Catheter-Directed Therapy: Outcomes Versus Standard of Care and Evaluation of Current Practice.

BACKGROUND: Small studies have noted benefit with the use of catheter-directed therapy (CDT) versus standard of care in treatment of pulmonary embolism, but none have focused on the variability of clinical practice with this modality. METHODS: International Classification of Diseases (ICD) codes were used to retrospectively identify consecutive adult patients admitted to an intensive care unit (ICU) with pulmonary embolism over a 2-year period. We evaluated inpatient mortality and major bleeding and assessed treatment variation. RESULTS: Of 284 patients included, 46 underwent CDT (9 massive pulmonary embolism, 37 submassive pulmonary embolism). Significantly more patients who underwent standard treatment had a history of congestive heart failure and diabetes. Obesity, higher troponin levels, and right heart strain were significantly more likely in the CDT group. No significant difference in inpatient mortality or major bleeding events was observed between the treatment groups. Tissue plasminogen activator use varied widely in the CDT group, and inferior vena cava filter utilization was significantly more common in the CDT group (18; 41%) compared with the standard group (40; 17%) (P < 0.01). CONCLUSIONS: In this study, no significant difference in inpatient mortality or major bleeding was found in patients in the intensive care unit with pulmonary embolism who underwent CDT compared with standard care. It may be beneficial to standardize this procedure given the potential benefit of CDT in patients with submassive pulmonary embolism.

High Scan Volume with Low Positive Scan Rate in Highest Utilizers: Computed Tomography Pulmonary Angiography in the Emergency Department.

BACKGROUND: We examined utilization patterns and predictors of computed tomography pulmonary angiography (CTPA) results in the emergency department (ED). OBJECTIVES: We retrospectively determined ED CTPA positive scan rate (PSR) among ED attendings based on a system that grouped attendings into scan quantity categories through >100. METHODS: We manually reviewed all scans ordered in 2017 in EDs in a multisite medical system. RESULTS: Of 10,032 ED CTPAs, 6168 were ordered by 153 ED attendings. Most attendings (123/153; 80%) ordered 60 or fewer scans with relatively high PSR (259/2927, PSR 8.8%; 95% confidence interval 7.8-9.9%). Of the ED attendings, 13 (3%) ordered more than 100 scans each (1981 scans; 32% of all scans), with PSR of 5.5% (95% confidence interval 4.5-6.5%). CONCLUSION: Most ED attendings were low- to mid-volume utilizers of CTPA and had a relatively high PSR. However, the small percentage of attendings who ordered more than 100 scans each accounted for a large percentage of the total scan volume and had a relatively low PSR. These findings suggest that sharing of performance feedback and best practices in the highest utilizers could help to improve CTPA PSR in the ED.

Atypical Intracerebral Developmental Venous Anomalies in Sturge-Weber Syndrome: A Case Series and Review of Literature.

BACKGROUND: Intracranial vascular abnormalities in Sturge-Weber syndrome, including leptomeningeal angiomatosis, anomalous cortical venous structures, and transmedullary developmental venous anomalies, are well recognized. Prominent vascular flow voids on T2-weighted magnetic resonance imaging (MRI) are occasionally identified in patients with Sturge-Weber syndrome, raising concern of arteriovenous malformations, a congenital high-flow vascular malformation with a risk of bleeding. METHODS: We report four patients with prominent flow voids on conventional MRI that suggested high-flow lesions. RESULTS: Diagnostic evaluation was performed with cerebral angiography in one patient and with a combination of magnetic resonance angiography and magnetic resonance venography in three patients. In all four patients, the conventional MRI-identified lesions represented prominent developmental venous anomalies and not arteriovenous malformations. CONCLUSIONS: This series highlights that developmental venous anomalies may appear in individuals with Sturge-Weber syndrome as unusually large and seemingly high-flow lesions on MRI. Noninvasive imaging with magnetic resonance angiography and magnetic resonance venography can be used in the management of such patients for further characterization of these vascular structures.

Dual-Propeller Cavopulmonary Pump for Assisting Patients with Hypoplastic Right Ventricle.

Various congenital heart defects (CHDs) are characterized by the existence of a single functional ventricle, which perfuses both the systemic and pulmonary circulation. A three-stage palliation procedure, including the final Fontan completion, is often adopted by surgeons to treat patients with such CHDs. The completion Fontan involves the creation of a total cavopulmonary connection (TCPC), commonly accomplished with an extracardiac conduit. This TCPC results in nonphysiologic flow conditions that can lead to systemic venous hypertension, reduced cardiac output, and ultimately the need for heart transplantation. A modest pressure rise of 5-6 mm Hg could correct the abnormal flow dynamics in these patients. To achieve this, we propose a novel conceptual design of a dual-propeller pump inside a flared TCPC. The TCPC dual-propeller conjunction was examined for hydraulic performance, blood flow pattern, and potential for hemolysis inside the TCPC using computational fluid dynamics (CFD). The effect of axial distance between the two propellers on the blood flow interference and energy loss was studied to determine the optimal separation distance. Both the inferior vena cava (IVC) and superior vena cava (SVC) propellers provided a pressure rise of 1-20 mm Hg at flow rates ranging from 0.4 to 7 lpm while rotating at speeds of 6,000-12,000 rpm. Larger separation distance provided favorable performance in terms of flow interference, energy loss, and blood damage potential. The ability of a dual-propeller micropump to provide the required pressure rise would help to augment the cavopulmonary flow and mimic flows seen in normal biventricular circulation.

Portal Vein Thrombosis: Imaging the Spectrum of Disease With an Emphasis on MRI Features.

OBJECTIVE: The purpose of this article is to review the classic and uncommon imaging findings of portal vein thrombosis (PVT) (acute, chronic, congenital, and septic thrombus) as visualized on multiple modalities, with an emphasis on MRI findings. Additional aims are to understand the imaging of obliterative portal venopathy and its clinical significance, appreciate morphologic changes of the biliary system that may accompany PVT, and recognize changes in liver enhancement patterns seen with PVT related to the hepatic arterial buffer response. The review also addresses morphologic changes of the liver that may occur after PVT, including nodular regenerative hyperplasia, central hepatic hypertrophy, and peripheral fibrosis that may stimulate cirrhosis, as well as the importance of portal vein mapping and the diagnostic findings and clinical significance of tumor within the portal vein in the liver transplant population. CONCLUSION: PVT may be a complication of liver cirrhosis, but it may also occur as a primary vascular disorder without liver disease. PVT can result in portal hypertension and may present with variceal bleeding or hypersplenism. Radiologists should be familiar with the imaging of PVT in patients of various ages and in different clinical scenarios. PVT can influence hepatic perfusion, the shape of the bile ducts, and liver architecture. Bland PVT and tumor-related PVT have major implications for hepatic transplant.

PathBot: A Radiology-Pathology Correlation Dashboard.

Pathology is considered the "gold standard" of diagnostic medicine. The importance of radiology-pathology correlation is seen in interdepartmental patient conferences such as "tumor boards" and by the tradition of radiology resident immersion in a radiologic-pathology course at the American Institute of Radiologic Pathology. In practice, consistent pathology follow-up can be difficult due to time constraints and cumbersome electronic medical records. We present a radiology-pathology correlation dashboard that presents radiologists with pathology reports matched to their dictations, for both diagnostic imaging and image-guided procedures. In creating our dashboard, we utilized the RadLex ontology and National Center for Biomedical Ontology (NCBO) Annotator to identify anatomic concepts in pathology reports that could subsequently be mapped to relevant radiology reports, providing an automated method to match related radiology and pathology reports. Radiology-pathology matches are presented to the radiologist on a web-based dashboard. We found that our algorithm was highly specific in detecting matches. Our sensitivity was slightly lower than expected and could be attributed to missing anatomy concepts in the RadLex ontology, as well as limitations in our parent term hierarchical mapping and synonym recognition algorithms. By automating radiology-pathology correlation and presenting matches in a user-friendly dashboard format, we hope to encourage pathology follow-up in clinical radiology practice for purposes of self-education and to augment peer review. We also hope to provide a tool to facilitate the production of quality teaching files, lectures, and publications. Diagnostic images have a richer educational value when they are backed up by the gold standard of pathology.

Comparison-Bot: an Automated Preliminary-Final Report Comparison System.

Regular comparison of preliminary to final reports is a critical part of radiology resident and fellow education as prior research has documented substantial preliminary to final discrepancies. Unfortunately, there are many barriers to this comparison: high study volume; overnight rotations without an attending; the ability to finalize reports remotely; the subtle nature of many changes; and lack of easy access to the preliminary report after finalization. We developed a system that automatically compiles and emails a weekly summary of report differences for all residents and fellows. Trainees can also create a custom report using a date range of their choice and can view this data on a resident dashboard. Differences between preliminary and final reports are clearly highlighted with links to the associated study in Picture Archiving and Communication Systems (PACS) for efficient review and learning. Reports with more changes, particularly changes made in the impression, are highlighted to focus attention on those exams with substantive edits. Our system provides an easy way for trainees to review changes to preliminary reports with immediate access to the associated images, thereby improving their educational experience. Departmental surveys showed that our report difference summary is easy to understand and improves the educational experience of our trainees. Additionally, interesting descriptive statistics help us understand how reports are changed by trainee level, by attending, and by exam type. Finally, this system can be easily ported to other departments who have access to their Health Level 7 (HL7) data.

Simulation-based morbidity and mortality conference: new technologies augmenting traditional case-based presentations.

The authors describe the use of a high-fidelity simulation laboratory to re-create a patient encounter for the purposes of enhancing a morbidity and mortality conference. The use of two separate technologies were enlisted: a METI high-fidelity patient simulator to re-create the case in a more lifelike fashion, and an audience response system to collect clinical impressions throughout the case presentation and survey data at the end of the presentation. The re-creation of the patient encounter with all relevant physical findings displayed in high fidelity, with relevant laboratory data, nursing notes, and imaging as it occurred in the actual case, provides a more engaging format for the resident-learner. This technological enhancement was deployed at a morbidity and mortality conference, and the authors report the impressions collected via the audience response system. Guidelines for those who wish to re-create this type of educational experience are presented in the discussion.

Effect of cocaine use on bone marrow-mediated erythropoiesis.

OBJECTIVES: Cocaine-mediated erythrocytosis is one of several effects that cocaine may have on hematologic indices; however, the precise mechanism by which cocaine induces peripheral erythrocytosis is not fully understood. The objective of this study was to examine the contribution of the bone marrow to cocaine-mediated erythrocytosis. METHODS: Differences in mean hemoglobin concentration, hematocrit, and reticulocyte counts were measured in consecutive cocaine-exposed and cocaine-unexposed patients who presented to the emergency department (ED) with chest pain. Acute cocaine exposure (<3 hours) was confirmed by history and toxicologic analysis of the urine on all patients. Means were compared using independent-samples t-test and covariates were examined using multiple regression. RESULTS: Seventy-nine patients met enrollment criteria. Hemoglobin and hematocrit levels were significantly elevated in the cocaine-using subjects (13.5/39.8) compared with controls (12.6/37.7; p < 0.02). However, no corresponding elevation in reticulocyte count (p = 0.2) was observed. Multivariate logistic regression revealed that male chest pain patients were significantly more likely to be exposed to cocaine (OR 5.15 [95% CI = 1.77 to 15.3]) than females (p = 0.001), and all relative increases in hemoglobin concentration in the cocaine-exposed group were attributable to gender. Cocaine exposure was not significantly associated with reticulocyte count. Multivariate linear regression revealed that of demographic, medical, and substance use covariates, only a history of diabetes mellitus was significantly associated with an elevated reticulocyte count (p = 0.009). CONCLUSIONS: Acute cocaine exposure is not associated with erythrocytosis in younger ED patients with chest pain. The lack of an elevated reticulocyte count suggests that bone marrow does not contribute to any transient erythrocytosis that may occur.

Validation of a brief observation period for patients with cocaine-associated chest pain.

BACKGROUND: Retrospective studies of patients with cocaine-associated chest pain suggest that a strategy of discharging patients from the emergency department after a 12-hour observation period if they do not have evidence of ischemia should be associated with a very low rate of complications. METHODS: We prospectively evaluated the safety of a 9-to-12-hour observation period in patients with cocaine-associated chest pain who were at low-to-intermediate risk of cardiovascular events. Consecutive patients who reported or tested positive for cocaine use and who received protocol-driven care in a chest-pain observation unit were included. Patients who had normal levels of troponin I, without new ischemic changes on electrocardiography, and who had no cardiovascular complications (dysrhythmias, acute myocardial infarction, or recurrent symptoms) during the 9-to-12-hour observation period were discharged from the unit. The main outcome was death from cardiovascular causes at 30 days. RESULTS: Three hundred forty-four patients with cocaine-associated chest pain were evaluated. Forty-two of these patients (12 percent) were directly admitted to the hospital. The study cohort comprised the remaining 302 patients. During the 30-day follow-up period, none of the patients died of a cardiovascular event (0 percent; 95 percent confidence interval, 0 to 0.99), and only 4 of the 256 patients for whom detailed follow-up data were available had a nonfatal myocardial infarction (1.6 percent; 95 percent confidence interval, 0.1 to 3.1). All four nonfatal myocardial infarctions occurred in patients who continued to use cocaine. CONCLUSIONS: Patients with cocaine-associated chest pain who do not have evidence of ischemia or cardiovascular complications over a 9-to-12-hour period in a chest-pain observation unit have a very low risk of death or myocardial infarction during the 30 days after discharge.