Teerath Peter Tanpitukpongse

Barriers to Recruiting Underrepresented Populations to Cancer Clinical Trials : A Systematic Review

Racial and ethnic minorities, older adults, rural residents, and individuals of low socioeconomic status are underrepresented among participants in cancer‐related trials. The authors conducted a systematic review to determine the barriers to participation of underrepresented populations in cancer‐related trials. Their search included English‐language publications that reported original data on the recruitment of underrepresented groups to cancer treatment or prevention trials between 1966 and December 2005 in multiple electronic databases. They also hand‐searched titles in 34 journals from January 2003 to December 2005 and they examined reference lists for eligible articles. Titles and abstracts were reviewed to identify relevant studies. Data on barriers to participation were synthesized both qualitatively and based on statistically significant associations with trial enrollment. Of 5257 studies that were cited, 65 studies were eligible for inclusion in the current analysis, including 46 studies on recruitment into cancer therapeutic trials, 15 studies on recruitment into prevention trials, and 4 studies on recruitment into both prevention and treatment trials. Numerous factors were reported as barriers to participation in cancer‐related trials. However, only 20 of the studies reported statistically significant associations between hypothesized barriers and enrollment. The available evidence had limitations in quality regarding representativeness, justification of study methods, the reliability and validity of data‐collection methods, potential for bias, and data analysis. The results indicated that underrepresented populations face numerous barriers to participation in cancer‐related trials. The current systematic review highlighting the literature on recruitment of underrepresented populations to cancer trials and may be used as the evidence base toward developing an agenda for etiologic and intervention research to reduce the disparities in participation in cancer‐related trials. Cancer 2008.

Provider roles in the recruitment of underrepresented populations to cancer clinical trials

Providers play a vital role in the successful recruitment of underrepresented patients to cancer clinical trials because they often introduce the opportunity of clinical trials. The purpose of the current systematic review was to describe provider‐related factors influencing recruitment of underrepresented populations to cancer clinical trials.

Effectiveness of strategies to recruit underrepresented populations into cancer clinical trials

Background Certain populations, including racial and ethnic minorities and older persons, have had a history of low participation in cancer-related trials, yet there has been little information reported on recruitment strategies tailored to improve their enrollment. Methods We conducted a systematic literature review to examine the methods used to study recruitment of underrepresented populations into cancer prevention and treatment trials and examined the studies that compared the efficacy and/or effectiveness of different recruitment strategies. We performed an electronic search through multiple databases including PubMed and a hand search of 34 journals. Potential studies were pulled and underwent title, abstract, and article review by at least two investigators. Results Fourteen articles examined recruitment of underrepresented populations into cancer trials and, of these, five compared efficacy or effectiveness of different strategies for recruitment of underrepresented populations into randomized or concurrent controlled trials. These five studies used various strategies but only three reported that specific recruitment strategies, such as media campaigns and churchbased project sessions, resulted in improvement in accrual to cancer trials. Conclusion There is limited evidence for efficacious or effective strategies to recruit underrepresented populations in cancer-related trials. The available evidence cannot be generalized to these heterogeneous groups. Further study is needed on efficacious strategies for recruitment of underrepresented populations into cancerrelated trials.

MRI of Pelvic Floor Dysfunction: Dynamic True Fast Imaging with Steady-State Precession Versus HASTE

OBJECTIVE The objective of our study was to retrospectively compare the degree of pelvic organ prolapse shown on dynamic true fast imaging with steady-state precession (FISP) versus HASTE sequences in symptomatic patients. MATERIALS AND METHODS Fifty-nine women (mean age, 57 years) with suspected pelvic floor dysfunction underwent MRI using both a sagittal true FISP sequence, acquired continuously during rest alternating with the Valsalva maneuver, and a sagittal HASTE sequence, acquired sequentially at rest and at maximal strain. Data sets were evaluated in random order by two radiologists in consensus using the pubococcygeal line (PCL) as a reference. Measurement of prolapse was based on a numeric grading system indicating severity as follows: no prolapse, 0; mild, 1; moderate, 2; or severe, 3. A comparison between sequences on a per-patient basis was performed using a Wilcoxons analysis with p < 0.05 considered significant. RESULTS Overall, 66.1% (39/59) of patients had more severe prolapse (>or= 1 degrees ) based on dynamic true FISP images, with 28.8% (17/59) of the cases of prolapse seen exclusively on true FISP images. Only 20.3% (12/59) of patients had greater degrees of prolapse on HASTE images than on true FISP images, with 10.2% (6/59) of the cases seen exclusively on HASTE images. A statistically significant increase in the severity of cystoceles (p < 0.01) and urethral hypermobility (p < 0.01)-with a trend toward more severe urethroceles (p < 0.07), vaginal prolapse (p < 0.09), and rectal descent (p < 0.06)-was shown on true FISP images. CONCLUSION Overall, greater degrees of organ prolapse in all three compartments were found with a dynamic true FISP sequence compared with a sequential HASTE sequence. Near real-time continuous imaging with a dynamic true FISP sequence should be included in MR protocols to evaluate pelvic floor dysfunction in addition to dynamic multiplanar HASTE sequences.

CT Diagnosis of Mucocele of the Appendix in Patients with Acute Appendicitis

OBJECTIVE The purpose of this study was to identify the CT features of mucocele of the appendix coexisting with acute appendicitis and to determine whether this entity can be differentiated from acute appendicitis without mucocele. MATERIALS AND METHODS CT scans of 70 patients (12 with acute appendicitis with mucocele, 29 with acute appendicitis without mucocele, 29 with a normal appendix) were retrospectively interpreted by two readers. The appendix was evaluated for maximal luminal diameter, cystic dilatation, luminal attenuation, appendicolith, mural calcification and enhancement, periappendiceal fat stranding, fluid, and lymphadenopathy. CT findings were compared by use of Mann-Whitney U and Fishers exact tests. Receiver operating characteristics analysis was performed to assess the diagnostic utility of appendiceal luminal diameter in differentiating acute appendicitis with from that without coexisting mucocele. RESULTS Cystic dilatation of the appendix and maximal luminal diameter achieved statistical significance (p < 0.05) for the diagnosis of acute appendicitis with mucocele. Mural calcification achieved statistical significance for one reader (p = 0.0049) and a statistical trend for the other (p < 0.1). A maximal luminal diameter greater than 1.3 cm had a sensitivity of 71.4%, specificity of 94.6%, and overall diagnostic accuracy of 88.2% for the diagnosis of acute appendicitis with mucocele. CONCLUSION Although there is overlap with acute appendicitis without mucocele, CT features suggestive of coexisting mucocele in patients with acute appendicitis include cystic dilatation of the appendix, mural calcification, and a luminal diameter greater than 1.3 cm.

Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension

OBJECTIVE Spinal leakage of CSF causes almost all cases of spontaneous intracranial hypotension. Leak detection and localization are important for both diagnosis and treatment. The myelographic appearance of the leaks may vary, however, depending on the cause of the leak, rate of leakage, and imaging modality used. CONCLUSION The purpose of this article is to review the imaging of spinal CSF leaks and to assist in the selection of appropriate imaging modalities in this condition.

Incidental Thyroid Nodules on CT or MRI: Discordance Between What We Report and What Receives Workup

OBJECTIVE The objective of this study was to determine the proportion of incidental thyroid nodules (ITNs) reported on CT or MRI that receive additional workup and the factors that influence workup. A secondary aim was to evaluate the effect of the American College of Radiology (ACR) white paper recommendations for reporting of ITNs. MATERIALS AND METHODS We retrospectively reviewed patients with ITNs reported on CT or MRI studies over 12 months. We identified patients with ITNs that underwent workup and the factors associated with workup. The ACR white paper recommendations were retrospectively applied to estimate how their use would have changed the number of nodules reported in the impression section of radiology reports and the number of cancers diagnosed. The recommendations are based on suspicious imaging features, patient age, and nodule size. RESULTS A total of 375 patients had ITNs reported. For 138 of these patients (37%), ITNs were reported by radiologists in the impression section of their reports; 26 patients (19%) received workup. Patients with ITNs reported in the impression section were 14 times more likely to undergo workup than were patients with ITNs reported only in the findings section of the radiology report. On multivariate analysis, the only factors associated with workup were younger patient age and larger nodule size (p ≤ 0.002). The ACR recommendations resulted in a 54% reduction in the number of ITNs reported in the impression section and one missed papillary cancer (TNM classification T1bN0M0). CONCLUSION Only one in five patients with ITNs reported in the impression section of CT or MRI reports underwent additional workup, and this decision was influenced by younger patient age and larger nodule size. These factors are components of the ACR recommendations, which have the potential to reduce the number of reported ITNs and improve the standardization of radiology reporting.

Imaging Signs in Spontaneous Intracranial Hypotension: Prevalence and Relationship to CSF Pressure

BACKGROUND AND PURPOSE: Patients with spontaneous intracranial hypotension often exhibit low CSF pressure and changes on brain MR imaging and/or evidence of CSF leak on myelography. We investigated whether individual imaging signs of spontaneous intracranial hypotension correlate with measured CSF pressure and how frequently these 2 markers of spontaneous intracranial hypotension were concordant. MATERIALS AND METHODS: We performed a retrospective, cross-sectional study of 99 subjects with spontaneous intracranial hypotension. Prevalence of brain and myelographic imaging signs of spontaneous intracranial hypotension was recorded. CSF pressure among subjects with or without individual imaging signs was compared by using a 2-tailed t test and ANOVA. Concordance between low CSF pressure (≤6 cm H2O) and imaging was defined as the presence of the sign in a subject with low CSF pressure or absence of the sign when pressure was not low. RESULTS: Dural enhancement, brain sagging, and venous distension sign were present in 83%, 61%, and 75% of subjects, respectively, and myelographic evidence of CSF leak was seen in 55%. Marginal correlations between CSF pressure and brain sagging (P = .046) and the venous distension sign (P = .047) were found. Dural enhancement and myelographic evidence of leak were not significantly correlated with CSF pressure. Rates of concordance between imaging signs and low CSF pressure were generally low, ranging from 39% to 55%. CONCLUSIONS: Brain and myelographic signs of spontaneous intracranial hypotension correlate poorly with CSF pressure. These findings reinforce the need to base the diagnosis of spontaneous intracranial hypotension on multiple diagnostic criteria and suggest the presence of patient-specific variables that influence CSF pressure in these individuals.

MRI of the Urethra in Women With Lower Urinary Tract Symptoms: Spectrum of Findings at Static and Dynamic Imaging

OBJECTIVE The purpose of our study was to determine the findings at both static and dynamic MRI in women with a clinically suspected urethral abnormality. MATERIALS AND METHODS MRI of the urethra was performed in 84 women with lower urinary tract symptoms using multiplanar T2-weighted turbo spin-echo and unenhanced and contrast-enhanced gradient-echo sequences. A dynamic true fast imaging with steady-state free precession sequence was performed during straining in the sagittal plane. Images were evaluated by two radiologists for urethral pathology and pelvic organ prolapse. MRI findings were correlated with clinical symptoms using the Fishers exact and Mann-Whitney tests. RESULTS Urethral abnormalities were found in 10 of 84 patients (11.9%), including two urethral diverticula, five Skenes gland cysts or abscesses, and three periurethral cysts. Thirty-three patients (39.3%) were diagnosed with pelvic organ prolapse, of whom 29 (87.9%) were diagnosed exclusively on dynamic imaging. In 29 of 33 patients with prolapse (87.9%), the urethra was structurally normal. MRI showed 13 cystoceles and 17 cases of urethral hypermobility not detected on physical examination. Patients with a greater number of vaginal deliveries, stress urinary incontinence, frequency of voiding, and voiding difficulty were statistically more likely to have anterior compartment prolapse (p < 0.05). CONCLUSION Including a dynamic sequence permits both structural and functional evaluation of the urethra, which may be of added value in women with lower urinary tract symptoms. Dynamic MRI allows detection of pelvic organ prolapse that may not be evident on conventional static sequences.

How common is normal cerebrospinal fluid pressure in spontaneous intracranial hypotension

Objectives To determine the proportion of patients with spontaneous intracranial hypotension (SIH) who had a cerebrospinal fluid (CSF) pressure >6 cm H2O and to investigate the clinical and imaging variables associated with CSF pressure (PCSF) in this condition. Methods We retrospectively reviewed 106 patients with SIH. PCSF was measured by lumbar puncture prior to treatment. Clinical and imaging variables – including demographic data, brain imaging results, symptom duration, and abdominal circumference – were collected. Univariate and multivariate analyses were performed to determine the correlation of these variables with PCSF. Results Sixty-one percent of patients had a PCSF between 6 and 20 cm H2O; only 34% had a PCSF ≤6 cm H2O. The factors associated with increased PCSF included abdominal circumference (p < 0.001), symptom duration (p = 0.015), and the absence of brain magnetic resonance imaging findings of SIH (p = 0.003). A wide variability in PCSF was observed among all patients, which was not completely accounted for by the variables included in the model. Conclusions Normal CSF pressure is common in patients with SIH; the absence of a low opening pressure should not exclude this condition. Body habitus, symptom duration, and brain imaging are correlated with PCSF measurements, but these factors alone do not entirely explain the wide variability in observed pressures in this condition and this suggests the influence of other factors.