Management options for pediatric venous thromboembolic disease: Beyond anticoagulation with endovascular therapies.

Venous thromboembolism (VTE) in pediatric patients is an uncommon but serious diagnosis that has an array of therapeutic options and challenges. An assessment of the existing literature on management of pediatric patients with VTE was conducted. The interventions reviewed include anticoagulation, thrombolysis, thrombectomy, inferior vena cava (IVC) filters, and venous stenting. For each intervention, a discussion of mechanism of action, indications, contraindications, and potential complications was performed. While anticoagulants are considered the first-line pediatric VTE treatment, many drugs remain investigational in this patient population and treatment recommendations are extrapolated from adult practice. Thrombolysis may be indicated in cases of acute thrombosis requiring more rapid clot resolution but presents a greater bleeding risk than anticoagulation. Similarly, thrombectomy also provides rapid clot resolution and offers a larger therapeutic window and usage in more mature thrombi than thrombolysis. In select patient groups, IVC filters may be indicated in the prevention of PE but present with inherent thrombogenicity and risk of migration. The data regarding pediatric VTE treatment options, monitoring, and long term outcomes is limited compared to the adult population. The relatively few clinical trials including pediatric patients have a relatively small sample size and are heterogenous with regards to predisposing factors that further exacerbate generalizability. Additional research is needed to help construct and evaluate a robust treatment algorithm for pediatric patients with VTE.

Eye Motion Tracking for Medical Image Interpretation Training.

INTRODUCTION: The significance of Eye Motion Tracking in aiding learners in training search patterns, pattern recognition, and efficiently using their gaze in terms of time and scanning distribution has been highlighted in the USAF Pilot Training Next initiative. METHODS: The innovation described further builds on this concept in the realm of medical imaging and the provision of real-time feedback of eye direction and gaze duration. RESULTS: This real-time indicator enables the trainer to adapt verbal queueing of the trainee in a personalized manner to improve knowledge transfer, and to increase the confidence of the trainer and trainee in the competency of the trainee. The initial experiment data set included bone radiographs, digital subtraction angiograms, and computed tomography images. DISCUSSION: Preliminary results and formative feedback from participants was encouraging with expert viewers able to use Eye Motion Tracking to successfully guide novice readers through search and gaze protocol patterns of the medical images.

Effect of a dedicated inferior vena cava filter retrieval program on retrieval rates and number of patients lost to follow-up.

PURPOSE We aimed to assess the efficacy of a dedicated inferior vena cava (IVC) filter retrieval program on filter retrieval rates and number of patients lost to follow-up. METHODS A dedicated IVC filter retrieval program began in July 2016. This consisted of tracking all patients with retrievable filters placed by interventional radiology (IR). At the time of filter placement, patients were scheduled for a retrieval consult in the IR clinic. Any missed appointments were followed up by a physician assistant. The program was overseen by a single IR physician. To assess this program's efficacy, we reviewed the records of all patients who had retrievable IVC filters placed by IR nine months prior to and nine months after program initiation. Demographics and clinical factors were then collected and compared. A P value of < 0.05 was considered statistically significant. RESULTS Prior to the program, 76 patients (31 males, 45 females; mean age, 64.2 years) had retrievable filters placed; 75% were placed due to a contraindication to anticoagulation. From this group, five filters were removed (6.6%), 42 patients were lost to follow-up (55.3%), 22 patients died (29.0%), and seven filters were deemed permanent by a physician after placement (9.2%). All five retrievals were successful and no complications were reported. After program initiation, 106 patients (59 males, 47 females; mean age, 58.8 years) had retrievable filters placed; 75.5% were placed due to a contraindication to anticoagulation. In this group, 30 filters were retrieved (retrieval rate 28.3%), 17 patients were lost to follow-up (16%), 23 patients died (21.7%), 28 filters were deemed permanent by a physician after placement (26.4%), and decisions were still pending in eight patients (7.5%). One patient (3.3%) had a minor complication during filter retrieval. Initiation of a filter retrieval program increased our retrieval rate (6.6% vs. 28.3%; P < 0.001) and reduced the number of patients with filters that were lost to follow-up (55.3% vs. 16%; P < 0.001). CONCLUSION Dedicated filter retrieval program is effective in increasing filter retrieval rates and decreasing the number of patients lost to follow-up.

Contemporary biological markers of exposure to fluoride.

Contemporary biological markers assess present, or very recent, exposure to fluoride: fluoride concentrations in blood, bone surface, saliva, milk, sweat and urine have been considered. A number of studies relating fluoride concentration in plasma to fluoride dose have been published, but at present there are insufficient data on plasma fluoride concentrations across various age groups to determine the 'usual' concentrations. Although bone contains 99% of the body burden of fluoride, attention has focused on the bone surface as a potential marker of contemporary fluoride exposure. From rather limited data, the ratio surface-to-interior concentration of fluoride may be preferred to whole bone fluoride concentration. Fluoride concentrations in the parotid and submandibular/sublingual ductal saliva follow the plasma fluoride concentration, although at a lower concentration. At present, there are insufficient data to establish a normal range of fluoride concentrations in ductal saliva as a basis for recommending saliva as a marker of fluoride exposure. Sweat and human milk are unsuitable as markers of fluoride exposure. A proportion of ingested fluoride is excreted in urine. Plots of daily urinary fluoride excretion against total daily fluoride intake suggest that daily urinary fluoride excretion is suitable for predicting fluoride intake for groups of people, but not for individuals. While fluoride concentrations in plasma, saliva and urine have some ability to predict fluoride exposure, present data are insufficient to recommend utilizing fluoride concentrations in these body fluids as biomarkers of contemporary fluoride exposure for individuals. Daily fluoride excretion in urine can be considered a useful biomarker of contemporary fluoride exposure for groups of people, and normal values have been published.