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Volumetric laser endomicroscopy and its application to Barrett's esophagus: results from a 1,000 patient registry

Smith, M S; Cash, B; Konda, V; Trindade, A J; Gordon, S; DeMeester, S; Joshi, V; Diehl, D; Ganguly, E; Mashimo, H; Singh, S; Jobe, B; McKinley, M; Wallace, M; Komatsu, Y; Thakkar, S; Schnoll-Sussman, F; Sharaiha, R; Kahaleh, M; Tarnasky, P; Wolfsen, H; Hawes, R; Lipham, J; Khara, H; Pleskow, D; Navaneethan, U; Kedia, P; Hasan, M; Sethi, A; Samarasena, J; Siddiqui, U D; Gress, F; Rodriguez, R; Lee, C; Gonda, T; Waxman, I; Hyder, S; Poneros, J; Sharzehi, K; Di Palma, J A; Sejpal, D V; Oh, D; Hagen, J; Rothstein, R; Sawhney, M; Berzin, T; Malik, Z; Chang, K
Volumetric laser endomicroscopy (VLE) uses optical coherence tomography (OCT) for real-time, microscopic cross-sectional imaging. A US-based multi-center registry was constructed to prospectively collect data on patients undergoing upper endoscopy during which a VLE scan was performed. The objective of this registry was to determine usage patterns of VLE in clinical practice and to estimate quantitative and qualitative performance metrics as they are applied to Barrett's esophagus (BE) management. All procedures utilized the NvisionVLE Imaging System (NinePoint Medical, Bedford, MA) which was used by investigators to identify the tissue types present, along with focal areas of concern. Following the VLE procedure, investigators were asked to answer six key questions regarding how VLE impacted each case. Statistical analyses including neoplasia diagnostic yield improvement using VLE was performed. One thousand patients were enrolled across 18 US trial sites from August 2014 through April 2016. In patients with previously diagnosed or suspected BE (894/1000), investigators used VLE and identified areas of concern not seen on white light endoscopy (WLE) in 59% of the procedures. VLE imaging also guided tissue acquisition and treatment in 71% and 54% of procedures, respectively. VLE as an adjunct modality improved the neoplasia diagnostic yield by 55% beyond the standard of care practice. In patients with no prior history of therapy, and without visual findings from other technologies, VLE-guided tissue acquisition increased neoplasia detection over random biopsies by 700%. Registry investigators reported that VLE improved the BE management process when used as an adjunct tissue acquisition and treatment guidance tool. The ability of VLE to image large segments of the esophagus with microscopic cross-sectional detail may provide additional benefits including higher yield biopsies and more efficient tissue acquisition. NCT02215291.
PMID: 31037293
ISSN: 1442-2050
CID: 4268322

CB1R mediated HDAC-EGR1 pathway causes neurobehavioral defects in postnatal ethanol exposedmice [Meeting Abstract]

Basavarajappa, B S; Subbanna, S; Joshi, V; Shivakumar, M
Alcohol abuse during pregnancy exposes the fetal brain to alcohol and impairs brain maturation, leading to persistent neurobehavioral abnormalities, including cognitive decline, which together is known as fetal alcohol spectrumdisorder (FASD). However, the molecular mechanisms triggering these developmental deficits are poorly explained. In this study, we report that the binge-type ethanol exposure of P7 mice, which activates caspase-3, enhanced the histone deacetylase (HDAC) 1, HDAC2 and HDAC3 levels and reduced histone 3 (lysine 14, K14) and histone 4 (lysine 8, K8) acetylation in mature neurons [neuron-specific nuclear (NeuN) positive]. Ethanol exposure repressed early growth response 1 (Egr1) gene and protein expression. The repressed gene promoter region displayed differential HDACs, enhanced G9a, H3K14ac and histone 3 (lysine 9, K9) dimethylation enrichment. However, CREB-binding protein (CBP) enrichment was reduced at Egr1 promoter region. Inhibition of class 1 HDACs with trichostatin (TSA) before ethanol exposure, rescued H3K14ac and H4K8ac levels and prevented caspase-3 activation. Antagonism or null mutation of cannabinoid receptor type-1 (CB1R) before ethanol exposure, which inhibits caspase-3 activation, prevented H3K14ac and H4K8ac loss. TSA administration before ethanol exposure prevented ethanol-induced loss of Egr1 expression, restored epigenetic remodeling and neurobehavioral defects in adult mice. Together, these findings demonstrate that ethanol-activated CB1R regulates epigenetic/ gene expression mechanisms causing persistent neurobehavioral defects. CB1R/HDAC-mediated epigenetic remodeling disrupts gene expression and is a critical step in cognitive decline development in FASD, which is reversed by restoring histone acetylation in the brain
ISSN: 1530-0277
CID: 4024692

MR lumbosacral neurography: Clinical outcomes and implications for treatment over a 5 year period [Meeting Abstract]

Joshi, V; Burke, C; Pack, J; Gyftopolous, S
Purpose: To evaluate the clinical impact of the introduction of MR neurographic imaging of the lumbosacral plexus at a large academic institution. Materials and Methods: A retrospective analysis of all MR lumbosacral neurograms performed at our institution between 2011 and 2016 was performed. For each neurogram, age, sex, reason for exam, imaging findings, and treatment was recorded. In addition, for cases in which treatment was noted, the follow up patient outcome (if present) was also noted. Results: A total of 142 lumbosacral plexus neurograms were performed (53 male, 89 female); the mean age was 47.2 years (range 19-79). 105 studies demonstrated positive findings. 35 scans demonstrated positive neural findings. 70 demonstrated positive non neural findings. 37 studies were negative for both neural and non-neural abnormalities. Regarding outcomes; 4 underwent surgery, 21 image-guided radiological treatments, 3 patients underwent non image-guided (trigger point) injections and the remainder were managed medically. Image-guided procedures included fluoroscopy guided facet joint injections (2), fluoroscopy guided sacroiliac joint injections (1), lumbosacral epidural steroid injection (6), hip joint injections (3), ultrasound-guided perineural injection of the sciatic nerve/ piriformis (7), pudendal nerve (1), and genitofermoral nerve (1). Conclusion: MR neurography of the lumbosacral plexus allows detailed evaluation of the neural structures but frequently demonstrates non neural pathology. While the majority of cases received medical or conservative treatment, a significant number went on to image-guided treatment. A familiarity with the neurogram imaging findings and possible treatment options may be of use to the MSK interventionalist
ISSN: 1432-2161
CID: 2454432

MRI after shoulder ultrasound for the patient suspected of a rotator cuff tear: One institution's experience [Meeting Abstract]

Joshi, V; Gyftopoulos, S
Purpose: Several studies have demonstrated that shoulder ultrasound is an accurate, commonly utilized tool for the evaluation of rotator cuff tears, but the ordering of a follow up MRI has been incompletely investigated. The purpose of our study is to gain a better understanding of how often MRI is ordered after ultrasound for patients suspected of a rotator cuff tear, and the reasons for the ordering of this additional imaging examination. Materials and Methods: We performed a retrospective review of the electronic medical records of consecutive adult patients who underwent a shoulder ultrasound (US) examination for the evaluation of suspected rotator cuff pathology between January 1st 2014 and January 1st 2016. Exclusion criteria included patients who had prior shoulder rotator cuff surgery, and those with contraindications to MRI. Recorded data variables included age, sex, date of ultrasound, ultrasonography report findings, date of subsequent MRI (if obtained), MRI report findings, reason for performance of subsequent MRI, time interval between US and MRI (if obtained), whether the patients went on to rotator cuff surgery, ultrasound ordering physician specialty, and the length of time patients received follow up at our institution. Results: A total of 348 patients (176 males, 172 females); mean age 55.2 (range 18 -84) were included in this study based on our inclusion/ exclusion criteria. A shoulder MRI was obtained after shoulder ultrasound in 9.2% (n = 32) of patients. The mean time between shoulder US and MR was 88 days (range 0 - 262). The reasons for obtaining a subsequent shoulder MRI included, in descending order, persistent pain (n = 14), preoperative evaluation (n = 2), patient desire for anMRI (n = 2), too large body habitus (n = 1), concern for labral tear (n = 1), and possible brachial plexus lesion (1). In 11 cases, the reason for obtaining an MRI was not listed. There were 28 patients who underwent rotator cuff repair surgery. Of these patients who went to surgery, 82% (n = 23) went to surgery based on shoulder US only, and 18% (n = 5) obtained an MRI prior to surgery. Of the shoulder ultrasound examinations performed, the ordering clinician specialty was, in descending order, 90.2% (n = 314) orthopedics, 5.7% (n = 20) rheumatology, 2.6% (n = 9) primary care, and 1.4% (n = 5) physical medicine and rehabilitation. The mean follow up time for each patient was 21.1 months (range 9 - 32.4 months). Conclusion: The vast majority of patients who receive shoulder ultrasound for the evaluation of rotator cuff pathology at our institution do not end up getting a shoulder MRI afterwards. In the patients that did, the most common reason was for persistent pain. The majority of patients who went on to receive rotator cuff repair surgery did so based solely on shoulder ultrasound findings
ISSN: 1432-2161
CID: 2454362

Isolated Atraumatic Injury of the Supraspinous and Interspinous Ligaments

Joshi, Vivek; Casden, A; Skovrlj, B; Doshi, A
We reported a rare case of atraumatic injury to the supraspinous and interspinous ligaments in a 33-year-old woman. Without the typical history or imaging findings of trauma to the vertebral bodies, imaging findings associated with injury to the posterior ligament complex may be difficult to distinguish between posterior ligament complex rupture, lumbar strain, or fluid collection. This case highlighted the radiologic modalities and imaging findings that may aid in the diagnosis and treatment of equivocal cases
ISSN: 1541-6593
CID: 3048812

Painless transient bone marrow edema syndrome in a pediatric patient [Case Report]

Joshi, Vivek; Hermann, George; Balwani, Manisha; Simpson, William L
Transient regional migratory osteoporosis, considered to be part of the spectrum of bone marrow edema syndrome, is a rare condition with an unknown etiology. Patients usually present with lower extremity pain, most commonly in the 4th-5th decades of life. We describe a 15-year-old male patient with type 1 Gaucher disease who presented with transient bone marrow edema syndrome with features most closely resembling regional migratory osteoporosis. The patient presented with bone marrow edema of the lateral tibial epiphysis of his right knee that was incidentally seen on routine surveillance MRI that was performed as protocol for patients with type 1 Gaucher disease on enzyme replacement therapy. At this time, the patient had no pain and physical examination was normal. Follow-up MRI of the right knee 4 months afterward showed complete resolution of the signal abnormality in the right tibial epiphysis, and repeat study 8 months later displayed a new focus of painless migratory edema of the medial tibial epiphysis of the same knee. These changes completely resolved as well. Marrow signal abnormalities in children with Gaucher disease can have a broad differential, including infection, marrow infiltration, trauma, osteonecrosis, and bone marrow edema syndrome, amongst others. Correct diagnosis of bone marrow edema syndrome is critical, as this disease process most often resolves on conservative measures. The unusual presentation of transient bone marrow edema syndrome with regional migratory osteoporosis features in a young patient with Gaucher disease is described.
PMID: 24893724
ISSN: 1432-2161
CID: 3048792

PACS administrators' and radiologists' perspective on the importance of features for PACS selection

Joshi, Vivek; Narra, Vamsi R; Joshi, Kailash; Lee, Kyootai; Melson, David
Picture archiving and communication systems (PACS) play a critical role in radiology. This paper presents the criteria important to PACS administrators for selecting a PACS. A set of criteria are identified and organized into an integrative hierarchical framework. Survey responses from 48 administrators are used to identify the relative weights of these criteria through an analytical hierarchy process. The five main dimensions for PACS selection in order of importance are system continuity and functionality, system performance and architecture, user interface for workflow management, user interface for image manipulation, and display quality. Among the subdimensions, the highest weights were assessed for security, backup, and continuity; tools for continuous performance monitoring; support for multispecialty images; and voice recognition/transcription. PACS administrators' preferences were generally in line with that of previously reported results for radiologists. Both groups assigned the highest priority to ensuring business continuity and preventing loss of data through features such as security, backup, downtime prevention, and tools for continuous PACS performance monitoring. PACS administrators' next high priorities were support for multispecialty images, image retrieval speeds from short-term and long-term storage, real-time monitoring, and architectural issues of compatibility and integration with other products. Thus, next to ensuring business continuity, administrators' focus was on issues that impact their ability to deliver services and support. On the other hand, radiologists gave high priorities to voice recognition, transcription, and reporting; structured reporting; and convenience and responsiveness in manipulation of images. Thus, radiologists' focus appears to be on issues that may impact their productivity, effort, and accuracy.
PMID: 24744278
ISSN: 1618-727x
CID: 2975782

Optimized imaging of the postoperative spine

McLellan, Anne Marie; Daniel, Simon; Corcuera-Solano, Idoia; Joshi, Vivek; Tanenbaum, Lawrence N
Few tasks in imaging are more challenging than that of optimizing evaluations of the instrumented spine. The authors describe how applying fundamental and more advanced principles to postoperative spine computed tomography and magnetic resonance examinations mitigates the challenges associated with metal implants and significantly improves image quality and consistency. Newer and soon-to-be-available enhancements should provide improved visualization of tissues and hardware as multispectral imaging sequences continue to develop.
PMID: 24792613
ISSN: 1557-9867
CID: 2975792

Paradoxical evolution of a cerebellar tuberculosis abscess after surgical drainage and antibiotic therapy

Joshi, Vivek; Germano, Isabelle; Meenakshi, Rana; Doshi, Amish
BACKGROUND:Involvement of the central nervous system (CNS) by a tuberculosis abscess is a rare form of extra-pulmonary tuberculosis. With proper treatment, the abscess most commonly follows a pattern of continued reduction in size. CASE DESCRIPTION/METHODS:A 71-year-old male with a past medical history of kidney transplant on immunosuppressive therapy, presented to the hospital with a 1-day history of headache. On physical examination, the patient had no focal neurological symptoms. Initial laboratory reports were unremarkable. Contrast enhanced magnetic resonance imaging (MRI) was performed, which showed a ring enhancing mass and perilesional edema in the left cerebellar hemisphere. The patient underwent a left posterior fossa biopsy and drainage. The lesion was encapsulated with a purulent center. Cultures revealed pan-sensitive mycobacterium tuberculosis and the patient was started on rifampicin, isoniazid, pyrazinamide, ethambutol, and B6. The patient was monitored carefully and brain MRIs were obtained at 1, 4, 9, 11, and 14 months. It was noted that the tuberculosis abscess had grown in size from month 4 to month 9 of treatment. Since the patient's neurologic examination and symptoms were stable at that time, the drug regimen was not changed. The 14-month follow up MRI showed that the abscess had nearly resolved. CONCLUSION/CONCLUSIONS:Rarely, the pattern of CNS tuberculosis abscess evolution may include growth, even with proper treatment. This pattern does not necessarily signify treatment failure, as our abscess resolved without change in treatment. Given the possibility of asymptomatic abscess enlargement, close clinical and imaging follow up are crucial in management of these cases.
PMID: 25317358
ISSN: 2229-5097
CID: 3048802

Empirical investigation of radiologists' priorities for PACS selection: an analytical hierarchy process approach

Joshi, Vivek; Lee, Kyootai; Melson, David; Narra, Vamsi R
Picture archiving and communication systems (PACS) are being widely adopted in radiology practice. The objective of this study was to find radiologists' perspective on the relative importance of the required features when selecting or developing a PACS. Important features for PACS were identified based on the literature and consultation/interviews with radiologists. These features were categorized and organized into a logical hierarchy consisting of the main dimensions and sub-dimensions. An online survey was conducted to obtain data from 58 radiologists about their relative preferences. Analytical hierarchy process methodology was used to determine the relative priority weights for different dimensions along with the consistency of responses. System continuity and functionality was found to be the most important dimension, followed by system performance and architecture, user interface for workflow management, user interface for image manipulation, and display quality. Among the sub-dimensions, the top two features were: security, backup, and downtime prevention; and voice recognition, transcription, and reporting. Structured reporting was also given very high priority. The results point to the dimensions that can be critical discriminators between different PACS and highlight the importance of faster integration of the emerging developments in radiology into PACS.
PMID: 20824302
ISSN: 1618-727x
CID: 2975742