29 results on '"Nancy J. McNulty"'
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2. Plasma DNA as a 'liquid biopsy' incompletely complements tumor biopsy for identification of mutations in a case series of four patients with oligometastatic breast cancer
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Ananta Bhatt, Todd W. Miller, Jason D. Wells, Nancy J. McNulty, Richard J. Barth, Jennifer R. Bean, Jiang Gui, Mary D. Chamberlin, Wendy A. Wells, Peter A. Kaufman, Jonathan D. Marotti, Michael J. Tsapakos, John M Gemery, Fred W. Kolling, Gary N. Schwartz, Kevin Shee, Bradley A. Arrick, and Heidi W. Trask
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0301 basic medicine ,Cancer Research ,Breast Neoplasms ,Article ,DNA sequencing ,Circulating Tumor DNA ,03 medical and health sciences ,0302 clinical medicine ,Breast cancer ,Biopsy ,Biomarkers, Tumor ,medicine ,Humans ,Neoplasm Metastasis ,Liquid biopsy ,Massive parallel sequencing ,medicine.diagnostic_test ,business.industry ,Liquid Biopsy ,High-Throughput Nucleotide Sequencing ,Cancer ,DNA, Neoplasm ,Prognosis ,medicine.disease ,030104 developmental biology ,Oncology ,Cell-free fetal DNA ,DNA profiling ,030220 oncology & carcinogenesis ,Mutation ,Cancer research ,Female ,business - Abstract
PURPOSE: Circulating tumor DNA in plasma may present a minimally invasive opportunity to identify tumor-derived mutations to inform selection of targeted therapies for individual patients, particularly in cases of oligometastatic disease where biopsy of multiple tumors is impractical. To assess the utility of plasma DNA as a “liquid biopsy” for precision oncology, we tested whether sequencing of plasma DNA is a reliable surrogate for sequencing of tumor DNA to identify targetable genetic alterations. METHODS: Blood and biopsies of 1–3 tumors were obtained from 4 evaluable patients with advanced breast cancer. One patient provided samples from an additional 7 tumors post-mortem. DNA extracted from plasma, tumor tissues, and buffy coat of blood were used for probe-directed capture of all exons in 149 cancer-related genes and massively parallel sequencing. Somatic mutations in DNA from plasma and tumors were identified by comparison to buffy coat DNA. RESULTS: Sequencing of plasma DNA identified 27.94 +/− 11.81% (mean +/− SD) of mutations detected in a tumor(s) from the same patient; such mutations tended to be present at high allelic frequency. The majority of mutations found in plasma DNA were not found in tumor samples. Mutations were also found in plasma that matched clinically undetectable tumors found post-mortem. CONCLUSIONS: The incomplete overlap of genetic alteration profiles of plasma and tumors warrants caution in the sole reliance of plasma DNA to identify therapeutically targetable alterations in patients, and indicates that analysis of plasma DNA complements, but does not replace, tumor DNA profiling. TRIAL REGISTRATION: Subjects were prospectively enrolled in trial NCT01836640 (registered April 22, 2013).
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- 2020
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3. Liver Abscesses: Factors That Influence Outcome of Percutaneous Drainage
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Nancy J. McNulty, Steffen J Haider, Massimo Tarulli, and Eric K. Hoffer
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Adult ,Male ,medicine.medical_specialty ,Percutaneous ,Adolescent ,Liver Abscess ,Radiography, Interventional ,Malignancy ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,Drainage ,Abscess ,Ultrasonography, Interventional ,Aged ,Retrospective Studies ,Aged, 80 and over ,Salvage Therapy ,business.industry ,General Medicine ,Middle Aged ,medicine.disease ,Anti-Bacterial Agents ,Surgery ,Survival Rate ,Catheter ,Treatment Outcome ,030220 oncology & carcinogenesis ,Clinical recurrence ,Female ,030211 gastroenterology & hepatology ,Radiology ,business ,Abdominal surgery ,Liver abscess - Abstract
The purpose of this study was to identify the details of percutaneous catheter drainage (PCD) of pyogenic liver abscesses, the etiologic factors, and the management techniques that contribute to successful treatment.The records of 75 consecutively registered patients who underwent PCD of 96 abscesses at a single institution between May 2009 and May 2014 were retrospectively reviewed. Thirty-nine patients (52%) were oncology patients, and 36 (48%) had recently undergone abdominal surgery. Primary success was defined as abscess healing with the primary PCD intervention and 30-day postdrainage survival. Salvage success was defined as abscess healing with follow-up secondary PCD placement for symptomatic hepatic satellite collections or for clinical recurrence. Catheter adjustments were performed during follow-up to optimize existing drains. Univariate, multivariate, and general linear mixed model analyses were performed. The median follow-up time after catheter removal was 6 months (range, 2-62 months).Drains were primarily successful in 54 patients (72%), and 17 patients (23%) needed salvage PCD; thus, overall success was achieved in 71 patients (95%). The other four patients (5%) died of sepsis. The primary success rate was reduced in patients with unresectable malignancies (p = 0.01), multiple abscesses (p = 0.01), and output ≥ 15 mL/d at catheter endpoint (n = 7, p = 0.001). Only unresectable malignancies had slightly lower overall success. Large abscesses (150 cmPCD was effective first-line treatment of complicated pyogenic liver abscesses, which often require catheter adjustment and salvage drainage procedures to reliably achieve success.
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- 2017
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4. Flipping Radiology Education Right Side Up
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Vikas Agarwal, Pallav Shah, Erin E. O'Connor, Jeffery P. Hogg, Thomas A Zeffiro, Sravanthi Reddy, Jessica G Fried, Petra J. Lewis, and Nancy J. McNulty
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Male ,medicine.medical_specialty ,task value ,education ,clerkship ,Academic achievement ,Logistic regression ,Flipped classroom ,030218 nuclear medicine & medical imaging ,Cohort Studies ,flipped learning ,03 medical and health sciences ,0302 clinical medicine ,Surveys and Questionnaires ,achievement emotions ,medicine ,ComputingMilieux_COMPUTERSANDEDUCATION ,Humans ,Radiology, Nuclear Medicine and imaging ,030212 general & internal medicine ,Achievement emotions ,neuroimaging ,Education, Medical ,Comparability ,Flipped learning ,Clinical Clerkship ,imaging ,Boredom ,Problem-Based Learning ,Test (assessment) ,Radiology Nuclear Medicine and imaging ,Female ,Radiology ,Clinical Competence ,medicine.symptom ,Psychology - Abstract
Rationale and ObjectivesIn flipped learning, medical students independently learn facts and concepts outside the classroom, and then participate in interactive classes to learn to apply these facts. Although there are recent calls for medical education reform using flipped learning, little has been published on its effectiveness. Our study compares the effects of flipped learning to traditional didactic instruction on students' academic achievement, task value, and achievement emotions.Materials and MethodsAt three institutions, we alternated flipped learning with traditional didactic lectures during radiology clerkships, with 175 medical students completing a pretest on general diagnostic imaging knowledge to assess baseline cohort comparability. Following instruction, posttests and survey examinations of task value and achievement emotions were administered. Linear mixed effects analysis was used to examine the relationship between test scores and instruction type. Survey responses were modeled using ordinal category logistic regression. Instructor surveys were also collected.ResultsThere were no baseline differences in test scores. Mean posttest minus pretest scores were 10.5% higher in the flipped learning group than in the didactic instruction group (P = 0.013). Assessment of task value and achievement emotions showed greater task value, increased enjoyment, and decreased boredom with flipped learning (all P
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- 2016
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5. Abstract P4-09-20: Plasma DNA as a surrogate for tumor biopsy to identify genetic alterations in patients with metastatic breast cancer
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Jennifer R. Bean, Todd W. Miller, Kari M. Rosenkranz, Frederick S. Varn, Nancy J. McNulty, Richard J. Barth, Chao Cheng, Jonathan D. Marotti, Michael J. Tsapakos, John M Gemery, Kevin Shee, Chamberlin, and Jiang Gui
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COLD-PCR ,Cancer Research ,Pathology ,medicine.medical_specialty ,Point mutation ,Brain tumor ,Cancer ,Tumor M2-PK ,Buffy coat ,Biology ,medicine.disease ,Metastatic breast cancer ,Breast cancer ,Oncology ,medicine - Abstract
Precision medicine requires that a patient's tumor be accurately genotyped to identify a potentially effective targeted therapy. However, genotyping a tumor in patients with oligometastatic disease is complicated by the potential for intratumor and intertumor heterogeneity, and the requirement for sufficient tumor tissue obtained by invasive biopsy for genetic profiling. We sought to determine whether circulating tumor DNA in plasma provides a surrogate for solid tumor biopsy, and captures the genetic heterogeneity of tumors in patients with metastatic breast cancer. We hypothesized that genetic mutations detected in plasma DNA are reflective of the genetic mutations present in all tumors within a patient. Eight patients with advanced/metastatic breast cancer have thus far been enrolled in an ongoing clinical study (NCT01836640). Tumor specimens from two (n=4) or three (n=4) tumor sites and blood were obtained with one month. Blood was separated into plasma and buffy coat fractions. DNA extracted from tissue, buffy coat, and plasma samples was used for massively parallel DNA sequencing using the Ion Proton platform with a custom TargetSeq capture probe set covering all exons of 196 genes (4.1 Mb). All tumor and buffy coat samples, and plasma samples from three patients have thus far been analyzed. Tumor mutations were identified by comparison to buffy coat DNA sequences. We achieved sequencing coverage of ∼100-fold for tumor and buffy coat DNA samples, and ∼1,000-fold for plasma DNA samples. In Patient #1, we obtained 14 tumor nodules from a mastectomy specimen and used 3 nodules for DNA sequencing; Among the 73 point mutations detected in DNA from at least one tumor nodule, 29 mutations (40%) were detected in plasma DNA, and 10 mutations were found in plasma but not in tumors. In Patient #5, we analyzed bilateral breast tumors and a brain metastasis; among 151 mutations detected in at least one tumor, 80 (53%) were found in plasma, and an additional 18 mutations were found in plasma but not tumors; mutations specific to the brain tumor were less likely to be found in plasma; interestingly, the bilateral breast tumors showed genetic and histologic similarity, and so were likely derived from a single clone. Patient #6 had only one lung metastasis evaluable by DNA sequencing; 64/125 (51%) tumor-derived mutations were detected in plasma, and an additional 26 mutations were found in plasma but not the tumor. Preliminary ResultsMutationsTumorPlasma (Plasma only)TotalPlasma concordance with tumorPlasma concordance with totalTumor concordance with totalPatient #17329 (10)8339.7%46.9%87.9%Patient #515180 (18)16952.9%57.9%89.3%Patient #612564 (26)15151.2%59.6%82.8% These data suggest that, although challenging to get multiple biopsies for comparison, plasma is a promising surrogate for solid tumor biopsy to identify potentially targetable mutations. However, the ability of plasma DNA to genetically reflect all tumors in a patient with oligometastatic disease remains to be clarified through further analysis. Citation Format: Chamberlin MD, Shee K, Varn FS, Bean JR, Marotti JD, Gui J, Gemery JM, Barth RJ, Rosenkranz KM, Tsapakos MJ, McNulty NJ, Cheng C, Miller TW. Plasma DNA as a surrogate for tumor biopsy to identify genetic alterations in patients with metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-09-20.
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- 2016
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6. Medical Student Performance After a Vertically Integrated Radiology Clerkship
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Nancy J. McNulty, Stefan Tigges, Mark E. Mullins, and Petra J. Lewis
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Male ,Clinical clerkship ,Educational measurement ,medicine.medical_specialty ,education ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,0302 clinical medicine ,Humans ,Medicine ,Radiology, Nuclear Medicine and imaging ,Curriculum ,Medical education ,business.industry ,Clinical Clerkship ,Medical school ,United States ,Test (assessment) ,030220 oncology & carcinogenesis ,Female ,Educational Measurement ,Radiology ,business ,Education, Medical, Undergraduate - Abstract
Purpose Proper selection of imaging examinations and basic image interpretation skills are essential for all physicians, yet only approximately 25% of US medical schools require clerkships in radiology. Although there is limited time in most medical school curricula to allow the addition of a required radiology clerkship, the authors developed one that is vertically integrated over a two-year period. This clerkship includes one week of contact with radiologists distributed over the M2 and M3 years, podcasts, online modules, required readings, and presentations. A standard national examination is administered at the end of the clerkship period. This clerkship was designed to address the educational needs of students while occupying minimal time in the curriculum. The purpose of this study was to determine if students completing this clerkship perform as well on a national radiology examination as students from other medical schools, regardless of their curricula. Methods At the end of the M3 year, these students take a computer-based radiology examination developed by the Alliance of Medical Student Educators in Radiology and used by students at multiple medical schools nationally. The mean and median scores of these students were compared with those of students at these other institutions. Results The mean and median scores of the students were 74% and 74% (standard deviation, 7.5%) compared with 74% and 50% (standard deviation, 8.4%) at other institutions. Conclusions Students completing this vertically integrated radiology clerkship had test scores comparable with those of students at other medical schools.
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- 2016
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7. Needs Assessment for Standardized Medical Student Imaging Education
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David M. Naeger, Nancy J. McNulty, Christopher M. Straus, and Emily M. Webb
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Medical education ,business.industry ,education ,ComputingMethodologies_IMAGEPROCESSINGANDCOMPUTERVISION ,Medical school ,National curriculum ,Appropriateness criteria ,Needs assessment ,ComputingMilieux_COMPUTERSANDEDUCATION ,Medical imaging ,Medicine ,Radiology, Nuclear Medicine and imaging ,Curriculum revision ,business ,Curriculum ,Inclusion (education) - Abstract
Rationale and Objectives: Medical imaging education often has limited representation in formal medical student curricula. Although the need for greater inclusion of radiology material is generally agreed on, the exact skillset that should be taught is less clear. The purpose of our study was to perform a needs assessment for a national radiology curriculum for medical students. Materials and Methods: We analyzed data from previous unpublished portions of the American College of Radiology/Alliance of Medical Student Educators in Radiology survey of Deans and Radiology Chairs regarding prevalence of radiology curricular revisions, assessment tools, use of the American College of Radiology Appropriateness Criteria, and resources used in curriculum revision. We also performed a literature search through both PubMED and a general search engine (Google) to identify available resources for designing and implementing imaging curricula and curricular revisions. Results: Medical school deans and chairs reported a need for more overall radiology content; one of every six programs (15%) reported they had no recognized imaging curriculum. Of schools currently with imaging curricula, 82% have undergone revision in the last 10 years using a variety of different resources, but there is no universally agreed on guide or standard curriculum. The PubMED and Google searches identified only 23 and eight resources, respectively, suggesting a sizable deficit in available guidance; however, a single published medical student radiology curriculum is available through the Alliance of Medical Student Educators in Radiology. Conclusions: There is a need, but few available resources, to guide educators in adding imaging content to medical school curricula. We postulate that a standardized national curriculum directed by a focused skillset may be useful to educators and could result in greater uniformity of imaging skills among graduating US medical students. A proposed skillset to guide a national curriculum in radiology is described.
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- 2015
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8. Development of the AMSER Standardized Examinations in Radiology for Medical Students
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Janet A. Neutze, Nancy J. McNulty, Stefan Tigges, Petra J. Lewis, Andres Ayoob, William Thoburn Randazzo, Sravanthi Reddy, and Christopher M. Straus
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medicine.medical_specialty ,Medical education ,business.industry ,Guidelines as Topic ,National curriculum ,United States ,Patient care ,Software deployment ,Subsequent revision ,Blueprint ,Medical imaging ,Curriculum development ,Medicine ,Radiology, Nuclear Medicine and imaging ,Educational Measurement ,Radiology ,business ,Curriculum ,Education, Medical, Undergraduate - Abstract
Rationale and Objectives The variability in medical imaging evaluation across US medical schools inspired leading radiology student educators to develop the Alliance of Medical Student Educators in Radiology (AMSER) Standardized Exam (SE). This examination tests the understanding of essential material and concepts which are endorsed by the AMSER National Medical Student Curriculum in Radiology. Materials and Methods The AMSER Electronics Committee developed and deployed the AMSER SE using Radiology ExamWeb (REW), a previously-developed databank of imaging questions. The Committee created an examination blueprint that placed emphasis on effective use of medical imaging and less emphasis on image interpretation. Question items correlating to the blueprint were used from the REW databank to draft AMSER SE version 1, which was piloted in early 2012. Item performance was then analyzed, and the exam was revised. After national deployment, a subsequent revision was performed 1 year later. AMSER SE version 2, developed in a similar manner, was released in early 2013 and will go through a similar process of revision. A 20-question Practice Exam was also developed. Results Since national deployment, more than 1400 students, in over 22 institutions, have taken the AMSER SEs. Conclusions The collaborative project of the AMSER Electronics Committee has resulted in the successful national deployment of two examinations using questions that have been validated and based on the AMSER peer-reviewed national curriculum. We hope that this assessment tool will help drive a more uniform approach to curriculum development, promoting more effective and safe use of medical imaging. This step should also help promote the value radiologists bring to the patient care arena.
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- 2015
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9. Changing the paradigm for diagnostic MRI in pediatrics: Don't hold your breath
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Michael L. Beach, Michael J. Tsapakos, Nancy J. McNulty, and Melissa M. Masaracchia
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medicine.medical_specialty ,Pediatrics ,030218 nuclear medicine & medical imaging ,Breath Holding ,03 medical and health sciences ,Patient safety ,0302 clinical medicine ,030202 anesthesiology ,medicine ,Medical imaging ,Humans ,Medical physics ,Child ,Artifact (error) ,Modality (human–computer interaction) ,medicine.diagnostic_test ,business.industry ,Magnetic resonance imaging ,Perioperative ,Controlled ventilation ,Radiation Exposure ,Magnetic Resonance Imaging ,Anesthesiology and Pain Medicine ,Tomography x ray computed ,Pediatrics, Perinatology and Child Health ,Patient Safety ,business ,Artifacts ,Tomography, X-Ray Computed - Abstract
Increasingly complex pediatric patients and improvements in technology warrant reevaluation of the risk associated with anesthesia for diagnostic imaging. Although magnetic resonance imaging is the imaging modality of choice for children given the potentially harmful effects of computerized tomography-associated ionizing radiation, we dare to suggest that certain patients would benefit from the liberalization of our current standard. Incorporating the use of newer computerized tomography technology may improve safety for those that are already at higher risk for adverse events. Furthermore, magnetic resonance imaging is not risk-free-what is often overlooked is the need for controlled ventilation and breath-holding to minimize motion artifact. As physicians at the forefront of the development and sustainability of the perioperative surgical home, anesthesiologists must work to not only optimize patients preoperatively but should also act as gatekeepers for procedural safety.
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- 2017
10. Radiology ExamWeb
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Jim Y Chen, Dana J Lin, Nancy J. McNulty, and Petra J. Lewis
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medicine.medical_specialty ,business.industry ,Software deployment ,Teaching method ,MEDLINE ,Medicine ,Web application ,Radiology, Nuclear Medicine and imaging ,The Internet ,Radiology ,business ,Curriculum - Abstract
Rationale and Objectives Faculty are often limited in time, knowledge, and resources to develop efficient, effective, and valid computer-based examinations to evaluate students. Our purpose was to develop a web-based pool of standardized National Board of Medical Examiners (NBME)-format, peer-reviewed, and peer-tested questions based on the Alliance of Medical Student Educators in Radiology (AMSER) National Medical Student Curriculum to evaluate the radiologic knowledge of medical students. Materials and Methods Members of the AMSER Electronics Committee submitted questions they had written for their institutions and later developed a 113-question standardized examination. Questions were edited by 24 subspeciality editors and then further edited by the authors to NBME recommendations. Software was developed using commercially available software ( www.ExamWeb.com ) with extensive modifications and additions following initial deployment. Students take examinations online and receive their scores immediately. Items were validated by identifying those answered >30 times and analyzing the following: number of times deployed, number of times correctly answered, distractor-specific breakdown, difficulty level (P), and point biserial coefficient (rbi). Results Radiology ExamWeb (REW) is available online with 3500 registered students from 65 institutions and 1800 active questions. Instructors can create examinations or use “shared examinations” made by another instructor but enabled for other institutions to administer or modify. More than 300 shared examinations have been developed. The AMSER curriculum was converted into database format and crosschecked with question items to ensure that the question pool adequately covered the spectrum of the curriculum. An AMSER standardized examination has been developed and deployed within REW. Conclusions REW has provided medical student educators with the means to evaluate students in a systematic way, using a nationally edited and regularly reviewed web-based process.
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- 2013
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11. Improving Accuracy in Reporting CT Scans of Oncology Patients
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Nancy J. McNulty, Petra J. Lewis, and Henry Andoh
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medicine.medical_specialty ,medicine.diagnostic_test ,business.industry ,Psychological intervention ,Computed tomography ,Newly diagnosed ,Audit and feedback ,Unequal variance ,Response Evaluation Criteria in Solid Tumors ,Significance testing ,medicine ,Radiology, Nuclear Medicine and imaging ,Medical physics ,Oncology patients ,business - Abstract
Rationale and Objectives In February 2010, our radiology department adopted the use of the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria for newly diagnosed oncology patients. Prior to staff used RECIST 1.1, we hypothesized that education and feedback interventions could help clarify differences between RECIST 1.0 and the newly adopted RECIST 1.1 guidelines and result in appropriate and accurate utilization of both reporting systems. This study evaluates the effect of education and feedback interventions on the accuracy of computed tomography (CT) reporting using RECIST criteria. Materials and Methods Consecutive CT scan reports and images were retrospectively reviewed during three different periods to assess for compliance and adherence to RECIST guidelines. Data collected included interpreting faculty, resident, type, and total number of errors per report. Significance testing of differences between cohorts was performed using an unequal variance t -test. Group 1 (baseline): RECIST 1.0 used; prior to adoption of RECIST 1.1 criteria. Group 2 (post distributed educational materials): Following adoption of RECIST 1.1 criteria and distribution of educational materials. Group 3 (post audit and feedback): Following the audit and feedback intervention. Results The percentage of reports with errors decreased from 30% (baseline) to 28% (group 2) to 22% (group 3). Only the difference in error rate between the baseline and group 3 was significant ( P = .03). Conclusion The combination of distributed educational materials and audit and feedback interventions improved the quality of radiology reports requiring RECIST criteria by reducing the number of studies with errors.
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- 2013
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12. Abstract P6-07-03: Broken promise of liquid biopsy: Plasma DNA does not accurately reflect tumor DNA in metastatic breast cancer
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Heidi W. Trask, John M Gemery, Richard J. Barth, Chamberlin, Kevin Shee, RJ West, Bradley A. Arrick, Todd W. Miller, Jiang Gui, Peter A. Kaufman, Wendy A. Wells, Michael J. Tsapakos, Nancy J. McNulty, Jennifer R. Bean, Jonathan D. Marotti, Gary N. Schwartz, Frederick S. Varn, JS Hamilton, and Chao Cheng
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CA15-3 ,Cancer Research ,Pathology ,medicine.medical_specialty ,Plasma dna ,Biology ,medicine.disease ,Metastatic breast cancer ,chemistry.chemical_compound ,Oncology ,chemistry ,medicine ,Liquid biopsy ,DNA - Abstract
Background: Circulating tumor DNA in plasma may present a minimally invasive approach to identify tumor-derived mutations that could be used to inform the selection of targeted therapies for individual patients, particularly in cases of metastatic disease where biopsy is often difficult. We hypothesized that plasma DNA will genetically reflect DNA derived from multiple tumors in patients with metastatic breast cancer. To test this hypothesis and assess the utility of plasma DNA obtained as a “liquid biopsy” for precision medicine, we sought to determine whether massively parallel sequencing of plasma DNA is a reliable surrogate for sequencing of DNA from tissue biopsies in patients with metastatic breast cancer. Methods: Blood samples were obtained from 7 patients with multiple advanced breast cancer lesions (recurrent breast and metastatic tumors), and tumor specimens were obtained thereafter by biopsy or surgical excision. DNA extracted from plasma, buffy coat of blood, and tumor tissues was used for probe-directed capture of all exons in 196 genes followed by massively parallel sequencing with an average coverage of 3000x for plasma DNA. Tumor and plasma DNA sequences were bioinformatically compared to buffy coat controls, and high-confidence somatic mutations were called. One patient with extensive metastatic disease was evaluated in further detail to study the contribution of different tumors to the overall plasma DNA pool. In this patient, 9 metastatic tumors were sampled in an axillary lymph node, heart, kidney (2), liver, omentum (3), and ovary by biopsy or at autopsy. Results: Mutations were found in plasma that were represented in one or more tumors in each patient. Three classes of mutations were discovered: 1) mutations overlapping between both plasma and tumors (e.g., TP53 p.R273C and SRC p.E527K); 2) mutations found in plasma but not tumors (e.g., AKT p.E17K and multiple known and novel ESR1 mutations); 3) mutations found in tumors but not plasma (e.g., PIK3CA p.H1047R, p.D350G, and p.N345K). The presence of mutations in each of these classes was validated in plasma and/or tumors using mutation-specific droplet digital PCR (ddPCR). In the patient with extensive metastatic disease, DNA sequencing revealed heterogeneity of tumor contribution to plasma DNA, with some tumors better represented than others. No correlation was found between tumor size (measured by CT scan) and mutational burden in plasma. Interestingly, a significant correlation was found between blood perfusion to the organ where the tumor resides and mutational burden in plasma, with the greatest tumor contribution coming from the heart metastasis (Pearson's r = 0.835, p=0.039). Conclusions: Plasma DNA sequencing adds a layer of depth to sequencing analysis of tumor biopsy samples, and serves to both confirm tumor-derived mutations as well as detect new mutations. However, plasma DNA profiling does not comprehensively reflect the mutational profiles of tumors in patients with metastatic breast cancer, and thus is unlikely to serve as a surrogate for tumor biopsy as a source of DNA for genetic profiling. Furthermore, plasma DNA contains many mutations not found in tumors, which will confound treatment decision-making and precision medicine.Background: Circulating tumor DNA in plasma may present a minimally invasive approach to identify tumor-derived mutations that could be used to inform the selection of targeted therapies for individual patients, particularly in cases of metastatic disease where biopsy is often difficult. We hypothesized that plasma DNA will genetically reflect DNA derived from multiple tumors in patients with metastatic breast cancer. To test this hypothesis and assess the utility of plasma DNA obtained as a “liquid biopsy” for precision medicine, we sought to determine whether massively parallel sequencing of plasma DNA is a reliable surrogate for sequencing of DNA from tissue biopsies in patients with metastatic breast cancer. Methods: Blood samples were obtained from 7 patients with multiple advanced breast cancer lesions (recurrent breast and metastatic tumors), and tumor specimens were obtained thereafter by biopsy or surgical excision. DNA extracted from plasma, buffy coat of blood, and tumor tissues was used for probe-directed capture of all exons in 196 genes followed by massively parallel sequencing with an average coverage of 3000x for plasma DNA. Tumor and plasma DNA sequences were bioinformatically compared to buffy coat controls, and high-confidence somatic mutations were called. One patient with extensive metastatic disease was evaluated in further detail to study the contribution of different tumors to the overall plasma DNA pool. In this patient, 9 metastatic tumors were sampled in an axillary lymph node, heart, kidney (2), liver, omentum (3), and ovary by biopsy or at autopsy. Results: Mutations were found in plasma that were represented in one or more tumors in each patient. Three classes of mutations were discovered: 1) mutations overlapping between both plasma and tumors (e.g., TP53 p.R273C and SRC p.E527K); 2) mutations found in plasma but not tumors (e.g., AKT p.E17K and multiple known and novel ESR1 mutations); 3) mutations found in tumors but not plasma (e.g., PIK3CA p.H1047R, p.D350G, and p.N345K). The presence of mutations in each of these classes was validated in plasma and/or tumors using mutation-specific droplet digital PCR (ddPCR). In the patient with extensive metastatic disease, DNA sequencing revealed heterogeneity of tumor contribution to plasma DNA, with some tumors better represented than others. No correlation was found between tumor size (measured by CT scan) and mutational burden in plasma. Interestingly, a significant correlation was found between blood perfusion to the organ where the tumor resides and mutational burden in plasma, with the greatest tumor contribution coming from the heart metastasis (Pearson's r = 0.835, p=0.039). Conclusions: Plasma DNA sequencing adds a layer of depth to sequencing analysis of tumor biopsy samples, and serves to both confirm tumor-derived mutations as well as detect new mutations. However, plasma DNA profiling does not comprehensively reflect the mutational profiles of tumors in patients with metastatic breast cancer, and thus is unlikely to serve as a surrogate for tumor biopsy as a source of DNA for genetic profiling. Furthermore, plasma DNA contains many mutations not found in tumors, which will confound treatment decision-making and precision medicine. Citation Format: Shee K, Chamberlin MD, Varn FS, Bean JR, Marotti JD, Wells WA, Trask HW, Hamilton JS, West RJ, Kaufman PA, Schwartz GN, Gemery JM, McNulty NJ, Tsapakos MJ, Barth RJ, Arrick BA, Gui J, Cheng C, Miller TW. Broken promise of liquid biopsy: Plasma DNA does not accurately reflect tumor DNA in metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-07-03.
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- 2017
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13. Cytomorphologic features of advanced lung adenocarcinomas tested for EGFR and KRAS mutations: A retrospective review of 50 cases
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Peter A. DeLong, C B S Mary Schwab, Vijayalakshmi Padmanabhan, Gregory J. Tsongalis, Vincent A. Memoli, James R. Rigas, Nancy J. McNulty, and Jonathan D. Marotti
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Male ,Pathology ,medicine.medical_specialty ,Lung Neoplasms ,Histology ,Cytoplasmic inclusion ,Adenocarcinoma of Lung ,Adenocarcinoma ,Biology ,medicine.disease_cause ,Pathology and Forensic Medicine ,Proto-Oncogene Proteins p21(ras) ,Necrosis ,Exon ,Proto-Oncogene Proteins ,TaqMan ,medicine ,Carcinoma ,Humans ,Epidermal growth factor receptor ,Aged ,Cell Size ,Retrospective Studies ,Mutation ,Mucin ,DNA, Neoplasm ,Exons ,General Medicine ,Middle Aged ,medicine.disease ,ErbB Receptors ,ras Proteins ,biology.protein ,Female ,KRAS ,Cell Nucleolus - Abstract
Associations between bronchioloalveolar carcinoma (BAC), mucinous differentiation, and epidermal growth factor receptor (EGFR) and KRAS mutations have been previously reported in studies of surgical specimens. We present the cytomorphology of lung adenocarcinomas, including metastases that were diagnosed by cytologic methods and the relationship to both EGFR and KRAS mutational status. We retrospectively reviewed the clinical and cytomorphologic features of 50 lung adenocarcinomas that were tested for both EGFR and KRAS mutations. Cytomorphologic features evaluated included cell size, architectural pattern, nucleoli, intranuclear cytoplasmic inclusions (INCI), mucin, necrosis, squamoid features, lymphocytic response, and histologic features of BAC differentiation. DNA was extracted from a paraffin-embedded cell block or frozen needle core fragments. Exon 19 deletions and the L858R mutation in exon 21 of EGFR were detected using PCR followed by capillary electrophoresis for fragment sizing. KRAS mutational analysis was performed by real-time PCR using a set of seven different Taqman(r) allelic discrimination assays to detect six mutations in codon 12 and one mutation in codon 13. Six cases (12%) showed EGFR mutations, 12 (24%) showed KRAS mutations, and 38 (62%) contained neither EGFR nor KRAS mutations. The majority of patients had stage IV disease (78%); 20 samples (40%) were from metastatic sites. The presence of prominent INCI (P = 0.036), papillary fragments (P = 0.041), and histologic features of BAC on paraffin block (P = 0.039) correlated with the presence of EGFR mutations. The presence of necrosis (P = 0.030), squamoid features (P = 0.048), and poorly differentiated tumors (P = 0.025) were more likely to be identified in the KRAS positive group.
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- 2011
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14. Complication Rates and Outcomes of 536 Implanted Subcutaneous Chest Ports
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Kiley D. Perrich, Eric K. Hoffer, Nancy J. McNulty, and Anne M. Silas
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medicine.medical_specialty ,Retrospective review ,medicine.diagnostic_test ,Nurse practitioners ,business.industry ,Significant difference ,Interventional radiology ,Port (computer networking) ,Surgery ,Chi-square test ,medicine ,Radiology, Nuclear Medicine and imaging ,business ,Complication ,Physician extenders - Abstract
Rationale and Objectives Totally implanted subcutaneous central venous access devices (chest ports) are an attractive option for patients in need of intermittent, recurrent venous access. In our department, these are placed by different operator types including interventional radiology (IR) attending physicians, dedicated IR nurse practitioners (NP), and IR fellows/radiology residents. The purpose of our study is to assess the rate of complications of subcutaneous chest port placement among the different operator types. Materials and Methods A retrospective review of all subcutaneous central venous access devices implanted in our department between October 8, 2004, and October 19, 2007, was undertaken. Total numbers of port days, overall complication rates for all operators, as well as complication rates for the various operator types were calculated and were compared using the chi square test. Results A total of 558 patients had totally implanted subcutaneous central venous access devices placed during the period of study. Of these, 536 had documented follow-up and comprise the study population. A total of 89 were placed by attending physician alone, 133 by an NP, and 314 by an IR fellow or resident, with supervision by an attending physician. Mean duration of port usage was 341 days with 182,522 total port days. A total of 39 complications occurred (7.28%), including 27 infections (5%). There was no statistically significant difference in overall complication rates, including infection rates, among operator groups ( P = .925). Conclusions Our results confirm that well-trained physician extenders and trainees can safely perform chest port placement and that these providers, under appropriate supervision, can help provide improved access to chest port placement for patients and referring clinicians.
- Published
- 2010
- Full Text
- View/download PDF
15. Testicular Seminoma with Lymph Node Metastases
- Author
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Steven J. Krohmer, Nancy J. McNulty, and Alan R. Schned
- Subjects
medicine.medical_specialty ,medicine.anatomical_structure ,business.industry ,Testicular seminoma ,Medicine ,Radiology, Nuclear Medicine and imaging ,Radiology ,business ,Lymph node - Published
- 2009
- Full Text
- View/download PDF
16. Oxford American Handbook of Radiology
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Petra J. Lewis, Nancy J. McNulty, Petra J. Lewis, and Nancy J. McNulty
- Subjects
- Medical radiology--Handbooks, manuals, etc, Diagnostic imaging--Handbooks, manuals, etc
- Abstract
The Oxford American Handbook of Radiology is a concise, image-rich guide to radiology for non-radiologists who wish to improve their understanding and utilization of imaging as well as their interpretative skills. An'Essentials'section covers topics such as imaging modalities, contrast, risks of imaging, imaging the pregnant patient and imaging algorithms for common presenting conditions. The remaining chapters are organized to facilitate easy review for students on either radiology or clinical clerkships such as OBGYN, medicine or surgery. Chapters include: chest imaging, abdominal imaging, neurological imaging, musculoskeletal imaging, women's imaging, interventional radiology, ultrasound, fluoroscopy, nuclear medicine and pediatrics. A pattern-based approach is used, allowing readers to develop the underlying concepts of image interpretation and then apply it to individual cases. All chapters include'Don't Miss'boxes to highlight crucial findings. Over 340 high quality annotated images and line drawings are included both in the text and on the included CD. Designed for quick reference on the wards and in the clinics, this structured and easily readable guide fits in a lab coat pocket.
- Published
- 2013
17. Multidetector CT of the Liver and Hepatic Neoplasms: Effect of Multiphasic Imaging on Tumor Conspicuity and Vascular Enhancement
- Author
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Richard H. Cohan, Melvyn Korobkin, Nancy J. McNulty, Joel F. Platt, Isaac R. Francis, Achamyeleh Gebremariam, and Kartik I Ragupathi
- Subjects
Adult ,Male ,medicine.medical_specialty ,Portal vein ,Injection rate ,Multidetector ct ,Portal venous phase ,Celiac artery ,medicine.artery ,Hepatic neoplasms ,medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,Aged ,Retrospective Studies ,Aged, 80 and over ,business.industry ,Liver Neoplasms ,Venous phase ,General Medicine ,Middle Aged ,Liver ,Female ,Radiology ,Tomography, X-Ray Computed ,business ,Arterial phase - Abstract
Our aim was to determine which of three contrast-enhanced phases (early arterial, late arterial, or portal venous) was optimal for achieving maximal enhancement of the celiac artery, portal vein, and hepatic parenchyma. We also wanted to learn which phase provided the maximal tumor-to-parenchyma difference when using multidetector CT (MDCT) with fixed timing delays.Fifty-two patients with suspected or known hepatic tumors underwent multiphasic contrast-enhanced MDCT using double arterial (early and late arterial) and venous phase acquisitions with fixed timing delays. All patients were administered 150 mL of IV contrast material at an injection rate of 4 mL/sec. Images were acquired at 20 sec for the early arterial phase, 35 sec for the late arterial phase, and 60 sec for the portal venous phase. Attenuation measurements of the celiac artery, portal vein, normal hepatic parenchyma, and the hepatic tumor were compared. Three reviewers independently and subjectively rated tumor conspicuity for each of the three phases. Ratings were compared using kappa statistics.Late arterial phase images showed maximal celiac axis attenuation, whereas portal venous phase images revealed the highest portal vein and normal hepatic parenchymal attenuation. Maximal tumor-to-parenchyma differences for hypovascular tumors was superior in the portal venous phase, but we found no significant differences in maximal tumor-to-parenchyma differences for hypervascular tumors among the evaluated phases. On subjective analysis, interobserver agreement was moderate to very good for the three phases. All three reviewers graded both hypovascular and hypervascular tumor conspicuity as superior in either the late arterial phase or the portal venous phase in most patients. In only one patient was the early arterial phase graded as superior to the late arterial and portal venous phases (by two of the three reviewers).When MDCT of the liver is performed using fixed timing delays, maximal vascular and hepatic parenchymal enhancement is achieved on either late arterial phase or portal venous phase imaging. In most patients, early arterial phase imaging does not improve tumor conspicuity by either quantitative or subjective analysis.
- Published
- 2003
- Full Text
- View/download PDF
18. Improving accuracy in reporting CT scans of oncology patients: assessing the effect of education and feedback interventions on the application of the Response Evaluation Criteria in Solid Tumors (RECIST) criteria
- Author
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Henry, Andoh, Nancy J, McNulty, and Petra J, Lewis
- Subjects
Neoplasms ,Practice Guidelines as Topic ,Humans ,New Hampshire ,Reproducibility of Results ,Guideline Adherence ,Medical Oncology ,Radiology ,Tomography, X-Ray Computed ,Sensitivity and Specificity - Abstract
In February 2010, our radiology department adopted the use of the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria for newly diagnosed oncology patients. Prior to staff used RECIST 1.1, we hypothesized that education and feedback interventions could help clarify differences between RECIST 1.0 and the newly adopted RECIST 1.1 guidelines and result in appropriate and accurate utilization of both reporting systems. This study evaluates the effect of education and feedback interventions on the accuracy of computed tomography (CT) reporting using RECIST criteria.Consecutive CT scan reports and images were retrospectively reviewed during three different periods to assess for compliance and adherence to RECIST guidelines. Data collected included interpreting faculty, resident, type, and total number of errors per report. Significance testing of differences between cohorts was performed using an unequal variance t-test. Group 1 (baseline): RECIST 1.0 used; prior to adoption of RECIST 1.1 criteria. Group 2 (post distributed educational materials): Following adoption of RECIST 1.1 criteria and distribution of educational materials. Group 3 (post audit and feedback): Following the audit and feedback intervention.The percentage of reports with errors decreased from 30% (baseline) to 28% (group 2) to 22% (group 3). Only the difference in error rate between the baseline and group 3 was significant (P = .03).The combination of distributed educational materials and audit and feedback interventions improved the quality of radiology reports requiring RECIST criteria by reducing the number of studies with errors.
- Published
- 2012
19. Radiology ExamWeb: development and implementation of a national web-based examination system for medical students in radiology
- Author
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Petra J, Lewis, Jim Y, Chen, Dana J, Lin, and Nancy J, McNulty
- Subjects
Internet ,Students, Medical ,Surveys and Questionnaires ,Teaching ,Educational Measurement ,Radiology ,Software ,United States ,Computer-Assisted Instruction - Abstract
Faculty are often limited in time, knowledge, and resources to develop efficient, effective, and valid computer-based examinations to evaluate students. Our purpose was to develop a web-based pool of standardized National Board of Medical Examiners (NBME)-format, peer-reviewed, and peer-tested questions based on the Alliance of Medical Student Educators in Radiology (AMSER) National Medical Student Curriculum to evaluate the radiologic knowledge of medical students.Members of the AMSER Electronics Committee submitted questions they had written for their institutions and later developed a 113-question standardized examination. Questions were edited by 24 subspeciality editors and then further edited by the authors to NBME recommendations. Software was developed using commercially available software (www.ExamWeb.com) with extensive modifications and additions following initial deployment. Students take examinations online and receive their scores immediately. Items were validated by identifying those answered30 times and analyzing the following: number of times deployed, number of times correctly answered, distractor-specific breakdown, difficulty level (P), and point biserial coefficient (rbi).Radiology ExamWeb (REW) is available online with 3500 registered students from 65 institutions and 1800 active questions. Instructors can create examinations or use "shared examinations" made by another instructor but enabled for other institutions to administer or modify. More than 300 shared examinations have been developed. The AMSER curriculum was converted into database format and crosschecked with question items to ensure that the question pool adequately covered the spectrum of the curriculum. An AMSER standardized examination has been developed and deployed within REW.REW has provided medical student educators with the means to evaluate students in a systematic way, using a nationally edited and regularly reviewed web-based process.
- Published
- 2012
20. Radiology Jeopardy/Blank Jeopardy Template
- Author
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Petra J. Lewis and Nancy J. McNulty
- Subjects
medicine.medical_specialty ,Medicine (General) ,Computer science ,Teaching method ,ComputingMilieux_PERSONALCOMPUTING ,Game ,General Medicine ,Blank ,Education ,R5-920 ,Interactive ,Teaching Methods ,Jeopardy ,ComputingMethodologies_DOCUMENTANDTEXTPROCESSING ,medicine ,Key (cryptography) ,ComputingMilieux_COMPUTERSANDEDUCATION ,Powerpoint ,Medical physics - Abstract
This resources features a hyperlinked PowerPoint Jeopardy-style game suitable for teaching fourth-year medical students key radiological findings. Also included is a blank version of the PowerPoint for educators to make their own version on any topic. This resource is used as an interactive means of education to reinforce topics covered during a clerkship or elective. By engaging students in a game, learning is enhanced. The supplied radiology version is applicable to fourth-year medical students as well as medical interns and junior medical/surgical residents. This resource has been used in various versions for fourth-year elective students since 2003. This session has been rated as “good or excellent” by 96% of student participants. A version is given annually to radiology residents by the body imaging fellows; it has been positively received, but we do not formally evaluate that session. An important part of the learning process is taking the time to discuss the answers before moving onto the next question.
- Published
- 2010
- Full Text
- View/download PDF
21. Accurate and Reproducible Application of the RECIST Criteria in CT Reporting in Oncology: A Learning Module
- Author
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Nancy J. McNulty and Petra J. Lewis
- Subjects
Oncology ,medicine.medical_specialty ,Medicine (General) ,medicine.diagnostic_test ,business.industry ,Carcinoma ,Internship and Residency ,Computed tomography ,General Medicine ,Education ,Computed Tomography ,R5-920 ,Response Evaluation Criteria in Solid Tumors ,Internal medicine ,medicine ,Neoplasm ,Lymph Nodes ,business - Abstract
Introduction The response evaluation criteria in solid tumors (RECIST) criteria were first published in 2000, and updated in 2009. Several important changes were made in the updated version (version 1.1) which significantly impact the appropriate selection of target lesions and the methods in which they are measured. It is difficult to find the time to educate department faculty and trainees on these changes, yet it is of the utmost importance to ensure accurate reporting. This educational module is designed for faculty, fellows, and residents who interpret and report cross sectional imaging studies on oncology patients. Methods This resource contains a PowerPoint file which can be used in three ways. First, it can be presented orally at an educational conference to an entire department or section familiar with these studies. Second, it can be viewed as a self-paced learning module which would optimally be completed in one session. The third use is as a quick-reference resource at the picture archiving and communication system workstation. The presentation can be loaded onto the computer at workstations where cross sectional imaging studies are read, to be used as a quick reference. The final slide in the presentation is a primer, used to guide appropriate selection of target lesions. This slide contains hyperlinks to other points in the presentation, to allow for a quick and targeted review of certain pertinent topics. Results This learning module has been used as both an oral presentation and a self-paced learning module. The presentation was given to radiology residents during noon conference and was well received. This module was also emailed out to all faculty, fellows, and residents for self-study. In addition, the module has been placed on the desktop at all computers where CT scans are interpreted at the authors' institution, to be used as a quick reference. Discussion The versatility of this resource allows the user several options to educate faculty and trainees on the proper application of the RECIST criteria. Accurate reporting using these criteria is essential to guide the proper care and treatment course of oncology patients. These criteria are also widely used in research trials, where accurate reporting is crucial.
- Published
- 2010
- Full Text
- View/download PDF
22. Best cases from the AFIP: testicular seminoma with lymph node metastases
- Author
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Steven J, Krohmer, Nancy J, McNulty, and Alan R, Schned
- Subjects
Adult ,Male ,Testicular Neoplasms ,Lymphatic Metastasis ,Humans ,Magnetic Resonance Imaging ,Seminoma ,Ultrasonography - Published
- 2009
23. Complication rates and outcomes of 536 implanted subcutaneous chest ports: do rates differ based on the primary operator's level of training?
- Author
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Anne M, Silas, Kiley D, Perrich, Eric K, Hoffer, and Nancy J, McNulty
- Subjects
Adult ,Aged, 80 and over ,Male ,Catheterization, Central Venous ,Incidence ,Middle Aged ,Risk Assessment ,Postoperative Complications ,Professional Competence ,Treatment Outcome ,Risk Factors ,Humans ,New Hampshire ,Female ,Aged - Abstract
Totally implanted subcutaneous central venous access devices (chest ports) are an attractive option for patients in need of intermittent, recurrent venous access. In our department, these are placed by different operator types including interventional radiology (IR) attending physicians, dedicated IR nurse practitioners (NP), and IR fellows/radiology residents. The purpose of our study is to assess the rate of complications of subcutaneous chest port placement among the different operator types.A retrospective review of all subcutaneous central venous access devices implanted in our department between October 8, 2004, and October 19, 2007, was undertaken. Total numbers of port days, overall complication rates for all operators, as well as complication rates for the various operator types were calculated and were compared using the chi square test.A total of 558 patients had totally implanted subcutaneous central venous access devices placed during the period of study. Of these, 536 had documented follow-up and comprise the study population. A total of 89 were placed by attending physician alone, 133 by an NP, and 314 by an IR fellow or resident, with supervision by an attending physician. Mean duration of port usage was 341 days with 182,522 total port days. A total of 39 complications occurred (7.28%), including 27 infections (5%). There was no statistically significant difference in overall complication rates, including infection rates, among operator groups (P = .925).Our results confirm that well-trained physician extenders and trainees can safely perform chest port placement and that these providers, under appropriate supervision, can help provide improved access to chest port placement for patients and referring clinicians.
- Published
- 2009
24. Implantable subcutaneous venous access devices: is port fixation necessary? A review of 534 cases
- Author
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Andrew R. Forauer, Nancy J. McNulty, Kiley D. Perrich, Robert M. Linville, and Anne M. Silas
- Subjects
Adult ,Male ,medicine.medical_specialty ,Catheterization, Central Venous ,Suture fixation ,Radiology, Interventional ,Fixation (surgical) ,Young Adult ,Catheters, Indwelling ,Postoperative Complications ,Subcutaneous Tissue ,medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,Device Removal ,Aged ,Retrospective Studies ,Aged, 80 and over ,Retrospective review ,business.industry ,Middle Aged ,medicine.disease ,Thrombosis ,Port (computer networking) ,Surgery ,Venous access ,Catheter ,Equipment Contamination ,Equipment Failure ,Female ,Port placement ,Cardiology and Cardiovascular Medicine ,business - Abstract
Conventional surgical technique of subcutaneous venous port placement describes dissection of the port pocket to the pectoralis fascia and suture fixation of the port to the fascia to prevent inversion of the device within the pocket. This investigation addresses the necessity of that step. Between October 8, 2004 and October 19, 2007, 558 subcutaneous chest ports were placed at our institution; 24 cases were excluded from this study. We performed a retrospective review of the remaining 534 ports, which were placed using standard surgical technique with the exception that none were sutured into the pocket. Mean duration of port use, total number of port days, indications for removal, and complications were recorded and compared with the literature. Mean duration of port use was 341 days (182,235 total port days, range 1–1279). One port inversion/flip occurred, which resulted in malfunction and necessitated port revision (0.2%). Other complications necessitating port removal included infection 26 (5%), thrombosis n = 2 (
- Published
- 2009
25. Tunneled hemodialysis catheter outcomes in elderly patients
- Author
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Thomas M. Kaneko, Andrew R. Forauer, and Nancy J. McNulty
- Subjects
Adult ,Male ,medicine.medical_specialty ,Prosthesis-Related Infections ,medicine.medical_treatment ,Hemodialysis Catheter ,Catheters, Indwelling ,Renal Dialysis ,medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,Tunneled catheter ,Dialysis ,Aged ,Aged, 80 and over ,business.industry ,Significant difference ,Retrospective cohort study ,Middle Aged ,Surgery ,Equipment Failure Analysis ,Radiography ,Catheter ,Treatment Outcome ,Cohort ,Kidney Failure, Chronic ,Female ,Hemodialysis ,Cardiology and Cardiovascular Medicine ,business - Abstract
Purpose This retrospective study evaluated tunneled catheter outcomes in patients aged 75 years and older undergoing hemodialysis. Materials and Methods Patients aged 75 years or older receiving hemodialysis comprised the study group. A control group of patients 40–60 years of age was randomly selected from the same dialysis quality assurance database. Demographic data, medical comorbidities, and catheter-specific data regarding indwelling time, function, interventions, and complications were recorded. Results Sixty-nine tunneled catheters were identified in 23 patients who comprised the study group (13 men and 10 women; mean age, 81.3 years; range, 75–88 y). The mean number of catheters per patient was three (range, 1–8). The mean indwelling time was 137.4 days (range, 2–622 d). Seventy-eight catheters were identified in the control group ( n = 29; 14 men and 15 women; mean age, 50.6 years; range, 41–59 y). The mean number of catheters per patient was 2.7 (range, 1–9). The mean indwelling time was 139.7 days (range, 1–994 d). There was no statistically significant difference in the mean number of catheters per patient ( P = .83) or the mean indwelling time ( P = .93) between the two groups. There was no significant difference between the two groups in the indications for catheter removal or exchange: infection ( P = 1.0), catheter no longer needed ( P = 1.0), and physical catheter malfunction ( P = .48). The calculated infection rates in the elderly patient and younger control groups were 0.30 per 100 catheter-days and 0.26 per 100 catheter-days, respectively. Conclusions Tunneled catheter outcomes in patients aged 75 years and older undergoing hemodialysis do not vary significantly compared with those in a younger cohort.
- Published
- 2008
26. Reactivation Mycobacterium Tuberculosis Presenting as Empyema Necessitans 55 Years Following Thoracoplasty
- Author
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Nancy J. McNulty
- Subjects
medicine.medical_specialty ,Tuberculosis ,biology ,business.industry ,TB, tuberculosis ,medicine.disease ,biology.organism_classification ,bacterial infections and mycoses ,Empyema ,Article ,Surgery ,respiratory tract diseases ,CT, computed tomography ,Mycobacterium tuberculosis ,Reactivation tuberculosis ,Pulmonary tuberculosis ,medicine ,Radiology, Nuclear Medicine and imaging ,Empyema necessitans ,Abscess ,business ,Collapse Therapy - Abstract
We describe the case of a 79-year-old man who presented with an enlarging mass on his chest wall. He had a history of thoracoplasty performed 55 years ago for treatment of pulmonary tuberculosis. The mass was subsequently proven to be the result of empyema neccesitans caused by reactivation tuberculosis. Empyema neccesitans is a well described entity in which an empyema spontaneously decompresses by dissecting into the chest wall and extrathoracic soft tissues. This can occur following necrotizing pneumonia, including pyogenic or tuberculus, or pulmonary abscess. Complications from collapse therapy for tuberculosis can be encountered decades following the surgery, however, empyema necessitans due to reactivation tuberculosis is rare. This case affords the opportunity to review the goals, techniques, and radiologic appearance of thoracoplasty.
- Published
- 2008
- Full Text
- View/download PDF
27. Multi--detector row helical CT of the pancreas: effect of contrast-enhanced multiphasic imaging on enhancement of the pancreas, peripancreatic vasculature, and pancreatic adenocarcinoma
- Author
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Achamyeleh Gebremariam, Isaac R. Francis, Richard H. Cohan, Joel F. Platt, Nancy J. McNulty, and Melvyn Korobkin
- Subjects
Adult ,Male ,medicine.medical_specialty ,Pancreatic abnormality ,Pancreatic disease ,Contrast Media ,Adenocarcinoma ,Sensitivity and Specificity ,Reference Values ,Parenchyma ,Confidence Intervals ,Odds Ratio ,Medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,Mesenteric arteries ,Pancreas ,Aged ,Probability ,Aged, 80 and over ,business.industry ,Middle Aged ,medicine.disease ,Multi detector ,Helical ct ,Pancreatic Neoplasms ,Radiographic Image Enhancement ,medicine.anatomical_structure ,Female ,Radiology ,business ,Tomography, X-Ray Computed - Abstract
To determine the optimal phase for enhancement of the normal pancreas and peripancreatic vasculature and the maximal tumor-to-pancreatic parenchymal enhancement difference by using multiphase, contrast material-enhanced, multi-detector row helical computed tomography (CT).Forty-nine patients with a normal-appearing pancreas but suspected of having pancreatic abnormality and 28 patients with proved pancreatic adenocarcinoma underwent multiphase, contrast-enhanced, multi-detector row CT during the arterial phase (AP), pancreatic parenchymal phase (PPP), and portal venous phase (PVP). Attenuation values of the normal pancreas, pancreatic adenocarcinoma, celiac and superior mesenteric arteries, and superior mesenteric and portal veins were measured during all three imaging phases. Quantitative analysis of these measurements and subjective qualitative analysis of tumor conspicuity were performed.Maximal enhancement of the normal pancreatic parenchyma occurred during the PPP. Maximal tumor-to-parenchyma attenuation differences during the PPP and PVP were equivalent but greater than that during the AP. Subjective analysis revealed that tumor conspicuity during the PPP and PVP was equivalent but superior to that during the AP. Maximal arterial enhancement was seen during the PPP, and maximal venous enhancement was seen during the PVP.A combination of PPP and PVP imaging is sufficient for detection of pancreatic adenocarcinoma, because it provides maximal pancreatic parenchymal and peripancreatic vascular enhancement. AP imaging can be reserved for patients in whom CT angiography is required.
- Published
- 2001
28. Abstract No. 346: Subcutaneous Venous Chest Port Outcomes: Is Pocket Fixation Necessary?
- Author
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Nancy J. McNulty, Kiley D. Perrich, R.M. Linville, Anne M. Silas, and Andrew R. Forauer
- Subjects
medicine.medical_specialty ,Fixation (surgical) ,business.industry ,medicine ,Radiology, Nuclear Medicine and imaging ,Cardiology and Cardiovascular Medicine ,business ,Surgery - Published
- 2009
- Full Text
- View/download PDF
29. Sequential Imaging of a Rapidly Progressive Rheumatoid Vasculitis: A Unique Depiction.
- Author
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Kim SS, Villela VA, and McNulty NJ
- Abstract
Rheumatoid vasculitis is a clinically heterogenous complication of rheumatoid arthritis (RA), primarily affecting small- and medium-sized vessels.
1 A 63-year-old man with long-standing seropositive erosive RA presented to our emergency department with abdominal pain and diarrhea.- Published
- 2023
- Full Text
- View/download PDF
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