Eric J. Keller is an interventional/diagnostic radiology resident (2019-2024) with a background in bioethics, medical anthropology, 4D flow MRI, and legal guardianship. He founded the Applied Ethics in Interventional Radiology (IR) working group, a multi-institutional group of faculty and trainees developing practical approaches to challenging situations in IR. He also serves on the Board of Directors of the Interventional Initiative, a nonprofit devoted to patient and clinician awareness, access, and advocacy regarding minimally invasive image-guided procedures.

Clinical Focus

  • Residency

Honors & Awards

  • Up and Coming Luminary, Western Angiographic & Interventional Society (2022)
  • Radiology Resident Research Grant, Society of Interventional Radiology Foundation (2020)
  • Etta Kalin Moskowitz Fund Research Award, Department of Radiology, Stanford University (2020)
  • Member, Alpha Omega Alpha Honor Medical Society (2018)
  • Member, Gold Humanism Honor Society (2018)
  • Lee F. Rogers Award for Excellence in Medical Student Research, Department of Radiology, Northwestern University (2017)
  • Enterprise Data Warehouse Pilot Data Grant, Northwestern Medicine (2017)
  • Center for Bioethics & Medical Humanities Pilot/Exploratory Grant, Northwestern University (2016)
  • Radiology Pilot Research Grant, Department of Radiology, Northwestern University (2015)
  • Dr. and Mrs. W.C. Culp Student Research Grant, Society of Interventional Radiology Foundation (2015)
  • Research Medical Student Grant, Radiological Society of North America (2015)

Boards, Advisory Committees, Professional Organizations

  • Board Member & Secretary, The Interventional Initiative (2021 - Present)
  • Founder, Applied Ethics in IR Working Group (2019 - Present)

Professional Education

  • Internship, Santa Clara Valley Medical Center, Transitional Year (2019)
  • M.D., Northwestern University, Feinberg School of Medicine, Medicine (2018)
  • M.A., Northwestern University, The Graduate School, Medical Humanities & Bioethics (2016)
  • B.A., Purdue University (IUPUI Campus), Chemistry (2013)
  • B.S., Purdue University (IUPUI Campus), Biology (2013)

All Publications

  • Development of a Medical Social Media Ethics Scale and Assessment of #IRad, #CardioTwitter, and #MedTwitter Posts: Mixed Methods Study. JMIR infodemiology Mlambo, V. C., Keller, E., Mussatto, C., Hwang, G. 2024; 4: e47770


    Social media posts by clinicians are not bound by the same rules as peer-reviewed publications, raising ethical concerns that have not been extensively characterized or quantified.We aim to develop a scale to assess ethical issues on medical social media (SoMe) and use it to determine the prevalence of these issues among posts with 3 different hashtags: #MedTwitter, #IRad, and #CardioTwitter.A scale was developed based on previous descriptions of professionalism and validated via semistructured cognitive interviewing with a sample of 11 clinicians and trainees, interrater agreement, and correlation of 100 posts. The final scale assessed social media posts in 6 domains. This was used to analyze 1500 Twitter posts, 500 each from the 3 hashtags. Analysis of posts was limited to original Twitter posts in English made by health care professionals in North America. The prevalence of potential issues was determined using descriptive statistics and compared across hashtags using the Fisher exact and χ2 tests with Yates correction.The final scale was considered reflective of potential ethical issues of SoMe by participants. There was good interrater agreement (Cohen κ=0.620, P<.01) and moderate to strong positive interrater correlation (=0.602, P<.001). The 6 scale domains showed minimal to no interrelation (Cronbach α=0.206). Ethical concerns across all hashtags had a prevalence of 1.5% or less except the conflict of interest concerns on #IRad, which had a prevalence of 3.6% (n=18). Compared to #MedTwitter, posts with specialty-specific hashtags had more patient privacy and conflict of interest concerns.The SoMe professionalism scale we developed reliably reflects potential ethical issues. Ethical issues on SoMe are rare but important and vary in prevalence across medical communities.

    View details for DOI 10.2196/47770

    View details for PubMedID 38536206

  • The Prevalence of Financial Conflict of Interest Disclosures by Endovascular Specialists on X (Twitter). Journal of vascular and interventional radiology : JVIR Webb, T., Menard, N., Hofmann, H. L., Repajic, M., Han, J., Keller, E. J., Kothary, N., Vairavamurthy, J. 2024


    Evaluate conflicts of interest (COI) among interventional radiologists and related specialties who mention specific devices or companies on the social media (SoMe) platform X, formerly Twitter.13,809 posts between 10/7/2021 and 12/31/2021 on X were evaluated. Posts by US interventional radiologists and related specialties that mentioned a specific device or company were identified. A positive COI was defined as receiving a payment from the device manufacturer or company within 36 months prior to posting. The CMS Open Payment database was used to identify financial payments. The prevalence and value of COIs were assessed and compared between posts mentioning a device or company and a paired control group using descriptive statistics and chi-squared tests and independent t-tests.Eighty posts containing the mention of 100 specific devices or companies were evaluated. COIs were present in 53% (53/100). When mentioning a specific device or product, 40% interventional radiologists had a COI, neurosurgeons 62%. Physicians who mentioned a specific device or company were 3.7 times more likely to have a positive COI relative to the paired control group (53/100 vs 14/100, p<0.001). Of the 31 physicians with a COI, the median physician received $2,270. None of the positive COIs were disclosed.Physicians posting on SoMe about a specific device or company are more likely to have a financial COI than authors of posts not mentioning a specific device or company. No disclosure of any COIs were present in the posts, limiting followers ability to weigh potential bias.

    View details for DOI 10.1016/j.jvir.2024.03.017

    View details for PubMedID 38513754

  • Interventional Radiology's Professional Identity Crisis: A Medical Anthropology Perspective. Journal of the American College of Radiology : JACR Keller, E. J. 2023

    View details for DOI 10.1016/j.jacr.2023.12.021

    View details for PubMedID 38157950

  • Subspecialty Training in IR. Journal of vascular and interventional radiology : JVIR Josephs, S., Keller, E. J., Vadlamudi, V., Annam, A., Abi-Jaoudeh, N. 2023; 34 (12): 2074-2075

    View details for DOI 10.1016/j.jvir.2023.08.015

    View details for PubMedID 38008541

  • Private Equity and Radiology: Productive Partnership or Inherently Misaligned? Seminars in interventional radiology Balesh, E., Hund, H., Keller, E. J. 2023; 40 (5): 449-451


    Private equity acquisition of medical groups and health care organizations is becoming increasingly important in medicine and is a trend that is likely to continue for the foreseeable future. Some question the ethical implications of private equity acquisitions, since the clear goal of such organizations is maximizing profitability, which may or may not be in the best interests of either the patient population or the provider group. This article will describe the role of private equity in the medical marketplace, with a focus on the role of private equity in radiology and interventional radiology specifically. Additionally, this article will explore this growing trend in the radiology marketplace and its anticipated effects upon patient care and professional satisfaction for radiologists.

    View details for DOI 10.1055/s-0043-1775720

    View details for PubMedID 37927526

  • Trainee Ethics in Interventional Radiology. Seminars in interventional radiology Cyphers, E. D., Keller, E. J., Makary, M. S. 2023; 40 (5): 472-474

    View details for DOI 10.1055/s-0043-1772816

    View details for PubMedID 37927524

  • Ethical Considerations for Artificial Intelligence in Interventional Radiology: Balancing Innovation and Patient Care. Seminars in interventional radiology Rockwell, H. D., Cyphers, E. D., Makary, M. S., Keller, E. J. 2023; 40 (3): 323-326

    View details for DOI 10.1055/s-0043-1769905

    View details for PubMedID 37484438

    View details for PubMedCentralID PMC10359128

  • Sinners and Saints: Medical Business Ethics in Interventional Radiology. Seminars in interventional radiology Cyphers, E. D., Keller, E. J., Reis, S. P., Makary, M. S. 2023; 40 (1): 113-116

    View details for DOI 10.1055/s-0043-1767689

    View details for PubMedID 37152798

    View details for PubMedCentralID PMC10159702

  • Required Suspension of DNR/DNI Orders in Interventional Radiology: a Survey of Prevalence and Practices. Journal of vascular and interventional radiology : JVIR Cyphers, E. D., Silberstein, S., Forsman, T., Keller, E. J., Makary, M. S. 2022

    View details for DOI 10.1016/j.jvir.2022.12.032

    View details for PubMedID 36563930

  • Patient Decision Aids Before Informed Consent Conversations for Image-Guided Procedures: Controlled Trials at Two Institutions. AJR. American journal of roentgenology Srinivas, S., Newton, I. G., Waradzyn, M., Kothary, N., Keller, E. J. 2022


    Background: Patient decision aids (PDAs) improve informed consent practices. Available PDAs for image-guided procedures are of limited quality. Objective: To evaluate the impact of PDAs on understanding and satisfaction among patients undergoing informed consent conversations before outpatient image-guided procedures. Methods: This prospective study included patients awaiting an interventional radiology clinic visit to discuss and obtain informed consent for an image-guided procedure. The study was conducted at two academic medical centers (site A: visits from August, 2020 to July, 2021; site B: January, 2021 to October, 2021). Patients were assigned systematically at site A, and randomly at site B, to electronically receive or not receive a 2-page PDA before the visit. PDAs described procedures and their benefits, risks, and alternatives at a 6th-8th grade health literacy level, and vetted by diverse patient focus groups. Patients completed a postvisit survey (site A: phone; site B: online) assessing understanding of the procedure and satisfaction with the consent conversation using 5-point scales. Data were pooled between sites. Results: The study included 105 patients (59 male, 46 female; median age, 67 years; 51 from site A, 54 from site B; 53 who received PDA, 52 who did not). Survey response rate was 100% (51/51) at site A and 67% (62/92) at site B. Patients who received, versus not received, a PDA reported greater understanding of benefits (4.5 vs 4.0, p<.001), risks (4.4 vs 3.6, p<.001), and alternatives (4.0 vs 3.3, p<.001), and of what procedures involved (4.4 vs 4.1, p=.02); and were more likely to feel that they were provided with enough time with the clinician (4.7 vs 4.5, p=.03), listened to carefully (4.8 vs 4.4, p<.001), free to choose any option including not to have the procedure (4.7 vs 4.3, p<.001), given enough time to make a decision (4.8 vs 4.3, p<.001), encouraged to ask questions (4.8 vs 4.5, p<.001), and had questions answered (4.8 vs 4.4, p=.001). Conclusion: Well-vetted plain-language PDAs provided before image-guided procedure consent conversations improve patients' self-perceived understanding of the procedure and satisfaction with the conversation. Clinical Impact: PDAs can be implemented effectively without requiring additional clinician time or effort.

    View details for DOI 10.2214/AJR.22.28165

    View details for PubMedID 36129221

  • Global Health and Interventional Radiology: Ethical Considerations. Cardiovascular and interventional radiology Chan, S. M., Laage Gaupp, F. M., Rockwell, H. D., Perez, A. W., Rukundo, I., Keller, E. J. 2022

    View details for DOI 10.1007/s00270-022-03236-6

    View details for PubMedID 35918432

  • VIP Patients in Interventional Radiology: Do Some Patients Deserve "Better" Care? Seminars in interventional radiology Rockwell, H., Keller, E. J., Tadros, A., Newton, I. 2022; 39 (4): 454-458

    View details for DOI 10.1055/s-0042-1757316

    View details for PubMedID 36406034

  • Suspending Do Not Resuscitate/Do Not Intubate Orders for Image-Guided Procedures SEMINARS IN INTERVENTIONAL RADIOLOGY Cyphers, E., Silberstein, S., Keller, E. J. 2022; 39 (03): 338-340

    View details for DOI 10.1055/s-0042-1751290

    View details for Web of Science ID 000847807600017

    View details for PubMedID 36062229

    View details for PubMedCentralID PMC9433145

  • Consent in Interventional Radiology-How Can We Make It Better? Canadian Association of Radiologists journal = Journal l'Association canadienne des radiologistes Forsman, T., Silberstein, S., Keller, E. J. 2022: 8465371221101625


    Informed consent is an important part of the clinician-patient relationship. However, studies suggest consent practices tend to be limited in consistency and completeness. This may be particularly challenging for interventional radiology given more limited public awareness and the often fast-paced, dynamic nature of our practices. This article reviews these challenges as well as ideal consent practices and potential approaches to improve consent in interventional radiology. Le consentement eclaire constitue un aspect fondamental de la relation clinicien-patient. Cependant, des etudes suggerent que les pratiques relatives au consentement ont tendance a etre limitees en matiere de coherence et d'exhaustivite. Cela peut s'averer particulierement difficile dans le cadre de la radiologie interventionnelle, compte tenu de la sensibilisation plus restreinte du public et de la nature souvent rapide et dynamique de nos pratiques. Cet article examine ces enjeux, ainsi que les meilleures pratiques relatives au consentement et les approches potentielles pour renforcer le consentement en radiologie interventionnelle.

    View details for DOI 10.1177/08465371221101625

    View details for PubMedID 35611696

  • #PauseBeforeYouPost: Ethical and Legal Issues Involving Medical Social Media. Seminars in interventional radiology Keller, E. J., Mlambo, V. C., Resnick, S. A., Vogelzang, R. L. 2022; 39 (2): 203-206

    View details for DOI 10.1055/s-0042-1745717

    View details for PubMedID 35781993

  • Confirmation of Ectopic Pancreatic Tissue: A Novel Use for 18F-Fluciclovine PET. Clinical nuclear medicine Keller, E. J., de Castro, C. M., Ghanouni, P., Shah, J. 2022


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

    View details for DOI 10.1097/RLU.0000000000004134

    View details for PubMedID 35261353

  • Cost-effectiveness of tunneled peritoneal catheters versus repeat paracenteses for recurrent ascites in gynecologic malignancies. Gynecologic oncology Wu, X., Keller, E. J., Rabei, R., Rockwell, H., Beeson, S., Heller, M., Kothary, N. 1800


    OBJECTIVE: To compare the cost-effectiveness of tunneled peritoneal catheter (TPC) versus repeated large-volume paracentesis (LVP) for patients with recurrent ascites secondary to gynecological malignancy.METHODS: A retrospective cohort study was performed at a single institution from 2016 through 2019 of patients with recurrent ascites from gynecologic malignancies that underwent either TPC or LVP. Data on procedural complications and hospital admissions were extracted. A cost-effectiveness analysis with Markov modeling was performed comparing TPC and LVP. Statistical analyses include base case calculation, Monte Carlo simulations and deterministic sensitivity analyses.RESULTS: There were no significant differences between the cohorts in the average number of hospital days (p = 0.21) or emergency department visits (p = 0.69) related to ascites. Palliative care was more often involved in the care of patients who had a TPC. The base case calculation showed TPC to be the more cost-effective strategy with a slightly lower health benefit (0.22980 versus 0.22982 QALY) and lower cost ($3043 versus $3868) relative to LVP (ICER of LVP compared to TPC: $44,863,103/QALY). Probabilistic sensitivity analysis showed TPC was the more cost-effective strategy in 8028/10,000 simulations. Deterministic sensitivity analysis showed TPC to be more cost-effective if its complication risk was >0.81% per 22 days or its procedural cost of TPC insertion was >$1997. When varying the cost of complications, TPC was more cost-effective if the cost of its complication was less than $49,202.CONCLUSIONS: TPC is the more cost-effective strategy when compared to LVP in patients with recurrent ascites from gynecological malignancy.

    View details for DOI 10.1016/j.ygyno.2022.01.011

    View details for PubMedID 35086684

  • Opportunities for Excellence in Interventional Radiology Training: A Qualitative Study. Journal of the American College of Radiology : JACR Oladini, L., Rezaee, M., Thukral, S., Raiter, S., Odetoyinbo, K., Keller, E., Hwang, G. 2022


    The training experience in interventional radiology (IR) residency programs varies widely across the country. The introduction of an IR training pathway has provided the impetus for the specialty to better define outstanding IR education and for programs to rethink how their curricula prepare IR trainees for real-world practice. Although ACGME competencies define several training components that are necessary for independent practice, few quantitative or qualitative studies have explored current perceptions on what constitutes optimal IR training. Our goal was to qualitatively explore program training features deemed most important to adequately prepare IR physicians for practice and assess whether there were differences in perception between academic and nonacademic practices.Semistructured interviews were conducted with 71 IR attending physicians, trainees, and support staff across the United States. All interviews were performed over the telephone by a single researcher for consistency and systematically coded by two independent coders for common themes. Frequency and prevalence of themes and facilitating features were analyzed.The most frequently perceived facilitating features included longitudinal patient care experience, practice-building education, interspecialty collaboration exposure, broad case mix, clinical decision-making exposure, diagnostic radiology training, procedural skills training, and graduated autonomy. Comparing nonacademic versus academic practice settings, significantly more nonacademic IR attending physicians expressed practice-building education (prevalence 72% versus 42%, frequency 2.2 versus 0.7, P < .01) as an important training experience.An understanding of perceived facilitating features for optimal IR trainee preparation, including potentially different needs between academic and nonacademic practices, can help programs prepare their trainees for a successful transition into practice.

    View details for DOI 10.1016/j.jacr.2022.01.011

    View details for PubMedID 35240105

  • Tunneled Peritoneal Catheter vs Repeated Paracenteses for Recurrent Ascites: A Cost-Effectiveness Analysis. Cardiovascular and interventional radiology Wu, X., Rabei, R., Keller, E. J., King, B., Kothary, N., Kohi, M., Taylor, A., Heller, M. 2022


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

    View details for DOI 10.1007/s00270-022-03103-4

    View details for PubMedID 35292833

  • Barriers to Informed Consent in Interventional Radiology: A Pilot Study Journal of Radiology Nursing Silberstein, S., Keller, E. J. 2022
  • Use and Types of Advance Care Planning Prior to Image-Guided Procedures Journal of Radiology Nursing Srinivas, S., Jaswal, S., Kothary, N., Newton, I., Keller, E. 2022
  • The power of proximity: Effects of a multidisciplinary fibroid clinic on inter-specialty perceptions and practice patterns. PloS one Keller, E. J., Nixon, K., Oladini, L., Chrisman, H. B., Chaudhari, A., Milad, M. P., Vogelzang, R. L. 1800; 17 (1): e0263058


    BACKGROUND: Multidisciplinary collaboration has generally been shown to have positive effects on healthcare but can be difficult to facilitate. This study assessed the effects of a multidisciplinary fibroid clinic on practice patterns and clinician perceptions to better understand drivers of interspecialty collaboration.MATERIALS AND METHODS: Annual rates of hysterectomies, myomectomies, and uterine fibroid embolizations (UFEs) performed in an urban healthcare system were collected from 2012-2019. Rates of each procedure were compared over time before and after launching a multidisciplinary fibroid clinic at the academic medical center. Referral rates were also compared. The gynecologists and interventional radiologists (IRs) involved in the clinic were interviewed 2 years prior to and after the clinic launch about their approaches to fibroids and perceptions of others who treat this condition. A phenomenological approach was used to identify and compare themes within the interviews by two researchers with excellent inter-rater agreement (kappa = 0.80).RESULTS AND DISCUSSION: Annual rates of fibroid procedures increased over time (p<0.01) but the relative number of UFEs decreased (p = 0.01). UFE referrals by the clinic gynecologists significantly increased as did the number of combined fibroid procedures (p<0.01). However, the rates of one fibroid procedure relative to others were not different between the clinic and rest of the healthcare system (p = 0.55). Specialty-specific perceptions of fibroid treatments and inter-specialty dynamics did not change. Despite this, clinicians unanimously perceived the clinic and post-clinic practice patterns as positive and distinct from their previous work and relationships between gynecology and IR elsewhere. Limitations of this study included its single clinic design and potential confounder of differences in advertising pre- versus post-clinic.CONCLUSION: Creating the right practice environment may be more important for fostering inter-specialty collaboration and work satisfaction than shared mental models or procedural volumes in certain practice settings.

    View details for DOI 10.1371/journal.pone.0263058

    View details for PubMedID 35077500

  • Perceptions of Ethics in Interventional Radiology. Current problems in diagnostic radiology Rockwell, H. D., Beeson, S. A., Keller, E. J., Kothary, N., Dickey, K. 1800


    PURPOSE: To characterize perceptions of ethics among interventional radiologists to guide the development of an applied, specialty-specific approach to ethics.MATERIALS AND METHODS: A 17-question survey on perceptions of ethics and use of ethics resources was developed and vetted via cognitive interviewing of 15 diverse, representative members of the target population. The survey was distributed via the Society of Interventional Radiology, receiving 685 responses (48% participation and 90% completion rates). Responses were compared between different demographics, and common themes from free text responses were identified via content analysis.RESULTS: Most respondents indicated ethics is important for IR (93%) and more focus on practical approaches to ethical issues is needed (73%). Various ethical issues were perceived to be important for IR, but differentiating palliative from futile care was ranked as the top ethical issue. Trainees had more ethics training (P=0.05) but less confidence in navigating ethical issues (P<0.01). Regardless of career stage, those with ethics training (44%) were more confident in navigating ethical issues (P<0.01). Use of resources such as information sheets for patients and resources for coping with complications were variable and limited by lack of availability or knowledge of such resources in IR.CONCLUSIONS: Interventional radiologists believe ethics is important and face diverse ethical issues, but they are challenged by variable experiences and access to practical tools to navigate these challenges.

    View details for DOI 10.1067/j.cpradiol.2021.11.002

    View details for PubMedID 34955285

  • Potential Bias in Image-Guided Procedure Research: A Retrospective Analysis of Disclosed Conflicts of Interest and Open Payment Records. Journal of vascular and interventional radiology : JVIR Hsieh, L. J., Madadi, S. R., Shore, K. T., Keller, E. J., Makary, M. S. 2021


    PURPOSE: To assess the prevalence of positive conflict of interest (COI) disclosures in U.S.-based interventional radiology (IR) research as well as the level of agreement between disclosed financial relationships and open payment data for top-cited image-guided procedure research.MATERIALS AND METHODS: All publications in volume 30 (2019) of the Journal of Vascular and Interventional Radiology (JVIR) were reviewed to estimate the prevalence of COI disclosures in IR research. Publications were categorized as primary research, systematic review, or other. Prevalence was then compared across JVIR publication subtype, categories, and whether they were device-focused with chi-squared tests. Additionally, the Web of Science database was searched for the top 10 cited studies of 10 common image-guided procedures with available U.S. physician payment data. Payments were categorized as historical (>1 year prior to publication) or active (<1 year prior to publication) and compared to disclosed financial COIs with one-way ANOVA.RESULTS: Positive COI disclosures were present in 29% (114 of 397) of publications in JVIR volume 30. Positive COI disclosures were most prevalent in Standards of Practice (50%, p = 0.01) and more prevalent in device-focused publications (54% vs 23%, p < 0.01). Among the 396 authors of 100 U.S.-based top-cited image-guided procedure publications, 383 (97%) failed to disclose at least one active financial relationship, with an average of $57,937 in undisclosed payments per publication.CONCLUSION: Conflicts of interest are prevalent in IR, like other areas of healthcare research, and conflicts of interest in top-cited image-guided procedure research are often underreported.

    View details for DOI 10.1016/j.jvir.2021.08.026

    View details for PubMedID 34756998

  • Disability in Interventional Radiology. Seminars in interventional radiology Habib, H., Keller, E. J. 2021; 38 (4): 500-503

    View details for DOI 10.1055/s-0041-1735604

    View details for PubMedID 34629721

  • Ethical Issuing Arising Around Biliary Interventions. Seminars in interventional radiology Garg, T., Shnayder-Adams, M. M., Keller, E. J., Makary, M. S. 2021; 38 (3): 388-392

    View details for DOI 10.1055/s-0041-1731407

    View details for PubMedID 34393351

  • Ethics in Interventional Radiology: A Case-Based Primer. Cardiovascular and interventional radiology Silberstein, S., Shnayder-Adams, M. M., Keller, E. J., Makary, M. S. 2021


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

    View details for DOI 10.1007/s00270-021-02894-2

    View details for PubMedID 34231013

  • The Ethics of Trauma Care: What Interventional Radiologists Should Know. Seminars in interventional radiology Hsieh, L. J., Keller, E. J., Shnayder-Adams, M. M., Salamo, R. M., Vairavamurthy, J. P. 2021; 38 (2): 239-242

    View details for DOI 10.1055/s-0041-1729154

    View details for PubMedID 34108812

    View details for PubMedCentralID PMC8175114

  • A Citizen of Two Worlds: The IR/DR Residency. Current problems in diagnostic radiology Goldman, D., Keller, E. J. 2021


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

    View details for DOI 10.1067/j.cpradiol.2021.03.010

    View details for PubMedID 33812721

  • The Bolivian trauma patient's experience: A qualitative needs assessment. Injury Rook, J. M., Wood, E., Boeck, M. A., Blair, K. J., Monroy, A., Ludi, E., Keller, E. J., Victorson, D., Foianini, E., Swaroop, M. 2020


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

    View details for DOI 10.1016/j.injury.2020.12.014

    View details for PubMedID 33386153

  • Perceptions of Futility in Interventional Radiology: A Multipractice Systematic Qualitative Analysis. Cardiovascular and interventional radiology Keller, E. J., Rabei, R., Heller, M., Kothary, N. 2020


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

    View details for DOI 10.1007/s00270-020-02675-3

    View details for PubMedID 33078233

  • COVID-19 Ethics: What Interventional Radiologists Need to Know. Journal of vascular and interventional radiology : JVIR Shnayder, M. M., Keller, E. J., Makary, M. S. 2020

    View details for DOI 10.1016/j.jvir.2020.07.003

    View details for PubMedID 32943297

  • Research Ethics in IR: The Intersection Between Care and Progress. Journal of vascular and interventional radiology : JVIR Bozorghadad, S., Newton, I. G., Perez, A. W., Makary, M. S., Keller, E. J. 2020; 31 (5): 846–48

    View details for DOI 10.1016/j.jvir.2020.02.014

    View details for PubMedID 32359529

  • Informed Consent: Beating a Dead Horse or an Opportunity for Quality Improvement? Journal of vascular and interventional radiology : JVIR Keller, E. J., Perez, A. W., Makary, M. S. 2020; 31 (1): 139–40

    View details for DOI 10.1016/j.jvir.2019.08.010

    View details for PubMedID 31864541

  • Efficacy of endovascular Z-configuration stenting for malignant versus nonmalignant caval obstruction. Journal of vascular surgery. Venous and lymphatic disorders Han, T. M., Bondarev, S. n., Keller, E. J., Vogelzang, R. L., Resnick, S. A. 2020


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

    View details for DOI 10.1016/j.jvsv.2020.02.022

    View details for PubMedID 32414673

  • You're Performing My Procedure: Teamwork and Tribalism in IR. Journal of vascular and interventional radiology : JVIR Bozorghadad, S., Perez, A. W., Makary, M. S., Keller, E. J. 2019

    View details for DOI 10.1016/j.jvir.2019.09.021

    View details for PubMedID 31771897

  • Predictors of Disease Recurrence after Venoplasty and Stent Placement for May-Thurner Syndrome JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Bondarev, S., Keller, E. J., Han, T., Young, V. A., Gupta, S., Vogelzang, R. L., Eskandari, M., Resnick, S. A. 2019; 30 (10): 1549–54


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

    View details for DOI 10.1016/j.jvir.2019.07.012

    View details for Web of Science ID 000490349600005

    View details for PubMedID 31526576

  • Gluteal Vein Anatomy: Location, Caliber, Impact of Patient Positioning, and Implications for Fat Grafting. Aesthetic surgery journal Turin, S. Y., Fracol, M., Keller, E., Markl, M., Collins, J., Krochmal, D., Kim, J. Y. 2019


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

    View details for DOI 10.1093/asj/sjz260

    View details for PubMedID 31574144

  • Reconsidering Requests-Futility in IR. Journal of vascular and interventional radiology : JVIR Clark, J. M., Keller, E. J. 2019; 30 (6): 961–62

    View details for DOI 10.1016/j.jvir.2019.01.025

    View details for PubMedID 31126607

  • Reflect and Remember: The Ethics of Complications in Interventional Radiology. Seminars in interventional radiology Keller, E. J. 2019; 36 (2): 104–7


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

    View details for DOI 10.1055/s-0039-1688423

    View details for PubMedID 31123380

  • Cost-Effectiveness of a Guided Peripherally Inserted Central Catheter Placement System: A Single-Center Cohort Study JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Keller, E. J., Aragona, E., Molina, H., Lee, J., Salem, R., Resnick, S. A., Chrisman, H., Collins, J. D. 2019; 30 (5): 709–14


    To assess the cost-effectiveness of peripherally inserted central catheter (PICC) placements using an ultrasound and electrocardiogram-guided system versus external measurements and confirmatory chest X-rays (CXRs).Sixty-eight guided PICC placements were performed in 63 outpatients (mean age, 43 ± 13 years; 50% male) and compared to 68 propensity score-matched PICC placements (mean age, 44 ± 13 years; 56% male) performed using external measurements by the same operators. Post-placement CXRs were used to confirm final catheter tip positioning. Cohorts were compared in terms of repositioning rates, desired tip positioning rates (in the lower third of the superior vena cava or at the cavoatrial junction), and estimated cost per PICC positioned as desired using manufacturer quotes, Medicare reimbursement rates, and hourly wages for staff time. Agreement between tip positioning according to the guided system versus CXR was also assessed.Guided PICC placements required less repositioning (1.5% vs 10.3%, P = .03) and resulted in more catheters positioned as desired (86.8% vs 67.6%, P = .01) than the external measurement approach. The cost per PICC positioned as desired was lower for guided placements ($318.54 vs $381.44), suggesting that the guided system was cost-effective in this clinical setting. Guided system-CXR agreement for tip position was poor (κ=0.25, P = .002) due to tips being slightly farther from the cavoatrial junction on CXR than indicated by the guided system.The guided PICC placement system was cost-effective in outpatients treated by a single division of interventional radiology at an academic institution.

    View details for DOI 10.1016/j.jvir.2018.07.032

    View details for Web of Science ID 000468259000015

    View details for PubMedID 30773436

  • Understanding Bias: A Look at Conflicts of Interest in IR. Journal of vascular and interventional radiology : JVIR Clark, J. M., Anderson, D., Makary, M. S., Keller, E. J. 2019; 30 (5): 765-766

    View details for DOI 10.1016/j.jvir.2019.01.002

    View details for PubMedID 31029391

  • The growing pains of physician-administration relationships in an academic medical center and the effects on physician engagement PLOS ONE Keller, E. J., Giafaglione, B., Chrisman, H. B., Collins, J. D., Vogelzang, R. L. 2019; 14 (2): e0212014


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

    View details for DOI 10.1371/journal.pone.0212014

    View details for Web of Science ID 000458761300069

    View details for PubMedID 30759151

    View details for PubMedCentralID PMC6373942

  • Who We Are and What We Can Become: The Anthropology of IR and Challenges of Forming a New Specialty JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Keller, E. J., Vogelzang, R. L. 2018; 29 (12): 1703–4

    View details for DOI 10.1016/j.jvir.2018.07.021

    View details for Web of Science ID 000453341200012

    View details for PubMedID 30502878

  • Single-Center Retrospective Review of Radiofrequency Wire Recanalization of Refractory Central Venous Occlusions Keller, E. J., Gupta, S. A., Bondarev, S., Sato, K. T., Vogelzang, R. L., Resnick, S. A. ELSEVIER SCIENCE INC. 2018: 1571–77


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

    View details for DOI 10.1016/j.jvir.2018.06.017

    View details for Web of Science ID 000450542400012

    View details for PubMedID 30293732

  • Reinforcing the Importance and Feasibility of Implementing a Low-dose Protocol for CT-guided Biopsies ACADEMIC RADIOLOGY Keller, E. J., Lewandowski, R. J., Goodwin, L., Yaghmai, V., Nemcek, A., Carr, J. C., Collins, J. D. 2018; 25 (9): 1146–51


    This study sought to more definitely illustrate the impact and feasibility of implementing a low-dose protocol for computed tomography (CT)-guided biopsies using size-specific dose estimates and multivariate analyses.Fifty consecutive CT-guided lung and extrapulmonary biopsies were reviewed before and after implementation of a low-dose protocol (200 patients total, mean age 61 ± 15 years, 128 women). Analyses of variance with Bonferroni correction were used to compare standard and low-dose protocols in terms of patient demographics, physician experience, target lesion size, total dose-length product, total acquisitions, size-specific dose estimate, signal-to-noise ratio, contrast-to-noise ratio, and lesion conspicuity ratings. All procedures were performed on the same 16-slice CT scanner.Voluntary protocol adherence was 100% (lung) and 89% (extrapulmonary). The low-dose protocol achieved significantly lower total average dose-length product [(lung) 735.6 ± 599.4 mGy × cm to 252.1 ± 101.9 mGy × cm, P < .001; (extrapulmonary) 724.7 ± 545.0 mGy × cm to 392.9 ± 239.5 mGy × cm, P < .001] and size-specific dose estimate [(lung) 5.2 ± 0.8 mGy × cm to 4.3 ± 1.5 mGy, P < .001; (extrapulmonary) 10.1 ± 6.7 mGy to 6.5 ± 2.7 mGy, P < .001]. Only the change in protocol was independently associated with lower size-specific dose estimates when controlling for the other variables (P < .0001). This was achieved with no significant differences in signal-to-noise ratio, contrast-to-noise ratio, or lesion conspicuity.Implementation of a low-dose protocol for CT-guided biopsies resulted in 21% and 36% of size-specific dose estimate reduction for lung and extrapulmonary biopsies, respectively, with excellent adherence. Interventional and body radiologists should implement low dose CT-guidance protocols aiming to improve patient safety.

    View details for DOI 10.1016/j.acra.2018.01.003

    View details for Web of Science ID 000454183700007

    View details for PubMedID 29426686

  • Perceptions of Quality in Interventional Oncology JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Keller, E. J., Kennedy, K. Y., Patel, A. P., Ivanovic, M., Collins, J. D., Sato, K., Thornburg, B. G., Riaz, A., Nemcek, A. A., Desai, K., Lewandowski, R. J., Salem, R., Vogelzang, R. L., Hickey, R. 2018; 29 (3): 367–72


    To inductively characterize perceptions of quality in interventional oncology (IO) based on values and experiences of patients and referring providers.Brief ethnographic interviews were completed with referring providers and patients before and after a variety of liver-directed procedures about their experiences, concerns, and perceptions of IO services at a single institution. Constructivist grounded theory was used to systematically analyze interview transcripts for themes until thematic saturation was achieved. All transcripts were analyzed by a reviewer with 3-years of experience performing such analyses, and 50% were randomly selected to be coded by 2 additional blinded reviewers. Interreviewer agreement was assessed via Cohen κ.Interviews with 22 patients (mean age, 65 y ± 13; 9 women) and 12 providers (mean age, 54 y ± 9; 6 women) were required to reach and confirm thematic saturation. Interreviewer agreement for interview themes was excellent (κ = 0.78; P < .001). Perceptions of high-quality IO care relied on interventional radiologists being responsive, friendly, and open; engaging in multidisciplinary collaboration; having thoughtful, dedicated support staff; and facilitating well-coordinated care after procedures and follow-up more than technical expertise and periprocedural comfort. Patient and provider perceptions of quality differed, but disjointed care after procedures was the most common critique among both groups.An inductive qualitative approach effectively characterized specific aspects of perceptions of high-quality IO care among patients and referring providers.

    View details for DOI 10.1016/j.jvir.2017.10.033

    View details for Web of Science ID 000427215900013

    View details for PubMedID 29395900

  • The consistency of myocardial strain derived from heart deformation analysis INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING Keller, E. J., Fang, S., Lin, K., Freed, B. H., Smith, P. M., Spottiswoode, B. S., Davids, R., Carr, M., Jolly, M., Markl, M., Carr, J. C., Collins, J. D. 2017; 33 (8): 1169–77


    The purpose of this study was to assess the consistency of semi-automated myocardial strain analysis by prototype software across field strengths, temporal resolutions, and examinations. 35 volunteers (48 ± 13 years; 20% women) and 25 patients (54 ± 12 years; 44% women) without significant cardiac dysfunction underwent cine cardiac magnetic resonance imaging (CMR) at 1.5 T with a temporal resolution of 39.2 msec. 34 subjects also underwent imaging at 3.0 T; 16 had repeat examinations within 14 days; and 9 underwent CMR with temporal resolutions of 12.5 and 39.2 msec on the same day. Prototype heart deformation analysis (HDA) software was used to retrospectively quantify strain from segmented balanced steady state free precession (bSSFP) cinegraphic images. Myocardial contours were automatically generated on short axis images and drawn at end-diastole by two independent reviewers on long-axis images. Contours were automatically propagated throughout the cardiac cycle. Global and regional peak systolic strain were compared across observers, field strengths, temporal resolutions, and examinations. Inter-observer agreement was excellent (ICC > 0.87, p < 0.01). Inter-examination variability was low, ranging from 1.7 (1.0-2.4)% to 2.5 (1.9-3.1)%, except for radial strain: 9.2 (7.6-10.5)%. Most global and regional strain values were not significantly different across field strengths and temporal resolutions (p > 0.05). Normal global peak systolic strain values with HDA were -25.0 (-24.0 to -26.1)% (LV circumferential), 60.5 (55.3 to 65.6)% (LV radial), -22.3 (-20.5 to - 24.0)% (LV longitudinal), and -26.0 (-23.8 to -28.2)% (RV longitudinal). HDA prototype software enabled efficient and consistent quantification of myocardial strain from conventional bSSFP cine CMR data, demonstrating clinical feasibility.

    View details for DOI 10.1007/s10554-017-1090-6

    View details for Web of Science ID 000405226700009

    View details for PubMedID 28239799

  • Four-Dimensional Flow MRI-Based Splenic Flow Index for Predicting Cirrhosis-Associated Hypersplenism AMERICAN JOURNAL OF ROENTGENOLOGY Keller, E. J., Kulik, L., Stankovic, Z., Lewandowski, R. J., Salem, R., Carr, J. C., Schnell, S., Markl, M., Collins, J. D. 2017; 209 (1): 46–53


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

    View details for DOI 10.2214/AJR.16.17620

    View details for Web of Science ID 000404057000019

    View details for PubMedID 28463524

  • Who We Are and What We Can Become: An Analysis of Professional Identity Formation in IR JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Keller, E. J., Mcgee, K. A., Resnick, S. A., Trerotola, S. O., Valji, K., Johnson, M. S., Collins, J. D., Vogelzang, R. L. 2017; 28 (6): 850–56


    To characterize the unique experiences, values, and perspectives of interventional radiology (IR) fellows.Sixteen fellows from 4 US vascular and IR programs were interviewed within 2 months of beginning and 2-3 months following their 2015-2016 fellowships about patient interactions, training experiences, and views of IR and other specialties. Interviews were systematically analyzed for dominant themes by using constructivist grounded theory. Four interviews with 2015-2016 interventional cardiology fellows, 16 interviews with IR attending physicians, and online descriptions of IR were also analyzed for context. Themes were compared qualitatively and quantitatively.Interobserver agreement was good for interview themes (κ = 0.70; P < .0001). IR fellows' professional identity emerged primarily from radiologic and surgical interests, with distinct emphasis on being "innovators," "thinking differently," and "needing to adapt and advertise abilities to survive." Fellows' descriptions of patient care were more clinically focused than past interviews with attending physicians (P = .05), but clinical interests common in medical specialties were limited, and descriptions of "nonprocedural patient care" were primarily periprocedural (81%). Descriptions of the future of the field conveyed competing pressures, loose role definition, and disconnect between academic and private-practice IR.IR fellows share professional interests, views of their field and others, and descriptions of patient care, but there is uncertainty regarding future roles of the specialty and a need for more specific and unified definitions of nonprocedural patient care in IR.

    View details for DOI 10.1016/j.jvir.2017.02.006

    View details for Web of Science ID 000403132500012

    View details for PubMedID 28292636

  • Why Vascular Surgeons and Interventional Radiologists Collaborate or Compete: A Look at Endovascular Stent Placements CARDIOVASCULAR AND INTERVENTIONAL RADIOLOGY Keller, E. J., Collins, J. D., Crowley-Matoka, M., Chrisman, H. B., Milad, M. P., Vogelzang, R. L. 2017; 40 (6): 814–21


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

    View details for DOI 10.1007/s00270-017-1570-z

    View details for Web of Science ID 000400443200002

    View details for PubMedID 28062898

  • Specialty-Specific Values Affecting the Management of Symptomatic Uterine Fibroids JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Keller, E. J., Crowley-Matoka, M., Collins, J. D., Chrisman, H. B., Milad, M. P., Vogelzang, R. L. 2017; 28 (3): 420–28


    To better understand why interventional radiologists and gynecologists differ in their approaches to symptomatic uterine fibroids.Conversational interviews were conducted with 26 interventional radiologists and gynecologists about their professional roles, clinical reasoning, and practice variation within and outside their specialty. Interview transcripts were systematically analyzed using NVivo 10 software (QSR International, Burlington, Massachusetts) according to grounded theory and content analysis to identify key themes and compare themes across specialties and practice environments. Data were supplemented with retrospective analysis of 7,659 patients with symptomatic uterine fibroids treated at a large academic center over 11 years.Interventional radiologists' shares of symptomatic uterine fibroid treatment and endovascular stent treatments have remained constant (P > .05) for 11 y at a large medical center, whereas minimally invasive gynecologic fibroid treatments and the percentage of interventional radiology (IR) procedures reimbursed by Medicaid/Medicare have increased significantly (r > .90, P < .001 and r = .93, P < .001). Interventional radiologists and gynecologists shared a commitment to do "the right thing" for patients, but each group possessed distinct professional values affecting how they viewed medical evidence, outcomes, and their colleagues. When differences were apparent and concerning, physicians tended to suspect ulterior motives not in patients' best interests.Interventional radiologists and gynecologists demonstrated wide-ranging perspectives regarding their role in caring for patients with symptomatic uterine fibroids. To promote genuine collaboration and adoption of shared goals, stakeholders should seek and promote a deeper understanding of specialty-specific values and culture.

    View details for DOI 10.1016/j.jvir.2016.11.008

    View details for Web of Science ID 000397075000016

    View details for PubMedID 28082073

  • Superior Abdominal 4D Flow MRI Data Consistency with Adjusted Preprocessing Workflow and Noncontrast Acquisitions ACADEMIC RADIOLOGY Keller, E. J., Collins, J. D., Rigsby, C., Carr, J. C., Markl, M., Schnell, S. 2017; 24 (3): 350–58


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

    View details for DOI 10.1016/j.acra.2016.10.007

    View details for Web of Science ID 000394727700014

    View details for PubMedID 27940231

  • Fostering better policy adoption and inter-disciplinary communication in healthcare: A qualitative analysis of practicing physicians' common interests PLOS ONE Keller, E. J., Crowley-Matoka, M., Collins, J. D., Chrisman, H. B., Milad, M. P., Vogelzang, R. L. 2017; 12 (2): e0172865


    In response to limited physician adoption of various healthcare initiatives, we sought to propose and assess a novel approach to policy development where one first characterizes diverse physician groups' common interests, using a medical student and constructivist grounded theory.In 6 months, a medical student completed 36 semi-structured interviews with interventional radiologists, gynecologists, and vascular surgeons that were systematically analyzed according to constructivist grounded theory to identifying common themes. Common drivers of clinical decision making and professional values across 3 distinct specialty groups were derived from physicians' descriptions of their clinical decision making, stories, and concerns.Common drivers of clinical decision making included patient preference/benefit, experience, reimbursement, busyness/volume, and referral networks. Common values included honesty, trustworthiness, loyalty, humble service, compassion and perseverance, and practical wisdom. Although personal gains were perceived as important interests, such values were easily sacrificed for the good of patients or other non-financial interests. This balance was largely dependent on the incentives and security provided by physicians' environments.Using a medical student interviewer and constructivist grounded theory is a feasible means of collecting rich qualitative data to guide policy development. Healthcare administrators and medical educators should consider incorporating this methodology early in policy development to anticipate how value differences between physician groups will influence their acceptance of policies and other broad healthcare initiatives.

    View details for DOI 10.1371/journal.pone.0172865

    View details for Web of Science ID 000394688200157

    View details for PubMedID 28235088

    View details for PubMedCentralID PMC5325554

  • Reduction of aberrant aortic haemodynamics following aortic root replacement with a mechanical valved conduit INTERACTIVE CARDIOVASCULAR AND THORACIC SURGERY Keller, E. J., Malaisrie, S., Kruse, J., McCarthy, P. M., Carr, J. C., Markl, M., Barker, A. J., Collins, J. D. 2016; 23 (3): 416–23


    Previous work suggests that aortic root and valve prostheses alter blood flow patterns in the ascending aorta, creating aberrant haemodynamics compared with those of healthy volunteers. Various valve designs have been proposed to better restore physiological haemodynamics. In this study, magnetic resonance imaging (MRI) was used to non-invasively assess three-dimensional (3D) ascending aortic haemodynamics after aortic root replacement (ARR) with a mechanical valved conduit postulated to create less turbulent blood flow.Ten patients (40 ± 9 years) underwent transthoracic echocardiography and contrast-enhanced multidimensional four-dimensional (4D) flow MRI at 1.5 T after ARR with an On-X mechanical valved conduit. Preoperative 4D flow MRI was available in 7 patients. Ten age- and gender-matched healthy volunteers (42 ± 13 years) were also analysed to characterize physiological flow. The presence of vortex/helix formation was graded by two blinded observers. Peak transvalvular pressure gradients were computed using the simplified Bernoulli equation. Patients' postoperative pressure gradients and helicity/vorticity grades were compared with preoperative gradients and those from healthy volunteers.Intra- and interobserver ratings showed good agreement (κ = 0.93, P < 0.01 and κ = 0.84, P < 0.01, respectively). Highly helical and/or vortical flow was observed in all patients preoperatively, which was significantly reduced postoperatively (P < 0.01 and <0.01, respectively), restoring similar flow patterns similar to those seen in volunteers (P = 0.56 and 0.56). Peak transvalvular pressure gradients (ΔP) were also significantly reduced [43 ± 21 vs 12 ± 7 mmHg, P < 0.05 (Echo); 48 ± 22 vs 16 ± 9 mmHg, P < 0.05 (MRI)], but remained significantly higher than those of volunteers (6 ± 1 mmHg, P < 0.01).Preliminary evidence suggests that ARR with an On-X mechanical valve significantly reduces aberrant aortic haemodynamics, producing flow patterns that resemble those in healthy volunteers.

    View details for DOI 10.1093/icvts/ivw173

    View details for Web of Science ID 000383902600012

    View details for PubMedID 27245620

    View details for PubMedCentralID PMC6390273

  • Physicians' professional identities: a roadmap to understanding "value" in cardiovascular imaging JOURNAL OF CARDIOVASCULAR MAGNETIC RESONANCE Keller, E. J., Vogelzang, R. L., Freed, B. H., Carr, J. C., Collins, J. D. 2016; 18: 52


    Quality improvement efforts in cardiovascular imaging have been challenged by limited adoption of initiatives and policies. In order to better understand this limitation and inform future efforts, the range clinical values related to cardiovascular imaging at a large academic hospital was characterized.15 Northwestern Medicine physicians from internal medicine, cardiology, emergency medicine, cardiac/vascular surgery, and radiology were interviewed about their use of cardiovascular imaging and imaging guidelines. Interview transcripts were systemically analyzed according to constructivist grounded theory and combined with 56 previous interviews with interventional radiologists, interventional cardiologists, gynecologists, and vascular surgeons to develop a model describing specialty-specific values. This model was applied to the 15 pilot interviews focused on cardiovascular imaging, highlighting specialty specific differences in values and practice patterns. Transcripts were also reviewed independently by a cardiologist and 2 radiologists followed by a group discussion to assess reproducibility and achieve a consensus regarding the results.Differences in perceived value of cardiovascular imaging and use of guidelines among physicians were well explained by three value-associated identity categories (managers, diagnosticians, and fixers) that were further differentiated along three axes (broad v. focused-thinkers, complex v. definitive-answer-seekers, and public visibility).Quality improvement in cardiovascular imaging may be limited by a lack of understanding and incorporation of the complexity of medical culture into ongoing initiatives. Both individually and during policy development, it is important to first understand the complexity of stakeholders' diverse perceptions of "value," "quality," and "appropriateness."

    View details for DOI 10.1186/s12968-016-0274-x

    View details for Web of Science ID 000383227100002

    View details for PubMedID 27566058

    View details for PubMedCentralID PMC5002193

  • Providing Context: Medical Device Litigation and Inferior Vena Cava Filters SEMINARS IN INTERVENTIONAL RADIOLOGY Keller, E. J., Vogelzang, R. L. 2016; 33 (2): 132–36


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

    View details for DOI 10.1055/s-0036-1581086

    View details for Web of Science ID 000376217000011

    View details for PubMedID 27247482

    View details for PubMedCentralID PMC4862861

  • Spatio-temporal Visualization of Regional Myocardial Velocities Eurographics Workshop on Visual Computing for Biology and Medicine Sheharyar, A., Chitiboi, T., Keller, E. J., Rahman, O., Schnell, S., Markl, M., Bouhali, O., Linsen, L. 2016: 89–98
  • Philosophy in Medical Education: A Means of Protecting Mental Health ACADEMIC PSYCHIATRY Keller, E. J. 2014; 38 (4): 409–13


    This study sought to identify and examine less commonly discussed challenges to positive mental health faced by medical students, residents, and physicians with hopes of improving current efforts to protect the mental health of these groups. Additionally, this work aimed to suggest an innovative means of preventing poor mental health during medical education.Literature on medical student, resident, and physician mental health was carefully reviewed and a number of psychiatrists who treat physician-patients were interviewed.The culture of medicine, medical training, common physician psychology and identity, and conflicting professional expectations all seem to contribute to poor mental health among medical students, residents, and physicians. Many current efforts may be more successful by better addressing the negative effects of these characteristics of modern medicine.Programs aimed at promoting healthy mental lifestyles during medical education should continue to be developed and supported to mitigate the deleterious effects of the challenging environment of modern medicine. To improve these efforts, educators may consider incorporating philosophical discussions on meaning and fulfillment in life between medical students and faculty. Through medical school faculty members sharing and living out their own healthy outlooks on life, students may emulate these habits and the culture of medicine may become less challenging for positive mental health.

    View details for DOI 10.1007/s40596-014-0033-y

    View details for Web of Science ID 000339803500005

    View details for PubMedID 24477902

  • Ethical Considerations Surrounding Survival Benefit-Based Liver Allocation LIVER TRANSPLANTATION Keller, E. J., Kwo, P. Y., Helft, P. R. 2014; 20 (2): 140-146


    The disparity between the demand for and supply of donor livers has continued to grow over the last 2 decades, and this has placed greater weight on the need for efficient and effective liver allocation. Although the use of extended criteria donors has shown great potential, it remains unregulated. A survival benefit-based model was recently proposed to answer calls to increase efficiency and reduce futile transplants. However, it was previously determined that the current allocation system was not in need of modification and that instead geographic disparities should be addressed. In contrast, we believe that there is a significant need to replace the current allocation system and complement efforts to improve donor liver distribution. We illustrate this need first by identifying major ethical concerns shaping liver allocation and then by using these concerns to identify strengths and shortcomings of the Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease system and a survival benefit-based model. The latter model is a promising means of improving liver allocation: it incorporates a greater number of ethical principles, uses a sophisticated statistical model to increase efficiency and reduce waste, minimizes bias, and parallels developments in the allocation of other organs. However, it remains limited in its posttransplant predictive accuracy and may raise potential issues regarding informed consent. In addition, the proposed model fails to include quality-of-life concerns and prioritize younger patients. We feel that it is time to take the next steps toward better liver allocation not only through reductions in geographic disparities but also through the adoption of a model better equipped to balance the many ethical concerns shaping organ allocation. Thus, we support the development of a similar model with suggested amendments.

    View details for DOI 10.1002/lt.23780

    View details for Web of Science ID 000331194500003

    View details for PubMedID 24166860