Anthony C. Gamst

Objective To investigate if size measurements of liver observations is more variable in the arterial phase as suggested by LI-RADS and assess potential higher instability in categorization in this particular phase. Secondarily, to assess inter- and intra-reader agreement for size across phases. Materials and methods Patients with liver cirrhosis who underwent multi-arterial phase MRI between 2017 and 2018 were retrospectively selected. Three radiologists measured liver observations in each phase, independently, in a random order. Mean size between early and late arterial phases (AP), 2, 3 and 10 min delay and the number of observations crossing the LI-RADS size thresholds (10 and 20 mm) per phase were compared using McNemar’s test. Reader agreement was evaluated using intraclass correlation coefficient (ICC) and bootstrap-based comparisons. Bonferroni’s correction was applied to pairwise comparisons. Results 94 observations (LR-3, LR-4, LR-5, and LR-M) were included. Mean sizes (mm) were late AP: 19.9 (95% CI 17.2, 24.2), 2 min delay: 19.8 (95% CI 17.1, 24.0), 3 min delay: 19.8 (95% CI 17.2, 24.0), 10 min delay: 20.2 (95% CI 17.5, 24.5) (p = 0.10–0.88). There was no difference between phases in number of observations that could have changed category due to variability in size (p = 0.546–1.000). Inter- and intra-reader agreement was excellent (ICC = 0.952–0.981). Conclusion Measurements of focal liver observations were consistent across all post-contrast imaging phases and we found no higher instability in LI-RADS category in any particular phase. Inter- and intra-reader agreement for size was excellent for each phase. Based on these findings, size measurement could be allowed on any post-contrast phase, including the arterial phase, if deemed appropriate by the radiologist.

Magnetic resonance elastography (MRE) is a promising technique for noninvasive assessment of fibrosis, a major determinant of outcome in nonalcoholic fatty liver disease (NAFLD). However, data in children are limited. The purpose of this study was to determine the accuracy of MRE for the detection of fibrosis and advanced fibrosis in children with NAFLD and to assess agreement between manual and novel automated reading methods. We performed a prospective, multicenter study of two‐dimensional (2D) MRE in children with NAFLD. MR elastograms were analyzed manually at two reading centers, and using a new automated technique. Analysis using each approach was done independently. Correlations were determined between MRE analysis methods and fibrosis stage. Thresholds for classifying the presence of fibrosis and of advanced fibrosis were computed and cross‐validated. In 90 children with a mean age of 13.1 ± 2.4 years, median hepatic stiffness was 2.35 kPa. Stiffness values derived by each reading center were strongly correlated with each other (r = 0.83). All three analyses were significantly correlated with fibrosis stage (center 1, ρ = 0.53; center 2, ρ = 0.55; and automated analysis, ρ = 0.52; P < 0.001). Overall cross‐validated accuracy for detecting any fibrosis was 72.2% for all methods (95% confidence interval [CI], 61.8%‐81.1%). Overall cross‐validated accuracy for assessing advanced fibrosis was 88.9% (95% CI, 80.5%‐94.5%) for center 1, 90.0% (95% CI, 81.9%‐95.3%) for center 2, and 86.7% (95% CI, 77.9%‐92.9%) for automated analysis. Conclusion: 2D MRE can estimate hepatic stiffness in children with NAFLD. Further refinement and validation of automated analysis techniques will be an important step in standardizing MRE. How to best integrate MRE into clinical protocols for the assessment of NAFLD in children will require prospective evaluation. (Hepatology 2017;66:1474–1485)

Background: Hospitalized smokers often quit smoking, voluntarily or involuntarily; most relapse soon after discharge. Extended follow-up counseling can help prevent relapse. However, it is difficult for hospitals to provide follow-up and smokers rarely leave the hospital with quitting aids (for example, nicotine patches). This study aims to test a practical model in which hospitals work with a state cessation quitline. Hospital staff briefly intervene with smokers at bedside and refer them to the quitline. Depending on assigned condition, smokers may receive nicotine patches at discharge or extended quitline telephone counseling post-discharge. This project establishes a practical model that lends itself to broader dissemination, while testing the effectiveness of the interventions in a rigorous randomized trial. Methods/design: This randomized clinical trial (N = 1,640) tests the effect of two interventions on long-term quit rates of hospitalized smokers in a 2 x 2 factorial design. The interventions are (1) nicotine patches (eight-week, step down program) dispensed at discharge and (2) proactive telephone counseling provided by the state quitline after discharge. Subjects are randomly assigned into: usual care, nicotine patches, telephone counseling, or both patches and counseling. It is hypothesized that patches and counseling have independent effects and their combined effect is greater than either alone. The primary outcome measure is thirty-day abstinence at six months; a secondary outcome is biochemically validated smoking status. Cost-effectiveness analysis is conducted to compare each intervention condition (patch alone, counseling alone, and combined interventions) against the usual care condition. Further, this study examines whether smokers’ medical diagnosis is a moderator of treatment effect. Generalized linear (binomial) mixed models will be used to study the effect of treatment on abstinence rates. Clustering is accounted for with hospital-specific random effects. Discussion: If this model is effective, quitlines across the U.S. could work with interested hospitals to set up similar systems. Hospital accreditation standards related to tobacco cessation performance measures require follow-up after discharge and provide additional incentive for hospitals to work with quitlines. The ubiquity of quitlines, combined with the consistency of quitline counseling delivery as centralized state operations, make this partnership attractive. Trial registration: Smoking cessation in hospitalized smokers NCT01289275. Date of registration February 1, 2011; date of first patient August 3, 2011.