Faculty Bibliography

RATIONALE AND OBJECTIVES/OBJECTIVE:The automated segmentation of organs and tissues throughout the body using computed tomography and magnetic resonance imaging has been rapidly increasing. Research into many medical conditions has benefited greatly from these approaches by allowing the development of more rapid and reproducible quantitative imaging markers. These markers have been used to help diagnose disease, determine prognosis, select patients for therapy, and follow responses to therapy. Because some of these tools are now transitioning from research environments to clinical practice, it is important for radiologists to become familiar with various methods used for automated segmentation. MATERIALS AND METHODS/METHODS:The Radiology Research Alliance of the Association of University Radiologists convened an Automated Segmentation Task Force to conduct a systematic review of the peer-reviewed literature on this topic. RESULTS:The systematic review presented here includes 408 studies and discusses various approaches to automated segmentation using computed tomography and magnetic resonance imaging for neurologic, thoracic, abdominal, musculoskeletal, and breast imaging applications. CONCLUSION/CONCLUSIONS:These insights should help prepare radiologists to better evaluate automated segmentation tools and apply them not only to research, but eventually to clinical practice.

Myocardial injury after non-cardiac surgery (MINS) is a common post-operative complication associated with adverse cardiovascular outcomes. The purpose of this systematic review was to determine the incidence, clinical features, pathogenesis, management, and outcomes of MINS. We searched PubMed, Embase, Central and Web of Science databases for studies reporting the incidence, clinical features, and prognosis of MINS. Data analysis was performed with a mixed-methods approach, with quantitative analysis of meta-analytic methods for incidence, management, and outcomes, and a qualitative synthesis of the literature to determine associated pre-operative factors and MINS pathogenesis. A total of 195 studies met study inclusion criteria. Among 169 studies reporting outcomes of 530,867 surgeries, the pooled incidence of MINS was 17.9% (95% CI 16.2%-19.6%). Patients with MINS were older, more frequently men, and more likely to have cardiovascular risk factors and known coronary artery disease. Post-operative mortality was higher among patients with MINS than those without MINS, both in-hospital (8.1%, 95% CI 4.4%-12.7% versus 0.4%, 95% CI 0.2%-0.7%; relative risk 8.3, 95% CI 4.2 - 16.6, p<0.001) and at 1-year after surgery (20.6%, 95% CI 15.9%-25.7% versus 5.1%, 95% CI 3.2%-7.4%; relative risk 4.1, 95% CI 3.0 - 5.6, p<0.001). Few studies reported mechanisms of MINS or the medical treatment provided. In conclusion, MINS occurs frequently in clinical practice, is most common in patients with cardiovascular disease and its risk factors, and is associated with increased short- and long-term mortality. Additional investigation is needed to define strategies to prevent MINS and treat patients with this diagnosis.

Hospital-acquired infections are common in neurointensive care units. We sought to review interventions which may reduce infection rates in neurocritically ill populations. We conducted a systematic review of studies targeting adult patients in neuro-intensive care units (neuro-ICUs) with an intervention designed to prevent ICU-acquired infections. Our outcome of interest was change in the prevalence or rates of infection between active and control arms of these studies. We excluded studies based on the following criteria: no English full-text version available; pediatric population; non-neurosciences ICU population; pre- or intraoperative methods to prevent infection; lack of discrete data for infection rates/prevalence; studies that were purely observational in nature and did not test an intervention; and studies performed in resource limited settings. We initially retrieved 3716 results by searching the following databases: PubMed/MEDLINE, EMBASE via Ovid, and Cochrane CENTRAL via Ovid. No date or language limits were used in the search. Computerized deduplication was conducted using EndNote followed by a confirmatory manual review resulting in 3414 citations. An additional 19 manuscripts were identified through review of references. The screening process followed a standard protocol, using two screeners at the title/abstract level to determine relevance and at the full-text level to determine eligibility for inclusion. The 3427 titles/abstracts were independently screened by two board-certified neurointensivists to determine relevance for full-text review, and 3248 were rejected. The remaining 179 abstracts were reviewed in full text using predetermined inclusion/exclusion criteria. Ultimately, 75 articles met our inclusion criteria and were utilized in the final analysis. The reviewed literature highlights the need for collaborative, multi-disciplinary, and multi-pronged approaches to reduce infections. Rates of VRI, SSI, VAP, CAUTI, and CLABSI can approach zero with persistence and a team-based approach.

Introduction Brain death is accepted as medically and legally equivalent to cardiopulmonary death throughout much of the world. However, families sometimes make "requests for accommodation" based on refusal to accept an established brain death declaration or desire to avert an examination for determination of brain death. We sought to evaluate the medical literature to identify the demographics and management of these requests. Methods We performed a comprehensive literature review of Cochrane, Embase and Medline for documents published between 1/1/92 and 7/15/17 that addressed requests for accommodation. Results We identified 19 documents for inclusion. In addition to the large number of requests (~1,000) described in two surveys of practitioners in the USA, we found 28 distinct requests for accommodation for persons of all ages (range: infancy to 87-years-old), nine of whom were children. Nearly every (25/28) request was made in the past 15 years. With the exception of one case from the United Kingdom, every request for accommodation was made in the USA. Requests for accommodation were made for a variety of reasons including belief that neurologic recovery could occur, desire to await arrival of additional family members prior to discontinuation of support, lack of conceptual acceptance of death with a beating heart and religious beliefs. Management of requests varied from continuation of support until cardiopulmonary arrest, withdrawal of organ support with a family's authorization, withdrawal of organ support against a family's wishes, transfer to another hospital or country or discharge home for continuation of organ support. In some cases, healthcare teams acted independently, but in others, they relied on recommendations from an ethics team or instructions from a court. Conclusions Requests for accommodation are increasing. This trend is particularly evident in the USA. Although the rationales for requests vary, uniform management guidelines are needed

Introduction Hypothermia can blunt brainstem reflexes and impair the elimination of sedatives and analgesics. As a result, it can be challenging to perform a brain death (BD) evaluation after treatment with therapeutic hypothermia. We sought to review the literature to determine when it is appropriate to do a BD evaluation after therapeutic hypothermia. Methods We reviewed Cochrane, Embase and Medline for documents published between 1/1/92 and 7/15/17 that addressed BD determination after use of therapeutic hypothermia. Results We identified 24 documents, all of which were published between 2008 and 2017. Two case studies on patients treated with therapeutic hypothermia who had findings consistent with BD, but subsequently demonstrated return of some brainstem activity, have garnered much attention in the literature: 1) A 10-month-old boy was cooled to 32-33degreeC and sedated for 24 hours then declared BD 10 hours after being rewarmed and 6 hours after discontinuation of sedation, but subsequently began breathing again; 2) A 55-year-old man was cooled to 33degreeC and sedated for 36 hours, then was declared BD 22 hours after being rewarmed and 28 hours after being taken off sedation, but later was found to breathe spontaneously and have corneal and cough reflexes. While the literature consistently questions when it is appropriate to conduct a BD evaluation after hypothermia, there is no answer based on high level evidence. Because it can be challenging to determine when a condition is irreversible after hypothermia, it has been noted that it can be helpful to augment a clinical evaluation for BD determination with ancillary testing to assess for cerebral blood flow. Conclusions There is a need for clear guidelines and expert consensus on timing of the clinical exam for BD determination and both the role for, and modality of, ancillary testing after therapeutic hypothermia

The transtheoretical model and the stages of change are often used to adapt treatment to the individual client. The aims of this study were to review the stages of change and popular measures of change readiness in psychotherapy and to conduct a meta-analysis of the relation between readiness measures and psychotherapy outcomes. We report data from 76 studies, encompassing 25,917 patients. Moderate-sized effects (d = 0.41) were found for the association among multiple disorders, including substance and alcohol use, eating disorders, and mood disorders. Outcomes were a function of the pretreatment stage of change; that is, the farther a patient along the stages, the better the treatment outcomes. This review added 37 studies to the data reported in 2010, further strengthening the link between readiness and therapy outcomes. The article concludes with limitations of the research, diversity considerations, and therapeutic practices for stage matching in psychotherapy specifically and behavioral health more generally.

BACKGROUND:A variety of physical interventions have been used to improve reactive balance in older adults. PURPOSE/OBJECTIVE:To summarize the effectiveness of active treatment approaches to improve reactive postural responses in community-dwelling older adults. DESIGN/METHODS:Systematic Review, guided by PRISMA guidelines. STUDY SELECTION/METHODS:A literature search included databases of PubMed, OVID, CINAHL, Clinicaltrials.gov, OTseeker, and PEDro up to December 2017. RCTs that evaluated quantitative measures of reactive postural responses in healthy adults following participation in an active physical training program were included. DATA SYNTHESIS/RESULTS:Of 4,481 studies initially identified, 11 RCTs covering 313 participants were selected for analysis. Study designs were heterogeneous, preventing a quantitative analysis. Nine of the eleven studies reported improvements in reactive postural responses. CONCLUSIONS:Several clinically-feasible training methods have the potential to improve reactive postural responses in older adults; however, conclusions surrounding efficacy of treatment methods are limited due to numerous methodological issues and heterogeneity in outcomes and intervention procedures.

High sugar intake may increase cancer risk by promoting insulin-glucose dysregulation, oxidative stress, inflammation, and body adiposity, but epidemiologic evidence is unclear. Associations between dietary sugars and lifestyle-related cancer risk from longitudinal studies were evaluated. We systematically searched PubMed, Embase, and CINAHL and identified 37 prospective cohort studies (1990-2017) reporting multivariable adjusted risk estimates for dietary sugars in relation to cancer. Of 15 and 14 studies on total sugar and sucrose respectively, 11 reported a null association in relation to cancer. Of 14 studies on fructose, 8 reported null associations, and 2 reported protective and 4 reported detrimental associations. In two of five studies on added sugars, a 60-95% increased cancer risk was observed with higher intakes. In 8 of 15 studies, a 23% to 200% higher cancer risk was observed with higher sugary beverage consumption. In conclusion, most studies were indicative of a null association, but suggestive detrimental associations were reported for added sugars and sugary beverages. Expected final online publication date for the Annual Review of Nutrition Volume 38 is August 21, 2018. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.