Publications by authors named "Charles Kim"

202 Publications

Ferumoxytol-enhanced MR Venography of the Central Veins of the Thorax for the Evaluation of Stenosis and Occlusion in Patients with Renal Impairment.

Radiol Cardiothorac Imaging 2020 Dec 19;2(6):e200339. Epub 2020 Nov 19.

Division of Vascular and Interventional Radiology (C.J.R.G., D.Y.J., J.R., C.Y.K.), Division of Cardiothoracic Imaging (J.G.M., D.Y.J., H.C.), Division of Abdominal Imaging, Department of Radiology (M.R.B.), Center for Advanced Magnetic Resonance Development (M.R.B.), and Division of Hepatology, Department of Medicine (M.R.B.), Duke University Medical Center, Box 3808, 2301 Erwin Rd, Durham, NC 27710.

Purpose: To assess the diagnostic performance of ferumoxytol-enhanced MR venography for the detection of thoracic central vein stenosis or occlusion with conventional venography as the reference standard.

Materials And Methods: In this retrospective study, consecutive patients from May 2012 to December 2018 underwent dedicated ferumoxytol-enhanced MR venography of the thoracic central veins and conventional venography within 6 months for detecting central venous stenosis. The central veins were divided into seven segments for evaluation. MR venography images were evaluated by three radiologists for presence of stenosis or occlusion. Interobserver agreement was assessed using Fleiss κ.

Results: A total of 35 patients were included (mean age, 49 years; age range, 12-75 years; 18 females). Of the 122 total venous segments with corresponding conventional venography, 73 were stenotic or occluded. The sensitivity and specificity for detection of stenosis or occlusion was 99% and 98%, respectively. The sensitivity and specificity for detecting occlusion alone was 96% and 98%, respectively. MR venography readers demonstrated moderate agreement in their ability to grade stenosis or occlusion (κ = 0.59). There were no adverse events related to contrast agent administration.

Conclusion: Ferumoxytol-enhanced MR venography demonstrated excellent sensitivity and specificity for detection of thoracic central vein stenosis or occlusion.© RSNA, 2020See also the commentary by Finn in this issue.
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http://dx.doi.org/10.1148/ryct.2020200339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977948PMC
December 2020

Socioeconomic Status is Associated with the Risk of Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation.

J Vasc Interv Radiol 2021 Mar 1. Epub 2021 Mar 1.

Division of Vascular and Interventional Radiology, Department of Radiology, Duke University School of Medicine, Durham. Electronic address:

Purpose: To determine whether socioeconomic status (SES) is associated with hepatic encephalopathy (HE) risk after transjugular intrahepatic portosystemic shunt (TIPS) creation.

Materials And Methods: This single-institution retrospective study included 368 patients (mean age = 56.7 years; n = 229 males) from 5 states who underwent TIPS creation. SES was estimated using the Agency for Healthcare Research and Quality SES index, a metric based on neighborhood housing, education, and income statistics. Episodes of new or worsening HE after TIPS, defined as hospitalization for HE or escalation in outpatient medical therapy, were identified from medical records. Multivariable ordinal regression, negative binomial regression, and competing risks survival analysis were used to identify factors associated with SES quartile, the number of episodes of new or worsening HE per unit time after TIPS, and mortality after TIPS, respectively.

Results: There were 83, 113, 99, and 73 patients in the lowest, second, third, and highest SES quartiles, respectively. In multivariable regression, only older age (β = 0.04, confidence interval [CI] = 0.02-0.05; P < .001) and white non-Hispanic ethnicity (β = 0.64, CI = 0.07-1.21; P = .03) were associated with higher SES quartile. In multivariable regression, lower SES quartile (incidence rate ratio [IRR] = 0.80, CI = 0.68-0.94; P = .004), along with older age, male sex, higher model for end-stage liver disease score, nonalcoholic steatohepatitis, and proton pump inhibitor use were associated with higher rates of HE after TIPS. Ethnicity was not associated with the rate of HE after TIPS (IRR = 0.77, CI = 0.46-1.29; P = .28). In multivariable survival analysis, neither SES quartile nor ethnicity predicted mortality after TIPS.

Conclusion: Lower SES is associated with higher rates of new or worsening HE after TIPS creation.
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http://dx.doi.org/10.1016/j.jvir.2020.11.022DOI Listing
March 2021

Comparison of optical performance among three dental operating microscopes: A pilot study.

J Conserv Dent 2020 Jul-Aug;23(4):374-376. Epub 2021 Jan 16.

Departments of Endodontics, Texas A and M College of Dentistry, Dallas, Texas, USA.

Introduction: Two important aspects of the dental operating microscope (DOM) that factor into its overall effectiveness are resolution and depth of field. Therefore, the objective of this study was to evaluate and compare the resolution and depth of field of DOMs from three well-known manufacturers using standardized test targets.

Materials And Methods: A resolution test, using the 1951 USAF Hi-Resolution Target (Edmund Optics, Barrington, NJ), and a depth of field test, using the Depth of Field Target 5-15 (Edmund Optics, Barrington, NJ), were performed by two calibrated observers. Three DOM systems such as Seiler IQ (Seiler Instrument Inc., St. Louis, USA), Global G-Series 6 step (Global Surgical Corp., St. Louis, USA), and Zeiss Extaro 300 (Carl Zeiss Meditec AG, Oberkochen, Germany) were used to compare the resolution and depth of field.

Results: The Zeiss Extaro 300 showed the highest maximum resolution and maximum DOF (64 lp/mm and 17mm, respectively). The Seiler IQ showed the lowest maximum resolution and maximum DOF (35.9 lp/mm and 11 mm, respectively).

Conclusion: Within the limitations of this study, the Zeiss Extaro 300 was superior in terms of resolution and depth of field as compared to the other two DOMs.
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http://dx.doi.org/10.4103/JCD.JCD_191_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883792PMC
January 2021

Use of Korean dramas to facilitate precision mental health understanding and discussion for Asian Americans.

Health Promot Int 2021 Feb 13. Epub 2021 Feb 13.

Department of Primary Care and Population Health, Stanford University, Stanford, CA 94305, USA.

Precision mental health holds great potential for revolutionizing care and reducing the burden of mental illness. All races and ethnicities such as Asian Americans, the fastest growing racial group in the United States (U.S.), need to be engaged in precision mental health research. Owing to its global popularity, Korean drama ('K-drama') television shows may be an effective educational tool to increase precision mental health knowledge, attitudes and behaviors among Asian Americans. This qualitative study examined the participants' perspectives about and acceptance of using K-dramas to educate and engage Asian Americans about precision mental health. Twelve workshops were conducted in English, Vietnamese and Korean with a convenience sample in the San Francisco Bay Area in the U.S. (n = 122). Discussions were coded for themes. Findings revealed that all language groups reported positive reactions to using K-dramas to learn about precision health, genetics and mental health. Overall, participants shared that they learned about topics that are not generally talked about (e.g. precision health; genetic testing; mental health), from other people's perspectives, and the importance of mental health. Participants expressed how much they enjoyed the workshop, how they felt relieved due to the workshop, thought the workshop was interesting, and had an opportunity for self-reflection/healing. This pilot test demonstrated that K-dramas has promise to be used as a health educational tool in a workshop format focused on mental health among a diverse group of Asian Americans. Given the widespread access to K-dramas, they present a scalable opportunity for increasing awareness about specific health topics.
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http://dx.doi.org/10.1093/heapro/daab012DOI Listing
February 2021

Blunt Transmediastinal Dissection with Radiofrequency Wire Reentry for Extravascular Bypass of Thoracic Central Venous Occlusions Refractory to Recanalization.

J Vasc Interv Radiol 2021 04 21;32(4):558-561. Epub 2021 Jan 21.

Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC 27710. Electronic address:

Extravascular perforation is a risk of recanalizing chronic central venous occlusions. The authors describe an endovascular technique to bypass venous occlusions using a combination of a hydrophilic guide wire and radiofrequency wire in 7 patients to achieve central venous access to the right atrium without major complications.
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http://dx.doi.org/10.1016/j.jvir.2020.11.015DOI Listing
April 2021

Single-Cell Mapping of Progressive Fetal-to-Adult Transition in Human Naive T Cells.

Cell Rep 2021 Jan;34(1):108573

Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California, San Francisco, San Francisco, CA, USA; Department of Pediatrics, Division of Neonatology, University of California, San Francisco, San Francisco, CA, USA. Electronic address:

Whereas the human fetal immune system is poised to generate immune tolerance and suppress inflammation in utero, an adult-like immune system emerges to orchestrate anti-pathogen immune responses in post-natal life. It has been posited that cells of the adult immune system arise as a discrete ontological "layer" of hematopoietic stem-progenitor cells (HSPCs) and their progeny; evidence supporting this model in humans has, however, been inconclusive. Here, we combine bulk and single-cell transcriptional profiling of lymphoid cells, myeloid cells, and HSPCs from fetal, perinatal, and adult developmental stages to demonstrate that the fetal-to-adult transition occurs progressively along a continuum of maturity-with a substantial degree of inter-individual variation at the time of birth-rather than via a transition between discrete waves. These findings have important implications for the design of strategies for prophylaxis against infection in the newborn and for the use of umbilical cord blood (UCB) in the setting of transplantation.
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http://dx.doi.org/10.1016/j.celrep.2020.108573DOI Listing
January 2021

Sharp Recanalization of Chronic Central Venous Occlusions of the Thorax Using a Steerable Coaxial Needle Technique from a Supraclavicular Approach.

Cardiovasc Intervent Radiol 2021 Jan 3. Epub 2021 Jan 3.

Department of Radiology, Division of Interventional Radiology, Duke University Medical Center, Durham, NC, 27710, USA.

Purpose: To evaluate the technical success and safety of a steerable coaxial sharp recanalization technique that utilizes routine needles in patients with refractory thoracic central venous occlusions.

Materials And Methods: This retrospective study was performed on 36-attempted sharp recanalizations in 35 patients (mean age 50 years, 23 male) performed via a supraclavicular approach. In all cases, an 18-gauge trocar needle was custom curved to provide directional control during fluoroscopic triangulation. A 22-gauge Chiba needle was then advanced coaxially across the occlusion. A tractogram was performed to assess for traversal of unintended structures. Procedures were completed by catheter placement, angioplasty, or stenting follow successful recanalizations.

Results: Sharp recanalization using this steerable coaxial needle technique demonstrated a technical success rate of 94% (34/36). The mean occlusion length was 30 mm (range 3-53 mm). In 11 patients, success was achieved using this technique after failure of other advanced techniques. In five procedures, stent interstices were traversed. Sharp recanalization was the direct cause of one major complication consisting of pleural transgression causing mild hemothorax treated successfully with a stent graft.

Conclusion: The proposed technique is effective and safe for patients who have failed traditional blunt recanalization techniques.

Level Of Evidence: Level 4, Case Series.
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http://dx.doi.org/10.1007/s00270-020-02728-7DOI Listing
January 2021

Hemodialysis catheter integrity during mechanical power injection of iodinated contrast medium for computed tomography angiography.

Abdom Radiol (NY) 2021 Jan 2. Epub 2021 Jan 2.

Department of Radiology, Duke University, 2301 Erwin Road, Box 3830, Durham, NC, 27710, USA.

Purpose: CT angiography (CTA) requires vascular access with flow rates of 5-7 mL/s. Hemodialysis (HD) is performed at 6-10 mL/s. The purpose of our study is to evaluate the structural integrity of HD catheters in the administration of contrast media via a mechanical power injector under varying conditions.

Methods: Four HD catheters were evaluated in an in vitro study. Tested were contrast media type (iopamidol 300 and 370 mgI/mL), temperature (25 and 37 °C), catheter diameter (14 Fr to 16 Fr all with double-lumen capacity), catheter length (19-32 cm), and simultaneous double-lumen or single-lumen injection within each of the catheters. Peak plateau pressures (psi) were recorded with flow rates from 5 to 20 mL/s in 5 mL/s increments. In total, 864 unique injections were performed.

Results: No catheter failure (bulging/rupture) was observed in 864 injections. Maximum pressure for single-lumen injection was 51.7 psi (double-lumen: 26.3 psi). Peak pressures were significantly lower in simultaneous double-lumen vs. single-lumen injections (p < 0.001) and low vs. high viscosity contrast media (p < 0.001). Neither larger vs. smaller diameter lumens (p = 0.221) nor single-lumen injection in arterial vs. venous (p = 0.834) were significantly different.

Conclusion: HD catheters can be used to safely administer iodinated contrast media via mechanical power injection in in vitro operating conditions. Maximum peak pressure is below the manufacturer's 30 psi limit at flow rates up to 20 mL/s in double-lumen injections and up to 10 mL/s in single-lumen injections, which is higher than the usual maximum of 8 mL/s for CT angiography in clinical settings.
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http://dx.doi.org/10.1007/s00261-020-02905-9DOI Listing
January 2021

Hepatocellular carcinoma Liver Imaging Reporting and Data Systems treatment response assessment: Lessons learned and future directions.

World J Hepatol 2020 Oct;12(10):738-753

School of Medicine, 1500 East Medical Center Drive, University of Michigan, Ann Arbor, MI 48109, United States.

Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality worldwide, with rising clinical and economic burden as incidence increases. There are a multitude of evolving treatment options, including locoregional therapies which can be used alone, in combination with each other, or in combination with systemic therapy. These treatment options have shown to be effective in achieving remission, controlling tumor progression, improving disease free and overall survival in patients who cannot undergo resection and providing a bridge to transplant by debulking tumor burden to downstage patients. Following locoregional therapy (LRT), it is crucial to provide treatment response assessment to guide management and liver transplant candidacy. Therefore, Liver Imaging Reporting and Data Systems (LI-RADS) Treatment Response Algorithm (TRA) was created to provide a standardized assessment of HCC following LRT. LI-RADS TRA provides a step by step approach to evaluate each lesion independently for accurate tumor assessment. In this review, we provide an overview of different locoregional therapies for HCC, describe the expected post treatment imaging appearance following treatment, and review the LI-RADS TRA with guidance for its application in clinical practice. Unique to other publications, we will also review emerging literature supporting the use of LI-RADS for assessment of HCC treatment response after LRT.
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http://dx.doi.org/10.4254/wjh.v12.i10.738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643220PMC
October 2020

Percutaneous Gastrojejunostomy Tube Insertion in Patients with Surgical Gastrojejunal Anastomoses: Analysis of Success Rates and Durability.

J Vasc Interv Radiol 2021 02 5;32(2):277-281. Epub 2020 Nov 5.

Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC 27710. Electronic address:

Patients with a gastrojejunal anastomosis pose challenging anatomy for percutaneous gastrojejunostomy (GJ)-tube placement. A retrospective review of 24 patients (mean age 67.8 years, 13 males) with GJ anastomoses who underwent attempted GJ tube placement revealed infeasible placement in 6 patients (25%) due to an inadequate window for puncture. When a gastric puncture was achieved, GJ tube insertion was technically successful in 83% (15/18) of attempts, resulting in an overall technical success rate of 63% (15/24). The most common tube-related complication was the migration of the jejunal limb into the stomach, which occurred in 40% (6/15) of successful cases. No major procedure related complications were encountered.
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http://dx.doi.org/10.1016/j.jvir.2020.10.001DOI Listing
February 2021

Percutaneous gastrojejunostomy tubes: Identification of predictors of retrograde jejunal limb migration into the stomach.

Clin Imaging 2021 Feb 26;70:93-96. Epub 2020 Oct 26.

Division of Interventional Radiology, Duke University Medical Center, Department of Radiology, 2301 Erwin Road, Durham, NC 27710, United States of America.

Purpose: To identify whether technically modifiable factors during gastrojejunostomy (GJ) tube insertion are predictive of retrograde jejunal limb migration into the stomach.

Materials And Methods: Retrospective review of our procedural database over a 5-year period revealed 988 successful primary GJ tube insertions. Medical records and imaging were reviewed for cases of retrograde jejunal limb migration. Primary analysis was performed on 74 patients with retrograde tip migration within 3 months after placement (37 males, mean age = 57). Comparison was performed on 67 control patients (34 males, mean age = 51) who had radiologically confirmed GJ tube stability for at least 6 months. Procedural fluoroscopic images were analyzed for multiple GJ tube configuration parameters. The stomach was designated into antrum, body, and fundus. Predictors of retrograde tip migration were analyzed with univariate and multivariate logistic regression analysis.

Results: A total of 110 patients (11.1%) had retrograde jejunal limb migration, with 74 (7.5%) occurring within 3 months of placement. On multivariate analysis, the factors associated with a significantly lower risk of tip malposition included gastric puncture site in the antrum (OR: 0.27, 95% CI: 0.13-0.56, p < 0.001) and GJ tract angle less than 30 degrees away from the pylorus (OR: 0.35, 95% CI: 0.16-0.76, p = 0.008). No patient in either cohort had a major complication within 30 days of procedure.

Conclusion: To minimize the risk of retrograde tip migration, GJ tubes should be inserted into the gastric antrum with an entry tract oriented as directly towards the pylorus as possible.
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http://dx.doi.org/10.1016/j.clinimag.2020.10.036DOI Listing
February 2021

Ceftobiprole Compared With Vancomycin Plus Aztreonam in the Treatment of Acute Bacterial Skin and Skin Structure Infections: Results of a Phase 3, Randomized, Double-blind Trial (TARGET).

Clin Infect Dis 2020 Sep 8. Epub 2020 Sep 8.

Basilea Pharmaceutica International Ltd., Basel, Switzerland.

Background: The development of novel broad-spectrum antibiotics, with efficacy against both gram-positive and gram-negative bacteria, has the potential to enhance treatment options for acute bacterial skin and skin structure infections (ABSSSIs). Ceftobiprole is an advanced-generation intravenous cephalosporin with broad in vitro activity against gram-positive (including methicillin-resistant Staphylococcus aureus) and gram-negative pathogens.

Methods: TARGET was a randomized, double-blind, active-controlled, parallel-group, multicenter, phase 3 noninferiority study that compared ceftobiprole with vancomycin plus aztreonam. The Food and Drug Administration-defined primary efficacy endpoint was early clinical response 48-72 hours after treatment initiation in the intent-to-treat (ITT) population and the European Medicines Agency-defined primary endpoint was investigator-assessed clinical success at the test-of-cure (TOC) visit. Noninferiority was defined as the lower limit of the 95% CI for the difference in success rates (ceftobiprole minus vancomycin/aztreonam) >-10%. Safety was assessed through adverse event and laboratory data collection.

Results: In total, 679 patients were randomized to ceftobiprole (n = 335) or vancomycin/aztreonam (n = 344). Early clinical success rates were 91.3% and 88.1% in the ceftobiprole and vancomycin/aztreonam groups, respectively, and noninferiority was demonstrated (adjusted difference: 3.3%; 95% CI: -1.2, 7.8). Investigator-assessed clinical success at the TOC visit was similar between the 2 groups, and noninferiority was demonstrated for both the ITT (90.1% vs 89.0%) and clinically evaluable (97.9% vs 95.2%) populations. Both treatment groups displayed similar microbiological success and safety profiles.

Conclusions: TARGET demonstrated that ceftobiprole is noninferior to vancomycin/aztreonam in the treatment of ABSSSIs, in terms of early clinical response and investigator-assessed clinical success at the TOC visit.

Clinical Trials Registration: NCT03137173.
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http://dx.doi.org/10.1093/cid/ciaa974DOI Listing
September 2020

Percutaneous Splenorenal Shunt Creation in a Patient with Chronic Portomesenteric Thrombosis.

J Vasc Interv Radiol 2020 09;31(9):1408-1409

Department of Interventional Radiology, Duke University Health System, Durham, North Carolina.

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http://dx.doi.org/10.1016/j.jvir.2020.04.009DOI Listing
September 2020

Implementation of a Hepatic Artery Infusion Program: Initial Patient Selection and Perioperative Outcomes of Concurrent Hepatic Artery Infusion and Systemic Chemotherapy for Colorectal Liver Metastases.

Ann Surg Oncol 2020 Dec 10;27(13):5086-5095. Epub 2020 Aug 10.

Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA.

Background: Hepatic artery infusion (HAI) combined with systemic chemotherapy is a treatment strategy for patients with unresectable liver-only or liver-dominant colorectal liver metastases (CRLM). Although HAI has previously been performed in only a few centers, this study aimed to describe patient selection and initial perioperative outcomes during implementation of a new HAI program.

Methods: The study enrolled patients with CRLM selected for HAI after multi-disciplinary review November 2018-January 2020. Demographics, prior treatment, and perioperative outcomes were assessed. Objective hepatic response was calculated according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1.

Results: During a 14-month period, 21 patients with CRLM underwent HAI pump placement. Of these 21 patients, 20 (95%) had unresectable disease. Most of the patients had synchronous disease (n = 18, 86%) and had received prior chemotherapy (n = 20, 95%) with extended treatment cycles (median 16; interquartile range, 8-22; range, 0-66). The median number of CRLMs was 7 (range, 2-40). Operations often were performed with combined hepatectomy (n = 4, 19%) and/or colectomy/proctectomy (n = 11, 52%). The study had no 90-day mortality. The overall surgical morbidity was 19%. The HAI-specific complications included pump pocket seroma (n = 2), hematoma (n = 1), surgical-site infection (n = 1), and extrahepatic perfusion (n = 1). HAI was initiated in 20 patients (95%). The hepatic response rates at 3 months included partial response (n = 4, 24%), stable disease (n = 9, 53%), and progression of disease (n = 4, 24%), yielding a 3-month hepatic disease control rate (DCR) of 76%.

Conclusion: Implementation of a new HAI program is feasible, and HAI can be delivered safely to selected patients with CRLM. The initial response and DCR are promising, even for patients heavily pretreated with chemotherapy.
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http://dx.doi.org/10.1245/s10434-020-08972-yDOI Listing
December 2020

Financial Effect of Unbundling Moderate Sedation from Procedural Codes in Radiology.

J Vasc Interv Radiol 2020 Aug;31(8):1302-1307.e1

Division of Interventional Radiology, Duke Health, DUMC Box 3808, Durham, NC, 27710.

Purpose: To assess and quantify the financial effect of unbundling newly unbundled moderate sedation codes across major payors at an academic radiology practice.

Materials And Methods: Billing and reimbursement data for 23 months of unbundled moderate sedation codes were analyzed for reimbursement rates and trends. This included 10,481 and 28,189 units billed and $443,257 and $226,444 total receipts for codes 99152 (initial 15 minutes of moderate sedation) and 99153 (each subsequent 15 minute increment of moderate sedation), respectively. Five index procedures-(i) central venous port placement, (ii) endovascular tumor embolization, (iii) tunneled central venous catheter placement, (iv) percutaneous gastrostomy placement, and (v) percutaneous nephrostomy placement-were identified, and moderate sedation reimbursements for Medicare and the dominant private payor were calculated and compared to pre-bundled reimbursements. Revenue variation models across different patient insurance mixes were then created using averages from 4 common practice settings among radiologists (independent practices, all hospitals, safety-net hospitals, and non-safety-net hospitals).

Results: Departmental reimbursement for unbundled moderate sedation in FY2018 and FY2019 totaled $669,701.34, with high per-unit variability across payors, especially for code 99153. Across the 5 index procedures, moderate sedation reimbursement decreased 1.3% after unbundling and accounted for 3.9% of procedural revenue from Medicare and increased 11.9% and accounted for 5.5% of procedural revenue from the dominant private payor. Between different patient insurance mix models, estimated reimbursement from moderate sedation varied by as much as 29.9%.

Conclusions: Departmental reimbursement from billing the new unbundled moderate sedation codes was sizable and heterogeneous, highlighting the need for consistent and accurate reporting of moderate sedation. Total collections vary by case mix, patient insurance mix, and negotiated reimbursement rates.
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http://dx.doi.org/10.1016/j.jvir.2020.04.034DOI Listing
August 2020

Infection and Activation of B Cells by Theiler's Murine Encephalomyelitis Virus (TMEV) Leads to Autoantibody Production in an Infectious Model of Multiple Sclerosis.

Cells 2020 07 27;9(8). Epub 2020 Jul 27.

Department of Microbiology-Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.

Theiler's murine encephalomyelitis virus (TMEV) induces immune-mediated inflammatory demyelinating disease in susceptible mice that is similar to human multiple sclerosis (MS). In light of anti-CD20 therapies for MS, the susceptibility of B cells to TMEV infection is particularly important. In our study, direct viral exposure to macrophages and lymphocytes resulted in viral replication and cellular stimulation in the order of DCs, macrophages, B cells, and T cells. Notably, B cells produced viral proteins and expressed elevated levels of CD69, an activation marker. Similarly, the expression of major histocompatibility complex class II and costimulatory molecules in B cells was upregulated. Moreover, TMEV-infected B cells showed elevated levels of antigen-presenting function and antibody production. TMEV infection appeared to polyclonally activate B cells to produce autoantibodies and further T cell stimulation. Thus, the viral infection might potentially affect the outcome of autoimmune diseases, and/or the development of other chronic infections, including the protection and/or pathogenesis of TMEV-induced demyelinating disease.
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http://dx.doi.org/10.3390/cells9081787DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7465974PMC
July 2020

Jejunostomy Tube Insertion for Enteral Nutrition: Comparison of Outcomes after Laparoscopic versus Radiologic Insertion.

J Vasc Interv Radiol 2020 Jul 24;31(7):1132-1138. Epub 2020 May 24.

Division of Interventional Radiology, Duke University Medical Center, Box 3808, Durham, NC, 27710.

Purpose: To retrospectively compare technical success and major complication rates of laparoscopically versus radiologically inserted jejunostomy tubes.

Materials And Methods: In this single-institution retrospective study, 115 patients (60 men; mean age, 59.7 y) underwent attempted laparoscopic jejunostomy tube insertion as a standalone procedure during a 10-year period and 106 patients (64 men; mean age, 61.0 y) underwent attempted direct percutaneous radiologic jejunostomy tube insertion during an overlapping 6-year period. Clinical outcomes were retrospectively reviewed with primary focus on predictors of procedure-related major complications within 30 days.

Results: Patients undergoing laparoscopic jejunostomy tube insertion were less likely to have previous major abdominal surgery (P < .001) or to be critically ill (P < .001) and had a higher body mass index (P = .001) than patients undergoing radiologic insertion. Technical success rates were 95% (110 of 115) for laparoscopic and 97% (103 of 106) for radiologic jejunostomy tube insertion (P = .72). Major procedural complications occurred in 7 patients (6%) in the laparoscopic group and in 5 (5%) in the radiologic group (P = 1.0). For laparoscopic jejunostomy tubes, only previous major abdominal surgery was significantly associated with a higher major procedure complication rate (14% [5 of 37] vs 3% [2 of 78] in those without; P = .039). In the radiologic jejunostomy group, only obesity was significantly associated with a higher major complication rate: 20% (2 of 10) vs 3% (3 of 96) in nonobese patients (P = .038).

Conclusions: Laparoscopic and radiologic jejunostomy tube insertion both showed high success and low complication rates. Previous major abdominal surgery and obesity may be pertinent discriminators for patient selection.
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http://dx.doi.org/10.1016/j.jvir.2019.12.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549126PMC
July 2020

Metoclopramide Reduces Fluoroscopy and Procedure Time during Gastrojejunostomy Tube Placement: A Placebo-Controlled Trial.

J Vasc Interv Radiol 2020 Jul 23;31(7):1143-1147. Epub 2020 May 23.

Department of Radiology, Division of Vascular & Interventional Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC 27710. Electronic address:

Purpose: To determine whether a single 10-mg intravenous dose of the promotility agent metoclopramide reduces the fluoroscopy time, radiation dose, and procedure time required for gastrojejunostomy (GJ) tube placement.

Methods: This prospective, randomized, double-blind, placebo-controlled trial enrolled consecutive patients who underwent primary GJ tube placement at a single institution from April 10, 2018, to October 3, 2019. Exclusion criteria included age less than 18 years, inability to obtain consent, metoclopramide allergy or contraindication, and altered pyloric anatomy. Average fluoroscopy times, radiation doses, and procedure times were compared using t-tests. The full study protocol can be found at www.clinicaltrials.gov (NCT03331965).

Results: Of 110 participants randomized 1:1, 45 received metoclopramide and 51 received placebo and underwent GJ tube placement (38 females and 58 males; mean age, 55 ± 18 years). Demographics of the metoclopramide and placebo groups were similar. The fluoroscopy time required to advance a guide wire through the pylorus averaged 1.6 minutes (range, 0.3-10.1 minutes) in the metoclopramide group versus 4.1 minutes (range, 0.2-27.3 minutes) in the placebo group (P = .002). Total procedure fluoroscopy time averaged 5.8 minutes (range, 1.5-16.2 minutes) for the metoclopramide group versus 8.8 minutes (range, 2.8-29.7 minutes) for the placebo group (P = .002). Air kerma averaged 91 mGy (range, 13-354 mGy) for the metoclopramide group versus 130 mGy (range, 24-525 mGy) for the placebo group (P = .04). Total procedure time averaged 16.4 minutes (range, 8-51 minutes) for the metoclopramide group versus 19.9 minutes (range, 6-53 minutes) for the placebo group (P = .04). There were no drug-related adverse events and no significant differences in procedure-related complications.

Conclusions: A single dose of metoclopramide reduced fluoroscopy time by 34%, radiation dose by 30%, and procedure time by 17% during GJ tube placement.
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http://dx.doi.org/10.1016/j.jvir.2020.02.028DOI Listing
July 2020

ACR Appropriateness Criteria® Radiologic Management of Urinary Tract Obstruction.

J Am Coll Radiol 2020 May;17(5S):S281-S292

Specialty Chair, University of Chicago Hospital, Chicago, Illinois.

Acute obstructive uropathy is a medical emergency, which often is accompanied by acute renal failure or sepsis. Treatment options to resolve the acute obstructive process include conservative medical management, retrograde ureteral stenting, or placement of percutaneous nephrostomy or nephroureteral catheters. It is important to understand the various treatment options in differing clinical scenarios in order to guide appropriate consultation. Prompt attention to the underlying obstructive process is often imperative to avoid further deterioration of the patient's clinical status. A summary of the data and most up-to-date clinical trials regarding treatment options for urinary tract obstruction is outlined in this publication. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.01.039DOI Listing
May 2020

ACR Appropriateness Criteria® Radiologic Management of Infected Fluid Collections.

J Am Coll Radiol 2020 May;17(5S):S265-S280

Specialty Chair, University of Chicago Hospital, Chicago, Illinois.

Infected fluid collections are common and occur in a variety of clinical scenarios throughout the body. Minimally invasive image-guided management strategies for infected fluid collections are often preferred over more invasive options, given their low rate of complications and high rates of success. However, specific clinical scenarios, anatomic considerations, and prior or ongoing treatments must be considered when determining the optimal management strategy. As such, several common scenarios relating to infected fluid collections were developed using evidence-based guidelines for management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.01.034DOI Listing
May 2020

ACR Appropriateness Criteria® Radiologic Management of Gastric Varices.

J Am Coll Radiol 2020 May;17(5S):S239-S254

Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin.

Hemorrhage, resulting from gastric varies, can be challenging to treat, given the various precipitating etiologies. A wide variety of treatment options exist for managing the diverse range of the underlying disease processes. While cirrhosis is the most common cause for gastric variceal bleeding, occlusion of the portal or splenic vein in noncirrhotic states results in a markedly different treatment paradigm. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.01.017DOI Listing
May 2020

Arteriovenous Graft Delamination and Dissection as a Cause of Graft Dysfunction.

J Vasc Interv Radiol 2020 05 15;31(5):852-854.e1. Epub 2020 Apr 15.

Duke University School of Medicine, Durham, North Carolina 27710; Department of Radiology, Division of Interventional Radiology, Duke University Medical Center, 2301 Erwin Road, Box 3808, Durham, NC.

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http://dx.doi.org/10.1016/j.jvir.2019.11.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586731PMC
May 2020

Post-discharge opioid use and handling in surgical patients: A multicentre prospective cohort study.

Anaesth Intensive Care 2020 Jan;48(1):36-42

Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Melbourne, Australia.

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http://dx.doi.org/10.1177/0310057X19895019DOI Listing
January 2020

Transient Reperfusion-Like Injury following Endovascular Treatment of Chronic Mesenteric Ischemia.

J Vasc Interv Radiol 2020 03 29;31(3):519-521. Epub 2020 Jan 29.

Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC 27710.

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http://dx.doi.org/10.1016/j.jvir.2019.09.015DOI Listing
March 2020

Length of Stay Predicts Risk of Early Infection for Hospitalized Patients Undergoing Central Venous Port Placement.

J Vasc Interv Radiol 2020 Mar 29;31(3):454-461. Epub 2020 Jan 29.

Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710. Electronic address:

Purpose: To compare early totally implantable central venous port catheter-related infection rates after inpatient vs outpatient placement and to determine whether the risk associated with inpatient placement is influenced by length of hospital stay.

Materials And Methods: In this single-institution retrospective study, 5,301 patients (3,618 women; mean age 57 y) underwent port placement by interventional radiologists between October 2004 and January 2018. The 30-day infection rate was compared between inpatients and outpatients using survival analysis. Among inpatients, the effect of time from admission to port placement and from placement to discharge was analyzed using a survival regression tree.

Results: The 30-day infection rate was 3.6% (95% confidence interval [CI] = 1.9%-6.1%) among 386 inpatients and 1.0% (95% CI = 0.7%-1.3%) among 4,915 outpatients (hazard ratio [HR] = 3.6, 95% CI = 2.0-6.6, P < .001). Inpatient placement was a significant risk factor after accounting for covariates in multivariate analysis (HR = 2.2, 95% CI = 1.0-4.7, P = .05) and controlling for demographic differences by propensity score matching (HR = 2.8, 95% CI = 1.0-7.8, P = .04). Infection rate was 11% (95% CI = 4.7%-22%) among 65 inpatients in whom time from admission to placement was ≥ 7 days, 5.1% (95% CI = 1.9%-11%) among 129 inpatients in whom admission to placement was < 7 days and time to discharge was > 3 days, and 0% (95% CI = 0%-2.1%) among 192 inpatients in whom admission to placement was < 7 days and time to discharge was ≤ 3 days (P < .001).

Conclusions: Inpatient port placement was associated with a higher risk of early infection. However, a clinical decision tree based on shorter length of stay before and after placement may identify a subset of hospitalized patients not at increased risk for infection.
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http://dx.doi.org/10.1016/j.jvir.2019.10.017DOI Listing
March 2020

Post-surgical opioid stewardship programs across Australia and New Zealand: Current situation and future directions.

Anaesth Intensive Care 2019 Nov 25;47(6):548-552. Epub 2019 Nov 25.

Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia.

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http://dx.doi.org/10.1177/0310057X19880904DOI Listing
November 2019

Treatment of Arm Swelling in Hemodialysis Patients with Ipsilateral Arteriovenous Access and Central Vein Stenosis: Conversion to the Hemodialysis Reliable Outflow Graft versus Stent Deployment.

J Vasc Interv Radiol 2020 Feb 6;31(2):243-250. Epub 2019 Nov 6.

Division of Interventional Radiology, Duke University Medical Center, Durham, North Carolina. Electronic address:

Purpose: To compare outcomes after conversion of arteriovenous (AV) access to Hemodialysis Reliable Outflow (HeRO) graft vs stent deployment in patients with arm swelling owing to ipsilateral central vein stenosis.

Materials And Methods: This single-center retrospective study comprised 48 patients (19 men, mean age 58 y) with arm swelling ipsilateral to AV access and central vein stenosis over a 13-year period who had clinical follow-up and without prior central stents. Twenty-one patients underwent placement of a HeRO graft with anastomosis of the HeRO graft to the existing graft or fistula, and 27 patients underwent central venous stent deployment. Symptomatic improvement in arm swelling and access patency rates after intervention were ascertained from medical records.

Results: Improvement in swelling within 1 month after HeRO conversion and stent deployment was found in 95% and 89%, respectively (P = .62). Swelling eventually recurred in 16 patients (59%) treated with stents compared with 1 patient (5%) who underwent HeRO conversion (P < .001). Primary access patency was statistically significantly longer after HeRO conversions than stent deployments, with 6- and 12-month primary patency rates of 89% and 72% vs 47% and 11% (P < .001). HeRO conversions also resulted in longer 6- and 12-month secondary access patency rates (95% and 95% vs 79% and 58%, P = .006). Mean number of interventions per 1,000 access days to maintain secondary patency was 2.7 for the HeRO group vs 6.3 for the stent group.

Conclusions: Although stent deployment and HeRO graft conversion are effective for alleviating arm swelling in the short term in patients receiving hemodialysis with clinically significant arm swelling and functioning AV access, the HeRO graft has more durable results.
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http://dx.doi.org/10.1016/j.jvir.2019.06.010DOI Listing
February 2020

Relative Sarcopenia With Excess Adiposity Predicts Survival After Transjugular Intrahepatic Portosystemic Shunt Creation.

AJR Am J Roentgenol 2020 01 31;214(1):200-205. Epub 2019 Oct 31.

Department of Radiology, Division of Abdominal Imaging, Duke University Medical Center, Durham, NC.

The purpose of this study was to assess the impact of relative sarcopenia with excess adiposity on mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation. In this single-institution retrospective study, patients underwent abdominal CT scans within 100 days before or 30 days after TIPS creation. Subcutaneous and visceral adipose tissue and muscle were segmented at the L3 vertebral level. Relative sarcopenia with excess adiposity was defined as the lowest sex-specific quartile of muscle area divided by muscle plus adipose. Dates of death, liver transplantation, TIPS occlusion, and hepatic encephalopathy (HE) after TIPS creation were identified. Mortality was evaluated using competing risks survival analysis. Number of HE episodes and time to first episode were analyzed using negative binomial regression and competing risks survival analysis, respectively. A total of 141 patients (91 men; mean age, 56 years) were included in this study. In univariate analyses, Model for End-Stage Liver Disease (MELD) score (hazard ratio [HR], 1.09 per point; CI, 1.05-1.13; < 0.001) and relative sarcopenia with excess adiposity (HR, 2.70; CI, 1.55-4.69; < 0.001) were significant risk factors for shorter survival after TIPS. In multivariate analysis, both MELD score (HR, 1.09; CI, 1.03-1.15; = 0.003) and relative sarcopenia with excess adiposity (HR, 2.65; CI, 1.56-4.51; < 0.001) were significant predictors of worse survival. The C-index at 30 days was 0.71 for MELD score, 0.72 for relative sarcopenia with excess adiposity, and 0.80 for a model including both. There was no association between relative sarcopenia with excess adiposity and number of HE episodes (incidence rate ratio, 1.08; CI, 0.49-2.40; = 0.84) or time to first HE episode (HR, 0.89; CI, 0.51-1.54; = 0.67). Relative sarcopenia with excess adiposity is a risk factor for mortality after TIPS and contributes additional prognostic information beyond MELD score.
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http://dx.doi.org/10.2214/AJR.19.21655DOI Listing
January 2020

Spinal Arterial Blood Supply Does Not Arise from the Bronchial Arteries: A Detailed Analysis of Angiographic Studies Performed for Hemoptysis.

J Vasc Interv Radiol 2019 Nov 4;30(11):1736-1742. Epub 2019 Oct 4.

Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, 1502 Erwin Road, Box 3838, Durham, NC 27710. Electronic address:

Purpose: To determine the angiographic prevalence of spinal arteries originating directly from the bronchial arteries in the setting of embolization for hemoptysis.

Materials And Methods: Over a 14-year interval, 205 patients underwent angiography for hemoptysis. Twenty-five patients were excluded because their bronchial arteries were not visualized. The remaining 180 patients underwent a total of 254 angiographic procedures (range, 1-8 per patient). Images were reviewed jointly by 2 interventional radiologists with formal fellowship training in both peripheral and neurological interventional radiology. All catheterized arteries were evaluated for arterial contribution to the spinal cord. For patients with multiple studies, each unique artery was reported only once. Embolization was performed during at least 1 procedure in 158 patients (88%). Electronic record review was used to assess neurological sequelae after the procedure.

Results: One or 2 bronchial arteries originating from the aorta were identified in 57 patients (32%) on the right and in 75 patients (42%) on the left. Conjoined bronchial arteries were found in 76 patients (42%). Spinal arterial supply was absent in all. A total of 102 patients (57%) had at least 1 right and 11 patients (6%) at least 1 left intercostobronchial artery. Spinal arterial supply from the intercostal portion of an intercostobronchial artery was found in 6 patients (5 right, 1 left). Medical record review revealed no postprocedure symptoms referable to spinal cord injury in any patient.

Conclusions: Spinal arterial supply does not originate directly from the bronchial artery but can originate from the intercostal portion of an intercostobronchial artery.
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http://dx.doi.org/10.1016/j.jvir.2019.07.033DOI Listing
November 2019

Refractory Metastatic Insulinoma Treated with Everolimus, Complicated by Cryptogenic Organizing Pneumonia.

Am J Med Case Rep 2019 18;7(7):125-132. Epub 2019 Jun 18.

Department of Medicine and Department of Endocrinology, State University of New York: Downstate Medical Center.

Insulinoma is a rare neuroendocrine pancreatic islet cell tumor of which the majority are benign and solitary. Its estimated incidence is 2 to 4 cases per 1 million person-years. We report the case of an 82-year-old female who presented with metastatic insulinoma to the liver and retroperitoneal lymph nodes. It was diagnosed based on positive Whipple's triad, elevated insulin, elevated C-peptide, and negative insulin auto-antibody. Her disease was initially managed with diazoxide 100 mg orally every 8 hours, octreotide LAR 30 mg intramuscularly every month, and sunitinib 12.5 mg orally three times a day. However, patient had recurrent symptoms and imaging consistent with worsened metastatic insulinoma; and thus, treatment was changed to everolimus 10 mg PO daily. Over the subsequent 10 months, the patient developed progressive shortness of breath and hypoxemia with and oxygen saturation (SpO2) of 89% on room air. Computerized tomography (CT) and lung biopsy were consistent with cryptogenic organizing pneumonia (COP) temporally associated with the initiation of everolimus. She was started on prednisone 1 mg/kg/day and within 48 hours, her symptoms and hypoxemia improved to SpO2 of 98-99% at room air and her repeat CT chest showed marked disease improvement. Given her good response with everolimus, it was continued in conjunction with the prednisone and to this day, patient has had a significant therapeutic response with normoglycemia and stable, well-controlled symptoms. This case is unique because to our knowledge, it is the first reported case of a patient with metastatic insulinoma complicated by the development of cryptogenic organizing pneumonia. It reaffirms the causal association between everolimus and cryptogenic organizing pneumonia that has been reported numerous times in literature. However, there has been no reported cases showing that the COP can be managed with prednisone concurrently with everolimus for the metastatic insulinoma without diminished clinical benefit. While pulmonary complications have been cited as reasons for discontinuation of everolimus therapy, our case report highlights the use of steroids as a viable therapeutic strategy that allows successful therapy with everolimus to be continued. In addition to presenting this case, we will also do a thorough review of the literature surrounding the available therapeutic options of metastatic insulinoma. This will include surgery, somatostatin analogs, antimicrobials, potassium channel activators, VEGF-A inhibitors, alkylating agents and mTOR inhibitors to provide a more in-depth picture of how we treat metastatic insulinoma.
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http://dx.doi.org/10.12691/ajmcr-7-7-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6693857PMC
June 2019