Sparse 3D contrast-enhanced whole-heart imaging for coronary artery evaluation

Background We investigated the feasibility of evaluating coronary arteries with a contrast-enhanced (CE) self-navigated sparse isotropic 3D whole heart T1-weighted magnetic resonance imaging (MRI) study sequence. Methods A total of 22 consecutive patients underwent coronary angiography and/or cardiac computed tomography (CT) including cardiac MRI. The image quality was evaluated on a 3-point Likert scale. Inter-reader variability for image quality was analyzed with Cohen’s kappa for the main coronary segments (left circumflex [LCX], left anterior descending [LAD], right coronary artery [RCA]) and the left main trunk (LMT). Results Inter-reader agreement for image quality of the coronary tree ranged from substantial to perfect, with a Cohen’s kappa of 0.722 (RCAmid) to 1 (LCXprox). The LMT had the best image quality. Image quality of the proximal vessel segments differed significantly from the mid- and distal segments (RCAprox vs. RCAdist, p < 0.05). The LCX segments showed no significant difference in image quality along the vessel length (LCXprox vs. LCXdist, p = n.s.). The mean acquisition time for the study sequence was 553 s (±46 s). Conclusion Coronary imaging with a sparse 3D whole-heart sequence is feasible in a reasonable amount of time producing good-quality imaging. Image quality was poorer in distal coronary segments and along the entire course of the LCX.

Radiologists Detect A Higher Frequency of Incidental Findings On Radiotherapy-Planning CT Scans of Breast Cancer Patients Than Oncologist

Purpose: Breast cancer patients scheduled for postoperative radiotherapy undergo radiotherapy-planning computed tomography (CT), and incidental findings (IFs) may appear. This study investigated the interobserver variability between radiologists and oncologists when assessing IFs on radiotherapy-planning CT scans in breast cancer patients prior to adjuvant radiotherapy. Methods: We included 383 breast cancer patients who underwent planning CT at the Aalborg University Hospital between February 1, 2017 and February 28, 2018. IFs noted by the oncologists were identified from medical records. Two specialized radiologists reviewed the scans and described their IFs. IFs were classified as benign or potential malignant lesions. Cohen’s kappa statistic was used to measure interobserver agreement.Results: A total of 513 IFs were registered. The radiologists registered 433 findings, and the oncologists noted 80 (1.1 and 0.2 IFs per patient, respectively). Most potential malignant IFs were found in the liver, lungs, bones, and lymph nodes. The radiologists and oncologists detected potential malignant lesions in 94 (25%) and 34 (9%) patients, respectively. The oncologists’ sensitivity for detecting IFs in the liver and lungs were 29% and 20%, respectively. The agreements on IFs in the liver and lungs were fair (Cohen’s kappa values of 0.33 and 0.28, respectively).Conclusion: Radiologists reported a significantly higher frequency of IFs and potential malignant lesions than oncologists. Additionally, the oncologists had a low sensitivity when reporting IFs in both the liver and lungs. These results emphasize the need for specialized radiologists to scrutinize planning CT scans of breast cancer patients to ensure the intention to treat.

Development of an Abstraction Tool to Assess Palliative Care Components

Background: Little is known regarding the fidelity of delivery of guideline-recommended components of palliative care in “real world” encounters. Objective: To develop a qualitative coding framework to identify components of clinical palliative care in clinical documentation across care settings. Design: Retrospective review of palliative care clinical documentation from medical providers, with directed qualitative content analysis to identify components of clinical care documented. Setting/Subjects: Purposively sampled deceased patients seen by palliative care at a US academic medical center between 7/1/2011–7/1/2018. Main Outcomes and Measures: The outcome of this work is a coding framework for use in future research. We assessed the robustness of the framework using Cohen’s kappa. Results: We reviewed sixty-two encounters from twenty-six patients. We identified 7 major themes in documentation: (1) addressing physical symptoms, (2) addressing psychological symptoms, (3) establishing illness understanding, (4) supporting decision making, (5) end-of-life planning, (6) understanding psychosocial context, and (7) care coordination. Interrater reliability varied widely between components, with Cohen’s kappa ranging from −.51 to 1. Conclusions: This pilot study provides a coding framework to measure documentation of clinical palliative care components. Several components could not be reliably identified using this framework, suggesting the need for additional measurement strategies.

Adherence to Antiseizure vs Other Medications Among US Medicare Beneficiaries With and Without Epilepsy

Objective:To 1) compare adherence to antiseizure medications (ASMs) versus non-ASMs among individuals with epilepsy, 2) assess the degree to which variation in adherence is due to differences between individuals versus between medication classes among individuals with epilepsy, and 3) compare adherence in individuals with versus without epilepsy.Methods:This was a retrospective cohort study using Medicare. We included beneficiaries with epilepsy (≥1 ASM, plus International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes), and a 20% random sample without epilepsy. Adherence for each medication class was measured by the proportion of days covered (PDC) in 2013-2015. We used Spearman correlation coefficients, Cohen’s kappa statistics, and multilevel logistic regressions.Results:There were 83,819 beneficiaries with epilepsy. Spearman correlation coefficients between ASM PDCs and each of the 5 non-ASM PDCs ranged 0.44-0.50, Cohen’s kappa ranged 0.33-0.38, and within-person differences between each ASM’s PDC minus each non-ASM’s PDC were all statistically significant (p<0.01) though median differences were all very close to 0. Fifty-four percent of variation in adherence across medications was due to differences between individuals. Adjusted predicted probabilities of adherence were: ASMs 74% (95% confidence interval [CI] 73%-74%), proton pump inhibitors 74% (95% CI 74%-74%), antihypertensives 77% (95% CI 77%-78%), selective serotonin reuptake inhibitors 77% (95% CI 77%-78%), statins 78% (95% CI 78%-79%), and levothyroxine 82% (95% CI 81%-82%). Adjusted predicted probabilities of adherence to non-ASMs were 80% (95% CI 80%-81%) for beneficiaries with epilepsy versus 77% (77%-77%) for beneficiaries without epilepsy.Conclusion:Among individuals with epilepsy, ASM and non-ASM adherence were moderately correlated, half of variation in adherence was due to between-person rather than between-medication differences, adjusted adherence was slightly lower for ASMs than several non-ASMs, and epilepsy was associated with a quite small increase in adherence to non-ASMs. Nonadherence to ASMs may provide an important cue to the clinician to inquire about adherence to other potentially life-prolonging medications as well. Although efforts should focus on improving ASM adherence, patient-level rather than purely medication-specific behaviors are also critical to consider when developing interventions to optimize adherence.

Development and Psychometric Testing of Coding Scheme for Dementia Family Communication Using Video Observation

Understanding communication behaviors between persons living with dementia and family caregivers is essential for meaningful social interaction and decrease problematic behaviors and caregiving burden. The purpose of this study was to develop and test the psychometric properties of a coding scheme for dementia care interactions. The coding scheme items were developed from literature and expert review, and the pilot testing on 16 video-recorded interactions. A secondary analysis was conducted using 77 videos from 21 dyads of dementia family interactions naturally occurred in the participant’s home. The final coding scheme consists of 11 codes for persons living with dementia (6 nonverbal and 5 verbal) and 12 codes for family caregivers (7 nonverbal and 5 verbal). Content validity was excellent (I-CVI = .93, S-CVI/UA = .71, S-CVI/Ave = .93 with 6 experts). Inter-item correlation was acceptable for both caregiver codes (positive nonverbal = .21, positive verbal = .15, negative nonverbal = .36, negative verbal = .29), and patient codes (positive nonverbal = .13, positive verbal = .27, negative nonverbal = .15, negative verbal = .18). Intra-rater reliability (Cohen’s Kappa = .83, percentage of agreement = 83.88%) and inter-rater reliability (Cohen’s Kappa = .81, percentage of agreement = 81.75%) were excellent. Findings suggest the preliminary psychometric properties of the newly developed coding scheme to assess dyadic interactions of persons living with dementia and their informal caregiver in-home care situations. Future testing of the coding scheme for application in communication interventions to improve quality social interaction in dementia care is discussed.

The diagnostic accuracy of MRI in determining the relations between paraclinoid aneurysms and the cavernous sinus

Purpose The location of paraclinoid aneurysms is determinant for evaluation of its intradural compartment and risk of SAH after rupture. Advanced MRI techniques have provided clear visualization of the distal dural ring (DDR) to determine whether an aneurysm is intracavernous, transitional or intradural for decision-making. We analyzed the diagnostic accuracy of MRI in predicting whether a paraclinoid aneurysm is intracavernous, transitional or intradural. Methods We conducted a prospective cohort between January 2014 and December 2018. Patients with paraclinoid aneurysms underwent 3D fast spin-echo MRI sequence before surgical treatment. The DDR was the landmark for MRI characterization of the aneurysms as follow: (i) Intradural; (ii) Transitional; and (iii) Intracavernous. The MRI sensitivity, specificity, positive and negative likelihood ratios were determined compared to the intraoperative findings. We also evaluated the intertechnique agreement using the Cohen’s kappa coefficient (κ) for dichotomous classifications (cavernous vs non-cavernous). Results Twenty patients were included in the cohort. The accuracy of MRI showed a sensitivity of 86.7% (95%CI:59.5–98.3) and specificity of 90.0% (95%CI:55.5–99.8). Analyzing only patients without history of SAH, accuracy test improved with a sensitivity of 92.3% (95%CI:63.9–99.8) and specificity reached 100% (95%CI: 63–100). Values of Cohen’s kappa (κ), intertechnique agreement was considered substantial for dichotomous classifications (κ = 0.754; p < 0.001). For patients without previous SAH, intertechnique agreement was even more coincident for the dichotomous classification (κ = 0.901; p < 0.001). Conclusion 3D fast spin-echo MRI sequence is a reliable and useful technique for determining the location of paraclinoid aneurysms in relation to the cavernous sinus, particularly for patients with no history of SAH.

Ultra-short Echo Time MR Imaging in Assessing Cartilage Endplate Damage And Association Between Its Lesion and Disc Degeneration For Chronic Low Back Pain Patients

Objective: To investigate the feasibility of ultra-short echo time (UTE) MRI in assessing cartilage endplate (CEP) damage and evaluating the relationship between total endplate score (TEPS) and lumbar intervertebral disc (IVD) degeneration.Materials and methods: 35 patients were measured for IVD using UTE imaging at 3T MR. Subtracted UTE images between short and long TEs were obtained to depict anatomy of CEP. The SNR and CNR were calculated to assess the image quality. A new grading criterion for endplate evaluation was developed based on Rajasekarank.S grading in this study. Two radiologists were employed to evaluate CEP and bony vertebral endplates (VEP) using new grading criterion and assess TEPS, independently. Cohen's kappa analysis was applied to evaluate the inter-observer agreement of endplate damage assessment between two radiologists, and the Kendall's TAU-B analysis was employed to determine the relationship between TEPS and IVD degeneration evaluated with Pfirrmann grading.Results: Well structural CEP was depicted on subtracted UTE images and confirmed by high SNR (33.0±2.92) and CNR values (9.4±2.08). Qualified subtracted UTE images were used by two radiologists to evaluate CEP and VEP damage. Excellent inter-observer agreement was confirmed by high value in Cohen's kappa test (0.839,P<0.001). Ensured by this, 138 endplates from 69 IVDs of 35 patients were classified into six grades based on the new grading criterion and TEPS of each endplate was calculated. In addition, the degeneration degree of IVDs were classified into five grades. Finally, using Kendall's TAU-B analysis, significant relationship was obtained between endplate damage related TEPS and IVD degeneration (r= 0.864,P<0.001).Conclusion: Ensured by high image quality, UTE imaging might be considered an effective tool to assess CEP damage. Additionally, further calculated TEPS has shown strong positive association with IVD degeneration, suggesting that the severity of endplate damage is highly linked with the degree of IVD degeneration.

Comparison of Forceps, Cryoprobe, and Thoracoscopic Lung Biopsy for the Diagnosis of Interstitial Lung Disease − The CHILL Study

Rationale: Transbronchial lung cryobiopsy (TBLC) has emerged as a less invasive method to obtain a tissue diagnosis in patients with interstitial lung disease (ILD). The diagnostic yield of TBLC compared to surgical lung biopsy (SLB) remains uncertain. Objectives: The aim of this study was to determine the diagnostic accuracy of forceps transbronchial lung biopsy (TBLB) and TBLC compared to SLB when making the final diagnosis based on multidisciplinary discussion (MDD). Methods: Patients enrolled in the study underwent sequential TBLB and TBLC followed immediately by SLB. De-identified cases, with blinding of the biopsy method, were reviewed by a blinded pathologist and then discussed at a multidisciplinary conference. Main Results: Between August 2013 and October 2017, we enrolled 16 patients. The raw agreement between TBLC and SLB for the MDD final diagnosis was 68.75% with a Cohen’s kappa of 0.6 (95% CI 0.39, 0.81). Raw agreement and Cohen’s kappa of TBLB versus TBLC and TBLB versus SLB for the MDD final diagnosis were much lower (50%, 0.21 [95% CI 0, 0.42] and 18.75%, 0.08 [95% CI −0.03, 0.19], respectively). TBLC was associated with mild bleeding (grade 1 bleeding requiring suction to clear) in 56.2% of patients. Conclusions: In patients with ILD who have an uncertain type based on clinical and radiographic data and require tissue sampling to obtain a specific diagnosis, TBLC showed moderate correlation with SLB when making the diagnosis with MDD guidance. TBLB showed poor concordance with both TBLC and SLB MDD diagnoses.

Evaluation of paper-based and web-based food frequency questionnaires for 7-year-old children in Singapore

Advances in technology enabled the development of a web-based, pictorial food frequency questionnaire (FFQ) to collect parent-report dietary intakes of 7-year-old children in the GUSTO study. This study aimed to compare intakes estimated from a paper-FFQ and a web-FFQ, and examine the relative validity of both FFQs against 3-day diet records (3DDR). Ninety-two mothers reported food intakes of their 7-year-old child on a paper-FFQ, a web-FFQ and a 3DDR. A usability questionnaire collected participants’ feedback on the web-FFQ. Correlations and agreement in energy, nutrients and food groups intakes between the dietary assessments were evaluated using Pearson’s correlation, Lin’s concordance, Bland-Altman plots, Cohen’s kappa and tertile classification. The paper- and web-FFQ had good correlations (≥0.50) and acceptable-good agreement (Lin’s concordance ≥0.30; Cohen’s kappa ≥0.41; ≥50% correct and ≤10% mis-classification into same or extreme tertiles). Compared to 3DDR, both FFQs showed poor agreement (<0.30) in assessing absolute intakes except micronutrients (web-FFQ had acceptable-good agreement); but showed acceptable-good ability to classify children into tertiles (κ≥0.21; ≥40% and ≤15% correct or misclassification). Bland-Altman plots suggest good agreement between web-FFQ and 3DDR in assessing micronutrients and several food groups. The web-FFQ was well-received (e.g. >89% found it user-friendly), and majority (81%) preferred the web-FFQ over the paper-FFQ. The newly developed web-FFQ produced intake estimates comparable to the paper-FFQ, has acceptable-good agreement with 3DDR in assessing absolute micronutrients intakes, and acceptable-good ability to classify children according to categories of intakes. The positive acceptance of the web-FFQ makes it a feasible tool for future dietary data collection.

Comparative Analysis of BIOCHIP Mosaic-Based Indirect Immunofluorescence with Enzyme-Linked Immunosorbent Assay for Diagnosing Myasthenia Gravis

Background: The detection of anti-acetylcholine receptor (AChR) and anti-muscle-specific tyrosine kinase (MuSK) antibodies is useful in myasthenia gravis (MG) diagnosis and management. BIOCHIP mosaic-based indirect immunofluorescence is a novel analytical method, which employs the simultaneous detection of anti-AChR and anti-MuSK antibodies in a single miniature incubation field. In this study, we compare, for the first time, the BIOCHIP MG mosaic with conventional enzyme-linked immunosorbent assay (ELISA) in the diagnosis of MG. Methods: A total of 71 patients with MG diagnosis were included in the study. Anti-AChR and anti-MuSK antibodies were measured separately by two different ELISA and simultaneously by BIOCHIP. The results were then compared. Results: The overall concordance between ELISA and BIOCHIP for anti-AChR reactivity was 74%. Cohen’s kappa was 0.51 (95% CI 0.32–0.71), which corresponds to 90% of the maximum possible kappa (0.57), given the observed marginal frequencies. The overall concordance for anti-MuSK reactivity was 84%. Cohen’s kappa was 0.11 (95% CI 0.00–0.36), which corresponds to 41% of the maximum possible kappa (0.27). Conclusion: The overall concordance among assays is not optimal.