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Informed consent is an important part of the clinician-patient relationship. However, studies suggest consent practices tend to be limited in consistency and completeness. This may be particularly challenging for interventional radiology given more limited public awareness and the often fast-paced, dynamic nature of our practices. This article reviews these challenges as well as ideal consent practices and potential approaches to improve consent in interventional radiology.

To compare the cost-effectiveness of tunneled peritoneal catheter (TPC) versus serial large-volume paracenteses (LVP) for patients with recurrent ascites.Retrospective, single-institution analysis of 100 consecutive patients undergoing LVP and eventual TPC placement (2015-2018) was performed with extraction of procedural complications and hospital admissions. LVPs were associated with 17 adverse events (AEs) while only 9 AEs occurred after TPC placement. While undergoing routine LVP, the patients had 30 hospitalizations monthly (177 days in total) and 10 hospitalizations monthly (51 days) after TPC placement. A cost-effectiveness analysis with Markov modeling was performed comparing TPC and LVP. Costs were based on Medicare reimbursement rates. Statistical analyses include base case calculation, Monte Carlo simulations, and deterministic sensitivity analyses.TPC placement was the dominant strategy with a comparable health benefit of 0.08060 quality-adjusted life-years (QALY) (LVP: 0.08057 QALY) at a lower cost of $4151 (LVP: $8401). Probabilistic sensitivity analysis showed TPC was superior in 97.49% of simulations. Deterministic sensitivity analysis demonstrated the superiority of TPC compared to LVP if the TPC complication rate was 9.47% per week and the complication rate for LVP was 1.32% per procedure. TPC was more cost-effective when its procedural cost was $5427 (base case: 1174.5), and remained as such when the cost of LVP was varied as much as $10,000 (base case: $316.48).In this study, TPC was more cost-effective than LVP in patients with recurrent ascites due to the reduced risk of infection, emergency department visits, and length of hospitalization stays.

PURPOSE To assess the prevalence of positive conflict of interest (COI) disclosures in U.S.-based interventional radiology (IR) research as well as the level of agreement between disclosed financial relationships and open payment data for top-cited image-guided procedure research. MATERIALS AND METHODS All publications in volume 30 (2019) of the Journal of Vascular and Interventional Radiology (JVIR) were reviewed to estimate the prevalence of COI disclosures in IR research. Publications were categorized as primary research, systematic review, or other. Prevalence was then compared across JVIR publication subtype, categories, and whether they were device-focused with chi-squared tests. Additionally, the Web of Science database was searched for the top 10 cited studies of 10 common image-guided procedures with available U.S. physician payment data. Payments were categorized as historical (>1 year prior to publication) or active (

As the field of interventional radiology assumes a larger role in patient care, the specialty has a growing responsibility to recognize and understand ethical dilemmas within the field. We present a case-based primer on common ethical issues in IR, including requests for potentially inappropriate procedures, surrogate decision making, informed consent, and managing conflicts of interest and procedural complications. This primer is intended to be used as a guide for discussion-based training in ethics in IR while inspiring further research in applied ethics in IR.

Objective The objective of this study was to assess factors associated with symptom resolution after endovascular stenting for superior or inferior vena cava syndrome. Methods Eighty-six consecutive vena cava Z-configuration stent placements in 82 patients (53 ± 14 years old) at a single institution were reviewed for patient demographics, comorbidities, and durability of stent patency (also evaluated were persistent or recurrent symptoms, stent occlusion, and need for repeated stenting). Logistic regression was used to identify independent factors associated with stent patency, and Φ coefficients and analysis of variance were used to compare cases subdivided by lesion location (superior vena cava, inferior vena cava) and the presence or absence of malignant disease. Results Clinical follow-up was available in 77 of 86 (90%) cases. Technical success with clinical failure (persistent symptoms) occurred in 40% of these cases with a median follow-up of 67 (interquartile range, 14-570) days and mortality rate of 63% during this period. Malignant obstructions had a significantly higher clinical failure rate of 54% compared with 15% for nonmalignant obstructions (Φ = 0.34; P = .002). However, only metastatic disease was independently associated with clinical failure when controlling for demographics, other comorbidities, and differential follow-up (adjusted odds ratio, 8.27; 95% confidence interval, 2.79-24.50). Conclusions Vena cava Z-stenting effectively resolves symptoms in 85% of nonmalignant obstructions compared with only 46% of malignant obstructions. Patients should be counseled accordingly, and those with malignant obstructions may require closer follow-up to evaluate the need for reintervention and goals of care.

To characterize perceptions of palliative versus futile care in interventional radiology (IR) as a roadmap for quality improvement. Interventional radiologists (IRs) and referring physicians were recruited for anonymous interviews and/or focus groups to discuss their perceptions and experiences related to palliative verse futile care in IR. Sessions were recorded, transcribed, and systematically analyzed using dedicated software, content analysis, and grounded theory. Data collection and analysis continued simultaneously until additional interviews stopped revealing new themes: 24 IRs (21 males, 3 females, 1–39 years of experience) and 7 referring physicians (3 males, 4 females, 6–14 years of experience) were analyzed. Many IRs (75%) perceived futility as an important issue. Years of experience (r = 0.60, p = 0.03) and being in academics (r = 0.62, p = 0.04) correlated with greater perceived importance. Perceptions of futility and whether a potentially inappropriate procedure was performed involved a balance between four sets of factors (patient, clinician, procedural, and cultural). These assessments tended to be qualitative in nature and are challenged by a lack of data, education, and consistent workflows. Referring clinicians were unaware of this issue and assumed IR had guidelines for differentiating between palliation and futility. This study characterized the complexity and qualitative nature of assessments of palliative verses futile care in IR while highlighting potential means of improving current practices. This is important given the number of critically ill patients referred to IR and costs of potentially inappropriate interventions.

To compare the cost-effectiveness of tunneled peritoneal catheter (TPC) versus repeated large-volume paracentesis (LVP) for patients with recurrent ascites secondary to gynecological malignancy.A retrospective cohort study was performed at a single institution from 2016 through 2019 of patients with recurrent ascites from gynecologic malignancies that underwent either TPC or LVP. Data on procedural complications and hospital admissions were extracted. A cost-effectiveness analysis with Markov modeling was performed comparing TPC and LVP. Statistical analyses include base case calculation, Monte Carlo simulations and deterministic sensitivity analyses.There were no significant differences between the cohorts in the average number of hospital days (p = 0.21) or emergency department visits (p = 0.69) related to ascites. Palliative care was more often involved in the care of patients who had a TPC. The base case calculation showed TPC to be the more cost-effective strategy with a slightly lower health benefit (0.22980 versus 0.22982 QALY) and lower cost ($3043 versus $3868) relative to LVP (ICER of LVP compared to TPC: $44,863,103/QALY). Probabilistic sensitivity analysis showed TPC was the more cost-effective strategy in 8028/10,000 simulations. Deterministic sensitivity analysis showed TPC to be more cost-effective if its complication risk was0.81% per 22 days or its procedural cost of TPC insertion was$1997. When varying the cost of complications, TPC was more cost-effective if the cost of its complication was less than $49,202.TPC is the more cost-effective strategy when compared to LVP in patients with recurrent ascites from gynecological malignancy.

This case features a 21-year-old woman with a history of ulcerative colitis who was incidentally found to have a para-jejunal mass when she presented with an ulcerative colitis flare. The mass was further characterized on MR enterography as most likely representing ectopic pancreatic tissue. Given the normal intense pancreatic uptake of 18 F-fluciclovine, PET/CT was subsequently used to confirm that the mass represented ectopic pancreatic tissue.

Background Deaths in gluteal autografting occur due to gluteal vein injuries, but data are lacking on the precise location and caliber of these veins. Objectives The authors sought to present the first in vivo study of gluteal vein anatomy utilizing magnetic resonance imaging. Methods Magnetic resonance imaging venography of 16 volunteer hemi-sections was conducted in the supine, prone, prone with a bump (jack-knife), and left and right decubitus positions in 1 session after a single contrast administration. Caliber and course of the superior and inferior gluteal veins (SGV/IGV) were analyzed vs bony landmarks and position changes. Results The SGV has a very short submuscular course before splitting into 2 smaller branches superolaterally. The IGV runs immediately deep to the gluteus maximus in the center of the buttock as a single large trunk, on average 56 mm deep (mean 27 mm of muscle belly and 30 mm subcutaneous fat). No intramuscular or subcutaneous branches greater than 2 mm were found. In the prone position, the IGV and SGV have an average caliber of 5.96 mm and 5.63 mm. Vessel caliber decreased by 21% and 27%, respectively, in the jack-knife position and by 14% and 15% in lateral decubitus. Conclusions The SGV and IGV are immediately deep to gluteus maximus approximately 6 cm deep with a caliber on the order of 6 mm in the prone position. The distribution of these vessels suggests there is no “safe zone” in the intramuscular or submuscular planes. The jackknife or lateral decubitus positions can decrease vein caliber by up to 27%, possibly reducing the risk of injury due to either traction or direct cannula impact.

Study Objective To assess the effects of a multidisciplinary fibroid clinic on practice patterns and clinician perceptions. Design Annual rates of hysterectomies, myomectomies, and uterine fibroid embolizations (UFEs) were collected from 2012-2019. Rates of each procedure were compared over time before and after launching a multidisciplinary fibroid clinic at the academic medical center. Referral rates were also compared. The minimally invasive gynecologic surgeons (MIGSs) and interventional radiologists (IRs) involved in the clinic were interviewed 2 years prior to and after the clinic launch about their approaches to fibroids and perceptions of others who treat this condition. A phenomenological approach was used to identify and compare themes within the interviews by two researchers with excellent inter-rater agreement (k = 0.80). Setting Urban healthcare system with an academic medical center (894 beds) as well as community affiliate hospitals. Patients or Participants 6361 procedures performed for symptomatic uterine fibroids from 2012-2019 for 5747 patients (average age 49±9 years). Interventions Creation of a multidisciplinary fibroid treatment clinic staffed by MIGSs and IRs. Measurements and Main Results Annual rates of fibroid procedures increased over time (p Conclusion Creating the right practice environment may be more important for fostering inter-specialty collaboration and work satisfaction than shared mental models or procedural volumes in certain practice settings.

To characterize perceptions of ethics among interventional radiologists to guide the development of an applied, specialty-specific approach to ethics.A 17-question survey on perceptions of ethics and use of ethics resources was developed and vetted via cognitive interviewing of 15 diverse, representative members of the target population. The survey was distributed via the Society of Interventional Radiology, receiving 685 responses (48% participation and 90% completion rates). Responses were compared between different demographics, and common themes from free text responses were identified via content analysis.Most respondents indicated ethics is important for IR (93%) and more focus on practical approaches to ethical issues is needed (73%). Various ethical issues were perceived to be important for IR, but differentiating palliative from futile care was ranked as the top ethical issue. Trainees had more ethics training (P=0.05) but less confidence in navigating ethical issues (P0.01). Regardless of career stage, those with ethics training (44%) were more confident in navigating ethical issues (P0.01). Use of resources such as information sheets for patients and resources for coping with complications were variable and limited by lack of availability or knowledge of such resources in IR.Interventional radiologists believe ethics is important and face diverse ethical issues, but they are challenged by variable experiences and access to practical tools to navigate these challenges.

The integrated interventional radiology (IR) residency accepted its first applicants in 2017. Achieving specialty status represents a significant milestone for IR; recognizing the expanding role of IR as part of an interdisciplinary team. However, this transition has had challenges that were well predicted by Heitkamp and Gunderman in 2014 and are reflected in the history of many specialties. New specialties often have complex relationships with their “parent” specialties, creating debates and tension regarding training, licensure, and scope of practice. Many of these factors have been discussed in opinion pieces by leaders in the field, reflecting upon the transition. There have also been surveys of matched IR/DR residents. However, there are few firsthand accounts of the challenges faced by trainees during such a transition, challenges that often are not well captured by an online survey.

Background Despite a significant burden of injury-related deaths, the Plurinational State of Bolivia (Bolivia), a lower- middle-income country in South America, lacks a formalized trauma system. This study sought to examine Bolivian trauma care from the patient perspective in order to determine barriers to care and targets for improvement. Methods Investigators conducted 15 semi-structured interviews with trauma patients admitted at four hospitals in Santa Cruz de la Sierra, Bolivia in June and July of 2016. Interviews were transcribed, translated, and analyzed through content and discourse analysis to identify key themes and perceptions of trauma care. Results Participants primarily presented with orthopedic injuries due to road traffic incidents and falls. Only one participant reported receiving first aid from a layperson at the scene of injury. Of the 15 participants, 12 did not know any number to contact emergency medical services (EMS). Participants expressed negative views of EMS as well as concerns for slow response times and inadequate personnel and training. Two thirds of participants were initially brought to a hospital without adequate resources to care for their injuries. Participants generally expressed positive views regarding healthcare workers involved in their hospital-based medical care. Conclusions This region of Bolivia has a disorganized, underutilized, and distrusted trauma system. In order to increase survival, interventions should focus on improving prehospital trauma care. Potential interventions include the implementation of layperson trauma first responder courses, the establishment of a medical emergency hotline, the unification of EMS, the implementation of basic training requirements for EMS personnel, and public education campaigns to increase trust in EMS.

PURPOSE To retrospectively review the effectiveness and safety of radiofrequency (RF) wire recanalization of refractory central venous occlusions (CVOs) and compare recurrent and nonrecurrent CVOs in terms of patient and occlusion characteristics. MATERIALS AND METHODS Twenty CVOs were treated in 18 patients (age 40 y ± 13; 9 women) with 11 superior vena cava (SVC) or brachiocephalic vein occlusions (ie, supradiaphragmatic) and 9 inferior vena cava or iliac vein occlusions (ie, infradiaphragmatic). Indications included pain, edema, ulceration, and/or dialysis arteriovenous fistula dysfunction peripheral to the CVO(s). All patients had multiple venous thrombotic risk factors, including mechanical venous compression, endothelial injury, and/or coagulopathies. CVO traversal was first attempted with standard and advanced techniques before RF wire recanalization and followed up with computed tomographic venography and clinic visits approximately 1, 3, 6, and 12 months after treatment. RESULTS Sixteen CVOs (80%) were successfully transversed and associated with symptom relief. One major complication occurred involving SVC perforation into the pericardial space. Primary CVO patency rate was 56% at a median follow-up of 14.1 months (interquartile range [IQR], 9.2-20.0 mo). Recurrent CVOs tended to be infradiaphragmatic (71% vs 12% for supradiaphragmatic; P = .02), longer (12.9 cm ± 10.0 vs 2.3 cm ± 1.3; P < .01), and associated with implanted venous stents, filters, or cardiac pacer/defibrillator leads (86% vs 22%; P = .01). Median time to restenosis/occlusion was 1.5 months (IQR, 1.1-6.1 mo). CONCLUSIONS RF wire recanalization is a relatively effective and safe option for refractory CVOs. Patients with longer, infradiaphragmatic CVOs associated with indwelling devices may require closer follow-up for CVO recurrence.

RATIONALE AND OBJECTIVES This study sought to more definitely illustrate the impact and feasibility of implementing a low-dose protocol for computed tomography (CT)-guided biopsies using size-specific dose estimates and multivariate analyses. MATERIALS AND METHODS Fifty consecutive CT-guided lung and extrapulmonary biopsies were reviewed before and after implementation of a low-dose protocol (200 patients total, mean age 61 ± 15 years, 128 women). Analyses of variance with Bonferroni correction were used to compare standard and low-dose protocols in terms of patient demographics, physician experience, target lesion size, total dose-length product, total acquisitions, size-specific dose estimate, signal-to-noise ratio, contrast-to-noise ratio, and lesion conspicuity ratings. All procedures were performed on the same 16-slice CT scanner. RESULTS Voluntary protocol adherence was 100% (lung) and 89% (extrapulmonary). The low-dose protocol achieved significantly lower total average dose-length product [(lung) 735.6 ± 599.4 mGy × cm to 252.1 ± 101.9 mGy × cm, P

OBJECTIVE The objective of this study is to evaluate the ability of spleen volume, blood flow, and an index incorporating multiple measures to predict cirrhosis-associated hypersplenism. MATERIALS AND METHODS A total of 39 patients (14 women and 25 men; mean [± SD] age, 52 ± 10 years) with cirrhosis and sequelae of portal hypertension underwent 4D flow MRI and anatomic 3-T MRI performed before and after contrast administration. Unenhanced 4D flow MRI was used to assess abdominal hemodynamics, and splenic volumes were measured on T1-weighted gradient-recalled echo MRI. Relationships among demographic characteristics, blood component counts, splenic volume, arterial flow, venous flow, and the percentage of shunted portal flow were assessed in 29 consecutive patients (i.e., the derivation group), to develop a splenic flow index. This index was assessed along with splenic volume and blood flow alone in 10 additional consecutive patients (i.e., the validation group) via ROC curve analysis, to identify platelet counts of less than 50 × 103 cells/μL, leukocyte counts of less than 3.0 × 103 cells/μL, or both. RESULTS In the derivation cohort (platelet count, 129 ± 76 × 103 cells/μL), splenic volume, arterial flow, venous flow, and the percentage of shunted portal flow were inversely correlated with platelet counts (ρ = -0.68, -0.68, -0.56, and -0.36, respectively; p < 0.05). Adding splenic volume to arterial flow and the product of venous flow and the percentage of shunted portal flow indexed to the body surface area yielded superior correlations with platelet counts, leukocyte counts, and the degree of severity of hypersplenism (ρ = -0.75, -0.48, and -0.75, respectively; p ≤ 0.001) and predicted severe hypersplenism (sensitivity, 100%; specificity, 100%) in the validation cohort (platelet count, 93 ± 71 × 103 cells/μL). CONCLUSION A splenic flow index that incorporates both splenic volume and blood flow is a better indicator of hypersplenism than is splenic volume alone.

To assess the impact of an alternative preprocessing workflow on noncontrast- and contrast-enhanced abdominal four-dimensional flow magnetic resonance imaging (4D flow MRI) data consistency.Twenty patients with cirrhosis and portal hypertension (5 women; 53 ± 10 years old) underwent 4D flow MRI at 3.0T before and after administration of 0.03 mmol/kg of gadofosveset trisodium with velocity sensitivities of 100 and 50 cm/s for arterial and venous flow quantifications, respectively. 4D flow MRI data were preprocessed using the conventional workflow (workflow 1), applying noise filters prior to eddy current correction, and an alternative workflow (workflow 2), first correcting for eddy currents and using noise filtering only if needed for anti-aliasing. Vessel segmentation quality was ranked by independent reviewers and compared via Wilcoxon signed-rank tests. Flow quantification and conservation of mass at two portal and one arterial branch points were compared via paired t tests.Segmentation quality was significantly higher for workflow 2 (P 0.05) with excellent interobserver agreement (κ = 0.92). Workflow 2 resulted in larger flow values (P 0.05) with improved conservation of mass (7.3 ± 6.1% vs. 27.7 ± 25.0%, P 0.001 [portal]; 10.7 ± 9.0% vs. 21.7 ± 21.6%, P = 0.02 [arterial]). Peak velocities and abdominal aortic flow were similar (P 0.05). Noncontrast acquisitions yielded significantly smaller portal flow values (P 0.05) with improved conservation of mass (5.8 ± 4.7% vs. 8.7 ± 6.9%, P = 0.05 [portal]; 6.2 ± 4.5% vs. 13.7 ± 10.2%, P = 0.03 [arterial]).Superior abdominal 4D flow MRI data consistency was obtained by applying eddy current correction before any other data manipulation, using noise masking and velocity anti-aliasing cautiously, and using noncontrast acquisitions.

Clinicians, particularly those in procedural specialties, tend to feel personally responsible when complications occur. Medical errors among surgeons have been studied and provide an insightful window into the ethics of complications. Ethically we must consider what we owe patient and families, ourselves, and our colleagues. To some degree, the answers are similar: reflection, confession, and resolution. We owe patients and families an explanation and lack of abandonment; we owe ourselves thoughtful reflection on what caused the complication and how we can learn from it; and we owe our colleagues assistance managing our complications and a chance to learn from our mistakes. As a specialty that prides itself on innovation and novel therapies, interventional radiology has a unique relationship with complications that has not been well developed. As the specialty grows, it will be important to provide forums for further understanding the ethical challenges in interventional radiology.

To understand how cultural differences between vascular surgeons (VSs) and interventional radiologists (IRs) affect their clinical decision making and inter-specialty relationships. Twenty-four conversational interviews were conducted with IRs and VSs about their approaches to patient care, views of their specialty and others, and solutions to any expressed concerns. Interview transcripts were systematically analyzed to identify and compare key themes according to the constructivist grounded theory and content analysis using NVivo 10 software. These data were supplemented with a retrospective analysis of 3658 endovascular stent placements performed at a large medical academic center over 11 years. Aggregate counts were divided by provider specialty, and trends were assessed via correlation coefficients. Endovascular stent placements were relatively equally divided between IR and VS over 11 years with some variability from placements by cardiology. IRs tend to lay claim to treatments as masters of procedures, whereas VSs base their claims on being masters of the treated diseases, leading to collaboration in some practices and bitter competition in others. The level of perceived competition was most associated with specialists’ awareness of and appreciation for specialty-specific values rather than differences in practice structure/reimbursement. Understanding cultural differences between IRs and VSs is imperative for fostering better collaboration to grow shared territory rather than competing for the same slice of the pie.

Background: To assess the technical success of ultrasound (US)-guided peripherally inserted central catheter (PICC) placement at a large academic medical center and evaluate the direct and indirect costs associated with malpositioned catheters.Methods: This retrospective chart review consisted of 250 consecutive inpatients and 150 consecutive outpatients (N = 400, aged 58 ± 17 years, 225 men and 175women) who underwent US-guided PICC placement at a single center. Repositioning rates were compared between high-complexity (inpatient) and low-complexity (outpatient) groups using a χ2 test and phi coefficient. Initial and final catheter tip position was assessed by radiography. Direct costs of repositioning were estimated using Medicare reimbursement rates. Indirect costs, including additional staff time, imaging, and delays in treatment, were assessed via a survey of PICC nurses and chart reviews.Results: Initial PICC placement resulted in an optimal tip position in 34% of patients and an optimal or acceptable position in 84% of patients. Repositioning rates were significantly higher for inpatients with a low to moderate association between inpatient PICC placement and the need for repositioning (χ2 = 9.603, P = .002; σ = 0.155, P = .002). In total, 77 catheters required repositioning, costing on average an additional $186.03 and 50 minutes of staff time per catheter as well as delaying catheter use in 23 patients for at least 24 hours.Conclusions: PICC malpositioning is a significant source of inefficiency, especially for inpatient services, that should be addressed to reduce expenditures and maximize patients' perceptions of quality health care.

OBJECTIVES: Previous work suggests that aortic root and valve prostheses alter blood flow patterns in the ascending aorta, creating aberrant haemodynamics compared with those of healthy volunteers. Various valve designs have been proposed to better restore physiological haemodynamics. In this study, magnetic resonance imaging (MRI) was used to non-invasively assess three-dimensional (3D) ascending aortic haemodynamics after aortic root replacement (ARR) with a mechanical valved conduit postulated to create less turbulent blood flow. METHODS: Ten patients (40 ± 9 years) underwent transthoracic echocardiography and contrast-enhanced multidimensional four-dimensional (4D) flow MRI at 1.5 T after ARR with an On-X mechanical valved conduit. Preoperative 4D flow MRI was available in 7 patients. Ten age- and gender-matched healthy volunteers (42 ± 13 years) were also analysed to characterize physiological flow. The presence of vortex/helix formation was graded by two blinded observers. Peak transvalvular pressure gradients were computed using the simplified Bernoulli equation. Patients' postoperative pressure gradients and helicity/vorticity grades were compared with preoperative gradients and those from healthy volunteers. RESULTS: Intra- and interobserver ratings showed good agreement (κ = 0.93, P < 0.01 and κ = 0.84, P < 0.01, respectively). Highly helical and/or vortical flow was observed in all patients preoperatively, which was significantly reduced postoperatively (P < 0.01 and

Over the last few years, an increasing number of lawsuits have been filed involving inferior vena cava filters. This has prompted the U.S. Judicial Panel on Multidistrict Litigation to centralize these lawsuits into two multidistrict litigations: one for Cook's filters and one for Bard's. Both sets of cases share similar questions of facts, in particular whether these filters' design and manufacturing practices made them unreasonably prone to serious complications. The resolution of these cases will add to a larger legal debate concerning how much legal protection the 1976 Medical Device Amendments should offer firms from tort liability. As a specialty that often relies on medical devices, it is not only important for interventional radiologists to have a general understanding of medical device litigation but also to reflect upon the approaches to informed consent regarding these devices.

BackgroundPhysician engagement has become a key metric for healthcare leadership and is associated with better healthcare outcomes. However, engagement tends to be low and difficult to measure and improve. This study sought to efficiently characterize the professional cultural dynamics between physicians and administrators at an academic hospital and how those dynamics affect physician engagement.Materials and methodsA qualitative mixed methods analysis was completed in 6 weeks, consisting of a preliminary analysis of the hospital system's history that was used to purposefully recruit 20 physicians across specialties and 20 healthcare administrators across management levels for semi-structured interviews and observation. Participation rates of 77% (20/26) and 83% (20/24) were achieved for physicians and administrators, respectively. Cohorts consisted of equal numbers of men and women with experience ranging from 1 to 35 years within the organization. Field notes and transcripts were systematically analyzed using an iterative inductive-deductive approach. Emergent themes were presented and discussed with approximately 400 physicians and administrators within the organization to assess validity and which results were most meaningful.Results & discussionThis investigation indicated a professional cultural disconnect was undermining efforts to improve physician engagement. This disconnect was further complicated by a minority (10%) not believing an issue existed and conflicting connotations not readily perceived by participants who often offered similar solutions. Physicians and administrators felt these results accurately reflected their realities and used this information as a common language to plan targeted interventions to improve physician engagement. Limitations of the study included its cross-sectional nature with a modest sample size at a single institution.ConclusionsA qualitative mixed methods analysis efficiently identified professional cultural barriers within an academic hospital to serve as an institution-specific guide to improving physician engagement.

Enediynes are a highly cytotoxic class of compounds. However, metallation of these compounds may modulate their activation, and thus their cytotoxicity. We previously demonstrated that cytotoxicity of 2 different metalloenediynes, including (Z)-N,N′-bis[1-pyridyl-2-yl-meth-(E)-ylidene]octa-4-ene-2,6-diyne-1,8-diamine] (PyED), is potentiated when the compounds are administered to HeLa cells during hyperthermia treatment at concentrations that are minimally or not cytotoxic at 37 °C. In this study, we further characterized the concentration-, time-and temperature-dependence of cytotoxicity of PyED on human U-1 melanoma cells. We also investigated the potential mechanisms by which PyED cytotoxicity is enhanced during hyperthermia treatment. Cell killing with PyED was dependent upon concentration, temperature during treatment, and time of exposure. Potentiation of cytotoxicity was observed when cells were treated with PyED at temperatures ≥39.5 °C, and enhancement of cell killing increased with temperature, and with increasing time at a given temperature. All cells exposed to PyED were shown to have DNA damage, but substantially more damage was observed in cells treated with PyED during heating. DNA repair was also inhibited in cells exposed to the drug during hyperthermia treatment. Thus, potentiation of PyED cytotoxicity by hyperthermia may be due to enhancement of drug-induced DNA lesions, and/or the inhibition of repair of sublethal DNA damage. While the selective thermal activation of PyED supports the potential clinical utility of metalloenediynes as cancer thermochemotherapeutic agents, therapeutic gain could be optimized by identifying compounds that produce minimal toxicity at 37 °C but which become activated and show enhancement of cytotoxicity within a tumor subjected to localized hyperthermic or thermal ablative treatment, or which might act as bifunctional agents. We thus also describe the development and initial characterization of a novel cofactor complex of PyED, platinated PyED (Pt-PyED). Pt-PyED binds to DNA like cisplatin, and much like PyED, cytotoxicity is greatly enhanced after treatment with the drug at elevated temperatures. However, in contrast to PyED, Pt-PyED is only minimally cytotoxic at 37 °C at concentrations at which cytotoxicity is enhanced by hyperthermia. Further development of cisplatin-based enediynes may result in compounds which, when activated, will possess multiple DNA binding modalities similar to cisplatin, but produce less side effects in tissues at normothermic temperatures.

Purpose To identify factors independently associated with disease recurrence after venoplasty and stent placement for May–Thurner syndrome (MTS). Materials and Methods Fifty-nine consecutive patients (age, 47 y ± 15; 93% female) were identified who had undergone endovascular stent placement for MTS. Patient charts were reviewed for demographic data, risk factors for venous thrombosis, comorbidities, and venous inflow or outflow at first follow-up (3 wk to 6 mo after treatment). Logistic regression was used to identify independent predictors of symptom recurrence or repeat intervention, and multivariate analysis of variance and receiver operator characteristic curve analysis were used to assess relationships between degrees of in-stent stenosis and other variables in the 73% of patients with available cross-sectional imaging. Median follow up was 20.7 months (interquartile range, 4.7–49.5 mo). Results All procedures were technically successful. Disease recurrence, defined as symptom recurrence following initial postprocedural resolution, was observed in 38% of patients. No preprocedural variable was found to be independently predictive of disease recurrence; however, poor venous inflow or outflow were both strongly associated with recurrent disease, with adjusted odds ratios and 95% confidence intervals of 38.02 (3.76–384.20; P = .002) and 7.00 (1.15–42.71; P = .04), respectively. Higher degrees of in-stent stenosis were also associated with symptom recurrence, with an area under the curve of 0.93 (P = .000002) and 39%–41% stenosis being 78%–83% sensitive and 88%–92% specific for symptom recurrence. Conclusions These results suggest that cross-sectional imaging can help differentiate patients in whom closer follow-up may be warranted after venoplasty and stent placement for MTS and also guide counseling regarding prognosis.