performed between cycles 1 and 2. The primary endpoint was objective response rate (ORR) by 14 weeks. Personalized ctDNA analysis using bespoke panels was performed on blood samples collected prior to each immunotherapy cycle. RESULTS: ctDNA was detected in at least one sample for 96% of patients. Pretreatment ctDNA allele fraction was negatively associated with treatment response, progression-free survival (PFS), and overall survival (OS). ctDNA increased in 90% of patients from pretreatment to postcryotherapy, and patients with a subsequent decrease in ctDNA or undetectable ctDNA after cryotherapy had significantly better PFS. Of the 27 evaluable patients, the ORR was 4% by RECIST and 11% by irRECIST. Median PFS and OS were 2.7 and 12.0 months, respectively. No new safety signals were observed. CONCLUSIONS: ctDNA represents a promising biomarker for monitoring response to treatment in patients with advanced STS, warranting future prospective studies. Combining cryotherapy and immune checkpoint inhibitors did not increase the response rate of STS to immunotherapy.

Yttrium-90 Radioembolization and Concomitant Systemic Gemcitabine, Cisplatin, and Capecitabine as the First-Line Therapy for Locally Advanced Intrahepatic Cholangiocarcinoma.

PURPOSE: To determine the safety and effectiveness of yttrium-90 transarterial radioembolization (TARE) combined with systemic gemcitabine, cisplatin, and capecitabine for the first-line treatment of locally advanced intrahepatic cholangiocarcinoma (iCCA). MATERIALS AND METHODS: Data of 13 patients with treatment-naïve, locally advanced iCCA treated with a downstaging protocol using gemcitabine, cisplatin, TARE, and capecitabine were retrospectively reviewed. Overall survival (OS), local tumor response (modified Response Evaluation Criteria in Solid Tumors), progression-free survival (PFS), technical adverse events, and toxicity were measured. RESULTS: Calculated from the time of diagnosis, the median OS was 29 months (95% confidence interval [CI], 15 to not reached), with a 1-year OS of 84.6% (95% CI, 52.2%-95.9%) and 2-year OS of 52.9% (95% CI, 20.3%-77.5%). The median OS values were 24 months (95% CI, 8 to not reached) and 21 months (95% CI, 5 to not reached) from the time of initial cycle of chemotherapy and TARE, respectively. Patients who were downstaged to surgery (n = 7, 53.8%) had a more favorable OS (median OS, not reached vs 15 months; P = .0221). Complete and partial radiologic responses were achieved in 5 (38.5%) and 6 (46.2%) patients, respectively. The median PFS was 13 months (95% CI, 12 to not reached). Although no serum toxicity with Grade >2 occurred within 3 months after TARE, 1 patient was no longer a surgical candidate given suboptimal nutrition status despite successful downstage on imaging studies. Two patients required a reduced dose or delay of post-TARE chemotherapy. CONCLUSIONS: First-line combination therapy with TARE and systemic gemcitabine, cisplatin, and capecitabine is an effective treatment with an acceptable safety profile for iCCA with a high rate of downstaging to resection.

ACR Appropriateness Criteria® Management of Liver Cancer: 2022 Update.

The treatment and management of hepatic malignancies can be complex because it encompasses a variety of primary and metastatic malignancies and an assortment of local and systemic treatment options. When to use each of these treatments is critical to ensure the most appropriate care for patients. Interventional radiologists have a key role to play in the delivery of a variety of liver directed treatments including percutaneous ablation, transarterial embolization with bland embolic particles alone, transarterial chemoembolization (TACE) with injection of a chemotherapeutic emulsion, and transarterial radioembolization (TARE). Based on 9 clinical variants, the appropriateness of each treatment is described in this document. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Opportunities for Excellence in Interventional Radiology Training: A Qualitative Study.

OBJECTIVE: The training experience in interventional radiology (IR) residency programs varies widely across the country. The introduction of an IR training pathway has provided the impetus for the specialty to better define outstanding IR education and for programs to rethink how their curricula prepare IR trainees for real-world practice. Although ACGME competencies define several training components that are necessary for independent practice, few quantitative or qualitative studies have explored current perceptions on what constitutes optimal IR training. Our goal was to qualitatively explore program training features deemed most important to adequately prepare IR physicians for practice and assess whether there were differences in perception between academic and nonacademic practices. METHODS: Semistructured interviews were conducted with 71 IR attending physicians, trainees, and support staff across the United States. All interviews were performed over the telephone by a single researcher for consistency and systematically coded by two independent coders for common themes. Frequency and prevalence of themes and facilitating features were analyzed. RESULTS: The most frequently perceived facilitating features included longitudinal patient care experience, practice-building education, interspecialty collaboration exposure, broad case mix, clinical decision-making exposure, diagnostic radiology training, procedural skills training, and graduated autonomy. Comparing nonacademic versus academic practice settings, significantly more nonacademic IR attending physicians expressed practice-building education (prevalence 72% versus 42%, frequency 2.2 versus 0.7, P < .01) as an important training experience. DISCUSSION: An understanding of perceived facilitating features for optimal IR trainee preparation, including potentially different needs between academic and nonacademic practices, can help programs prepare their trainees for a successful transition into practice.

A review of oral kallikrein inhibitor berotralstat for hereditary angioedema.

Orladeyo, a once-daily oral formulation of berotralstat (formerly BCX-7353), is a novel oral small-molecule drug developed by BioCryst Pharmaceuticals for the prevention of hereditary angioedema (HAE) attacks. It was first approved by the U.S. Food and Drug Administration (FDA) in 2020, and in 2021 also gained approval for marketing in Japan and the European Union. Preclinical and phase I studies showed promising efficacy and safety, and several multicenter international Angioedema Prophylaxis (APeX) phase II and III trials have since been initiated to further evaluate berotralstat. The ongoing phase III APeX-2 trial showed a 67% reduction in HAE attacks at the standard 150-mg dosing. Mild to moderate gastrointestinal side effects are most commonly seen and minimal serious adverse effects have been reported. Other first-line therapies for HAE prophylaxis rely on burdensome subcutaneous or intravenous routes. Thus far berotralstat has shown to be effective and well tolerated for HAE prophylaxis with the convenience of once-daily oral dosing.

Native cardiac magnetic resonance T1 mapping and cardiac mechanics as assessed by speckle tracking echocardiography in patients with beta-thalassaemia major.

BACKGROUND: We hypothesize that cardiac magnetic resonance (CMR) native T1 is associated with myocardial deformation in thalassaemia patients. The present study aimed to compare CMR native T1 values to conventional T2* values in patients with beta-thalassaemia and to explore relationships between these CMR parameters of myocardial iron overload and left ventricular (LV) and left atrial (LA) myocardial deformation. METHODS: Thirty-four (16 males) patients aged 35.5 ± 9.2 years were studied. Myocardial T2* and T1 mapping were performed to assess the cardiac iron overload, while two-dimensional speckle-tracking echocardiography was performed in determine LV and LA myocardial deformation. RESULTS: T2* was 36.4 ± 8.7 ms with 3 patients having myocardial iron load (T2*<20 ms). The native T1 was 947.1 ± 84.8 ms, which was significantly lower than the reported normal values in the literature. There was a significant correlation between T1 and T2* values (r = 0.68, p < 0.001). There were no significant correlations between T1 and T2* values and conventional and tissue Doppler parameters of left ventricular systolic and diastolic function. On the other hand, T1, but not T2*, values were found to correlate negatively with maximum LA area indexed by body surface area (r = -0.34, p = 0.047) and positively with LA strain rate at atrial contraction (r = 0.36, p = 0.04). There were no associations between either of these CMR parameters with indices of ventricular deformation. CONCLUSIONS: In patients with beta-thalassaemia major, native T1 values are decreased, associated with T2* values, and correlated with maximum LA area and LA strain rate at atrial contraction.

A Comprehensive Update of the Incidence and Demographics of Laryngoceles in Adults.

OBJECTIVE: To provide updated data on the incidence, types, and demographics of laryngoceles in the adult population. METHODS: We searched the medical archives of our institute for computed tomography (CT) studies acquired between January 1, 2007 and December 31, 2017 in which the term "laryngocele" appeared in the radiology reports. Two of the authors reviewed relevant images for the presence, type, distribution, and laterality of true laryngoceles. Demographic and clinical data were extracted from medical records and the incidence was calculated. RESULTS: Laryngoceles were detected in 53 out of the 79 893 patients with relevant CT data, which equates to an incidence of 151 per 2.5 million (0.06:1000) patients per year. The male:female ratio was 3:1, average age was 60 (±18) years, and incidence peaked among patients in the sixth decade of life. Nine patients (17%) had known laryngeal cancer; however, the majority of the cohort did not have follow up clinic visits. CONCLUSION: Our study demonstrates that the incidence of laryngoceles is much greater than previously reported. In most cases, the diagnosis of a laryngocele was an incidental radiological finding. Male gender predilection and age at presentation are in agreement with previous reports. Association of laryngoceles with laryngeal cancer could not be calculated due to low rates of follow ups. LEVEL OF EVIDENCE: 3.

Color Change of Intranasal Fluorescein Cannot Detect Cerebrospinal Fluid Leaks.

BACKGROUND: The color change of topical intranasal fluorescein has been used to confirm the presence of cerebrospinal fluid (CSF) during endoscopic endonasal surgery. We aimed to validate the use of topical intranasal fluorescein for CSF detection. METHODS: Blood, CSF, saliva, and normal saline were combined with decreasing fluorescein concentrations (from 10% to 0.1%). The solutions were photographed in high definition on nasal pledgets and in 1.5-mL Eppendorf tubes. The color difference (ΔE) was objectively measured via the International Commission on Illumination coordinates. Four otolaryngologists who were unaware of the study parameters also evaluated the samples for perceptible color differences. The human eye cannot detect color differences at an International Commission on Illumination ΔE of <5. RESULTS: All otolaryngologists agreed a color difference could be seen with blood across all fluorescein concentrations. However, a perceptible color difference between the experimental samples that excluded blood was not appreciable. Objectively, the ΔE was <5 on average for all nonblood samples when mixed with 5% and 10% fluorescein in the Eppendorf experiment. The ΔE for the nonblood samples was >5 for the remaining tested. Similarly, the average ΔE for the nonblood samples in the pledget experiment was >5 across all fluorescein concentrations. The blood ΔE was consistently >50 throughout all fluorescein concentrations in the Eppendorf experiment and >20 throughout the pledget experiment, correlating with the subjective ease of discernment between blood and the control sample in both groups. CONCLUSIONS: Color change alone is not sufficient to determine a difference between CSF, saliva, and saline. Blood, however, is readily identified using this method. Adjunct characteristics, in addition to the color change, are necessary to properly identify an active CSF leak.

Safety and Feasibility of Cryoablation during Immunotherapy in Patients with Metastatic Soft Tissue Sarcoma.

PURPOSE: Patients with metastatic soft tissue sarcoma (STS) undergo a wide array of treatments, including surgery, radiation, chemotherapy, immunotherapy, and ablative therapies, to control their disease. The combination of cryoablation and immunotherapy may lead to an enhanced antitumor immune response via the abscopal effect. It is hypothesized that the combination of cryoablation and immunotherapy in patients with metastatic STS is safe and feasible. MATERIALS AND METHODS: A single-center retrospective analysis was performed on patients with metastatic STS who underwent cryoablation. Sixteen patients were treated with 27 cryoablation procedures while receiving ipilimumab and nivolumab from April 2017 to July 2020. Response Evaluation Criteria in Solid Tumors, 1.1, were used to determine the outcomes of nontarget tumors. Progression-free survival (PFS) and overall survival (OS) were calculated from the date of the first cryoablation after initiating immunotherapy until progression or death. RESULTS: Thirty-four tumors were cryoablated, 23 of which were intentionally subtotal. The most common tumor subtype was liposarcoma (n = 4). Thirteen (81%) patients had previously demonstrated disease progression on multiple lines of chemotherapy. All tumors cryoablated with a complete intention demonstrated a complete response. Seven patients had a clinical benefit, including 1 with a complete response, 1 with a partial response, and 5 with stable disease. The median OS was 14.1 months, with a median PFS of 2.3 months (95% confidence interval, 1.8-14.3). Five patients had pneumothoraces after cryoablation, 2 of whom required chest tube placement. Eleven patients experienced adverse events related to immunotherapy, 10 of whom experienced grade 1 or 2. CONCLUSIONS: Cryoablation in patients with metastatic STS undergoing immunotherapy is feasible and safe.

Thyroid Dysfunction in Ménière's Disease: A Comprehensive Review.

INTRODUCTION: The precise etiology of Ménière's disease (MD) remains unknown; however, given the association of MD with serum antibodies and human leukocyte antigen (HLA) complex, several studies have proposed a relationship between MD and thyroid disorders. Similarly, multiple hypotheses exist regarding the metabolic disturbances of fluctuating thyroid hormone as a potential contributing agent in the development of MD. METHODS: A total of 171 abstracts were identified and screened by 2 independent reviewers. Based on inclusion and exclusion criteria, 8 studies were selected for final analysis. Due to heterogeneity of clinical data, meta-analysis was not feasible. RESULTS: The prevalence of autoimmune thyroid disease and hypothyroidism in MD varied significantly from 1 to 38%. Notable bias was introduced given the lack of standardization of diagnostic criteria across studies. Articles that described autoimmune thyroid-specific antibodies and HLA types also presented inconclusive results. Multiple studies noted a potential etiologic role of hypothyroidism in MD, which was often confounded by thyroxine supplementation. CONCLUSIONS: Despite a potential correlation in the medical literature between thyroid disorders and MD, there is currently no definitive causal relationship. Although most of the present medical literature focuses on autoimmunity, dysregulated thyroid hormone levels may also be implicated in the association of MD with thyroid disorders.

Long-Term Remission with Ipilimumab/Nivolumab in Two Patients with Different Soft Tissue Sarcoma Subtypes and No PD-L1 Expression.

Checkpoint inhibitor therapy has been shown to improve outcomes in multiple solid malignancies; however, data are limited in soft tissue sarcoma. We present two cases of patients with advanced soft tissue sarcoma of different subtypes (dedifferentiated liposarcoma and myxofibrosarcoma) with zero percent PD-L1 expression by immunohistochemistry who were treated with ipilimumab and nivolumab followed by maintenance nivolumab. Both patients had failed multiple lines of systemic treatment and experienced long-term remission after starting ipilimumab and nivolumab. Genetic testing revealed that no genetic mutations were found in common between the two cases. One patient received concurrent cryoablation, which may have sensitized his tumor to immunotherapy. Checkpoint inhibitor therapy may improve outcomes in soft tissue sarcoma regardless of PD-L1 status, especially when combined with cryoablation. Studies are needed to evaluate whether treatment response varies by sarcoma subtype and what molecular markers can be used to guide patient selection.

Needs of Referring Providers by Practice Type: Results of a Survey at an Academic Medical Center.

OBJECTIVE. The purpose of this study was to test a published hypothetic framework of different referring provider needs for primary care, specialty care, and urgent or emergency care practitioners through questions asked in an annual survey at an academic medical center. MATERIALS AND METHODS. Seven questions regarding provider needs were included in an annual online anonymous survey of referring providers. Multiple-choice response options were provided. Differences in responses between provider types were assessed using the Mann-Whitney U test. RESULTS. The survey was sent to 3325 providers, and 514 responses were received (response rate, 15.5%). The analysis included 340 responses: 81 from primary care, 205 from specialty care, and 54 from urgent or emergency care. Results indicated that urgent or emergency care providers need examinations to be performed and interpreted more quickly, specialist providers prefer greater radiologist specialization, urgent or emergency care providers order imaging with greater frequency, primary care and urgent or emergency care providers order a greater breadth of imaging, primary care providers report greater reliance on radiologist interpretations, and all provider types highly value direct interactions with radiologists. All results were statistically significant and matched established hypotheses. CONCLUSION. Our results support the concept that referring providers tend to value different aspects of radiology services differently, according to predictable characteristics. The findings suggest that the concept of value in radiology is highly context-specific and can be evaluated, at least in part, using practice-specific referring provider assessments.

Spontaneous Bleeding From Multiple Intercostal Arteries in a Patient With Coarctation of the Aorta.

A 59-year-old man with a history of coarctation repair, mechanical aortic valve, and warfarin therapy presented with right flank pain. Computed tomography showed a large hematoma encircling an intact descending thoracic aorta. Computed tomography angiography demonstrated multiple areas of intercostal artery extravasation. An interventional radiologist performed angiography and embolization. The patient's course was complicated by an effusion and hypoxia, but no further bleeding was noted. We hypothesize that coarctation associated aneurysms and potential vessel wall weakness are the causes of hematoma in our case. We present this case with history of repaired coarctation with multiple spontaneous intercostal artery aneurysmal rupture.

Oral plasma kallikrein inhibitor BCX7353 for treatment of hereditary angioedema.

Hereditary angioedema (HAE) is rare disorder caused by a SERPING1 gene mutation that triggers severe swelling of the skin and upper airway. Treatment options for HAE with deficient and dysfunctional C1-inhibitor are expanding to include small-molecule drugs that inhibit protein interactions in the kallikrein-kinin system. Discovered by BioCryst Pharmaceuticals, BCX7353 is a synthetic, once-daily, small molecule drug that can be taken as an oral capsule to treat HAE attacks and for prophylaxis. This article will summarize recent and current BCX7353 clinical trials. Overall, results indicate BCX7353 is a promising form of therapy with a rapid 1 h onset of action, long duration of action, and acceptable tolerance.