Publications by authors named "Alexander Norbash"

91 Publications

Matching Imaging Services to Clinical Context: Why Less May Be More.

J Am Coll Radiol 2021 Jan;18(1 Pt B):154-160

Professor and Vice Chair of Radiology, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.

Radiologists are facing an evolving dilemma of increased imaging examination volumes while maintaining the highest levels of diagnostic quality. This scenario places radiologists at risk for error, burnout, and loss of opportunities that add value beyond imaging interpretations. We propose a new framework categorizing radiology tests based on clinical intent, level of imaging technique, and appropriate level of reporting detail.
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http://dx.doi.org/10.1016/j.jacr.2020.06.022DOI Listing
January 2021

Gender Disparity in Radiology Society Committees and Leadership in North America and Comparison With Other Continents.

Curr Probl Diagn Radiol 2020 Oct 13. Epub 2020 Oct 13.

Department of Radiology, Emory University Hospital, GA.

Purpose: To evaluate gender distribution in radiology professional society leadership positions. Our study intends to assess and compare the gender distribution among leadership roles and professional society committee memberships of the radiology societies and seek an understanding of potential associations between gender, academic research metrics, institutional academic rank, and leadership roles.

Methods: We identified radiology professional society committee members to assess relative gender composition in 28 radiology societies in North America, Europe, and Australia/New Zealand. The research metrics were obtained from the SCOPUS database and demographics and institutional affiliation through institutional websites' internet searches. Gender distribution by academic ranks and other discontinuous variables were analyzed using the Chi-Square test. Wallis tests.

Results: Of the 3011 members of society committees, 67.9% were male, and 32.1% female. Among all the society members, the data showed that the proportion of committee members holding leadership positions was comparable between males (25.7%) and females (22.5%). However, when we did a subgroup analysis and disaggregated the data by leadership positions, we noted that among those who held the leadership positions, the proportion of males was more significant (n = 526, 70.7%) compared to females (n = 218, 29.3%). Overall, males had higher median publications, citations, H-indices, and active years of research (P< 0.0001). At all university academic ranks, men outnumbered females (P = 0.0015, Chi-square 15.38), with the most considerable disparity at the rank of professor (71.9% male, 28.1% female, P = 0.0003).

Conclusion: There was male predominance amongst committee members in radiology societies. Our study found no significant differences between those in leadership positions, suggesting that once a member of a committee, females are equally likely as males to attain leadership positions. Analysis of committee members' academic rank and committee leaders demonstrated underrepresentation of females at higher academic ranks, and males overall had higher research metrics than females.
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http://dx.doi.org/10.1067/j.cpradiol.2020.09.011DOI Listing
October 2020

Roadmap for Resuming Elective Neuroendovascular Procedures Following the First COVID-19 Surge.

J Stroke Cerebrovasc Dis 2020 Nov 27;29(11):105177. Epub 2020 Jul 27.

Departments of Radiology, Boston Medical Center, Boston University-School of Medicine, FGH Building, 3rd Floor, 820 Harrison Avenue, Boston, MA 02118, USA; Neurology, Boston Medical Center, Boston University-School of Medicine, Boston, MA, USA; Neurosurgery, Boston Medical Center, Boston University-School of Medicine, Boston, MA, USA.

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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383144PMC
November 2020

Impact of Coronavirus Disease 2019 (COVID-19) on the Practice of Clinical Radiology.

J Am Coll Radiol 2020 09 9;17(9):1096-1100. Epub 2020 Jul 9.

Massachusetts General Hospital, Boston, Massachusetts.

The speed at which coronavirus disease 2019 (COVID-19) spread quickly fractured the radiology practice model in ways that were never considered. In March 2020, most practices saw an unprecedented drop in their volume of greater than 50%. The profound changes that have interrupted the arc of the radiology narrative may substantially dictate how health care and radiology services are delivered in the future. We examine the impact of COVID-19 on the future of radiology practice across the following domains: employment, compensation, and practice structure; location and hours of work; workplace environment and safety; activities beyond the "usual scope" of radiology practice; and CME, national meetings, and professional organizations. Our purpose is to share ideas that can help inform adaptive planning.
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http://dx.doi.org/10.1016/j.jacr.2020.07.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346805PMC
September 2020

Early-Stage Radiology Volume Effects and Considerations with the Coronavirus Disease 2019 (COVID-19) Pandemic: Adaptations, Risks, and Lessons Learned.

J Am Coll Radiol 2020 09 9;17(9):1086-1095. Epub 2020 Jul 9.

Chair, Department of Radiology, University of California, Los Angeles, California.

Objective: The coronavirus disease 2019 (COVID-19) pandemic resulted in significant loss of radiologic volume as a result of shelter-at-home mandates and delay of non-time-sensitive imaging studies to preserve capacity for the pandemic. We analyze the volume-related impact of the COVID-19 pandemic on six academic medical systems (AMSs), three in high COVID-19 surge (high-surge) and three in low COVID-19 surge (low-surge) regions, and a large national private practice coalition. We sought to assess adaptations, risks of actions, and lessons learned.

Methods: Percent change of 2020 volume per week was compared with the corresponding 2019 volume calculated for each of the 14 imaging modalities and overall total, outpatient, emergency, and inpatient studies in high-surge AMSs and low-surge AMSs and the practice coalition.

Results: Steep examination volume drops occurred during week 11, with slow recovery starting week 17. The lowest total AMS volume drop was 40% compared with the same period the previous year, and the largest was 70%. The greatest decreases were seen with screening mammography and dual-energy x-ray absorptiometry scans, and the smallest decreases were seen with PET/CT, x-ray, and interventional radiology. Inpatient volume was least impacted compared with outpatient or emergency imaging.

Conclusion: Large percentage drops in volume were seen from weeks 11 through 17, were seen with screening studies, and were larger for the high-surge AMSs than for the low-surge AMSs. The lowest drops in volume were seen with modalities in which delays in imaging had greater perceived adverse consequences.
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http://dx.doi.org/10.1016/j.jacr.2020.07.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346772PMC
September 2020

Operational Radiology Recovery in Academic Radiology Departments After the COVID-19 Pandemic: Moving Toward Normalcy.

J Am Coll Radiol 2020 09 11;17(9):1101-1107. Epub 2020 Jul 11.

Department of Radiology, Henry Ford Health System, Detroit, Michigan.

This article presents a current snapshot in time, describing how radiology departments around the country are planning recovery from the baseline of the coronavirus disease 2019 pandemic, with a focus on different domains of recovery such as managing appointment availability, patient safety and workflow changes, and operational data and analytics. An e-mail survey was sent through the Society of Chairs of Academic Radiology Departments list server to 114 academic radiology departments. On the basis of data reported by the 38 survey respondents, best practices and shared experience are described for three key areas: (1) planning for recovery, (2) creating a new normal, and (3) measuring and forecasting. Radiology practices should be aware of the common approaches and preparations academic radiology departments have taken to reopening imaging in the post-coronavirus disease 2019 world. This should all be done when maintaining a safe and patient-centric environment and preparing to minimize the impact of future outbreaks or pandemics.
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http://dx.doi.org/10.1016/j.jacr.2020.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7833200PMC
September 2020

Aspiration Thrombectomy Versus Stent Retriever Thrombectomy Alone for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

Cureus 2020 May 31;12(5):e8380. Epub 2020 May 31.

Internal Medicine, John H Stroger J. Hospital of Cook County, Chicago, USA.

Introduction This meta-analysis was conducted to assess the safety and efficacy of aspiration thrombectomy versus stent retriever thrombectomy for acute ischemic stroke (AIS). Methods We queried online databases for original studies comparing aspiration thrombectomy with stent retriever thrombectomy in patients with AIS. After article selection, data were extracted on multiple baseline characteristics and prespecified endpoints. Dichotomous data were presented as risk ratios (RRs) and corresponding 95% confidence intervals (CIs); continuous data as mean differences and 95% CIs. The data were pooled using a random-effects model. Subgroup analysis was conducted based on study type, site of occlusion, and age. Results We shortlisted nine relevant studies (n=1453 patients; n=690 receiving aspiration thrombectomy and n=763 receiving stent retriever thrombectomy). Meta-analysis demonstrated no significant difference between the two groups in the rates of successful recanalization (RR: 0.96 [0.87, 1.06]; p=0.42), excellent functional outcome (RR: 0.90 [0.80, 1.01]; p=0.06), or procedure time (weighted mean difference (WMD): -5.39 minutes [-11.81, 1.04]; p=0.10). However, when removing the study by Nishi et al., sensitivity analysis resulted in a significant reduction in procedure time with aspiration (WMD: -11.01 [-15.54, -6.49]; p<0.0001). No significant difference was observed in safety outcomes, including all-cause mortality (RR: 0.82 [0.57, 1.19]; p=0.30), intracranial hemorrhage (RR: 0.93 [0.55, 1.59]; p=0.80), symptomatic intracranial hemorrhage (RR: 0.72[0.42, 1.21]; p=0.57), or embolization to new territory (RR: 0.71 [0.42, 1.19]; p=0.19). Subgroup analysis revealed that aspiration thrombectomy led to significantly better outcomes in patients with a mean age ≤65 (RR: 1.15 [1.03, 1.29]; p=0.001), and stent retriever thrombectomy led to increased recanalization success in patients with a mean age >65 (RR: 0.89 [0.80, 1.00]; p=0.05). Conclusions Our updated meta-analysis reveals that both aspiration and stent retriever thrombectomy are comparably effective in the management of AIS. Shorter procedure times may potentially be attained with aspiration thrombectomy, and outcomes with each procedure may be age-dependent.
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http://dx.doi.org/10.7759/cureus.8380DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328696PMC
May 2020

The Business Case for Diversity and Inclusion.

J Am Coll Radiol 2020 May 2;17(5):676-680. Epub 2020 Jan 2.

Emory University School of Medicine, Atlanta, Georgia. Electronic address:

Although there is an increasing understanding of the importance of diversity and inclusion in all aspects of radiology training and practice, many radiology practices have yet to invest into programs that raise awareness and assure that diversity and inclusion goals are met. In many instances, leadership fails to see the value of such investments. Here, we explore what can be learned from other industries in making the business case for diversity and inclusion.
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http://dx.doi.org/10.1016/j.jacr.2019.11.018DOI Listing
May 2020

Coil migration during or after endovascular coiling of cerebral aneurysms.

J Neurointerv Surg 2020 May 29;12(5):505-511. Epub 2019 Oct 29.

Neurology, Radiology and Neurosurgery, Boston University School of Medicine, Boston, Massachusetts, USA.

Background: Coil migration is a complication of endovascular coiling of cerebral aneurysms that has not been well studied.

Objective: To report the frequency, risk factors, management strategies, and outcomes of coil migration.

Methods: This was a retrospective analysis of the clinical and radiological data of patients who underwent cerebral aneurysm coiling complicated by coil migration at five neuroendovascular centers in the United States, Canada, and France between 2008 and 2018.

Results: Eighteen cases of coil migration met our study criteria with an occurrence of 0.3% (18/6071 cases) (procedural migration: 55%, delayed migration: 45%). The mean aneurysm maximal diameter, neck, and height to neck ratio in migration cases were 3.4±1.4 mm (range 2-7.6 mm), 2.4±0.9 mm (range 1.2-4.4 mm), and 1.4±0.4 (range 1-2.15), respectively. The 2 mm diameter coil was the most common (39%, range 1-2.5 mm) migrated coil. The length of the migrated coil was ≤4 cm in 95% of cases.Patients managed conservatively (5/18, 28%) did well. Thromboembolic and/or hemorrhagic complications were noted in 6/10 migration patients treated by endovascular modalities and in all migration patients who underwent surgical treatment (4/4). Three deaths occurred (3/18, 17%) related to high Hunt and Hess grade subarachnoid hemorrhage.

Conclusion: Coil migration is an uncommon but important complication of cerebral aneurysm coiling. Small aneurysms, aspect ratio <1.6, and small coils are significant risk factors. Endovascular treatment, such as using a stent retriever, can be considered for procedural, proximal migration, and/or in cases of vessel occlusion. Delayed or distal migration should be managed conservatively.
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http://dx.doi.org/10.1136/neurintsurg-2019-015278DOI Listing
May 2020

Error Disclosure and Apology in Radiology: The Case for Further Dialogue.

Radiology 2019 10 13;293(1):30-35. Epub 2019 Aug 13.

From the Department of Radiology and Institute for Professionalism and Ethical Practice, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (S.D.B.); Department of Radiology, Penn State Milton S. Hershey Medical Center, Hershey, Pa (M.A.B.); Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (J.Y.S.); Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass (R.E.); Department of Radiology, Detroit Medical Center, Detroit, Mich (H.A.); Department of Radiology, Envision Physician Services, Plantation, Fla (H.A.); Department of Radiology, University of California, San Diego, San Diego, Calif (A.N.); Department of Medicine and Department of Bioethics and Humanities, University of Washington, Seattle, Wash (T.H.G.).

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http://dx.doi.org/10.1148/radiol.2019190126DOI Listing
October 2019

Moving a National Medical Meeting in Response to California's Anti-Lesbian, Gay, Bisexual, and Transgender Discrimination Travel Ban.

J Am Coll Radiol 2019 Jul 30;16(7):1006-1008. Epub 2019 Apr 30.

University of California San Diego, San Diego, California.

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http://dx.doi.org/10.1016/j.jacr.2019.01.024DOI Listing
July 2019

A Call to Action - Our Radiology Chairs Are Burning Out.

Acad Radiol 2019 10 30;26(10):1385-1389. Epub 2019 Apr 30.

Department of radiology, UC San Diego 402 Dickinson Street, Suite 454 San Diego, CA.

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http://dx.doi.org/10.1016/j.acra.2019.03.002DOI Listing
October 2019

Novel Geographic Thematic Study of the Largest Radiology Societies Globally: How Is Gender Structure Biased Within Editorial Boards?

AJR Am J Roentgenol 2019 Jul 11;213(1):2-7. Epub 2019 Apr 11.

Department of Radiology, Vancouver General Hospital/University of British Columbia, 899 W 12th Ave, Vancouver, BC V5Z 1M9, Canada.

Radiology has traditionally been a male-dominated medical specialty, and this is also reflected in the authorship of radiology publications and the composition of radiology journal editorial boards. The purpose of this study was to quantify the extent of the gender disparities reflected within the journal editorial boards of the largest international radiologic societies. Methods were crafted to generate a geographically based gender analysis of the editorial boards of the largest general radiologic societies globally. All editorial board members of journals that were published by societies included in the study and that had an impact factor of 1 or greater were assessed to determine the gender composition of the board and the research productivity and career advancement of its members. Analyzed metrics included gender, academic rank, departmental leadership positions, subspecialty, total number of peer-reviewed publications, total number of citations, the h-index, and total number of years of active research. Significant gender disparity was noted across the six journal editorial boards included. Overall, 80.87% of editorial board members were men and 19.13% were women. Men were more prevalent than women across all academic ranks. Male editorial board members had longer publishing careers (22.5 vs 18 years; = 0.015), a higher total number of publications (110 vs 65 publications; < 0.001), and a higher h-index (25 vs 19; < 0.001) than their female counterparts. Female editorial board members at higher academic ranks were less represented on editorial boards and were also less likely to have formal departmental leadership titles. Editorial boards have significant gender disparities, with no specific geographic regional variation noted. Male editorial board members published more, had higher h-indexes, and held more departmental leadership positions than their female counterparts.
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http://dx.doi.org/10.2214/AJR.18.20965DOI Listing
July 2019

Society of Chairs of Academic Radiology Departments Statement of Support for Paid Parental Leave.

J Am Coll Radiol 2019 03;16(3):271-272

The Louis Marx Professor and Chair, Department of Radiology, NYU Langone Health, New York, New York.

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http://dx.doi.org/10.1016/j.jacr.2018.12.029DOI Listing
March 2019

Impact of Neuroradiology Staffing on Academic Hospital Level Quality and Cost Measures for the Neuroscience Service Line.

J Am Coll Radiol 2018 Nov 26;15(11):1609-1612. Epub 2018 Jul 26.

Department of Radiology, Neuroradiology Section, University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1016/j.jacr.2018.06.010DOI Listing
November 2018

Balloon-Assisted Cannulation for Difficult Anterior Cerebral Artery Access.

Interv Neurol 2018 Feb 15;7(1-2):48-52. Epub 2017 Nov 15.

Department of Department of Radiology, University of California, San Diego, California, USA.

The anterior communicating artery is a common location for intracranial aneurysms. Compared to surgical clipping, endovascular coiling has been shown to improve outcomes for patients with ruptured aneurysms and we have seen a paradigm shift favoring this technique for treating aneurysms. Access to the anterior cerebral artery can be challenging, especially in patients with tortuous anatomy or subarachnoid hemorrhage or in patients presenting with vasospasm. We present a technique for cannulating the anterior cerebral artery using a balloon inflated in the proximal middle cerebral artery as a rebound surface.
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http://dx.doi.org/10.1159/000481542DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881150PMC
February 2018

Faculty Relative Value Unit Incentives and Resident Education.

J Am Coll Radiol 2018 03 12;15(3 Pt A):463-465. Epub 2018 Jan 12.

Harvard Medical School, BIDMC, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.jacr.2017.10.037DOI Listing
March 2018

Safety-Net Academic Hospital Experience in Following Up Noncritical Yet Potentially Significant Radiologist Recommendations.

AJR Am J Roentgenol 2017 Nov 4;209(5):982-986. Epub 2017 Aug 4.

1 Boston University Medical Center, Boston, MA.

Objective: In this retrospective study, we identified the types of noncritical recommendations radiologists issued over a 15-day period, the percentage of noncritical radiology recommendations that were not acted on or acknowledged in the medical records, potential causes for recommendations not being acted on, and the potential risk of harm to patients.

Materials And Methods: We conducted a retrospective review of radiology reports and patient records from January 1, 2014, to January 15, 2014, at a large tertiary academic center and regional safety-net hospital.

Results: A total of 6851 reports were reviewed; 857 (13%) contained at least one noncritical recommendation, with 978 total recommendations. The two most common recommendations were additional imaging (63%, n = 615) and clinical correlation (23%, n = 229). The majority of radiology recommendations were followed (67%, n = 655), but 323 cases (33%) contained no evidence that recommendations were followed. Of those that were not followed, 39% (n = 126) had no documentation in the medical records of the recommendation being acknowledged. Of those, 32% (n = 40) had important findings, half of which (n = 20) could have benefited from a verbal communication (18 mass lesions, two instances of fetal death).

Conclusion: Radiologists' recommendations contained in written reports of noncritical findings may not be consistently followed or acknowledged in the medical records. Our study shows that a few report recommendations that were not consistently followed or acknowledged contained findings that referred to potentially harmful conditions. The results triggered an investment in systems improvement at the studied institution.
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http://dx.doi.org/10.2214/AJR.17.18179DOI Listing
November 2017

The 100 Most Influential Papers in the Field of Thrombolytic Therapy: A Bibliometric Analysis.

Am J Cardiovasc Drugs 2017 Aug;17(4):319-333

The University of British Columbia, Vancouver, Canada.

Background: Bibliometric analyses are used by researchers and research funding agencies to help determine areas of greatest interest, and consequently which topics and domains warrant increased research attention. Bibliometric analyses have similarly been published in a number of clinical subspecialties concerning areas of specific medical interest; however, a thorough literature search revealed that such a study has been absent in the field of thrombolytics to date. To bridge this gap, we conducted a citation analysis of the 100 most influential articles on thrombolytics.

Methods: Scopus was selected as the database of choice. Two independent researchers explored the database to extract relevant articles. The articles were ranked according to the number of citations, and a sequential list of the top 100 original articles was prepared in descending order. A detailed analysis was carried out to identify trends and uncover significant discriminators. A second list containing the top 10 review articles was also separately prepared.

Results: The 100 most-cited articles regarding thrombolytics were published between 1973 and 2015, with the most articles (n = 29) published in the 5-year period extending from 1996 to 2000. The total number of citations of these 100 most-cited articles ranged from a low of 389 to a high of 6971, with a median of 612.5 citations. These 100 most-cited articles originated from 26 different countries, with more than half from the USA (n = 54), followed by the next most popular countries of origin Germany (n = 20) and France (n = 15). The New England Journal of Medicine (n = 26) and The Lancet (n = 26) contributed the majority of the articles.

Conclusion: Our analysis provides insight into the span of research activity and the nature of inquiry dealing with 'thrombolytic therapy,' with the hope that such analysis may help to effectively guide future research. Our analysis also yielded a list of the most highly cited and presumably most impactful guideline articles within this field, for distinct consideration.
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http://dx.doi.org/10.1007/s40256-017-0227-2DOI Listing
August 2017

Transitional Leadership: Leadership During Times of Transition, Key Principles, and Considerations for Success.

Acad Radiol 2017 06 24;24(6):734-739. Epub 2017 Feb 24.

University of California, San Diego, School of Medicine, 402 Dickinson Street, Suite 454, San Diego, CA 92103. Electronic address:

Rationale And Objectives: To suggest a methodical approach for refining transitional management abilities, including empowerment of a growing leader, leading in an unfamiliar organization or leading in an organization that is changing.

Materials And Methods: Management approaches based on the body of work dealing with leadership studies and transitions and dealing with leadership during times of transition and change management were consolidated and categorized.

Results: Transitional leaders can benefit from effective leadership training including defining and prospectively accruing necessary experiences and skills; strengthening information gathering skills; effectively self-assessing; valuing and implementing mentoring; formulating strategy; and communicating.

Conclusions: A categorical approach to transitional leadership may be implemented through a systems-based and methodical approach to gaining the definable, and distinct sets of skills and abilities necessary for transitional leadership success.
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http://dx.doi.org/10.1016/j.acra.2017.01.005DOI Listing
June 2017

Effect of team training on improving MRI study completion rates and no-show rates.

J Magn Reson Imaging 2016 10 6;44(4):1040-7. Epub 2016 Apr 6.

Chair, Department of Radiation Oncology, University of Washington School of Medicine.

Purpose: Magnetic resonance imaging (MRI) is a high-cost imaging modality, and an optimized encounter ideally provides high-quality care, patient satisfaction, and capacity utilization. Our purpose was to assess the effectiveness of team training and its impact on patient show-up and completion rates for their MRI examinations.

Materials And Methods: A total of 97,712 patient visits from three tertiary academic medical centers over 1-year intervals were evaluated, totaling 49,733 visits at baseline and 47,979 after training. Each center's MRI team received team training skill training including advanced communication and team training techniques training. This training included onsite instruction including case simulation with scenarios requiring appropriate behavioral and communicative interventions. Orientation and training also utilized customized online tools and proctoring. The study completion rate and patient show-up rate during consecutive year-long intervals before and after team training were compared to assess its effectiveness. Two-sided chi-square tests for proportions using were applied at a 0.05 significance level.

Results: Despite differing no-show rates (5-22.2%) and study incompletion rates (0.7-3.7%) at the three academic centers, the combined patients' data showed significant (P < 0.0001) improvement in the patients' no-show rates (combined decreases from 11.2% to 8.7%) and incompletion rates (combined decreases from 2.3% to 1.4%).

Conclusion: Our preliminary results suggest training of the imaging team can improve the no-show and incompletion rates of the MRI service, positively affecting throughput and utilization. Team training can be readily implemented and may help address the needs of the current cost-conscious and consumer-sensitive healthcare environment. J. MAGN. RESON. IMAGING 2016;44:1040-1047.
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http://dx.doi.org/10.1002/jmri.25219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5612491PMC
October 2016

Normal saline as a natural intravascular contrast agent for dynamic perfusion-weighted MRI of the brain: Proof of concept at 1.5T.

J Magn Reson Imaging 2016 12 28;44(6):1580-1591. Epub 2016 Apr 28.

Boston University School of Medicine, Boston, Massachusetts, USA.

Purpose: Gadolinium-based contrast agents have associated risks. Normal saline (NS) is a nontoxic sodium chloride water solution that can significantly increase the magnetic resonance imaging (MRI) relaxation times of blood via transient hemodilution (THD). The purpose of this pilot study was to test in vivo in the head the potential of normal saline as a safer, exogenous perfusion contrast agent.

Materials And Methods: This Health Insurance Portability and Accountability Act (HIPAA)-compliant prospective study was approved by the local Institutional Review Board (IRB): 12 patients were scanned with T -weighted inversion recovery turbo spin echo pulse sequence at 1.5T. The dynamic inversion recovery pulse sequence was run before, during, and after the NS injection for up to 5 minutes: 100 ml of NS was power-injected via antecubital veins at 3-4 ml/s. Images were processed to map maximum enhancement area-under-the-curve, time-to-peak, and mean-transit-time. These maps were used to identify the areas showing significant NS injection-related signal and to generate enhancement time curves. Hardware and pulse sequence stability were studied via phantom experimentation. Main features of the time curves were tested against theoretical modeling of THD signal effects using inversion recovery pulse sequences. Pearson correlation coefficient (R) mapping was used to differentiate genuine THD effects from motion confounders and noise.

Results: The scans of 8 out of 12 patients showed NS injection-related effects that correlate in magnitude with tissue type (gray matter ∼15% and white matter ∼3%). Motion artifacts prevented ascertaining NS signal effects in the remaining four patients. Positive and negative time curves were observed in vivo and this dual THD signal polarity was also observed in the theoretical simulations. R-histograms that were approximately constant in the range 0.1 < |R| < 0.8 and leading to correlation fractions of F (|R| > 0.5) = 0.45 and 0.59 were found to represent scans with genuine THD signal effects.

Conclusion: A measurable perfusion effect in brain tissue was demonstrated in vivo using NS as an injectable intravascular contrast agent. J. Magn. Reson. Imaging 2016;44:1580-1591.
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http://dx.doi.org/10.1002/jmri.25291DOI Listing
December 2016

Inadvertent Stent Retriever Detachment: A Multicenter Case Series and Review of Device Experience FDA Reports.

Interv Neurol 2016 Mar 20;4(3-4):75-82. Epub 2015 Nov 20.

Boston University School of Medicine, Boston, Mass., USA.

Mechanical thrombectomy using retrievable stents or stent retriever devices has become the mainstay of intra-arterial therapy for acute ischemic stroke. The recent publication of a series of positive trials supporting intra-arterial therapy as standard of care for the treatment of large vessel occlusion will likely further increase stent retriever use. Rarely, premature stent detachment during thrombectomy may be encountered. In our multicenter case series, we found a rate of detachment of less than 1% (n = 7/1,067), and all were first-generation Solitaire FR devices. A review of the US Food and Drug Administration database of device experience yielded 90 individual adverse reports of detachment. There were 82, 1 and 7 detachments of Solitaire FR (first generation), Solitaire FR2 (second generation) and Trevo devices, respectively. We conclude with a brief overview of the technical and procedural considerations which may be helpful in avoiding this rare complication.
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http://dx.doi.org/10.1159/000441920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4817378PMC
March 2016

Radiology 24/7 In-House Attending Coverage: Do Benefits Outweigh Cost?

Curr Probl Diagn Radiol 2016 Jul-Aug;45(4):241-6. Epub 2016 Feb 18.

Department of Radiology, Boston University School of Medicine and Boston Medical Center, Boston, MA. Electronic address:

Many radiology practices, including academic centers, are moving to in-house 24/7 attending coverage. This could be costly and may not be easily accepted by radiology trainees and attending radiologists. In this article, we evaluated the effects of 24/7 in-house attending coverage on patient care, costs, and qualitative aspects such as trainee education. We retrospectively collected report turnaround times (TAT) and work relative value units (wRVU). We compared these parameters between the years before and after the implementation of 24/7 in-house attending coverage. The cost to provide additional attending coverage was estimated from departmental financial reports. A qualitative survey of radiology residents and faculty was performed to study perceived effects on trainee education. There were decreases in report TAT following 24/7 attending implementation: 69% reduction in computed tomography, 43% reduction in diagnostic radiography, 7% reduction in magnetic resonance imaging, and 43% reduction in ultrasound. There was an average daytime wRVU decrease of 9%, although this was compounded by a decrease in total RVUs of the 2013 calendar year. The financial investment by the institution was estimated at $850,000. Qualitative data demonstrated overall positive feedback from trainees and faculty in radiology, although loss of independence was reported as a negative effect. TAT and wRVU metrics changed with implementation of 24/7 attending coverage, although these metrics do not directly relate to patient outcomes. Additional clinical benefits may include fewer discrepancies between preliminary and final reports that may improve emergency and inpatient department workflows and liability exposure. Radiologists reported the impression that clinicians appreciated 24/7 in-house attending coverage, particularly surgical specialists. Loss of trainee independence on call was a perceived disadvantage of 24/7 attending coverage and raised a concern that residency education outcomes could be adversely affected.
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http://dx.doi.org/10.1067/j.cpradiol.2016.02.007DOI Listing
May 2017

Duplication of the Posterior Cerebral Artery and the 'True Fetal' Variant.

Interv Neurol 2015 Oct 18;4(1-2):64-7. Epub 2015 Sep 18.

Department of Radiology, Boston Medical Center, Boston, Mass., USA.

We present a rare case of bilateral posterior cerebral artery variant anatomy seen in a patient presenting with acute ischemic stroke. An embryological explanation of the variant configuration is discussed along with demonstrative radiologic images and a display of the vascular territory supplied.
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http://dx.doi.org/10.1159/000437310DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4640087PMC
October 2015

Expanding Endovascular Therapy of Very Small Ruptured Aneurysms with the 1.5-mm Coil.

Interv Neurol 2015 Oct 18;4(1-2):59-63. Epub 2015 Sep 18.

Department of Radiology, Boston University School of Medicine, Boston Mass., USA.

Background: Very small ruptured aneurysms (≤3 mm) demonstrate a significant risk for procedural rupture with endovascular therapy. Since 2007, 1.5-mm-diameter coils have been available (Micrus, Microvention, and ev3), allowing neurointerventionalists the opportunity to offer patients with very small aneurysms endovascular treatment. In this study, we review the clinical and angiographic outcome of patients with very small ruptured aneurysms treated with the 1.5-mm coil.

Methods: This is a retrospective cohort study in which we examined consecutive ruptured very small aneurysms treated with coil embolization at a single institution. The longest linear aneurysm was recorded, even if the first coil was sized to a smaller transverse diameter. Very small aneurysms were defined as ≤3 mm. Descriptive results are presented.

Results: From July 2007 to March 2015, 81 aneurysms were treated acutely with coils in 78 patients presenting with subarachnoid hemorrhage. There were 5 patients with 3-mm aneurysms, of which the transverse diameter was ≤2 mm in 3 patients. In all 5 patients, a balloon was placed for hemostatic prophylaxis in case of rupture, and a single 1.5-mm coil was inserted for aneurysm treatment without complication. Complete aneurysm occlusion was achieved in 1 patient, residual neck in 2, and residual aneurysm in 2 patients. Aneurysm recanalization was present in 2 patients with an anterior communicating artery aneurysm; a recoiling attempt was unsuccessful in 1 of these 2 patients due to inadvertent displacement and distal coil embolization, but subsequent surgical clipping was successful. Another patient was retreated by surgical clipping for a residual wide-neck carotid terminus aneurysm. One patient died of ventriculitis 3 weeks after presentation; all 4 other patients had an excellent outcome with no rebleed at follow-up (mean 21 months, range 1-62).

Conclusion: The advent of the 1.5-mm coil may be used in the endovascular treatment of patients with very small ruptured aneurysms, providing a temporary protection to the site of rupture in the acute phase. If necessary, bridging with elective clipping may provide definitive aneurysm treatment.
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http://dx.doi.org/10.1159/000437275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4640086PMC
October 2015

Novel brain MRI abnormalities in Gitelman syndrome.

Neuroradiol J 2015 Oct 6;28(5):523-8. Epub 2015 Oct 6.

Neuroradiology, Hamad Medical Corporation, Qatar.

Gitelman syndrome is an autosomal recessive renal tubular disorder characterized by hypokalemic metabolic alkalosis, hypomagnesemia and hypocalciuria. The syndrome is caused by a defective thiazide-sensitive sodium chloride co-transporter in the distal convoluted tubules of the kidneys. Gitelman syndrome could be confused with Bartter syndrome; the main differentiating feature is the presence of low urinary calcium excretion in the former. Descriptions of neuroradiological imaging findings associated with Gitelman syndrome are very scarce in the literature and include basal ganglia calcification, idiopathic intracranial hypertension and sclerochoroidal calcification. Cauda equina syndrome-like presentation has been reported, but without any corresponding imaging findings on lumbar spine MRI. We report a 13-year-old male with Gitelman syndrome who presented with altered mental status following a fall and scalp laceration and unremarkable brain CT, followed during hospitalization by somnolence and seizures. Metabolically the patient demonstrated hypokalemia and hypomagnesemia. MRI demonstrated features of encephalopathy including predominantly right-sided cerebral hemispheric signal abnormality and cytotoxic edema, with bilateral symmetric involvement of the thalami, midbrain tegmentum and tectum and cerebellar dentate nuclei. MRI after five months obtained during a later episode of encephalopathy showed resolution of the signal abnormalities with setting in of brain atrophy and also areas of newly developed cytotoxic edema in the left thalamus, bilateral dorsal midbrain and right greater than left dentate nuclei. The described abnormalities, either recurrent or in isolation, have not previously been published in patients with Gitelman syndrome. We believe that the findings are due to alteration of respiratory chain function secondary to the metabolic derangement and hence have a similar imaging appearance as encephalopathy related to mitochondrial cytopathy or metabolic encephalopathy.
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http://dx.doi.org/10.1177/1971400915609340DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4757220PMC
October 2015

Fulfilling the health care economics milestones: adopting an online curriculum for radiology residency programs.

J Am Coll Radiol 2015 Mar;12(3):314-7

Department of Radiology, Tufts Medical Center, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.jacr.2014.09.030DOI Listing
March 2015

The impact of the Patient Protection and Affordable Care Act on radiology: beyond reimbursement.

J Am Coll Radiol 2015 Jan;12(1):29-33

Yale University School of Medicine, New Haven, Connecticut.

The 2014 ACR Forum focused on the noneconomic implications of the Affordable Care Act on the field of radiology, with specific attention to the importance of the patient experience, the role of radiology in public and population health, and radiology's role in the effort to lower overall health care costs. The recommendations generated from the Forum seek to inform ACR leadership on the best strategies to pursue to best prepare the radiology community for the rapidly evolving health care landscape.
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http://dx.doi.org/10.1016/j.jacr.2014.09.035DOI Listing
January 2015

Radiologist manpower considerations and Imaging 3.0: effort planning for value-based imaging.

J Am Coll Radiol 2014 Oct 12;11(10):953-8. Epub 2014 Aug 12.

Weill Cornell University School of Medicine, New York, New York.

Our specialty is seeking to establish the value of imaging in the longitudinal patient-care continuum. We recognize the need to assess the value of our contributions rather than concentrating primarily on generating revenue. This recent focus is a result of both increased cost-containment efforts and regulatory demands. Imaging 3.0 is a value-based perspective that intends to describe and facilitate value-based imaging. Imaging 3.0 includes a broad set of initiatives addressing the visibility of radiologists, and emphasizing quality and safety oversight by radiologists, which are new directions of focus for us. Imaging 3.0 also addresses subspecialty imaging and off-hours imaging, which are existing areas of practice that are emblematic of inconsistent service delivery across all hours. Looking to the future, Imaging 3.0 describes how imaging services could be integrated into the framework of accountable care organizations. Although all these efforts may be essential, they necessitate manpower expenditures, and these efforts are not directly covered by revenue. If we recognize the urgency of need in developing these concepts, we can justify the manpower and staffing expenditures each organization is willing to shoulder in reaching Imaging 3.0.
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http://dx.doi.org/10.1016/j.jacr.2014.05.022DOI Listing
October 2014