Sandeep Deshmukh

Phase I evaluation of intravenous ascorbic acid in combination with gemcitabine and erlotinib in patients with metastatic pancreatic cancer.

Background Preclinical data support further investigation of ascorbic acid in pancreatic cancer. There are currently insufficient safety data in human subjects, particularly when ascorbic acid is combined with chemotherapy. Methods and Findings 14 subjects with metastatic stage IV pancreatic cancer were recruited to receive an eight week cycle of intravenous ascorbic acid (three infusions per week), using a dose escalation design, along with standard treatment of gemcitabine and erlotinib. Of 14 recruited subjects enrolled, nine completed the study (three in each dosage tier). There were fifteen non-serious adverse events and eight serious adverse events, all likely related to progression of disease or treatment with gemcitabine or erlotinib. Applying RECIST 1.0 criteria, seven of the nine subjects had stable disease while the other two had progressive disease. Conclusions These initial safety data do not reveal increased toxicity with the addition of ascorbic acid to gemcitabine and erlotinib in pancreatic cancer patients. This, combined with the observed response to treatment, suggests the need for a phase II study of longer duration. Trial Registration Clinicaltrials.gov NCT00954525

Role of MR Imaging of Uterine Leiomyomas before and after Embolization

Leiomyoma, the most common uterine neoplasm, is composed of smooth muscle with varying amounts of fibrous connective tissue. Most leiomyomas are asymptomatic, but patients may present with abnormal uterine bleeding or bulk-related symptoms. Over the past decade, uterine fibroid embolization (UFE) has been an effective minimally invasive treatment for symptomatic patients. Magnetic resonance (MR) imaging is the most accurate imaging technique for detection and evaluation of leiomyomas and therefore has become the imaging modality of choice before and after UFE. As leiomyomas enlarge, they may outgrow their blood supply, resulting in various forms of degeneration that change their appearance. Leiomyomas are classified as submucosal, intramural, or subserosal. Submucosal and subserosal leiomyomas may be pedunculated, thus simulating other conditions. Understanding the MR imaging appearance of leiomyomas allows differentiation from other entities. The superior tissue contrast of MR imaging allows diagnosis of leiomyomas with a high level of confidence, ultimately leading to a decrease in the number of surgeries performed and thus reducing healthcare expenditures. MR imaging findings that influence the planning of UFE include the location, size, number, and vascular supply of leiomyomas. In addition, MR imaging can be used to assess the success of UFE and evaluate for potential complications.

Erratum to: Identifying decreased peristalsis of abnormal small bowel segments in Crohn’s disease using cine MR enterography: the frozen bowel sign

AbstractPurpose The purpose of this study was to evaluate whether affected bowel in Crohn’s disease patients can be identified by observing decreased peristalsis (frozen bowel sign) using cine balanced steady-state free precession (cine BSSFP) images.Materials and methods5 radiologists independently reviewed cine BSSFP sequences from randomized MR Enterography (MRE) exams for 30 normal and 30 Crohn’s disease patients, graded overall small bowel peristalsis from slowest to fastest, and graded peristalsis for the most abnormal small bowel segment. Sensitivity and specificity of the frozen bowel sign for diagnosing Crohn’s disease were calculated. T tests of the peristalsis difference between abnormal segments and overall small bowel were conducted.ResultsFor 5 readers, the sensitivity and specificity of cine BSSFP of the frozen bowel sign for diagnosing Crohn’s disease ranged from 70% to 100% and 87% to 100%, respectively. There were significant differences in peristalsis between abnormal small bowel segments and the overall small bowel for Crohn’s patients, but not in the overall small bowel between normal-MRE patients and Crohn’s disease patients.ConclusionAbnormal Crohn’s small bowel segments have significantly decreased peristalsis compared to normal small bowel, which can be identified using cine BSSFP sequences as the frozen bowel sign.

Hepatic MR Imaging Techniques, Optimization, and Artifacts

This article describes a basic 1.5-T hepatic magnetic resonance (MR) imaging protocol, strategies for optimizing pulse sequences while managing artifacts, the proper timing of postgadolinium 3-dimensional gradient echo sequences, and an effective order of performing pulse sequences with the goal of creating an efficient and high-quality hepatic MR imaging examination. The authors have implemented this general approach on General Electric, Philips, and Siemens clinical scanners.

Tubercular Pancreatic Abscess Presenting as Fever and Cystic Pancreatic Lesion with Endoscopic Management

Isolated pancreatic tuberculosis is a rare presentation of tubercular infection. There are few reported cases of pancreatic tuberculosis diagnosed by endoscopic ultrasound with fine-needle aspiration (EUS FNA) [1–5], though EUS is often used in the evaluation of pancreatic cystic lesions [6]. We present a case of a tubercular pancreatic abscess presenting as a cystic lesion in a patient with undiagnosed immunodeficiency. The abscess was aspirated by EUS FNA and treated with endoscopic drainage and antimycobacterial medications.

Abdominal imaging and patient education resources: enhancing the radiologist-patient relationship through improved communication.

IntroductionThe relative ease of Internet access and its seemingly endless amount of information creates opportunities for Americans to research medical diseases, diagnoses, and treatment plans. Our objective is quantitative evaluation of the readability level of patient education websites, written for the lay public, pertaining to common radiologic diagnostic test, and radiologic diagnoses specific to abdominal imaging.MethodsIn October 2015, 10 search terms were entered in the Google search engine, and the top 10 links for each term were collected and independently examined for their readability level using 10 well-validated quantitative readability scales. Search terms included CT abdomen, MRI abdomen, MRI enterography, ultrasound abdomen, X-ray abdomen, cholecystitis, diverticulitis, hepatitis, inflammatory bowel disease, and pancreatitis. Websites not written exclusively for patients were excluded from the analysis.ResultsAs a group, the 100 articles were assessed at an 11.7 grade level. Only 2% (2/100) were written at the National Institutes of Health (NIH), and American Medical Association (AMA) suggested 3rd to 7th grade level to meet the 8th grade average reading level in the United States. In fact, 49% were written at a level that required a high school education or higher (greater than 12th grade).ConclusionsWith websites like radiologyinfo.org, generating over a million visitors a month, it is that clear there is a public interest in learning about radiology. However, given the discordance between the level of readability of the majority of the Internet articles and the NIH and AMA guidelines noted in this study on abdominal imaging readability, it is likely that many readers do not fully benefit from these resources on abdominal imaging.

Quantitative analysis of the level of readability of online emergency radiology-based patient education resources

PurposeThe vast amount of information found on the internet, combined with its accessibility, makes it a widely utilized resource for Americans to find information pertaining to medical information. The field of radiology is no exception. In this paper, we assess the readability level of websites pertaining specifically to emergency radiology.MethodsUsing Google, 23 terms were searched, and the top 10 results were recorded. Each link was evaluated for its readability level using a set of ten reputable readability scales. The search terms included the following: abdominal ultrasound, abdominal aortic aneurysm, aortic dissection, appendicitis, cord compression, CT abdomen, cholecystitis, CT chest, diverticulitis, ectopic pregnancy, epidural hematoma, dural venous thrombosis, head CT, MRI brain, MR angiography, MRI spine, ovarian torsion, pancreatitis, pelvic ultrasound, pneumoperitoneum, pulmonary embolism, subarachnoid hemorrhage, and subdural hematoma. Any content that was not written for patients was excluded.ResultsThe 230 articles that were assessed were written, on average, at a 12.1 grade level. Only 2 of the 230 articles (1%) were written at the third to seventh grade recommended reading level set forth by the National Institutes of Health (NIH) and American Medical Association (AMA). Fifty-two percent of the 230 articles were written so as to require a minimum of a high school education (at least a 12th grade level). Additionally, 17 of the 230 articles (7.3%) were written at a level that exceeded an undergraduate education (at least a 16th grade level).ConclusionsThe majority of websites with emergency radiology-related patient education materials are not adhering to the NIH and AMA’s recommended reading levels, and it is likely that the average reader is not benefiting fully from these information outlets. With the link between health literacy and poor health outcomes, it is important to address the online content in this area of radiology, allowing for patient to more fully benefit from their online searches.

Imaging of ocular melanoma metastasis

Ocular melanoma is the most common adult primary intraocular tumour. Although <1% of patients have metastatic disease at the time of initial diagnosis, most will develop metastasis at varying lengths of time. Metastasis surveillance is therefore critical in the follow-up of patients with ocular melanoma. Liver is the most common site of metastasis and prognosis is based on the treatment of liver metastasis. Hence, imaging of liver metastasis is vital. MRI is the most specific modality for imaging liver metastasis and is at least as sensitive as CT. Extrahepatic metastasis such as retroperitoneal nodules and bone metastases are also better evaluated on MRI. Gadolinium-based contrast agents are extremely helpful for detecting liver lesions. In particular, newer hepatobiliary contrast agents which offer an additional hepatobiliary phase of excretion help in the detection of even tiny liver metastases. Diffusion-weighted imaging is helpful when an i.v. contrast cannot be administered. Treated lesions are also better evaluated with MRI. CT is useful for evaluating lung nodules, large liver metastasis or in patients in whom MRI is medically contraindicated. The disadvantage lies in its inability to detect small liver metastasis and the radiation dose involved. The lesions treated with iodized oil as part of chemoembolization procedures can be followed on CT. Ultrasound can be used only for detecting hepatic metastases. However, it is heavily operator dependent, technically challenging and time consuming especially in patients who are large. Extrahepatic metastasis cannot be seen on ultrasound. Its utility is primarily for the biopsy of liver lesions. Positron emission tomography (PET)-CT can detect lung nodules and large liver lesions but is insensitive to small liver lesions. Moreover, the high radiation dose is a major disadvantage.

Incidental left atrial and ventricular thrombi on routine CT: outcome and influence on subsequent management at an urban tertiary care referral center

Incidental left-sided cardiac thrombi are occasionally encountered on CT. This study examined clinical findings and outcome in patients with incidental cardiac thrombi on CT. Our image database was reviewed for incidental left-sided cardiac thrombi on CT. These patients’ charts were retrospectively reviewed. Thirty-five patients had incidental left-sided cardiac thrombi on CT, 26 of which were ventricular and 9 atrial. Thirty-two thrombi were unknown prior to the CT, and the radiologist interpretation triggered echocardiography or anticoagulation in most cases. Embolic complications occurred in 14 patients, 4 of which were fatal. Twelve patients had concomitant cancer, 6 of which were newly discovered. Incidental left-sided cardiac thrombi on CT appeared to confer substantial morbidity and mortality in our study. In many cases, the cardiac thrombi were new and led to changes in management. A high rate of malignancy was also noted, which may be related to the hypercoagulable state of malignancy.

Contrast-enhanced or noncontrast CT for renal colic: utilizing urinalysis and patient history of urolithiasis to decide

PurposeIn the emergency setting, flank pain commonly leads to a noncontrast CT despite a significant percentage of patients having alternative diagnoses, often difficult to characterize without contrast. We investigated the combined utility of urinalysis and history of urolithiasis in identifying patients who are unlikely to have urolithiasis and may benefit from a contrast-enhanced study.MethodsRetrospective review of 350 patients from May 2013 to May 2016 was performed for patients in the emergency department with renal colic that underwent noncontrast CT and urinalysis testing.ResultsUrolithiasis was present in 282 of the 350 patients reviewed (81%), of which 175 (62%) had an obstructing calculus. RBC-positive urinalysis was present in 231 patients with calculi on CT (sensitivity 82%). Patient history of urolithiasis plus urinalysis had a sensitivity of 94% for detecting calculi. Thirty-five patients (10%) had alternative diagnoses, 33 of which were in patients without obstructing calculi. Sixty-seven patients underwent noncontrast CT despite no history of urolithiasis and a negative urinalysis, 10 of which (15%) had alternative diagnoses. Only three cases in this subset (4%) had nonobstructing 1–2-mm calculi, potentially missed with contrast. In this subset, the projected proportion of optimally characterized cases with intravenous contrast is 96%, compared to 85% without contrast (p = .03).DiscussionGiven the high combined sensitivity of urinalysis and patient history (94%), this simple analysis can confidently direct clinicians to a contrast-enhanced CT in “rule-out” cases of flank pain in patients with a negative history and negative urinalysis, particularly given that 15% of these patients had alternative diagnoses.