Kaitlin M. Woo

Quantitative assessment of cervical softening during pregnancy in the Rhesus macaque with shear wave elasticity imaging

Abnormal parturition, e.g. pre- or post-term birth, is associated with maternal and neonatal morbidity and increased economic burden. This could potentially be prevented by accurate detection of abnormal softening of the uterine cervix. Shear wave elasticity imaging (SWEI) techniques that quantify tissue softness, such as shear wave speed (SWS) measurement, are promising for evaluation of the cervix. Still, interpretation of results can be complicated by biological variability (i.e. spatial variations of cervix stiffness, parity), as well as by experimental factors (i.e. type of transducer, posture during scanning). Here we investigated the ability of SWEI to detect cervical softening, as well as sources of SWS variability that can affect this task, in the pregnant and nonpregnant Rhesus macaque. Specifically, we evaluated SWS differences when imaging the cervix transabdominally with a typical linear array abdominal transducer, and transrectally with a prototype intracavitary linear array transducer. Linear mixed effects (LME) models were used to model SWS as a function of menstrual cycle day (in nonpregnant animals) and gestational age (in pregnant animals). Other variables included parity, shear wave direction, and cervix side (anterior versus posterior). In the nonpregnant cervix, the LME model indicated that SWS increased by 2% (95% confidence interval 0-3%) per day, starting eight days before menstruation. During pregnancy, SWS significantly decreased at a rate of 6% (95% CI 5-7%) per week (intracavitary approach) and 3% (95% CI 2-4%) per week (transabdominal approach), and interactions between the scanning approach and other fixed effects were also significant. These results suggest that, while absolute SWS values are influenced by factors such as scanning approach and SWEI implementation, these sources of variability do not compromise the sensitivity of SWEI to cervical softening. Our results also highlight the importance of standardizing SWEI approaches to improve their accuracy for cervical assessment.

Juvenile Osteochondritis Dissecans: Cartilage T2 Mapping of Stable Medial Femoral Condyle Lesions

Purpose To determine whether a T2 mapping sequence could depict early changes in the composition and microstructure of cartilage overlying stable lesions of the medial femoral condyle in patients with juvenile osteochondritis dissecans (JOCD). Materials and Methods This retrospective study analyzed a sagittal T2 mapping sequence performed between September 1, 2015, and March 31, 2017, on 16 patients (10 boys and six girls; median age, 11.5 years) with 18 stable medial femoral condyle JOCD lesions and 18 age-, sex-, and skeletal maturation-matched control participants (11 boys and seven girls; median age, 11.5 years). Cartilage T2 values were quantitatively measured within regions of interest placed around the cartilage within and overlying the JOCD lesion in patients with JOCD and around the cartilage on the weight-bearing medial femoral condyle in patients with JOCD and controls. Wilcoxon signed rank and Wilcoxon rank sum tests were used to compare T2 values. Results T2 values were significantly higher (P < .001) for cartilage within the JOCD lesion than for cartilage overlying the JOCD lesion in patients with JOCD. However, there were no significant differences in T2 values between cartilage overlying the JOCD lesion and cartilage on the weight-bearing medial femoral condyle in patients with JOCD (P = .67) or in T2 values of the cartilage on the weight-bearing medial femoral condyle between patients with JOCD and controls (P = .30). Conclusion There were no significant quantifiable differences in T2 values of cartilage overlying stable JOCD lesions and normal cartilage on the medial femoral condyle, suggesting no substantial changes in cartilage composition and microstructure.

Detection of pediatric musculoskeletal pathology using the fluid-sensitive sequence

BackgroundMusculoskeletal complaints are common among children, and magnetic resonance (MR) is increasingly used to supplement the clinical assessment. The validation of a short triage protocol could reduce the number of unnecessary contrast-enhanced MR studies that sometimes also require the need for sedation.ObjectiveTo compare the diagnostic accuracy between fluid-sensitive sequence and contrast-enhanced MR study in the detection of musculoskeletal pathology in the pelvis and the appendicular skeleton in children older than 2xa0years.Materials and methodsWe performed a retrospective review between Feb. 1, 2016, and Oct. 31, 2016, and identified 99 studies from 96 patients (48 boys and 48 girls; mean age ± standard deviation, 11.1±4.6xa0years) without syndromic deformity, recent trauma, a history of infectious or inflammatory arthropathy, prior instrumentation or incomplete records. Two radiologists reviewed each study twice, at least 1xa0month apart, first using only the fluid-sensitive sequences (triage study) and later using the contrast-enhanced study. Readers rated the presence or absence of pathology independently and generated final impressions in consensus. We used Cohen’s kappa (κ) and percentage agreement to compare agreement between readers and between studies, respectively.ResultsInter-reader agreement was overall higher for the contrast-enhanced studies (κ range = 0.91–1) than for the triage studies (κ range = 0.49–1). Percentage agreement between studies was high for the detection of pathology (97–100%) and for the impressions (93%). Clinical diagnoses were stress reaction or overuse in 31%, infection in 21%, space-occupying process in 17%, normal in 15%, inflammatory in 14%, and both inflammatory and overuse in 1%. The full study increased diagnostic confidence in five studies and accuracy in two but did not alter management.ConclusionThe fluid-sensitive sequence had a near-perfect percentage of agreement with the contrast-enhanced study in the detection of musculoskeletal pathology and could possibly be used to screen children who need a contrast-enhanced MR study.

Granulocyte colony-stimulating factor utilization postautologous hematopoietic stem cell transplant in multiple myeloma patients: Does one size fit all?

Purpose To evaluate a single institution’s experience with granulocyte colony-stimulating factor after autologous hematopoietic stem cell transplant in myeloma patients to identify populations that benefit most from granulocyte colony-stimulating factor administration. Methods Retrospective chart reviews were conducted on patients 18+ years with multiple myeloma that underwent autologous hematopoietic stem cell transplant at UW Health from January 2012 to May 2016. Data collection included demographics, length of stay, time to engraftment, Eastern Cooperative Oncology Group performance status score, and hematopoietic cell transplantation-comorbidity index. The primary outcome was days from transplant to engraftment, defined as absolute neutrophil count u2009>u2009500/mm3 for two consecutive days or absolute neutrophil countu2009>u20091000/mm3 once. A subset analysis was performed on patients whose date of engraftment was known. Results In total, 216 individual patients were included in the full cohort and 122 patients included in the subset analysis. Median time to engraftment between patients administered granulocyte colony-stimulating factor and the nongranulocyte colony-stimulating factor group was 12 versus 19 days (Pu2009<u20090.001) in the full cohort and 12 versus 14 days (Pu2009<u20090.001) in the subset analysis. The average length of stay posthematopoietic stem cell transplant in the granulocyte colony-stimulating factor group was 15 days versus 17 days in the nongranulocyte colony-stimulating factor group (Pu2009=u20090.026) in the subset analysis. Additionally, no difference in time to engraftment was seen when stratified by age, Eastern Cooperative Oncology Group performance status score, or hematopoietic cell transplantation-comorbidity index. Conclusion Our study supports use of granulocyte colony-stimulating factor posthematopoietic stem cell transplant in myeloma patients to decrease time to engraftment and length of stay. Consideration should be given to utilization in all patients in this population posthematopoietic stem cell transplant. Further research is needed to identify the populations that benefit most from granulocyte colony-stimulating factor administration.

In pediatric familial hypercholesterolemia, lipoprotein(a) is more predictive than LDL-C for early onset of cardiovascular disease in family members

BACKGROUNDnLow-density lipoprotein cholesterol (LDL-C) level and lipoprotein(a) [Lp(a)]xa0≥xa050xa0mg/dL predict atherosclerotic cardiovascular disease (ASCVD) risk in adults with familial hypercholesterolemia (FH), but their role for children with FH is less clear.nnnOBJECTIVEnThis study examined the relationship between elevated Lp(a) and LDL-C levels in a pediatric population with FH and onset of ASCVD in family members.nnnMETHODSnRetrospective review of pediatric patients with FH identified LDL-C, Lp(a), and family history of ASCVD. Logistic regression modeling evaluated the association between the childs Lp(a) and peak LDL-C level with earliest age of ASCVD onset in their family.nnnRESULTSnOne hundred twenty-nine children from 109 families were identified. Children from families with early-onset ASCVD were 3 times more likely to have high Lp(a) than those with a family history of late-onset ASCVD (OR: 3.77, 95% CI: 1.16-12.25, Pxa0=xa0.027) but were not more likely to have highly elevated peak LDL-C (≥190xa0mg/dL) (OR: 0.45, 95% CI: 0.11-1.80, Pxa0=xa0.26).nnnCONCLUSIONnChildren with FH and family history of early-onset ASCVD were more likely to have Lp(a) ≥50xa0mg/dL than children with FH and family history of late-onset ASCVD. Family history of early-onset ASCVD was more predictive of a childs Lp(a) level than of a childs peak LDL-C. Measurement of Lp(a) in children with FH may better characterize their cardiovascular risk, particularly when knowledge of family history is limited. Lp(a) testing may also identify children with FH that could benefit from more aggressive management to reduce ASCVD risk.

Do Headache Patients Require More Care in Between Visits Than Other Neurology Outpatients

There is evidence that time spent in patient care in between patient visits is increasing and a contributor to physician burnout. The extent of this work on providers in the field of headache medicine is unknown.

Evaluation of Response to Enzalutamide Consecutively After Abiraterone Acetate/Prednisone Failure in Patients With Metastatic Castration-resistant Prostate Cancer

Introduction: Treatment of metastatic castration‐resistant prostate cancer (mCRPC) has evolved significantly during the past decade, and the preferred combination and/or sequence of these treatments remains controversial. In this retrospective study, we explored clinical and pathologic factors that could predict response to consecutive treatment with enzalutamide (ENZA) after disease progression (PD) on abiraterone acetate and prednisone (AA/P). Patients and Methods: Data were collected from 40 consecutive patients with mCRPC who were treated with ENZA without other interim therapy after progression on AA/P. Results: The median time from prostate cancer initial diagnosis to AA/P treatment was 6.2 (range, 0.9‐16.3) years. The median prostate‐specific antigen (PSA) progression‐free survival (PSA‐PFS) from treatment initiation was 8.5 months (95% confidence interval [CI], 7.1‐10.1 months) and 2.3 months (95% CI, 1.8‐3.4 months) on AA/P and ENZA, respectively. The median time to PD from treatment initiation was 9.7 months (95% CI, 7.1‐12.4 months) and 3 months (95% CI, 2.3‐4.1 months) on AA/P and ENZA, respectively. The correlations were weak between the best percent change in PSA on ENZA and time from diagnosis to AA/P initiation, best absolute or percentage change in PSA on AA/P, time to PSA progression or PD on AA/P. Patients with longer than the median duration of treatment with AA/P (11.73 months) had longer PSA‐PFS on ENZA (median 2.8 vs. 1.9 months; P = .035). Conclusions: In this retrospective analysis, we did not find any clinical or pathologic factors associated with response to ENZA administered consecutively after AA/P. Patients with longer than median AA/P treatment duration had longer PSA‐PFS on ENZA. Further evaluations and validation are greatly needed.

Role of Early Pulmonary Hypertension as a Risk Factor for Late Pulmonary Hypertension in Extremely Preterm Infants

Objective The evidence on the role of early pulmonary vascular disease (PVD) in the development of late pulmonary hypertension (PH) in the extremely preterm infants is limited. Objectives were to determine the incidence of early and late PH in extreme preterm infants and to evaluate the role of early PH as a risk factor for development of clinically detected late PH. Methods It was a retrospective analysis of early echocardiograms (day of life 5‐14) in preterm infants, 22 to 27 weeks gestation, admitted to the University of Iowa NICU between July 01, 2012 to June 30, 2015. Late echocardiograms performed for clinical suspicion of PH were also analyzed. Results A total of 154 infants were included in the study. Early PH was diagnosed in 31 (20%) infants. Twenty‐four (16%) infants were evaluated for clinically suspected PH. Eight (5%) infants were diagnosed with late PH. Infants with early PH had echocardiograms performed earlier than infants without the evidence of early PH. Early PH was not associated with the development of late PH (p = 0.99). Conclusion Early PH is common among extremely preterm infants (20%). Five percent of infants had clinically detected late PH. Infants with early PH had echocardiograms performed earlier than infants without the evidence of early PH. Early PH was not associated with the development of clinically detected late PH.

International survey on the use of complementary and alternative medicines for common toxicities of radiation therapy

Purpose Complementary and alternative medicines (CAMs) are widely used by patients with cancer. However, little is known about the extent to which these potential remedies are used internationally to treat the most common toxicities of radiation therapy. We report on the results of an international survey that assessed the use of CAMs. Methods and Materials Surveys were distributed to 1174 practicing radiation oncologists. Questions evaluated the perceptions of CAMs and specific practice patterns for the use of CAM remedies in the treatment of common radiation-induced toxicities (eg, skin, fatigue, nausea, diarrhea, and mucositis/xerostomia). The responses were compared between the groups using the χ2 test and stratified on the basis of provider location, number of years in practice, and perception of CAMs. Results A total of 114 radiation oncologists from 29 different countries completed the survey, with a balanced distribution between North American (n = 56) and non-North American (n = 58) providers. Among the responding clinicians, 63% recommended CAMs in their practice. The proportion of clinicians who recommend CAMs for radiation toxicities did not significantly vary when stratified by provider’s number of years in practice (P = .23) or location (United States/Canada vs other; P = .74). Overall, providers reported that 29.4% of their patients use CAMs, and 87.7% reported that their practice encouraged or was neutral on CAM use, whereas 12.3% recommended stopping CAMs. The most common sources of patient information on CAMs were the Internet (75.4%), friends (60.5%), and family (58.8%). Clinicians reported the highest use of CAMs for radiation skin toxicity at 66.7%, followed by 48.2% for fatigue, 40.4% for nausea, and 36.8% for mucositis/xerostomia. Conclusions Nearly two-thirds of the surveyed radiation oncologists recommend CAMs for radiation-related toxicities; however, they estimated that less than one third of patients use CAMs for this purpose. This suggests a need for further investigation and perhaps greater patient education on the roles of CAMs in treating radiation toxicities.

Quantitating whole lesion tumor biology in rectal cancer MRI: taking a lesson from FDG-PET tumor metrics

PurposeTo determine the value of novel whole tumor metrics in DWI-MRI and DCE-MRI of rectal cancer treatment assessment.Materials and methodsThis retrospective study included 24 uniformly treated patients with rectal adenocarcinoma who underwent MRI including diffusion-weighted (DW) and dynamic contrast-enhanced (DCE) sequences, before and after chemoradiotherapy. Two experienced readers independently measured tumor volume and apparent diffusion coefficient (ADC) on DWI-MRI and tumor volume and transfer constant Ktrans on DCE-MRI. In addition, we explored and defined Total Lesion Diffusion (TLD) as Total DWI tumor volume multiplied by mean volumetric ADC and Total Lesion Perfusion (TLP) as the total DCE tumor volume multiplied by the mean volumetric Ktrans. These metrics were correlated with histopathologic percent tumor regression in the resected specimen (%TR). Inter-reader agreement was assessed using the concordance correlation coefficient (CCC).ResultsFor both readers, post-treatment TLP revealed comparable correlations with %TR compared with Ktrans (reader 1; Spearman’s rhoxa0=xa0−xa00.36 vs. −xa00.32, reader 2; Spearman’s rhoxa0=xa0−xa00.32 vs. −xa00.28). In addition, TLP afforded the highest inter-reader agreement at post-treatment among TLP, DCE vol, and Ktrans (CCC: 0.64 vs. 0.36 vs. 0.35). Post-treatment TLD showed similar correlation with %TR as DWI volume in reader 1 and superior correlation with %TR for reader 2 (reader 1; Spearman’s rho −xa00.56 vs. −xa00.57, reader 2; Spearman’s rho −xa00.59 vs. −xa00.45).ConclusionThe novel tumor metrics TLD and TLP revealed similar results to established metrics for correlation with tumor response with equivalent or superior inter-reader agreements and we recommend that these be studied in larger trials.