Publications by authors named "James Ronald"

55 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

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

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

The Prevalence of Uterine Fibroids in African American Women with Hemoglobin SS Sickle Cell Disease as Determined by Pelvic Magnetic Resonance Imaging.

Acad Radiol 2020 Aug 17. Epub 2020 Aug 17.

Department of Radiology, Division of Interventional Radiology, Duke University School of Medicine, DUMC 3808, 2301 Erwin Rd, 1502 Duke North, Durham, NC 27710. Electronic address:

Rationale And Objectives: This study explores the relationship between the development of uterine fibroids and hemoglobin SS sickle cell disease (SCD) by examining the prevalence of uterine fibroids as detected by pelvic magnetic resonance imaging (MRI) in African American (AA) women with and without SCD.

Materials And Methods: A single-center, retrospective review was performed of all adult AA women at a large, academic medical center who received pelvic MRI from January 1, 2007 to December 31, 2018. Propensity score matching conditional on age and ZIP code evaluated the differences in fibroid prevalence between the two groups. Subanalyses by age in 10-year intervals were also performed.

Results: Twenty-one (23.9%) of 88 patients with SCD had fibroids on pelvic MRI versus 1493 (52.1%) of 2868 patients without SCD (p value <0.001). After propensity score matching, 21 (24.7%) of 85 patients with SCD compared to 52 (61.2%) of 85 patients without SCD had fibroids (p value <0.001). Subanalyses in 10-year age intervals showed significance for patients between 30 and 39 years old in which 4 (13.8%) of 29 SCD patients versus 374 (65.3%) of 573 no SCD patients had fibroids (p value <0.001), and for patients between 40 and 49 years old in which 9 (42.9%) of 21 SCD patients versus 667 (73.8%) of 904 no SCD patients had fibroids (p value = 0.002).

Conclusion: These findings indicate an overall significantly lower prevalence of uterine fibroids in AA women with SCD, suggesting that SCD may be protective against the development of uterine fibroids in these patients.
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http://dx.doi.org/10.1016/j.acra.2020.07.032DOI Listing
August 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

Knowledge Retention in Radiology Residents for Audience Response System Versus Traditional Hot-Seat Conference.

J Am Coll Radiol 2021 Feb 28;18(2):305-308. Epub 2020 Jul 28.

Vice Chair of Education, Department of Radiology, Duke University Medical Center, Durham, North Carolina.

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http://dx.doi.org/10.1016/j.jacr.2020.07.008DOI Listing
February 2021

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

Cerebral monitoring during transcarotid artery revascularization with flow reversal via transcranial doppler ultrasound examination.

J Vasc Surg 2021 Jan 22;73(1):125-131. Epub 2020 Apr 22.

Department of Surgery, Duke University Medical Center, Durham, NC. Electronic address:

Objective: Transcarotid artery revascularization (TCAR) is a hybrid technique for carotid artery revascularization that relies on proximal carotid occlusion with flow reversal for distal embolic protection. The hemodynamic response of the intracranial circulation to flow reversal is unknown. In addition, the rate and pattern of cerebral embolization during flow reversal has yet to be investigated. The aim of this study was to characterize cerebral hemodynamic and embolization patterns during TCAR.

Methods: A single-institution retrospective study of patients with carotid artery stenosis undergoing TCAR with intraoperative transcranial Doppler (TCD) monitoring of the middle cerebral artery (MCA) was performed. Primary outcomes included changes in MCA velocity and MCA embolic signals observed throughout TCAR.

Results: Eleven patients underwent TCAR with TCD monitoring of the ipsilateral MCA. The average MCA velocity at baseline was 50.6 ± 16.4 cm/s. MCA flow decreased significantly upon initiation of flow reversal (50.5 ± 16.4 cm/s vs 19.1 ± 18.4 cm/s; P = .02). The reinitiation of antegrade flow resulted in a significant increase in the number of embolic events compared with baseline (P = .003), and embolic events were observed in two patients during flow reversal.

Conclusions: TCD monitoring of patients undergoing TCAR revealed that the initiation of flow reversal results in a decrement in ipsilateral MCA velocity. Furthermore, embolic events can occur during flow reversal and are significantly associated with the reinitiation of antegrade flow in the internal carotid artery. However, both of these hemodynamic events were well-tolerated in our cohort. These findings suggest that TCAR remains a safe neuroprotective strategy for carotid revascularization.
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http://dx.doi.org/10.1016/j.jvs.2020.03.051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577965PMC
January 2021

A mobile ELF4 delivers circadian temperature information from shoots to roots.

Nat Plants 2020 04 13;6(4):416-426. Epub 2020 Apr 13.

Centre for Research in Agricultural Genomics (CRAG), CSIC-IRTA-UAB-UB, Campus UAB, Bellaterra, Barcelona, Spain.

The circadian clock is synchronized by environmental cues, mostly by light and temperature. Explaining how the plant circadian clock responds to temperature oscillations is crucial to understanding plant responsiveness to the environment. Here, we found a prevalent temperature-dependent function of the Arabidopsis clock component EARLY FLOWERING 4 (ELF4) in the root clock. Although the clocks in roots are able to run in the absence of shoots, micrografting assays and mathematical analyses show that ELF4 moves from shoots to regulate rhythms in roots. ELF4 movement does not convey photoperiodic information, but trafficking is essential for controlling the period of the root clock in a temperature-dependent manner. Low temperatures favour ELF4 mobility, resulting in a slow-paced root clock, whereas high temperatures decrease movement, leading to a faster clock. Hence, the mobile ELF4 delivers temperature information and establishes a shoot-to-root dialogue that sets the pace of the clock in roots.
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http://dx.doi.org/10.1038/s41477-020-0634-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197390PMC
April 2020

GIGANTEA Integrates Photoperiodic and Temperature Signals to Time when Growth Occurs.

Mol Plant 2020 03 17;13(3):357-359. Epub 2020 Feb 17.

University of York, Department of Biology, Heslington, York YO10 5DD, UK; Key Laboratory of Plant Stress Biology, School of Life Sciences, Henan University, Kaifeng 475004, China. Electronic address:

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http://dx.doi.org/10.1016/j.molp.2020.02.008DOI 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

Ultrasound-guided non-targeted liver core biopsy: comparison of the efficacy of two different core needle biopsy systems using an ex-vivo animal model and retrospective review of clinical experience.

Clin Imaging 2020 May 9;61:36-42. Epub 2020 Jan 9.

Department of Radiology, Duke University Medical Center, 2301 Erwin Road, Box 3808, Durham, NC 22710, United States of America. Electronic address:

Purpose: To compare the efficacy of two 18-gauge core needle biopsy systems, the Achieve® (Merit Medical) and the Marquee® (BD Bard), using an ex-vivo animal liver model and retrospective review of clinical experience.

Methods: Sixty ex-vivo liver biopsy samples were obtained using the Achieve® (n = 30) and the Marquee® (n = 30) needles. In addition, 20 liver biopsy samples from 20 patients obtained using the Achieve® (n = 10) and Marquee® (n = 10) were compared retrospectively. One pathologist, blinded to needle type, recorded total core length and the number of complete portal triads. Ex vivo measurements were compared using mixed effects linear, logistic, and ordinal regression. In vivo measurements were compared using Student's t-test.

Results: For the Achieve® and Marquee® needles, the mean(SD) total core length (mm) of ex vivo samples was 11.0(3.3) and 12.6(3.4), respectively (P = 0.069) and the adequacy rate was 23.3% and 50%, respectively (P = 0.04). Mean number of portal triads of ex vivo samples was 7.2(2.9) and 8.6(3.8), respectively (P = 0.13), and the adequacy rate was 73.3% and 83.3%, respectively (P = 0.32). For in vivo samples, the Achieve® and Marquee® needles demonstrates mean(SD) total core length (mm) of 24.6(7.1) and 32.0(4.6), respectively (P = 0.01), adequacy rate (P = 0.06). Mean number of portal triads was 14.9(4.8) and 19.6(4.1), respectively (P = 0.03), adequacy rate (P = 0.47).

Conclusions: Slightly longer core biopsies were obtained with the Marquee® needle compared with the Achieve® needle. Early clinical experience demonstrates no significant difference in sample adequacy rates. Both needle types can be expected to provide adequate samples for pathologic assessment of liver tissue.
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http://dx.doi.org/10.1016/j.clinimag.2020.01.005DOI Listing
May 2020

The LI-RADS Version 2018 MRI Treatment Response Algorithm: Evaluation of Ablated Hepatocellular Carcinoma.

Radiology 2020 02 17;294(2):320-326. Epub 2019 Dec 17.

From the Department of Radiology (M.C., E.S., J.R., M.R.B.), Division of Gastroenterology, Department of Medicine (M.R.B.), and Center for Advanced Magnetic Development (M.R.B.), Duke University Medical Center, 200 Trent Dr, Durham, NC 27710; Departments of Radiology (M.C., K.A.M., B.M., L.M.B.B.) and Pathology (L.C., J.H.); Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC (R.L., C.L., S.L.).

Background The Liver Imaging Reporting and Data System LI-RADS) treatment response algorithm (TRA) is used to assess presumed hepatocellular carcinoma (HCC) after local-regional therapy, but its performance has not been extensively assessed. Purpose To assess the performance of LI-RADS version 2018 TRA in the evaluation of HCC after ablation. Materials and Methods In this retrospective study, patients who underwent ablation therapy for presumed HCC followed by liver transplantation between January 2011 and December 2015 at a single tertiary care center were identified. Lesions were categorized as completely (100%) or incompletely (≤99%) necrotic based on transplant histology. Three radiologists assessed pre- and posttreatment MRI findings using LI-RADS version 2018 and the TRA, respectively. Interreader agreement was assessed by using the Fleiss κ test. Performance characteristics for predicting necrosis category based on LI-RADS treatment response (LR-TR) category (viable or nonviable) were calculated by using generalized mixed-effects models to account for clustering by subject. Results A total of 36 patients (mean age, 58 years ± 5 [standard deviation]; 32 men) with 53 lesions was included. Interreader agreement for pretreatment LI-RADS category was 0.40 (95% confidence interval [CI]: 0.15, 0.67; < .01) and was lower than the interreader agreement for TRA category (κ = 0.71; 95% CI: 0.59, 0.84; < .01). After accounting for clustering by subject, sensitivity of tumor necrosis across readers ranged from 40% to 77%, and specificity ranged from 85% to 97% when LR-TR equivocal assessments were treated as nonviable. When LR-TR equivocal assessments were treated as viable, sensitivity of tumor necrosis across readers ranged from 81% to 87%, and specificity ranged from 81% to 85% across readers. Six (11%) of 53 treated lesions were LR-TR equivocal by consensus, with most (five of six) incompletely necrotic at histopathology. Conclusion The Liver Imaging Reporting and Data System treatment response algorithm can be used to predict viable or nonviable hepatocellular carcinoma after ablation. Most ablated lesions rated as treatment response equivocal were incompletely necrotic at histopathology. © RSNA, 2019 See also the editorial by Do and Mendiratta-Lala in this issue.
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http://dx.doi.org/10.1148/radiol.2019191581DOI Listing
February 2020

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

Local Tumor Control and Patient Outcome Using Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma: iRECIST as a Potential Substitute for Traditional Criteria.

AJR Am J Roentgenol 2019 12 15;213(6):1232-1239. Epub 2019 Oct 15.

Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710.

The purpose of this study was to investigate whether, compared with traditional criteria, the modified Response Evaluation Criteria in Solid Tumors version 1.1 for immune-based therapeutics (iRECIST) improves prediction of local tumor control and survival in patients with hepatocellular carcinoma (HCC) treated with stereotactic body radiotherapy (SBRT). Fifty-one HCC lesions (mean size, 3.1 cm) treated with SBRT in 41 patients (mean age, 67 years) were retrospectively included. Each patient underwent CT or MRI before SBRT and at least once after SBRT. Best overall response was categorized using Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1), iRECIST, World Health Organization (WHO) criteria, modified Response Evaluation Criteria in Solid Tumors (mRECIST), and European Association for the Study of the Liver (EASL) criteria. Lesions were then classified as local tumor control (i.e., stable disease, partial response, or complete response) or local treatment failure (i.e., progressive disease) by each tumor response criteria. Proportions of local tumor control were compared using the McNemar exact test. The 1-year overall survival was estimated using the Kaplan-Meier method. The median follow-up after SBRT was 21.0 months. The local tumor control rate was 94.1% (48/51) by iRECIST, 88.2% (45/51) by RECIST 1.1, 72.5% (37/51) by WHO criteria, 80.4% (41/51) by mRECIST, and 72.5% (37/51) by EASL criteria. The local tumor control rate was significantly higher according to iRECIST compared with WHO ( = 0.0010) and EASL ( = 0.0225) criteria. The 1-year survival rate for patients with local tumor control according to iRECIST (86.4%) was higher (although not statistically significant) compared with the 1-year survival rate for patients with local tumor control according to the other response criteria. iRECIST may provide more robust interpretation of HCC response after SBRT, yielding improved prediction of local tumor control and 1-year survival rates compared with traditional criteria.
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http://dx.doi.org/10.2214/AJR.18.20842DOI Listing
December 2019

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

Reproducibility of CT Radiomic Features within the Same Patient: Influence of Radiation Dose and CT Reconstruction Settings.

Radiology 2019 12 1;293(3):583-591. Epub 2019 Oct 1.

From the Department of Radiology (M.M., J.R., F.V., R.C.N., D.M.) and Duke Advanced Imaging Laboratories (J.S., E.S.), Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710; Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim-Heidelberg University, Mannheim, Germany (M.M.); Section of Department of Radiology, DIBIMED, University of Palermo, Palermo, Italy (F.V.); Siemens Healthineers, Malvern, Pa (J.C.R.); and Department of Radiology, Stanford University, School of Medicine, Stanford, Calif (B.N.P.).

Background Results of recent phantom studies show that variation in CT acquisition parameters and reconstruction techniques may make radiomic features largely nonreproduceable and of limited use for prognostic clinical studies. Purpose To investigate the effect of CT radiation dose and reconstruction settings on the reproducibility of radiomic features, as well as to identify correction factors for mitigating these sources of variability. Materials and Methods This was a secondary analysis of a prospective study of metastatic liver lesions in patients who underwent staging with single-energy dual-source contrast material-enhanced staging CT between September 2011 and April 2012. Technique parameters were altered, resulting in 28 CT data sets per patient that included different dose levels, section thicknesses, kernels, and reconstruction algorithm settings. By using a training data set ( = 76), reproducible intensity, shape, and texture radiomic features (reproducibility threshold, ≥ 0.95) were selected and correction factors were calculated by using a linear model to convert each radiomic feature to its estimated value in a reference technique. By using a test data set ( = 75), the reproducibility of hierarchical clustering based on 106 radiomic features measured with different CT techniques was assessed. Results Data in 78 patients (mean age, 60 years ± 10; 33 women) with 151 liver lesions were included. The percentage of radiomic features deemed reproducible for any variation of the different technical parameters was 11% (12 of 106). Of all technical parameters, reconstructed section thickness had the largest impact on the reproducibility of radiomic features (12.3% [13 of 106]) if only one technical parameter was changed while all other technical parameters were kept constant. The results of the hierarchical cluster analysis showed improved clustering reproducibility when reproducible radiomic features with dedicated correction factors were used (ρ = 0.39-0.71 vs ρ = 0.14-0.47). Conclusion Most radiomic features are highly affected by CT acquisition and reconstruction settings, to the point of being nonreproducible. Selecting reproducible radiomic features along with study-specific correction factors offers improved clustering reproducibility. © RSNA, 2019 See also the editorial by Sosna in this issue.
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http://dx.doi.org/10.1148/radiol.2019190928DOI Listing
December 2019

Focusing on the nuclear and subnuclear dynamics of light and circadian signalling.

Plant Cell Environ 2019 10 16;42(10):2871-2884. Epub 2019 Aug 16.

Department of Biology, University of York, YO10 5DD, York, UK.

Circadian clocks provide organisms the ability to synchronize their internal physiological responses with the external environment. This process, termed entrainment, occurs through the perception of internal and external stimuli. As with other organisms, in plants, the perception of light is a critical for the entrainment and sustainment of circadian rhythms. Red, blue, far-red, and UV-B light are perceived by the oscillator through the activity of photoreceptors. Four classes of photoreceptors signal to the oscillator: phytochromes, cryptochromes, UVR8, and LOV-KELCH domain proteins. In most cases, these photoreceptors localize to the nucleus in response to light and can associate to subnuclear structures to initiate downstream signalling. In this review, we will highlight the recent advances made in understanding the mechanisms facilitating the nuclear and subnuclear localization of photoreceptors and the role these subnuclear bodies have in photoreceptor signalling, including to the oscillator. We will also highlight recent progress that has been made in understanding the regulation of the nuclear and subnuclear localization of components of the plant circadian clock.
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http://dx.doi.org/10.1111/pce.13634DOI Listing
October 2019

Measuring Phytochrome-Dependent Light Input to the Plant Circadian Clock.

Methods Mol Biol 2019 ;2026:179-192

Department of Biology, University of York, York, UK.

The circadian clock allows plants to synchronize their internal processes with the external environment. This synchronization occurs through daily cues, one of which is light. Phytochromes are well established as light-sensing proteins and have been identified in forming multiple signaling networks with the central circadian oscillator. However, the precise details of how these networks are formed are yet to be established. Using established promoter-luciferase lines for clock genes crossed into mutant lines, it is possible to use luciferase-based imaging technologies to determine whether specific proteins are involved in phytochrome signaling to the circadian oscillator. The methods presented here use two automated methods of luciferase imaging in Arabidopsis to allow for high-throughput measurement of circadian clock components under a range of different light conditions.
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http://dx.doi.org/10.1007/978-1-4939-9612-4_15DOI Listing
March 2020

DIfferential Subsampling With Cartesian Ordering With Respiratory Triggering Versus Conventional Liver Acquisition With Volume Acquisition: A Multiple Reader Preference Study.

J Comput Assist Tomogr 2019 Jul/Aug;43(4):623-627

From the Department of Radiology.

Objective: The aim of this study was to compare respiratory-triggered DIfferential Subsampling with Cartesian Ordering (rtDISCO) and breath-held Liver Acquisition with Volume Acquisition (LAVA) image quality.

Methods: In this institutional review board-approved, Health Insurance Portability and Accountability Act-compliant prospective study, 25 subjects underwent T1 imaging with rtDISCO and LAVA before and after intravenous contrast. Three readers scored individual series and side-by-side comparisons for motion and noise. Eight clinical tasks were qualitatively assessed.

Results: As individual series, readers rated rtDISCO images as more degraded by motion on both precontrast (mean rtDISCO score, 2.7; LAVA, 1.6; P < 0.001) and postcontrast images (rtDISCO, 2.4; LAVA, 1.8; P < 0.001). Readers preferred LAVA images based on motion on both precontrast (mean preference, -1.2; P < 0.001) and postcontrast images (mean preference, -0.7; P < 0.001) on side-by-side assessment. There was no preference between sequences for 6 of 8 clinical tasks on postcontrast images.

Conclusions: Readers preferred LAVA with respect to motion but not noise; there was no preference in most of the tested clinical tasks.
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http://dx.doi.org/10.1097/RCT.0000000000000888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6629493PMC
July 2019

Heat the Clock: Entrainment and Compensation in Circadian Rhythms.

J Circadian Rhythms 2019 May 14;17. Epub 2019 May 14.

Department of Mathematics, University of York, UK.

The circadian clock is a biological mechanism that permits some organisms to anticipate daily environmental variations. This clock generates biological rhythms, which can be reset by environmental cues such as cycles of light or temperature, a process known as entrainment. After entrainment, circadian rhythms typically persist with approximately 24 hours periodicity in free-running conditions, in the absence of environmental cues. Experimental evidence also shows that a free-running period close to 24 hours is maintained across a range of temperatures, a process known as temperature compensation. In the plant , the effect of light on the circadian system has been widely studied and successfully modelled mathematically. However, the role of temperature in periodicity, and the relationship between entrainment and compensation, are not fully understood. Here we adapt recent models to incorporate temperature dependence by applying Arrhenius equations to the parameters of the models that characterize transcription, translation, and degradation rates. We show that the resulting models can exhibit thermal entrainment and temperature compensation, but that these phenomena emerge from physiologically different sets of processes. Further simulations combining thermal and photic forcing in more realistic scenarios clearly distinguish between the processes of entrainment and compensation, and reveal temperature compensation as an emergent property which can arise as a result of multiple temperature-dependent interactions. Our results consistently point to the thermal sensitivity of degradation rates as driving compensation and entrainment across a range of conditions.
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http://dx.doi.org/10.5334/jcr.179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6524549PMC
May 2019

Management of Port Occlusions in Adults: Different-Site Replacement versus Same-Site Salvage.

J Vasc Interv Radiol 2019 Jul 24;30(7):1069-1074. Epub 2019 May 24.

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

Purpose: To compare the safety and effectiveness of different-site port placement versus same-site port salvage in adult patients with occluded ports.

Materials And Methods: Ninety-five occluded subcutaneous infusion ports (ports) in 95 patients presenting between July 1, 2002, and June 30, 2017, were retrospectively reviewed: 48 (51%) different-site placements (replacements; same-day indwelling port removal and different-site new port placement) and 47 (49%) same-site salvages (salvages; 35 fibrin sheath strippings, 12 over-the-wire exchanges). Demographic information, indication for initial placement and replacement or salvage, procedural details, post-intervention primary catheter patency, and post-intervention port sequelae were recorded. Post-intervention primary catheter patency, and malfunction and infection rates were compared with Kaplan-Meier estimation and the log-rank test, and Fisher exact test, respectively. The association of patient risk factors and port patency was assessed with Cox regression.

Results: Median primary catheter patency after replacement was 254 days (interquartile range [IQR], 297) and after salvage was 391 days (IQR, 906) (P = .25). Within the salvage group, median primary catheter patency after stripping was 391 days (IQR, 658) and after exchange was 666 days (IQR, 1412) (P = .08). There was no statistical difference in malfunction (P = .12) and infection (P = .74) rates between the replaced and salvaged groups or in malfunction (P = .09) and infection (P = .1) rates between the exchanged and stripped subgroups. None of the patient or catheter characteristics assessed were significantly associated with primary catheter patency.

Conclusions: There was no statistical difference between patency, malfunctions, or infections after replacement and salvage, or after stripping and exchange, so technique selection should be based on the patient's estimated lifetime venous access requirements, cost, and physician preference.
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http://dx.doi.org/10.1016/j.jvir.2019.02.027DOI Listing
July 2019

Physiological and Genetic Dissection of Sucrose Inputs to the Circadian System.

Genes (Basel) 2019 05 2;10(5). Epub 2019 May 2.

Department of Plant Developmental Biology, Max-Planck Institute for Plant Breeding Research, Cologne D50829, Germany.

Circadian rhythms allow an organism to synchronize internal physiological responses to the external environment. Perception of external signals such as light and temperature are critical in the entrainment of the oscillator. However, sugar can also act as an entraining signal. In this work, we have confirmed that sucrose accelerates the circadian period, but this observed effect is dependent on the reporter gene used. This observed response was dependent on sucrose being available during free-running conditions. If sucrose was applied during entrainment, the circadian period was only temporally accelerated, if any effect was observed at all. We also found that sucrose acts to stabilize the robustness of the circadian period under red light or blue light, in addition to its previously described role in stabilizing the robustness of rhythms in the dark. Finally, we also found that CCA1 is required for both a short- and long-term response of the circadian oscillator to sucrose, while LHY acts to attenuate the effects of sucrose on circadian period. Together, this work highlights new pathways for how sucrose could be signaling to the oscillator and reveals further functional separation of CCA1 and LHY.
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http://dx.doi.org/10.3390/genes10050334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6563356PMC
May 2019

LI-RADS Treatment Response Algorithm: Performance and Diagnostic Accuracy.

Radiology 2019 07 30;292(1):226-234. Epub 2019 Apr 30.

From the Department of Radiology (E.L.S., M.C., C.M.M., B.C.A., E.B., G.L.J., C.Y.K., J.R., M.R.B.), Department of Pathology (D.M.C.), Division of Gastroenterology, Department of Medicine (L.Y.K., M.R.B.), and Center for Advanced Magnetic Resonance Development (G.L.J., M.R.B.), Duke University Medical Center, Box 3808, Durham, NC; and Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY (R.K.D.).

Background In 2017, the Liver Imaging Reporting and Data System (LI-RADS) included an algorithm for the assessment of hepatocellular carcinoma (HCC) treated with local-regional therapy. The aim of the algorithm was to enable standardized evaluation of treatment response to guide subsequent therapy. However, the performance of the algorithm has not yet been validated in the literature. Purpose To evaluate the performance of the LI-RADS 2017 Treatment Response algorithm for assessing the histopathologic viability of HCC treated with bland arterial embolization. Materials and Methods This retrospective study included patients who underwent bland arterial embolization for HCC between 2006 and 2016 and subsequent liver transplantation. Three radiologists independently assessed all treated lesions by using the CT/MRI LI-RADS 2017 Treatment Response algorithm. Radiology and posttransplant histopathology reports were then compared. Lesions were categorized on the basis of explant pathologic findings as either completely (100%) or incompletely (<100%) necrotic, and performance characteristics and predictive values for the LI-RADS Treatment Response (LR-TR) Viable and Nonviable categories were calculated for each reader. Interreader association was calculated by using the Fleiss κ. Results A total of 45 adults (mean age, 57.1 years ± 8.2; 13 women) with 63 total lesions were included. For predicting incomplete histopathologic tumor necrosis, the accuracy of the LR-TR Viable category for the three readers was 60%-65%, and the positive predictive value was 86%-96%. For predicting complete histopathologic tumor necrosis, the accuracy of the LR-TR Nonviable category was 67%-71%, and the negative predictive value was 81%-87%. By consensus, 17 (27%) of 63 lesions were categorized as LR-TR Equivocal, and 12 of these lesions were incompletely necrotic. Interreader association for the LR-TR category was moderate (κ = 0.55; 95% confidence interval: 0.47, 0.67). Conclusion The Liver Imaging Reporting and Data System 2017 Treatment Response algorithm had high predictive value and moderate interreader association for the histopathologic viability of hepatocellular carcinoma treated with bland arterial embolization when lesions were assessed as Viable or Nonviable. © RSNA, 2019 See also the editorial by Gervais in this issue.
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http://dx.doi.org/10.1148/radiol.2019182135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6614909PMC
July 2019

Proton Pump Inhibitor Use Is Associated with an Increased Frequency of New or Worsening Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation.

J Vasc Interv Radiol 2019 02 11;30(2):163-169. Epub 2019 Jan 11.

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

Purpose: To determine whether proton pump inhibitor (PPI) use increases the rate of new or worsening hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) creation.

Materials And Methods: In this retrospective study, 284 of 365 patients who underwent TIPS creation from January 1, 2005, to December 31, 2016, were analyzed (186 male, mean age 56 y, range 19-84 y). Dates of PPI use and dates of new or worsening HE, defined as hospitalization or escalation in outpatient medical management, were extracted from medical records. Mixed-effects negative binomial regression was used to test for an association between PPI usage and HE.

Results: After TIPS creation, among 168 patients on PPIs chronically, there were 235 episodes of new or worsening HE in 106,101 person-days (0.81/person-year). Among 55 patients never on PPIs, there were 37 episodes in 31,066 person-days (0.43/person-year). Among 61 patients intermittently taking PPIs, there were 78 episodes in 37,710 person-days while on PPIs (0.75/person-year) and 25 episodes in 35,678 person-days while off PPIs (0.26/person-year). In univariate regression, PPI usage was associated with a 3.34-fold increased rate of new or worsening HE (incidence rate ratio [IRR] 3.34; P < .001). In multivariate regression, older age (IRR 1.05; P < .001), male sex (IRR 1.58; P = .023), higher Model for End-Stage Liver Disease score (IRR 1.06; P = .015), previous HE or HE-preventive medication use (IRR 1.51; P = .029), and PPI use (IRR 3.19; P < .001) were significant risk factors. Higher PPI doses were associated with higher rates of HE (IRR 1.16 per 10 mg omeprazole equivalent; P = .046).

Conclusions: PPI usage is associated with increased rates of new or worsening HE after TIPS creation.
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http://dx.doi.org/10.1016/j.jvir.2018.10.015DOI Listing
February 2019

No Increased Mortality After TIPS Compared with Serial Large Volume Paracenteses in Patients with Higher Model for End-Stage Liver Disease Score and Refractory Ascites.

Cardiovasc Intervent Radiol 2019 May 2;42(5):720-728. Epub 2019 Jan 2.

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

Purpose: To compare survival after transjugular intrahepatic portosystemic shunt (TIPS) creation versus serial large volume paracenteses (LVP) in patients with refractory ascites and higher Model for End-Stage Liver Disease (MELD) scores.

Materials And Methods: In this retrospective study, from 1/1/2013 to 10/1/2018, 478 patients (294 male; mean age 58, range 23-89) underwent serial LVP (n = 386) or TIPS (n = 92) for ascites. Propensity-matched cohorts were constructed based on age, MELD, Charlson comorbidity index, varices, and hepatic encephalopathy. Survival was analyzed using a Cox proportional hazards model in which MELD score and TIPS were treated as time-dependent covariates. An interaction term was used to assess the impact of TIPS versus serial LVP on survival as a function of increasing MELD.

Results: In the overall patient sample, higher MELD score predicted worse survival after either serial LVP or TIPS [hazard ratio (HR) = 1.13; p < 0.001], but there was no significant interaction between TIPS and higher MELD score conferring worse survival (HR = 1.01; p = 0.55). In 92 propensity-matched serial LVP and 92 TIPS patients, higher MELD score predicted worse survival after either serial LVP or TIPS (HR = 1.19; p < 0.001), but there was no significant survival interaction between TIPS and higher MELD (HR = 0.97; p = 0.22). In 30 propensity-matched serial LVP patients and 30 TIPS patients with baseline MELD greater than 18, TIPS did not predict worse survival (HR = 0.97; p = 0.94).

Conclusion: Higher MELD predicts poorer survival after either serial LVP or TIPS, but TIPS creation is not associated with worse survival compared to serial LVP in patients with higher MELD scores LEVEL OF EVIDENCE: Level 4, case series.
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http://dx.doi.org/10.1007/s00270-018-02155-9DOI Listing
May 2019