Retrospective Review of Fluoroscopic Swallowing Studies and Outcomes at an Academic Health Center

Introduction: Aspiration is often associated with underlying medical conditions and can cause pneumonia or death. Aspiration risk can be assessed via video fluoroscopic swallowing study (VFSS) or barium swallow (BaSw). We aimed to assess the diagnoses and clinical course of patients who were evaluated for potential aspiration through VFSS or BaSw to determine if there is a degree of aspiration that increases the risk of developing pneumonia and/or death. Methods: We conducted a retrospective chart review of 374 patients in TJUH who were evaluated via VFSS or BaSw from January 1 to June 30, 2017. We recorded the degree and contents of aspiration, the underlying diagnoses, and evidence of subsequent pneumonia. We then collected data for any future admissions concerning for pneumonia. Results: Of the 374 patients, 165 had swallowing studies positive for laryngeal penetration or aspiration. Of the 165 patients, 78 patients (47.2%) had evidence of clinical and radiological pneumonia, and 18 of those 78 patients (23.1%) died. We found that 61 of 165 exhibited laryngeal penetration. Of those 61, 23 patients (37.7%) showed clinical and radiological signs of pneumonia, and 7 of the 23 (30.4%) died of aspiration pneumonia. Discussion: The incidence of pneumonia was considerable in persons with an abnormal swallow and the mortality rate was substantial. Minimally abnormal swallows with laryngeal penetration, but no true aspiration, still had serious consequences. While the incidence of pneumonia was lower (37.7%), there was a substanitial mortality rate (30.4%)

Adaptive Statistical Iterative Reconstruction-V for Lung Nodule Analysis

Introduction: Low-dose CT in lung cancer screening has demonstrated benefits in select patients. As the traditional filtered back projection (FBP) technique is limited by poor image quality, adaptive statistical iterative reconstruction-V (ASIR-V) algorithm has been developed to achieve higher image quality with processing efficiency. Objective: To investigate the impact of various CT scan parameters on the semi-automated measurement of lung nodules using a Computer Aided Detection (CAD) program. Methods: This IRB-exempt phantom experiment was conducted with a CT scanner capable of ASIR-V algorithm. Eight lung nodules sized 5-12 mm, of solid or ground glass type, were placed inside a multipurpose chest phantom with or without fat slabs. Voltage (kV), current (mA), and ASIR-V levels were varied, and series of CT images were produced. A CAD program semiautomatically analyzed the series and produced nodule diameters and volumes. Nodule measurement variance and the significance of variables were analyzed by one-way ANOVA and univariate regression. Results: Nodule diameter and type contributed to error in both diameter and volume measurements. Current also impacted diameter measurement error. ASIR-V, kV, and fat slabs did not contribute to nodule measurement systematic error. On regression analysis, error is negatively related to mA and solid nodules, but is positively related to nodule diameter or volume. Discussion: These results reinforce that nodule size, type, and mA have the highest influence on CAD software performance nodule quantification accuracy. ASIR-V and kV do not significantly alter the measurement error but, instead, maintain the accuracy of nodule evaluation while minimizing radiation dose

Artificial Neural Networks for the prediction Thermo Physical Properties of Liquid Mixtures

A predictive method based on Artificial networks has been developed for the thermophysical properties of binary liquid mixtures at (303.15, 313.15 and 323.15) K. In method 1, a committee ANN was trained using 5 physical properties combined with absolute temperature as its input to predict thermo physical properties of liquid mixtures. Using these data, predicted values were determined for intermediate mole fraction of different systems without conducting experiments. In method 2, a committee ANN was trained using mole fraction and molecular weight as its input to predict the thermo physical properties of liquid mixtures. The five physical properties of five binary mixtures were taken for this study along with their molecular weights. ANN with back-propagation algorithm is proposed, for Multi-pass Turning Operation and developed in MATLAB. Compared to other prediction techniques, the proposed ANN approach is highly accurate and error is <1%

Reference absolute and indexed values for left and right ventricular volume, function and mass from cardiac computed tomography

Introduction Left ventricular ( LV ) and right ventricular ( RV ) volumetric and functional parameters are important biomarkers for morbidity and mortality in patients with heart failure. Purpose To retrospectively determine reference mean values of LV and RV volume, function and mass normalised by age, gender and body surface area ( BSA ) from retrospectively electrocardiographically gated 64‐slice cardiac computed tomography ( CCT ) by using automated analysis software in healthy adults. Materials and Methods The study was approved by the institutional review board with a waiver of informed consent. Seventy‐four healthy subjects (49% female, mean age 49.6 ± 11) free of hypertension and hypercholesterolaemia with a normal CCT formed the study population. Analyses of LV and RV volume (end‐diastolic, end‐systolic and stroke volumes), function (ejection fraction), LV mass and inter‐rater reproducibility were performed with commercially available analysis software capable of automated contour detection. General linear model analysis was performed to assess statistical significance by age group after adjustment for gender and BSA . Bland–Altman analysis assessed the inter‐rater agreement. Results The reference range for LV and RV volume, function, and LV mass was normalised to age, gender and BSA . Statistically significant differences were noted between genders in both LV mass and RV volume ( P ‐value < 0.0001). Age, in concert with gender, was associated with significant differences in RV end‐diastolic volume and LV ejection fraction ( P ‐values 0.027 and 0.03). Bland–Altman analysis showed acceptable limits of agreement (±1.5% for ejection fraction) without systematic error. Conclusion LV and RV volume, function and mass normalised to age, gender and BSA can be reported from CCT datasets, providing additional information important for patient management.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109344/1/jmiro12186.pd

Predictors and Characteristics of Rib Fracture Following SBRT for Lung Tumors

Background: The utilization of stereotactic body radiation therapy (SBRT) is increasing for primary and secondary lung neoplasms. Despite encouraging results, SBRT is associated with an increased risk of osteoradionecrosis-induced rib fracture. We aimed to (1) evaluate potential clinical, demographic, and procedure-related risk factors for rib fractures and (2) describe the radiographic features of post-SBRT rib fractures. Methods: We retrospectively identified 106 patients who received SBRT between 2015 and 2018 for a primary or metastatic lung tumor with at least 12 months of follow up. Exclusion criteria were incomplete records, previous ipsilateral thoracic radiation, or relevant prior trauma. Computed tomography (CT) images were reviewed to identify and characterize rib fractures. Multivariate logistic regression modeling was employed to determine clinical, demographic, and procedural risk factors (e.g., age, sex, race, medical comorbidities, dosage, and tumor location). Results: A total of 106 patients with 111 treated tumors met the inclusion criteria, 35 (32%) of whom developed at least one fractured rib (60 total fractured ribs). The highest number of fractured ribs per patient was five. Multivariate regression identified posterolateral tumor location as the only independent risk factor for rib fracture. On CT, fractures showed discontinuity between healing edges in 77% of affected patients. Conclusions: Nearly one third of patients receiving SBRT for lung tumors experienced rib fractures, 34% of whom experienced pain. Many patients developed multiple fractures. Post-SBRT fractures demonstrated a unique discontinuity between the healing edges of the rib, a distinct feature of post-SBRT rib fractures. The only independent predictor of rib fracture was tumor location along the posterolateral chest wall. Given its increasing frequency of use, describing the risk profile of SBRT is vital to ensure patient safety and adequately inform patient expectations

Outpatient facility-based order variation in combined imaging.

OBJECTIVE: Combined computed tomography (CT) occurs when one anatomical area is simultaneously imaged both without and with contrast, or two overlapping anatomical areas are imaged concurrently. While this has been studied in a Traditional Medicare population, it has not been studied in other populations subject to prior authorization. This study explores between-facility variation in ordering and receiving orders to render combined CT in a mixed commercial and Medicare Advantage population. METHODS: Orders for CT abdomen (without/with contrast), CT thorax (without/with contrast), and concurrent CT brain and sinus authorized by a prior authorization company from 2013-2017, pertaining to patients with commercial or Medicare Advantage health plans from one national insurer, were extracted. Orders were issued and rendered by both hospitals and nonhospitals. The analysis was performed separately for each anatomical area in two ways: orders were grouped by ordering facility, and by designated rendering facility. For each facility, the ratio of combined to total orders was calculated, and analysis of variance was used to determine whether there were significant differences in this rate by year. The association between health plan type and combined imaging rates was assessed. RESULTS: Combined rates [ratio±standard deviation] for abdomen, thorax, and brain/sinus were 0.306±0.246, 0.089±0.142, and 0.002±0.01 respectively when the analysis was conducted according to ordering facility, and 0.311±0.178, 0.096±0.113, and 0.001±0.006 when the analysis was conducted according to designated rendering facility. Combined CT abdomen and CT thorax rates decreased monotonically from 2013 to 2017, decreases that were significant (P \u3c .01) regardless of whether orders were grouped by ordering or rendering facility. Combined CT abdomen and CT thorax rates significantly differed between orders pertaining to people with commercial and Medicare Advantage plans. DISCUSSION: Variability was greater when orders were grouped by ordering facility, rather than rendering facility. Health plan type may influence whether a patient receives combined CT

Type I Interferons Are Associated with Subclinical Markers of Cardiovascular Disease in a Cohort of Systemic Lupus Erythematosus Patients

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/94405/1/Somers_2012_Type_I_Interferons_subclinical_markers.pdf165

Predictors and Characteristics of Rib Fracture Following SBRT for Lung Tumors

Background Stereotactic body radiation therapy (SBRT) is an increasingly utilized therapy for primary and metastatic lung tumors. Despite promising tumor control, SBRT is associated with increased risk of rib osteoradionecrosis leading to rib fracture. We aimed to 1) determine clinical, demographic, and procedural risk factors of osteonecrosis and 2) radiographically characterize rib osteonecrotic fractures. Methods We retrospectively identified 106 patients who underwent SBRT between 2015 and 2018 for a primary or metastatic lung neoplasm with a minimum of 12 months of follow up. Patients with incomplete records, prior ipsilateral thoracic radiotherapy, or relevant trauma were excluded. Computed tomography (CT) scans were reviewed to identify and characterize rib fractures. Multivariate logistic regression modeling was used to elucidate clinical, demographic, and procedural risk factors (e.g., age, sex, race, medical comorbidities, dosage, and tumor location). Results A total of 106 patients with 111 treated tumors satisfied the inclusion criteria, 35 (32%) of whom developed at least one fractured rib (60 total ribs). The maximum number of affected ribs per subject was five. Multivariate regression identified posterolateral location as an independent risk factor for rib fracture. Radiographically, fractures in 77% of affected subjects showed discontinuity between healing edges. Discussion Post-SBRT fractures demonstrated distinct discontinuity, a possible signal of osteoradionecrosis. Tumor location along the posterolateral chest wall was the only independent predictor of rib fracture. Given its increasing frequency of use, understanding the risk profile of SBRT is vital to maintain patient safety and appropriately inform patient expectations

The Pulmonary Venous Ridge Length to Stratify Stroke Risk in Atrial Fibrillation

Purpose of Study: To evaluate the left superior pulmonary venous ridge length (RL) and the left atrial appendage fractal dimension (LAA FD) as predictors of cardioembolic ischemic stroke (CVA) and transient ischemic attack (TIA) in patients with atrial fibrillation (AF). Materials, Methods and Procedures: A multicenter, retrospective multicenter study was conducted on patients with AF who underwent cardiac CT prior to catheter ablation between 01/01/2010 and 12/31/2015. Patients were grouped by the presence or absence of prior CVA/TIA. Patients with mitral stenosis, prior mechanical aortic valve replacement, ascending aortic arch atheroma, highrisk patent foramen ovale, history of atrial septal repair or device, preexisting LAA thrombus or intra-cardiac tumor, or prior open-heart surgery were excluded. Further exclusion was performed for patients with sub-optimal or unavailable cardiac CT imaging by investigators blinded to clinical data. Blinded investigators obtained RL by measuring the distance between the left superior pulmonary venous ostium and the internal ostium of the left atrial appendage. LAA FD was calculated using semi-automated volume rendering and processing software (ImageJ, Bethesda, MD) [1] and LAA FD are presented as means (95% confidence interval) and were compared between groups using unpaired t-tests. Logistic regression analysis was used to construct receiver operating curves and to assess the abilities of RL and LAA FD to predict prior CVA/TIA. Results: 225 patients met inclusion criteria. Mean RL were 4.32 (3.80-4.93) and 5.20 (4.93-5.48) for patients with (n=24; mean age: 59.4; 70.8% male) and without (n=165; mean age: 59.3; 75.4% male) prior CVA/TIA, respectively(p=0.033). Mean LAA FD were 2.29 (95% CI: 2.24-2.34) and 2.33 (2.32-2.34) for patients with (n=22; mean age: 60.3; 68.2% male) and without (n=171; mean age: 59.3; 74.9% male) prior CVA/TIA, respectively (p=0.052). In a regression model including LAA FD, RL, and established predictive markers, only RL predicted prior CVA/TIA (OR 0.73; 0.54 to 0.98; p=0.034). Discussion: Lower RL values were associated with prior CVA/TIA, whereas LAA FD values were similar between patients with AF with and without prior CVA/TIA. RL is a novel marker that may refine clinical decision-making regarding anticoagulation goals and treatment decisions for patients with AF. Future studies with larger samples should investigate the clinical utility of RL to improve CVA/TIA risk stratification of patients with AF and prospectively reduce the incidence of CVA/TIA in this population

Molecular Testing Guideline for the Selection of Patients With Lung Cancer for Treatment With Targeted Tyrosine Kinase Inhibitors: American Society of Clinical Oncology Endorsement of the College of American Pathologists/International Association for the Study of Lung Cancer/Association for Molecular Pathology Clinical Practice Guideline Update

Purpose In response to advances in the field, the College of American Pathologists (CAP), the International Association for the Study of Lung Cancer (IASLC), and the Association for Molecular Pathology (AMP) recently updated their recommendations for molecular testing for the selection of patients with lung cancer for treatment with targeted tyrosine kinase inhibitors. ASCO has a policy and set of procedures for endorsing clinical practice guidelines that have been developed by other professional organizations. Methods The molecular testing guideline was reviewed for developmental rigor by methodologists. Then an ASCO Expert Panel reviewed the content and the recommendations. Results The ASCO Expert Panel determined that the recommendations from the CAP/IASLC/AMP molecular testing guideline are clear, thorough, and based upon the most relevant scientific evidence. ASCO endorsed the guideline with minor modifications. Recommendations This update clarifies that any sample with adequate cellularity and preservation may be tested and that analytical methods must be able to detect mutation in a sample with as little as 20% cancer cells. It strongly recommends against evaluating epidermal growth factor receptor (EGFR) expression by immunohistochemistry for selection of patients for EGFR-targeted therapy. New for 2018 are recommendations for stand-alone ROS1 testing with additional confirmation testing in all patients with advanced lung adenocarcinoma, and RET, ERBB2 (HER2), KRAS, and MET testing as part of larger panels. ASCO also recommends stand-alone BRAF testing in patients with advanced lung adenocarcinoma. Recommendations are also provided for testing methods for lung cancers that have a nonadenocarcinoma non-small-cell component, for patients with targetable mutations who have relapsed on targeted therapy, and for testing the presence of circulating cell-free DNA. Additional information is available at www.asco.org/thoracic-cancer-guidelines and www.asco.org/guidelineswiki