Citations

ABSTRACT Background: Successful use of nurse practitioner (NP) and physician assistant (PA) care models is vital to delivering optimal patient care, maintaining financial stability, and reducing staff burnout and turnover. Local Problem: A large cardiovascular surgery practice experienced substantial growth, leading to an obsolete NP and PA care model. Consequently, workplace satisfaction scores were reduced, and the NP and PA turnover rate in 2018 was unacceptably high. Methods: A multidisciplinary redesign team was formed to address gaps in the care model through a quality-improvement initiative. The team analyzed current workflows, collected external and internal survey data, conducted patient tracers, and observed staff. Seventeen collaborative care models were proposed by frontline staff members and presented to their peers for feedback. This feedback was used to select the best aspects of the proposed models to create a new model. Interventions: The updated care model consisted of several key changes, which included reducing NP- and PA-to-patient ratios, eliminating redundant tasks, shifting from location-based to surgical team–based coverage, ensuring top-of-scope practice, developing specialty service lines, and separating inpatient and outpatient practices. Results: After implementation of the new care model, NP and PA turnover rates decreased from baseline by an average of approximately 74% per year. Departmental work culture scores concomitantly increased from 68% to 85% after implementation of the new care model. Conclusions: Adapting care models in conjunction with departmental growth is crucial to enhancing staff satisfaction and reducing burnout.

Abstract Background The STOMP2 trial sought to determine whether the implantable autologous cell therapy AVB-114 is an effective add-on therapy for patients with persistent Crohn’s perianal fistulas. The trial design incorporated wait-list controlled (WLC) elements, allowing eligible control group subjects who completed the 9 mo primary endpoint visit in Part 1 to request AVB-114 treatment in Part 2 and strengthen the evaluation of AVB-114’s safety and effectiveness. Methods Eligible patients had a single perianal fistula tract and had failed prior treatment or had documented medication intolerance to biologic or conventional Crohn’s disease therapy. Subjects at 14 U.S. sites were randomized 1:1 to either standard of care (SoC; fistula optimization including seton placement) or AVB-114 implantation. The primary endpoint was combined fistula remission at 9 mo, defined as no collections >2cm on MRI, visual closure of the external opening, and no drainage of fluid despite gentle finger compression. A logistic regression time from exposure model through 9 mo utilized complete Part 1 data and all available Part 2 data to estimate combined AVB-114 effectiveness. Results Part 1 combined remission (using Non-Responder Imputation) was 8.3% (2/24) for SoC and 45.8% (11/24) for AVB-114 (38% difference, 95% CI 11 – 60%, post-hoc p-value of 0.0078). Twenty SoC subjects were treated with AVB-114 in Part 2. Four of the 9 Part 2 subjects with 9 mo combined remission data available were in combined fistula remission (44.4%). No subjects failed 9 mo radiological remission (first component of the primary endpoint), thus clinical remission (composite of the latter two components) was equivalent to combined remission. AVB-114 clinical remission in Part 1 and Part 2 to-date were similar, and when combined provided narrower estimates with the same coverage (Figure 1). Mean (SD) 9 mo perianal disease activity index (PDAI) scores for SoC, Part 1 AVB-114, and Part 2 AVB-114 were 5.0 (2.6), 4.1 (2.9), and 3.8 (3.5), respectively. Lower 9 mo scores and decreases from baseline were independently associated with an increased probability of clinical remission. Two serious treatment-emergent adverse events (TEAEs; pseudopolyposis and proctalgia) occurred, with the latter attributed to AVB-114. Non-serious product related TEAE were predominantly related to postoperative perianal pain. Two grade 2 (moderate) AEs of cellulitis and abdominal wall abscess were attributed to adipose tissue collection. Conclusion Both the randomized and combined (all-treated) analyses demonstrated substantial AVB-114 effectiveness through 9 mo in this challenging patient population. AEs were anticipated, and generally mild and infrequent. Conflict of interest: Schwartz, David: 1) Abbvie: consultant 2) Janssen: Consultant 3) Takeda: Consultant 4) Avbios- consultant 5) Olympus- consultant Dozois, Eric: TBD Ehman, Eric: TBD Faubion, William: TBD Hudesman, David: Consultant: Avalo, Abbvie, Abivax, Biocon, BMS, CorEvitas, Eli Lilly, Johnson and Johnson, Pfizer, Prometheus, Sanofi, Takeda, Fresenius Kabi Research Support: Pfizer and Johnson and Johnson Espen, Benjamin: employee of Avobis Bio LLC Pabla, Baldeep: Astellas, J & J - Advisory Board Prometheus - Speaker Eli Lilly - Speaker Papadakis, Konstantinos: TBD

ABSTRACT Purpose Magnetic resonance elastography (MRE) of the heart has predominantly utilized breath‐held acquisitions with limited anatomic coverage. This work investigates the feasibility of 3D, free‐breathing cardiac MRE. Methods A 3D hybrid radial and EPI acquisition is utilized and combined with retrospective binning of k ‐space via physiologic monitoring, iterative reconstruction, MRE processing and inversions, and post‐processing specialized for cardiac imaging. Results Feasibility of free‐breathing stiffness mapping of the left ventricular myocardium was demonstrated in 11 participants. Myocardial stiffness estimates were obtained throughout the left ventricle for seven temporal states of the cardiac cycle. Stiffness estimates were presented in participant‐specific images, 17‐segment bullseye plots, and stiffness plots throughout the cardiac cycle. Results indicate increased stiffness in systolic states, with localized stiffness heterogeneity observed between participants, illustrating a key benefit of 3D cardiac MRE acquisition. Mean stiffness estimates obtained through 11 subjects were 4.44 ± 0.68 kPa (begin‐systole), 5.74 ± 0.94, 5.42 ± 0.87 (end‐systole), 3.84 ± 0.71 (begin‐diastole), 3.51 ± 0.74, 3.54 ± 0.52, and 3.55 ± 0.59 kPa (end‐diastole). Statistical testing indicated significant differences in stiffness across cardiac states with one‐way, repeated‐measures ANOVA ( p < 0.001) and Friedman's test ( p < 0.001). Experiments in scanning three participants with and without applied motion indicated that stiffness changes were more robustly detected in systole than in diastole, although patterns were subject‐specific. Comparison of free‐breathing stiffness measurements against reference breath‐held measurements yielded similar systolic stiffness estimates. Conclusions This study establishes the feasibility of free‐breathing, 3D cardiac MRE in healthy volunteers. With the current framework, stiffness estimation appears more robust in systole, and the reliability of diastolic estimates is limited and subject‐specific.

ABSTRACT Purpose Abnormal restrictions at myofascial interfaces are a key factor in chronic low back pain (CLBP) with myofascial pain syndrome (MPS), but no established imaging method exists for quantitative assessment. This pilot study evaluated the clinical feasibility of MR elastography (MRE)‐based slip interface imaging (SII) for visualizing myofascial mobility in CLBP‐MPS patients versus age−/sex‐/BMI‐matched healthy participants. A new SII biomarker, maximal normalized displacement discontinuity (), was introduced, and the previously developed normalized octahedral shear strain (NOSS) map was used for comparison. Preliminary assessments of vibration‐frequency effects, repeatability, and group differences in inter‐muscular mobility were conducted. Methods MRE was conducted at 30, 60, and 90 Hz to compare with NOSS for visualizing inter‐muscular slip interfaces at the quadratus lumborum‐erector spinae (QL‐ES) and erector spinae‐multifidus (ES‐M) muscle boundaries at L3‐L4. Repeatability of and NOSS was assessed at 30 Hz (identified as the best‐performing frequency) using within‐subject coefficients of variation and a linear mixed‐effects model from within‐ and between‐day scans. Clinical feasibility was then assessed via Wilcoxon rank‐sum tests in six CLBP‐MPS patients and matched controls. Results at 30 Hz exhibited superior delineation of slip interfaces compared to higher frequencies and NOSS. demonstrated significantly lower variation and better repeatability than NOSS. Healthy participants showed continuous, well‐defined slip interfaces, whereas CLBP‐MPS patients displayed disrupted interfaces with significant mobility reduction at L4 ES‐M. Conclusion SII with lower vibration frequency and map enhances visualization of lower back myofascial mobility and shows potential for assessing differences between healthy individuals and CLBP‐MPS patients.

ABSTRACT Background Magnetic resonance elastography (MRE) has demonstrated potential in characterizing intracranial tumors, including glioblastoma. The influence of pathology on measurement consistency and interobserver agreement needs evaluation to promote MRE implementation as a quantitative biomarker. Purpose To assess repeatability and interobserver agreement of absolute and normalized magnitude of the complex shear modulus (| G *|), storage modulus ( G ′), and loss modulus ( G ″) in glioblastoma. Study Type Prospective. Population Thirteen adults (5 male, 8 female, mean age 66.23 years) with histopathologically confirmed glioblastoma. Field Strength/Sequence 3 T MRI, modified single‐shot spin‐echo echo‐planar imaging. Assessment Two same‐session MRE acquisitions were performed with patient repositioning. The solid tumor component was independently segmented by 2 observers on contrast‐enhanced T1‐weighted images co‐registered to MRE maps. Statistical Tests Repeatability was assessed using the repeatability coefficient, coefficient of variation, and Bland–Altman plots, and interobserver agreement by the intraclass correlation coefficient. The Wilcoxon signed‐rank test compared parameters and coefficients of variation between tumor‐normal‐appearing white matter and absolute and normalized measurements. Significance was set at 0.05. Results Tumor | G *| and G ′ showed repeatability coefficients of 0.07–0.08 kPa and 0.05 kPa, compared with 0.13 kPa (| G *|) and 0.15–0.16 kPa ( G ′) for normalized measurements. Coefficients of variation in tumor regions were 1.42% ± 1.12%–1.60% ± 1.41% for | G *| and 1.19% ± 0.96%–2.08% ± 2.22% for G ′, significantly lower than normalized values (4.82% ± 4.49%–4.21% ± 4.27% for | G *|; 5.12% ± 5.04%–5.45% ± 4.53% for G ′). Tumor | G *| and G ′ showed excellent interobserver agreement (intraclass correlation coefficients 0.97 and 0.95). Tumor G ″ demonstrated higher variability than | G *| and G ′ (coefficients of variation 8.58% ± 7.69%–7.51% ± 6.73%), with no significant difference between absolute and normalized measurements ( p = 0.14). Data Conclusion Tumor | G *| and G ′ are the most repeatable metrics in glioblastoma. Normalization reduces measurement repeatability due to normal‐appearing white matter variability. The small sample size ( n = 13) limits generalizability. Evidence Level 2. Technical Efficacy Stage 2.

Background: It is crucial to evaluate liver fibrosis in metabolic dysfunction-associated steatotic liver disease (MASLD). Digital pathology, an automated method for quantitative fibrosis measurement, provides valuable support to pathologists by providing refined continuous metrics and addressing inter-observer variability. Although non-invasive tests (NITs) have been validated as consistent with manual pathology, the relationship between digital pathology and NITs remains unexplored. Methods: This study included 99 biopsy-proven MASLD patients. Quantitative-fibrosis (Q-Fibrosis) used second-harmonic generation/two-photon excitation fluorescence microscopy (SHG/TPEF) to quantify fibrosis parameters (q-FPs). Correlations between eight NITs and q-FPs were analyzed. Results: Using manual pathology as standard, Q-Fibrosis exhibited excellent diagnostic performance in fibrosis stages assessment with area under the receiver operating characteristic curves (AUCs) ranging from 0.924 to 0.967. In addition, magnetic resonance elastography (MRE) achieved the highest diagnostic accuracy (AUC: 0.781–0.977) among the eight NITs. Furthermore, MRE-assessed liver stiffness measurement (MRE-LSM) showed the strongest correlation with q-FPs, particularly adjusted by string length, string width, and the number of short and thick strings within the portal region. Conclusions: Both MRE and digital pathology demonstrated excellent diagnostic accuracy. MRE-LSM was primarily determined by collagen extent, location and pattern, which provide a new perspective for understanding the relationship between the change in MRE and histological fibrosis reverse.

ABSTRACT Background and Aims Clinically significant portal hypertension (CSPH; hepatic venous pressure gradient (HVPG) ≥ 10 mmHg) is a severe complication of chronic liver disease, with increased risk of variceal bleeding and liver decompensation (at HVPG ≥ 12 mmHg). This study evaluated the performance of multiparametric (mp)MRI for diagnosing CSPH and predicting liver decompensation, compared to ultrasound‐based shear wave elastography (SWE) and blood tests. Methods In this prospective single‐centre study (2018–2022), 59 patients (M 30, mean age 52.7 years) underwent mpMRI and HVPG measurement, with an average interval of 32 ± 31 days. The mpMRI protocol included 2D/3D MR elastography (MRE), T 1 /proprietary iron‐compensated T 1 (cT 1 )/T 1ρ mapping, gadoxetate‐enhanced dynamic contrast‐enhanced MRI (DCE‐MRI) of the liver and spleen, SWE and blood tests. Statistical analyses included Mann–Whitney U tests, ROC analysis, logistic regression and Cox proportional hazards models. Results CSPH was present in 13 patients (22%). Several MRI parameters showed high diagnostic performance for CSPH (AUC ≥ 0.8), with spleen stiffness‐2D MRE (AUC 0.88, 95% confidence interval (CI) 0.78–0.98) and liver uptake on DCE‐MRI (AUC 0.83, 95% CI 0.70–0.96) performing best, while SWE had AUCs of 0.63 (95% CI 0.45–0.81) for liver and 0.67 (95% CI 0.44–0.89) for spleen. Combining spleen stiffness‐2D MRE and liver uptake achieved an AUC of 0.93 (95% CI 0.86–1.00) for diagnosing CSPH. For predicting decompensation, spleen stiffness‐3D MRE and liver uptake rate had AUCs of 0.83 (95% CI 0.68–0.99) and 0.83 (95% CI 0.70–0.95), respectively, outperforming SWE. Conclusions Spleen stiffness measured with MRE combined with gadoxetate liver uptake (measured with DCE‐MRI) can diagnose CSPH and predict liver decompensation, with superior performance compared to SWE. Trial Registration ClinicalTrials.gov identifier: NCT03436550

ABSTRACTBackgroundPercutaneous transluminal angioplasty and stenting (PTAS) in patients with carotid stenosis may have potential effects on brain parenchyma. However, current studies on parenchymal changes are scarce due to the need for advanced imaging modalities. Consequently, the alterations in brain parenchyma following PTAS remain an unsolved issue.PurposeTo investigate changes to the brain parenchyma using magnetic resonance elastography (MRE).Study TypeProspective.Population13 patients (6 women and 7 men; 39 MRI imaging sessions) with severe unilateral carotid stenosis patients indicated for PTAS were recruited between 2021 and 2024.Field Strength/SequenceNoncontrast MRI sequences including MRE (spin echo) were acquired using 3 T scanners.AssessmentAll patients underwent MRE before (preprocedural), within 24 h (early postprocedural) and 3 months after (delayed postprocedural) PTAS. Preprocedural and delayed postprocedural ultrasonographic peak systolic velocity (PSV) was recorded. MRE stiffness and damping ratio were evaluated via neural network inversion of the whole brain, in 14 gray matter (GM) and 12 white matter (WM) regions.Statistical TestsStiffness and damping ratio differences between each pair of MR sessions for each subject were identified by paired sample t tests. The correlations of stiffness and damping ratio with stenosis grade and ultrasonographic PSV dynamics were evaluated by Pearson correlation coefficients. The statistical significance was defined as p < 0.05.ResultsThe stiffness of lesion side insula, deep GM, and deep WM increased significantly from preprocedural to delayed postprocedural MRE. Increasing deep GM stiffness on the lesion side was positively correlated with the DSA stenosis grade significantly (r = 0.609). The lesion side insula stiffness increments were positively correlated with PSV decrements significantly (r = 0.664).Data ConclusionRegional brain stiffness increased 3 months after PTAS. Lesion side stiffness was positively correlated with stenosis grades in deep GM and PSV decrements in the insula.Evidence Level2.Technical EfficacyStage 2.

AbstractPurposeWhile standard MR elastography (MRE) uses harmonic mechanical waves, there are some applications in which imaging and analysis of transient mechanical motion are of interest. Wavelet MRE has been developed for detecting broadband motion from transient excitation. The goal of this study was to evaluate the accuracy and efficiency of wavelet MRE for transient displacement detection in brain MRE applications.MethodsTransient motion was induced in a gel phantom, while MRE images were acquired using bipolar motion‐encoding gradient (MEG) at multiple frequencies (20–200 Hz). Displacements were estimated using (1) combinations of multiple MEGs forming the wavelet MRE and (2) deconvolution from a single MEG. These estimated displacements were used to calculate the MRE phase for each MEG. Correlation (r2) between the calculated and acquired phases was evaluated.Three healthy volunteers were scanned twice in a clinical scanner using wavelet MRE with an occipital impact. Time‐resolved brain translation, rotation, and maximal principal strain were calculated. Repeatability was assessed both qualitatively and through Pearson correlation.ResultsWavelet MRE outperformed standard MRE in displacement estimation, showing higher correlations between calculated and acquired phase, even with fewer phase offsets. In the volunteer study, consistent temporal motion dynamics and spatial maximal principal strain distributions across repeated scans demonstrated the repeatability of wavelet MRE.ConclusionThis study validated the accuracy and efficiency of wavelet MRE for broadband motion detection and demonstrated its feasibility and repeatability in vivo. This technique shows promise for advancing our understanding of the injury risks and mechanisms associated with sports‐related head trauma.

Radiologists are integral members of the interdisciplinary team for patients with mucinous appendiceal neoplasms and can directly affect care by suggesting the diagnosis of pseudomyxoma peritonei, optimizing imaging protocols for evaluating peritoneal implants, and reporting the primary tumor and spilled tumor cells thoroughly.