Implementing a Quality Intervention to Improve Confidence in Outpatient Venous Thromboembolism Management.

INTRODUCTION: Guidelines recommend that patients with acute venous thromboembolism (VTE) represented by low-risk deep vein thrombosis (DVT) and pulmonary embolism (PE) receive initial treatment at home versus at the hospital, but a large percentage of these patients are not managed at home. This study assessed the effectiveness of a quality intervention on provider knowledge and confidence in evaluating outpatient treatment for patients with VTE in the emergency department (ED). METHODS: A pilot program to overcome obstacles to outpatient VTE treatment in appropriate patients was initiated at Baylor Scott & White Health Temple ED. Subsequently, a formalized quality intervention with a targeted educational program was developed and delivered to ED providers. Provider surveys were administered pre- and post-quality intervention in order to assess clinical knowledge, confidence levels, and perceived barriers. Patient discharge information was extracted from electronic health records. RESULTS: Twenty-five ED providers completed the pre- and post-surveys; 690 and 356 patients with VTE were included in the pre- and post-pilot and pre- and post-quality intervention periods, respectively. Many ED providers reported that a major barrier to discharging patients to outpatient care was the lack of available and adequate patient follow-up appointments. Notably, after the quality intervention, an increase in provider clinical knowledge and confidence scores was observed. Discharge rates for patients with VTE increased from 25.6% to 27.5% after the pilot intervention and increased from 28.5% to 29.9% after the quality intervention, but these differences were not statistically significant. Despite instantaneous uptick in discharge rates after the interventions, there was not a long-lasting effect. CONCLUSION: Although the quality intervention led to improvements in provider clinical knowledge and confidence and identified barriers to discharging patients with VTE, discharge rates remained stable, underscoring the need for additional endeavors.

When patients develop blood clots in their veins or have blood clots travel to their lungs, they may seek treatment at the hospital emergency department. As a best practice, most people can treat blood clots with medicines at home; however, many patients are treated at the hospital. This study looked at how an education program for doctors in the hospital could help more patients be treated at home. The education program improved doctors' knowledge and confidence when evaluating patients with blood clots who could be treated at home. However, this study found that the number of patients treated at home was the same before and after the doctors participated in the education program. Two major problems that prevented patients from being treated at home were not having follow-up appointments readily available and patients taking their medicine as needed. More and different types of programs may help doctors understand the best ways to treat patients with blood clots in the emergency department.

Utilization of neonatal sedation and anesthesia: an SPR survey.

BACKGROUND: There is little data regarding the use of sedation and anesthesia for neonatal imaging, with practice patterns varying widely across institutions. OBJECTIVE: To understand the current utilization of sedation and anesthesia for neonatal imaging, and review the current literature and recommendations. MATERIALS AND METHODS: One thousand, two hundred twenty-six questionnaire invitations were emailed to North American physician members of the Society for Pediatric Radiology using the Survey Monkey platform. Descriptive statistical analysis of the responses was performed. RESULTS: The final results represented 59 institutions from 26 U.S. states, the District of Columbia and three Canadian provinces. Discrepant responses from institutions with multiple respondents (13 out of 59 institutions) were prevalent in multiple categories. Of the 80 total respondents, slightly more than half (56%) were associated with children's hospitals and 44% with the pediatric division of an adult radiology department. Most radiologists (70%) were cognizant of the neonatal sedation policies in their departments. A majority (89%) acknowledged awareness of neurotoxicity concerns in the literature and agreed with the validity of these concerns. In neonates undergoing magnetic resonance imaging (MRI), 46% of respondents reported attempting feed and bundle in all patients and an additional 46% attempt on a case-by-case basis, with most (35%) using a single swaddling attempt before sedation. Sedation was most often used for neonatal interventional procedures (93%) followed by MR (85%), nuclear medicine (48%) and computed tomography (31%). More than half of respondents (63%) reported an average success rate of greater than 50% when using neonatal sedation for MR. CONCLUSION: Current practice patterns, policies and understanding of the use of sedation and anesthesia for neonatal imaging vary widely across institutions in North America, and even among radiologists from the same institution. Our survey highlights the need for improved awareness, education, and standardization at both the institutional level and the societal level. Awareness of the potential for anesthetic neurotoxicity and success of non-pharmacologic approaches to neonatal imaging is crucial, along with education of health care personnel, systematic approaches to quality control and improvement, and integration of evidence-based protocols into clinical practice.

Gastroschisis in one twin neonate with extracorporeal liver.

We report a rare case of gastroschisis with extracorporeal liver suspected on late first trimester ultrasound and confirmed with second trimester ultrasound and magnetic resonance imaging in one fetus in a twin pregnancy. Liver herniation is common in omphalocele, a membrane-covered abdominal wall defect associated with other congenital anomalies. However, it is highly uncommon in gastroschisis, an uncovered abdominal wall defect aside of the cord insertion. Presence of liver herniation complicates prenatal differentiation between omphalocele and gastroschisis. The twins were born at 31 weeks' gestation due to preterm labor. The baby was treated with a silo device, followed by biologic mesh and a wound vac with instillation of fluid to prevent desiccation. Ultimately, the baby died of sepsis, with multiorgan failure and polymicrobial infection.

Magnetic resonance imaging diagnosis of a skeletal dysplasia mimicking erosive arthropathy.

This case report of a 14-year-old boy with arthralgia and clinically suspected inflammatory arthropathy highlights how magnetic resonance imaging (MRI) ultimately diagnosed skeletal dysplasia. A genetic evaluation revealed a transient receptor potential vanilloid 4 (TRPV4) pathogenic variant. This is a rare description of the MRI appearance of this type of dysplasia in long bone epiphyses corresponding with the histological findings of disrupted endochondral ossification. This report offers imaging support to the description of endochondral bone growth disruption in TRPV4-related skeletal dysplasias.

Imaging of solid congenital abdominal masses: a review of the literature and practical approach to image interpretation.

Fetal abdominal tumors are rare, usually benign, and cause a great deal of anxiety for expectant parents and the physicians counseling them. In this paper the author reviews the most common fetal abdominal tumors in the liver (hemangioma, mesenchymal hamartoma, hepatoblastoma, metastases) and the kidney (congenital mesoblastic nephroma, Wilms tumor, malignant rhabdoid tumor, and clear cell sarcoma), and suprarenal mass lesions (adrenal neuroblastoma, adrenal hemorrhage, and subdiaphragmatic extralobar pulmonary sequestration). The author describes the imaging approach, imaging appearance and differentiating features of tumors, and differences between fetal and childhood appearances of tumors.

Hyperuricosuria, hematuria, and novel bladder images with IgA nephropathy.

Episodic (recurrent) macroscopic hematuria in patients with IgA nephropathy is usually associated with a benign prognosis, although some patients experience a transient fall in glomerular filtration rate during the episodes. We present a 15-year-old girl with mild IgA nephropathy who had multiple episodes of macroscopic hematuria associated with severe but transient decreases in estimated glomerular filtration rate, low levels of serum uric acid, and marked increases in fractional excretion of uric acid. Ultrasound studies showed marked inflammatory changes in the bladder, especially involving the trigone. Cystoscopic findings were consistent with these changes. We hypothesize that the macroscopic hematuria may have resulted, at least in part, from hyperuricosuria causing acute irritation of the bladder mucosa in the trigone area.

Evolution and regression of imaging findings in treated pulmonary Langerhans cell histiocytosis.

In rare instances, pediatric Langerhans cell histiocytosis (LCH) may manifest as lung disease. While the imaging features at presentation have been reported, we present sequential computed tomography (CT) scans of a 3-year-old boy with pulmonary LCH, revealing the evolution and regression of the disease. Sequential CT scans during treatment demonstrated variable evolution of pulmonary cysts, including changes in size, thinning of walls, and a pattern of collapse into irregular nodules and involution. Our case represents a rare opportunity to examine sequential CT findings of pediatric pulmonary LCH regression.

Pedunculated focal nodular hyperplasia in a healthy toddler.

Focal nodular hyperplasia (FNH) is a benign hepatic tumor rarely seen in pediatric patients, with most cases reported in school-aged children with a history of malignancy, liver disease, chemotherapy, or hematopoietic stem cell therapy. Despite having advanced radiographic imaging, diagnosing FNH before surgical resection can be difficult. We report a rare case of pedunculated FNH presenting as a large abdominal mass palpated on physical exam in a healthy 3-year-old girl with no history of malignancy or underlying liver disease. Ultrasound, computed tomography, and magnetic resonance imaging (MRI) did not demonstrate the typical imaging characteristics of FNH, because the mass was pedunculated with a poorly visualized central scar. Because approximately 75% of all primary hepatic tumors in this age group are malignant, this report also discusses the importance of adding hepatobiliary phase imaging with MRI to avoid, if possible, the need for biopsy or surgical resection of a benign hepatic tumor.

Limited, fast magnetic resonance imaging as an alternative for preoperative evaluation of pectus excavatum: a feasibility study.

OBJECTIVE: The purpose of this study was to determine the reliability, feasibility, and image quality of a limited, fast magnetic resonance imaging (MRI) protocol for preoperative evaluation of pectus excavatum in a pediatric population referred for presurgical imaging. MATERIALS AND METHODS: A total of 47 patients, median age 14 years, referred for preoperative imaging of pectus excavatum, underwent axial balanced steady-state free precession MRI of the chest, with a limited patient charge. Two pediatric radiologists independently conducted a blinded retrospective study. The Haller and asymmetry indices were calculated at the level of greatest anterior-posterior chest narrowing. In addition, right heart compression and image quality were subjectively assessed, and scan duration was determined. RESULTS: Intraclass correlation coefficient reliability was between 0.85 and 0.98, indicating almost perfect agreement for quantitative measurements. Subjective evaluation of right heart compression and image quality showed moderate interreader agreement. Image quality was graded as good or excellent by both readers for all studies. No difference in the Haller index was observed between modalities in 3 patients on both computed tomographic scan and MRI (P = 0.2697). The median scan duration was 8 minutes. CONCLUSIONS: Limited MRI is a reliable and cost-effective alternative for preoperative assessment of pectus excavatum. It is fast, free of ionizing radiation, and there is excellent interreader reliability for measurements of chest wall deformity.

Breathe in... breathe out... stop breathing: does phase of respiration affect the Haller index in patients with pectus excavatum?

OBJECTIVE: The purpose of this article is to determine whether the phase of respiration at the time of imaging affects chest wall measurements and compression of internal structures in patients with pectus excavatum. MATERIALS AND METHODS: Forty-seven patients (median age, 14 years) imaged for preoperative pectus excavatum underwent limited axial balanced steady-state free precession MRI of the chest at inspiration, expiration, and stop quiet breathing. Two radiologists, who were blinded to prior measurements, independently calculated the Haller index, asymmetry index, and sternal tilt in each phase of respiration. Compression of internal structures was recorded. Statistical comparison was performed. RESULTS: The Haller index was significantly lower at inspiration, compared with stop quiet breathing and expiration, with medians (interquartile ranges) of 3.96 (3.27-4.61), 5.16 (4.02-6.48), and 5.09 (4.14-6.63), respectively (p < 0.0001 for both). No significant difference in Haller indexes was observed between expiration and stop quiet breathing (p = 0.1171). Of 11 patients with a Haller index less than 3.25 at inspiration, eight (72.7%) had an index greater than 3.25 on expiration and stop quiet breathing, which accounted for 17% (8/47) of all patients imaged. Compression of the liver or vascular structures was present in 24 (51%) patients. There was no significant difference in the asymmetry index, sternal tilt, or right heart compression between phases of respiration. CONCLUSION: Obtaining the Haller Index at inspiration may result in a value significantly lower than that at expiration, potentially affecting surgical and financial decision making. Compression of the liver and vascular structures was observed in 51% of patients, but additional research is needed to determine the clinical significance of this finding.

Comprehensive MR evaluation of renal disease: added clinical value of quantified renal perfusion values over single MR angiography.

PURPOSE: To evaluate the diagnostic accuracy of quantified renal perfusion parameters in identifying and differentiating renovascular from renal parenchymal disease. MATERIALS AND METHODS: In all, 27 patients underwent renal perfusion measurements on a 3.0 T magnetic resonance imaging (MRI) system. Imaging was performed with a saturation recovery TurboFLASH sequence (TR/TE 177/0.93 msec, flip angle 12 degrees , 5 slices/sec). All patients also underwent high-resolution MR angiography (MRA) (TR/TE 3.1/1.09, flip angle 23 degrees , spatial resolution 0.9 x 0.8 x 0.9 mm(3)). MR perfusion measurements were analyzed with a two-compartment model, quantifying the plasma flow (F(P))-a characteristic renal first-pass perfusion parameter. A receiver-operator characteristic analysis was used to determine the optimal threshold value for distinguishing normal and abnormal plasma flow values. Utilizing this cutoff, sensitivity and specificity of solitary MR perfusion measurements, MRA, and a diagnostic strategy combining the two were evaluated. RESULTS: Quantified MR perfusion values yielded a sensitivity of 100% and a specificity of 85% utilizing the optimal plasma flow threshold value of 150 mL/100 mL/min, whereas single MRA achieved a sensitivity of 51.9% and a specificity of 90%. Combining both methods enabled improved detection of renovascular and renoparenchymal disease with a sensitivity of 96.3% and specificity of 90%. CONCLUSION: In distinction to MRA, quantified MR perfusion measurements allow for the detection of pure renal parenchymal disorders. The combination of MRA with these perfusion measurements suggests an algorithm by which parenchymal and renovascular diseases may be reliably distinguished and the hemodynamic significance of the latter reliably determined.

Isolated right superior vena cava drainage into the left atrium diagnosed noninvasively in the peripartum period.

Isolated right superior vena cava drainage into the left atrium is an extremely rare cardiac anomaly, especially in the absence of other cardiac abnormalities. Only 28 of 5,127 reported consecutive congenital cardiac cases involved superior vena cava drainage into the left atrium, and all were associated with other cardiac anomalies. Of 19 reported cases of right superior vena cava drainage into the left atrium, most patients have been children who were experiencing mild hypoxemia and cyanosis. Herein, we describe the case of a 34-year-old woman who presented with asymptomatic hypoxemia in the peripartum period. She was diagnosed to have isolated drainage of the right superior vena cava into the left atrium. To the best of our knowledge, this is the 1st reported instance of such diagnosis by use of noninvasive imaging only, without cardiac catheterization. We also review the medical literature that pertains to our patient's anomaly.

Atypical abdominal hernias in the emergency department: acute and non-acute.

The objective of this pictorial essay is to review uncommon abdominal hernias, many of which present to the Emergency Department with abdominal pain. These hernias may be congenital, post-traumatic, or iatrogenic in origin. They may present as an acute (surgical) abdomen without localizing signs or symptoms. They may present with an obvious antecedent event such as motor vehicle trauma or simply present as an incidental finding. Multi-detector computed tomography is currently the study of choice to diagnose abdominal hernia and to evaluate the possible complications such as small bowel obstruction and/or strangulation. This modality can delineate a "zone of transition" (abnormally dilated bowel transitioning to normal or decreased bowel caliber) or identify the involved anatomy. It can also suggest compromised blood supply.

Is the chest x-ray an appropriate screening exam for ER patients with AMS?

Emergency department patients with altered mental status (AMS) regularly undergo a routine chest radiograph at our institution. While there are many causes of chest pathology seen on the chest radiograph that may cause an altered mental status, it is not clear that a routine chest radiograph for these patients affects management. The goal of this study is to determine if a chest radiograph is an appropriate screening examination for AMS. This is a retrospective review of 100 consecutive patients who underwent head computed tomography for altered mental status in the emergency department and had a chest radiograph during the same visit. Of 100 patients undergoing a routine chest radiograph for AMS, 17 had findings which altered patient care, 15 of those had signs/symptoms which clearly indicated that a chest radiograph was needed, and the other two had leukocytosis. The routine performance of a chest radiograph in the setting of a patient presenting to the emergency department with altered mental status affected medical management in 17%, a modest benefit. The positive predictive value of a chest x-ray in these patients may be improved if certain symptomatologies are present.

Van Wyk and Grumbach syndrome revisited: imaging and clinical findings in pre- and postpubertal girls.

BACKGROUND: In 1960 Van Wyk and Grumbach described a syndrome of juvenile hypothyroidism, precocious puberty and ovarian enlargement. These findings undergo complete regression with thyroid hormone replacement therapy. This diagnosis can be made on the basis of imaging findings and thyroid function analysis, avoiding surgery. OBJECTIVE: To relate the distinctive clinical and imaging features and putative pathophysiological mechanism of a series of patients with Van Wyk and Grumbach syndrome (VWGS). MATERIALS AND METHODS: Patients with VWGS diagnosed at two large children's hospitals over a 6-year period beginning in 1999 were retrospectively reviewed. A literature review was also conducted. RESULTS: Five female patients were diagnosed with cystic ovarian enlargement and hypothyroidism at ages ranging from 9 to 17 years. Isosexual precocious puberty was found in prepubescent patients. Associated findings included delayed bone age, ascites, and pleural and pericardial effusions. Ovarian cyst involution occurred following treatment of the hypothyroidism. CONCLUSION: The association of primary hypothyroidism with cystic ovarian enlargement and precocious puberty is important to recognize. In the absence of suspected ovarian torsion, surgery is unnecessary, as cyst regression occurs after appropriate thyroid hormone replacement. Noncompliance with hormone replacement therapy should be considered when cystic ovarian enlargement is noted in patients with a history of hypothyroidism.