Assistance from Automated ASPECTS Software Improves Reader Performance.

PURPOSE: To compare physicians' ability to read Alberta Stroke Program Early CT Score (ASPECTS) in patients with a large vessel occlusion within 6 hours of symptom onset when assisted by a machine learning-based automatic software tool, compared with their unassisted score. MATERIALS AND METHODS: 50 baseline CT scans selected from two prior studies (CRISP and GAMES-RP) were read by 3 experienced neuroradiologists who were provided access to a follow-up MRI. The average ASPECT score of these reads was used as the reference standard. Two additional neuroradiologists and 6 non-neuroradiologist readers then read the scans both with and without assistance from the software reader-augmentation program and reader improvement was determined. The primary hypothesis was that the agreement between typical readers and the consensus of 3 expert neuroradiologists would be improved with software augmented vs. unassisted reads. Agreement was based on the percentage of the individual ASPECT regions (50 cases, 10 regions each; N=500) where agreement was achieved. RESULTS: Typical non-neuroradiologist readers agreed with the expert consensus read in 72% of the 500 ASPECTS regions, evaluated without software assistance. The automated software alone agreed in 77%. When the typical readers read the scan in conjunction with the software, agreement improved to 78% (P<0.0001, test of proportions). The software program alone achieved correlations for total ASPECT scores that were similar to the expert readers who had access to the follow-up MRI scan to help enhance the quality of their reads. CONCLUSION: Typical readers had statistically significant improvement in their scoring of scans when the scan was read in conjunction with the automated software, achieving agreement rates that were comparable to neuroradiologists.

Radiation therapy and PD-1/PD-L1 blockade: the clinical development of an evolving anticancer combination.

Several inhibitors of programmed cell death-1 (PD-1) and programmed death ligand-1 (PD-L1) have been approved as a form of immunotherapy for multiple cancers. Ionizing radiation therapy (RT) has been shown to enhance the priming and effector phases of the antitumor T-cell response rendering it an attractive therapy to combine with PD-1/PD-L1 inhibitors. Preclinical data support the rational combination of the 2 modalities and has paved way for the clinical development of the combination across a spectrum of cancers. In this review, we highlight the preclinical and clinical development of combined RT and PD-1/PD-L1 blockade to date. In addition to a comprehensive evaluation of available safety and efficacy data, we discuss important points of consideration in clinical trial design for this promising combination.

Radiologists Are Actually Well Positioned to Innovate in Patient Experience.

Patient experience is becoming increasingly prioritized, most notably as a component of recently passed health care legislation that aims to link physician reimbursement to quality of care and cost-effectiveness. For several reasons, radiologists are better positioned to seize opportunities to enhance patient experience than is readily apparent. We propose that discrete components along the imaging value chain can be evaluated specifically for their effect on patient experience and improved to this end. We also emphasize that the field of radiology has traditionally been the earliest adopter and a serial innovator in health information technology, and we suggest possible ways to leverage the newest technological tools to improve patient experience. Finally, we discuss how carefully vetted opportunities for direct patient interaction might expand the reach of diagnostic radiologists as members of integrated health systems. We believe that emerging patient experience metrics present unconventional opportunities for radiologists to make imaging even more meaningful for the many patients who entrust us with their care. SIX SUMMARY POINTS.

Improving Access to Image-guided Procedures at an Integrated Rural Critical Access Hospital: Ultrasound-guided Thyroid Biopsy Program.

PURPOSE: Critical access hospitals face difficulty providing all services locally and may need to refer patients off-site for additional care. Providing on-site minimally invasive biopsies, may obviate visits to tertiary or quaternary care centers. This study aims to assess feasibility and outcomes of an ultrasound-guided thyroid biopsy program in a critical access hospital. METHODS: In this HIPAA compliant, IRB approved study, the Interventional Radiology (IR) database of a 19-bed, island, rural, critical access hospital without onsite pathology services affiliated with our quaternary care institution was retrospectively reviewed to identify all thyroid biopsies that were performed on site since inception of the service in April 2014 through August 2016. A specialized biopsy and specimen collection protocol was created as each specimen was transferred to and analyzed by the pathology department at our affiliated quaternary care institution. RESULTS: Two IR physicians carried out thyroid biopsies on 34 nodules in 29 patients during the study period. The mean age of patients was 56.5 ± 14.0, with a range of 35-85 and 86% female, 14% male. 94.1% of nodules had adequate material for interpretation on the first biopsy and 97.1% upon repeat biopsy. Ultimately, 5 patients (with 6 nodules) underwent surgical resection at the integrated quaternary care center. Surgical resection identified one atypical follicular adenoma, one follicular variant of papillary thyroid carcinoma, two papillary carcinomas, and two Hürthle cell tumors. CONCLUSION: IR thyroid biopsy services may be successfully provided in the rural setting without onsite pathology analysis and adequacy checks, enhancing patient access and streamlining care while also expanding the reach of tertiary care centers.

Left Colonic Bleeding Secondary to Inferior Mesenteric Vein Stenosis.

Lower gastrointestinal bleeding is most commonly associated with diverticulosis, ischemic colitis, vascular ectasia, and anorectal disease and less commonly associated with colonic malignancy. Infrequently, it is associated with mesenteric varices, a rare etiology that is not well documented in the radiology literature. We present a case of a 50-year-old man diagnosed as having intermittent left colonic bleeding from mesenteric varices due to a critical stenosis at the portal vein-inferior mesenteric vein confluence. This case illustrates a multimodality imaging approach to arrive at the diagnosis with a brief discussion of an atypical endovascular intervention. At the conclusion, we suspect that venous stenting may be suboptimal in treating mesenteric variceal bleeding and recurrence is likely unavoidable.

MR angiography can guide ED management of suspected acute aortic dissection.

BACKGROUND: Aortic dissection is typically evaluated with computed tomography angiography (CTA). However, the feasibility of using magnetic resonance angiography (MRA) in the ED is unclear. This study examined the indications and outcomes of MRA in suspected aortic dissection evaluation in the ED. METHODS: An IRB approved review identified patients who underwent MRA in the ED for acute thoracic aortic dissection from January 2010 to June 2016. Demographics, clinical assessment, CTA contraindications, outcomes, and ED disposition were analyzed. RESULTS: 50 MRAs were ordered for suspected thoracic aortic dissection. 21 (42%) for iodinated contrast allergy, 21 (42%) for renal insufficiency, 2 (4%) due to both, 2 (4%) to spare ionizing radiation, 2 (4%) for further work-up after CTA, and 2 (4%) due to prior contrast enhanced CT within 24h. Median ED arrival to MRA completion time was 311min. 42 studies were fully diagnostic; 7 were limited. One patient could not tolerate the examination. 49 MRAs were completed: 2 (4%) patients had acute dissection on MRA and 47 (96%) had negative exams. 17 (35%) received gadolinium. 18 (37%) patients were discharged home from the ED with a median length of stay of 643min. 2 (4%) were admitted for acute dissection seen on MRA and 29 (59%) for further evaluation. CONCLUSION: MRA has a clear role in the evaluation for acute thoracic aortic dissection in the ED in patients with contraindications to CTA, and can guide management and facilitate safe discharge to home.

Incidental findings and recommendations are common on ED CT angiography to evaluate for aortic dissection.

PURPOSE: The aim of this study was to assess the outcomes, incidental findings, recommendations, and adherence to recommendations on computed tomography angiography (CTA) studies obtained in the emergency department (ED) to evaluate for aortic dissection. METHODS: The institutional database of ED patients was retrospectively reviewed to identify CTA examinations for dissection during 2014. The radiology report and electronic medical records were reviewed to assess outcomes, radiology report incidental findings, and recommendations, as well as adherence to these recommendations. RESULTS: There were 370 dissection CTAs performed during the 12-month study period. The average age of the patients was 63 years (range, 15-97 years). Eighty-seven patients (23.5%) had clinically significant aortic pathology including 46 patients (12.4%) with dissection and 19 (5.1%) which were new. Three hundred twenty-nine (88.9%) of patients had at least 1 incidental finding. One hundred six (28.6%) of patients had recommendations on the radiology report, and 44.3% of these were for pulmonary nodules. Thirty recommendations (28.3%) were acted upon, most commonly related to pulmonary nodule. CONCLUSION: Computed tomography angiography is useful in detecting aortic pathology. However, emergency physicians should be aware of the potential for clinically significant incidental findings and recommendations. Adherence to recommendations was limited, and future research could investigate mechanisms to improve compliance.