Objectives: In the presence of escalating global concerns regarding physician burnout, this study aims to analyze the prevalence and associated factors of burnout among radiologists in Germany. Methods: A comprehensive online survey, inclusive of 73 targeted questions including a German-modified version of the Maslach Burnout Inventory, was distributed among all members of the German Radiological Society and the German Interventional Radiological Society between May and August 2023. The survey encompassed aspects of employment, workload, well-being, and coping mechanisms. Data from 172 completed surveys were analyzed, with correlations explored via crosstabs and the Pearson-chi-square test. Results: In total, 76.7% of participating radiologists were identified to be burnt out. The prevalence was significantly associated with increased workload, reduced sleep quality, suboptimal working conditions, reduced job satisfaction, and the negative interplay between work, family life, and health. Median work satisfaction was described as “satisfied” while median workload was assessed as “frequently overwhelming of work.” A total of 41.9% of respondents noted facing daily time pressure. Radiologists’ concerns about work interfering with private family life were voiced by approximately 70%, and 73.3% highlighted the perceived negative effects on their health. Conclusion: The pronounced prevalence of burnout among German radiologists demonstrates an urgent, unmet need for comprehensive interventions and systemic changes. Our findings act as a catalyst for initiating targeted, multifaceted strategies and dialogs, essential for fostering a resilient and effective healthcare ecosystem. Further large-scale systematic studies should follow to analyze the findings in broad. Clinical relevance statement: Consistent with other countries, there is a high prevalence of burnout among radiologists in Germany. A call for further investigation is recommended to help mitigate adverse outcomes associated with physician burnout. Key Points: • The prevalence of burnout has yet not been evaluated for German radiologists. • German radiologists have a high prevalence of burnout. • Steps must be implemented to engage this problem to prevent worsening. Graphical

Background: Even though the introduction of ¹⁷⁷Lu-PSMA-617 RLT represents a major milestone in the treatment of mCRPC, there are still patients who do not respond adequately to this therapy and for whom there are only limited options left. Augmenting ¹⁷⁷Lu-PSMA-617 RLT with the alpha-emitter ²²⁵Ac-PSMA-617 may present an escalating treatment option to increase efficacy. In this study, we aim to evaluate outcome and safety of ²²⁵Ac-PSMA-617 augmentation to ¹⁷⁷Lu-PSMA-617 RLT in patients who present insufficient response to monotherapy with ¹⁷⁷Lu-PSMA-617 RLT. Patients and Methods: The study included n = 51 mCRPC patients enrolled in a prospective registry receiving ¹⁷⁷Lu-PSMA-617 monotherapy and showing insufficient response, followed by initiation of ²²⁵Ac-PSMA-617 augmentation, with adjusted activities depending on individual patient characteristics. Biochemical response, progression-free survival, and overall survival were assessed. Adverse events were evaluated according to the Common Terminology Criteria for Adverse Events (CTCAE v.5.0). Results: After initiation of ²²⁵Ac-PSMA-617 augmentation to ¹⁷⁷Lu-PSMA-617 RLT, 24/51 patients (47.1%) exhibited partial remission, 16/51 (31.4%) stable disease, and 11/51 (21.6%) progressive disease. The median progression-free survival and overall survival rates were 6.3 months and 9.1 months, respectively. The majority of CTCAE gradings remained stable after initiating augmentation. Severe adverse events were rare, and no treatment termination due to side effects was recorded. Conclusions: ²²⁵Ac-PSMA-617 augmented ¹⁷⁷Lu-PSMA-617 radioligand therapy seems to be an effective escalating treatment option in patients after failure of conventional ¹⁷⁷Lu-PSMA-617 RLT and represents a promising approach balancing antitumor effect and tolerable side effects.

Purpose: This study aims to evaluate the outcome and renal safety of prostate-specific membrane antigen (PSMA)–radioligand therapy (RLT) in patients with metastatic castration-resistant prostate carcinoma (mCRPC) and preexisting renal impairment. Methods: Ninety-four patients with preexisting renal impairment were included in this retrospective analysis. Inclusion criterion was a glomerular filtration rate (GFR) of ≤60 mL/min (equivalent to Common Terminology Criteria of Adverse Events [CTCAE] ≥2). Patients underwent either [¹⁷⁷Lu]Lu-PSMA-617 RLT exclusively (n = 63) or additionally in augmented manner with [²²⁵Ac]Ac-PSMA-617 (n = 31). The median number of administered cycles was 4 (range, 1–16 cycles) with a mean cumulative activity of 29.9 ± 16.3 GBq (range, 6.9–87.2 GBq) [¹⁷⁷Lu]Lu-PSMA-617. Main blood parameters of interest were creatinine, cystatin C, and the respective GFR values. Changes in GFR were categorized according to CTCAE v5.0. Results: In the entire cohort, mean best PSA response was −56.73% ± 45.71%, with 63 of 94 patients (67%) experiencing partial remission. The median progression-free survival and overall survival were 6.7 and 14.1 months, respectively. Under PSMA-RLT, 5 of 94 patients (5.3%) improved to CTCAE grade 0, and 23 of 94 (24.5%) improved to CTCAE grade 1. Three of 94 patients (3.2%) improved from CTCAE grade 3 to grade 2, and only 5 of 94 (5.3%) decreased. The majority (58/94 [61.7%]) of patients stayed stable in terms of CTCAE grading. Conclusion: PSMA-RLT is an effective and safe treatment in mCRPC patients with preexisting impaired renal function (CTCAE ≥2). In daily clinical practice, patients should not be categorically excluded from enrolment to PSMA-RLT due to renal impairment.

The aim of this retrospective study was to identify pre-therapeutic predictive laboratory and molecular imaging biomarkers for response and overall survival (OS) in patients with metastatic castration-resistant prostate cancer (mCRPC) treated with prostate-specific membrane antigen (PSMA)-targeted radioligand therapy (RLT). Pre-therapeutic laboratory and [⁶⁸Ga]Ga-PSMA-11 PET/CT data of n = 102 mCRPC patients receiving [¹⁷⁷Lu]Lu-PSMA-617 RLT within a prospective registry (REALITY Study, NCT04833517) were analyzed including laboratory parameters such as alkaline phosphatase (ALP), prostate-specific antigen (PSA), gamma glutamyl transferase (GGT), glutamate oxaloacetate transaminase (GOT), glutamate pyruvate transaminase (GPT), neuron specific enolase (NSE), hemoglobin (Hb), and imaging parameters such as maximum standardized uptake value of the tumor lesions (SUV_max), the mean standardized uptake value of all tumor lesions (SUV_mean), the whole-body molecular tumor volume (MTV), and the whole-body total lesion PSMA (TLP). Mann–Whitney U test, univariate and multivariable Cox-regression were performed to test for association of the parameters with response and OS. The SUV_mean of all lesions was significantly different between responders and non-responders (SUV_mean responders 8.95 ± 2.83 vs. non-responders 7.88 ± 4.46, p = 0.003), whereas all other tested biochemical and imaging parameters did not reveal significant differences. Hb and the molecular imaging parameters MTV and TLP showed a significant association with OS (p = 0.013, p = 0.005; p = 0.009) in univariant Cox regression; however, only TLP remained significant in multivariable analysis (Hazard ratio 1.033, p = 0.009). This study demonstrates a statistically significant association between the quantitative PET/CT imaging parameter SUV_mean and PSA response, as well as between the baseline TLP and OS of mCRPC patients undergoing RLT.

Background: Hypoxic-ischemic brain injury (HIBI) is a feared complication post-cardiac arrest (CA). The timing of brain imaging remains a topic of ongoing debate. Early computed tomography (CT) scans can reveal acute intracranial pathologies but may have limited predictive value due to delayed manifestation of HIBI-related changes. Radiomics analyses present a promising approach to identifying subtle imaging markers, potentially aiding early HIBI detection. Methods: This study retrospectively assessed post-CA patients between 2016 and 2023 who received immediate brain CTs. Patients without acute intracranial pathology on initial scans and who underwent follow-up brain CTs within 14 days post-return of spontaneous circulation (ROSC) were included. Image segmentation involved manual basalganglia segmentation and automated whole-brain segmentation. Radiomics features were calculated using Pyradiomics (v3.0.1) in 3DSlicer (v5.2.2). Feature selection involved reproducibility analysis via ICC and LASSO regression, retaining five features per segmentation method. A logistic regression model for each segmentation method underwent 5-fold cross-validation. Results were summarized with ROC analyses and average sensitivity and specificity. Results: A total of 83 patients (average age: 65 ± 13.3 years, 19 women) with CA and ROSC were included. Follow-up CT scans after 5.2 ± 2.9 days revealed brain edema in 47 patients. The model using manual segmentation achieved an average AUC of 0.76, sensitivity of 0.59, and specificity of 0.78. The automated segmentation model showed an average AUC of 0.66, sensitivity of 0.49, and specificity of 0.68. Conclusions: Radiomics, particularly focused on the basalganglia area in normal-appearing brain CTs after CA and ROSC, may enhance predictive insights for HIBI and the development of brain edema.

Background: Image quality and diagnostic accuracy in computed tomography angiography (CTA) reach their limits in imaging of below-the-knee vessels. Purpose: To evaluate whether image quality in CTA of lower limbs is further improvable by combining side-separate reconstruction with a larger matrix size and whether resulting noise can be compromised with iterative reconstruction (IR). Material and Methods: From CTA of the lower extremities of 26 patients (5 women, 21 men; mean age = 68.5 ± 10.3 years), the lower legs were reconstructed side-separately with different reconstruction algorithms and matrix sizes including filtered back projection (FBP) with a 512 × 512 matrix, FBP with a 1024 × 1024 matrix, IR (SAFIRE) with a 512 × 512 matrix, and IR (SAFIRE) with a 1024 × 1024 matrix. A total of 208 CT series were evaluated. Subjective image quality was assessed by two readers using a 5-point Likert scale. Image noise was assessed by measuring signal-to-noise and contrast-to-noise ratios. Results: Subjective image quality was rated significantly higher when using a 1024 × 1024 matrix ( P < 0.001) and could further be increased with IR. Vessel sharpness was rated significantly better with a larger matrix ( P < 0.001). Visible and measured image noise was significantly higher with a 1024 × 1024 matrix but could be reduced by using IR ( P < 0.001), even to a level below FBP with a 512 × 512 matrix while reconstructing with a larger matrix ( P < 0.001). Conclusion: Image quality, image noise, and vessel sharpness can be further improved in CTA of the lower extremities with side-separate reconstruction using a 1024 × 1024 matrix size and IR.