Body

DALLAS - May 10, 2019 - A UT Southwestern study suggests why urinary tract infections (UTIs) have such a high recurrence rate in postmenopausal women - several species of bacteria can invade the bladder walls.

UTI treatment is the most common reason for antibiotic prescriptions in older adults. Because of the prevalence of UTIs, the societal impact is high and treatment costs billions of dollars annually.

"Recurrent UTI (RUTI) reduces quality of life, places a significant burden on the health care system, and contributes to antimicrobial resistance," said Dr. Kim Orth, Professor of Molecular Biology and Biochemistry at UTSW and senior author of the study, published in the Journal of Molecular Biology.

The investigation demonstrates that several species of bacteria can work their way inside the human bladder's surface area, called the urothelium, in RUTI patients. Bacterial diversity, antibiotic resistance, and the adaptive immune response all play important roles in this disease, the study suggests.

"Our findings represent a step in understanding RUTIs in postmenopausal women," said Dr. Orth, also an Investigator of the prestigious Howard Hughes Medical Institute who holds the Earl A. Forsythe Chair in Biomedical Science and is a W.W. Caruth, Jr. Scholar in Biomedical Research at UTSW. "We will need to use methods other than antibiotics to treat this disease, as now we observe diverse types of bacteria in the bladder wall of these patients."

Since the advent of antibiotics in the 1950s, patients and physicians have relied on antibiotics for UTI treatment.

"As time went on, however, major antibiotic allergy and resistance issues have emerged, leading to very challenging and complex situations for which few treatment choices are left and one's life can be on the line," said Dr. Philippe Zimmern, Professor of Urology and a co-senior author. "Therefore, this new body of data in women affected by RUTIs exemplifies what a multidisciplinary collaboration can achieve going back and forth between the laboratory and the clinic."

UTIs are one of the most common types of bacterial infections in women, accounting for nearly 25 percent of all infections. Recurrence can range from 16-36 percent in premenopausal women to 55 percent following menopause. Factors thought to drive higher UTI rates in postmenopausal women include pelvic organ prolapse, diabetes, lack of estrogen, loss of Lactobacilli in the vaginal flora, and increased colonization of tissues surrounding the urethra by Escherichia coli (E. coli).

The latest findings build on decades of clinical UTI discoveries by Dr. Zimmern, who suggested the collaboration to Dr. Orth, along with other UT System colleagues.

The UTSW team, which included researchers from Molecular Biology, Pathology, Urology, and Biochemistry, examined bacteria in bladder biopsies from 14 RUTI patients using targeted fluorescent markers, a technique that had not been used to look for bacteria in human bladder tissue.

"The bacteria we observed are able to infiltrate deep into the bladder wall tissue, even past the urothelium layer," said first and co-corresponding author Dr. Nicole De Nisco, an Assistant Professor of Biological Sciences at UT Dallas who initiated this research as a postdoctoral fellow in Dr. Orth's lab. "We also found that the adaptive immune response is quite active in human RUTIs."

Accessing human tissue was key, the researchers note, as the field has largely relied on mouse models that are limited to lifespans of 1.3 to 3 years, depending on the breed.

"Most of the work in the literature has dealt with women age 25 to 40," said Dr. Zimmern, who holds The Felecia and John Cain Chair in Women's Health, recently established in his honor. "This is direct evidence in postmenopausal women affected with RUTIs, a segment of our population that has grown with the aging of baby boomers and longer life expectancy in women."

Future studies will focus on determining effective techniques to remove these bacteria and chronic inflammation from the bladder, finding new strategies to enhance immune system response, and pinpointing the various bacterial pathogens involved in RUTIs.

Bottom Line: This study of nearly 134,000 patients admitted to intensive care units in France examined the association of age with risk of death in the hospital and then three months and three years after discharge.

Authors: Matthieu Legrand, M.D., Ph.D., L'Assistance Publique-Hopitaux de Paris, France, and coauthors

(doi:10.1001/jamanetworkopen.2019.3215)

Editor's Note: The article includes conflict of interest disclosures. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Compared to patients who see their primary care doctor earlier in the day, cancer screening rates decline significantly as the day goes on, according to a new study from researchers in the Perelman School of Medicine and the Wharton School both of the University of Pennsylvania. The researchers, whose findings were published today in JAMA Network Open, believe these rates of decline may be in part due to "decision fatigue" -- which results from the cumulative burden of screening discussions earlier in the day -- and doctors falling behind in their busy schedules.

"Our findings suggest that future interventions targeting improvements in cancer screening might focus on time of day as an important factor in influencing behaviors," said the study's lead author, Esther Hsiang, a Wharton Business School student and researcher with the Penn Medicine Nudge Unit. "We believe that the downward trend of ordering may be the result of 'decision fatigue,' where people may be less inclined to consider a new decision after they've been making them all day. It may also stem from overloaded clinicians getting behind as the day progresses."

The researchers found that, among eligible patients, primary care doctors ordered breast cancer screening more often for patients seen in the 8 a.m. hour (64 percent) as compared to those with appointments at 5 p.m. (48 percent). Similarly, for colon cancer screening, tests were also ordered more frequently for 8 a.m. patients (37 percent) compared to those coming in later in the day (23 percent).

Examining data from 2014 through 2016 across 33 Pennsylvania and New Jersey primary care practices, the researchers found that ordering rates had far-reaching effects. When looking at the entire population eligible for screenings at these practices (roughly 19,000 for breast cancer and 33,000 for colorectal cancer), the researchers tracked whether the patients completed a screening within a year of their appointment. The data showed that the downward trend associated with the timing of the appointments carried over.

Breast cancer screening--which included mammograms--stood at a 33 percent one-year completion rate for the entire eligible population who had their appointment in the 8 a.m. hour. But for those who had clinic visits at 5 p.m. or later, just 18 percent completed screenings. For colorectal cancer, screenings such as colonoscopies, sigmoidoscopies, and fecal occult blood tests were completed by 28 percent of the patients with appointments in the 8 a.m. hour. That number dropped to 18 percent for patients who saw the doctor at 5 p.m. or later.

The one-year completion results cast long shadows. While doctors may simply be deferring discussions about screening to future appointments, it assumes that the decision will be made the next time. Additionally, these types of cancer screenings also require coordination with a different department and another visit on the part of the patient, which provide several opportunities for further lapses in screening.

Researchers also observed that although order rates fell as the day progressed, there was a brief spike in screening orders for breast and colon cancers when patients saw their clinician around noon. For example, breast cancer screening orders dropped to 48.7 percent at 11 a.m. but increased to 56.2 percent around noon, before gradually falling off again. This trend held true for one-year completion rates, as well. The study team suggest that this may be due to lunch breaks that give clinicians and opportunity to catch up and start fresh.

A downward trend in outcomes by hour was noted in a study in 2018 examining the rates of flu vaccinations by the time of day when patients saw a clinician. In that study, a "nudge" was built into the system that prompted doctors to accept or decline an influenza vaccine order, which helped spur an increase of vaccinations by nearly 20 percent, as compared to patients with doctors who weren't nudged.

"Our new study adds to the growing evidence that time of day and decision fatigue impacts patient care," said Mitesh Patel, MD, MBA, director of the Penn Medicine Nudge Unit and an assistant professor of Medicine. "In past work, we've found that nudges in the electronic health record can be used to address these types of gaps in care, which we suspect will be the case here. Future research could evaluate how nudges may be implemented in order to improve cancer screening."

WINSTON-SALEM, N.C. - May 10, 2019 - A diet proven to have beneficial effects on high blood pressure also may reduce the risk of heart failure in people under age 75, according to a study led by researchers at Wake Forest School of Medicine, part of Wake Forest Baptist Health.

The observational study of more than 4,500 people showed that those individuals under 75 who most closely adhered to the DASH (Dietary Approaches to Stop Hypertension) diet had a significantly lower risk of developing heart failure than those whose eating habits were least in keeping with the diet.

The research is published in the current online issue of the American Journal of Preventive Medicine.

"Only a few prior studies have examined the effects of the DASH diet on the incidence of heart failure, and they have yielded conflicting results," said the study's lead author, Claudia L. Campos, M.D., associate professor of general internal medicine at Wake Forest School of Medicine. "This research showed that following the DASH diet can reduce the risk of developing heart failure by almost half, which is better than any medicine."

The DASH diet emphasizes the eating of fruits, vegetables, nuts, whole grains, poultry, fish, and low-fat dairy products while reducing consumption of salt, red meat, sweets and sugar-sweetened beverages. It is similar to the Mediterranean diet but differs in recommending low-fat dairy products and excluding alcoholic beverages.

For the study the researchers reviewed the cardiovascular health records over 13 years of 4,478 men and women of multiple ethnicities from six U.S. sites who were between ages 45 and 84 with no history of cardiovascular disease when they were enrolled in the Multi-Ethnic Study of Atherosclerosis between 2000 and 2002.

The assessment of their dietary habits was based on their responses to a 120-item questionnaire covering the serving size and frequency of consumption of specific foods and beverages. Using this data, the study team divided the participants into five groups, each representing 20 percent of the study population, based on how well (or poorly) their eating habits aligned with the DASH diet.

The risk of heart failure did not vary significantly by DASH compliance for the population as a whole, but it did for participants under 75, with those in the group with the highest DASH compliance group having an incidence rate 40 percent lower than those in the lowest compliance group.

"Heart failure is a frequent cause of hospitalization in older adults and is associated with substantial health care costs, so identifying modifiable risk factors for of heart failure is an important public health goal," Campos said. "This research provides a framework for further exploration of the DASH diet as an effective element in the primary prevention of heart failure."

Adverse childhood experiences (ACEs) encompass traumas such as abuse, neglect, and household challenges. In an Arthritis Care & Research study of adults with lupus, higher ACE levels, as well as the presence of ACEs from each of these three domains, were associated with worse patient-reported accounts of disease activity, organ damage, depression, physical function, and overall health status.

In the study of 269 patients, more than 60 percent identified at least one ACE, and more than 15 percent indicated at least four ACEs.

"More than half of participants with lupus reported ACE exposure, many of whom experienced substantial trauma in childhood. There is a clear difference in patient-reported outcomes with cumulative ACE exposure in these individuals," said lead author Dr. Kimberly DeQuattro, of the University of California, San Francisco. "This work in lupus supports more broadly the body of studies on adversity and trauma in childhood that have found a link between ACEs and health. It is a call to action to focus efforts on ACE prevention in childhood as well as clinical and mental health interventions that foster resilience in adulthood."

Trials with people with newly-diagnosed colorectal and non-small cell lung cancer suggest that whole body MRI could reduce the time it takes to diagnose the stage of cancers. The results are from two prospective trials with nearly 500 patients across 16 UK hospitals, published in The Lancet Gastroenterology & Hepatology and The Lancet Respiratory Medicine journals.

Whole body MRI scans reduced the average time to determine the size of tumours and how much they had spread by five days for colorectal cancer patients and six days for lung cancer patients. The treatments decided upon were similar, since results from MRI were as accurate as from standard investigations, but the costs per patient were reduced by nearly a quarter in the case of colorectal cancer and were almost halved for lung cancer. More research is needed to determine how this affects outcomes for patients.

Despite their accuracy and efficiency, the authors note that MRI scanners are not as widely available as other imaging technologies and are in high demand. In the trials, many of the hospitals were not able to find time on their MRI scanners, meaning that patients were examined in nearby hospitals.

"Our results, obtained in a real-world NHS setting, suggest that whole body MRI could be more suitable for routine clinical practice than the multiple imaging techniques recommended under current guidelines," says lead author Professor Stuart Taylor from UCL, UK. "While demands on NHS MRI scanners is currently high, MRI can image the whole body in one-hour or less Adopting whole body MRI more widely could save rather than increase costs, as well as reducing the time before a patient's treatment can begin." [1]

Appropriate treatment cannot be decided upon until the size of a tumour and the extent to which it has spread to nearby lymph nodes and other parts of the body has been determined. Standard NHS pathways often involve different imaging techniques - such as CT, PET-CT or focused MRI scans - which vary in accuracy in different organs. Several appointments and follow-up examinations can therefore be necessary.

For the first time, the two new trials compare the diagnostic accuracy and efficiency of whole body MRI with the standard NHS pathways, which use a range of imaging techniques for assessing colorectal and lung cancers. The standard imaging tests recommended by the National Institute for Health and Care Excellence (NICE) [2] were undertaken as usual and the usual multi-disciplinary panel made a first treatment decision based on their results. Once this decision had been recorded, they considered images and reports from whole body MRI. If the latter highlighted a need for further tests, these were carried out. The panel were then able to say whether their first treatment decision would have different based on WB-MRI result. In the interests of patient care, the final decision was made based on results from all tests.

Patients were also followed up after 12 months to better evaluate the accuracy of whole body MRI compared with standard tests. For example, whether one approach was more sensitive than the other in detecting spread of the primary tumour to other parts of the body. Based on this data, the panel were able to retrospectively evaluate what the optimal treatment decision should have been.

Sensitivity and specificity of diagnosis for whole body MRI did not differ from standard tests for both cancers. The use of whole body MRI reduced the time it took to complete diagnostic tests, from an average of 13 days to an average of 8 days in the colorectal cancer trial and from 19 days to 13 days in the lung cancer trial. Costs were reduced from an average of £285 to £216 in the colorectal cancer trial and from an average of £620 to £317 in the lung cancer trial.

In the colorectal cancer trial, agreement with the final multi-disciplinary panel treatment decision based on standard investigations and whole body MRI was similar and high (95% and 96%, respectively), as were results for the lung cancer trial (99% for standard investigations, and 98% for whole body MRI).

Eight of the 16 hospitals in the colorectal cancer trial and 11 of the 16 hospitals in the lung cancer trial did not have the infrastructure to perform whole body MRI.

The authors note that their findings are specific to colorectal and non-small cell lung cancer and might not be relevant to tumours arising in other parts of the body. In addition, waiting times might not be representative of other UK hospitals or of hospitals in other countries. A further limitation of the lung cancer trial is that sensitivity in detecting the spread of cancers - including the development of secondary tumours and the spread to lymph nodes - was low using both current standard imaging techniques and whole body MRI. Further research is needed to improve the performance of non-invasive imaging.

Writing in a linked Comment, Professor Andreas Schreyer from Brandenburg Medical School, Germany, says of the colorectal cancer trial: "MRI has faced considerable backlash within the medical community due to relatively high costs and the problems involved in finding a timely slot for imaging because of the high demand for this method. This is why it is particularly important to think outside the box and look out for new medical pathways and paradigms and not to be driven by prejudices. It could be more efficient to adapt the known therapeutic concept of hitting hard and early to diagnostic imaging to improve medical outcomes and economic performance."

In a prospective study of 18,481 pregnant women in China who had never given birth before, obesity in early pregnancy was linked to higher risks of spontaneous abortion, preterm birth, and large birth weight in newborns.

In the Obesity study, being underweight during pregnancy was linked to higher risks for early neonatal deaths, as well as low birth weight.

The findings point to the importance of an appropriate weight before and during pregnancy.

"Women who plan pregnancies and their prenatal care providers may wish to weigh these findings to decrease the related risks," said senior author Dr. Jianmeng Liu, of the Peking University Health Science Center, in China.

AUGUSTA, Ga. (May 7, 2019) - During big procedures like open heart surgery, patients need anticoagulants to prevent dangerous blood clot formation and regular bedside monitoring to make sure the drugs aren't also causing problems like excessive bleeding.

Investigators comparing some common bedside testing platforms to quickly determine how fast blood is clotting, called activated clotting time, or ACT, suggest other providers also compare results among the systems out there and use a more lengthy laboratory-based measure to confirm what they find.

"It's like walking on a knife's edge," Dr. Thomas Z. Thompson, a third-year pathology resident at the Medical College of Georgia and AU Health. "You have to really get it within a certain range," he says of the delicate balance of keeping the viscosity of the blood just right so it does not form clots that go to the lungs or brain and, conversely, does not result in bleeding.

Their perusal, published in the journal Laboratory Medicine, determined the iSTAT platform, which enables not just a bedside determination of ACT within a few minutes but can also provide results on a wide variety of other internal measures like sodium levels in the blood, a better overall option for streamlining patient care and proficiency testing.

Fast-acting heparin is the commonly used anticoagulant and ACT, the most commonly used measure to keep tabs on clotting time during treatments like cardiothoracic surgery and percutaneous, or through the skin, procedures to insert a stent to improve blood flow in the heart.

That way, caregivers know how much heparin is inhibiting the ability to clot so they can make adjustments, for example, if the operation is wrapping up. This "point of care" approach also has been shown to decrease the need for blood transfusions later, although it is generally more costly than tests done in the lab.

Point of care ACT measures are typically used in more critical situations where results need to be as close to real time as possible, Thompson says.

Critical situations include procedures like ECMO, or extracorporeal membrane oxygenation, which is generally performed as a lifesaving measure for babies, requires a lot of manipulation of the blood, including removing it from the body, putting it through a machine which adds oxygen and then back into the baby, Thompson says.

"If you have a concern post-surgery for a knee or hip replacement, there is a baseline anticoagulation we want to keep you at," says Thompson. "But for big procedures like these, we anticoagulate patients to a much higher extent because we are taking blood typically right out of the patient, running it through a machine and giving it back to them. Artificial travel is much more a coagulant than the blood just passing through our bodies," he says of procedures like ECMO and coronary bypass surgery, one of the most common surgeries performed in the United States.

"That is where we come in because we have the test that tells the surgeon you can start the surgery and we also have the test that says now you can reverse the heparin you have given the patient, so that they are now back to baseline when you finish the surgery," Thompson says.

The anti-coagulant heparin is quick acting, so patients can get it right before their procedure starts and once their anticoagulation level is adequate, it can begin. As things wrap up, caregivers in the operating room, as an example, can begin to reverse the heparin, by giving another drug that binds to and eliminates it, so the patient gets back to baseline.

"These tests are done at the patient's bedside versus coming all the way to the lab," Thompson says, adding that the reduced time, from a few minutes versus about a half hour, is particularly important in critical care situations when results need to be as close to real time as possible. To do that well, point of care assessments are meant to be as simple and quick - and accurate - as possible.

So they compared head on several instruments commonly used to determine ACT.

This included two versions of the Hemochron analyzers, which provide an indirect measure of ACT, one which disrupts two magnets when a clot is formed and another which looks at impedance of flow between two optical sensors. While the Hemochron analyzers had the shortest of the short turnaround time for the point of care tests, the MCG investigators had difficulty obtaining consistent ACTs even when comparing results of two Hemochron instruments to each other.

The Hepcon system, which requires the most blood for the point of care ACT instruments they compared, basically uses a plunger, which is slowed by the increased ability of the blood to clot to indirectly calculate the ACT. Thompson uses the analogy of pushing your hand through gelatin versus water. It also calculates ongoing heparin levels and how much reversal agent that patient would need at that moment, one reason why cardiothoracic surgeons and anesthesiologists thought it might be more useful in patient care.

But since the test only provides a value of total heparin, not the physiologically active heparin, it was not of additional value for that reason, the investigators determined. However its ACT results were consistent with iSTAT as well as the laboratory gold standard anti-Xa, which takes about a half hour compared with a few minutes to do and requires blood be taken to a lab for testing.

The investigators note that Hepcon has a particular niche for open-heart surgery with cardiopulmonary bypass where the patient's body is cooled to decrease blood and oxygen needs of the body during surgery. Cooling can decrease the anticoagulation process and lead to patients being given too much heparin. Hepcon works well in this scenario because it provides both ACT and heparin concentrations at the bedside, they say.

The iSTAT instrument made by Abbott adds diatomaceous earth, which is essentially dirt, as a clotting activator, and a substitute for thrombin, a molecule found in our blood that can both promote or prevent blood clotting, to the few drops of blood to see how quickly a clot forms.

It's considered a direct measure of what happens in our blood because it essentially mimics how thrombin interacts with fibrinogen, a major factor for blood clotting naturally, Thompson says. iSTAT takes a little longer than other methods of measuring ACT, they note, but its breadth of offerings helps streamline patient care and proficiency testing, they write.

Investigators note that inconsistent results with Hemochron during ECMO and repeated failure of proficiency testing had already prompted the decision to stop using the instruments at AU Health, and prompted them to further compare ACT instrument results with this study.

They also note that the only recommended ranges for ACT are based on testing from Hemochron and another point of care test they did not study. For their studies, the iSTAT ACT measures were consistently lower than the other two tests. That likely means the clotting speeds were the same but the number assigned to that speed by each test was different, says Dr. Gurmukh Singh, vice chair of the MCG Department of Pathology, medical director of chemistry, toxicology, and point of care testing at AU Health Inc., and the study's senior author.

The anti-Xa test, which adds a chemical that the affects the color of heparin so it can be picked up by a sensor, is still a go-to test when there is no sense of urgency because of its accuracy, Singh notes. One example is checking the heparin levels on a patient with deep vein thrombosis who is getting a checkup but not having a procedure.

Typically at the bedside they only use one instrument to get the ACT, and Thompson and Singh now both suggest iSTAT.

Point of care testing reduces the number of people handling samples and the opportunity for samples to degrade before testing but can be more costly than standard lab testing.

While all the tests require just a few drops of blood, Hepcon, which is literally a larger instrument, uses a bit more, and iSTAT has the longest average turnaround time.

With ECMO, which uses similar heart-lung bypass technology, the baby is not cooled so ACT testing alone should suffice, notes Jennifer Chazelle, point of care manager at AU and a study coauthor. For these babies, point of care testing is performed every 30 minutes while they are being placed on ECMO, hourly for a period and then shifts to every two to three hours.

It tends to be the holder of the CLIA, or Clinical Laboratory Improvement Amendments program of the Centers for Medicare & Medicaid, license who ultimately makes decisions about which instruments are used. In the case of AU Health, that is Singh.

Indianapolis -- Regenstrief Institute research scientists are presenting some of the institute's latest research on patient engagement and advocacy at the Society of General Internal Medicine Annual Meeting in Washington, D.C., May 8-11.

The meeting covers the breadth and depth of general internal medicine. This year's theme is Courage to Lead: Equity, Engagement, and Advocacy in Turbulent Times. The conference gives Regenstrief researchers the opportunity to discuss how to advance health equity with other top researchers from around the country.

Joy L. Lee, PhD, is leading a workshop on doctors' use of electronic communication to correspond with patients. Marianne S. Matthias, PhD, and Michael Weiner, M.D., MPH, are also participating in the workshop. In addition, Dr. Lee is presenting two posters on her research involving patient portals and secure messaging between patients and doctors.

Jennifer L. Carnahan, M.D., is participating in a panel discussion on advocating for patients while navigating ethical and moral dilemmas.

Matt Bair, M.D., is presenting on the Care Management for the Effective Use of Opioids (CAMEO) trial, which looked at the effectiveness of pharmacological vs. behavioral approaches for treating chronic lower back pain.

David Haggstrom, M.D., is the veterans affairs liaisons chair for the annual meeting program committee. In this role, Dr. Haggstrom helped to facilitate the hosting of five peer-reviewed Veterans Affairs Special Series workshops on topics including social and behavioral determinants of health, interprofessional teamwork, trainees as change agents and opioid use disorder treatment in primary care. He is also participating in an effort to develop a new VA partnered research program curriculum for SGIM researchers interested in this type of research within learning healthcare systems. In addition, he helped to initiate planning activities on behalf of the new SGIM-VA Innovation and Implementation Interest Group.

According to the SGIM website, the Society of General Internal Medicine is a national medical society of 3,000 physicians who are the primary internal medicine faculty of every medical school and major teaching hospital in the U.S. Members teach students, residents and fellows how to care for adult patients in addition to conducting research that improves primary care, preventive measures and treatment services for patients.

The following Regenstrief Institute research scientists have served as SGIM presidents: Kurt Kroenke, M.D. (2001-2002) and William Tierney, M.D. (1996-1997).

Founded in 1969 in Indianapolis, Indiana, the Regenstrief Institute is a local, national and global leader dedicated to a world where better information empowers people to end disease and realize true health. The Regenstrief Institute and its researchers are responsible for a growing portfolio of major health care innovations and studies. Examples range from the development of global health information technology standards that enable the use and interoperability of electronic health records to improving patient-physician communications, to the creation of models of care that inform practice and improve the lives of patients around the globe.

Panels and Workshops

Can You Read Me Now? Effective Electronic Communication with Patients in Primary Care
Joy L. Lee, PhD, M.S.; Marianne S. Matthias, PhD; Michael Weiner, M.D., MPH.
Presenter: Joy L. Lee, PhD, M.S.: PhD from Johns Hopkins Bloomberg School of Public Health, M.S. from Harvard T.H. Chan School of Public Health, B.A. from Bowdoin College.

How to Advocate for Your Patient While Navigating Ethical and Moral Dilemmas
Panelist: Jennifer L. Carnahan, M.D., MPH: M.D., M.A. and MPH from University of Virginia, B.A. from New College of Florida.

Scientific Abstract Oral Presentations

Care Management for the Effective Use of Opioids (CAMEO): A Randomized Trial
Matt Bair, M.D., M.S.; Kurt Kroenke, M.D. MACP; Teresa M. Damush, PhD.
Presenter: Matt Bair, M.D., M.S.: M.D. from Medical College of Wisconsin, M.S. from Indiana University Purdue University Indianapolis, B.S. from St. Mary's College of California.

Veteran Perspectives on Cancer Care Coordination
Will L. Tarver, DrPH, MLIS; Edward J. Miech, EdD; David A. Haggstrom, M.D., MAS.
Presenter: Will L. Tarver, DrPH, MLIS (Dept. of Veterans Affairs HSR&D Fellow).

Poster Presentations

Too Many Don'ts and Not Enough Dos: A Survey of Hospital Portal Information for Patients
Joy L. Lee, PhD, M.S.; Marianne S. Matthias, PhD; Michael Weiner, M.D., MPH.
Presenter: Joy L. Lee, PhD, M.S.: PhD from Johns Hopkins Bloomberg School of Public Health, M.S. from Harvard T.H. Chan School of Public Health, B.A. from Bowdoin College.

What is Misuse? Clinician Consensus on Secure Messaging with Patients
Joy L. Lee, Ph.D. M.S.; Marianne S. Matthias, PhD; Michael Weiner, M.D., MPH.
Presenter: Joy L. Lee, PhD, M.S.: PhD from Johns Hopkins Bloomberg School of Public Health, M.S. from Harvard T.H. Chan School of Public Health, B.A. from Bowdoin College.

Leesburg, VA, May 6, 2019--A new technique for imaging of microbubble ultrasound contrast agents may be useful in detection of prostate cancer (PCa) not found by multiparametric magnetic resonance imaging (MRI), according to a study to be presented at the ARRS 2019 Annual Meeting, set for May 5-10 in Honolulu, HI.

The first in vivo application of contrast-enhanced SHI in the prostate, the pilot study was conducted to evaluate contrast-enhanced subharmonic imaging (SHI) of the prostate for detection of PCa.

Building on the authors' previous work demonstrating the effectiveness of contrast enhanced harmonic imaging (HI) for detection of prostate cancer, 55 patients referred for prostate biopsy were imaged using conventional grayscale, color, and power Doppler, conventional contrast HI, SHI -- a new technique for imaging of microbubble ultrasound contrast agents with up to a 10-fold increase in contrast-to-background signal ratio relative to conventional HI -- and flash replenishment in combination with SHI (MIP-SHI).

The results demonstrated contrast-enhanced SHI enhancement in all patients. Detection of PCa using contrast-enhanced SHI included 9 of 31 patients with a prior negative MRI or negative MRI-guided biopsy, suggesting SHI may be useful in detection of PCa not found by multiparametric MRI.

"Diagnosis of clinically significant prostate cancer with non-invasive means is a real clinical challenge," said author of the study Ethan Halpern, MD. " Although multi-parametric MRI is currently used for this purpose, ultrasound has numerous advantages. Ultrasound systems are portable. Ultrasound studies are far less expensive and more widely available as compared with MRI. Contrast enhanced ultrasound studies can be performed at the same sitting as the ultrasound-guided biopsy, while mp-MRI requires two visits, one for the diagnostic MR study and a second for the fusion biopsy. There is no need for a fusion imaging system (additional hardware/software) when using contrast enhanced ultrasound. No additional effort is required to properly register the contrast-enhanced ultrasound diagnostic study with the targeting system for biopsy. Combining contrast enhanced ultrasound with subharmonic imaging has the potential to provide a new, non-invasive method for diagnosis and characterization of prostate cancer."

6 million adults in U.S. have heart failure

Rise is likely due to obesity and diabetes epidemics

Life expectancy in U.S. is dropping, possibly due to heart failure rise

Heart failure is number one reason adults are admitted to hospital

CHICAGO --- Death rates due to heart failure are now increasing, and this increase is most prominent among younger adults under 65, considered premature death, reports a new Northwestern Medicine study.

The increase in premature death from heart failure was highest among black men under age 65.

This study is showing for the first time that death rates due to heart failure have been increasing since 2012. The rise in deaths comes despite significant advances in medical and surgical treatments for heart failure in the past decade.

The study will be published May 6 in the Journal of the American College of Cardiology.

"The success of the last three decades in improving heart failure death rates is now being reversed, and it is likely due to the obesity and diabetes epidemics," said Dr. Sadiya Khan, assistant professor of medicine at Northwestern University Feinberg School of Medicine and a Northwestern Medicine cardiologist. "We focused on patients with heart failure because they have the highest mortality related to cardiovascular death. They have a prognosis similar to metastatic lung cancer."

An estimated 6 million adults in the U.S. have heart failure. It's the number one reason older adults are admitted to the hospital, Khan said.

"Given the aging population and the obesity and diabetes epidemics, which are major risk factors for heart failure, it is likely that this trend will continue to worsen," she said.

Recent data that show the average life expectancy in the U.S. also is declining, which compounds Khan's concern that cardiovascular death related to heart failure may be a significant contributor to this change.

The study used data from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research data, which includes the underlying and contributing cause of death from all death certificates in the U.S. between 1999 to 2017 for 47,728,569 individuals. Researchers analyzed the age-adjusted mortality rate for black and white adults between the age of 35 to 84 years who died from heart failure.

Simply put, heart failure is when the heart muscle doesn't function properly in its squeezing or relaxing functions. It causes symptoms like shortness of breath and swelling. When the heart can't adequately squeeze to pump blood, it's called heart failure with reduced ejection fraction; when the heart can't relax it's called heart failure with preserved ejection fraction.

"To combat this disturbing trend, we need to focus on improving the control of risk factors, including blood pressure, cholesterol and diabetes," Khan said. "Healthy lifestyle changes promoting a normal body mass index also can protect from developing heart failure as well as engaging in regular physical activity and consuming a healthy, well-balanced diet."

In future research, Khan said she wants to better understand what causes the disparities in cardiovascular death related to heart failure.

Leesburg, VA, May 5, 2019-- Zero TE (ZTE) skull magnetic resonance imaging
(MRI) can be a possible option for clinical use in patients with skull lesions and may be helpful in managing radiosensitive trauma patients, according to a study to be presented at the ARRS 2019 Annual Meeting, set for May 5-10 in Honolulu, HI.

The study was conducted to investigate the clinical feasibility of ZTE skull MRI for evaluating skull lesions in patients with head trauma, assessing its diagnostic image quality and quantitative values in comparison with computerized tomography (CT).

Thirteen patients with head trauma were evaluated using brain CT and skull MRI. Image quality assessments of the two imaging modalities were graded on a 5-point Likert scale by two attending neuroradiologists. To assess the quantitative analyses between image modalities, skull thickness and ratio of bone tissue property were measured, and interobserver reliability was measured with weighted kappa statistics and intraclass correlation coefficient.

ZTE skull MRI showed comparable diagnostic image quality to CT images for evaluating skull fracture with good correlation of quantitative measurement. Images were successfully obtained from all patients with ZTE skull MRI, and skull structures matched well with images obtained using CT scan.

The results suggest that in some cases ZTE skull MRI may be a clinical alternative to CT imaging in patients with skull lesions and, because it does not generate radiation, ZTE skull MRI may be a useful option when imaging radiosensitive trauma patients such as children or pregnant women.

Leesburg, VA, May 5, 2019-- Residents who passed the American Board of Radiology (ABR) Core Examination perceived the value of a range of preparation resources as higher than those who failed, according to a study to be presented at the ARRS 2019 Annual Meeting, set for May 5-10 in Honolulu, HI.

The study was conducted to assist program directors and future residents with improving study preparation for the ABR Core exam.

Fourth year radiology residents across the United States who took and received their results after the first examination of the ABR Core exam in 2018 were surveyed with free response and multiple choice questions about (American Institute for Radiologic Pathology) AIRP lectures, conference lectures, books, 3rd-year in-training exam scores, United States Medical Licensing Examination (USMLE) step scores, study time off, ABR core exam overall score, and ABR core exam sections scored less than 350.

Preliminary results based on 186 residents of 1163 radiology resident test takers who responded to the survey reveal that residents who passed the exam perceived the value of resources including Crack the Core series, question banks, and conference lectures as higher than those who failed. In particular, responders who passed the ABR exam had more study time off and had higher USMLE step 1 scores compared to residents who failed.

Additional research is still needed to identify and develop the best resources and strategies to prepare future residents for the ABR core exam. However, findings suggest that more time off and use of resources more commonly used by the pass cohort may lead to a greater chance on passing the ABR Core Exam.

Leesburg, VA, May 5, 2019--Clinicians need more education in the types of breast pain that necessitate an imaging workup and what imaging to order, according to a study to be presented at the ARRS 2019 Annual Meeting, set for May 5-10 in Honolulu, HI.

A previous survey found agreement among breast imaging radiologists' imaging decisions in accordance with the literature and practice guidelines. The study was conducted to determine what if any difference exists between referring clinicians' and radiologists' approach to the imaging evaluation of breast pain as a sole presenting symptom.

One hundred and eleven clinicians participated in an online survey of 11 questions regarding preferred imaging evaluation of various types of breast pain based on patient age, pain location, and whether pain was constant or intermittent.

Findings include 72% of respondents believe a weak correlation between breast pain and breast cancer exists, while 23% believe there is a neutral correlation. However, despite most clinicians asserting they believe in only a weak correlation between breast pain and breast cancer, many still order imaging studies, resulting in wasted healthcare resources. Forty-eight percent of respondents said they order imaging for breast pain to exclude malignancy, 26% for reassurance only, and 25% to evaluate the breast tissue for a cause of pain.

While results demonstrate an understanding across specialties of the importance of imaging and breast pain, they also suggest more education for clinicians is needed in the types of breast pain that necessitate an imaging workup and what imaging to order.

Leesburg, VA, May 5, 2019--High negative predictive values (NPV) in mammography architectural distortion (AD) without ultrasonographic (US) correlate or magnetic resonance imaging (MRI) enhancement suggests follow-up rather than biopsy may be safely performed, according to a study to be presented at the ARRS 2019 Annual Meeting, set for May 5-10 in Honolulu, HI.

Management of MG-detected AD varies among practices when tomosynthesis-guided biopsy is not available. The study was conducted to evaluate outcomes of architectural distortion on mammography (MG) with or without a magnetic resonance (MR) correlate.

Unexplained AD on MG cases with subsequent MR were retrospectively reviewed by MG type, biopsy type and cancer results, cancer type, tumor grade, and receptor status. Among the study group of 57 patients, the NPV of MG AD without MR correlate or enhancement was 97.2%. Forty-four of 57 had MG AD without US correlate. Of 12 patients without US but with MR correlate, cancers (25%) were masses on MR, majority of benign findings (58.3%) were nonmass enhancement (NME), and RS/CSL (41.7%) was mass or NME. No MG AD without US or MR correlate was found to be cancer. The NPV of MG AD without US or MR correlate or enhancement was 100%.

The results indicate that follow-up rather than biopsy may be safely performed in cases of MG AD without US and MRI correlate or enhancement, reducing the need for intervention and lowering healthcare costs.

"With 3D tomosynthesis widely incorporated in many practices, MG AD without US or MRI correlate poses a management dilemma to radiologists," author of the study Vandana Dialani, MD said. "This study is especially important for institutions which do not have tomo-guided biopsy capabilities and may revert to contrast imaging as a next step in managing MG AD. Our study shows that the NPV of MG AD without US correlate or MR enhancement was 100% and follow-up rather than biopsy may be considered."